Case study #1 New Patient

PATIENT INFORMATION 

Age: 63 years old female Ethnicity: Hispanic  ASA III

Blood pressure: 133/77 Pulse: 71 Corresponding to Hypertension stage 1

CHIEF COMPLAINT 

” I want to get a dental cleaning”

HEALTH HISTORY  INFORMATION

The patient presented with a history of hypertension,  currently managed with:

Losartan 50mg (1/day)

Aspirin 81mg (1/day)

She reports a surgical history of occipital fatty lymphoma removal (May 2025). The patient also reports urinary incontinence, requiring bathroom as needed.

No known allergies and denies smoking and alcohol use

DENTAL HISTORY

Last dental visit and radiograph: May 2019. The patient reported wearing a dental partial denture.

Patient reported” bleeding during brushing, dry mouth, sensitivity to cold, dental anxiety due to previous cleaning experience. OH- Brushes 2x/day ( hard manual toothbrush, Colgate), occasional mouth rinse use. Does not floss regularly or use a tongue scraper.

EXTRAORAL AND INTRAORAL EXAM (CANCER SCREENING) 

Unilateral submandibular lymph node enlargement ( right side) fixed, non-tender, TMJ crepitation, well-demarcated keratinized lesion on the nose.

Scalloped and coated tongue, enlarged tonsils, Trauma lesion on gingiva margin on lingual aspect  of # 7- signs due to denture ( denture stomatitis)

DENTAL CHARTING 

Class of the Occlusion 1 ( right ), Class 2 (left), Overjet 1mm, overbite 5%.  Open margin crow # 3 with suspicious lesion

GINGIVAL DESCRIPTION AND PERIODONTAL STATUS 

Generalized pink-pale gingiva with moderate-severe inflammation. Margin > 2mm apica to CEJ (recession). Irregular margins, blunted papilla with smooth, shiny, non-resilient tissue.

PERIODONTAL CHARTING 

Generalized probing depths: 4-5mm with localized posterior pockets: 6-8mm. Moderate- severe bleeding on probing.

 RADIOGRAPHIC FINDINGS (FMS)

General subgival calculus, suspicious lesion #3 distal root, horizontal bone loss 15% . Periapical pathology not present

DENTAL HYGIENE DIAGNOSIS

Based on all findngs the patient had a periodontal disease stage I, grade B

IMPLEMENTATION  AND PATIENT ORAL HYGIENE EDUCATION

During the appointment, I monitored and documented the patient’s blood pressure at the beginning of each visit due to her history of hypertension. I explained to the patient that this is a standard and important procedure in dental hygiene care because blood pressure can affect treatment decisions, bleeding risk, and overall patient safety. I informed her that consistent monitoring helps us identify any medical risks before proceeding with treatment.

I also educated the patient on the biological relationship between periodontal disease and hypertension. I explained that periodontal inflammation can contribute to a systemic inflammatory response, which may negatively impact cardiovascular health and blood pressure control. In addition, I discussed how hypertension and its medications may affect gingival health by affecting blood flow and increasing bleeding tendencies during periodontal therapy. The patient demonstrated understanding of the connection between oral health and systemic health.

Throughout the visit, I reduced the patient’s dental anxiety. I used a calm and supportive approach, explaining each step of the procedure before performing it to increase her comfort and cooperation.

I used plaque disclosure for visual demonstrate biofilm accumulation, and I reviewed her Plaque Index results with her to track progress. I demonstrated proper flossing technique, emphasizing the “C-shape” method, and had the patient return to demonstrate and to ensure correct performance. I also reinforced the Modified Bass brushing technique, with special attention to lingual surfaces that were previously being missed.

Because of her periodontal probing depths exceeding 4 mm in multiple areas, I recommended the use of a Waterpik for subgingival cleaning, while emphasizing that it should not replace mechanical flossing.

Overall, the patient responded well to instruction and showed improved understanding of the relationship between her oral and systemic health conditions, as well as improved oral hygiene compliance during the visit.