Case Study #1: Pollen Allergy and Retained Primary Teeth

Health History Overview:

  • An 18 year old Asian female presented to our school clinic for a dental cleaning. Her last annual physical was in September 2023. The patient reported to be lactose intolerant and has a pollen allergy but is currently not on any medications. She also does not drink alcohol or smoke. Therefore, the patient was classified as ASA 2.
  • Vital Sign: Patient’s blood pressure was taken at the beginning of the initial visit and was recorded at 116/81 with a pulse reading of 66 which corresponds to stage 1 hypertension. After 5 minutes, a second blood pressure was taken and was recorded at 103/72 with a pulse recording of 83 which corresponded to normal. The patient reported that she had no history of high blood pressure.
  • Her last dental visit was in August 2013 for dental cleaning and FMS. Patient reports feeling sensitivity to cold foods on the right posterior teeth. She also experiences bleeding while brushing and bad breath.
  • She is currently using a manual toothbrush (medium bristle) twice a day with Colgate Total toothpaste and Crest mouthwash.

Clinical Findings:

  • Extraoral Findings: Crepitus on the right jaw.
  • Intraoral Findings: Slight unilateral mandibular torus on the right. Brown macule on the right labial commissure. Central fissure. Traumatic lesion on the right posterior floor of the mouth. The patient had a retained primary molar (tooth L) with a stainless steel cap. The entire retained primary molar was fully exposed from crown to root as it appeared to be decaying above tooth #20 which was impacted due to limited tooth space.
  • Gingival Description: Generalized red spongy gingiva with bulbous interdental papillae on the maxillary anterior with rolled gingival margins.
  • Dental Charting:
    • Bilateral Class 1 occlussion
    • 6mm over jet.
    • 70% overbite.
    • Missing tooth #1 and 16.
    • Retained tooth L with stainless steel crown.
    • Tooth #20 erupted.
    • Retained primary root on tooth #30-ML.
  • With the information gathered during the medical history and intraoral examination, it was decided that a full mouth series was needed before proceeding. While exposing the patient to the full mouth series, it was difficult to place and have the patient fully bite down due to her having a very small mouth and hypersensitive gagging reflex. Relaxation protocols and small breaks were practiced in between to relieve the patient of any pain and stress during the radiographic exposure. After the full mouth series exposure, it was decided that a panoramic series was also needed in order to capture the third molar images.
  • Radiographic Statement: Exposed full mouth series and panoramic. The radiographs show localized 15% horizontal bone loss on tooth #20 and vertical bone loss on tooth #30. Localized subgingival calculus on the posterior teeth. No suspicious carious lesion. Retained tooth L with stainless steel crown. Retained primary root on tooth #30-ML. Impacted tooth #1,16, 17 and 32. No periapical pathology.
  • Periodontal Charting: Generalized 1-3m pocket depth. Localized 4-5mm pocket depth on the posterior teeth. Moderate BOP.
  • Calculus Detection: Generalized heavy subgingival calculus. Localized supragingival calculus on the mandibular anterior lingual surfaces.
  • Plaque Index: 1.2 (Fair)

Periodontal Status and Case Value:

  • Although there was localized horizontal and vertical bone loss located on tooth #20 and 30, the cause of bone loss in those areas was not due to periodontal disease. Therefore, it was determined that the patient displayed signs of generalized heavy gingivitis due to moderate bleeding upon probing and heavy calculus build up.

Dental Hygiene Treatment Plan:

The patient was referred to see an oral surgeon to evaluate the third molars and retained primary teeth. She was then advised to return to the facility for two more visits to complete her dental cleaning due to heavy subgingival calculus deposits. Full mouth series and panoramic radiographs were necessary to get a better understanding of the patient’s oral health. Topical 20% benzocaine and Oraqix were provided for pain management. The patient responded well to topical anesthesia that was provided during the cleaning. CAMBRA assessment was completed to evaluate the patient’s diet, family dental history and other risk factors that may affect their oral health. Patient was informed to reduce sugary food/beverage intake and to practice flossing/brushing after meals. Hand instruments and ultrasonic were used to remove plaque and calculus. The Modified Bass toothbrush technique and C-shaped flossing method were demonstrated and instructed to the patient to incorporate into their oral care routine. NaF 5% varnish was applied at the end of the dental cleaning to re-mineralize and help prevent further teeth decay. The patient was given post procedural instructions and was advised to follow up in 4 months. She was informed that due to the heavy calculus build up, moderate bleeding and retained primary teeth, it was crucial that she schedules an appointment with an oral surgeon and maintain good oral hygiene to prevent any further bone loss in those localized areas.