Running head: CAPSTONE PROJECT: A SOCIAL SMOKER 1

Capstone Project: A Social Smoker

By: Stacy Yu

In partial fulfillment

Of the requirements for

Lake Washington Institute of Technology

DHYG 438: Senior Capstone

Danette Lindeman, RDH, MEd

Spring Quarter 2019

4/17/2019
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Assessments
Medical History
A 25 year old female comes to the Lake Washington Institute of Technology

dental clinic with a chief concern of the need to have her teeth examined and cleaned.

The patient has been under the care of ICHS, a community health clinic in Holly Park

Seattle for both dental and medical care. She was interested in trying our clinic for her

next dental cleaning.

At her initial appointment, a health history was completed and reviewed. The

patient presented with no medications or notable health concerns. The patient had an

IUD placed for pregnancy prevention 8 months prior to her initial exam. The patient did

not originally record this in her health history, but we later discussed at her next

appointment her lifestyle habits such as cigarette smoking. The patient enjoys social

smoking and this occurs most often on the weekends. Since she is still considered a

smoker, she is a patient who is more at risk for periodontal disease due to its

ingredients and by-products. “Smoking creates a favorable environment for bacteria in

the mouth like Porphyromonas gingivalis, Prevotella intermedia, and Aggregatibacter

actinomycetemcomitans as by-products of smoking inhibit the mechanisms of

preventing the growth of bacteria in the oral cavity” (Shah, 2016).

After the completion of her health history, vitals were taken. The patient had a

blood pressure reading of 110/72 mmHg using a manual cuff. Her pulse recorded at 68

bpm and was regular. The patient was overall healthy, but because of her IUD and

occasional smoking, was categorized in ASA II.

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Extraoral and Intraoral Examination

During her initial appointment, a thorough extraoral examination of the head and

neck was done. The patient’s chin is centered over her forehead and her ramus is even.

She had a few moles, the more prominent ones on her upper lip measured 1x1mm and

on the left side of her neck measured 1x1mm. The patient presented with scattered

pustules on her cheeks and chin. Upon opening of the jaw, there was lateral deviation to

the right side. In the intraoral examination, the patient had moist, red labial mucosa.

There was slight bilateral linea alba on the buccal mucosa. Her palate was rounded and

her airway was a little difficult to see. There was exostosis present around the buccal of

her maxilla and mandible. Her maxillary right 3rd molar was present and her maxillary

left 3rd molar was erupting. Her tongue was slightly coated with bilateral scalloping.

Gingival Description
The patient exhibited gingivitis. The marginal gingiva was coral pink with slight

pigmentation on both the maxilla and mandible. There was localized slight erythema on

sextants 1 and 3, as well as on the lingual surface of the mandible. The gingiva was

generally knife edged with localized slight rolling around the lingual of sextants 1 and 3,

as well as the buccal of the mandibular premolars. Her tissue was generalized pointed,

firm, and stippled.

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Tooth Chart and Occlusal Assessment

During the doctor’s exam, the occlusal assessment was verified as class I Angle’s

classification for both the right and left canines, including the right molar. The left molar

was verified as class III. The patient has a slight overbite with an edge to edge bite

involving #13-14 over #19-20. Patient also has 2mm overjet. The patient’s hard tissues

include three composite fillings (#2, 18, 31) and four amalgam fillings (#3, 19, 21, 30).

She has a root canal on #14 that has a composite access filling. The patient

acknowledged the need for a crown which was recommended by her previous dentist

and was further reiterated by Dr. Koutsoumbas during her new exam. These

restorations have been placed due to the presence of tooth decay and to prevent any

further damage. There is localized attrition on the incisal edges on her anterior teeth,
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#7-10 and #23-26. Bruxism and malocclusion can contribute to the presence of attrition.

Due to having a few fillings on her posterior teeth, it is important to have recall exams

and take radiographs periodically for maintenance but also to monitor for new or

recurrent decay.

Dental Examination
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For the patient’s restorative treatment plan, Dr. Koutsoumbas explained to the

patient that the filling which was previously placed on #14 still looks good and healthy,

but ultimately a crown is still ideal. A crown prep and seat was treatment planned. Dr.

also recommended a PRR on #15 due to deep grooves and for preventive care. The

treatment plan and reasoning was fully explained and understood by the patient.

Periodontal Chart

The initial periodontal chart presented with generalized 2-3 mm pockets,

localized 4 mm pockets with a 7 mm pocket on the distal of #31, localized 1-2 mm

recession, and localized slight bleeding on probing on the posterior teeth. These results
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are related to the presence of gram negative bacteria, which play a role in gingivitis and

periodontal disease. Additionally, recession results from toothbrush abrasion, the

patient’s habit of bruxism, malocclusion, or bone loss. The goal for this patient includes

completion of initial therapy Scaling and Root Planing (SRP). Following initial SRP

therapy, the patient will most likely be recommended a 6 month prophy, but this recare

interval will be determined at the tissue re-evaluation. The patient currently uses an

Oral-B electric toothbrush, so an angled brushing technique was demonstrated to her

with emphasis on gentle pressure in order to avoid further damage to the gingiva and

teeth. The “C” shaped flossing technique was also demonstrated to the patient using

waxed floss. Since the patient presented with a 7mm pocket on the distal of #31, a perio

aid was recommended and demonstrated to her to help with biofilm removal.

Caries Risk Assessment

The main risk factors for this patient includes her occasionally smoking, her high

carb intake, and lack of using interproximal aids. Smoking causes the immune system

to have a lowered response to bacteria, which results in the ability for biofilm to

accumulate. Also, “Recent research have suggested that plaque is more adherent to the

tooth and less freely removed from the teeth of smokers due to the deposition of tars

from smoke” (Shah, 2016). As a result, tooth brushing is less effective in smokers than

those who do not smoke. A high carb intake increases risk of caries. Fermentable carbs

are easily broken down by bacteria in the mouth and produce acid as a by-product. The

acid from this bacteria then breaks down the tooth structure and can further cause

caries. The last risk factor is the patient does not currently floss so biofilm is most likely

building up interproximally. It will be important for me to discuss the possibility of

CAPSTONE PROJECT: A SOCIAL SMOKER 8

tobacco cessation in order to improve her health orally and systemically. I will also

discuss dietary habits and go through a nutritional analysis with the patient. During her

future SRP appointments, homecare habits will be reviewed and demonstrated,

including proper flossing techniques.

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Risk Assessment

The patient does not currently take any medications or have any health

concerns besides being a social smoker. She has an IUD placed to prevent pregnancy.
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The patient has a medium stress level that comes from working 6 days a week from 10-

7pm and her exercise level is also moderate. There was no significant findings within

the hard and soft tissues. The patient was open to OHI/product recommendations and

any new information. My biggest goal for her was to improve homecare and discuss

tobacco cessation.

Radiographs

Plaque Index and Oral Hygiene

After disclosing the patient, she presented with a plaque index score of 70%. The

patient brushes two times daily with an Oral-B toothbrush and medium bristles. The

patient stated she used to floss daily for a month until she stopped. She explained the

reason she stopped was because she got busy. After all assessments were completed,

the patient was classified as II/2/D2.

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Pre-Treatment Intraoral Photographs

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Nutritional Analysis
A seven day food log was given to the patient to keep track of what she was

eating from Monday-Sunday. The patient was able to record what she had for breakfast,

lunch, dinner, and any snacks in between the meals. After the patient completed all

seven days of food logging, it was reviewed during our appointment. The most

noticeable concerns regarding her diet was the amount of refined grains and sodium

being consumed, as well as the occasional consumption of sugary drinks. The patient

also had a coffee product almost every day which falls into the category of a

fermentable liquid. Fermentable carbohydrate consumption is known to cause an

increase of caries risk due to the fact that they are easily broken down by bacteria in the

mouth which then releases acid as a by-product. The acid then breaks down tooth

structure. “Dental caries cannot develop without the presence of dietary fermentable

carbohydrates, in particular sugar… Gingival bleeding and destructive periodontal

disease are sensitive markers to both abnormalities in macronutrient content (excessive

carbohydrates or poly-unsaturated fat intake, deficient protein intake) and micronutrient

intake (e.g. vitamin C and B12)” (Hujoel, 2017). Another concern was the amount of

sodium that was being consumed daily. Although my patient does not have high blood

pressure, we do not want to risk the development of it.

The recommendations given to the patient were to try and lessen the amount of

refined grains being consumed or to find possible replacements for them, such as whole

grain bread. It was also recommended to watch her daily sodium intake or choose

options that had lower sodium content. Decreasing the amount of coffee consumption

was not an option for the patient because she works long hours, so it was
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recommended to reduce the amount of sipping on the coffee throughout the day and to

drink more water afterwards to wash it away. The patient was understanding and

agreed to commit to trying more whole wheat options or substitutes, as well as drinking

more water throughout the day and sipping less on her sugary drinks.

Dental Hygiene Diagnosis

The dental hygiene diagnosis was used to outline the individualized care plan for

the patient. The patient has an IUD placed for pregnancy prevention and also socially

smokes. My goal planned for the patient is to encourage her to have an annual checkup

by her physician since she does not routinely receive one and to also discuss tobacco

cessation later on in our appointments. The patient’s last continuing care appointment

was in January of 2018, which was 7 months prior to when I saw her for her new patient

assessments. The patient is on Apple Health insurance and is not covered for more

than one cleaning annually so was searching for an option that would be financially

sound. On the EO/IO examination, I recorded scattered moles and pustules. We will

later talk about her diet and stress levels, as well as possibly going to see a

dermatologist for her acne. Her gingival description and periodontal findings were

potentially resultant from pathogenic bacteria and may also be due to her homecare

habits.

My goals are to instruct the patient on proper brushing technique with her electric

toothbrush in order to get her bristles underneath her gum tissue. The patient currently

uses an Oral-B tooth brush, which has proven to be more effective on removal of plaque

compared to a manual tooth brush. “Results of the comparative assessment between

the two brushes, the use of the Oral-B brush presented a statistically significant
CAPSTONE PROJECT: A SOCIAL SMOKER 14

reduction of 89% in plaque index, 85% in gingival index, and 93% in bleeding scores.

The manual brush presented reduction of 68% in plaque index, 75% in gingival index,

and 72% in bleeding scores” (Dhir, 2018). Furthermore, “An 8-week clinical study

comparing Oral-B brush with a sonic brush revealed statistically significant plaque

reduction results for the Oral-B brush. Whole mouth, gingival margin, and approximal

plaque reductions were 27.7%, 46.8%, and 29.3% greater, respectively, compared with

that of the sonic brush, while the reductions in gingivitis, gingival bleeding, and the

number of bleeding sites were 34.6%, 36.4%, and 36.1%” (Dhir, 2018).

Another goal is to demonstrate “c” shaped flossing and to encourage the use of

floss in her oral hygiene routine. I will also recommend her to switch to softer bristles.

The patient will be instructed on how to use a perio aid to help debride the 7mm pocket

located on #31. The patient’s source for fluoride comes from using her OTC toothpaste

2x daily and drinking fluoridated water. This patient would benefit from fluoride

application in order to protect and prevent risk of caries. Through examination of hard

tissues, the patient presented with attrition on her anterior teeth, this is often times

caused by clenching and grinding, but can also be due to malocclusion. Patient stated

she does not notice herself clenching or grinding much, but is definitely interested in

orthodontic work in the future. The patient has been extremely compliant during her

initial treatment and has been showing motivation.

Planning

The goal of performing full mouth SRP therapy on this patient is to get her tissue

back into a healthy state by reducing pocket depths and stabilizing the progression of

gingival disease. While seeing the patient for quadrant cleanings, there will also be
CAPSTONE PROJECT: A SOCIAL SMOKER 15

instructions and education on how the patient can improve her current homecare and

lifestyle habits. After each quadrant cleaning, I also plan to use subgingival irrigation to

help aid in the healing process. The patient has agreed to switch her Oral-B bristles to

softer ones and to brush her teeth at an angle towards her gums. The patient has begun

flossing every other day using the “c” shaped flossing technique. Our end goal is to

increase her flossing frequency to once a day. I am hoping to increase the patient’s

knowledge and understanding on the importance of proper homecare. We also

discussed that later on we would talk about tobacco cessation. When the patient returns

in 4-6 weeks for her tissue re-evaluation, plaque index will be measured again as well

as during her continuing care appointments in order to document changes. The dental

hygiene treatment plan consisted of 4 quadrants of non-surgical periodontal therapy

(4341). This is the recommended treatment because the patient presented with four or

more teeth periodontally involved in each quadrant. There was generalized 4mm

pockets and one 7mm pocket in her posterior teeth, as well as 1-2 mm localized

recession areas. Education was given to the patient on why fluoride would be beneficial

for her, due to its desensitizing property, protection from caries, and remineralization of

tooth structure. Education was also given to the patient to reduce pocket depths and

maintain health. The patient agreed to incorporate flossing again in her routine.

Implementation

Treatment was planned to be completed in 6 appointments and was able to

completed within that amount of appointments. New patient assessments took a total of

2 appointments while her subsequent 4341 SRPs took 1 session per quadrant. At the

first appointment, an angled brushing technique was demonstrated since it was

CAPSTONE PROJECT: A SOCIAL SMOKER 16

important for the patient to be using a technique that would allow the bristles to reach

underneath the gums. Through research, it has also been proven the Bass method is

the most effective way of plaque removal. “Through a review of the efficacy of plaque

control by various tooth brushing techniques, it was found that, compared to all the

prevalent tooth brushing techniques, (Stillman’s method, Charters method, Scrub

method etc.), modified Bass/Bass technique is the most effective in reducing plaque

and gingivitis. Literature also suggests that, in some instances, by using the Bass

technique the cleaning efficiency can reach a depth of 0.5 mm subgingivally”

(Janakiram, 2018). The patient implemented this technique with her Oral-B toothbrush

and less biofilm was visible at her visits. The patient was also instructed to replace her

bristles with softer ones.

At her second appointment, the “C” shaped flossing technique was demonstrated

to the patient. The patient showed interest in getting back into the habit of flossing from

her previous appointments and responded well to the demonstration. At her last

appointment, a review of both the brushing and flossing techniques were given to the

patient to ensure she would continue using them. The disease process and the benefits

of fluoride were also explained to the patient. Overall, the patient showed continuous

motivation in improving her homecare throughout the appointments. Before our

appointments together, the patient had no idea of her current oral health status and her

motivation was influenced by the need for her to have a deep cleaning. The patient

wanted to get her oral health stable again.

Treatment began with using the cavitron. The green universal cavitron tip was

used since the patient had biofilm and multiple clickable pieces of calculus in the
CAPSTONE PROJECT: A SOCIAL SMOKER 17

interproximal surfaces of her posterior teeth. The cavitron helped loosen and take away

pieces of calculus as well as remove biofilm and irrigate the pockets. Due to the deeper

pockets present in her posterior teeth, both universal curettes and Graceys were used

for hand scaling. The 13/14 and 11/12 were used for easy access to the posterior teeth

on the mesial and distal surfaces due to their ability to go subgingival into deeper

pockets. Calculus removal strokes were used only in areas where calculus pieces were

found. On the anterior teeth, the sickle scaler was used to get into the tight contact

areas and the ¾ universal was used to get subgingival calculus pieces. Each quadrant

was assessed with an explorer using an assessment stroke and if rough or left over

were pieces found, a 4R 4L or 5/6 was used. At her last SRP of the LL quadrant,

subgingival irrigation was used with Chlorhexidine in order to accelerate the healing of

her gum tissue in that area. The patient handled each appointment very well. Oraqix

was used in each quadrant except the LL where local anesthesia was used due to

increased sensitivity. The patient was also instructed to use warm salt water rinses if

she experienced soreness after the SRP appointments.

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Post-Treatment Intraoral Photographs

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Evaluation

The patient presented for a tissue re-evaluation 4 weeks after the last SRP quad.

Through the tissue re-evaluation it was determined that this patient responded well to

the SRP treatment. There was reduction in pocket depths in most areas, although some

areas remained the same. A few 4mm pockets in the posterior interproximal regions

reduced to 3mm pockets. There were still 4mm pockets that remained the same from
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previous measurements. The patient had all four of her wisdom teeth extracted in

October at Swedish Medical Center. The patient presented with a healing socket behind

#31 which may have contributed to the increase in pocket depth from 7mm to 11mm.

There was also a general reduction in BOP. Her gingival condition improved. Overall

less erythematous, edematous, and rolled tissue. She started with slight redness on

sextants 1, 3, and on the linguals of the mandible. The erythema reduced in areas, with

localized slight redness on sextants 1, 4, 6 lingual at the tissue re-evaluation. Patient

also had slight rolled gingival margins on the lingual of sextant 1 & 3, as well as the

buccal mandibular premolars that were no longer present at the tissue re-evaluation.

The patient’s gingiva remained knife edged, stippled, and pointed. Another plaque index

was completed to compare with the previous plaque index prior to initial therapy. The

score was 70% initially and 18% at the tissue re-evaluation appointment. This is a

significant decrease in plaque present. The patient had been consistent with brushing

twice daily for at least two minutes and had also increased her flossing frequency from

occasionally to every other day. The patient was pleased to hear in the decrease of

plaque present. It was encouraged that she continue her routine as the results were

showing improvements in health. The “c” shaped flossing technique was re-

demonstrated to the patient to ensure she was flossing effectively and also a perio-aid

was demonstrated to help keep the pocket on the distal of #31 clean.

A tobacco cessation was also completed during this appointment since the

patient is a social smoker. First, I asked the patient if she wanted to quit smoking. She

showed interest in quitting so I further discussed the effects of smoking such as

staining, increase in blood pressure, increase in lung cancer, and other effects on oral
CAPSTONE PROJECT: A SOCIAL SMOKER 21

health. The patient stated that she smokes on the weekends and usually smokes about

two cigarettes. Her biggest trigger is alcohol and will only smoke when she has had

about three or more drinks. The patient stated that in order to stop smoking, she would

have to start consuming less alcohol. This was already a goal that she was planning to

accomplish in the future anyways, so she did not think it would be difficult. I encouraged

the patient to work on that goal and would follow up with her in a week to see how she

was doing. I followed up with the patient about a week later and the patient stated that

she has been consuming less alcohol on the weekends, which has resulted in her

smoking less or none at all. I reassured the patient on doing a good job and let her

know to contact me if she needed support.

Periodontal Maintenance

This patient was placed on a 6 month prophy recall appointment schedule. This

is because the patient was categorized in AAP II which means that there is generalized

slight bone loss. The 6 month recall plan is a non-surgical approach in preventing

further gingival disease. The patient presented to the clinic for where an adult prophy

was completed with fluoride varnish placed at the end of the appointment. Homecare

techniques was also reviewed with the patient including brushing towards the gumline,

behind terminal molars, and flossing with a “c” shape. It is important for the patient to

come back every 6 months for a checkup and cleaning in order to monitor for any

caries, remove any residual build up that is being missed with homecare, and also

examine the patient’s homecare and overall oral health.

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Reflective Conclusion

For this project, I was able to use the skills and knowledge that I have acquired

overtime from didactic classes and also from clinic to provide thorough, quality

treatment to my patient. Through didactic classes, for instance Periodontology, I was

able to explain to my patient the disease process and importance of having good

homecare. I was able to educate the patient on homecare techniques and products that

would work best for her individually. I was also able to give my patient advice on

nutrition and what she could work on in order to decrease her risk of caries. I used my

knowledge on smoking and it’s relation to periodontal disease to perform a tobacco

cessation. With my clinical skills, I was able to design a treatment plan that was fitting

for the patient. I used the cavitron and specific instruments in areas that worked best,

along with pain management techniques.

I believe that I grew extremely throughout the course of this project. I took much

longer during the first appointments to fully complete everything. As time went on, I

found myself improving and becoming more and more efficient. Different tasks started

to become more comfortable to me including instrumentation, using certain instruments

in specific areas, different positioning, cavitroning, and administering local anesthetic. I

also became more comfortable with conveying important information to the patient.

I excelled in time management and patient comfort. I never experienced an

issue with running behind with time during my appointments. My patient did show up
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late to almost all of her appointments, but I was still able to get her out in time for work. I

also made sure my patient was always comfortable during the appointments, whether

that was with pain management or just offering a pillow. My patient praised me for

providing her with pain-free procedures. The area I believe I can improve on is finding a

way to be more motivating to the patient and using the right words. My patient did

improve on her homecare, but I feel as though I could have been better at explaining

why it is so important to have good oral health. I do think I will become more

comfortable with this overtime.

Documentation

All aspects of documentation were completed. At every appointment when writing

chart notes, a thorough explanation of procedure was completed. During each visit, the

patient’s chief concern was addressed. The chart audit was completed. The student’s

ability to maintain accurate documentation was evident. All chart entries were proofread

by an instructor to ensure documentation was accurate. This senior capstone project

serves as a tool to assess all aspects of a patient’s wellbeing and not just oral concerns.

It serves as an ideal example and template that should be followed when treating all

patients. As dental hygienist we must treat our patients with the utmost quality of care

while catering a care plan specific to their individualized needs. Analysis of each phase

of treatment for this patient was an effective way of demonstrating the knowledge we

received through didactic and clinical learning here in the LWTech Dental Hygiene

Program.
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References

Dhir, S., & Kumar, V. (2018). Efficacy of oscillating – Rotating toothbrush (Oral –B) on

periodontal health - A 4 week controlled clinical and microbiologic study. Journal

of the International Clinical Dental Research Organization,10(1), 12.

doi:10.4103/jicdro.jicdro_32_17

Hujoel, P. P., & Lingström, P. (2017). Nutrition, dental caries and periodontal disease: A

narrative review. Journal of Clinical Periodontology,44. doi:10.1111/jcpe.12672

Janakiram, C., Taha, F., & Joe, J. (2018). The Efficacy of Plaque Control by Various

Tooth brushing Techniques-A Systematic Review and Meta-Analysis. Journal of

Clinical & Diagnostic Research,12(11), 1-6.

doi:10.7860/JCDR/2018/32186.12204

Shah, A., Batra, M., Baba, I., Saima, S., & Yousuf, A. (2016). Periodontal disease and

smoking: An overview. Clinical Cancer Investigation Journal,5(2), 99.

doi:10.4103/2278-0513.177132