Smoking: The Exacerbator of Periodontal Disease

1. Smoking: The Exacerbator of Periodontal Disease Bobby Atwal March 5, 2014

2. Introduction 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.

3. Patient Background • Mr. Jones • Age 62 • Retired from U.S. army • Long term battle with alcoholism (Sober for 18 months). • Lives in Sacramento

4. 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.

5. Medications • 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)

6. Dental history • Last dental visit was in 1990 (24 years ago) • Area of concern: Patient feels he needs to replace his full upper denture.

7. 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.

8. Chief Complaint • Does not like his smile. He wants a new denture.

9. 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 night.

10. 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

11. Gingival Description • Color: Generalized Pigmented/light pink fibrotic • Papillary contour: blunted (type III embrasures) • Marginal: rolled • Consistency: soft, spongy • Texture: smooth, shiny

12. Assessments • 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 mobility. • Generalized 3-6mm PPD with generalized 2-4mm recession.

13. Radiographs

14. Human Needs

15. 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.

16. Periodontal Diagnosis with Initial Prognosis Mr. Jones presents with generalized advanced chronic periodontitiswith 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.

17. Treatment Planned (Appointment #1)

18. Treatment Planned (Appointment #1) • New Patient Assessments • FMX • 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.)

19. 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 calculus • 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 plan. • 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.

20. Treatment Planned(Appointment #3)

21. Treatment Planned (Appointment #3) • 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.

22. 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 Calculus: Generalized roughness and localized stain on anteriors. OHI: 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.

23. 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

24. Results 

25. Reflection 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

26. References 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 http://www.ncbi.nlm.nih.gov/pubmed/1428302 * Non-clinical images from Google Images