CC: Routine Hygiene Cleaning
Patient Overview
- Age: 79, Ethnicity: Asian, Indonesian Sex: Male, ASA II
- Substance Use: No smoking, no consumption of alcohol
- Blood Pressure during visit 1: 128/79mmHg, Pulse 73 bmp (per City Tech clinical guidelines- BP corresponds to elevated)
Medical History
During the medical history update, patient reported currently being under the care of a physician, with last medical checkup being in 2024. Mr. J also reported having seasonal allergies but does not take any medications for this because though the symptoms are moderate, they are manageable. No other systemic conditions or complications noted.
Current Medications
- OTC Vitamin C 500mg– 1x a day/morning
- He reports taking this medication for the last 40 years and took medication on the morning of the appointment. Dental side effects of this medication include being destructive to the tooth enamel. Adverse side effects include nausea and heartburn.
- OTC Garlic Pills– 1x a day/ morning
- Also reports taking medication for the past 40 years and took medication before appointment. Dental side effects of this medication include halitosis. Adverse side effects include gastrointestinal irritation.
Dental History
- Last Cleaning: 2022 at New York City College of Technology.
- Last x-ray was an FMX taken at this time and had not been exposed to any other x-rays since.
- Patient pointed to his upper right side and reported losing a tooth because it was loose and fell out approx. 3-4 months ago.
Oral Hygiene Routine
- Brushes at least 1x/day, manual toothbrush, soft bristles, OTC Dentifrice being Colgate
- No floss uses, uses antiseptic Listerine mouthwash after brushing every day.
Dental Findings
- Case Value: Medium
- Perio Status: Stage IV, Grade B
- Caries risk: Moderate according to CAMBRA
- Other Dx findings: Generalized moderate attrition on posteriors, with localized mild attrition on #24 . Abrasion on #5, #12, #20. Mild localized crowding subjected to lower anteriors. #5 is fractured to the dentin. Wear facets present on all posteriors.
Visit 1 summary:
During the first visit, I completed a detailed updated medical history including measuring blood pressure and obtained consent from patient. A extraoral examination revealed slight moveable, bilateral, swollen, and palpable submandibular lymph node towards the posterior regions. Patient was unaware and reported it being asymptomatic. A detailed intraoral examination was then performed which revealed slow salivary flow on the parotid glands, demarcated and granulated gingiva on #14L and #19L, fissured tongue, and 1×2 mm, flat, regular border, white lesion with a bright red halo on lower bottom lip adjacent to #20. Faculty assessed lesion and deemed it to be an aphthous ulcer. Pt verbally and signed written consent to have intraoral pictures taken for documentation and future monitoring. This was recorded in patient chart.
After taking intraoral pictures, I reviewed the images with the patient to enhance his awareness on his current oral health condition. I informed the patient that a referral will be formulated and given to him during his second visit. I completed the remaining assessments, including gingival statement, dental charting, periodontal charting, calculus detection, and formulated a treatment plan in alignment to the patient’s case value and needs.
After having assessments checked, I proceeded to patient education. The patient declined the disclosing plaque index gel, therefore, based the bridge and possible limited dexterity, I recommended a water flosser. I used videos and a demo water flosser and explained to the patient what the button settings are, how to position and hold the tool, as well as the benefits of using it. I further educated the patient on the connection between plaque build-up and oral health conditions, including gum irritation and halitosis. He was inclined to implement this technique into his oral regime at home by the end of the first appointment.
Dental Charting:
Periodontal Charting:
Based on clinical consultation, posterior teeth were approached with caution. Patient reported no pain but was aware of recession.
Visit 2 summary:
During the second visit, I reviewed Mr. J’s medical history and made note of any changes into his chart. Patient reported he purchased a water flosser to use. I proceeded to conduct an intraoral exam, to revalue findings from previous appointment. During his second visit, the canker sore had resided, but white tongue, irritated tonsils and slow salivary flow remained.
I then exposed a full mouth series (FMS) of radiographs due to multiple caries, faulty pontics, and increasing expose of roots from his prior visit in 2022.
Full Mouth Series radiograph:
Findings are: Multiple suspicious carious lesions detected #30M, #10M, and #21D. Lamina dura presents with a radiolucent widening on #13. Patient presents with localized 50% HBL between #24 & #25, with generalized >20% HBL. Furcation involvement on #30 and #19. Calculus detected on #2D, #15D, #31M, #24D, #25M. #4 presents with a slit root, with patient reporting no discomfort.
After FMS exposure, the patient declined the disclosing plaque index gel again, so I decided it was best to emphasize how to clean his tongue properly. After educating the patient about the benefits of this tool, I proceeded to show him videos of how to use it and answered any questions he had.
Due to the plaque buildup and calculus, I completed thorough debridement using both the ultrasonic Cavitron and hand scaling, approaching posterior teeth with caution and not touching tooth #3-4 and #13-15. Though topical 20% Benzocaine was offered to the patient prior to debridement, the patient opted to proceed without it and tolerated treatment well. The patient declined both engine polishing and fluoride. To conclude the treatment, I wrote a referral for the patient to get evaluated.
Supporting the Patient’s Journey to Better Oral Health:
Before the treatment, the patient expressed concerns about his strength and health of his teeth and showcasing an extent of insecurity. I prioritized making Mr. J feel comfortable in the chair as well as provided him with a formulated OHI that would be simple and easy for him to practice. I took time to demonstrate in depth, explain, and educate the patient about each step of his treatment, so he felt more secure and confident in both him and the clinician. As the visits progressed, Mr. J was visually more intrigued and excited about learning more, and upon following up, stated that he had also informed his wife about the water flosser. To further support Mr. J in his journey to bettering his oral health, I welcomed him to reach out to me at any point with any questions or concerns that arise. His re-care interval was set to 3 months to monitor progress and maintain improvements in his oral health.
Approximately two weeks later, I followed up with Mr. J after his treatment was completed. He stated that he started implementing the water flosser and tongue scraper into his routine and they have both been working well for him since.