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Periodontics · patient case with 2 questions

Spontaneous toothache on antihypertensive therapy

Patient: Female, 54 years old

Chief complaint: “This tooth throbs for twenty minutes after anything cold. It woke me up last night.”

History: Hypertension, controlled. Medications: hydrochlorothiazide, lisinopril. No known allergies.

Findings: Tooth #19 has a deep distal-occlusal carious lesion. Cold provokes a sharp pain that lingers about 20 minutes. Percussion is mildly tender. Probing depths 2–3 mm throughout with no bleeding on probing; the periapical shows an intact lamina dura and normal bone levels.

Question 1

What is the periodontal diagnosis for this tooth?

  1. Necrotising gingivitis
  2. Clinically healthy periodontium on an intact periodontium
  3. Localised gingivitis
  4. Stage I periodontitis
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Correct answer: B. Clinically healthy periodontium on an intact periodontium

  • A. Necrotising gingivitis presents with papillary necrosis, pain, spontaneous bleeding and a pseudomembrane. Nothing of the sort is described.
  • B. CORRECT. Probing depths of 2 to 3 mm, NO bleeding on probing, no attachment loss and no radiographic bone loss meet the 2017 World Workshop definition of periodontal HEALTH on an intact periodontium. The threshold is under 10 percent of sites bleeding, with depths of 3 mm or less. The tooth's problem is entirely PULPAL, and it is worth naming the periodontal status explicitly so the case is not over-treated.
  • C. Gingivitis requires INFLAMMATION — the defining criterion is bleeding on probing at 10 percent or more of sites. There is none here.
  • D. Periodontitis requires interdental CLINICAL ATTACHMENT LOSS at two or more non-adjacent teeth, with radiographic bone loss. Neither is present.

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Question 2

Which analgesic is the most appropriate choice for this patient?

  1. Acetaminophen
  2. Ibuprofen
  3. Naproxen
  4. Ketorolac
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Correct answer: A. Acetaminophen

  • A. CORRECT. This patient is on an ACE INHIBITOR plus a THIAZIDE DIURETIC. NSAIDs inhibit renal prostaglandins, which the kidney relies on to maintain afferent arteriolar dilation. Combining an NSAID with an ACE inhibitor and a diuretic is the recognised “TRIPLE WHAMMY” that precipitates acute kidney injury, and NSAIDs also blunt the antihypertensive effect of both drugs. ACETAMINOPHEN carries none of these interactions and is the correct choice.
  • B. Ibuprofen would normally be first-line for pulpal pain because inflammatory pain is prostaglandin-driven, but the ACE inhibitor plus diuretic combination makes it the wrong choice here.
  • C. Naproxen is an NSAID with the same interaction profile, and its longer half-life prolongs the renal and blood-pressure effects.
  • D. Ketorolac is among the most nephrotoxic NSAIDs and is explicitly contraindicated with this drug combination.

Note: The definitive treatment is still endodontic. Analgesics buy time; they do not treat an inflamed pulp.

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Practice patient cases Periodontics study notes