Hypertension stage I. ASA II
40 years old Hispanic female presents to the clinic for a dental cleaning and exam.
CC: ” I need a cleaning and have sensitivity when brushing.”
Health history:
BP: 140/97 P: 84 corresponds to Hypertension II, ASA II.
(After informing her about the BP reading, the patient reports: “That is weird, my BP is usually normal.” (Patient received a referral for Hypertension stage II).
She reports being in good health condition, but has anemia, and was prescribed to take Iron 1 x day on her last physical exam. She also takes OT vitamin C, collagen, and Omega # to promote health, reports having no allergies or medical conditions,
Profile:
Patient reports brushing 3 x day using a manual toothbrush, has no preference for toothpaste, and flosses and rinses with mouthwash once a day, does not use a tongue scraper, but brushes her tongue with her toothbrush 3 x a day. Last dental cleaning 9/2025, done by a friend, and last dental X-rays were more than 10 years ago.
Clinical findings:
Extraoral examination: WNL, asymptomatic clickable TMJ.
Intraoral examination: WNL, white-coated tongue, bilateral enlarged tonsils, 2 mm flat,
Dental charting: bilateral class I occlusion based on canines, Overjet 3mm, Overbite 5%, localized attrition noticed on anterior teeth.
Missing teeth # 14, 30 & 32.
Incisal fracture on teeth # 8 & 9.
Caries on teeth # 2, 3, 15, 17, 18, 20, 29,31 occlusal, Interproximal caries btw 8-9 and 13 Mesial.
Composite restorations on teeth # 3B, 12DO, 13MO & amalgam restoration on 19 Occlusal.
Gingival and periodontal statement: pink /pale gingiva, smooth and shiny in texture, GM near to CEJ, papilla is blunted. Generalized 2-3 mm PD on anterior teeth, 4-5 mm on posterior teeth, generalized BOP.
Calculus statement: interproximal subgingival grainy calculus, localized subgingival clickable calculus on posterior teeth.
PI: 1.1-fair Stain: Medium
Radiographic statement: H-FMS exposed 3/2026, interproximal caries btw teeth # 8-9, retained root of tooth # 14, generalized HBL 15-30 observed.
Dental hygiene diagnosis: after completing all the assessments, the patient is found to be at high risk for caries due to frequent consumption of sugary drinks, unusual morphology that compromises OH, more than three new carious lesions, and 15-30% HBL.
Dental Hygiene treatment plan and care:
Patient was informed of the connection between oral health and systemic health, especially in her case, when BP is at that level, where the body has to work harder to keep everything balanced. Some examples were given to the patient. ( like when there is inflammation in the mouth, this adds some extra stress to the body, which directly affects the readings), Referrals given for comprehensive oral/periodontal evaluation, and medical evaluation (HTN II).Â
Due to high risk for caries, the patient was recommended to reduce the intake of sugars and rinse with water after meals, and introduced to the Modified TB technique and C-shape flossing technique. For sensitivity, it was recommended to use Sensodyne TP.
20 % Benzocaine topical and local anesthetic for pain management ( 1-1/4 of 1.7 ml of 2% Lidocaine 1:100K Epinephrine administered via PSA/MSA/ASA infiltration, patient tolerated well), hand scale/cavitron whole mouth, engine polished with medium grit prophy paste, 5 % NaF Varnish applied. (Patient was very happy with the results)
Reflection: due to tenacious interproximal and subgingival calculus in posterior pockets, careful hand scaling, complemented by ultrasonic debridement, topical, and local anesthetic, was required to ensure patient comfort and adequate debridement. This combination reduced calculus and BOP since the first visit, improved periodontal status, and facilitated future restorative care. The case reinforced the importance of meticulous scaling technique, appropriate use of anesthesia, and clear clinician-patient communication; a 3-M recare was scheduled for re-evaluation and stabilization.
Clinical evidence
