Portfolio Focus Question Selections

Chapter 5- Case 3
Your dental team has a new patient who has gingivitis. The patient has poor plaque
biofilm control, generalized deposits, poorly controlled diabetes mellitus, a history of
smoking cigarettes, and inadequate dietary intake of calcium. In your patient counseling,
how would you characterize the likelihood that the patient will develop periodontitis in
the future and what might you tell the patient about this?
I would start by explaining to the patient that they present many of the risk factors that contribute
to the development of periodontal disease. You would want to start to work with them on the
things they could do that would help prevent or slow the process of the disease. You would
want to discuss their home oral care with them because they present poorly controlled plaque
biofilm and generalized calculus deposits. You may want to suggest different brushing and
flossing methods to reduce and control the buildup. Patients with diabetes have a higher risk for
oral health problems because of the blood sugar being poorly controlled; uncontrolled diabetes
impairs white blood cells which is the bodys main defense against bacterial infections in the
mouth. When left uncontrolled diabetes also leads to a decrease in saliva flow, this increases
the risk for tooth decay and infection. Diabetes also causes blood vessels to thicken which
restricts the flow of nutrients to the mouth as well as other body parts, it also slows the waste
removal. In combination the ability of the patient to fight infection is reduced. Those with
uncontrolled diabetes also do not heal as fast after oral surgeries because the blood flow to the
area may be impaired. Those who smoke and have diabetes have a 20% higher risk of
developing periodontitis. Smoking also reduces the blood flow to areas which may affect
wounds healing in the mouth. Even though they are a former smoker they are still at a higher
risk than others. The patient needs to be encouraged to get diabetes under control and
continue to not smoke. The patient should also be given some dietary counseling to ensure all
food groups are incorporated into their daily diet. It would be important to increase calcium
intake to help maintain bone strength. I would put the patient on a 3 month recall to monitor the
effect diabetes has on the oral cavity.
Chapter 6- Case 1
You have just completed a thorough cleaning of a tooth surface. Describe what deposits
you might expect to form on the tooth surface over the next few days if the patient does
absolutely no further cleaning of the tooth surface.
Within several minutes after cleaning a film forms over the tooth surface, this film is the acquired
pellicle. The acquired pellicle is composed of a variety of salivary glycoproteins and antibodies.
Its function is to protect the enamel from the acidic environment, unfortunately the pellicle also
alters the charge and energy of the tooth surface, causing bacterial adhesion. Within a few
hours after the pellicle formation bacteria begin to adhere to the pellicle. The first bacteria to
adhere to the acquired pellicle are nonpathogenic gram positive oragnisms, including

Streptococcus mitis, Streptococcus oralis, and Actinomyces viscous. The early colonizers being
to multiply and send out a signal that indicate the conditions are favorable for the next group to
join the biofilm. Many intermediate colonizers cannot adhere to the acquired pellicle but these
gram-negative bacteria coaggregate with the early colonizers. Some intermediate colonizers
include Fusobacterium nucleatum and Prevotella intermedia. These intermediate colonizers
then coaggregate with the late colonizing gram- negative anaerobic bacteria. The late
colonizers include P. gingivalis, and Capnocytophanga gingivalis. One late colonizing grampositive bacteria is Actinomyces israelii.
Chapter 9 Case 2
Mrs. Smith is a new patient in the dental office. Mrs. Smith is 45 years of age and works
as an accountant. Mrs. Smith had not received regular dental care in the past; however,
her new employer provides dental insurance for his employees. Mrs. Smith has chronic
periodontitis. How will you explain inflammatory periodontal disease to Mrs. Smith?
To begin explaining Mrs. Smiths disease state to her I would find a visual aid to show her the
difference between healthy gum tissue, gingivitis, and periodontitis. I would start at the very
beginning explaining how bacteria colonize on the teeth and form the plaque biofilm. The
presence of these bacteria signal the bodys defense system to the infection site. When the
bacterial biofilm and the bacteria are not removed daily by homecare such as brushing and
flossing, the bodys defense system is initiated and releases cells that over time actually begin
to destroy the tissue around the tooth. At this stage only the gum tissue is infected, it may be
red in color, swollen, and may bleed. The tooth however is still in the bone, there has been no
bone loss, and the disease state is reversible. When this bacteria is left undisrupted they
multiply and the bodys defense system is overwhelmed and begins to attack the gum tissue
and the surrounding bone. This tissue and permanent bone destruction increases the pocket
depth of the tissue around the tooth. The depths of these pocket are too deep for a normal
brushing and flossing to reach. However with regular recall visits and proper daily homecare,
we can help Mrs. Smith reduce the risk of the infection from spreading somewhere else in her
body. There are always several different analogies you could use to describe the condition to
Mrs. Smith if she doesnt seem to understand. I like the analogy of the tooth pocket being like a
turtle neck, or the analogy of termites eating the foundation of a house away to describe the
progression.
Chapter 11 Case 1
A new patient with severe chronic periodontitis has a history of smoking one to two
packs of cigarettes each day. The patient informs you that he will do anything to save
his teeth, but that he cannot quit smoking. What counsel would you provide this patient
about the effect of the smoking habit on the likelihood of long-term control of his
periodontitis?
I would start to council the patient by simply stating the facts. It would be important to let them
know that cigarette smoking is one of the most significant risk factors in the development of
periodontal disease, and that more than half of the periodontitis cases in the U.S. are

associated with smoking. There are many studies that compare smokers with nonsmokers with
periodontitis and smokers have more recession of the gingival margin and more attachment
loss, they have more bone loss, deeper pocket depths around the tooth, more furcation
involvement and more tooth loss. Tobacco smoking plays a role in periodontal disease that
does not respond to treatment even with patient compliance and appropriate therapy. There are
also studies that show smokers harbor different types of bacteria in the plaque biofilm as well as
higher numbers of pathogenic bacteria within the mouth. Smoking also results in changes in the
pocket which may lead to the presence and survival or more pathogenic bacteria. I would make
sure I inform my patient that clinically smoking may lead to a fibrotic response in the gum
tissue with less bleeding, inflammation and redness, but there can be hidden deep pockets,
attachment and bone loss. Smoking and nicotine impair the bodys host defense. Tobacco
smoke and nicotine can inhibit the functions of the bodys cells to attack the infection, and may
also increase the production of the bodys inflammatory mediators which then begin to attack
the surrounding tissue and bone. Smoking impairs healing in all aspects of periodontal
treatment.
I would then start to discuss with my patient the effects of smoking cessation on the
periodontium. The periodontal health status of former smokers is not as good as those that
have never smoked but it is better than those that currently smoke. The effects of smoking
cannot be reversed but can be beneficial to the health of the peridontium and the overall health
of the individual. Some benefits of tobacco cessation are reduction of the pathogenic bacteria
present in the plaque biofilm, improved circulation to the gingiva and an improvement in the
bodys immune response. There are many options to help an individual quit or cut back on
smoking. I would inform my patient of the variety of options, such as medications (Chantix),
Nicoderm patches and chewing gum, support groups such as the quit line.

Chapter 28- Case 1

A patient shows you a bottle of mouth rinse and asks you if it would be alright to use this
mouth rinse instead of brushing and flossing frequently. You study the label on the
bottle of mouth rinse and find that the active ingredients are the essential oils. How
should you respond to this patient about substituting this rinse for other self-care efforts
such as brushing and an interdental brush?
I would start by letting the patient know that there is no alternative to daily brushing and flossing
that would be effective enough to disrupt the plaque biofilm. I would start by explaining using
my favorite analogy of peanut butter on a knife. The plaque biofilm is the sticky peanut butter
and when rinsed under water most of the peanut butter is left behind until removed with a dish
brush or sponge. Same as the rinse is not effective in removing the peanut butter, the oral
mouth rinse is not effective in removing the plaque biofilm. There are many benefits of mouth
rinses when used in conjunction with daily brushing and flossing, they are not effective as an
alternative option.