1. A Study on Oral Health in Dental Medicine.
By: Sam Hammer
11-27-16
Dr. Havoonjian
Clinical Observation Study

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In my term of studying and observing dental medicine in the field of those who are under
privileged it has been quite a spectacular learning experience having to do with restorative
dentistry. I find dentistry unique in the way that is focused on preventative measures that embody
the whole care of the oral cavity. I got the opportunity to work with a wonderful man, Dr. Rogers
D.D.S. at his own practice in Yorba Linda and at his facility he runs for City Help through the
Dream Center L.A. which services the oral needs of the under privileged going through the
discipleship program. In my time, I was trained in, participated in, and help administer several
procedures including composite fillings, extractions, prophylaxis (professional cleaning), and
many other preventative exercises.
While serving chairside with Dr. Rogers there was a patient we would see often who had
a vast dental history of his own and was going through the discipleship program named Pete. I
choose to do this study on Pete because of his vast history and the effect it has had on his oral
health, but also because of the extensive maturity of his predicament has improved since his first
appointment almost 6 months ago.
Pete is a thirty-two year-old Caucasian male who was heavily involved in a lot of turmoil
in the latter half of his teens and early twenties. He grew up in a Christian household and his
father was a pastor. When Pete reached seventeen years of age a devastating experience hit his
life which in turn determined his course for the next 8 years. His parents divorced and by turning
of seventeen he got heavily involved in a gang. The gang presence influenced him to participate
in other destructive measures that currently have affected the condition of his oral health. After
joining a gang, he begun to take drugs, and was experienced in all the four major areas that drugs
are derived from. He found himself slowly getting addicted to Synthetic Cathinone’s (bath salts),
Cocaine, Opioids, and Methamphetamine. After spending an extended bit of time addicted to
drugs and life in a gang Pete turned twenty-five and was pending charges for attempted murder
and looking at 2 life sentences. The judge chose to extend him grace by saying that he needed to
find help and enroll himself into a program to turn his life around in hopes it would turn his
choices around as well, and that is how Pete found his way to the Dream Center L.A. and into the
on campus Dental Clinic. Pete has made exceptional growth, now being enrolled in the
discipleship program for almost a year he only has nine weeks left before he starts looking at
transitional living and independence apart from the program. Currently, his family is being
restored and he is looking at an awesome opportunity to participate in bible college once exiting
the Dream Center L.A. Pete states for himself that “The Dream Center has given him purpose
and firm direction in his journey and walk with the Lord.” I am really glad that I choose to work
with this patient partly because it is a privilege to participate in what restoration God is already
doing in his life even if it is from the simple avenue of me getting to care for his oral health.
Pete has an extensive history of abnormalities in his mouth which were caused by lots of
the drugs he did. His current condition is a result of his participating in taking oxytocin in the
form of swallowing pills for several years. He also established an addiction to smoking crystal
meth and misuse of that has caused much deterioration of his enamel and dentine. Pete also
practiced abuse in the form of powdered cocaine inhalation threw the nasal canal (snorting).
Lastly, probably one of the most destructive drugs he abused was a synthetic

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cathinone(psychoactive-addictive, mind altering) in the form of bath salts in which participation
is unclear whether it was smoked, swallowed, snorted, or injected. Consequently, because of
Pete’s drug abuse he has developed several issues with his oral health. One of the several
conditions he has is called Xerostomia. Xerostomia, also known as “dry mouth,” is a common,
but frequently overlooked condition that is typically associated with salivary gland hypofunction,
which is the objective measurement of reduced salivary flow (ADA Council of Scientific Affairs,
2015). Another condition that Pete has plenty of which has resulted in an extensive amount of 11
composite fillings is tooth decay. Obviously, the tooth decay has been a result to the physical
abuse to maintaining healthy oral hygiene consequently payable to drugs. His cracked teeth and
decay are a result to not having a lot of saliva present killing bacteria, bacteria and sugars calcify
and make teeth become more brittle. Tooth decay can cause CTS (cracked tooth syndrome)
which can only be taken care of with composite fillings, or RCT (root canal therapy), (Lubisich
et al., 2010). In conclusion to the abuse, Pete also deals with some forms of gum disease,
periodontal diseases range from simple gum inflammation to serious disease that results in major
damage to the soft tissue and bone that support the teeth. In the worst cases, teeth are lost
(NIDCR, 2013). These conditions if not taken care of can significantly affect Pete’s life by
altering his ability to function healthily in daily tasks like eating, drinking, sleeping, and even
sinus control.
In knowing how to best provide care for the patient it is imperative to have a firm
understanding of his upbringing and what issues have played a role in his poor oral health today.
In doing so, the steps moving forward are towards closer preventative measures to limit the risk
of malpractice which can significantly prohibit one’s oral health ability to function correctly.
Having a firm understanding of the etiology of the diseases is crucial in knowing how to treat
them.
As stated before, Pete struggles with Xerostomia which is condition known as “dry
mouth”. Reduced salivary flow can cause difficulties in tasting, chewing, swallowing, and
speaking; it can also increase the chance of developing dental decay, demineralization of teeth,
tooth sensitivity, and/or oral infections (CDCAP, 2011). So, it is very important to know how to
treat it. Severity of dry mouth symptoms may range from mild oral discomfort to significant oral
disease that can compromise the patient’s health, dietary intake, and quality of life. Estimates of
xerostomia prevalence in the general population are imprecise because of limited data; estimates
range from 0.9% to 64.8% of people deal with it (CDCAP, 2011). In understanding the functions
of saliva one can understand the importance of Xerostomia relevance to oral hygiene. Saliva is
made up of several integral proteins that make up enzymes that clean the oral cavity. It also helps
facilitate the mastication of food by providing digestive enzymes, and protecting the physical
tissues from bacteria. While also maintaining a neutral pH so that teeth don’t demineralize. One
of the major medications that can cause dry mouth is Opioids which my patient has successfully
participated in to a full extent. If continued abuse was to occur than salivary gland aplasia (loss
of taste) would be the most common symptom present. After looking through some of his
personal patient history he has no cases of degenerative diseases, HIV/AIDS, or Lymphoma
which are major conditions outside of Opioid abuse that can contribute to Xerostomia (ADA
Council of Scientific Affairs, 2015). If abuse was to occur Pete would be putting himself at a

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high risk of dental erosion, demineralization and dental caries (which can affect enamel structure
leaving exposed roots), and continue to diminish salivary gland function. In which this would be
a case for a more aggressive approach that would be needed for assessment like oral surgery
procedures.
In addition to Pete’s Xerostomia he also deals with various forms of gum disease. In
September 2012, the CDC found that one out of every two American adults aged 30 and over has
periodontal disease. A study they did titled, Prevalence of Periodontitis in Adults in the United
States: 2009 and 2010 estimates that 47.2 percent, or 64.7 million American adults, have mild,
moderate or severe periodontitis, the more advanced form of periodontal disease. In adults 65
and older, prevalence rates increase to 70.1 percent (P.I. et al., 2009). Of specifically Pete’s age
range 20-34 years of age he is a part of the 3.84% that have developed gum disease from 1999-
2004, Pete would have been 20 in 2004, and 17 in 2001. Including, he is a part of the 5.82% of
white (non-Hispanic) ethnicity of the time to develop gum disease, while also being a part of the
14.74% of current smokers who get gum disease during the time range (NIDCR, 2013).
Periodontal is defined as having to do with around the teeth specifically the gums, but not
limited to the gums. Gum disease develops with the presence of bacteria that forms plaque on
our teeth. When plaque isn’t removed well it can calcify and become hard and then one has tartar
on their teeth which brushing can’t take care of. So, given the amount of time till one sees the
dentist (generally every six months) the buildup of tartar can become harmful and cause
inflammation in the gums. When there is inflammation in the gums, it’s called gingivitis
(moderate form of periodontal disease), taking care of the gums can simply begin with smooth
brushing. This is a moderate form because it doesn’t involve loss of bone, or tissue, but instead
causes inflammation, gum recession, and bleeding. The last phase after gingivitis is periodontitis
which is an advanced form of gum disease where there has been a large deficit in receding gum
line that exposes the tooth and the tooth becomes extremely sensitive (NIDCR, 2013). When the
tooth is very exposed than the root can become exposed as well and lead to exposed tissue
therefore creating pockets of exposure around the tooth. Inside those pockets bacteria get in there
and start to grow under the gum line and cause decay and due to bacterial infection will break
down bone and tissue. The risk is that everything that keeps teeth in place (connective tissue,
bone, gums) will deteriorate and the teeth will need to be removed if they haven’t already fallen
out. Pete was luckily in the moderate stage of periodontal disease where his gums bled a lot only
due to lack of flossing primarily and neglect in good brushing habits. In doing a routine
prophylaxis check on his gum line there wasn’t any recession less then 3cm which is really good
and shows that there isn’t any bacteria under the gum line. Now that he has started brushing he
has improved in his overall gingiva care around the enamel and actually his roots have become
stronger since developing healthy oral care habits.
In continuation to the patients conditions the last severity in which he struggles with is
the patient has several cracked teeth, and decayed holes in his teeth. To begin with the fractured
teeth, the American Association of Endodontists (AAE) has identified five types of cracks in
teeth. Whereas it is important as a clinician to be familiar with all fractured forms as an aide in
diagnosis, it is often difficult to distinguish clinically among the various types of cracks

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(Lubisich et al., 2010). Pete has Craze lines which are visible fractures that only involve enamel.
However, it is not always possible to determine that a visible fracture is limited to
enamel. Fractured cusps originate in the crown of the tooth, extend into dentin, and the fracture
terminates in the cervical region. A problem common to all the classification systems is that they
fail to connect the descriptions to the clinical consequences, or treatment recommendations
(Lubisich et al., 2010). Several studies have shown that mandibular and maxillary molars are the
most affected by CTS (cracked teeth syndrome). Due to the several types of fractures its come
from a source of things, specifically lack of saliva to keep the mouth moist and causes brittle
teeth that become fragile and more easy to break. This condition can also cause pain during
chewing or biting, unexplained sensitivity to cold, and pain on release of pressure which can
make diagnosis difficult. Taking trauma to the face can also cause CTS and of course, substance
abuse. I am unaware whether, or not Pete has experienced several maxo-facial traumas, or not,
however he has participated in drug abuse which has solidified an increased response to having
CTS. Pete is a part of the 6.16% for age, 9.95% for being male, 10.67% for being white, 10.55%
for being a former smoker who has decayed, missing, or filled permanent teeth from 1999-2004
year for 20 to thirty-four year old’s in oral health (Lubisich et al., 2010).
In asserting his tooth decay being attached to his drug abuse background, Pete had lots of
decay from just basic acidic and sugar like diets from the past and not taking better care of his
teeth. There are several factors that are tied to why tooth enamel decay, attrition (natural tooth to
tooth friction), abrasion(physical wear and tear from brushing, or chewing), abfraction(occurs
from stress fracture in the tooth), and corrosion. Of those four corrosion is the most popular, this
chemically occurs when acidic contents hit the teeth and erodes away the dentine from the
enamel. Tooth enamel is hardest tissue in the human body and enamel covers the crown which is
the part of the tooth that's visible outside of the gums. Because enamel is translucent, you can see
light through it. But the main portion of the tooth, the dentin, is the part that's responsible for
your tooth color, whether white, grey, or yellowish. Your diet is generally responsible for the
discoloration of one’s dentine. Pete has a bit of discoloration and lots of decaying spots due to
his addiction to meth. He has a case called “meth mouth” which is a condition of corrosion.
“Meth mouth” is characterized by severe tooth decay and gum disease, which often causes teeth
to break, or fall out.
Picture of Pete’s Condition after first couple of visits.

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An examination of the mouths of 571 methamphetamine users showed (JADA, 2005):
- 96% had cavities
- 58% had untreated tooth decay
- 31% had six or more missing teeth
The teeth of people addicted to methamphetamines are characterized by being blackened,
stained, rotting, crumbling, and falling apart. Often, the teeth cannot be saved and must be
removed. The extensive tooth decay is likely caused by a combination of drug-induced
psychological and physiological changes resulting in dry mouth and long periods of poor oral
hygiene. Methamphetamine itself is also acidic so that doesn’t help at all in general care. Pete
had definitely showed side-effects of being addicted to meth which has lead him down the road
of trying to restore his mouth for him.
In assessing anyone’s health it is should be every dental surgeon’s concern to get a firm
understanding for their patients’ health history, who they are, and the choices they have made to
get them in the condition they are at in any point in time. In doing so the physician can offer
authentic care, gather information to research, and ensure the patients’ health is the utmost
concern. After understanding a lot of background of Pete’s history and what oral problems that
has caused for him, it’s important to finish with a clear understanding of how a dental surgeon
diagnosis and treats his/hers own patient’s condition. In this case its beneficial to understand how
one goes about diagnosing Pete’s condition and further providing the care that he needs to move
forward in a healthier aspect for his oral health.
In any diagnosis in the mouth the basic procedure that one needs to do is take an x-ray.
Dental radiographic interpretation is essential to any good understanding of what is going on in
the mouth. As long as the dentist knows what’s going on with the mouth internally and what it
looks like when there is something wrong he is clear to start a physical exam to test the
assurances of his hypothesis of what may be the issues as seen in radiographic imaging. The
most frequently used type of radiography is periapical radiography, it is used in intraoral view
which results in imaging of the entire tooth and surrounding structures (Moix, 2014). Sufficient
reasons to use periapical radiography is for carious (cavity) involvement in the tooth,
interproximal decay, traumatic injuries believed to be at the alveolar process, periodontal
disease, and implants to name the most common. All these symptoms can be seen and imaging of
them become present in periapical x-ray imaging.

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There is one more instrument used in interpreting dental problems and that’s OPG
radiographs. An OPG radiograph is an extra-oral technique which produces a radiograph with
wide view of the maxilla and mandible. It can also be referred to as “rotational panoramic
radiography” (Moix, 2014). The dental surgeon would use this primarily with pre/post-operative
assessment, mandibular fractures, orthodontic assessment, tumors, assessment of the TMJ,
impacted teeth and gross caries to state the most common (Moix, 2014).

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By understanding what instrument is used for what specific reasons most D.D.S.’s
through extensive study know what to look for. In diagnosing and treating what Pete has I was
able to see and interpret three root canals, and some restorative work (because its shows up like
white snow in the x-ray), and several craze lines and fractured cusps by how Dr. Rogers pointed
out there irregular position of the enamel.
In assessing Pete for Xerostomia one of the giveaways is what D.D.S.’s call is buffalo
breath, (really bad breath). This is noticeable before even taking a periapical radiography x-ray.
When looking at the teeth, the Dr. is looking at a few things, if there is increased incidence of
tooth decay (cervical and incisal), enamel demineralization (chalky spots at the cervical regions
of the teeth), enamel erosion and attrition, increased plaque accumulation, and increased tooth
hypersensitivity (ADA Council of Scientific Affairs, 2015). Above all, the Dr. is looking for a lot
of dryness, whether it has to do with the cavity as a whole, the lips, tongue, and swelling and
enlargement of salivary glands. Questions may have something to do with:
- Does the amount of saliva in your mouth seem to be too little?
- Does your mouth feel dry when eating a meal?
- Do you sip liquids to aid in swallowing dry food?
- Do you have difficulty swallowing?
There is also Diagnostic tests to determine the severity of xerostomia as well.
Unstimulated whole saliva often is collected by means of the draining, or drooling method, in
which a patient’s head is tilted forward and pooled saliva is collected into a sterile container. An
unstimulated whole saliva flow rate of less than 0.1 milliliter per minute is suggestive of
significant SGH (salivary gland hypofunction), (ADA Council of Scientific Affairs, 2015). The
Dr. can also insist on getting a blood test if they believe it may be directly related to internal
diseases like AIDS/HIV. In managing this problem depending on the severity it can consist of
techniques as simple as educating the patient that emphasizes healthy oral hygiene and use of
better fluorides, and maybe even conversations about substance abuse. Prescribing medication
through a more pharmacologic approach can help in jumpstarting certain processes of the
salivary glands to develop more saliva and function properly after getting appropriate help from
family physician as well. In Pete’s circumstance Dr. Rogers had him getting started on better oral
hygiene and in general he saw a definite increase in his oral health stability due to appropriate
administered care provided by the patient, so in retrospect Dr. Rogers used patient education to
treat Pete’s Xerostomia.
In assessment of a patient’s periodontal predicament it’s important to use periapical
radiography x-ray to assess the surrounding areas of the root and enamel and focus in on the gum
line specially. Several signs to knowing if you have moderate gum disease is found by having
bad breath that won’t go away, there is discoloration on the gum being that it is more red and
swollen than it should be. When flossing the gums bleed moderately, shows that there is
tenderness and not a lot of support, loose teeth, and receding gum line leading to sensitive teeth
(NIDCR, 2013). These could all be very sensitive measures to an already apparent problem, or
existing issue. The Dr. can assess these symptoms by:

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- Asking about your medical history to identify underlying conditions, or risk factors (such
as smoking) that may contribute to gum disease.
- Examine the gums and note any signs of inflammation.
- Use a tiny ruler called a “probe” to check for and measure any pockets. In a healthy
mouth, the depth of these pockets is usually between 1 and 3 millimeters. This test for
pocket depth is usually painless.
In diagnosing moderate gum disease the main goal of treatment is control the infection.
The number and types of treatment will vary, depending on the extent of the gum disease. Any
type of treatment requires that the patient keep up good daily care at home. The dentist may also
suggest changing certain behaviors, such as quit smoking, as a way to improve treatment
outcome. Treating gum disease is simply dependent upon a very specific cleaning, scaling, and
root planning of the oral cavity. The dentist, or periodontist will remove the plaque through a
deep-cleaning method called scaling and root planing. Scaling means scraping off the tartar from
above and below the gum line. Root planing gets rid of rough spots on the tooth root where the
germs gather, and helps remove bacteria that contribute to the disease. In some cases a laser may
be used to remove plaque and tartar (NIDCR, 2013). This procedure can result in less bleeding,
swelling, and discomfort compared to traditional deep cleaning methods. There is also
medications than can be prescribed and the most common that Dr. Rogers uses is Antibiotic Gel.
It is a gel that contains the antibiotic doxycycline, and is used for controlling bacteria and reduce
the size of periodontal pockets (NIDCR, 2013). It is administered by the dentist putting it in the
pockets after scaling and root planing. The antibiotic is released slowly over a period of about
seven days.
Than lastly depending on how bad the abscess may be there is surgical treatment which is
generally done by a periodontist who has specialized in procedure techniques. Of the procedure
available there is Flap Surgery and Bone and Tissue Grafs. A flap surgery is simply the exercise
of the removing tartar deposits in deep pockets, or to reduce the periodontal pocket and make it
easier for the patient, dentist, and hygienist to keep the area clean (NIDCR, 2013). This common
surgery involves lifting back the gums and removing the tartar. The gums are then sutured back
in place so that the tissue fits snugly around the tooth again. After surgery the gums will heal and
fit more tightly around the tooth. This sometimes results in the teeth appearing longer. Surgical
Graphing consists of a specialist placing a natural, or synthetic bone in the area of bone loss,
which in return can help promote bone growth. A technique that can be used with bone grafting
is called guided tissue regeneration. In this procedure, a small piece of mesh-like material is
inserted between the bone and gum tissue. This keeps the gum tissue from growing into the area
where the bone should be, allowing the bone and connective tissue to regrow (NIDCR, 2013).
Growth factors like proteins that can help your body naturally regrow bone may also be used. In
cases where gum tissue has been lost, the periodontist may suggest a soft tissue graft, in which
synthetic material or tissue taken from another area of your mouth is used to cover exposed tooth
roots (NIDCR, 2013).
In Pete’s case his treatment consisted of being prescribed medication of antibiotic gel to
help dispose of any bacterial build up under the gum line and was guided in more patient
education on how to further take care of his teeth and how to continually practice healthier oral

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health habits. His gums improved after several appointments and cleanings which inhibited him
from having to see special treatment in surgical removal of bacteria.
In understanding Pete’s background and abuse of meth which is a very acidic product it
has caused a lot of tooth decay which has also lead to CTS which threatens the overall integrity
of his crown and root. In diagnosing tooth decay and CTS there are several measures and
markers to look at to determine the severity of the exposure of teeth to decay and fracture. The
signals of enamel erosion may be determined by sensitivity. Certain foods (sweets) and
temperatures of foods (hot or cold) may cause pain in the early stage of enamel erosion. By the
dentist testing patient’s exposure to hot or cold feels, they are able to depict better what level of
the root may be exposed due to decay and erosion. Discoloration plays an important role in
diagnosis because as more enamel may be eroded then the dentin is exposed and the color
generally is yellow.
Cupping is one of the more common ways of assessing for decay as well. It is when
indentations appear on the surface of the teeth. When enamel erodes, the tooth is more
susceptible to cavities, or tooth decay. When the tooth decay enters the hard enamel, it has entry
to the main body of the tooth. Small cavities may cause no problems at first. As cavities grow
and penetrate the tooth, they can affect the tiny nerve fibers, resulting in an extremely
painful abscess, or infection (Lubisich et al., 2010). The way to treat most tooth decay is by the
dentist proceeding in covering the tooth with a crown, or veneer. If it is several teeth in the same
row than a bridge is needed to protect the teeth from further decay. In Pete’s case he has 11
composite fillings with A3 shading. He has a bridge on #7,8,9, and composite fillings on
#3,4,5,6,13,14,27. He has had all this administered since his first evaluation on 6-24-16 and his
last appointment was 11-4-16 making it his ninth appointment this year. He has come a long way
with his teeth, there were some teeth that could only be saved by getting RCT (root canal
therapy) where they pretty much killed the tooth and some of the decay was to deep that the
endodontist extracted the tooth and put an implant in. Pete has definitely seen better days.
In diagnosing his CTS one of the best ways is by doing the bite test. A plastic wedge is
placed over each occlusal cusp. The patient’s pain is evaluated upon closing and opening, with
pain upon release usually indicative of a cracked tooth (Lubisich et al., 2010). Also, generally
radiographs and researchist are looking at using ultrasound as capable technique to imaging the
cracks. That diagnostic procedure has been described in the literature, yet hasn’t been tested in a
controlled clinical trial. Thus, CTS remains difficult to diagnose and a source of frustration for
both the dentist and patient (Lubisich et al., 2010). Treating CTS falls along the same lines as a
dentist would treat tooth decay, crowns or fillings are most acceptable in preserving the
structural integrity of the tooth. The specific treatment protocol suggested is to remove any
existing restoration, evaluate the health of the pulp and remaining coronal tooth structure, and if
indicated, restore with a full crown. Any tooth with irreversible pulpitis or a necrotic pulp should
have RCT prior to crown placement (Lubisich et al., 2010). If the tooth has a crack running
down to split it in half than it is important to wait for the crack to make its way to the bone and
let the pieces get loose than extract them individually. As it relates to Pete’s cracks his condition

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is being watched, but is not being treated because the acuity of it is low and Dr. Rogers thinks
time will tell what needs to happen.
I am thankful for what opportunity I have had to participate in this clinical observational
study on Pete. My desire and passion for the area has grown immensely since beginning and Dr.
Rogers deserves a lot of thanks for that for including me in what it is he is already doing. In
working with Pete and other patients at the Dream Center L.A. clinic I have come to appreciate
the role I have in helping others receive the care they need to be able to function the best that
God made them to be even if it is from the most physical level. I desire to carry my passions to
work with underserving, unreached people overseas to the country I am from, India and set up
my own clinic there to serve and offer hope to a hurting people. I have very much appreciated
seeing how Dr. Rogers practices, and Dr. Diorio and the several other Dr.’s I have shadowed in
this time and coming away with a firmer understanding of where I believe the Lord is calling me
in Dental Medicine. Working with Pete has been wonderful even though I would see him for
about one hour once a week, I am encouraged in that I get to participate in his restoration
alongside of him by getting to learn how his oral health has begun to be physically restored back
to health. I look forward to where the area of dental medicine is going to take me in the future
and how my passion will grow thanks to this clinical opportunity I have had to experience
upfront chairside work and development as a pre-dental concentrated Biologist.

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