This patient is a 37 year old Latino male. He arrived with a chief complaint of having not had a dental cleaning since he was in high school. A complete medical history was taken at the initial appointment. At the beginning of the appointment, he reported that he has major dental anxiety. His blood pressure was in the normal range at 108/70, pulse 73 bmp. His medications include Truvada, taken daily for 2 years, for HIV prevention. He smokes e-cigarettes daily and marijuana at nighttime. He reported that his gums bleed when he brushes. He reported a dental infection that he had two years prior that caused the left side of his face to swell, and he went to the hospital for treatment. His last dental exam, cleaning, radiographs, and one cavity filling were done in 2002. He did not follow up with any dental care or treatment after taking a course of amoxicillin. In the clinic, the patient did not show signs of facial swelling. He reported that his dental condition was poor due to previously struggling with depression which caused him to neglect his oral hygiene. His oral hygiene routine consists of brushing in a circular motion with a manual toothbrush 1-2 times per day, cleans tongue with toothbrush, and flosses occasionally when he feels food stuck in his teeth.
Clinical Findings
All assessments were completed and here are the significant findings. The patient reported tenderness upon intraoral palpation of the left buccal mucosa. Dental charting revealed 3 teeth with retained root tips with active caries, as well as two other teeth with caries. His gingiva was generalized dark pink and firm, localized red rolled margins on posterior buccal and mandibular linguals, and interdental papillae were generalized red. Perio charting revealed generalized 2-3 mm probing depths, localized 4 mm on posteriors, localized 1 mm of recession on #29 and #30 buccal aspects, and generalized light BOP. His plaque score was 1.5 with the biofilm found mainly along the gingival margin and on posterior buccal and lingual surfaces. He had generalized heavy subgingival and supragingival calculus. I exposed an FMS which revealed generalized 10% horizontal bone loss, localized calculus on the mandibular molars, caries on #5-distal, and retained root tips. A CAMBRA analysis revealed a past history of alcohol abuse, 3+ new caries, and no established dental home. His periodontal status was Stage 1 Grade B Periodontitis.
Treatment
For oral hygiene instruction, c-shaped flossing technique was taught at the first visit, and the Modified Bass toothbrushing method was taught at the second visit. The treatment plan consisted of 2 visits in total. At the first visit all assessments and a single quadrant were completed using hand scaling and ultrasonic. At the second visit, the remaining three quadrants were completed. Once scaling was completed, I engine polished and applied fluoride varnish. No topical or local anesthesia was needed while scaling as the patient was not in discomfort, although it was on the treatment plan to use as needed. A referral was given for a general dentist for caries and for an oral surgeon for the retained root tips
Anxiety
This patient was very anxious at his first visit and informed me of his extreme dental anxiety. He avoided going to the dentist for so long because of his fear. My main goal for his visits was to take my time and make him as relaxed and comfortable as possible. Before starting any assessments, I inquired more about why he is so fearful of going to the dentist office. He told me that he knew he had some broken and decayed teeth and that he was afraid of hearing bad news confirming his poor dental condition.
By taking the time to ask questions and understand his anxiety, I was then able to very delicately deliver the news of my assessment findings. Although I confirmed his fear of having decay and periodontal disease, he was more at ease throughout the appointment because I took the time to listen. Once his treat went was completed in the second appointment, he thanked me for making him feel so comfortable and supported. This is a moment I will never forget because he was one of my first patients who I made a big impact on and he had an impact on me too. Treating patients with anxiety has made me a better and more empathetic clinician.
