Mr.

Tomlinson
Caitlyn Olds, Kirsten Schrobback, Jenna
Martene, & Natalie Stockley
Introduction to
Mr. Tomlinson:
Mr. Tomlinson is a 48-year-old patient who is new to
your dental office. He works as a computer
technician in a large local firm. This is his first job
following an extended tour of military duty.
During his initial visit, Mr. Tomlinson explains that
he has no dental problems, but he decided to make
an appointment for a “cleaning” since he has a new
dental insurance plan. He tells you that everyone in
his family has always had pretty good teeth, so he is
certain that you will not find anything wrong with his
teeth or with his old fillings.
Mr. Tomlinson's
Health History:
On the day of his first visit to your dental
office, Mr. Tomlinson’s blood pressure is
132/82 mm Hg and his pulse is 64 beats/min.
Review of Mr. Tomlinson’s health history
reveals that he is taking two medications:
atorvastatin tablets and fluticasone
propionate nasal spray.
He states that he is currently under treatment
for post-traumatic stress disorder (PTSD) that
has resulted from his multiple military
deployments.
 What factors in Mr. Tomlinson’s health history will be
critical for the dental team to consider during treatment?

PTSD may induce the following

Mr. Tomlinson's blood CDHO BP Guidelines:
pressure is elevated and would symptoms within the dental
require them to take the 1. Re-check BP after 5 minutes setting:
client's BP again after 5 2. Continue with dental hygiene Increased blood pressure
minutes
care and Procedures as sweating
Monitor the client’s BP at
subsequent appointments. required trembling
Refer to the CDHO guidelines 3. Give the patient/client a uneasiness, etc.
listed written note of all the BP Stress reduction protocols in
Implications to DH care: readings place to ease the client
Atorvastatin medication 4. Refer the patient/client for a morning appointments
muscle weakness or
medical consultation avoiding triggers
myopathy can cause
difficulty brushing teeth calm communication
(CDHO, 2014)
and swallowing
Caitlyn
 What signs of inflammation are evident in
Mr. Tomlinson’s clinical photographs?

Photo #1 Photo #2 Photo #3

Right side facial view: Left side facial view

Anterior teeth facial view: 24-27 facial
21/22 facial 14, 16, 17 facial
44 & 47 facial 33/34 Interproximal

Caitlyn
(Gehrig, 2020)
 What etiologic risk factors for
gingival and periodontal diseases
are evident from Mr. Tomlinson’s
clinical evaluation?

Generalized plaque biofilm

Generalized Supragingival and
Subgingival Calculus
Faulty and leaking margins on existing
restorations
Generalized attrition and wear facets
Generalized staining
Possible carious lesions
(Gehrig, 2020)
Caitlyn
 Does Mr. Tomlinson’s periodontal evaluation
indicate that he has attachment loss on some of
his teeth? How did you arrive at your conclusion?
CAL is the apical migration of the junctional epithelium
to the tooth root, when this happens there is also
destruction to the gingival and PDL fibers.

Yes Mr. Tomlinson’s periodontal evaluation indicates

that he has attachment loss.

Normal attachment loss ranges from 0.5-1mm in a

healthy adult. Mr. Tomlinson has CALs that range from 1-
7mm making his attachment loss severe in localized
areas.

Natalie
(Gehrig, 2020)
 What etiologic risk factors for gingival
and periodontal diseases are evident
on Mr. Tomlinson’s radiographs?
Modifiable Local Anatomical Risk Factor:
Bone Loss:
20-30% on 32-42.
Can make OSC difficult in the areas of bone loss
leading to gingivitis and periodontitis.
If the bone loss continues it can lead to tooth
loss increasing the risk for periodontitis.
Un-erupted 8s on Max:
Specifically the 18. If if begins to erupt it can
push against the 17 and make the teeth shift and
lead to bone loss around those posterior teeth.
Difficult to perform OSC in this area as well.
Modifiable Local Acquired Risk Factor:
Abfraction on 12M

Natalie
(Gehrig, 2020)
On Mr. Tomlinson’s radiographs, what
specific findings indicate that the
alveolar bone level is normal or
abnormal?
If there was no bone loss the crest
of the bone would be 1-2 mm from
the enamel on the radiographs.
An example of this is below:

Localized HBL of 50% on

17D and 26D.

Generalized 20-30% HBL

Natalie
(Gehrig, 2020)
 How should you characterize Mr. Tomlinson’s periodontal condition?
Do you think he has gingivitis, periodontitis, neither, or both? What
clinical or radiographic findings did you use to reach your conclusion?
Periodontal Condition: Stage III Grade B periodontitis
Staging:
Localized areas of CAL 5mm or more
Bleeding generalized
Mobilities: 26 (Grade 1 mobility)
Bone Loss: Generalized HBL 20-30%
Localized HBL 50% (17D & 26D)
Missing Teeth: 8
Generalize PD's: 1-4mm, localized 5-7mm
Furcations: present on 16, 17, and 26
Grading:
50% bone loss. (50% / 48 age) = 1.0
(indirect evidence)
No Grade Modifiers

Jenna (Gehrig, 2020)

 Develop a step-by-step plan for nonsurgical
periodontal therapy for Mr. Tomlinson.
PHASE I: Non-Surgical Periodontal Therapy - Includes all measures used to control
periodontal disease
Toothbrushing (modified stillman), Interdental Brush (proxabrush), OHE
(periodontitis), OHE (Caries Process)
Debridement, Fluoride varnish

PHASE II: Surgical Therapy - Includes any needed surgical interventions to control or
eliminate periodontal disease
Possible need for Periodontal Flap Surgery (allows for more effective scaling and
root planing in deep pockets)
Possible need for Soft Tissue Grafting (augments the width of attached gingiva due
to recession)
Jenna (Gehrig, 2020)
 Develop a step-by-step plan for nonsurgical
periodontal therapy for Mr. Tomlinson.
PHASE III: Restorative Therapy - Includes placement of dental restorations and
replacement of missing teeth by fixed or removable prostheses.
Referral to DDS for suspected caries and faulty restorations

PHASE IV: Periodontal Maintenance - Includes all measures used by the dental team
and the patient to keep periodontitis from recurring once inflammatory disease is
brought under control. (Maintenance)
Possible referral to periodontist
4-6 week re-eval
3-4 month SPT intervals

Jenna (Gehrig, 2020)

 What information should your team
give Mr. Tomlinson about his
periodontal condition?
Periodontitis is a bacterial infection that causes destruction of the
periodontium, which is the supporting structures of your teeth. It includes the
gingiva, alveolar bone, periodontal ligaments, and cementum. Periodontitis is
irreversible, but can be stabilized and managed. Treatment is needed to help
stabilize periodontitis so that the condition does not progress and/or worsen
leading to further disease and possible tooth loss.

Signs and symptoms can include:

Recession
Attachment loss
Inflammation https://www.peaceperio.com/procedures/periodontal-disease/types/

Bleeding
Loose or mobile teeth
Infection
Modifiable risk factors that can advance the progression of the disease can include:
Plaque and calculus
Furcations
Poor contacts of restorations
Abnormal tooth surfaces (attrition and wear facets)
Kirsten
 What should Mr. Tomlinson be told about the possible
need for periodontal surgery later in his treatment?
Clients with unstable stage 3 grade B periodontitis require nonsurgical periodontal therapy
(NSPT) to stabilize their condition. They may also require surgical interventions to help create
the best prognosis.
The goal of periodontal surgery is to eliminate pathological changes in periodontal pockets
and create a stable and healthy periodontal environment.
Periodontal Flap Surgery: a surgical procedure where incisions are used to allow for
separation of the gingival tissues (epithelial and connective) from the underlying structures
(cementum and alveolar bone).
allows for more effective scaling and root planing in deep pockets

Soft Tissue Grafting: a surgical procedure used to augment or increase the amount of
attached gingiva
often used in sites of recession or areas requiring root coverage

Pain Management:
The periodontist will use Topical anesthetic and LA to help manage pain throughout the
surgery
After surgery, you may be prescribed antibiotics or pain meds, take as prescribed
Alternatively, Tylenol or Advil can be taken as needed
Client Management:
Sutures stabilize and secure soft tissue after surgery
They can be absorbable (lasts 1-3 weeks) or non-absorbable (removal after 1 week)
A periodontal dressing may be used as a protective material to cover the surgical site
and promote healing
Follow-up appointments are needed.

Kirsten
What should Mr. Tomlinson be told about the need for
continuing treatment such as periodontal maintenance?
All clients with periodontitis require supportive periodontal therapy (SPT). SPT maintenance appointments occur
usually every 3-4 months to help ensure the client's condition is stabilized. It is the most important part of periodontal
treatment. Without maintenance, a recurrence of disease can occur.

Goal of periodontal maintenance:

The goal is to prevent the recurrence or progression of
destruction that is seen in periodontitis
It is performed in intervals to assist with maintaining periodontal
health
It is routinely done throughout the life of the natural dentition
Discontinuation would only occur if NSPT or Periodontal Surgery
is indicated

Periodontal Maintenance Includes:

Updating Med Hx
Client interview
Clinical Assessments (PD, CAL, BOP, Furcation Involvement,
Mobilities)
Evaluation of self-care
Identify treatment needs https://www.mouthhealthy.org/all-topics-a-z/scaling-and-root-planing

Biofilm removal
Periodontal instrumentation
Client Counseling and education
Kirsten Fluoride application
Care Plan:
DH Diagnosis: Stage 3 Grade B Periodontitis
Goal statement: Create an oral environment supportive of
periodontal health by 4-6 week re-eval.
End of care, goal met? Next Steps:

DH Diagnosis: Ct is at moderate risk for caries development related

to biofilm accumulation, modified by faulty restorations
Goal statement: Reduce risk though OHE - Caries Process,
Debridement, Fluoride Varnish and referral to DDS for restorative tx
by end of care.
End of care, goal met? Next Steps:

Kirsten & Caitlyn

Interventions: Appointment
DH intervention: Debridement (ultrasonic and hand scaling)
Expected outcome: Teeth will be deposit free
Plan:
#1. Debride Q 1/4, OHE Caries Risk,
Evaluation:
OHE - Periodontitis, OSCI - Modified
Stillmans, OSCI - Interdental
DH intervention: OSCI - Modified Stillman, OSCI - Interdental Cleaning (Proxa-Brush)
Cleaning (Proxa-brush))
Expected outcome: ct. will demonstrate correct brushing and flossing methods
Evaluation:
#2. Debride Q 2/3, Fluoride Varnish,
DDS Referral for Restorative Tx,
DH intervention: OHE - Caries Process
Referral to Periodontist
Expected outcome: ct. will reiterate caries process
Evaluation:
#3. 4-6 week re-eval

DH intervention: DDS Referral

Expected outcome: ct. will have faulty restorations restored and obtain DDS Dx for any new suspected carious lesions.
Evaluation:

DH intervention: Fluoride Tx - Varnish

Expected outcome: Increase tooth surface resistance, Decrease risk of caries
Evaluation:

DH intervention: OHE - Periodontitis

Expected outcome: ct. will identify own risk factors for periodontal disease, ct. will explain what periodontal disease is
Evaluation:

DH intervention: 4-6 week re-eval

Expected outcome: re-assess tissues response to treatment, pink and firm
Evaluation:
Kirsten & Caitlyn
Summary:
 References:
CDHO. (2014). CDHO Factsheet: Hypertension [PDF file]. College of Dental Hygienists of Ontario.
https://www.cdho.org/Advisories/CDHO_Advisory_Hypertension.pdf

CDHO. (2019). CDHO Factsheet: Anxiety and anxiety disorders. College of Dental Hygienists of Ontario.
https://www.cdho.org/Advisories/CDHO_Factsheet_Anxiety_and_Anxiety_Disorders.pdf

Gehrig, J. (2020). Foundations of Periodontics for the Dental Hygienist, Enhanced 5th. Navigate