Ann Dobbs: Case History

Patient profile:

• DOB 11/25/45
• Female, Caucasian
• Born in Michigan, currently lives in Rochester.

Social history:

• Patient currently employed as executive secretary at large manufacturing firm (3 years)
• No current dental insurance
• Mother of 4 grown children, grandmother to 6 children

Medical history:

• Hypertension - takes medication
• BP was 135/95 at the initial appointment; hygienist noted that she was 'out of breath' when she arrived
• Seasonal atmospheric allergies (Spring)
• Medications - Aldomet (500 mg. bid), Claritin-D (1 tablet, prn)

Dental History:

• Patient admits that she has neglected her dental care since she switched jobs & no longer has dental insurance
• Last set of BWX radiographs dated 12/1/1999. (shown below)
• Had annual cleanings prior to the change in jobs
• Patient answered positively for bleeding gums (occasionally when brushing) and dry mouth

Chief Complaint:

• "I'm worried about my teeth. I don't want to lose them."

OFE:

• bilateral mandibular tori
• coated tongue
• Class I occulsion, 5 mm overjet
• slight abrasion on the premolars

GE:

• Margins are slightly enlarged
• Papillae are blunt
• Recession on S1L & S3L (see below)
• PSR

Chart:

Patient Education:

• Current: brushes after breakfast & before bed
• Scrub technique
• No interdental care
• Plaque score 43%, bleeding is 66%

Radiographs (1999)

Intraoral photos (current)

Deposits:

• Medium large proximal calculus
• S5L has medium bands
• Medium stain generalized
• Plaque is proximal

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