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
● No allergies, recent
● Not taking any medications
● Brushes twice daily with fluoridated dentifrice. surgeries, recent
● Uses a phenol mouthrinse daily. hospitalization, or
● Does not floss regularly. 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. ASA II
b. ASA III
c. ASA IV
d. 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 person’s ASA classification.
Dental
Assessment
● 4 year old
Radiographs -
needs new ones
● No active caries
● Poor Amalgam
restorations on
MD#30, DOL#19 ● Restoration on
potentially #3 is
etiologic. questionable
● Recommend to due to lack of
use a threader for tooth structure
flossing those and restorative
areas margins at
● Refer to DDS for biologic width
evaluation.
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 Left Molar: Unclassifiable
Missing maxillary 1st molar 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 Upright patient position, minimize duration that patient is reclined.
risks
2. Freedom from Fear and No fear. Use anesthesia.
Stress
3. Wholesome Facial Selective polishing, inform about in-office and at-home tooth whitening
Image options.
4. Biologically Sound and Refer to DDS to evaluate overhanging amalgam restorations. Refer to
functional dentition 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 Recommend alcohol-free 0.05% fluoride mouthrinse and sodium lauryl sulfate-
Membrane Integrity of free dentifrice. Recommend saliva substitutes, sugar free gum, and other non-
Head and Neck cariogenic solutions for xerostomia. Advise on effect of smoking on xerostomia
and periodontal disease.
6. Freedom from Head and Sit patient upright during procedure. Minimize duration that patient is reclined.
Neck Pain
7. Conceptualization and Emphasize benefit of regular flossing, educate on oral health effects of
Problem Solving tobacco use, and question interest regarding smoking cessation.
8. Responsibility for Oral Educate and motivate patient to floss daily. Patient must maintain 3 month
health 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:
1 12/9/2015 E&I, FMX, Evaluate full mouth periodontal and dental condition (general assessment,
periodontal assessment, restoration assessment), treatment plan, selective polishing
2 12/16/2015 E&I, Plaque index, SRP ULQ with anesthesia (radiographically evident calculus #15M),
selective polish, OHI and smoking cessation
3 12/23/2015 E&I, plaque index, SRP LLQ with anesthesia (most severe furcation involvement),
selective polish, OHI and smoking cessation
4 12/30/2015 E&I, plaque index, SRP LRQ with anesthesia (less severe furcation involvement),
selective polish, OHI and smoking cessation
5 1/6/2016 E&I, plaque index, SRP URQ with anesthesia, selective polish, OHI and smoking
cessation
6 ~2/6/2016 Evaluation of periodontal condition. Rescale residual calculus, plaque index, OHI and
(3-4 weeks) 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 patient’s 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, don’t force
The bone loss in the patient’s 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.
