Periodontal+Case++3+HIV

= Periodontal Case #3 - HIV  =




 * Patient Profile**: Patient is a 35 year old, single, Caucasian male, truck driver.




 * Chief Complaint**: Patient is concerned with the appearance of his mouth.


 * Dental History**: Patient bleeds when brushing his teeth and has recurrent sores in his mouth that he states are painful. He recieves regular teeth cleanings one time a year. Last DDS Exam was on October 20, 2009. Last radiographs were bitewings also on October 20, 2009.


 * Medical History**: Patient had Pneumonia two months ago and it was treated with antibiotics. He has a visual impairment that is corrected with glasses. Patient is HIV positive and indicates that his CD4 count is 350 cells/mm3 and his platelet count is 40,000 per microliter. Patient vitals are within normal limits.


 * Patient Medication**: Lamivudine, Abacavir, Zidovudine, and a multivitamin.


 * Medication: Abacavir**
 * Last Time Taken:** 8:00am This Morning **Period of Time Taken:** Since 2002
 * Dosage:** 300 mg Twice a Day **Taken For:** Treatment of HIV infection
 * Dental Implications:** N/A
 * Dental Contraindications:** N/A


 * Medication: LamiVUDine**
 * Last Time Taken:** 8:00am This Morning **Period of Time Taken:** Since 2002
 * Dosage:** 150 mg Twice a Day **Taken For:** Treatment of HIV infection
 * Dental Implications:** N/A
 * Dental Contraindications:** N/A


 * Medication: Zidovudine**
 * Last Time Taken**: 8:00am This Morning **Period of Time Taken:** Since 2002
 * Dosage:** 300 mg Twice a Day **Taken For:** Treatment of HIV infection
 * Dental Implications:** taste perversion, oral mucosa pigmentation, dysphagia, and mouth ulcer.
 * Dental Contraindications:** N/A


 * Medication: Centrum**
 * Last Time Taken:** 8:00am This Morning **Period of Time Taken:** Since 2000
 * Dosage:** 1 Tablet **Taken For:** Multivitamin
 * Dental Implications:** N/A
 * Dental Contraindications:** N/A

The patient was sent to his physician to verify that he can be safely treated for a cleaning
 * Medical consult:**



The following assessments were gathered at his first appointment
 * Clinical Findings:**
 * Extra oral:** within normal limits.
 * Intra oral:** patient has a 3mm by 3mm aphthous ulcer on his left buccal mucosa opposite of tooth # 14.
 * Gingival description:** The free gingiva is generalized erythmatous, spongy, scalloped, and shinny, with localized hemorrhagic, flaccid, purulent, and cratering, and sloughing in the LRQ. The attached gingiva is generalized erythmatous, fibrotic, and hyperkeratosis.
 * MBI:** 15%
 * Probing depths:** generalized 3-5mm
 * BOP:** 34%
 * Recession:** 2mm on buccal of #27-28, 30 & 32, 3mm on buccal of #29 & 31.
 * Muccogingival defects:** none
 * Mobility:** + 23-26, Class II on #30
 * Fremitits:** + 7-10
 * Furcations:** Class III on the buccal of #30.
 * Angles class:** Class I bilaterally
 * Facial profile:** Mesognathic
 * Salivary flow:** adequate
 * ASA:** Class III
 * ADA:** Generalized III
 * AAP:** Generalized moderate with localized severe chronic periodontitis due to plaque and calculus and modified by HIV.
 * Calculus code:** Full mouth Medium

The following was noted during the DDS Exam and explained to the patient:
 * Referral form**

Do to the assessments that were collected the patient needs the following treatment.
 * Critical Thinking Form**

The following is the treatment plan for Mr. Case #3, assuming he brought in an FMX. Chlorehexidine will be administered to all pocket depths 5mm and over. For comfort of the patient and operator, anesthesia will be used (2% Lidocaine with epinephrine 1:100,000).
 * Treatment Plan**

Based off the assessments gathered, with adherence to oral hygiene instruction and maintaining recare appointments Mr. Case #3 will see slight improvements in his oral appearance. His generalized prognosis is fair and localized poor prognosis for #30 due to the class III furcation.
 * Prognosis**