Patient Case Presentation

Madison Phillips

Dental Hygiene Department, South College Nashville

September 5, 2023
Patient Case Presentation:

Patient:
● 51 year old male
● Father of two girls
● Married for 30 years
● Full-time factory employee
● Chief Complaint: “Here to be your patient so you pass”

Medical History:
● Surgery to reattach ligaments in hand due to trauma in 2019
● No allergies
● Hypertension-diagnosed in 2017
○ Medication: Metoprolol 50mg once a day at night
■ Oral considerations: Xerostomia, Bleeding Gums

**Periodontal disease is a risk factor for cardiovascular diseases. Since the patient already has
hypertension they are at a greater risk for more serious cardiovascular conditions.

Dental History:
● Wisdom teeth removed (age 25)
● The patient could not state dates for restorations. Stated “It had been a long time”

Vitals:
● Visit 1: ASA III
○ Blood Pressure: 132/84 mmHg Regular on the right arm @1:37pm (Stage 1
Hypertension)
○ Pulse: 72 bpm Strong
○ Temperature: 97.2 F
○ Respiratory Rate: 16 bpm Deep
○ Pulse Ox: 97%
● Visit 2: ASA II
○ Blood Pressure: 128/82 mmHg Regular on the right arm @8:36 (Elevated)
○ Pulse: 74 bpm Strong
○ Temperature: 97.6 F
○ Respiratory Rate: 14 bpm Deep
○ Pulse Ox: 99%
** Patients' ASA changed between appointments due to blood pressure. Discussed with the
patient to speak to their primary care provider about his hypertension medication.
Clinical Findings:
● Extraoral Exam:
○ Head and Neck: Generalized facial hair; 20mm long flesh-colored scar on the left
side of the forehead, Dark Brown regular Bordered nevus 2mmx2mm on the right
ear; Brown regular bordered nevus 2mmx2mm on the right side of the forehead;
Generalized ephelides across the face a head; Spider angiomas across the cheeks;
Flesh-colored birthmark on the back of the head 20mmx20mm
○ Lymph Nodes: Palpable submandibular node on the left
○ TMJ: No clicking or popping; Patient has a full range of motion
● Intraoral Exam:
○ Labial and Buccal Mucosa: Bilateral lina albea; Bilateral lip pits; Fordyce
granules on the buccal mucosa bilaterally; Brown petechiae near the right lip
commissure on the buccal mucosa
○ Palate: Pale pink; Red/white irregular bordered lesion on the lingual of #2 due to
food trama
○ Oropharynx: Bilateral tonsils are present
○ Tongue: Slightly fissured
○ Floor of the mouth: Sublingual caruncles are present on each side of the frenum
○ Salivary flow: Free-flowing
○ Frenum attachment: Sublingual and maxillary frenum present
○ Glands: Milkable
**STOP-BANG:4- Moderate risk
** Nicotine Dependence Assessment: N/A Patient does not smoke
Radiographs:

Findings:
● Radiographic calculus: #2, #31
● Restoration Overhang: #31 M
● Horizontal Bone Loss: <15%

Hard tissue assessment:

● Angles Classification: Molar R&L Class 1; Canine R&L Class 1
● Overbite: Severe (deep)
● Overjet: 4mm
● Midline: deviated to the right 1mm
● Alignment: #7-torsiverted, #10-labioverted, #11-torsiverted, #22-labioverted, #24&25-
labioverted, #27-torsiverted
● The patient presented with a prominent talons cusp on the lingual of #10
● Generalized occlusal Wear from bruxing

Dental chart:
**Caries Risk Assessment: High (CAMBRA)- Due to prolonged exposure to soft drinks
throughout the day
● Exiting restorations:
○ #2 occlusal composite
○ #3 occlusal/lingual amalgam
○ #4 occlusal composite
○ #12 mesial/occlusal composite
○ #14 occlusal/lingual composite
○ #15 occlusal composite
○ #18 mesial/occlusal amalgam
○ #19 porcelain fused to metal crown
○ #30 distal/occlusal amalgam
○ #31 mesial/occlusal amalgam
● Monitor:
○ #2 Lingual
○ #3, #4 around restoration margin
○ #30-Crown in the future
○ Erosion, Abfraction and Attrition on #12-15, #20,#24,#25,#30,#31
● Treat:
○ #31 with a crown

Periodontal Assessment at Initial Appointment:

 ● BOP 17%
● Generalize 4mm pockets
● Gingival recession 1-2 mm (#2,3,12,14,15,18,30,31)
● 5mm pocket depth on the mesial and distal of #14
● 6mm pocket on the mesial of #15

Gingival Assessment:
● Color: Coral pink
● Size: Fits snugly around the tooth
● Margin Position: Near the CEJ
● Margin Shape: Meets the tooth with a rounded edge
● Papilla Shape: Fills the embrasure space
● Texture: Stippled
● Consistency: Resilient with compressed air
● Localized findings: #22 erythematous rolled margin, #23-24 presents with bulbous
papilla, #23-27 has rolled margins, Margin is apical to the CEJ 1-2mm on
#2,#3,#12,#14,#15,#18,#22,#27,#30,#31

Dental Hygiene Diagnosis:

● The patient presents with localized periodontal disease
○ Stage: II
 ■ Due to Bone loss and Pocket depths
○ Grade: B
■ Due to % bone loss/age=0.29
○ Calculus Skill: II
○ Periodontal Skill: IV

Treatment plan:
● Due to attachment loss(pocket depths) and bleeding NSPT 1-3 Teeth (UL), with LA was
the recommended treatment
● Due to the 6mm pocket, Arestin was planned to be placed on the mesial of #15
● 4-6 week Re-eval

Goals of treatment:
● Remove calculus deposits
● Educate patient on the systemic connections of periodontal disease
● Educate patient on proper home care
● Decrease Pocket depth
● Decrease bleeding
● Decrease bacteria in the oral cavity
● Maintain the remaining periodontium/ Stop the disease process

Plaque control record: Mainly in the interproximal spaces and linguals of all mandibular teeth
● Visit 1: 56%
● Visit 2: 52%
● Visit 3: 34%
● Visit 4: 35%

Oral Hygiene Instruction:

● Modified stillman toothbrushing method for two minutes, two times a day
● Recommended electric toothbrush
● Recommended Floss picks and a water flosser due to the patient's limited mobility in his
right hand due to trauma; also recommended leaving floss picks in his car for his one-
hour long drive to work.
● The toothpaste recommended was parodontax to help reduce bleeding
● Due to the patients Cambra score rinsing with water after sipping on soft drinks was
recommended
● Plaque score goal of 25% for the next visit
● The patient was able to demonstrate all recommended techniques

Implementation of treatment:
 ● Visit 1: Assessments( Health history review, Questionnaires, EO/IO, Dental Chart,
Periodontal chart, Calculus detection, Comp exam, Treatment plan proposal)
● Visit 2: OHI, Plaque score, NSPT UL (with LA), Arestin (Mesial of #5)
○ LA: PSA injection on the left side, Articaine 1:100,000 epi and Benzocaine 20%
Pina colada topical was used
○ Arestin: post-op instruction and take-home literature was provided
● Visit 3(Re-eval): Assessments ( Health history review, Questionnaires, EO/IO, Dental
Chart, Periodontal chart, Calculus detection)
● Visit 4 (Re-eval): OHI, Plaque score, debridement of all 4 quads using hand instruments
and ultrasonic instruments, Rubber cup polish with fine grit prophy paste, Fluoride
varnish

** Due to the patient's blood pressure we delivered the cardiac dose of epinephrine.
**Patient tolerated the procedure well.

Re-Evaluation Appointment: Two appointments needed

Vitals:
● Visit 3 (Re-eval)
○ Blood Pressure: 126/78 mmHg Regular on the right arm @8:38 pm (Elevated)
○ Pulse: 58 bpm Strong
○ Temperature: 98.2 F
○ Respiratory Rate: 14 bpm Deep
○ Pulse Ox: 98%
● Visit 4: (Re-eval)
○ Blood Pressure: 124/78 mmHg Regular on the right arm @8:30pm (Elevated)
○ Pulse: 62 bpm Strong
○ Temperature: 97.2 F
○ Respiratory Rate: 16 bpm Deep
○ Pulse Ox: 98%

Periodontal exam:
Dental Hygiene Diagnosis:
● Localized Gingivitis
○ Stage: N/A
○ Grade: N/A
■ Due to no longer having active periodontal disease
○ Periodontal Skill: II
○ Calculus Skill: II
Results:
● Patient responded to the treatment well.
● BOP decreased by 6%
● Pocket depths decreased (from Generalized 5,6mm to 4,3mm)
○ Pocket that was treated with arrestin went from 6mm to 4mm pocket

Recare plan:
● After the completion of the patient's re-evaluation appointment, the patient was put on a
3-month periodontal maintenance re-care schedule.