Management of Advanced Periodontal Disease in a medically complex elderly patient
This case highlights the management of a medically compromised older adult with advanced periodontal disease, emphasizing the importance of comprehensive assessment, individualized care planning, and patient education in improving both oral and systemic health outcomes.
Patient Overview
An 83-year-old Caucasian female presented to the clinic in October 2025 with the chief complaint, “I need a cleaning.” She returned in March 2026 for a subsequent prophylaxis appointment, which allowed for evaluation and documentation of changes in her oral health status over time.
Medical History
The patient is under the care of a physician, with her last medical checkup completed in December 2025. Patient was diagnosed with hypertension, and prescribed Amlodipine 5 mg and Triamterene 35 mg (diuretic). She has a history of right eye surgery in Sept 2023 with recent hospitalization in Jan 2026 due to fractured ribs, but no surgical intervention was needed. Patient is allergic to Penicillin. Blood pressure readings were 118/77, 98bpm on Oct 2025 visit, and 127/86, 83bpm on March 2026 visit. No use of smoking, drinking or recreational drugs reported.
ASA Classification: III (due to age >80 and systemic conditions)
Last dental radiographs taken in Oct 2025 (BWs and PAN). Patient reports consistent brushing once everyday using a soft toothbrush and Crest toothpaste, flosses with interdental brushes citing difficulty with contacts and crowns. Reports to own a water flosser but has not used it yet.
Assessments
Extraoral Findings:
- Bilateral TMJ crepitus, asymptomatic
Intraoral Findings
- Amalgam tattoo (6 mm gray lesion) on left buccal mucosa near retromolar pad
- Fissured, coated tongue
- Xerostomia (low salivary flow reported)
- Palatal burn lesion (2–3 mm red area near #14)
- Abscess noted near retromolar pad adjacent to #3
Periodontal and Hard tissue Findings
Generalized probing depths range from 1–3 mm. Localized 4 mm periodontal pockets are present on the posterior lingual surfaces. Generalized gingival recession of 3–5 mm is noted. No bleeding on probing or exudate is present despite signs of inflammation.
Calculus Detection
Light interproximal calculus is present, primarily on the mandibular anterior teeth.
Gingival Assessment
The gingiva is generalized red in color with a soft, bulbous, and flaccid consistency. The interdental papillae appear blunted, and the gingival margins are positioned 3–5 mm apical to the CEJ.
Dentition & Occlusion
- Class I occlusion bilaterally
- Overjet: 2 mm
- Overbite: 0% (edge-to-edge anterior bite with flaring)
Generalized recession is present, most pronounced on the facial and lingual surfaces of the mandibular anterior teeth. Furcation involvement is noted on #3 with reported sensitivity. Attrition is evident in the lower anterior region, along with incisal wear on #23–25. Chipping is present on #14, which the patient reports occurred after biting on a hard object.
Staining
Mild extrinsic staining on lower anterior teeth
- Case Type:Â Light
- Periodontal Diagnosis: Generalized Stage IV, Grade B Periodontitis
- Caries Risk:Â High
Treatment Provided
Visit #1 (October 2025):
During the visit, all comprehensive assessments mentioned above were completed and all possible treatment options were discussed with the patient.
Significant emphasis was placed on individualized oral hygiene instruction. The patient was reinforced on the importance of brushing twice daily and encouraged to incorporate a water flosser to improve accessibility and effectiveness of interproximal cleaning as she expressed difficulty with using string flossers. Continued use of interdental brushes was supported, with instruction provided on proper sizing and technique. Education also focused on the importance of consistent biofilm disruption, the impact of xerostomia on caries risk, and the necessity of a 3-month maintenance interval.
The patient required multiple restroom breaks throughout the appointment due to diuretic use, with assistance provided approximately three times per visit to ensure comfort and safety during treatment. The appointment was dismissed with the completion of assessments until treatment plan for this visit.
Visit #2 (October 2025):
The patient returned for completion of care. Medical history was reviewed and no significant changes were reported since the previous appointment. Blood pressure was taken and remained elevated, therefore continued monitoring was performed throughout the visit. The patient stated that they had attempted to follow previous oral hygiene recommendations.
Radiographs were taken, including four bitewings and a panoramic image. Although a full-mouth series (FMS) was initially considered to better assess the patient’s condition, it was determined that the procedure would be too lengthy and uncomfortable for this elderly patient. Therefore, for the patient’s comfort and efficiency of care, the radiographic plan was modified to include only bitewings and a panoramic radiograph.
Radiographs displayed no calculus, or suspicious caries. Generalized bone loss of 50-60% present with furcation involvement on tooth #3.
Full mouth debridement was completed using hand scaling and ultrasonic instrumentation to remove deposits. Instrumentation was performed with modifications to patient positioning. Engine polishing was completed, followed by the application of 5% sodium fluoride varnish. Treatment planning was reviewed and completed, and a 3-month recare interval was established.
Visit #1 RECARE (March 2026):
Patient returned after 5 months for the cleaning appointment. I reviewed the medical history, obtained vital signs, and confirmed there were no immediate contraindications to treatment. It was also noted that the patient had recently experienced a rib fracture approximately two months prior, requiring modifications in patient positioning and treatment delivery to maximize comfort during care.Â
As previously recorded, patient has been continuing diuretic medication. Due to the effects of this medication, accommodations were made throughout the appointment to allow for multiple restroom breaks to ensure patient comfort and safety during treatment.
Following assessment, plaque disclosure was completed and oral hygiene instructions were reviewed. The patient mentioned they continued proper brushing technique with emphasis on areas of plaque retention. Demonstration was provided, and the patient was asked to repeat the technique to confirm understanding.
Treatment rendered during this visit included ultrasonic scaling, hand scaling, polishing, and application of 5% fluoride varnish. Due to the patient’s history of recent rib fracture, frequent repositioning and supportive measures were provided throughout treatment to minimize discomfort. Because of the patient’s diuretic use, restroom assistance was provided three times during the appointment.
The patient tolerated treatment well and was dismissed in stable condition. A three-month recare interval was recommended.
Evaluation of Care
The prognosis of this patient will depend on several important factors:
- Maintaining consistency with the oral hygiene instructions provided during appointments
- Returning for periodontal maintenance visits at the recommended 3-month recare interval
- Monitoring and managing systemic health conditions, including elevated blood pressure
With the improvements the patient demonstrated in oral hygiene and willingness to follow recommendations, the overall prognosis can be considered fair to good if compliance is maintained. Consistent brushing, flossing, and routine professional cleanings will help reduce future plaque and calculus accumulation while improving gingival health.
By attending regular recall visits every three months, the patient will be better able to maintain periodontal stability, prevent progression of bone loss, and reduce the risk of future dental complications. In addition, following through with comprehensive dental care will help address restorative needs and support long-term oral health.
Reflection
As a clinician, this case was especially significant to me because it involved caring for an elderly patient with multiple considerations that required patience, flexibility, and close attention to comfort. In addition to the patient’s oral health needs, I had to consider her recent rib fracture, elevated blood pressure readings, mobility limitations, and frequent need for restroom breaks due to diuretic use. These factors made the appointment more complex than a routine prophylaxis, and I learned that successful treatment is not only about instrumentation, but also about continuously assessing the patient’s well-being throughout the visit.
One of the greatest challenges was making sure the patient remained comfortable and safe at all times. I had to carefully adjust chair positioning, move slowly during treatment, provide assistance when standing or walking, and frequently check in to ensure she was tolerating the appointment well. Working with an older adult patient taught me the importance of empathy, patience, and understanding that treatment often needs to proceed at the patient’s pace rather than the clinician’s pace.
Another valuable lesson from this case was the importance of communication and building rapport. Because elderly patients may feel anxious, fatigued, or overwhelmed during longer appointments, taking time to explain each step and provide reassurance made a noticeable difference in the patient’s comfort level and cooperation. Establishing trust helped create a more positive clinical experience for both the patient and myself.
As a future dental hygienist, this experience reinforced that patient-centered care goes far beyond cleaning teeth. It requires adapting treatment plans to each individual’s medical history, physical limitations, emotional needs, and personal comfort. This case strengthened my ability to think critically, remain compassionate under challenging circumstances, and provide safe, individualized care—skills that are essential in delivering quality dental hygiene treatment.