Case Study #2: Ms. B – Orthostatic Hypotension, Hearing Impaired (Three Visits)
Patient Overview:
- Age: 75, Ethnicity: Asian, Sex: Female, ASA II
- Non-smoker, non-drinker.
- Hearing impaired, orthostatic hypotension (dizziness with position changes), history of gastric reflux and hypertension,
- Blood pressure: 132/82 mmHg (per CityTech clinic’s guideline- Hypertension Stage I), Pulse: 73 bpm
- Recare interval: 3 months
Medical History:
- Last physical exam in 02/2024; blood work normal per physician. History of gastric reflux and hypertension; takes 4 medications (noted in chart). Side effects include dry mouth and orthostatic hypotension (dizziness with position changes).
- No allergies or recent hospitalizations.
Current Medication:
- Patient is taking 4 prescription medications (recorded in chart)
- Omeprazole 40 mg 1 capsule 1x daily for stomach – gastric reflux (take 30 min before lunch)
- Amlodipine/Valsartan 1 capsule 5mg/160mg 1x daily for blood pressure/kidney
- Rosuvastatin 10mg 1 capsule 1x daily for cholesterol (avoid grapefruit)
- Vitamin D3 2,000IU 1 capsule 1x daily (taken with food)
- Dental side effects include dry mouth and orthostatic hypotension
Social History:
Non-smoker, non-drinker.
Dental History & Oral Hygiene Habits:
- Last dental exam, cleaning, and FMS completed in June 2022.
- Has temporary restorations for over 30 years on maxillary anterior teeth.
- Brushes 2x daily with a soft manual toothbrush and Colgate anti-cavity toothpaste; uses circular brushing technique.
- Flosses nightly, uses metal tongue scraper 2x daily, and no oral rinses.
- Patient reports occasional lightheadedness during dental procedures and dry mouth at night only.
Visit 1 Summary:
During the first visit, I completed a thorough review of the patient’s medical and dental history and obtained informed consent for treatment. An extraoral and intraoral examination (EO/IO) revealed an asymptomatic right TMJ click upon jaw opening and mild redness around the uvula and soft palate. A full-mouth series (FMS) of radiographs was recommended, as the patient’s last dental X-rays were taken over two years ago. All assessments were completed during this visit, including dental charting, periodontal charting, calculus detection, and treatment planning. I discussed all clinical findings with both the patient and supervising faculty. Referrals were provided for a comprehensive periodontal evaluation and continued monitoring of her hypertension.
NYCCT Dental Hygiene Care clinic Blood pressure chart:
Visit 2 Summary:
At the start of the second visit, I recorded the patient’s blood pressure, which remained within Hypertension Stage I according to the clinic’s guidelines. I also repeated the extraoral and intraoral (EO/IO) examination to check for any new findings. A key reason for performing the EO/IO exam at each visit is to screen for herpetic lesions (cold sores), which are common but pose a potential risk of vision loss if spread to the eyes, as noted by King (2017) in an article published on PubMed. These lesions can also spread easily during dental procedures. No new findings or changes were noted during this exam.
A full-mouth series (FMS) was exposed during this visit to support updated dental charting. The radiographs revealed several root canal treatments and confirmed the presence of a temporary restoration on the maxillary anterior teeth, which has been in place for over 30 years. The patient reported she was unaware the restoration was temporary, as this was never communicated to her. She explained the procedure was completed many years ago at a dental clinic in Vietnam. Based on clinical consultation, hygiene treatment was to avoid maxillary canine to canine due to the condition of the bridge temporary restoration. A treatment note was documented to guide the next visit.
FMS radiograph:
Pt was exposed to FMS at City Tech with 7mA and 70kV. Findings are no caries radiographically, generalized 40-60% horizontal bone loss, localized subgingival calculus presents on proximal surfaces of posterior teeth. Pt was informed of findings.
Dental charting:
Perio charting:
Dental Findings:
- Case Value: Heavy
- Perio status: Stage III Grade B, generalized
- Caries risk: Medium
- Other Dx findings: Mobility (+1) of tooth #24, attrition #21-27, abfraction #20,21
Based on full-mouth series (FMS) radiographs and comprehensive periodontal charting, the patient was diagnosed with Stage III, Grade B periodontitis in accordance with the 2017 American Academy of Periodontology (AAP) classification guidelines. A 3-month recare interval was recommended to closely monitor periodontal stability, manage inflammation, and prevent further progression of the disease.
Treatment Plan and Pain management:
The patient required two re-visits to complete dental hygiene treatment. As there were no reported allergies, Oraqix (2.5% lidocaine and prilocaine gel) was selected for localized pain management and was administered to the quadrant being treated. A combination of ultrasonic Cavitron and hand scaling was used for effective debridement. Treatment began on the right side (quadrants 1 and 4 – UR and LR) during Visit 2, and the left side (quadrants 2 and 3 – UL and LL) was completed during Visit 3. Last visit concluded with engine polishing to remove extrinsic stains, followed by the application of 5% sodium fluoride (NaF) varnish to help strengthen enamel and protect against caries.
Throughout treatment, I tried my best to ensure the patient’s comfort and safety. I communicated clearly before adjusting the dental chair or changing positions, and I regularly checked in to ask if she felt any dizziness, especially given her history of orthostatic hypotension. I also confirmed that she had eaten prior to the appointments, as this can help prevent lightheadedness. The patient openly communicated any sensitivity or discomfort during scaling. I reassured her that she was in full control of the procedure and encouraged her to raise her left hand at any time—whether to pause, ask a question, or express a concern. This approach helped build trust and ensured a more positive and supportive clinical experience.
Patient Oral Hygiene education:
During each revisit, I applied plaque disclosing gel and reviewed the patient’s Plaque Index (PI) to assess plaque control. Her PI score improved from 1.8 to 1.0, reflecting reduced plaque accumulation. I explained that a higher PI score indicates more plaque, while a lower score reflects improvement. I used a mirror to show the patient where the disclosing gel revealed plaque, helping her visually understand her progress and areas needing more attention.
When reviewing flossing techniques. I asked the patient to demonstrate how she uses string floss, and I reinforced the correct method—wrapping the floss around each tooth to effectively clean the proximal surfaces. Because she has a temporary anterior bridge on the maxillary arch, I introduced the Waterpik as an adjunct tool to help clean under and around the bridge. I clarified that while the Waterpik is helpful, it should not replace flossing, but rather be used alongside it to support gum health.
Reinforcing the technique and regularly reassessing her PI score allowed for adjustments and helped the patient stay motivated. As her technique improved, her PI score decreased. During the final visit, I also reviewed the Modified Bass brushing method and recommended that she begin brushing on the lingual surfaces. I explained that these areas are often more difficult to clean and easy to miss, so starting with them encourages a more effective and consistent two-minute brushing routine.
The patient also expressed concern about brown staining on her teeth from daily coffee consumption. I acknowledged her concern and suggested sipping water between sips of coffee to reduce the contact time of the coffee on tooth surfaces and help minimize staining. She appreciated this advice and asked what foods are beneficial for her teeth. I recommended yogurt as a good source of calcium and phosphate, which help strengthen tooth enamel.
References
King M. Prophylaxis and treatment of herpetic infections. The Journal of clinical and aesthetic dermatology. January 2017. Accessed April 19, 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC5300736/.
