Case Study 13

Patient Profile: Patient is a 41-year old White Caucasian female, 5’6” and weighs 165 lbs.

Chief Complaint: "My front teeth are sensitive to cold."

Dental History: Patient saw a dental hygienist four years ago and followed recommended recare intervals for six months and has not received any professional dental care since.

Medical History: Patient had a hysterectomy nineteen years ago and bladder surgery nine years ago. She has a family history of type 2 diabetes. She remarked about being frequently thirsty and that "sugar makes her sick." Patient reports a history of hepatitis and was unsure of the type. Medications include: (Escitalopram oxalate) Lexapro®, (Enalapril maleate) Vasotec® and a daily 81 mg aspirin. Her blood pressure was recorded at 145/92.

Extraoral Examination:

  • Assessment reported within all normal limits.

Supplemental Information:

  • Patient presented with moderate calculus and heavy plaque.

Health Behaviors:

  • Patient does not floss.
  • She uses a manual medium bristled toothbrush once daily.
  • Reports using a daily phenol rinse to remove a bad taste.

Bleeding Index: 45%

Plaque Free Score: 30%

Social History: She smokes 1½ packs of cigarettes daily and has been smoking for 20 years.




Mandibular Anterior Lingual/Maxillary Palatal Mandibular Anterior Lingual/Maxillary Palatal
Full Direct Full Direct
Right Side Right Side
Left Side Left Side


Click to view a larger image:

Full Direct Full Direct
Mandibular Lingual Mandibular Lingual
Left Side Left Side
Right Side
Intraoral Image 4
Maxillary Palatal Maxillary Palatal
Mandibular Anterior Lingual Mandibular Anterior Lingual
Left Palatal Left Palatal
Right Palatal Right Palatal


Your Faculty has access to the answers in this case study. Please ask them to look in the Faculty Corner for the answers to this case.
  1. According to Angle’s classification of malocclusion, the BEST classification for this patient is:
  1. Which of the following characteristics describes the alveolar bone around the mandibular right second premolar?
  1. Which question is MOST important to be asked before proceeding with treatment?
  1. Which of the following types of dentifrices would BEST address the patient's needs?
  1. Which of the following referrals would be BEST for this patient?
  1. Which statement should be discussed while talking with the patient?
  1. What should be recommended to the patient in order to reduce continued loss of bone in the furcation areas?
  1. What instruction should be provided to the patient regarding her blood pressure recording?
  1. What potential side effect might the patient experience from the prescribed medications?
  1. What components from the patient’s assessment data present oral risk concerns?