Case Scenario 2: Periodontal Disease – Smoker

Your patient, William Bagley shows up after 5 years of not seeing a dentist or hygienist. His chief complaint is that his teeth have gotten very brown and wants a whiter smile. He admits he hasn’t been taking very good care of his teeth because he has been so busy with the construction company that he owns. He wants you to “clean them up” today and is curious about whitening his teeth and his available options.

You review his health history where he reveals he is a smoker and has no allergies or history of tooth sensitivity. When you ask further questions about the stain you learn he drinks 2-3 cups of coffee a day and his home care habits consist of using a manual toothbrush in the morning with “whatever toothpaste my wife buys.” He also indicates he has tried to stop smoking but has relapsed. Upon completing an oral assessment, you notice very inflamed tissue with generalized bleeding on probing with pocket depths of 4-5 mm and slight recession throughout his mouth. Radiographs reveal calculus, which is confirmed through exploring. The brown stain he is concerned about is primarily on lingual and interproximal surfaces. No caries are detected and all previous restorations are in good condition.

After all assessments, you decide the patient will need scaling and root planing (SRP) treatment, which will take two-three appointments. You give Mr. Bagley a hand mirror so he can see the condition of his mouth and show him his radiographs pointing out the calculus. Next you explain the SRP procedure, stressing the importance of regaining and maintaining a state of health. You discuss that the brown stain is extrinsic – meaning the SRP will help remove that surface stain and will help address his concern with wanting whiter teeth. You explain that after the SRP treatment, and he regains health, you will be happy to discuss other whitening options if he still feels he would like his teeth to be whiter.

You educate the patient on proper homecare habits including recommending an electric oscillating rotating toothbrush and stannous fluoride toothpaste for his gingival condition and tooth whitening. Use of interdental aides, such as a proxy or interdental brush are stressed since the papilla does not fill the embrasure space in most areas. After having him demonstrate these homecare procedures and suggest he do them twice a day. This, along with counseling him on smoking cessation and regular maintenance appointments should address his periodontal condition and reduce the amount of staining.