Case 20

Archie McCoy Tang Blanton

Alejandro Garcia

The Patient
50-year old White Caucasian male in good health.
Chief Complaint: "I am very concerned about the
stain on my front teeth."
He is very energetic, smokes one pack of cigarettes
daily and has 2-3 alcoholic drinks weekly.
Patient has dry mouth frequently.
NO VITAL SIGNS RECORDED
has a slipped disc in his neck
4 year old X-rays

Not taking any medications

Brushes twice daily with fluoridated dentifrice.
Uses a phenol mouthrinse daily.
Does not floss regularly.

No allergies, recent
surgeries, recent
hospitalization, or
visits to a doctor.

The patient is a smoker, has a slipped disc in

his neck, and has 2-3 alcoholic drinks per
week. These combined factors make him...
a.
b.
c.
d.

ASA II
ASA III
ASA IV
Carne ASAda

ANSWER:
a. ASA II
Tobacco use or a slipped disc would
categorize him as ASA II, but
moderate alcohol use would not.
Combining factors does not increase
a persons ASA classification.

Dental
Assessment

4 year old
Radiographs needs new ones
No active caries
Poor Amalgam
restorations on
MD#30, DOL#19
potentially
etiologic.
Recommend to
use a threader for
flossing those
areas
Refer to DDS for
evaluation.

Restoration on
#3 is
questionable
due to lack of
tooth structure
and restorative
margins at
biologic width

Missing Information
Vital signs not recorded
Record patient vitals before any procedure
Intraoral images: Incomplete
Missing photograph of right side
Radiographs: Incomplete and 4 years old
Missing maxillary right canine
Lack of open contacts
Needs updated FMX

Occlusion
Right Canine: Class I

Left Canine: Class I

Occlusion
Right Molar: Unclassifiable
Missing maxillary 1st molar

Left Molar: Unclassifiable

Missing intraoral image

AAP Classification
Generalized 2-3 mm recession & 1-3 mm
pockets
Generalized moderate chronic
periodontitis
Severe bone loss in posterior teeth
Class I and Class II furcations in all molars
Localized severe chronic periodontitis

Periodontal Condition
Severe horizontal bone loss
But gingiva appear healthy
1-3 mm pockets
May be related to smoking
Past moderate to severe periodontitis
Controlled with successful periodontal
therapy

8 Human Needs
1. Protection from health
risks

Upright patient position, minimize duration that patient is reclined.

2. Freedom from Fear and

Stress

No fear. Use anesthesia.

3. Wholesome Facial
Image

Selective polishing, inform about in-office and at-home tooth whitening

options.

4. Biologically Sound and

functional dentition

Refer to DDS to evaluate overhanging amalgam restorations. Refer to

prosthodontist to evaluate prognosis for crown on #3, quad SRP with
anesthesia. Oral hygiene instruction.
3 months maintenance.

8 Human Needs
5. Skin and Mucous
Membrane Integrity of
Head and Neck

Recommend alcohol-free 0.05% fluoride mouthrinse and sodium lauryl sulfatefree dentifrice. Recommend saliva substitutes, sugar free gum, and other noncariogenic solutions for xerostomia. Advise on effect of smoking on xerostomia
and periodontal disease.

6. Freedom from Head

and Neck Pain

Sit patient upright during procedure. Minimize duration that patient is reclined.

7. Conceptualization and
Problem Solving

Emphasize benefit of regular flossing, educate on oral health effects of

tobacco use, and question interest regarding smoking cessation.

8. Responsibility for Oral

health

Educate and motivate patient to floss daily. Patient must maintain 3 month
recall schedule to monitor bone loss and overall periodontal condition.

Modifications to Treatment
Medical History: Missing Vital Signs
Before any treatment:
Heart rate
Respiration
Blood pressure
Make sure he is safe to treat
People with high blood pressure
can feel fine

Modifications to Treatment
Medical History: Missing Vital Signs
Before any treatment:
Heart rate
Respiration
Blood pressure
Make sure he is safe to treat
People with high blood pressure
can feel fine
Shoulder pain when reclined for
extended periods:
Upright patient position

Treatment Plan
Appointment

Date/Interval

Procedures:

12/9/2015

E&I, FMX, Evaluate full mouth periodontal and dental condition (general assessment,
periodontal assessment, restoration assessment), treatment plan, selective polishing

12/16/2015

E&I, Plaque index, SRP ULQ with anesthesia (radiographically evident calculus #15M),
selective polish, OHI and smoking cessation

12/23/2015

E&I, plaque index, SRP LLQ with anesthesia (most severe furcation involvement),
selective polish, OHI and smoking cessation

12/30/2015

E&I, plaque index, SRP LRQ with anesthesia (less severe furcation involvement),
selective polish, OHI and smoking cessation

1/6/2016

E&I, plaque index, SRP URQ with anesthesia, selective polish, OHI and smoking
cessation

~2/6/2016
(3-4 weeks)

Evaluation of periodontal condition. Rescale residual calculus, plaque index, OHI and
smoking cessation, selective polishing

Maintenance

3 month recall

Oral prophylaxis, OHI and smoking cessation

Specialist Referral
Refer to prosthodontist
Evaluation of restoration on
tooth #3.

Refer to a DDS
Overhanging amalgam
restorations
MD#30, DOL#19

Oral Health Instruction

Xerostomia
Sugar-free gum
Alcohol-free mouth rinse
Avoid sodium lauryl sulfate dentifrice
Does not floss regularly
Explain connection between flossing,
interproximal plaque, and periodontal
disease.
Interdental brush; Floss threader for
overhanging restorations
Tobacco Cessation
Assess readiness to quit

Tobacco Cessation
The 5 As

ASK patients smoking history and habits

ASSESS readiness to quit
ADVISE patient on the benefits of quitting
ASSIST patient to quit smoking
ARRANGE follow up visits

Only if he wants to quit

inform, dont force

The bone loss in the patients radiographs

indicates moderate-to-severe periodontitis.
The patient currently has healthy gingiva with
shallow pockets, so his condition has
improved to slight periodontitis.
a. Both statements are true.
b. Both statements are false.
c. The first statement is true, the second
statement is false.
d. The first statement is false, the second
statement is true.

ANSWER:
c. The first statement is true, the
second statement is false.
The patient is still classified as having
moderate or severe periodontitis. His
gingiva may have recovered, but the
bone loss is irreversible.