Case 1
32-year-old, Female, African American
BP 115/89 (corresponds to Hypertension Stage I) Pulse 70
Medical hx: Pt reports no medical conditions, denies taking any prescribed medications and NKA. Pt states she does not have a primary care physician and does not recall her last office visit with a physician. Pt takes Excedrin (OTC) as needed when she has a headache (monthly) and Chlorophyll daily (600mg).
ASA 2 due to BP. A referral was given to the patient for the BP reading.
Social hx: Pt reports she is a social drinker and has 2 glasses of wine and/or champagne 1x a month or socially. She does smoke hookah 2x a month for about an hour.
Dental hx: Pt states she had braces at age 14- for a year and a half and does not wear her retainer. Her last dental visit was Dec 2023 for a dental cleaning. Pt states she experiences pressure on the left side of her maxilla due to her benign ossifying fibroma apical to # 10-#12 area (biopsy was conducted). She states it grew after her braces were removed. She had surgery to remove it in 2014 but when it regrew, she had to have it surgically removed a second time in 2020.
She reports using a manual toothbrush 1-2x a day with Colgate toothpaste. Pt does not floss but uses Crest mint oral rinse daily.
Clinical findings:
EO: Left side TMJ deviation-asymptomatic, bilateral submandibular lymph nodes enlarged.
IO: White coated tongue, bilateral mandibular tori-right side more prominent, ossifying fibroma b/w #11 & #12 that reaches the lingual surface. Operculum on #17 & #32.
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Dental charting: COO: Bilateral Class I Overjet: 4mm Overbite: 50%
Gingival statement: Generalized red, spongy, rolled, enlarged, bulbous gingiva. Gingival margin coronal to CEJ. Gingival hyperplasia on left side of mandibular teeth.
Perio charting: Generalized 3-4mm PD with localized 5-6mm PD on molar region. Heavy BOP. No furcations/exudate/suppuration present. Localized 1-2 mm recession on LR premolar region.
Calculus: Generalized moderate subgingival and supragingival calculus on posterior teeth. Heavy subgingival, supragingival and interproximal calculus on mandibular anterior teeth.
RADIOGRAPHIC STATEMENT:
FMX: FMX revealed generalized horizontal radiographic bone loss of less than 15%. Generalized calculus noted. Radiolucency apical to # 24-#26. No caries noted.
PAN: PAN revealed root resorption on mandibular anterior teeth. Widened PDL on #30. Pt was informed of the findings and sent a copy of her x-rays to her email.
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Case Value: Heavy
Perio Status: Stage I, Grade B
Caries risk: Moderate as per CAMBRA
Over the course of three visits, this patient demonstrated an exceptionally low tolerance for discomfort during periodontal therapy. To facilitate treatment, Oraqix (2.5% lidocaine and 2.5% prilocaine) was administered in each quadrant. Despite its application, the patient continued to report significant pain during scaling. Local anesthetic infiltration was recommended; however, the patient declined.
In response, I implemented multiple strategies to support the patient’s comfort, including frequent pauses throughout the procedures and repositioning the patient upright to allow recovery periods. Additionally, due to increased sensitivity associated with a fibroma located between teeth #11 and #12, instrumentation in that area was minimized.
Scheduling the patient across three visits allowed me to provide the highest standard of care while respecting her pain tolerance and emotional needs. This case highlighted the necessity of flexible treatment planning, effective communication, and prioritizing patient-centered care.
Case 2
65-year-old, Female, Hispanic
BP 121/83 (corresponds to Hypertension Stage I) Pulse 77
Medical hx: Pt has Type 2 diabetes, which is controlled with Trulicity (4.5mg/0.5ml) and Jardiance (10mg) and states her A1C was under 7 because she visits her doctor regularly. Patient’s hypothyroidism is controlled with Levothyroxine (50mg) 1x a day. Pt had breast cancer in 2010. Pt has a pacemaker since 2020 and saw her cardiologist 4 months ago and will follow up with him next month. Pt has her hypertension controlled with Metropolol (200mg), Entresto (24-26 mg) 2x a day, and Aspirin (81mg). Pt is also on rosuvastatin (10mg) for cholersterolemia and takes OTC: magnesium, vitaminB12 and vitamin D. Pt states she has no allergies.
ASA 3
Social hx: Pt is a non drinker/smoker
Dental hx: Pt reports her last cleaning was last year. She uses both a manual and electric toothbrush 2x a day. She is currently using Tom’s non-fluoridated toothpaste and uses a tongue scraper. She uses biotene oral rinse 2x a day and flosses after every meal
Clinical findings:
EO: Crepitus on left side of TMJ- asymptomatic
IO: 1×1 red macule on buccal mucosa adjacent to tooth #15 and palatal torus.
Dental charting: COO: Class I (canines used) Overjet: 5mm Overbite: 10% Moderate occlusal wear/attrition, abfraction on buccal of tooth #29 & #28. Bonding on #28, #29, and #15-DB missing. Erosion on all maxillary anterior teeth. Tooth #30 is missing.
#28 & #29 composite bond is missing
#15 composite bond is missing
Gingival statement: Generalized pink, blunted, firm gingiva with localized slightly rolled and enlarged GM on maxillary molar (lingual aspect). 1-2 mm apical to CEJ. #14 is supra-erupted and beginning stage of furcation (Grade I) can be seen. #3-Lingual has a Grade I furcation. Attrition noted on all anterior teeth.
Perio charting: Generalized 2-4mm PD with 1-2 mm recession on both facials and lingual of all teeth. Localized light BOP present.
Calculus: Supragingival calculus present on lingual interproximal of mandibular anterior teeth.
Stain: Light extrinsic stains on anterior lingual surfaces
RADIOGRAPHIC STATEMENT: Exposed 4 HBWs. Generalized horizontal bone loss of 33%-40% with vertical bone loss on #12-M, #13-M and #29-M. Suspected caries on #3-M. #13 a root canal treatment is present. Overhangs noted on #4-M, #12-M, #13-M and #15-M. Pt was informed of the findings and given a copy of her x-rays on a flash drive.
Case Value: Medium
Perio status: Stage III/ Grade B
Caries risk: High due to suspected caries and CAMBRA.
During this clinical experience, I cared for a patient with a very low pain tolerance and extensive dentin exposure resulting from missing bonds and gingival recession. From the start, it became clear that traditional ultrasonic instrumentation with the Cavitron was not an option, as even light use caused significant discomfort. Local anesthetic infiltration was recommended; however, the patient declined.
To adapt to her needs, I completed full-mouth scaling using only hand instruments. Before beginning, I applied Oraqix to help manage her sensitivity and create a more comfortable experience. Despite these measures, her discomfort required that the treatment be divided into two separate appointments.
Throughout both visits, I was mindful to work efficiently but gently, using careful, controlled strokes to minimize any potential pain while still ensuring thorough debridement. This experience emphasized the importance of flexibility in treatment planning, patient-centered care, and the ability to adjust clinical techniques based on individual patient needs. It also strengthened my confidence in hand instrumentation skills and reinforced the value of building trust and communication with anxious or sensitive patients.
REFLECTION:
These experiences taught me the importance of tailoring my approach to meet each patient’s unique needs. It reinforced my ability to stay flexible under challenging circumstances and highlighted the value of patience, empathy, and careful communication. Moving forward, I will continue to prioritize patient comfort by thoroughly assessing sensitivity levels beforehand and adapting my instrumentation techniques as needed. These cases strengthened my hand scaling skills and boosted my confidence in managing patients with high levels of anxiety or discomfort, which I believe will be invaluable in my future practice as a dental hygienist. I now understand even more clearly that effective dental hygiene care isn’t just clinical skills – it’s also about empathy, communication, and truly listening to the patient’s needs. I know these experiences will shape how I approach future patients, especially those who are anxious or sensitive.