Luis Moreno & Gita Ansari

 Patient’s name: Grover Holland  Sex: Male  Age: 36  Ethnicity: Caucasian  Profession: Registered Nurse  Marital status: Partnered

 HIV positive since  Suffers from depression  Severe dental phobia  Allergic to sulfa drugs

 All childhood immunizations  High fever as a child  Recurrent headaches  Recurrent backaches  Urinary infection  Other unspecified STDs.

 Atripla: antiretroviral drug for HIV infection  Pristiq Desvenlafaxin: NSRI drug for depression  Last medical exam: Jan/12/2010  CD4 count: 540  Viral load: undetectable

 4 quadrants of Root planings  Tooth #1 surgical extraction  Tooth #2 RCT, build up and PFM  Tooth #14 DO composite filling  Tooth #15 DO composite filling  Tooth # 19 B composite filling  Tooth # 30 MO composite filling  Perio consultation

 BP: 130/90  Pulse: 74  Respiration: 14  ASA: II  Alginate impressions  Intraoral photos  OHI

 Extraoral: WNL  Intraoral: WNL  Salivary flow: adequate  PI: 26%  MBI: 90%  Calculus: Meduim-heavy  Periodontal probings: generalized 2-4 and localized 5-7.  AAP: Generalized moderate chronic perio.

 Color: generalized coral attached gingiva. Apparent red free gingival margin due to LGE.  Contour: generalized soft, spongy, hemorrhagic and edematous  Consistency: generalized bulbous, swollen  Texture: generalized glossy, smooth and shiny  Alveolar mucosa: WNL  Tongue: WNL

 Mesognathic profile  End to end bite on right posterior teeth.  Edge to edge on anterior teeth.  Cross bite on tooth #10 and all left side posteriors.  No TMD present.  No deflexion or deviation.  No myalgia at the time of evaluation.

 Second appointment  BP: 124/78  P: 80  R: 14  Sc/Rp LLQ &ULQ with anesthesia.  Third appointment  BP: 128/82  P: 77  R: 16  Sc/Rp URQ &LRQ with anesthesia.

 Fourth appointment  BP: 124/80  P: 60  R: 14  MBI 48%  Plaque index 10%  Intraoral photographs  OHI  Nutritional counseling.  Research:  Highly active antiretroviral therapy.