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Info on pt: The pt I have chosen is a 20 year old male. He is a tobacco user and

April 8, 2024

Info on pt:
The pt I have chosen is a 20 year old male. He is a tobacco user and although he has recently slowed down, he still does it quite a bit. He visits the dentist every 6 months, although he does not have adequate home care. NKDA and does not take any medications. No surgeries or previous medical conditons. Brushes 1x daily and flosses seldom. Has recession on all canines and it is prominent. 
Vitals at the last visit were
BP 127/81
Pulse 98
Resp 18
Pt is 5’6 and weighs 250 pounds. Sedentary lifestyle. 
Pt had well water in his home until he was 5 years old. He has always had caries and “bleeding gums”. Pt holds smokeless tobacco in right vestibule but moves it around. Been chewing since he was 10 years old and has very frequently since then. Pt loves soda, very rarely drinks water. IO/EO findings were normal besides the corrugated tobacco spot in right vestibule. Heavy supra and sub calculus. Heavy plaque buildup throughout entire dentition. Recurrent caries. porcelain  Crown on #4. 
Pt has composite restorations throughout entire dentition besides 8 teeth on mandibular area (please include specific teeth # as I am in a hurry: as seen on chart in google doc) Missing wisdom teeth only. Some marginal overhangs. 
Probing depths varied from a couple 1-3 mm depths to some 5’s. No furcations detected, several recessions (make recession mm and what teeth that and probing depths were on up). No mobility. Heavy bleeding throughout while probing. Pt had pain. 
Pt had a full mouth series x rays taken October 2023. Heavy staining (due to tobacco)
Instructions from teacher:
Please find attached an example of a previous students Dietary Analysis. It is not perfect and I do not want you to follow their outline verbatim. But it is simply an example, since some students like to see examples. And then there is one from the ancillaries with the textbook.  (Attached in the files)
In addition, remember when writing “scientifically do not use first, second, or third person. There may be some of this used in the example, just limit as much as possible. There will be point deductions! For example “I recommended to the patient” would not be the correct way, instead “it was recommended to the patient ….”  No I, me, she, he, his, hers, etc. 
And remember I said chapter 21 in your Nutrition text would be a good reference/resource for your use, as well as there is a chapter in your Wilkins DH textbook on dietary analysis. I have attached a food diary sheet as well. See that is only a 24 hour diary that is needed, no more.  *Book is Stegeman:The Dental Hygienists Guide to Nutritional Care 5th ED*
*I have attached the food diary in the files; i filled it out myself over my patient and if you have any questions please send me a message; if need be, just fill in the blanks with certain foods, amounts, etc*
The paper does not have specifications on how many pages, words, sources, etc. Please try to be realistic and go off of the information included in the examples. *DENTAL TERMS MUST BE CORRECTLY AND CONSISTENTLY USED THROUGHOUT*
I have also attached the rubric. This paper is for my final in a very important class, so please follow the rubric very closely. 
**Teacher has also included that it may be good to share patient x rays and charts in the essay. I have included a google doc that shows all carious lesions and their composite/decay chart as of January 25, 2024.** If you have any questions, once again please feel free to reach out. I only chose xrays that include the caries, if i need to include other x rays let me know and I will get them sent in. Also periodontal chart, if you want to include that I can also attach that file. 
Please do not follow the examples exactly how they are, she has stressed this to us. If I can help with anything at all please let me know. 

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