Rachels

RAP
Patient
Presentation
#1625

Patient Profile
27 year-old female
African-American
Full-Time College Student

Medical Assessment
Systemic Diseases: patient denies having any systemic
diseases
Allergies: Occasional seasonal allergies/dust; asthma
Medications: None
Premedication: None
Hospitalizations: None
Vitals: 118/78; 118/78; 118/80-WNL
General Health: Patient states, healthy I do not floss
and like my soda; I dont like how my upper left front
tooth sticks out more than the other one
ASA II- due to occasional asthma

Periodontal
Assessment

Last Dental Exam: 1/2014

Last Hygiene: 1/2014

Restorations: 2, 3, 14, 15, 16, 18, 30 Occlusal

No Ortho

PI: 95%

MBI: 100%

Oral Hygiene: Poor

Calculus Code: Medium 4

AAP: Generalized Moderate Periodontitis with Localized Severe on

Molars

Probings
Probing Depths:
-Mostly 2-3mm pockets on anterior teeth, Localized 4-7mm pockets on
premolars and molars

Recession:

Lingual of lower anteriors

Gingival Description:
generalized pinkish-reddish, pigmented, scalloped and bulbous

Occlusion:
Right
Molar

Right
Canine

Left
Molar

Class I

Class I
Class I
(borderline
Class II div.

Left
Canine
Class I
(borderline
Class II div.

Probing
Before:

After:

Dental Hygiene
Treatment Plan

Appointment

Treatment Plan

1
2/27/15

RMH, Explain project and

expectations, Vitals, E & I,
Periodontal assessment,
Photos, Disclose, Photos, Gave
patient 3 day diet log.
Recommended referral to Ortho
for anterior protrusion.
Recommended Periodontist,
also general dentist or oral
surgeon for implant or bridge
for #31. Also oral surgeon for
evaluation on wisdom teeth.

2
3/13/14

RMH, Vitals, E & I, Diet

counseling, CAMBRA, OHI, gave
more diet forms, Applied 5%
Nafl Varnish

RMH, Vitals, E & I, Perio re-eval,

Treatment Progress
Before:
PI: 95%
BOP: 100%
PD:4-7mm
AAP: Gen moderate periodontitis w/
localized severe on molars

After:
PI: 67%
BOP: Localized mainly to molars 45%
PD:4-6mm (with a reduction by 1
number)
AAP: Gen moderate periodontitis w/
localized severe on molars

Patient Education
PI: 95%- patient stated- I dont floss
1. -Introduced C-flossing method and floss aids
2.

-recommended flossing 2x per week for the first week,

3.

-Increase flossing to every other day the 2nd week

4.

-Increase flossing 3rd week to once a day

Brushing:
-Modified Bass technique

-Tell-Show-Do brushing and stressed importance of getting all areas

Fluoride:
-Recommended

using a fluoride toothpaste .243% NaF and ACT Rinse

(CAMBRA), Applied a 5% NaF during 2nd appointment.

Nutrition Counseling
Patient Exceeded RDA Recommendations
-Carbs & Protein
Deficient in Vitamin A & C
Patient states she snack during day and drinks soda
daily.

Nutrition Recommendations:
Avoid excessive snacking
Avoid cariogenic food if you are going to snack or eat
more fruits and vegetables
Avoid sugary drinks and sodas

Research
Sip all day, get decay

According to the United States Department of

Agriculture Food Consumption..
-50% of all children between 6 & 11 years old drink soft drinks
-Soft drinks have no nutritional content
-Most soft drinks have a pH of 2.4 and take 32 glasses of high
pH alkaline water to neutralize the soda
-Consuming soft drinks quadruples chances of getting decay

Research

What would I do
differently:
Work on someone I can rely on
Get xrays on patient
Scale

References:
Harvard T.H Chan School of Public Health. Sugary
Drinks. Available at
hsph.harvard.edu/nutritionsource/healthydrinks/sugary. February 24, 2015.
California Center for Public Health Advocacy. How
sugar-sweetened beverages become a leading
contributor to the obesity epidemic. kickthecan.info.
March, 2014.