2. Patient: Rivka Levy
Age: 78
Gender: Female
Height: 4’11”
Weight: 115 lbs
Vital
Signs:
HR: 66
Respiratory rate: 22
Blood Pressure: 121/78
Temperature: 98.8
Chief
complaint
Dental Cleaning
Medical
Alert
Prehypertension
COPD
Emphysema
Asthma
Hypothyroidism
Sulfa drug/codeine allergy
Current Medications:
Oxybutynin (overactive bladder)
Levothyroxine (hypothyroidism)
Spiriva (inhaler)
Symbicort (inhaler)
Summary of Medical History
Patient is currently under the care of a
physician for multiple systemic problems
including prehypertension, COPD,
emphysema, asthma, and hypothyroidism.
Patient smokes 1 pack of cigarettes daily
and has attempted to quit but has not been
successful. Patient also suffers from celiac
disease, osteoporosis and has sulfa drug
and codeine allergies which she says make
it difficult for her to manage pain,
especially those caused by dental
procedures.
3. Dental History
Patient recently had tooth #31 extracted
and then was complaining of pain because
she thought tooth was still impacted but
there is nothing there. Dentist also
smoothed down #8 because it was chipped
and recommended a crown but patient
doesn’t want it due to cost.
Social History and Story:
Rivka is an energetic 78 year old woman
who lives in Salt Lake City with her
boyfriend, Stan. They enjoy reading,
traveling, and spending time together.
This summer they visited Wyoming.
Stan has encouraged her to quit smoking
but Rivka cannot stop her bad habits.
She has been coming to UCDH since 2008
and enjoys interacting with the students
here. A few years back, she was once
involved in a serious automobile accident
on her way to an appointment. Besides
that, she has never missed a cleaning.
Additional Notes
Rivka has difficulty walking from the
waiting room to the dental chair and must
take frequent bathroom breaks during
appointments. She prefers to remain
upright in the chair and has quite a few
coughing attacks during treatment. Be sure
patient has her inhaler with her at all
times and have a cup of water on the tray.
10. Summary of Periodontal Status
Patient presents with a dental hygiene diagnosis of generalized severe periodontitis
evidenced radiographically by generalized moderate bone loss. Her current status is
likely due to poor oral hygiene, smoking, and other systemic health related problems.
Furcation involvement is evident on numbers 3, 14, 19, and 30. Class II mobility is
evident clinically on numbers 7, 8, 9, and 10 with class III mobility on numbers 23 and
24. There is generalized recession of 1-6 mm. Probe depths are within normal limits
with localized 4 mm pockets in the posterior region and light BOP. There is < 1 mm of
attached gingiva on numbers 21-27.
All teeth present with generalized erosion and there is attrition on maxillary and
mandibular anterior teeth. There is generalized brown stain due to smoking and
abfractions on #2 and #25.
Gingival specifics are generalized erythematous tissue, slightly enlarged, blunted,
fibrotic, loss of stippling and cratering. In quad 4 there is localized blue marginal
gingiva.
Patient has hairy tongue and mandibular tori.
11. Treatment Plan
Individual Oral Hygiene Education Instruction: Patient currently brushes 5-7 times a day
rigorously which is causing recession so I recommend a soft brush using the modified
bass technique for 2 minutes twice a day, floss, and a tongue scraper
Tobacco Cessation Counseling: I explained the harmful effects smoking has orally and
systemically but patient is uninterested in quitting
Radiographs: FMX with bitewings to assess for caries and bone loss
Periodontal Maintenance: Hand-scale all four quadrants, floss
Fluoride Professional Topical Application: 5% “enamelast” fluoride varnish
Comprehensive dental exam
3 Month Recall Appointment
12. Date Treatment Record
05/09/13 TX: PM quads 1-4, no LA needed, CHX prn, polished crowns of teeth only with medium paste, flossed, sent pt home
with fluoride varnish to use tomorrow night.
05/29/14 TX: PM quads 1-4, OHE, floss, CHX prn, refer to half price dental.
10/29/15 TX: 4 BWX, 2 PAs, 1 retake, PD quads 1-4 , OHE, rc polish with fine paste, floss, CHX rx, rook fluoride varnish home to
apply tonight.
07/26/16 CC: Cleaning
HH: WNL, no changes
EO: WNL
IO: Hairy tongue and mandibular tori
Calculus: Gen mod grainy with loc spicules
TX: PM quads 1-4 HS only sensodyne paste, floss, fluoride varnish
10/05/16 CC: Cleaning, 3 mo recall
HH: WNL, no changes
REF: Half price dental for comp exam, #8 chipped tooth, possible retained root on #31, check 2x2 vascularized lesion
on floor of the mouth under tongue
TX: PM quads 1-4 HS, light polish, floss, OHE, varnish
