Introduction

Mr. Burgundy is a 68 year old Caucasian male who presented to clinic for a six month dental
hygiene recall. Upon his arrival, I thoroughly reviewed and updated his medical history, medications, and
dental history. This enabled me to become aware of any systemic diseases, medications, or life style
behaviors he may have had, and identify anything that could have potentially altered the appointment or
negatively impact his current oral health status. Mr. Burgundy is currently prescribed several medications
for the treatment of hypertension, frequent anxiety attacks, post-traumatic stress disorder (PTSD), and an
enlarged prostate. He is currently experiencing xerostomia due to two of these medications. He is a
current cigarette smoker, and has continued to smoke a pack a day for the past fifty years. Upon
completing his medical history, he enlightened me by stating that he would like to quit smoking.
I have chosen Mr. Burgundy for my case reasoning project due to his current addiction to
cigarette smoking. I feel that understanding the association between cigarette smoking and periodontal
disease, as well as oral cancer, is completely imperative. I feel that although several patients who are
seated in our chairs are tobacco users, very rarely do we take the time as students to focus in on one of
these patients and aid them in cessation of this habit. Using him as my case doc patient has given me the
perfect opportunity to share and inform my classmates of how I informed him of the potential risks, and
how I managed to provide him with tips. Furthermore, this patient was completely unaware of his
medications causing xerostomia, nor was he aware of the risks associated with xerostomia. In addition to
his xerostomia, several previous extractions and restorations have been done due to tooth decay. I felt it
would be very beneficial to discuss and provide ways to lower his risks for more possible future decay by
providing nutritional counseling and thorough oral hygiene instructions.

Medical History Significance

Condition
Hypertension

Description/Impact on dental hygiene care

Confirm with patient that they have taken their medication for treatment of
1

hypertension.
If blood pressure reading is over 160/100, a medical consult must be made,
and dismissal of patient is at the discretion of faculty.
Stress, anxiety, and duration must be limited during dental appointment.
Vasoconstrictors should be used with caution, no more than 1.8 ml carpules
of Lidocaine 1:100,000 epi should be used.
Post-traumatic Stress
Disorder; Frequent
Anxiety Attacks

Tobacco Smoker

Develops after a terrifying ordeal that involved physical harm or the threat
of physical harm. Patient may be easily startled, or have angry outbursts.
Mr. Burgundy experienced PTSD due to witnessing a friend in the military
burn alive. He stated that he sees his friend in the sky frequently. When
calling him to remind him of his dental appointment, I asked him to bring a
list of his medications, and he experienced an angry outburst, cursed at me,
and hung up on me. In the clinical setting, it is important to minimize stress
and anxiety, and to remain calm when patients experience symptoms of
PTSD.
Complete a thorough IOE to detect any oral lesions including leukoplakia,
smokers melanosis, and nicotine stomatitis.
Increased risk for periodontal disease, tooth loss, caries, and staining.
Impaired wound healing.

Breathing Problems
Enlarged prostate

Experiences coughing and shortness of breath due to smoking.

His last prostate-specific antigen (PSA) test level was 3.5 ng/mL
No significant effect on dental hygiene care.

Family History
Allergies

Parental history of cancer, arthritis, and hypertension.

Tomato seeds

Medication
Citalopram
Taken as
needed

Tamsulosin

Lisinopril

Description & Significance to dental treatment

Description: anti-depressant used for treatment of his anxiety attacks & PTSD.
Significance:
Xerostomia (normal salivary flow resumes upon discontinuation)
Abnormal taste
Confirmed to prolong QT interval & is accepted as having a risk of causing torsade
de pointes. Suggested the clinician consult with the physician prior to use of a
vasoconstrictor in suspected patients, & that the vasoconstrictor (epinephrine,
mepivacaine, and levonordefrin) be used with caution.
May impair platelet aggregation due to platelet serotonin depletion, possibly
increasing risk of bleeding complications. Risk of bleeding complication can be
increased by coadministration of other antiplatelet agents (NSAIDs & aspirin).
Description: Tx of signs and symptoms of benign prostatic hyperplasia (BPH)
Significance:
Orthostatic hypotension & tooth disorder
Description: used for the treatment of hypertension.
2

80 mg/day

Tizanidine
4 mg/day
Amlodipine
10 mg/day

Significance:
May experience orthostatic hypotension as they stand up after treatment;
especially if lying in a dental chair for extended period of time; use caution with
changes in position during and after dental treatment.
An angiotensin-converting enzyme (ACE) Inhibitor cough is a dry, hacking,
nonproductive cough that can potentially interfere with dental procedures if patient
has this side effect.
Description: taking for hypertension. Labeled use for management of spasticity.
Significance:
Significant xerostomia (normal salivary flow resumes upon discontinuation)
Description: Used for the treatment of hypertension.
Significance:
Gingival hyperplasia (although less common with this medication than other
calcium channel blockers) (usually resolves upon discontinuation); consultation
with physician is suggested.

Dental History
Mr. Burgundy first presented to VCU Dental Care on January 23rd, 2013 with several primary and
secondary caries. He has since then undergone several restorations, including amalgam and composite
fillings, root canal therapy, extractions, and core buildups and crowns. He is currently in need of an
additional extraction due to a severe class IV caries on tooth number thirty. After his dental examination
during his dental hygiene appointment, further incipient decay was noted cervically on the facial of tooth
number six, and distally on tooth number eleven. Appointments were already scheduled for further
restorative treatment. As of February 2014, he has no history of reactions towards dental treatments.
However, lack of funds and insurance has played a huge impact on his planned dental treatments.
Abnormalities & Deviations
EOE:
Various macules on head & neck
Crepitus on left TMJ, asymptomatic

IOE:
2x3 mm lesion on right lateral border of tongue where he bit
it & a bump was removed
2x2 mm fibroma on buccal gingiva where tooth #8 use to
be, & 1x1 mm fibroma on maxillary frenum
Bilateral mandibular tori
Xerostomia present & slightly coated tongue

Tooth
Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Restoration
Missing
Missing
MODL composite
Extracted
Missing
MDLF composite
Missing
Missing
Missing
Missing
MDLF composite
Missing
Missing
Missing

Tooth
Number
17
18
19
20
21
22
23
24
25
26
27
28
29
30

15

Missing

31

16

Missing

32

Angles Classification of Occlusions:

Right canine Angle Class: III
Right molar Angle Class: I

Restoration
Missing
Extracted
Missing
Missing
DB composite, O amalgam
OF composite
Sound
Sound
Sound
Sound
Sound
B composite
Missing
Porcelain to high noble metal crown
*Planned treatment for extraction
Root canal tx; stainless steel temporary
crown
*Planned treatment for gold crown
Missing

Left Canine Angle Class: III

Left Molar Angle Class: N/A

Hard Tissue Charting

Oral Health Beliefs & Current Oral Health Practices
Mr. Burgundy is currently utilizing a medium bristled toothbrush once a day. He is prescribed and
using Prevident fluoridated toothpaste. He uses Act mouth rinse once a day. He does not floss, and
explained that its something he will never do. He does not perform any other type of oral self-care or
prevention methods. Practicing proper oral hygiene at home did not seem to be of much importance to
him.
Caries Risk Assessment
After reviewing Mr. Burgundys dental history and obtaining information on his dietary habits, I
have concluded that he falls under the high caries risk. He falls under the lesions category of having three
or more current carious lesions. Secondly, his sucrose exposure between meals easily exceeds five times a
day. He stated that he is constantly sipping on sodas throughout the day. In addition, he experiences
xerostomia due to his medications.
Periodontal Status
4

Mr. Burgundy is currently on a six month recall for a routine adult prophylaxis. During his visit, I
completed assessments and entered a new periodontal chart exam. His perio exam revealed generalized 13 mm probing depths, with localized 4-5 mm probing depths. He had generalized recession of 1-3 mm,
and localized recession of 4-5 mm. He had generalized severe attachment loss, ranging from 1 mm to 8
mms. Class I furcations were discovered on the buccal surfaces of tooth numbers three and thirty. Based
on these assessments, his dental hygiene diagnosis was indicative of generalized severe chronic
periodontitis.
I believe that Mr. Burgundys current periodontal status has resulted from multiple factors,
including his addiction to cigarettes, inadequate plaque removal, xerostomia, and constant exposure to
soda. Scientific evidence has proven that tobacco is strongly correlated with periodontal disease. I
discussed with this patient that smokers are highly susceptible to all types of infections due to its negative
effect on the inflammatory and immune response. I further explained to Mr. Burgundy that there is
scientific evidence which supports that there is a strong correlation between the amount that a person
smokes and the severity of the disease. I felt that this implied to him, as he smokes a pack of cigarettes a
day. One fact that has stuck with me throughout this entire semester is that the risk for periodontal disease
increases six-fold with those who smoke. I was able to share this with Mr. Burgundy as well, and he
seemed very shocked. Aside from smoking, I discussed with Mr. Burgundy that inadequate plaque
removal could be a strong cofactor as well. Without flossing prior to brushing, he is allowing food debris
to harbor in between his teeth, which can eventually break down into bacteria and acids. The bacteria and
acids can then lead to tooth decay, gingivitis, and periodontitis. Lastly, xerostomia and constantly sipping
on soda all day may also be contributing to his tooth decay. Thorough oral hygiene instructions were
necessary for this patient.

Radiographs
Based on several recent radiographs taken in order to diagnose caries, and to continue restorative
treatment procedures, faculty and I discussed that it was not necessary to take additional radiographs at

this appointment. Mr. Burgundy had a panoramic radiograph taken on January 23 rd, 2013. Due to his lack
of posterior teeth, four bitewings were and are not necessary. On September 23rd, 2013, a vertical PA was
taken of tooth number eleven, and additional vertical PAs of tooth numbers 21, 22, and 23 were taken as
well. He then has another horizontal bitewing taken on January 21 st, 2014 of his right upper and lower
molars, which included his upper right canine, as well as his lower right premolar and canine. During his
dental examination at the end of his appointment, the dentist stated that a PA is necessary at his next
appointment due to his 2x2 fibroma were tooth number eight previously was.
Pre-treatment Intraoral Photographs
Prior to treatment, Mr. Burgundy presented to clinic with generalized moderate plaque biofilm
deposits, generalized slight calculus, and localized moderate calculus in sextant five. His gingival
description was generalized coral pink with localized red areas, slightly edematous gingiva, and knife-like
papilla. Root structure was exposed due to generalized recession of 1-3 mm, and localized recession of 45 mm. Class I furcations were present on the buccal surfaces of tooth numbers three and thirty. In
addition, a 2x2 mm fibroma where tooth number eight use to be present was visible, as well as another
1x1 mm fibroma on his maxillary frenum. A 2x3 mm lesion on the right lateral border of his tongue was
present, which he stated was from the removal of a fibroma caused by self-injury. Deviations were
present including bilateral mandibular tori and a slightly coated tongue.
Treatment Planning
Appt
#
1

Tooth/
Quad
All
quads

Treatment

Justification

Prognosis Statement

Adult
prophylaxi
s (D1110)

By removing the etiology, Mr.

Burgundys gingival health should
improve, and probing depths should
decrease.

All
quads

Periodic
oral
evaluation

Remove generalized moderate

supragingival plaque/ calculus
buildup, & localized
subgingival moderate calculus
in sextant 5
Several abnormal hard and
soft tissue variants to be
examined

A periodic oral evaluation completed

by the dentist will determine if any
further treatment is necessary.

All
quads

Topical
fluoride
varnish

Several previous restorations,

xerostomia, sensitivity and
incipient caries present

Tooth
#8

1 Vertical
PA

Patient has a 2x2 mm fibroma

where tooth #8 was previously
located

Applying fluoride will help prevent

future decay and restorations, and
reduce sensitivity caused by root
exposure.
Radiograph will help determine if
any further treatments are necessary
for removal of the fibroma.

Agreement: Mr. Burgundy provided his consent for all of above treatments.

Dental Hygiene Diagnosis Statements

1.

DH Diagnosis
Statement
Xerostomia due to
medications

Goal

Prognosis

Reduce xerostomia by
swishing with
Biotene twice a day

By swishing with Biotene twice a day,

Mr. Burgundy will substitute the functions
that saliva will normally carry out,
including buffering the pH to decrease her
caries risk.

2.

Moderate calculus
present in sextant five
due to inadequate plaque
removal

Eliminate plaque
buildup by brushing
with a soft bristled
toothbrush at least
twice a day

By increasing Mr. Burgundys brushing

from once a day to two times a day, he
will be able to better reduce plaque
buildup, thus leading to less calculus
formation.

3.

Several incipient caries

present due to frequently
sipping on soda

Lower caries risk by

limiting the frequency
of soda, and by
swishing with water
after consumption of
soda

By swishing with water and reducing the

frequency of soda intake, Mr. burgundy
will be able to buffer the pH of his saliva
and reduce further demineralization and
possible erosion.

4.

Hypersensitivity due to
generalized recession of
1-3 mms, and localized
recession of 4-5 mms

Maintain
hypersensitivity
through use of
Sensodyne toothpaste

Using Sensodyne toothpaste, Mr.

Burgundy will be able to reduce the
sensitivity he is experiencing in at least
two weeks.

5.

Generalized moderate
with localized severe
attachment loss due to
smoking a pack of
cigarettes a day
Interproximal tooth
decay due to inadequate
plaque removal

Decrease amount of
cigarettes a day by
replacing boredom with
brushing teeth

Because smoking is such a strong risk

factor for periodontal disease, by reducing
the amount he smokes a day will decrease
his chance of further attachment loss and
tooth loss.
Mr. Burgundy does not floss, so by
adding flossing to his daily oral hygiene
self-care he will be able to better remove
plaque and food debris from the
interproximal surfaces, thus resulting in
less tooth decay.

6.

Decrease caries risk by

flossing at least once a
day

Post-treatment Photographs
Mr. Burgundys adult prophylaxis was completed utilizing the cavitron, hand scaling, rubber cup
polishing, and flossing. All generalized moderate plaque biofilm and slight calculus deposits were
removed, as well all localized moderate calculus deposits. His gingiva was still slightly edematous with
8

localized red areas. Oral hygiene instructions were strongly implemented and discussed in order for Mr.
Burgundy to improve his gingival health and eliminate inflammation.
Oral Hygiene Instructions
To best benefit my patient, I provided Mr. Burgundy with specific individualized oral hygiene
instructions. In the beginning of his appointment, he advised me that he very frequently sips on soda
throughout the entire day. He further explained that he is consistently told that he needs to decrease his
soda intake, but he stated that that was never going to happen and he didnt want to hear it. I advised him
that every time he takes a sip of soda, bacteria in his mouth metabolize the high fructose corn syrup, thus
causing the pH in his mouth to drop, ultimately leading to erosion. In addition, soda contributes to the
more rapid and extensive demineralization of enamel. I explained to him that its not so much the quantity
that we are worried about, but the frequency specifically. To help prevent any further erosion or
demineralization, I asked him to try and limit the frequency of his soda consumption by drinking it with a
meal. I also asked him to swish with water after he sips on his soda to buffer the pH of his saliva.
Furthermore, I advised him that using a medium or hard bristled tooth brush could be contributing to his
recession, and that it can harm his gingiva, root surface, and enamel. I provided him with a soft bristled
toothbrush, and instructed him to use it at least twice a day, rather than just once a day. I provided him
with a GUM Dual Action Tongue Cleaner as well, due to his slightly coated tongue. I explained to him
that the bristle side is used first to dislodge plaque and bacteria from the crevices of his tongue, and the
scraper side is used secondly to remove the loosened plaque and bacteria. I gave him Sensodyne
toothpaste to help with his sensitivity, which was caused by his recession. I told him to use the
Sensodyne in the morning, but to continue to use his Prevident toothpaste at night. I informed him that
it would take at least two weeks for him to notice a difference in his sensitivity. Mr. Burgundy was very
interested in the oral hygiene instructions I provided him with, but he remained adamant in his ways.
As previously stated, Mr. Burgundy is a very heavy smoker. He stated that he had tried to quit
smoking several times, but he failed consistently. He further discussed that house and yard work takes up
a majority of his time, so he enjoys smoking his cigarettes to take a break from his work. He explained
9

that he really wants to quit, but it occupies him when he is bored. Although this patient presented to me
prior to our theory lecture on smoking, I managed to find ways to help him with his decision. I advised
him about the multiple ways that I was already with that have been created to aid in smoking cessation,
and that he didnt necessarily have to quit cold turkey. I told him about products such as nicotine
patches and chewing gum. I also mentioned that he could try picking up other habits like taking a walk or
reading a book when his is bored. Due to his lack of brushing, I gave him the idea to replace a few
cigarettes a day with brushing his teeth instead, and that it takes almost the same amount of time to smoke
a cigarette. Although I am now able to provide more information on smoking cessation, he was quite
enthusiastic about this idea, and said that he was going to try it.
Recall/evaluation Interval
Mr. Burgundy has continued to be placed on a 6-month recall interval. Notes were made in his
chart to of the visible decay that was noted during his dental treatment on the cervical 1/3 rd of the facial of
tooth #6, and distally on tooth #11. . He is currently in the process of having restorative treatment, so
appointments were already scheduled for operative. In addition, the clasp of his upper removable partial
denture for tooth number eleven needs adjustment. Looking back at this patient from the beginning of the
semester, I feel that it may have been fairly necessary to place Mr. Burgundy on a shorter dental hygiene
recall status for multiple reasons. He is considered to be at a high risk for caries, so he would benefit from
being monitored more frequently of his oral hygiene status. Furthermore, he had localized 4-5 mm
probing depths. Until he improves his self at home oral hygiene care, professional removal of plaque and
calculus through closer dental hygiene appointment intervals would be beneficial in improving his overall
oral health.
Evaluation of the Project
Completing this case reasoning project has opened my eyes in many ways as a dental hygiene
clinician. It allowed me to focus on one specific patient whose medications, health issues, and behaviors
induced a negative impact on their overall oral health. It furthermore allowed me to apply my new found
10

knowledge on the several negative effects that tobacco smoking has on an individuals oral cavity as well
as their overall health. Not everyone has the opportunity to come across a patient who is as strong of a
tobacco user as Mr. Burgundy, so this has allowed me to be able to share my experience with other
classmates. Although the information I was able to provide this patient with was limited, it will be that
much easier to discuss smoking cessation with my next patient. Overall, this project allowed me to make
a difference in my patients life by educating him on how important his oral hygiene care is, and I was
able to open his eyes by providing him with smoking cessation tips.
Conclusion
Mr. Burgundys lifestyle choices, medications, and medical status currently play a huge role in
negatively impacting his overall oral health status. His current restorations, abundance of missing teeth,
severe attachment loss, and recession are prime examples of his need for proper and accurate education to
better his oral health status. After thoroughly assessing my patient, I feel that I am now better able to
provide for my next patient that presents to clinic with a strong history of tobacco smoking. After dealing
with a patient who was very stubborn when providing oral hygiene instructions, I better understand how
important it is for clinicians to have the ability to connect with their patients. The happier the patient is
with you, and the more comfortable they feel communicating with you, the better the chances are that
they will listen to you and take your advice seriously. I have also learned that you cannot always take
things to heart when working with patients. They are all unique individuals, and everyone acts the way
that they do for their own reasons. I was terrified for nearly a week over the anticipation of this
appointment after the way our phone conversation went, and he ended up being my favorite patient.
Overall, this case reasoning project has enabled me to identify my strengths and weaknesses as a dental
hygiene clinician, and I cant wait to strengthen these weaknesses throughout the next year in clinic.

11