Case Study #1: Mr. A – Recent Car Accident (Two Visits)
Patient Overview
- Age: 38, Ethnicity: African American, ASA II
- Substance Use: 2–3 beers on weekends, several blunts of marijuana weekly for the past 20 years
- Blood Pressure: 125/84 mmHg, Pulse: 68 bpm (per City Tech clinic’s guideline–hypertension I)
Medical History
During the medical history review, Mr. A reported involvement in a car accident in March 2025. He received a medical evaluation, including a CT scan, at NYC Health + Hospitals (212-562-5555), with all results reported as normal.
Current medications:
- Meloxicam 15 mg – 1 pill/week (muscle relaxant; dental side effect: gingival bleeding)
- Motrin 500 mg PRN – pain management (not currently taken)
- Tylenol PRN – pain management (not currently taken)
The patient only takes Meloxicam occasionally and reports no current pain or discomfort at either visit.
Dental History & Oral Hygiene Habits
- Had orthodontic treatment (braces) from ages 12–14; no current retainer use
- Last dental extraction: 2022 (two upper left molars)
- Could not recall last dental cleaning or radiographs
Oral hygiene routine:
- Brushes 1–2x/day with a medium manual toothbrush and Colgate anticavity toothpaste
- No flossing, and uses Listerine antiseptic mouthwash.
Dental Findings:
- Case Value: Heavy
- Perio status: Perio Stage III Grade C
- Caries risk: High
- Other Dx findings: attrition on anterior teeth, multiples retained roots tips
Visit 1 Summary:
During the first visit, I completed a full health history review and obtained informed consent from the patient. An extraoral and intraoral examination (EO/IO) revealed a leukoplakia-like lesion on the lateral border of the tongue that did not wipe off with gauze. Faculty assessed the lesion and suggested it may be due to inadequate tongue cleaning. An intraoral photo was taken for documentation and future monitoring. A full mouth series (FMS) of radiographs was exposed due to multiple retained root tips and missing teeth, and the patient’s dental charting was updated. I discussed all findings with the patient and supervising faculty, and referrals were provided for a comprehensive periodontal evaluation, caries risk assessment, hypertension monitoring, and public health dental clinics.
Based on clinical consultation, hygiene treatment and periodontal charting were limited to the maxillary canines to canines (#6–11) and mandibular first premolars (#21–28), and a treatment note was documented to guide the next visit.
Full Mouth Series radiograph:
Findings are: multiple suspicious caries presents on proximal surfaces of posterior teeth, generalized heavy subgingival calculus presents, generalized 30-40% horizontal bone loss, furcation involvement #31 and #19. Patient informed of findings.
Dental charting:
Perio charting:
Based on clinical consultation, hygiene treatment and periodontal charting were limited to the maxillary canines to canines (#6–11) and mandibular first premolars (#21–28), and a treatment note was documented to guide the next visit.
Visit 2 summary:
At the second visit, I completed the remaining assessments, including periodontal charting, calculus detection, and formulation of a treatment plan in alignment with the treatment limitations previously discussed. During this visit, I utilized an intraoral camera to capture before-and-after images of the treated areas. I reviewed these images with the patient to visually demonstrate the effectiveness of the dental cleaning and to enhance his awareness of his current oral health condition.
I disclosed the patient’s teeth using plaque index gel, which revealed a Plaque Index (PI) score of 1.2, considered Fair. I explained that this score reflects moderate plaque accumulation, especially along the gumline and interproximal surfaces. I used this opportunity to educate the patient on the connection between plaque buildup and oral health issues, emphasizing the importance of improving his daily hygiene routine.
To support this, I introduced the Modified Bass brushing technique for more effective plaque removal at the gumline and recommended the use of a floss holder to make daily interdental cleaning more manageable. I provided personalized oral hygiene instruction, emphasized the importance of brushing twice daily, and demonstrated proper flossing technique. I then asked the patient to perform a “teach-back” to confirm his understanding and encourage proper daily use. When he expressed concern about gum bleeding during flossing, I reassured him with a relatable analogy—comparing it to muscle soreness when starting a new workout (an analogy I learned from my classmate, Jissel). I explained that consistent, proper flossing would lead to healthier gums and less bleeding over time.
Due to the presence of heavy plaque and generalized brown staining, I completed thorough debridement using both the ultrasonic Cavitron and hand scaling, utilizing two inserts during the procedure. Although topical anesthesia was initially planned, the patient opted to proceed without it and tolerated the treatment well. I then performed engine polishing to remove extrinsic stains and smooth the tooth surfaces. To conclude the treatment, I applied 5% sodium fluoride varnish (NaF) to help protect the teeth against caries.
Throughout the visit, I observed that the patient appeared more comfortable and receptive to care. I concluded the appointment by encouraging him to follow up with the recommended referrals for treatment of retained root tips, active carious lesions, and hypertension I.
Before and after hygiene treatment images:
Supporting the Patient’s Journey to Better Oral Health:
Before beginning treatment, the patient expressed concern about the condition of his teeth and shared that he felt insecure, stating, “My teeth are messed up a lot, right?” I reassured him that while there are dental issues, his oral health can still be improved with consistent care and proper hygiene. I took the time to explain, demonstrate, and educate him on effective brushing and flossing techniques, stressing the importance of daily habits to protect his teeth. As the visit progressed, the patient became more comfortable and expressed greater interest in taking better care of his oral health. He also inquired about other public dental facilities. He mentioned that his mother receives dental care at City Tech and plans to recommend the school clinic to others to help them improve their dental care. To further support him, I provided a comprehensive list of public health dental clinics that offer additional treatments such as extractions, periodontal evaluations, and other necessary care, as discussed during his first visit. This will help guide him in accessing the care he needs moving forward. His re-care interval was set to 3 months to monitor progress and maintain improvements in his oral health.
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