CC: Routine Hygiene Cleaning: “I need to evaluate a filling on lower right side”.
Patient Overview
- Age: 47, Ethnicity: African American, Sex: Female, ASA II
- Substance Use: Occasional marijuana use; consumes two glasses of wine occasionally
- Blood Pressure during visit 1: 126/88mmHg, Pulse 82 bmp (per City Tech clinical guidelines- BP corresponds to Hypertension Stage 1)
Medical History
During the medical history update, the patient stated she is currently under the care of a physician, with her most recent check-up in April 2024. She reports mild seasonal allergies, managed with over the counter (OTC) medications. No additional systemic conditions or complications were reported.
Current Medications
- OTC Vitamin D and K2– last taken on 3/17/25.
- Dental side effects of this medication include increased risk of dental caries and gingival inflammation.
- Adverse side effects include upset stomach and frequent urination.
- OTC Zyrtec– last taken on 3/17/25.
- Dental side effects of this medication include xerostomia and black hairy tongue.
- Adverse side effects include dizziness and headache.
Dental History
- Last Prophylaxis: 2023 at New York City College of Technology.
- Last x-ray was taken in 2019 (Patient recalls ~4 images taken, no recent x-rays).
- Patient reported a problematic dental filling on the lower right side, describing it as “breaking” when flossing.
Oral Hygiene Routine
- Previously instructed in the Modified Bass technique during her 2023 visit but has not incorporated it into her routine.
- Inconsistent use of string floss and Listerine mouthwash.
Dental Findings
- Case Value: Medium
- Stain: Moderate
- Perio Status: Stage I, Grade B (determined during limited focus visit)
- Caries risk (CAMBRA): High
- Other Dx findings: Peg laterals #7 & #10.
Visit 1 summary:
During the initial visit, I performed an updated and detailed medical history, obtained informed consent, and measured vital signs. Extraoral examination revealed a palpable, movable, unilateral submandibular lymph node on the right side—reported by the patient as asymptomatic. A detailed intraoral examination was then performed which revealed a coated white tongue attributed to lack of brushing that morning), bilateral scalloped lateral boarders of tongue and keratinization on retromolar pads. I then conducted the patient’s dental charting, comprehensive periodontal charting, gingival statement, and calculus detection.
Dental Charting
During dental charting, it was noted that the patient is experiencing mesial drifting of molars.
Periodontal Charting
After completing all assessments and obtaining the necessary approvals from both the supervising professor and the patient, I developed a comprehensive treatment plan tailored to the patient’s specific needs. I then transitioned into patient education, beginning with a review of the patient’s oral hygiene status. Her Plaque Index (PI) score was 0.3, which, according to Greene & Vermillion’s OHI-S, falls within the “good” range. However, fresh plaque accumulation was noted on the maxillary lateral incisors, indicating a need for improved plaque control. To address this, I reintroduced the Modified Bass brushing technique, utilizing a hands-on teaching approach. I began with a typodont demonstration and reinforced the method using the “Tell-Show-Do” technique. The patient was then able to successfully demonstrate the technique using a disposable toothbrush. Additionally, due to the presence of multiple diastemas, I introduced the use of an interproximal brush to enhance interproximal cleaning and support long-term oral hygiene maintenance.
Once the patient demonstrated full competence and understanding of the oral hygiene instructions provided, I proceeded with comprehensive scaling. Utilizing both the Cavitron ultrasonic scaler and hand instrumentation, I effectively scaled all quadrants of the mouth with no reported discomfort from the patient throughout the procedure. Although the patient declined engine polishing, she opted for the application of 5% sodium fluoride varnish to support enamel remineralization and caries prevention. Additionally, the patient agreed to return for a limited focus visit to complete a Full Mouth Series (FMS) of radiographs for further diagnostic evaluation.
Limited Focus Visit
Upon the patient’s arrival for the limited focus visit, I began by conducting a thorough intraoral examination to identify any changes in her oral condition since the previous appointment. Following clinical assessment, I escorted the patient to the radiology suite, where I successfully exposed a complete Full Mouth Series (FMS) of radiographs in accordance with clinical protocols. Upon detailed analysis of the FMS, I identified several significant findings: impacted teeth at positions #1, #17, and #32; the presence of radiographic calculus on one surface; and suspicious radiolucencies in the dentin regions of teeth #12D, #20D, and #21D. Additionally, localized horizontal bone loss of approximately 15% was observed between the mandibular anterior teeth and between teeth #12 and #13.
In collaboration with supervising faculty and upon clinical consultation, it was determined that further diagnostic imaging was warranted. A panoramic radiograph was subsequently taken, which corroborated the impaction of #17 and #32 and revealed associated pericoronal radiolucencies suggestive of pathology. The panoramic image also displayed a significantly widened lamina dura, a midline bony cleft at the palatal suture, and a pronounced diastema between teeth #8 and #9. Given the extent and complexity of these findings, a formal referral was provided for an oral surgery evaluation, as well as for further medical assessment regarding the patient’s elevated blood pressure noted in previous visits. This comprehensive diagnostic process not only enhanced the accuracy of the patient’s treatment planning but also ensured appropriate interdisciplinary care. I concluded the appointment by encouraging him to follow up with the recommended referrals for treatment.
FMS radiograph
PAN exposure
At the conclusion of the visit, the patient’s periodontal condition was evaluated using the Staging and Grading Periodontitis quick-reference guide, resulting in a diagnosis of Stage I, Grade B periodontitis.
Supporting the Patient’s Journey to Better Oral Health
Supporting Ms. B’s journey to better oral health meant addressing both her immediate concerns and long-term needs with care and precision. From her initial visit, I prioritized building trust by listening to her experiences and educating her on the importance of preventive care—something she had not consistently practiced. By reintroducing techniques like the Modified Bass brushing method and incorporating interproximal cleaning tools tailored to her diastemas, I ensured she left each visit feeling more confident and in control of her oral hygiene. Through comprehensive assessments, patient-centered education, and a clear treatment plan, I guided Ms. B toward making informed decisions about her dental health and empowered her to take meaningful steps toward lasting improvements.