Case study # 2

CASE STUDY #2 SR. J

Patient information

A 62 years old Hispanic American male who presented for a recare appointment with the chief complaint, “I want a dental cleaning.” He is classified as ASA II due to dental anxiety but reports no medical conditions, medications, or allergies. He maintains a generally healthy lifestyle, denying the use of tobacco, alcohol, or drugs. His last dental visit was in November 2025, and he currently uses a manual toothbrush with Colgate toothpaste four times daily and mouthwash once a day. However, he does not routinely floss or use a tongue cleaner,

Extraoral and Intraoral Findings

Extraoral and intraoral examination revealed bilateral linea alba, a high-arched palate, a coated and scalloped tongue, and asymptomatic TMJ crepitus on the right side. Initial findings also showed moderately inflamed tonsils, which improved at the follow up visit.

Occlusion and Hard Tissue Findings

The patient presents with a Class III occlusion bilaterally, an overjet of 3 mm, and minimal overbite (edge-to-edge presentation). Severe generalized attrition is present, indicating long-term occlusal wear. These findings are significant in understanding the patient’s functional and restorative needs.

Periodontal Status

The patient demonstrates a heavy case value with a diagnosis consistent with Stage IV, Grade B periodontitis. Initial periodontal findings included generalized probing depths of 4 mm with localized posterior pockets measuring 6–8 mm. Moderate to severe bleeding on probing and generalized subgingival and supragingival calculus were noted. Gingival tissues appeared inflamed, spongy, and non-resilient with blunted papilla and apical migration of the gingival margins. At the follow up visit, inflammation and bleeding were significantly reduced, although localized disease remained present.

Plaque Control and Oral Hygiene Status

At the initial visit, the patient had a plaque index of 1.8, indicating fair plaque control. He reported brushing multiple times per day but admitted inconsistent flossing . At the follow up visit, plaque control improved, with a reduced plaque index of 1.33. However, residual plaque and calculus were still present, particularly in interproximal and lingual areas, reflecting continued difficulty with interdental cleaning.

Patient Education & Implementation

During the visit, oral hygiene instruction was reinforced based on the patient’s periodontal condition and observed plaque accumulation. I emphasized the importance of interdental cleaning since the patient reported inconsistent flossing. The use of string floss was reviewed again, and I demonstrated proper technique, encouraging the patient to “hug the tooth” and gently slide it down below the gingival margin. I also introduced interdental brushes and explained their benefit in accessing areas with 4–6 mm probing depths, especially in posterior regions where residual calculus was present.

The patient also reported that he had not visited a dental provider in almost 10 years prior to the first visit, which significantly contributed to the advanced periodontal condition observed. I explained how long-term absence of routine dental maintenance can lead to progressive attachment loss, increased calculus accumulation, and worsening periodontal disease severity. This helped the patient understand the importance of regular professional care in preventing further deterioration.

Because of his heavy case value and Stage IV periodontal diagnosis, I reinforced the importance of consistent home care in preventing further disease progression. I reviewed the Modified Bass brushing technique and corrected brushing angles to improve sulcular access and plaque removal effectiveness.

In addition, I addressed the patient’s dental anxiety and discussed the option of nitrous oxide (N₂O) for future visits to improve comfort and cooperation during periodontal maintenance. The importance of maintaining a 4-month recare interval was emphasized due to his high caries risk, advanced periodontal status, and extended period without dental care.

Overall, the patient demonstrated improved understanding of his oral health condition and the relationship between home care, lack of regular dental visits, periodontal disease progression, and long-term dental prognosis.

CASE STUDY #2 SR. J

Patient information

Extraoral and Intraoral Findings

Occlusion and Hard Tissue Findings

Periodontal Status

Plaque Control and Oral Hygiene Status

Patient Education & Implementation

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The OpenLab at City Tech:A place to learn, work, and share

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