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Case Study 51

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Patient History

Patient Profile: 

At the beginning of treatment the patient, a 5-year old Hispanic female, was 43” (108 cm) tall and weighed 40 lbs. (18 kg). She lives at home with both parents and two older siblings and will enter the 1st grade in two months.

Chief Complaint: 

Mother is worried about the “enamel chipping away from the teeth and their yellow color.”

Medical History: 

Last medical examination was at age 3 yrs. for a severe cough. Patient was seen in the emergency room of a local hospital and diagnosed with bilateral pneumonia. Patient was admitted to hospital respiratory therapy unit, given IV antibiotics (which antibiotic is not known) and released after three days. According to the mother there have been no other medical issues.

Dental History: 

Patient has never been to the dentist. Mother brushed teeth for the patient until about 6 months ago. Now the patient brushes her own teeth with a soft textured manual brush and “some type of toothpaste with fluoride in it.” Patient rinses only with water after brushing teeth; does not use floss or any type of interproximal cleaning aid; and only brushes 1-2 times a day for about 30 seconds each time.

Supplemental Information: 

Questions to the mother regarding dietary habits revealed a high carbohydrate diet with lots of pastries, corn meal and corn flour-based foods. Patient is allowed access to drink diet soft drinks and lots of orange juice.

Extraoral Examination: 

No palpable lymph nodes. No facial skin lesions. Frontal view of the face is bilaterally symmetrical. Eye movement is normal. Overall, head and neck examination was negative for any significant findings.

Intraoral Examination: 

Visual exam reveals multiple carious teeth. Teeth exhibit a chalky-white enamel and a strikingly yellow color of the exposed dentin. Interestingly, there is little plaque and only a mild gingivitis. A complete periodontal charting was not done.

Bleeding Index: 

Did not do periodontal charting

Plaque Score: 

15% (12/80 surfaces)

% Carious Surfaces: 

30% (24/80 surfaces)