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Final Care Plan/Treatment Summary
Medical/Dental/Personal History: Patient presents as a healthy 44 year old single female. She has a history of caries with the most recent one treated in April of 2014. August of this year, tooth #30 was extracted. Patient is not on any medication but has an allergy to mango and papaya.
Priorities (patient problems): Ms. Labovites first came to CCCC clinic in March of 2014 because she was experiencing pain in the posterior region of her mandibular. Radiographs of the maxillary and mandibular molars were taken at CCCC clinic. Patient returned April 15, 2014 with copy of FMX she'd had in March of 2014 from an office outside CCCC clinic.
ORA: Patient drinks espresso every day as well as smokes cigarettes and is concerned about oral cancer. She is contemplating smoking cessation, however is not ready to set a quit date. Patient does experience sensitivity to hot and cold. Noted grinding habits due to stressful job but does wear a night guard.
Vital Signs: BP - 138/90 Right Arm Sitting (RAS). Pulse 72 per minute, Respirations 14 per minute.
Intraoral and Extraoral Exam: bilateral linea alba, coated tongue, high maxillary frenum with skin tag, severely low mandibular frenum, slightly fissured tongue with slight petichia on anterior.
Gingival Characteristics (10/6/15): MX: gen pink, loc ery interprox; gen flat slightly enlarged;gen knife-edge mar, loc rolled; #3-6(B); gen triangular pap MD: gen pink, loc slight ery #28-31(B), #17 & #18(B); gen enlarged; gen rolled mar; gen triangular pap; gen firm, loc sli spongh (#7-10)(B)
Calculus: Sub (MX & MD): loc/mod/posterior. Supra: MX: none Supra MD: loc/heavy/ling anterior
Wear facets: #6-11 (edge to edge occlusion), #22-27 (edge to edge occlusion)
Lateral Jaw Excursions: RW/LNW: normal; LW/RNW: normal
Furcation Involvement: Class I-14B
Suspicious areas: #3M,13D,14MD,20D,4B,20DO
Probable depth: MX: 6mm: (buccal) 15DB (lingual) 2ML, 3DL 5mm: (buccal) 2BM, 3DB, 15MB. (lingual) 5DL, 14DL, 15DL 4mm (buccal) 5MDB, 6MDB, 7MB, 10DB, 13DB, 14MB (lingual) 2DL, 3ML, 5ML, 9ML, 11DL, 14DL MD 6mm: (lingual) 17DL 5mm: 17ML, 2DL (buccal) 17DB 6mm, 17MB
Biofilm: MX/MD: gen mod
OHI-S (Appointment 1): 0.7-1.8 = Fair Oral Hygiene
AAP Classification: Class III
Original Care Plan: (See attached)
Appointment 2 (10/6/15): RMH, no changes, tongue slightly coated, slight fissured tongue, petechia sli tip of tongue, ging chart/perio examination, smoking cessation interview, nutritional counseling began; gave patient daily nutritional log; will return at next visit; Indices; OHI review flossing and brushing anteriors
Appointment 3 (10/13/15: RMH, no changes. OHI reviewed flossing/Bass method. Pt is very aggreeable to flossing more often. Review smoking cessation; pt still contemplating. Review nutritional counseling; pt brought in 4-day journal to be assessed. Pre-rinse 30 sec CHX 12% ultrasonic/hand instrument debrided MX R
Appointment 4 (10/22/15): RMH, no changes. Oral risk assessment; OCE: Smoking cessation review. Nutritional counseling; went over eating habits and areas where pt can add to her diet; protein and going to sign up for gym membership. Antimicrobial inserted on #3M under instructors supervision. Gave patient instructions re antimicrobial and copy in folder. Pre-rinse 30 sec CHX debride MD R ultrasonic/hand instrument. Pt sensitive on #24L, #25L
Gingival Characteristics MX R: gen/pink; gen/flat; gen knife-edge mar;gen triangular pap; AG:gen/stippled,FG:gen/smooth
Biofilm MX R: gen light
Calculus: Sub Sub MX R: loc/sl/interprox #3,#4 Supra: none
Appointment 5 (11/5/15): RMH, no changes. Review ging charact/deposits MX and MD R. OHI review Bass method; nutritional counseling. Pre-rinse 30 sec CHX; Hand instrument/ultrasonic MX L
Gingival Characterictics MX MD R: gen/pink; gen/flat; MX R gen/knife-edge/mar/triangular pap MD R gen/rolled/mar; triangular/pap; gen/firm/loc/spongy #8,#9/FG:smooth,AG:stippled
Appointment 6 (11/12/15): RMH, no changes. OCE. Review ging characteristics/deposits MX/MD R; OHI review tufted brush for open contacts. Pre-rinse 30 sec CHX; Oraqix 2.5%/2.5% Lidocaine Prilocaine 1/2 carpule MD anteriors; no reaction. Hand instrument MD L; Dr. Chrusz exam pt; referral in folder, will give to pt at following appt. Local for pt MD L ant to complete. Have #19D rechecked for calc. Local- heavy sub calc; pt very sensitive to debride
Gingival Characteristics MD L he posterior region of her mandibular. Radiographs of the maxillary and mandibular molars were taken at CCCC clinic. Patient returned April 15, 2014 with copy of FMX she'd had in March of 2014 from an office outside CCCC clinic.
Appointment 6 (11/12/15):