PERIO PROJECTLuis Moreno

&Gita Ansari

General information

Patient’s name: Grover Holland Sex: Male Age: 36

Ethnicity: Caucasian

Profession: Registered Nurse

Marital status: Partnered

Medical History

HIV positive since 1990.

Suffers from depression

Severe dental phobia

Allergic to sulfa drugs

Past history

All childhood immunizations High fever as a child Recurrent headaches Recurrent backaches Urinary infection Other unspecified STDs.

Medications and health status

Atripla: antiretroviral drug for HIV infection

Pristiq Desvenlafaxin: NSRI drug for depression

Last medical exam: Jan/12/2010 CD4 count: 540 Viral load: undetectable

Treatment plan

4 quadrants of Root planings Tooth #1 surgical extraction Tooth #2 RCT, build up and PFM Tooth #14 DO composite filling Tooth #15 DO composite filling Tooth # 19 B composite filling Tooth # 30 MO composite filling Perio consultation

First appointmentAssessment only

BP: 130/90 Pulse: 74 Respiration: 14 ASA: II Alginate impressions Intraoral photos OHI

Oral assessment

Extraoral: WNL Intraoral: WNL Salivary flow: adequate PI: 26% MBI: 90% Calculus: Meduim-heavy Periodontal probings: generalized 2-4 and

localized 5-7. AAP: Generalized moderate chronic perio.

Gingival description

Color: generalized coral attached gingiva. Apparent red free gingival margin due to LGE.

Contour: generalized soft, spongy, hemorrhagic and edematous

Consistency: generalized bulbous, swollen

Texture: generalized glossy, smooth and shiny

Alveolar mucosa: WNL Tongue: WNL

Occlusal clasification

Mesognathic profile End to end bite on right posterior teeth. Edge to edge on anterior teeth. Cross bite on tooth #10 and all left side

posteriors. No TMD present . No deflexion or deviation. No myalgia at the time of evaluation.

Radiographs

Study models

Study models

Treatment

Second appointment

BP: 124/78 P: 80 R: 14 Sc/Rp LLQ &ULQ

with anesthesia.

Third appointment BP: 128/82 P: 77 R: 16 Sc/Rp URQ &LRQ

with anesthesia.

Treatment

Fourth appointment BP: 124/80 P: 60 R: 14 MBI 48% Plaque index 10% Intraoral

photographs OHI Nutritional

counseling.

Research: Highly active

antiretroviral therapy.