PLAQUE INDEX CALCULUS INDEX • End-to-end bite • -Hyperdontia/ supernumerary teeth. Mesiodents • Hypodontia/ Anodontia • Fusion • Macrodontia • Microdontia/ Peg-lateral teeth • Gemination • Dens in dent • Dilaceration • Dens evaginatus: small mass of enamel or accessory cusp. Projecting on the occlusal surface of molars and premolars. • Talon cusp: one or more well-delineated cusps on the lingual of Max and Mand anterior teeth. • Taurodontism (ball like tooth): pulp chambers are enlarged at the expense of the dentinal walls • Labioversion (facioversion) • Linguoversion • Supraversion (Infraversion/supereruption) plaque index---sextants 0---no debris or stain present 1--- covering no more than 1/3 of the tooth surface, or the presence of extrinsic stains without debris, regardless of surface area covered. 2--- covering more than 1/3 but not more than 2/3 3---- covering more than 2/3 Calculus index---sextants 0--- No calculus present 1--- Supragingival calculus covering not more than 1/3of the tooth surface, 2--- covering more than 1/3 but not more than 2/3, or the presence of flecks of subgingival calculus around the cervical portion of the tooth 3---- covering more than 2/3, or a continuous heavy band of subgingival calculus around the cervical portion of the tooth SLIGHT, MODERATE, OR HEAVY Localize ---less than 30%. Generalized ---30 % or more (more than 1/3 of the dentition is involved) Suspected conditions are charted in GREEN: Screening page: suspected restorations required till classifications DD1-4. PSR – PERIODONTAL SCREENING AND RECORDING CODE 0 colored area of probe completely visible - no calculus, bleeding, or defective margins, gingival tissues healthy CODE 1 colored area of probe remains completely visible - no calculus or defective margins, BLEEDING on probing CODE 2 colored area of probe remains completely visible - supragingival or subgingival calculus detected, defective margins detected CODE 3 colored area of probe partially visible CODE 4 colored area of probe COMPLETELY disappears > 5.5 mm pocket depths Code ( * ) – should be added to sextant score When is the asterisks added? FURCATION INVASION MOBILITY Always take chart with you &wear lab coat in rad lab !! Black, white facing white!! 1. x-ray prescribed : which x-rays are prescribed & sign up 2. Reception: payment, stamp, and let client sit there 3. Dispensary: show receipt and get materials 4. Clinic: sign up for setting up exposure room, ending time 5. Rad lab : disinfection, barrier (control panel), open package with bare hands, keep the package, film sequence, and setting. 6. Clinic: sign-up for being ready in taking x-ray, & the ending time 7. Waiting area: waiting for Jamy or Gina with client 8. Rad lab: sit client, lab coat, goggle, lead apron (no gloves), napkin , explanation & get the consent, right exposure image. 9. Waiting area: let client sit there for 10 mins 10. Rad lab: disinfection, over gloves bring tray to dark room. New gloves Wipe film & develop, sign the # of films developed & room #, mount: client’s name, date of exposure, Dr’s name, what films were taken (specific), my name. 11. Clinic: over glove take the tray, chart, gloves and client back 12. Sterilization: show XCP and tray to dispensary staff & clean. Takes view box. Note: Tray or Paint-on application Obtained verbal informed consent to proceed with fluoride treatment by trays / paint-on. Started fluoride application at (time), completed at (time), total time spent for _ minutes. Dried all teeth using (gauze/air water syringe) and placed dry angles and cotton rolls to maintain dry working field. Applied (brand name) (%)(type)(flavour) to all teeth (teeth number) for 4 minutes by using (size of trays or cotton tip applicator) Suction was used to remove extra fluoride throughout. (Trays if used) and all barriers were removed, and the client was asked to expectorate as much as possible. Visually assessed tissues after fluoride application. No adverse reactions (or list if adverse reactions). Post fluoride instruct were given to client. Explained to client not to eat, drink and rinse for 30 mins after fluoride treatment. Client understands and verbalizes back. Fluoride application evaluated by instructor. Fluoride varnish (5% sodium fluoride varnish, Timer, instruction paper) 1. Get consent and explain benefit and the procedure 2. Recline client for ergonomic access to oral cavity 3. Wipe application area with gauze or cotton rolls 4. Insert a saliva ejector 5. Apply teeth for 1-3 minutes 6. floss 7. Allow rinse on completion of procedure 8. Remind client to avoid eating hard foods, drinking hot or alcoholic beverages, brushing, and flossing until the next day or at least for 4-6 hours Topical fluoride tray technique ( tray, cotton rolls, Dri angle, F gel, timer, saliva ejector, gauze, tissues, cup) 1. Seat client in upright position 2. Get consent and explain the procedure 3. Try tray of appropriate size 4. Load fluoride gel in to trays: 2ml maximum per tray for small children, 4 mL maximum per tray for large children (>44 lb), 2.5 mL maximum per tray for adults 5. Moisture control and saliva syringe 6. Insert both trays and saliva ejector, ask client to bite gently 7. Set timer for 4 minutes. Never leave client alone during procedure 8. Tilt chine down to remove trays 9. Ask client to expectorate, suction excess fluoride from the mouth with saliva ejector 5 DHD’S 1 MED AND DENTAL HISTORIES Prepare evaluation sheet, referral letter. take the Oxford privacy policy form. Children 16 or younger, takes pulse and respiration only, no probing and no PSR. Diabetess: carry juice with them and know blood sugar readings before they are coming. under controlled) In the medical history box, you can include: ALLERGIES, HYPERTENSION, DIABETES, CANCER, HYPERLIPIDEMIA, AUTOIMMUNE DISEASE, BLOOD DISORDERS, USE OF BLOOD THINNERS (IBUPROFEN), HEPATITIS, SEIZURES, RESPIRAOTRY DISEASE, AND PSYCHIATRIC DISORDERS For all medication that was taken, write was medication, dosage, when it was taken and how. 2. VITALS: Regular temperature: 36 – 38 degrees Pulse: 60 – 100 BPM Respiration: 12 to 20 respiration per minute Blood Pressure: 120/80 mmHg RESTORATIONS TO CLASSIFICATION – IN GREEN PEN 3. SCREENING NOTES: New Client: (DATE) Called client to book appointment on (date), client confirmed/rescheduled etc. (for Semester III/IV). Completed (OR REVIEWED) COVID screening at triage. All answers were negative. Temperature was C. Completed medical and dental history with the client. Client is not taking any medications and has no contraindications to treatment. OR list the conditions/medication/allergies. Vital sign taken on left arm, BP__ mmHg, pulse__ BPM, Respiration ___RPM. Client has read and signed the Oxford College General Release form and the privacy policy (updated annually). Client rinsed with preprocedural rinse with Listerine Zero of 7.5ml for 30 seconds. Exam kit #___ load #__ Type 5 CI passed sterilized on (date/time), by student’s name.) Obtained verbal informed consent to proceed with screening. Client’s medical and dental history reviewed and evaluated by the instructor. Completed screening. See screening notes and findings above. Re-Care Clients: Discussed the long-term goals with the client: For example: Reports using (---) twice a day; goal met, tongue brushing once a day, goals met, using floss pick once a day, goal met. Client hasn’t followed up on the referral to their dentist for 26O caries, goal unmet. Bleeding sites will be determined after probing. 4. PROGRESS NOTES: Client accepted for treatment as DD__. Client paid 30$ registration fee at reception. I obtained verbal consent to proceed with hard tissue exam. Hard tissue completed and evaluated by Dr.__. Clinical findings were discussed with the client, no radiographs were prescribed by dentist. Declining x-rays: DDS name prescribed #x-rays, type, for diagnostic purposed. Client declined, reason why they declined. Explained safety precautions; list them, client still declines: Client’s signature. Completed nutritional assessment. Nutritional assessment reviewed by the instructor. Caries risk is (--). Obtained verbal informed consent to proceed with extraoral/intraoral and soft tissue exam and home care program. Completed intra and extraoral, soft tissue exams. Intra and extraoral soft tissue evaluated by the instructor. Home care program completed and reviewed by the instructor. Obtained verbal informed consent to proceed with probing and indices. Completed probing and indices. Probing and indices evaluated by the instructor. Discussed short term and long-term goals with the client IMPLEMENTATION: Obtained verbal consent to proceed with oral health education (OHE) Started OHE with the client at (time) and completed at (--) for a total of (--) minutes. Completed discussion about gingivitis and/or periodontitis process and causes, discussed caries disease process, explained with the flip chart. Demonstrated (--- ) brushing technique and (---) flossing technique, (list every aids mentioned in the care plan) on typodont. Client verbalized and demonstrated back the techniques and verbalized back the caries and dental disease process. Discussed with client the importance of returning for re-care after (4 months) and client verbalized back. Discussed detrimental effects of (oral habit) and client verbalized back. Authorization to scale: Started scaling at (---), scaled (---), using (hand) scaler. Removed plaque, stains, (supra/sub) gingival calculus. Deposits were (---), bleeding was (---). (If topical anesthesia used: type, brand, flavor, client compliance and tissue reaction). Cleaned instruments with hydrogen peroxide. Client compliance was (good or sensitive). Flossed all scaled teeth. Finished scaling at (12:00pm). Total time spend on scaling was (50 minutes) Scaling evaluated by the instructor. Treatment modification: Scaled only 26,27,28, unable to complete (--) as per care plan due to lack of time, client acknowledges modification—Client’s signature Second scaling appointment: Obtained verbal consent to proceed with OHE review and scaling and fluoride treatment with (tray/varnish). Reinforced the importance of maintaining a good oral health and reviewed OHE. Obtained scaling order from the instructor. Visually reassess soft tissue area of previously scaled teeth, soft tissue appears pink and healthy. Fluoride (varnish) at (time), completed at (---). Total time (---). Dried all teeth with gauge. Applied fluoride varnish 5% (brand, name, flavour) to all teeth. Visually assessed tissue after fluoride varnish application, no adverse reactions post fluoride varnish application. Post-fluoride application instructions given verbally and written to the client: not to eat anything hard and crunchy, any hot beverage or alcohol, and avoid CARIES RISK ASSESSMENT First, when assessing a diet for caries risk, one of the most important factors is consumption. If there's a 20-minute gap in between eating a meal and eating again, that would count as two separate exposures. It's important for students to document if foods are consumed together or separately when completing their assessment, as this will change the client's exposure. A meal can have multiple foods that can cause a caries risk but if consumed together, the exposure is only counted as 1 exposure. For example; Caries risk foods should be circled in red ** my computer skills only go so far! As you can see, the same foods, can produce two different outcomes. When a cariogenic food (carbs) is consumed with a cariostatic food (protein and fat), the caries risk is neutralized. The cariogenic foods should still be identified in the caries risk assessment with a red circle, but that exposure wouldn't count. For example, For the caries risk assessment, students should only be completing their assessment based on their client's one day diet provided. Often students will circle multiple food categories because their client may have verbalized that they consume these foods but if it's not included in their one-day diet, then it shouldn't be counted. Students should only be completing an analysis on what is documented on their 1-day diary. - the * information doesn't' need to be included in the dietary box, this is just for learning purposes Foods in this section, should have a red check mark listed on top of it. If a food item isn't listed, a food with the closest consistency should be chosen. The exposure numbers and tally of exposures can be documented in blue ink. The caries risk assessment, ideally, should be completed the same day the hard tissue is completed. Students should be spending 15-20 minutes completing this assessment to obtain accurate information from their clients. Students will often forget to ask what the client drank that day or if foods are consumed together or separately. These are important factors when determining if a client is at high risk for caries. Your instructors have all been informed and will be checking and correcting your caries risk assessment forms. Breakfast 1 plain bagel with strawberry jam 1 banana 1 glass of OJ (consumed together in one sitting) 1 solid exposure: 40 minutes Breakfast 1 plain bagel with strawberry jam 1 banana 1 glass of OJ (all consumed separately) 2 solid exposure + 1 liquid exposure: 100 minutes Breakfast 4 slices of bacon 2 eggs 2 slices of bread; white 1 glass of apple juice (Consumed together) Protein/fat from bacon and eggs cancels out the acid exposure from the carbs/sugar from the bread and juice by neutralizing the pH, reducing the chance of the pH dropping below 5.5, minimizing the caries risk. 0 caries risk. Breakfast 4 slices of bacon 2 eggs 2 slices of bread; white 1 glass of apple juice (consumed together) *1 liquid- juice & 1 solid-bread; consumed together (counts as 1 solid exposure) but protein/fat from bacon and egg cancels the pH exposure 0 caries risk Lunch 1 Chicken Caesar Salad with bacon and croutons 2 glass water 1 cup coffee w/ milk and sugar (continue to drink coffee after meal) *1 solid- croutons but protein from chicken and bacon cancels the pH exposure 0 caries risk 1 liquid-coffee w/ sugar= 1 liquid exposure Dinner 1 6oz steak Baked potato with butter and sour cream 1 cup peppers, carrots, green beans 2 glass water 1 dinner roll (consumed together) 1 slice apple pie with vanilla ice cream (dessert 30 minutes after dinner) *1 solid- dinner roll cancelled by steak 0 caries risk 1 solid- apple pie +1 liquid- ice cream= 1 solid exposure Snack: AM: granola bar PM: apple with peanut butter Evening: 1 glass red wine * 1 solid - granola bar * 1 liquid - wine Conducting Intraoral Assessments • Look at the lips overall. • Have the client smile and then open the mouth slightly. Visually inspect and bidigitally palpate the lower lip. • Use the same technique for the upper lip. Gently pull the lower lip away from the teeth to observe the labial mucosa. Bidigital Palpation of Inner Cheek • Gently pull the buccal mucosa slightly away from the teeth to bidigitally palpate the inner cheek on each side using circular compression. • The parotid papilla and duct should be the same color and firmness as surrounding tissue. They should be able to produce saliva. • Dry the area with gauze and observe the salivary flow from each parotid duct. Abnormal findings may include excessive flow or xerostomia. • Retract the mucosal tissue enough to visually inspect the vestibular area and gingival tissue, including the maxillary tuberosity, posterior to the last maxillary molar, and the retromolar pad, posterior to the last mandibular molar. • Bidigitally palpate these areas using circular compression. • Oral mucosa should be a continuous pinkish-red color or pigmented in relation to the normal coloration of the client’s skin. It should be firm in texture, free of lesions, and moist. • Labial and buccal mucosa should have a pebbly consistency and rough surface texture owing to minor salivary glands. • Attached gingiva should have stippling with a firm consistency and it should be anchored to the teeth and underlying alveolar bone. • Abnormal findings include: Pigmented, red or white or a combination of red and white, ulcerated lesions, which may indicate erosive dermatologic disease or oral cancer; whitened areas caused by candidiasis or lichen planus. • Look for signs of odontogenic infections; trauma associated with domestic abuse; ulceration and scarring associated with parafunctional habits; alcohol and smoker’s breath; halitosis associated with caries and periodontal disease, necrotizing periodontitis, or sweet and fruity ketosis associated with diabetic acidosis. Other considerations to note include Fordyce spots, the white raised line of linea alba at the occlusal plane; bony projections or exostosis on alveolar ridges, mandibular torus, amalgam tattoo; and scarring from third molar removal Palate and Pharynx • Palatal and pharyngeal tissue should be pink or pigmented in relation to the normal coloration of the client’s skin. It should be moist and devoid of lesions. • Compress the hard and soft palates, but avoid circular compression to prevent initiating the gag reflex. Red dots or petechiae may be caused by nicotinic stomatitis or denture stomatitis, an indication of cancer, or inflammation from postnasal drip; trauma may be caused by child or sexual abuse; sagging tissue may be caused by facial paralysis. Check tonsils for tonsillitis or tonsillar masses. Assessing the Tongue • To access the tongue, have the client extend it. Wrap a gauze square around the anterior third of the tongue to obtain a firm grip. Digitally palpate the dorsal surface. Turn the tongue slightly on its side to inspect its base and lateral borders. Bidigitally palpate the lateral surfaces. Be aware of triggering the gag response. • To access the ventral surface, have the client lift the tongue to permit inspection and digital palpation. • It should be bilaterally symmetric, extremely vascular, reddish-pink in color or pigmented in relation to client’s skin, all moist, and with full range of motion. • Atypical findings may include clefts on ventral surface resulting from fissured tongue; geographic tongue; papillary atrophy; lingual varicosities; coated or stained tongue; large tongue, called macroglossia ; tongue-thrusting habit; scalloped or scarred lateral surfaces. Abnormal findings may include hairy leukoplakia; tenderness; color changes; shortened lingual frenum with limited movement; enlargement or induration, or sign of cancer; extreme loss of papillae related to nutritional disorders; trauma caused by child abuse; infection from piercings; difficulty swallowing. • The intraoral examination of the palate and the pharynx include the hard and soft palate, faucial pillars, palatine tonsils, uvula, oropharynx, and nasopharynx. • Have the client tilt the head back slightly. Use the mouth mirror and light source. • Have client extend the tongue and view the soft palate. Gently place the mouth mirror on the middle of the tongue and ask the client to say “ah.” Visually observe the uvula and visible part of the pharynx. TALKING POINTS: • The lingual frenum is a midline fold of tissue between the tongue’s ventral surface and the mouth floor. • The sublingual folds are tissue ridges on each side of the mouth that form a V-shaped configuration from the lingual frenum to the base of the tongue. The sublingual folds contain duct openings from the sublingual salivary gland. • The sublingual caruncle, located at the anterior end of each sublingual fold, contains the submandibular and sublingual duct openings. The mandibular torus (singular) or tori (plural) is an atypical finding that may be found on the mandibular lingual surface in the premolar area. TERMINOLOGY USED TO DESCRIBE SURFACE TEXTURE Texture terms Description Corrugated Wrinkled surface Crater Central depression Crust Hard covering that is comprised of dried serum, pus, blood, or a combination Fissured Surface texture that may exhibit ridges and irregularities Induration Hardness of tissue from an increased number of surrounding epithelial cells Papillary Rough surface that contains small nodulations or elevated projections Pseudomembrane Loose membranous surface layer of exudate that contains microorganisms formed during an inflammatory reaction Smooth Deep lesion that pushes up and stretches the surface tissue Verrucous Rough wartlike surface with multiple irregular folds Staging and Grading Periodontitis The 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions resulted in a new classification of periodontitis characterized by a multidimensional staging and grading system. The charts below provide an overview. Please visit perio.org/2017wwdc for the complete suite of reviews, case definition papers, and consensus reports. PERIODONTITIS: STAGING Staging intends to classify the severity and extent of a patient’s disease based on the measurable amount of destroyed and/or damaged tissue as a result of periodontitis and to assess the specific factors that may attribute to the complexity of long-term case management. Initial stage should be determined using clinical attachment loss (CAL). If CAL is not available, radiographic bone loss (RBL) should be used. Tooth loss due to periodontitis may modify stage definition. One or more complexity factors may shift the stage to a higher level. See perio.org/2017wwdc for additional information. Classification at-a-Glance 2018 Classification of Periodontal and Peri-Implant Diseases and Conditions Periodontal Health, Gingival Diseases and Conditions • Periodontal Health and Gingival Health • Gingivitis: Dental Biofilm-Induced • Gingival Diseases: Non-Dental Biofilm-Induced Periodontitis • Necrotizing Periodontal Diseases • Periodontitis • Periodontitis as a Manifestation of Systemic Disease • Periodontal Abscesses and Endodontic-Periodontal Lesions Periodontal Manifestations of Systemic Diseases and Developmental and Acquired Conditions • Systemic Diseases or Conditions Affecting Periodontal Supporting Tissues • Mucogingival Deformities and Conditions • Traumatic Occlusal Forces • Tooth- and Prosthesis-Related Factors Peri-Implant Diseases and Conditions • Peri-Implant Health • Peri-Implant Mucositis • Peri-Implantitis • Peri - Implant Soft and Hard Tissue Deficiencies Three Steps to Staging and Grading a Patient Step 1: Initial Case Overview to Assess Disease Screen: • Full mouth probing depths • Full mouth radiographs • Missing teeth Mild to moderate periodontitis will typically be either Stage I or Stage II Severe to very severe periodontitis will typically be either Stage III or Stage IV Step 2: Establish Stage For mild to moderate periodontitis (typically Stage I or Stage II): • Confirm clinical attachment loss (CAL) • Rule out non-periodontitis causes of CAL (e.g., cervical restorations or caries, root fractures, CAL due to traumatic causes) • Determine maximum CAL or radiographic bone loss (RBL) • Confirm RBL patterns For moderate to severe periodontitis (typically Stage III or Stage IV): • Determine maximum CAL or RBL • Confirm RBL patterns • Assess tooth loss due to periodontitis • Evaluate case complexity factors (e.g., severe CAL frequency, surgical challenges) Step 3: Establish Grade • Calculate RBL (% of root length x 100) divided by age • Assess risk factors (e.g., smoking, diabetes) • Measure response to scaling and root planing and plaque control • Assess expected rate of bone loss • Conduct detailed risk assessment • Account for medical and systemic inflammatory considerations INTRA ORAL AND EXTRA ORAL What to document as you describe your lesions: Differential Diagnosis • Location and distribution • Size and shape • Color • Texture • Attachment and depth • Consistency • Mobility • Symptomatology Overjet - mm Overbite- % Chart forms: Order Medical history (yellow) Medical history update (yellow) Drug Write Ups (yellow) Medical Clearance (white) Referrals- medical (white) General Release (white) Covid forms (white) Referrals- dental (white) Limited Treatment (white) Requisition Requests (white) Duplication Requests (white) Smoking cessation (pink) Caries Risk Assessment (pink) E/O I/O (pink) Probing (pink) Hard Tissue (pink) Home Care (pink) DHDs (blue) Care Plan (blue) Consent (white) (most recent forms are placed on top) Terminal plane ideal molar relationship when the primary teeth are in centric occlusion. There are two ways this can occur- flush terminal and mesial step Flush terminal primary maxillary and mandibular second molars occlude in an end-to- end relationship Mesial step the primary mandibular second molar is mesial to the primary maxillary second molar Distal step primary mandibular molar occludes distal to the primary maxillary second molar, which is not an ideal molar relationship