Patient Profile: Patient is a 42-year old African-American female, 5’8” and weighs 175 lbs. She has not received regular dental care and reports her teeth need to be cleaned.
Chief Complaint: “I am concerned that I have gum disease. I have bad breath and my gums bleed when I brush.”
Dental History: The patient only visits the dental office when in pain.
Medical History: The patient does not receive annual physical examinations. She has a family history of hypertension, diabetes type 1, depression and cancer. She is allergic to sulfa medications and Penicillin. She currently takes: (Omeprazole) Prilosec®, (Acetaminophen) Tylenol®, (Levothyroxine) Levoxyl® and (Venlafaxine HCL) Effexor®. Her blood pressure was recorded at 160/110.
Bleeding Index: 55%
Plaque Free Score: 35%