Patient with hypertension stage II.
Demographics: Patient is a 31 year old Caucasian male
Assessment: CC: Had pain for a few days in mandibular posterior right. Last dental cleaning services in 2019. Vital signs: blood pressure 145/98 – hypertension stage II, pulse – 84 beats per minute. Second reading after 30 minutes: blood pressure 139/84 – hypertension stage I, pulse – 85 beats per minute. The patient has seafood allergy; experiences anaphylaxis as a reaction. Last episode was 5 years ago. Patient takes dexamethasone if needed. ASA II due to possible hypertension and allergy. Last physical visit August 2020. Last dental visit 2019, dental cleaning and restorations were performed.
Social Hx: non-smoker, non-drinker.
Extraoral findings: Papules ~ 1mm on head and neck areas. TMJ left side clicking during moving left and right. Round bluish macule ~2 mm on lower lip left corner.
Intraoral findings: keratinized labial mucosa and petechiae on lower lip due to lip biting. Slight ankyloglossia.
Dental assessment: Class I of occlusion; bilaterally Overjet 6 mm; Overbite 10%.
Suspicious caries lesion teeth # 16, 28, 30.
Periapical pathology #30.
Cambra: moderate caries risk.
Gingival Statement: Generalized pink scalloped gingiva. Localized moderate red inflamed gingiva with rolled gingival margin on mandibular teeth facial. Shiny bulbous papillae on anterior mandibular facial. Minimal localized BOP. Minimal bleeding upon scaling.
Attrition: localized mild on anterior teeth.
Calculus detection: Generalized moderate calculus deposits detected interproximally. Localized supra moderate calculus deposits on the lingual side of anterior teeth mandible. Light stains were presented on the lingual aspect of the anterior maxillary and mandibular teeth.
Generalized biofilm mostly located along the gingival margin. Plaque Index (PI) score: 0.9– Fair.
Diagnosis of oral condition: Case value was determined to be medium; Stage I– Grade A periodontitis, based on localized horizontal bone loss ~30% mandibular anterior and #30. Mild attrition on maxillary and mandible anterior teeth. Moderate caries risk – the patient has carious lesions in the past 36 months.
Planning and Implementation: Exposed FMS radiographs to evaluate oral health, the bone loss and #30.
Radiographic findings: #30 – distal root periapical pathology detected; localized horizontal bone loss ~30% mandibular anterior and #30; calculus detected on #2-D, #4-M, #5-MD, #7-D, #8-M, #9-M, #12-M, #15-D, #18-MD, #20-M, #21-MD, #22-D, #23-M, #24-MD, #25-MD, #26-M, #29-M, #30-D, #31-M.
Full mouth scaling and root planing performed using hand instruments. Topical Benzocaine 20% applied. Stains polished with medium grit prophy paste. Sodium Fluoride varnish 5% applied. Post instructions were given.
Oral Hygiene Instructions: Oral B E-toothbrush technique discussed and corrected. Referral to evaluate high BP was given.
Referral given to evaluate suspicious carious lesions on teeth # 1, 16, 17, 28, 30, 31; periapical pathology on the distal root of #30
Evaluation:
Treatment was performed in two visits. On the revisit, the gingiva on the previously scaled quadrant was evaluated – slight gingival inflammation was still present, but it was a positive tissue response and improvements could be seen. The patient responded well to the treatment. The patient was motivated and purchased the disclosing solution to make sure there is no visible plaque on his teeth. FMS was challenging as patient had a gag reflex while taking X-ray images of the posterior teeth. Revisit every 3 months recommended.
My reflection:
A patient came in with a complaint regarding occasional pain in the mandibular right posterior tooth. It was important to me as a future hygienist to treat this patient and evaluate the cause of possible pain. FMS was initiated to evaluate the area and the whole dental health as there were areas of localized recession and localized PD 5mm. The whole procedure went very well without any incidents and with controlled bleeding. On the second appointment, the gingiva appeared pinker with less bleeding. The patient was very impressed to see the results and motivated to follow all the oral hygiene instructions. Patient took the picture of the disclosing solution. I mentioned disclosing tablets as well as another way to see the plaque.
Patient had a gag reflex while taking iX-ray images of the posterior teeth. It is important that the patient can go through the procedure comfortably. I instructed the patient to breathe through his nose. And was counting to 5 while exposing so it was easier for the patient to hold the sensor as he was aware of timing and felt in control of gagging.
Patient was not aware of his high blood pressure, however, stated that experiences headaches a few times a week. For me it was important to let the patient be aware of his overall health as well. I asked questions regarding his diet if there was a lot of sodium intake. It was important to educate the patient that uncontrolled high BP does not only affect his heart, but the kidneys as well. It was a pleasure and a little personal achievement when the patient followed up with the referral and was prescribed medications to monitor his blood pressure. The patient followed up with the referral regarding PAP on #30, and the tooth was extracted due to the infection on the apex of the distal root. Carious lesions were not treated at that visit.
It was important to me that despite the fact that I’m still a student, the patient saw a specialist in me and trusted my opinion and followed up with referrals.
