Patient A:
Assessment/Diagnosis:
54 year old hispanic male came in February 2025 for a cleaning. Pt. has hypertension and is pre diabetic. He takes Hydrchlorothiazide 25mg, Telmisartan80 mg and Amlodipine 10mg for hypertension. Pt. also takes Glimepiride 1mg and Xigduo 1 tab a day for pre diabetes. Last physical was February 2025. Previously pt. had presented with hypertensive crisis and was dismissed and a medical clearance from his doctor was requested, which he brought in this visit. His BP on this visit was 142/78 corresponding to hypertension stage 2. Pt. is a non drinker, non smoker. He brushes twice a day with a manual toothbrush and uses Sensodyne toothpaste. Doesn’t floss and uses LIsterine gold.
Upon oral cancer screening slight bilateral crepitus was noted, no discomfort. Pt. had mandibular tori and palatal torus. Bilateral redness of the tonsils was present and a 1x1mm fistula on the muccogingiva of tooth #9. He had bilateral class I occlusion, overbite 10% and overjet 3mm on the right side and 4mm on the left side. Gingiva was moderately pale and enlarged generalized, margins were apical to CEJ generalized, and papillae were mildly bulbous generalized. Texture was shiny and consistency flaccid. Generalized moderate BOP. PDs were generalized 3-6mm with sporadic areas of 8-11mms. Generalized heavy sub gingival and supra gingival calculus. PI was 1 along the gingival margins and moderate stain along the gingival margins. Moderate generalized attrition was noted and abfraction of teeth #s 4,5,12 and 13.
Planning:
It was determined that an FMS was needed for the pt. due to not having visited a dentist in a while, clinically presented with a fistula and had mobility class II on teeth #9,30 and 31. His case value was determined to be heavy, due to the sub gingival and supra gingival calculus present. His cleaning was split into 3 separate visits in order to give his gums apt healing time due to his pre diabetic status. Flouride varnish was recommended to prevent caries and relieve sensitivity in areas of recession. A referral was given for periodontal evaluation, due to probing depths and mobility in multiple areas. He was given a 3 month recare interval in order to prevent the fast progression of periodontal disease.
Implementation:
During the initial visit teeth #s 27-22 were scaled to completion. No other areas were touched until we had radiographs to determine if we could continue treatment. Pt. was taught modified Stillman brushing method to prevent further recession and abfraction. During his second visit BP was 142/86, he mentioned incorporating the modified Stillman brushing technique in his daily routine. An FMS was exposed and his periodontal status was classified as stage 3 grade C. He was classified as a stage 3 due to bone loss, PD, recession, and mobility. He was graded as C due to being a pre diabetic. Radiographs showed 80% localized horizontal bone loss in the areas of #9 and #31. Generalized 40% horizontal bone loss. No carious lesions and a periapical radiolucency on tooth #31. And localized light calculus deposits in the mandibular anterior teeth. During this visit #27-22 were rescaled and QDs 2 and 3 were scaled to completion avoiding tooth #9. Pt. was taught how to use C shape flossing due to not having an interdental aid habit in his daily routine. During his third visit BP was 141/83, he mentioned he didn’t incorporate C shape flossing into his routine as he doesn’t like the string floss. QDs 1 and 4 were scaled to completion avoiding the area of #30-32. Pt. was taught to use floss picks as he mentioned preferring them over string floss. Pts. teeth were polished and flouride was applied.
Evaluation:
Both times the pt. came back second and third visit he mentioned noticing the difference in his teeth and expressed how happy he was to finally have a teeth cleaning. He mentioned his wife was making him an appointment to have a full periodontal evaluation especially to look at teeth #s 9 and 31. He also mentioned he was trying to incorporate all the OHI given to him, so he wouldn’t let so much plaque build up. He mentioned having had a good experience and wanting to return in 3 months to keep up with his oral health.
