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Case Report

Sean Alexander, a 46-year-old male clerk, presented with swollen, bad-looking gums that he thought put people off. He had a history of epilepsy treated with phenytoin for 15 years and had not visited the dentist in 8 years. Clinical examination found significant gingival overgrowth worse in the front teeth and bleeding on probing, with pocketing from 5-9 mm. Radiographs showed normal alveolar bone levels. He was diagnosed with gingival hyperplasia from phenytoin therapy with marginal gingivitis and given a treatment plan of oral hygiene instructions, scaling, gingivectomy, and supportive periodontal therapy. The overall prognosis for his teeth

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28 views1 page

Case Report

Sean Alexander, a 46-year-old male clerk, presented with swollen, bad-looking gums that he thought put people off. He had a history of epilepsy treated with phenytoin for 15 years and had not visited the dentist in 8 years. Clinical examination found significant gingival overgrowth worse in the front teeth and bleeding on probing, with pocketing from 5-9 mm. Radiographs showed normal alveolar bone levels. He was diagnosed with gingival hyperplasia from phenytoin therapy with marginal gingivitis and given a treatment plan of oral hygiene instructions, scaling, gingivectomy, and supportive periodontal therapy. The overall prognosis for his teeth

Uploaded by

liudifair
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Case Presentation-An Example For Periodontal Patient

Patient Information

By Jun 2009/3/21

Brief Introduction Chief Complaint History Taking

Clinical Examination

Name Sean Alexander Age 46 Gender Male Occupation Clerk Contact 021-44444444 A 39-year-old white male with hypertension, chronic obstructive pulmonary disease (COPD), and a history of multiple back and neck injuries was brought to the hospital by family members because of low urinary output during the previous 12 hours. My gums are swollen and look bad Social history Does not smoke or drink Thinks that the appearance of his gums puts people off Family history No relevant family history Medical history Developed grand mal epilepsy when he was three years old and has taken phenytoin for 15 years Dental history Has not visited the dentist for 8 years Periodontal Significant gingival overgrowth Worse in maxillary and mandibular anterior sextants and on buccal surfaces compared with lingual surfaces Gingival generally firm Pocketing 5-9 mms Bleeding on probing not generalized Oral Hygiene The patient does not use a toothbrush or dental floss Radiographic Radiographs show that the alveolar bone was at nearly normal levels relative to the CEJs Present Pic. & Probing Depths

Diagnosis Treatment plan

Gingival hyperplasia as a result of dilantin therapy superimposed marginal gingivitis ADA case type 1 Instructions in oral hygiene Scaling Gingivectomy Supportive periodontal therapy

Referral
Treatment Pic.

Prognosis

Overall prognosis for the teeth is good Chance of recurrence of gingival overgrowth is high After-treatment Pic.

Conclusion References

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