Jim Hamilton: Case History

Patient profile:

• DOB 4/24/55
• Male, Caucasian
• Born in upstate New York

Social history:

• Patient currently employed as a foreman at an automotive die factory
• Patient has dental insurance
• Married, father of two

Medical history:

• BP was 120/80 at the initial appointment
• Arthritis in hands which diminishes strength and slightly limits dexterity. This was brought on by constant use & injuries related to career as a die maker.
• Allergic to sunscreen
• He uses smokeless tobacco
• Medications - Vioxx

Dental History:

• Patient admits that he tends to avoid dental care - he finds dental visits 'stressful'
• Last set of BWX radiographs dated 5/1/1998. (shown below)
• His dental care has been irregular
• He gets frequent headaches, but does not clench or grind

Chief Complaint:

• "I hate to come to the dentist, but the stain on my teeth is getting bad"

OFE:

• corrugated lesion in the maxillary mucobuccal fold (shown below)
• coated tongue
• Class I occulsion, 4 mm overjet
• slight abrasion on the premolars

GE:

• Tissue is inflamed
• Margins are  enlarged
• Papillae are blunt
• Recession on S2F & S5L
• PSR

Chart:

Patient Education:

• Current: brushes  before bed
• Random technique
• No interdental care
• Plaque score is 43%, Bleeding score is 33%

Radiographs (1998)

Intraoral photos (current)

Deposits:

• Light/medium generalized posterior proximal
• Very heavy in S5
• Generalized light/medium stain
• Medium plaque

Return to: