The patient was seen for an extraoral and intraoral exam on April 18. The patient’s general appearance, facial symmetry, lymph nodes, and glands were within normal limits. The skin was as follows: generalized 1x1mm to 5x4mm regular and irregular melanotic macules on the facial and neck regions, a 2x2mm erythemic macule superior to the left labial commissure and inferior and lateral to the left ala. There was a 3x1mm erythemic linear ulcer superior to the left angle of the mandible and lateral to the left labial commissure. The eyes presented with bilateral erythemic sclera. The TMJ deviates to the left upon closing.
The patient’s breath odor, alveolar ridge, hard palate, and salivary ducts were within normal limits. The lips presented with fordyce spots on the upper lip and commissures of the lower lip. A linear erythemic ulcer was found on the labial mucosa adjacent to teeth #4 through...
... middle of paper ...
...• Presented treatment plan
• Gracey formative
• Began manual scaling URQ
• PHP score – 2.3, which is fair
• OHE: Biofilm theory was discussed and the Stillman brush method was taught due to recession.
Appointment 3 (April 26, 2016)
• HH assessment
• Prerinsed with Listerine
• Completed manual scale of UR
• OHE: Due to short appointment, briefly discussed Stillman method.
Appointment 4 (May 2, 2016)
• HH assessment
• Prerinsed with Listerine
• Manual scaled and checked in UR, LR, LL, and UL
• Completed nutrition formative
• PH: 7
• PHP: 2, which is fair
• OHE: Discussed Perio theory due to patient’s current periodontal disease, probe readings and bone loss. Taught C-shape flossing and recommended Superfloss
Appointment 5 (May 3, 2016)
• HH assessment
• Prerinsed with Listerine
• Polished and fluoride
• Instructor manual scaled tooth # 18
• Took PA of tooth #18
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