DHG 161 Final Exam
ASA Classifications
*American Society of Anesthesiologists (ASA) Physical Status Classification System* - An overall estimate of medical risk of a patient *ASA I* - a patient without apparent systemic disease: a normal healthy patient *ASA II* - a patient with mild systemic disease *ASA III* - a patient with severe systemic disease that limits activity but is not incapacitating *ASA IV* - a patient with an incapacitating systemic disease that is a constant threat to life *ASA V* - a moribund patient not expected to survive 24 hours with ot without care
Chisel scaler
*Characteristics* 1. Single straight cutting edge 2. Blade is continuous with a slightly curved shank 3. End of blade is flat and beveled at 45 degree *Purposes and uses* 1. Removal of supragingival calculus from exposed proximal surfaces of anterior teeth where interdental gingiva is missing 2. Dislodgement of heavy calculus from the proximal areas of mandibular anterior teeth. When the calculus on the lingual surfaces ma form a continuous bridge across several teeth, the chisel can be puches horizontally from the facial aspect to break up the large masses of calculus 3. Proximal surfaces of premolars when flexibility of he lips and cheeks permits retraction for proper positioning of the cutting edge
Hoe scaler
*Characteristics* 1. Single straight cutting edge 2. Blade turned at 99 degree angle to shank 3. Cutting edge beveled at a 45 degree angle to the end of the blade 4. Shank is cariously angulated for adaptation of cutting edges to accessible tooth surfaces; some are paired * Purposes* Removes supragingival calculus, particularly large, accessible, tenacious pieces
File scaler
*Characteristics* Stainless steel 1. Multiple cutting edges lined up as a series of miniature hoes on a round, oval, or rectangular base 2. Blades at 90 degree angle with shank 3. Shanks are variously angulated and most are paired 4. Reduced tactile sensitivity because of the series of blades Diamond coated 1. Design varies 2. Not true files, scalers, or curets because there are no blades, the diamond coating is placed 180 to 360 degrees around the ti depending on the manufacturer, and the diamond coating is used to remove the calculus * Purposes and Uses* 1. Traditional - crushes and fractures heavy calculus into fragments prior to use of curets - can removed burnished calculus that other instruments cannot remove - for patient's that ultrasonic instruments cannot be used on - smoothing of overextended or rough amalgam restorations 2. Diamond-coated - finishing root surfaces and accessing furcation areas
Purpose of mouthwashes
*Dental clinic* 1. Reduce intraoral mo's 2. Reduce aerosols 3. To promote shrinkage of soft tissues; facilitate accurate impressions *Self-care* 1. Biofilm control 2. Caries prevention 3. Remineralization 4. Prevent gingivitis 5. Malodor control 6. Post treatment therapy
ADPIED *Dental hygiene diagnosis*
*Description* Analysis and critical decision making *Criteria* - analyze and interpret all data - determine patient needs - incorporate dental hygiene diagnosis into overall dental treatment plan
ADPIED *Documentation*
*Description* Complete and accurate recording of information *Criteria* - document all components of care objectively, legibly, concisely, and accurately - recognize ethical and legal aspects of recordkeeping - respect and protect patient information
ADPIED *Implementation*
*Description* Delivrey of dental hygiene interventions *Criteria* - review, implement, and modify care plan and plan for continuing care - communicate with patient
ADPIED *Planning*
*Description* Making clinical decisions within the context of ethical and legal principles *Criteria* - identify, prioritize, and sequence interventions - coordinate resources and collaborate with other healthcare providers - present plan and explain rationale, risk benefits, expected outcomes, alternatives, and prognosis to patient - obtain informed consent or refusal
ADPIED *Assessment*
*Description* Ongoing collection and interpretation of patient data *Criteria* - collect personal, dental, and health history - provide comprehensive clinical examination - assess risks to general and oral health
ADPIED *Evaluation*
*Description* Reviewing and documenting outcomes throughout the process of care *Criteria* - use measurable criteria - communicate with patient - collaborate with other healthcare providers
Basic ingredients of toothpastes
*Detergent* 1-2% - sodium lauryl sulfate *Cleaning and polishing* 20-40% - phosphates (whiten) - carbonates (deodorizes) - silica (mechanically cleans) *Binders* (thickeners) 1-2% - gums - colloids - cellulose *Humectants* 20-40% - retain moisture - xylitol - sorbitol - glycerol * Preservatives* 2-3% - prevent bacterial growth and prolong shelf life - alcohol - benzoates - dichlorinated phenols *Flavoring agents* (sweeteners) 1-1.5% - xylitol - glycerol - sorbitol * Water* 20-40% *Therapeutic agents* 1-2%
Evaluation procedures necessary to maintain a patient's oral health
*Evaluation of Health Behavior Outcomes* Provides evidence of the patient's response to the clinician's counseling and education interventions and also development of oral self-care skills. If the evaluation process indicates that goals have not been met, the data collected during evaluation can provide a baseline from which the dental hygienist can again collaborate with the patient to develop new or next step goals 1. Visual inspection - PFS - self-care skills are evaluated by observing a demonstration of each skill by the patient 2. Interview evaluation
Basic ingredients of disclosing agents
*Formula* 1. Iodine preparations - unpleasant taste 2. Aniline - shown to be potentially carcinogenic 3. Erythromycin 4. Fluorescein - ultraviolet light 5. Two-tone
Frequency of care to maintain a patient's oral health
*Frequency planning* 1. The frequency of continuing care or maintenance depends on the needs of each patient 2. Appointment intervals may vary from 2 to 6 months 3. The time interval is re-evaluated periodically and changed in accordance with changing needs *Contributing factors* - Risk for periodontal disease activity - Risk for dental carious lesions - Risk for oral cancer: tobacco and alcohol users - Predisposing diseases, conditions, and behaviors for periodontal disease including diabetes, HIV/AIDS, host genetic factors, smoking, stress - Compliance: keeping appointments, personal daily biofilm control - Previous treatment: patient who has a history of disease, either dental caries or periodontal infection, is at a greater risk for recurrence - Local factors: rate of calculus formation - Restorative complications: implants, prosthetic replacements
Technique of polishing (include clinical implications and precautions)
*Grasp and fulcrum* 1. Modified pen grasp 2. Intraoral fulcrum 3. Fulcrum may be several teeth away: may even split if needed *Paste selection* 1. FIll prophy cup with paste 2. Spread paste over several teeth ESTABLISH FULCRUM *Activate rheostat* 1. Rubber cup almost in contact with tooth 2. Activate rheostate - lowest speed possible 3. Do not wipe tooth 4. Cup is always in contact with tooth but pressure varies *Adaptation of cup* 1. Divide tooth in thirds 2. Begin at the gingival margin 3. Gently flare cup 4. Carefully sneak cup subgingivally 5. Turn corners at the line angles *Procedure* 1. Use patting motion 2. Stop and add paste as needed 3. Adapt to line angles 4. If using coarse or medium paste for stain removal, follow up with fine for polishing the surface - when using two different pastes, use 2 different cups *BE SURE TO FLARE CUP INTO INTERPROXIMALS SO AS TO REMOVE ANY PLAQUE FROM LINE ANGLES*
Optimum level of fluoride found in water to help provide maximum protection while not causing fluorosis State the chemicals
*Optimum levels* 1. 0.7 - 1.2 ppm depending on the climate - 0.7 ppm for warmer climates and 1.2 ppm for colder climates 2. Optimum fluoride concentration - 0.7 ppm for all communities 3. Fluorosis begins at 2 ppm - adults cannot get fluorosis
Sharpening technique
*Remove metal from the face* - not recommended - creates a weak working-end that can easily break 1. Advantages - sharpens both cutting edges at one time 2. Disadvantages - decreases strength of the instrument - shortens instrument use-life *Remove metal from lateral surfaces* - recommended - creates a strong working-end 1. Advantages - preserves strength of instrument - provides longest instrument use 2. Disadvantages - requires knowledge of the correct angulation for sharpening
Markings on a periodontal probe
*UNC 15* 1. Marking pattern - all mm from 1 to 15 marked 2. MM increments - 1-15 (plastic) (we have this probe in our kit) *Williams* 1. Marking pattern - no mark at 6 mm 2. MM increments - 1-2-3-5-7-8-9-10 (metal) (we have this probe in our kit) *Michigan "O"* 1. Marking pattern - marks at 3, ,6, and 8 mm 2. MM increments - 3-6-8 (we do not have this probe in our kit)
Criteria that determines the sequence of patient care
*Urgency* 1. discomfort or pain that requires first attention could apply to: - an area of the gingiva that is particularly difficult to clean because of inaccessibility - an area with a periodontal abscess or with NUG *Existing etiologic factors* 1. In patients with gingival or periodontal infection or risk for dental caries, success of the treatment depends on through, daily biofilm removal. Biofilm control measures are introduced and success is evaluated before additional dental hygiene interventions will be effective. *Severity and extent of the condition* 1. The number and length of appointments and the sequencing of procedures planned are affected by the severity of the condition. Findings that indicate the severity of gingival or periodontal infection include: - changes in color, size, shape, or consistency of the gingiva - probing depths - bleeding on probing - mobility of the teeth - clinical and radiographic signs of attachment or bone loss *Individual patient requirement* Items from a particular patient's history that may require adaptation in appointment length, spacing, or sequencing when planning dental hygiene care include: 1. Antibiotic premedication - because bacteremia can occur, initial instruction and practice of biofilm-removing procedures are carried out while the patient is premedicated - efficient use of appointment time and/or spacing of appointment dates will avoid unnecessary extra antibiotic coverage 2. Systemic disease - chronic disease will influence the content and length of appointments - the associations between periodontitis and systemic conditions influence patient counseling 3. Physical disability - physical limitations will require adaptation of the appointment plan
Methods for evaluating treatment outcomes
*Visual examination* 1. Obtain biofilm score after the soft tissue visual inspection has been completed so the use of disclosing solution does not interfere with soft tissue examination 2. Gingival examination looks for changes in tissue color, size, shape (contour), and consistency and compares them to examination findings documented prior to treatment 3. Visual examination can also determine whether a goal related to caries risk, such as restorative treatment or sealants, has been completed *Periodontal Probing* 1. A complete probing is performed and documented using a form that allows comparison with pretreatment assessment data 2. Current pocket depths and bleeding points noted during probing are documented in the periodontal record *Tactile Evaluation* 1. All tooth surfaces, particularly in areas demonstrating bleeding points, are assessed with a periodontal explorer for residual calculus deposits and other iatrogenic factors 2. Use of an explorer with a long straight terminal shank is needed for areas with pockets of 5 mm or deeper 3. Residual calculus can be expected on any subgingival surface the demonstrates bleeding on gentle probing 4. Smooth root surfaces free of calculus create a biologically compatible root surface that can support healing in the overlying tissues 5. Special checks for difficult-to-access areas include: - concavities and depressions of the root anatomy - subgingival margins of crowns, fixed partial denture, or overhanging restoration - furcation invasions
How does remineralization occur? What is the role of fluoride?
*What is reminerlization?* - the process of moving minerals back into the subsurface of the enamel. Saliva provides protective factors to promote remineralization *How does remineralization occur?* 1. Minerals are restored to the crystal structure and tooth destruction is arrested - the white spot will "harden" and the area may now be hypermineralized - calcium, phosphate, and other ions from saliva and plaque are redeposited into the weakened areas - will occur once the pH rises above the "critical level" 2. Remineralized areas are likely to be stronger and more acid resistant that original enamel - fluoroapatite has been formed 3. Requirements to encourage remineralization: - good plaque control vigorous fluoride therapy - restricted sugar uptake *What is the role of fluoride in the process of demineralization and remineralization?* 1. Prevents demineralization 2. Enhances remineralization by fluoroapatite 3. Inhibits bacterial activity by inhibiting enolase
Purpose of toothpastes
- Preventative - Therapeutic - Cosmetic 1. Reduction of biofilm - triclosan - zinc citrate - stannous fluoride 2. Reduction of gingivitis - triclosan (antibacterial) 3. Prevention of caries - sodium fluoride - sodium monofluorophosphate - stannous fluoride - xylitol 4. Remineralization - fluoride 5. Reduction of dental hypersensitivity - 5% potassium nitrate (most effective) - strotium citrate - sodium citrate 6. Reduction of supragingival calculus formation - pyrophosphate salts**** - zinc salts (zinc chloride) - sodium hexmetaphosphate - triclosan
Curved/sickle scaler
- Two cutting edges on a curved blade - Face is flat in cross section and curved lengthwise - The face converges with the two lateral surfaces to form the tip of the scaler, which is a sharp point - In cross section, the blade is triangular - Internal angles of 70 to 80 degrees are formed where the lateral surfaces meet the face at the cutting edges *Angulation of the shank* 1. Straight - single instrument in which the relationship of the shank, blade, and handle are in a flat plane; adaptable primarily for anterior teeth, although may be used for scaling premolars when the lips and cheeks permit retraction for correct angulation 2. Modified or contra-angle - paired instruments that are mirror images of each other to provide access to the proximal surfaces of posterior teeth; one adapts from the facial and the other from the lingual and palatal aspects *Purposes and uses* 1. Principally for removal of supragingival calculus 2. Can be used slightly subgingivally when it is continuous with the supracalculs and the tissue is spongy and flexible to permit easy access - must be careful to not traumatize the tissue *Contraindications* 1. Cause undue trauma to the gingival tissue because of the large size, thickness, and length of the blade 2. Pointed tip and straight cutting edges cannot be adapted to the curved root surfaces. Risk of grooving or scratching the cemental surface is increased 3. Tactile sensitivity decreased with larger, heavier blades *Application* 1. Angulation: - the face of the blade is adapted to the surface at an angle of approximately 70 degrees 2. Stroke: - Pull stroke only for this type of blade 3. Small scalers can be useful for removal of fine supragingival deposits directly under contact areas and between overlapping teeth
Straight scaler/Jacquette
- Two cutting edges on a straight blade - Face (between the cutting edges) is flat - The face converges with the two lateral surfaces to form the tip of the scaler, which is a sharp point - Cross section of the blade is triangular - Internal angles of 70 to 80 degrees are formed where the lateral surfaces meet the face at the cutting edges *Purposes, uses, contraindications, and application the same as sickle scalers*
*Written Care Plan* Expected outcomes
- at least one goal for each oral health problem identified in the DH diagnosis - a realistic time frame for measuring success
Risk factors for caries
- behavioral factors (inadequate biofilm removal) - dietary factors (frequent use of cariogenic foods/beverages) - low fluoride - tooth morphology and position (deep occlusal pits and fissures, exposed root surfaces, rotated positioning) - xerostomia - personal and family history of dental caries/restorative dentistry - developmental factors (modification of dental enamel) - genetic factors (immune response) For adults (things that the clinician can address) 1. Medium or high mutans streptococci and lactobacilli count 2. Visible heavy plaque between or on teeth 3. Frequent snacking between meals - more than 3 times daily 4. Deep pits and fissues 5. Recreational drug use 6. Inadequate drug use 7. Salivary-reducing factors - medication, radiation, systemic conditions 8. Exposed roots 9. Orthodontic appliances For children 1. Mother or primary caregiver with active dental decay in the last 12 months 2. Sleeps with bottle or nurses on ad lib bases 3. Bottle contains fluids other than milk or water 4. Visible cavities, white spots, or obvious decalcification 5. Recent dental restorations (<2 years) 6. Bleeding gums or heavy plaque on teeth 7. Frequent (more than three times) between-meal snacks of sugars or cooked starch 8. Appliances present (space maintainers, obturators, etc.) 9. Visually inadequate salivary flow 10. Presence of saliva-reducing factors, as follows: - medications, such as for asthma or hyperactivity - medical reasons (cancer treatment) or genetic predisposition
Risk factors for periodontal disease
- behavioral factors (inadequate biofilm removal, diet, noncompliance with DH recommendations) - tobacco use - systemic conditions - hormonal considerations - genetic factors - nutritional status - iatrogenic factors (overhangs, open contacts, residual calculus)
*Written Care Plan* Evaluation methods
- includes assessment data collection and comparison with initial assessment findings - clearly identifies how progress toward each goal will be measured
*Written Care Plan* Diagnostic statements
- link observed or potential oral health problems identified during the patient assessment to probable etiology or risk factors - relate to problems and solutions that can be addressed within the dental hygiene scope of practice
Sodium Fluoride (NaF)
- neutral due to pH of 7.0 - 2.0% solution - efficacy based on 4 or 5 applications once a week in relationship with eruption patterns - 9,050 ppm fluoride - quarterly or semiquaterly applications - optimum if you want to get the optimum amount of fluoride uptake in the tooth - used in fluoride varnishes - used for bulimic patients (pH is neutral so it doesn't add any acid to the teeth) - used on OTC rinses - used in the presence of tooth colored restorations, porcelain fused-to-metal and with sealants - most effective delivery is via tray - 4 minute application - do not let patient swallow fluoride - cannot eat, drink, rinse, or smoke for 30 minutes after treatment
*Written Care Plan* The appointment plan
- outlines intervention sequence in order of clinical performance - can be adapted at each appointment to respond to new information or an immediate need of the patient - properly prioritized and sequenced treatment and education will be more comfortable for the patient and more effective in reaching planned oral health goals
*Written Care Plan* Demographic Data
- patient name, dob, and gender - a designation of initial or maintenance therapy - the name of the student or clinician who prepared the written plan - the date the written plan was prepared - notation of the patient's chief complaint or statement indicating the patient's reason for presenting for treatment
*Written Care Plan* Periodontal diagnosis and status
- the periodontal diagnosis formulated in collaboration with the dentist is included in the DH care plan
Risk factors for oral cancer
- tobacco use of any kind - heavy alcohol use - excessive sun exposure (lips and face) - exposure to the human papillomavirus - genetic susceptibility
Analysis of probing results
1-3 mm means it is a healthy sulcus 4 mm and above means that there is a pocket of some type, whether it is a gingival pocket or a periodontal pocket cannot be determined without radiographs
Acidulated Phosphate Fluoride (APF)
1. 1.23% solution 2. pH of 3.5 3. 4 minute trays 4. Acidic pH enhances the uptake 5. Application: tray (2.6ml for adults) or by painting 6. Form: thixotropic or gel - thixotropic expands, the foam turns into liquid after so much time and goes into the nook and crannies of the teeth 7. Etches porcelain, composites, and sealants
Stannous Fluoride
1. 8.0% solution 2. pH 2.4 to 2.8 3. Seldom used due to unpleasant taste, instability, and staining of teeth (tin oxide) 4. unstable solution 5. Gingival sloughing and discoloration of tooth - colored restorations
Correct probing technique
1. Act of walking the tip of the probe along the junctional epithelium within the sulcus or pocket for the purpose of assessing the health status of the periodontal tissue - walking stroke: a series of bobbing strokes that are made within the sulcus or pocket while keeping the probe tip against the tooth surface - move forward in 1mm increments 2. Probe tip is kept in contact with the tooth surface at all times (1-2mm of the side of the probe) - probe tip should NOT be held away from the tooth 3. Probe should be as parallel as possible to the tooth surface
Basic ingredients of mouthwashes
1. Active ingredients: - may contain more than 1 ingredient (thus may have many claims) - factors that influence efficacy: dilution by saliva, length of time rinsing, supporting evidence 2. Water - largest percentage by volume 3. Alcohol - increases the solubility of ingredients - 0% to 26.9% - enhances flavor - no link to oral cancer 4. Flavoring - essential oils
When should instruments be sharpened? What is the infection control of the sharpening device (sidekick)?
1. At the first sign of dullness 2. After the removal of the screw and file board, those are packaged for sterilization. Then the rest of the sidekick is wiped down with a dicide wipe twice
How does demineralization occur?
1. Breakdown of tooth surface with loss of mineral content 2. Involves dissolution of the calcium and phosphate ions from the hydroxyapatite crystal 3. Occurs when the pH drops: - below 4.5 to 5.5 for enamel - 6.0 to 6.7 for cementum - "critical pH levels" 4. Requirements to prevent demineralization - good plaque control - vigorous fluoride therapy - restricted sugar intake What is demineralization - process by which the minerals of the tooth structure are dissolved into solution by the organic acids produced from the fermentable carbohydrate by the acidogenic bacteria - with repeated bathing of the tooth surface with the acids produced in the course of a day, the tooth demineralization can outpace the remineralization process resulting in a cavitated carious lesion - smooth surface caries and pit and fissure carious lesions can result when cariogenic nutrients are available
Systemic fluoride
1. By way of the circulatory system to developing teeth 2. Exposure prior to tooth eruption
What is a working stroke?
1. Calculus removal stroke 2. Instrument is adapted to the tooth at a 70 degree angle, then firm pressure is applied to the instrument in order to remove the calculus 3. Not used to find calculus, only used in the parts of the mouth where calculus has already been located with the explorer in order to remove it
Correct care of a manual toothbrush
1. Cleaning: - clean after each use - hold under strong stream of water - tap handle to remove remaining particles - use one brush to clean another - rinse completely and tap out excess water 2. Storage - keep in open air with head up right - keep apart from other brushes - portable container should have sufficient holes to allow complete drying 3. Replace before filaments are worn 4. Replace every 2-3 months
Dental floss/tape - correct use - precautions
1. Correct use - use new/clean piece between each proximal surface - monitor pressure - sawing motion between teeth - cleaning stroke (clean each tooth separately, slide up and down) - use floss aids if necessary - be careful of floss cuts/clefts 2. Precautions - remember tissue is not keratinized and vulnerable to disease - infection begins here first so biofilm control is important - too much pressure can be destructive to the attachment - floss cuts and clefts are caused by the floss being too long, snapping floss through contacts, not wrapping floss, not using a fulcrum
Scalers classified by their shape, function, and technique
1. Curved scaler/sickle scaler 2. Straight scaler/Jacquette 3. File scaler 4. Hoe scaler 5. Chisel scaler
*Written Care Plan* Planned intervention
1. DH interventions are measures applied to regenerate, restore, or maintain oral health are specific to the individual patient's assessment findings and include: - clinical treatments, such as scaling, root planing, and debridement, selected for the purpose of arresting or controlling existing disease - preventive measures, such as dental sealants, that maintain tooth integrity - education and counseling in such topics as etiology and progression of oral disease and elimination of risk factors - individualized oral hygiene instructions and personal daily oral care regimens based on patient needs and abilities
Components of a written care plan
1. Demographic data 2. Assessment finding and risk factors 3. Periodontal diagnosis and status 4. Caries risk status 5. Diagnostic statements 6. Planned intervention 7. Expected outcomes 8. Evaluation methods 9. The appointment plan 10. Re-evaluation
Purpose of an explorer
1. Detect, by tactile sense, the texture and character of the tooth structure - for calculus defects or irregularities in the surfaces and margins of restorations, and other irregularities not apparent to direct observation - used to confirm direct observation - avoid using on white spots (areas that have been remineralized) 2. Define the extent of instrumentation needed and guide techniques - for scaling and root planning - removing an overhanging filling 3. Evaluate the completeness of treatment - for periodontal nonsurgical treatment as shown by the smooth tooth surface - for removal of an overhanging filling by the smooth margins of the restoration
Patients who would benefit from fluoride supplements - administration - dosage schedule
1. Determine the need for dietary fluoride supplements: - make certain the child is not recieving optimum fluoride - find out if community water is fluoridated - request water analysis if on a private water source - fluoride has been proven to pass across the placenta during the 5th and 6th month of pregnancy and enter the prenatal deciduous teeth, however, administration of prenatal dietary fluoride supplements is not recommended 2. Do recommend fluoride supplements for: - patients with private water supply that does not contain fluoride - when fluoride level is less than optimum - patient lives in an unflouridated community
Topical fluoride
1. Directly to the exposed surface of erupted teeth 2. Frequent exposure through out life 3. Absorbed from water, toothpaste, mouthrinses, and foods 4. Inhibits demineralization and promotes remineralization 5. Uptake is most rapid on enamel during the first years of eruption
Rationale for maintaining sharp instruments
1. Easier to remove calculus (instrument bites into tooth) 2. Improved stroke control 3. Fewer strokes required 4. Increased patient comfort and satisfaction 5. Reduced clinician fatigue
Interdental tips - indications for use - proper utilization
1. Indications for use - exposed interproximal tooth surfaces - biofilm removal at/or just below gingival margin 2. Procedure - trace along gingival margin with tip - rub tip on proximal surfaces - rinse tip after and during treatment
Single end or tufted brushes - indications for use - proper utilization
1. Indications for use - open interproximal areas - fixed dental prosthesis - difficult to reach areas 2. Procedure - place bristles into interproximal - rotating motion with intermittent pressure - sulcular brushing method
Toothpick in a holder (perio-aid) - indications for use - proper utilization
1. Indications for use - perio patients for removal of biofilm at/or just below margin, interpoximals, furcations - orthodontic appliances 2. Procedures - insert round toothpick into holder, break off other end - apply to gingival margin; trace areas - less than 45 degree angle; go just below the margin - frayed ends may be used as a brush; may be used for desensitization - remove impacted food
Interdental brushes - indications for use - proper utilization
1. Indications for use - remove biofilm; open embrasures, orthodontic appliances, fixed prosthesis, implants, splints, space maintainers, Class IV root furcations - concave areas - apply chemotherapeutic agents 2. Procedure - select appropriate brush: diameter - moisten; insert at angle; brush in and out
Gauze strips - indications for use - proper utilization
1. Indications for use - used for widely spaced teeth - teeth next to edentulous areas - abutment teeth - under cantilevered sections; under fixed appliances 2. Procedure - 1 inch guaze about 6-8 inches long; folded - position near gingival crest
Tufted dental floss (superfloss) - indications for use - proper utilization
1. Indications for use - used with wide embrasures - on abutments and under pontics 2. Procedure - curve floss in "C"; move floss vertically and horizontally - thread through pontic; floss mesially and distally of abutments
Proper sequence for determining mucogingival involvement
1. Measure the total gingiva by laying the probe over the surface of the gingiva and measuring from the free margin to the mucogingival junction 2. Measure the pocket depth 3. Subtract the pocket measurement from the total gingiva to obtain the width of the attached gingiva
Proper sequence for determining probing depth
1. Measurement taken from the GM to the BOP (JE) 2. When the GM appears at a level between probe marks, round up to the higher marking on the probe for the final measurement 3. Dry the area being probed to improve visibility
*Written Care Plan* Assessment finding and risk factors
1. Medical history - systemic diseases and conditions: current and past - medications - overall health status - functional assessment 2. Social and dental history - treatment history - oral health knowledge and behaviors - cultural factors 3. Clinical examination - extraoral and intraoral - soft and hard tissue 4. Link to risk factors - risk for increased oral disease - increased risk of systemic disease due to oral infection - potential for compromised treatment outcomes
What is the administration and dosage schedule of fluoride based on a patient's need for it?
1. No fluoride supplements from birth to 6 months 2. 6 mo. to 3 yr - 0.25 mg/day; less than 0.3 ppm 3. 3 to 6 yr - 0.5 mg/day; less than 0.3 ppm - 0.25 mg/day; between 0.3 and 0.6 ppm 4. 6 to 16 yr. - 1.0 mg/day; less than 0.3 ppm - 0.5 mg/day; between 0.3 and 0.6 ppm
Purpose of a periodontal probe
1. Periodontal instrument marked in millimeter increments that is used to evaluate the health of the periodontal tissue 2. Used to determine health or disease - classify as gingivitis for periodontitis by determing if bone loss has occured and if the pocket is gingival or periodontal 3. Used to measure - sulci depth - attachment level - recession level - width of attachment - presence of bleeding - measure oral lesions 4. Uses - assess the periodontal status for preparation of a treatment plan - make a sulcus and pocket survey - determine CAL - bleeding on probing - measure gingival recession - determine consistency of gingival tissue - guide treatment - evaluate success and completeness of treatment - evaluation of continuing care and periodontal maintenance appointments
Purpose of disclosing agents
1. Personalized patient education 2. Self-assessment 3. Cont. evaluation of the effectiveness of the instruction 4. Preparation of biofilm indices 5. Conducting research studies
*Toothbrushing method* Fone's
1. Purpose - easy to learn - used for young children - may be detrimental for overvigorous adult brushers 2. Procedure - close teeth together - use fast, wide circular motions that sweeps over both maxilla and mandible - bring anterior teeth edge to edge to complete - light pressure - in and out strokes for lingual and palatal 3. Problems - can cause trauma if used by a vigorous brusher
*Toothbrushing method* Modified Stillman's
1. Purpose - for cleaning tooth surfaces and stimulation of gingiva - incorporates a rolling stroke with the vibratory stroke - helps minimize gingival trauma and increase biofilm removal effects 2. Procedure - direct filaments apically - place on attached gingiva at a 45 degree angle - press to flex filaments; tissue will blanch - vibrate for count of 10 - roll brush towards occlusal surface - replace brush and repeat stoke - repeat stroke 5 times or more 3. Problems - tissue lacerations can occur - vibratory aspect may be ineffective if patient rolls brush too quickly
*Toothbrushing method* Bass
1. Purpose - removal of dental biofilm adjacent to and directly beneath the gingival margin - for open interproximal areas, cervical areas, and exposed roots - after periodontal surgery - adaptation around abutments 2. Procedure - direct filament apically at a 45 degree angle - direct filaments straight into sulcus - press lightly - vibrate back and forth for a count of 10 - reposition brush and repeat 3. Problems - can be turned into vigorous scrub - high dexterity needed - can also use a "roll stroke" before; never combine the 2 methods THERE IS NOT A MODIFIED BASS METHOD
*Toothbrushing method* Charter's
1. Purpose - to clean interproximal areas - tips of filaments are forced into interproximal areas - loosen debris and biofilm - massage and stimulate marginal and interdental gingiva - clean proximal surfaces if tissue is missing - clean exposed root surfaces - clean abutments - used around orthodontic appliances 2. Procedure - rolling stroke should be done first to accomplish cleaning - place filament against enamel towards occlusal place at a 45 degree angle - flex filaments - vibrate and count to 10 - reposition and repeat - overlap strokes - modified stillman is frequently advised for anterior lingual and palatal surfaces 3. Problems - does not clean sulcus - limited brush placement in some areas - requires high dexterity
What patients require prophylactic antibiotics prior to treatment? Why?
1. Recommended for patient with cardiac conditions associated with the highest risk of adverse outcomes from endocarditis, including: - prosthetic cardiac valve - previous endocarditis - unrepaired congenital heart disease, including those with palliative shunts and conduits - completely repaired congenital heart disease with prosthetic material or device, whether placed by surgery or catheter intervention, during the first 6 months after the procedure - repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic device - cardiac transplantation recipients with cardiac valvular disease - consultation with the orthopedic surgeon is recommended for those with prosthetic joints 2. All dental procedures that involve: - manipulation of gingival tissue - the periapical region of teeth - perforation of the oral mucosa
Varnish
1. Safe and effective 2. Used for sensitivity and caries prevention 3. Sets quickly 4. Easy to apply 5. Used for dental hypersensitivity 6. Fluoride of choice for dentin hypersensitivity 7. 5% solution or 22,600 ppm 8. Substantivity 9. Not for home use 10. Contain 5% sodium fluorid thus an increased concentration 11. 0.3 to 0.5 mL/application 12. Prolongs fluoride exposure to the tooth (retained for 24 to 48 hours) 13. Stays on teeth for a day or two; works great because it lasts so long 14. 18 to 77% caries reduction in permanent teeth 15. Ability to remineralize initial caries lesions in primary teeth (80% reversal of lesions) 16. Indicated for - infants, toddlers, children, and adults at moderate risk for decay - reversing demineralization and white spots - when longer fluoride contact is desired - control of dentinal hypersensitivity - special needs patients - patients with severe gag reflexes 17. No documented cases of acute or chronic fluoride toxicity resulting from varnish use 18. Not for home use 19. Every 3 to 6 months 20. More effective in caries reduction than traditional professional topical fluorides 21. 14% more effective than topical gels
Proper sequence for determining clinical attachment level
1. Select a fixed point - CEJ if it can be found 2. Measure the presence of visible recession - CEJ is visible - measure from CEJ to GM - CAL is found by adding the pocket depth to the measurement taken from the CEJ to the GM 3. Measuring when the CEJ is covered by the gingival margin - slide probe into the pocket and feel for the CEJ, measure from the CEJ to the GM - subtract the measurement of the CEJ to the GM from the total pocket depth 4. Measuring when the GM is level with the CEJ - the pocket depth equals the CAL
Chemicals used in the water fluoridation process
1. Sodium fluoride (dry compound) 2. Sodium silicofluoride (dry compound) 3. Hydrofluorosilic acid (solution) - The EPA (Eviornmental Protection Agency) monitors the concentration levels of fluoride in drinking water - FDA sets the limit of fluoride in bottled water
Desirable characteristics of a manual toothbrush
1. Soft 2. Multi-tufted 3. Polished, round, nylon bristles
What is the rationale for determining the clinical attachment level
1. Stability of attachment is a characteristic of health 2. A loss of clinical attachment is a primary clinical feature of periodontitis as the JE migrates toward the apex 3. When periodontal disease is active, pocket formation and migrations of the attachment along the cemental surface continues 4. Evaluation can be made of the outcome of periodontal treatment and the stability of the attachment during maintenance examinations
Importance of sequencing and prioritizing patient care
1. To provide evidence-based, individualized patient care - determined by analysis of assessment data - based on documented evidence of success - enhanced by the clinician's ability to assess the value of information available in the scientific literature 2. To eliminate or control etiologic and predisposing disease factors - the principle etiologic agents in both dental caries and periodontal and gingival diseases are the microorganisms of dental biofilm - dental hygiene interventions can modify a cariety of risk factors that predispose the patient to oral disease 3. To eliminate the signs and symptoms of disease - measures to eliminate signs of infection such as gingival bleeding and probing depths are included in the care plan 4. To promote oral health and prevent recurrence of disease - education on the etiology of oral disease - counseling on prevention measures and elimination of risk factors - instruction and supervision in daily self-care techniques - encouragement of regularly scheduled maintenance follow up for dental hygiene care
Correct exploring technique
1. Uses tactile sensitivity 2. Must have a light grasp 3. Explorer: instrument of choice for: - initial location of deposits - re-evaluation 4. During instrumentation, the curet is used for detection once the area feels smooth with curet, re-evaluate with explorer *Grasp* relaxed, light modified pen grasp; middle finger rests lightly on the shank *Adaptation* 1-2 mm of the side of the tip *Lateral pressure* Light pressure against the tooth *Activation* Rocking motion (digital allowed with the use of an explorer) *Stroke characteristics* Fluid, sweeping stroke *Stroke number* Many overlapping strokes *Common errors* - avoid "death grip" - avoid too much pressure 1. Adapt instrument and gently slide subgingivally 2. Keep tip in contact with root surface, slide tip apically until you feel the base of the pocket 3. Use a vertical or oblique stroke to move instrument up root 4. DO NOT remove the instrument from the pocket 5. Walk around tooth 6. Short strokes, about 2-3 mm (overlapping) 7. Lead with the tip into the interproximals
*Written Care Plan* Caries risk status
1. understanding of a patient's individualized risks for dental caries can guide the plan for: - oral health education and couseling - selection of treatment interventions, such as dental sealants or fluoride recommendations to enhance remineralization
What is the usual dosage and time sequence of prophylactic premedications?
30-60 min before procedure Standard Amoxicillin - adult: 2 g orally - child: 50 mg/kg orally Unable to take oral medications Ampicillin - adult: 2 g IM or IV - child: 50 mg/kg IM or IV Cefazolin or celtriaxone - adult: 1 g IM or IV - child: 50 mg/kg IM or IV Allergic to penicillins of ampicillin - oral Cephalexin - adult: 2 g orally - child: 50 mg/kg orally Clindomycin - adult: 600 mg orally - child: 20 mg/kg orally Azithromycin or Clarithromycin - adult: 500 mg orally - child: 15 mg/kg orally Allergic to penicillins and unable to take oral medications Cefazolin or ceftriazone - adult: 1 g IM or IV - child: 50 mg/kg IM or IV Clindomycin - adult: 600 mg IM or IV - child: 25 mg/kg IM or IV
Informed consent
A patient's voluntary agreement to a treatment plan after details of the proposed treatment have been presented and comprehended by the patient
Informed refusal
A patient's voluntary agreement to a treatment plan after details of the proposed treatment have been presented and comprehended by the patient
Potential detrimental effects of polishing
Aerosol production and splatter: 1. Dental aerosols may be suspended for up to 24 hours 2. Splatter - do not polish patients with a communicable disease - do not expose susceptible patients to the aerosols 3. Be sure to wear PPEs Bacteremia 1. Presence of bacteria in the blood stream 2. Be sure to review medical history 3. May need to premed patient Iatrogenic damage to the tooth surface 1. Removal of fluoride rich layer 2. Generates heat 3. Injury to gingiva 4. Sensitivity at CEJ 5. Tooth surface abrasion (xerostomia patients and decalcified areas) 6. Damage to restorations - gold, composites 7. Aerosol production Allergies to ingredients 1. Usually the result of flavor additives or preservatives in the product 2. Allergic reactions more common in patients with history of hay fever, allergic skin rashes, or asthma
When should a patient's medical history be taken? Why?
At the beginning of each appointment so that you can know how to plan the treatment and if there are any special precautions that should be made, also to be prepared in case there is an emergency
Where can fluoride be found in the tooth structure?
Concentration is greatest on the surface (next to the source of the fluoride) - enamel: outer surface - dentin: inner surface
Standard of care
Criteria or protocols that define the minimal quality of care required to defend against a legal dispute against the practice of one's profession; usually established by federal laws, state and local statutes and codes and/or testimony from an "expert witness," and is supported by guidelines or recommendations documents published by professional associations Three sources for determining standard of care in a legal dispute - opinion of expert witnesses - journals, guidlines, or other published documents from recognized professional associations or other authoritative sources - federal, state, or local statutes and/or regulations
Contraindications for polishing
Dental consideration 1. Lack of stain 2. Sensitive teeth 3. Exposed cementum or dentin 4. Newly erupted teeth - mineralization is not complete 5. Implant abutments - titanium abutments should not be polished - implant superstructure can be polished if needed 6. Areas of demineralization - removes enamel 7. Gingiva that is enlarged, spongy, or bleed easily Systemic considerations 1. Communicable disease 2.. Susceptibility to infection
Indications for stain removal/polishing
External stain that can be removed by polishing - most common are chlorhexidine and tobacco
Why is scaling preferable to polishing when removing tenacious stain?
If you leave the rubber cup on the tooth for too long a period of time you can over heat the tooth and damage the pulp It also removes more of the tooth surface (enamel)
Wooden interdental cleaners - indications for use - proper utilization
Made of basswood or birch wood Triangular in cross section 1. Indications for use - proximal surfaces where gingiva is missing (type III embrasure - only for patient who follows directions well - a new cleaner for each arch or quadrants due to splaying of wood can traumatize the tissue!! 2. Procedure - fulcrum - soften wood by moistening with saliva - insert tip pointed slightly to occlusal or incisal - base of the wedge triangle to the gingiva - move in and out - discard at first sign of splaying do NOT hold the wedge horizontally as it will flatten the papilla
Methods of evaluating self-care and health behavior outcomes
Measure short-term and long term outcomes 1. Short-term - reduced dental biofilm -no bleeding on probing - resolution of erythematous tissue - reduced swelling and edema 2. Long-term outcomes - reduced probing depths - no further loss in attachment level - decrease or no change in mobility
Purpose of a Nabor's probe
Preferred to assess the extent of furcation involvement over standard periodontal probes for accuracy 1. Mandibular molars (bifurcated) - furcation accessible from the facial and lingual aspects 2. Mandibular first premolars (bifurcated) - furcation accessible from the mesial and distal aspects; under the contact area 3. Maxillary primary molars - widespread roots 4. Maxillary molars (trifurcated) - access for probing is from the mesiolingual, buccal, and distolingual surfaces
Tissue conditioning as it relates to SRP
Purpose Anticipated outcomes of a tissue-conditioning program include: 1. Gingival healing - tissues become less edematous - bleeding is minimized - scaling procedures are facilitated 2. Reduced bacterial accumulation - less likelihood that bacteremias will be produced during scaling - contamination is reduced in the aerosols produced 3. Learning by the patient while conditioning the tissue for scaling, the patient can do the following - practice oral health behaviors - experience the benefits of a clean mouth - form lifetime habits for continued maintenance Procedure 1. Initiate a pretreatment program of daily biofilm removal 2. Recommend daily use of an antibacterial rinse after thorough brushing and flossing before going to bed 3. Select affected quadrants for scaling only after patient cooperation has been demonstrated
Proper sequence for determining visible recession level
Use a probe to measure from the CEJ to the gingival margin
Markings on a PSR probe
WHO probe which has a 0.5 mm ball at the tip and mm markings at 3.5, 8.5, and 11.5 mm. Color coding from 3.5 to 5.5 mm
Determination as to which probe currently meets standard of care (periodontal probe)
Williams probe
What is an exploratory stroke?
With the use of an assessment instrument a light stroke is used to feel calculus
*Written Care Plan* Re-evaluation
at the re-evaluation appointment: - new assessment data are collected and analyzed - a determination is made regarding whether expected outcome of the care plan have been met - continuing care appointment interval is determined
