Smoking: The Exacerbator of Periodontal Disease

Smoking: The Exacerbator of Periodontal Disease

Bobby AtwalMarch 5, 2014

IntroductionThe 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 BackgroundMr. JonesAge 62Retired from U.S. armyLong term battle with alcoholism (Sober for

18 months).Lives in Sacramento

Health HistoryControlled HypertensionRecovering alcoholicProstate cancer in the past, radiation

treatment for 8 weeks was successfulSmokes approximately one pack of cigarettes

every three days.

MedicationsAmlodipine, 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 historyLast dental visit was in 1990 (24 years ago)Area of concern: Patient feels he needs to

replace his full upper denture.

Social HistoryMr. 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 ComplaintDoes not like his smile. He wants a new

denture.

Current Oral Hygiene StatusVisible heavy plaque on teeth and gingival

marginInitial DI-S score 1.6 (fair)*Localized bleeding on probingPatient brushes once daily and does not

regularly clean his denture. Sometimes does not remove denture at night.

Extra Oral/Intra Oral FindingsTMJ pops on the right sideThyroid cartilage feels bumpyCorrugated vestibulesHard palate slightly yellow with long palatine

sutureTongue coated yellowFull upper denture

Gingival DescriptionColor: Generalized Pigmented/light pink

fibroticPapillary contour: blunted (type III

embrasures)Marginal: rolledConsistency: soft, spongyTexture: smooth, shiny

AssessmentsOcclusion not applicable due to full upper

dentureMissing #’s 17,20,29, and 32MOD amalgam restorations #’s 18,19,30, and

31Generalized heavy subgingival ledges on

posteriors and walls of heavy supra on anteriors with slight mobility.

Generalized 3-6mm PPD with generalized 2-4mm recession.

Radiographs

Human NeedsHuman Needs Met/ Unmet

Cause Evidenced by:

Freedom from Health Risks

No Smoking Health History

Freedom from Head & Neck Pain

Yes

Freedom From Stress Yes

Skin &Mucous Membrane Integrity of the Head & Neck

No Visible Carious Lesions

Clinical/ Radiographic Assessments

Biologically Sound Dentition

No Missing Teeth

Clinical Exam

Conceptualization and Problem Solving

Yes

Responsibility for Oral Health

No Visible Heavy Plaque

Clinical Exam

Wholesome Facial Image

No Doesn’t Like to Smile

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 PrognosisMr. 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 #1)New Patient AssessmentsFMXClinical PhotosTobacco CessationOral 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 InstructionSRP Lower Right Quad with ultrasonic & hand scalingLocal Anesthesia (IA/Li/LB) due to pocket depth and tenacious

calculusTobacco 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.

Treatment Planned(Appointment #3)

Treatment Planned (Appointment #3)Oral Hygiene InstructionSRP LLQ (Finish LRQ first) with ultrasonic & hand

scalingLocal 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

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.

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

Results

ReflectionWhat I would have done differently:Have a more personalized and sincere

approach to tobacco cessationIncluded six surfaces during DI-SScheduled the re-evaluation earlierWorked faster and more efficiently

ReferencesFogari, 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