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Bobby Atwal

March 5, 2014
The purpose of this presentation is to examine local
contributing factors such as smoking as a periodontal
link and the effects of poor oral hygiene in
combination with removable oral appliances on the
oral cavity.
Mr. Jones case is unique to this presentation because of
the presence of periodontitis and the local
contributing factors which may be leading to the
progression of disease.
Patient Background
Mr. Jones
Age 62
Retired from U.S. army
Long term battle with alcoholism (Sober for 18
Lives in Sacramento

Health History
Controlled Hypertension
Recovering alcoholic
Prostate cancer in the past, radiation treatment for 8
weeks was successful
Smokes approximately one pack of cigarettes every
three days.
Amlodipine, a calcium channel blocker.
Key adverse affect: gingival hyperplasia
* In both normotensive and hypertensive smokers,
calcium entry blockers produced a significant
attenuation of the rise in blood pressure induced by
cigarette smoking..may be useful in the treatment of
hypertensive smokers who were unwilling or unable to
stop smoking (Fogari 1992)
Dental history
Last dental visit was in 1990 (24 years ago)
Area of concern: Patient feels he needs to replace his
full upper denture.
Social History
Mr. Jones lives at home with his wife. Ever since he
retired he has had extra time on his hands. He believes
that the extra time in combination with quitting
drinking has led to him smoking more often. He tries
to limit how much he smokes and has successfully
decreased the habit from a pack a day to a pack every
three days.
Chief Complaint
Does not like his smile. He wants a new denture.
Current Oral Hygiene Status
Visible heavy plaque on teeth and gingival margin
Initial DI-S score 1.6 (fair)*
Localized bleeding on probing
Patient brushes once daily and does not regularly clean
his denture. Sometimes does not remove denture at
Extra Oral/Intra Oral Findings
TMJ pops on the right side
Thyroid cartilage feels bumpy
Corrugated vestibules
Hard palate slightly yellow with long palatine suture
Tongue coated yellow
Full upper denture
Gingival Description
Color: Generalized Pigmented/light pink fibrotic
Papillary contour: blunted (type III embrasures)
Marginal: rolled
Consistency: soft, spongy
Texture: smooth, shiny

Occlusion not applicable due to full upper denture
Missing #s 17,20,29, and 32
MOD amalgam restorations #s 18,19,30, and 31
Generalized heavy subgingival ledges on posteriors
and walls of heavy supra on anteriors with slight
Generalized 3-6mm PPD with generalized 2-4mm
Human Needs
Human Needs Met/
Cause Evidenced by:
Freedom from Health Risks No Smoking Health History
Freedom from Head & Neck
Freedom From Stress Yes
Skin &Mucous Membrane
Integrity of the Head & Neck
No Visible Carious
Clinical/ Radiographic
Biologically Sound Dentition No Missing Teeth Clinical Exam
Conceptualization and
Problem Solving
Responsibility for Oral
No Visible Heavy
Clinical Exam
Wholesome Facial Image No Doesnt Like to
Patient Statement
Patient Goal
Mr. Jones would like to keep his remaining teeth. He
wants to avoid ending up with a full set of dentures,
therefore, he is beginning to accept that he needs
urgent dental treatment.
Periodontal Diagnosis with Initial
Mr. Jones presents with generalized advanced chronic
periodontitis with heavy calculus and plaque.
Initial prognosis is poor due to greater than 50%
attachment loss and the presence of mobility.
Recommendation: SRP 4 or more teeth per quad with
good home care and 3 month re-care intervals.

Treatment Planned (Appointment #1)
Treatment Planned (Appointment
New Patient Assessments
Clinical Photos
Tobacco Cessation
Oral Hygiene Instruction (modified Bass method
tooth brushing instructions given to help Mr. Jones
remove plaque from the gingival margin. Instructions
for denture cleaning were also given.)
Treatment Planned (Appointment #2)
Oral Hygiene Instruction
SRP Lower Right Quad with ultrasonic & hand scaling
Local Anesthesia (IA/Li/LB) due to pocket depth and tenacious
Tobacco cessation

*Procedures Performed:
Tobacco cessation was not performed due to patient refusal on
first appointment.
Gingival irrigation was performed and added to the treatment
Calculus remained at the end of the appointment.
Instructions were given for using the end tuft brush for cleaning
the distals of the most posterior molars.
Treatment Planned(Appointment
Treatment Planned (Appointment
Oral Hygiene Instruction
SRP LLQ (Finish LRQ first) with ultrasonic & hand scaling
Local Anesthesia (IA/Li/LB)
*Procedures Performed:
Instructions for dental soft picks were given for
interproximal cleaning of type 3 embrasures.
Clinical photo was taken since the treatment was half
complete. This photo was taken to contrast the difference
between the treated and untreated quadrants.
Re-evaluation (6 weeks later)
Gingival Description:
Mr. Jones tissue had responded very well to treatment. The
margins had healed and mobility was reduced.
Periodontal Condition:
Generalized probing depth decrease of approximately 1mm
Generalized roughness and localized stain on anteriors.
Plaque index showed that most of the plaque was located in the
lower right posterior region. This indicates that Mr. Jones was
having trouble brushing on the right side. This became evident
when Mr. Jones was asked to demonstrate tooth brushing.
Adjustments were made to help Mr. Jones grasp and angle the
toothbrush to allow for a more effective brushing stroke.
Re-evaluation (continued)
*Procedures Performed:
Ultrasonic and root planing strokes with hand instruments
were performed to smooth the grainy root surfaces
Air Polish: Prophy jet with sodium bicarbonate powder was
utilized due to the amount of stain present
5% Sodium Flouride varnish was applied and post op
instructions were given
Dental referral for urgent need due to open carious lesions
Radiograph release
What I would have done differently:
Have a more personalized and sincere approach to
tobacco cessation
Included six surfaces during DI-S
Scheduled the re-evaluation earlier
Worked faster and more efficiently
Fogari, R., Zoppi, A., Malamani, G., & Corradi, L. (1992).Effects of calcium channel blockers
on cardiovascular responses to smoking in normotensive and hypertensive
smokers.Retrieved from

* Non-clinical images from Google Images