Case Study I

Case Study I

6 month recare/M/Type II: 69 year old Asian male. Patient is currently taking the following medications 1x daily: 50mg Lopressor and 80mg low-dose Aspirin for hypertension. 50mg Simvistatin for hyperlipidemia. Smoker. BP: 130/86, Pulse: 59. ASA II. Chief complaint: Dry mouth. No significant findings upon extra-oral and intra-oral examination.

Dentition: Composite restorations in anteriors. Amalgam restorations in posteriors. NP PFM crowns/bridges in mandibular posteriors. Attrition: #6-#11 and #22-#27.

Periodontal: Gingival tissue is pale pink due to poor vascularity as a result of smoking, blunted, firmly attached, and stippled. Generalized Type II due to 4-5mm probing depths, minimal BUP, recession, radiographic evidence of generalized slight bone loss. Generalized medium sub-gingival calculus and localized supra-gingival calculus on the lingual surface of the mandibular anteriors. Localized medium stain on facial and lingual surfaces of mandibular anteriors.

Radiographs: 4 horizontal bite-wings exposed to evaluate the height of the alveolar bone and the integrity of the restored teeth. Radiographs revealed generalized slight bone loss. No evidence of caries/PAP.

Oral Hygiene Instruction: Modified patient’s plaque removal technique and demonstrated the modified bass toothbrush method. Recommendations: Use of electric toothbrush 2x daily for 2 minutes, flossing 2x daily (Patient is an avid flosser), use of Biotene Dry Mouth Rinse to alleviate xerostomia symptoms, use of fluoridated dentifrice and mouth rinse (Listerine Total Care- 10mL for 30 seconds daily) due to presence of recession- These areas are predominantly susceptible to caries.

Treatment Plan/Implementation:

V1: Completed assessments. 4HBW exposed and interpreted. OHI. Handscaled and used ultrasonics on all 4 quads. Selective polishing with fine grit prophy paste. 5% Sodium Fluoride Varnish applied; Post-operative instructions given verbally.

N.V.: 6 month recare (November 2018).

When managing a patient who has a systemic condition, it is imperative that a thorough medical history review and blood pressure screening is conducted prior to treatment to aid in the prevention of the occurrence of a medical emergency. Although this patient is controlled, the dental hygienist must also consider the side effects/oral manifestations associated with the medications being taken. In addition, the patient’s chief complaint (“Dry mouth”) was addressed and Biotene Dry Mouth Rinse was recommended.