Pt Assessment

Lecture 2 Medical History Considerations (6)

1.

List reasons why the patients medical condition is important to the dentist
a. Increasing number of patients with significant health problems
b. Many patients taking multiple meds, combining w/ medications we give them
c. Use of oral, inhalation and IV sedation techniques
d. General improvement in standard of care provide best treatment possible
e. Risk management for the dentist = to avoid lawsuits

2.

List six objectives of the pre-treatment health evaluation

a. To help establish the oral diagnosis
ii. Oral conditions may be caused or worsened by medical conditions or medications
b. Determine pre-existing conditions
i. Significantly effect dental treatment
ii. Routine treatment may worsen the patients medical condition or cause death
c. Discover undiagnosed medical conditions

High blood pressure vital signs

HIV, cancer persistent fever, weight loss

d. Management of medical emergencies

Most can be avoided!

Rapid assessment of patients condition

e. Patient Management

Develop rapport

Determine patients level of anxiety

f. Protect yourself, family, employees, other patients

3.

List the seven tools used to evaluate the patients health

a. Health history questionnaire
- general questions/ known dz/ symptoms/ medications
b. Verbal interview with the patient
c. Vital signs
baseline in case of emergencies
take at all examination appointments
take at all appts when drugs will be used
for hypertensive patients, take at all appts
d. Functional capacity
determination of cardiac risk
ability to perform basic daily activities
Ability to perform at 4 METs without
shortness of breath
fatigue
chest tightness or pain
e. Clinical examination

f.

g.

- signs of occult dz/ signs of drug side effects = xerostomia most common
Work up possible problems
- collection of all info about condition in one place = SOAP (help collect and organize
data)
GOAL to determine: Is condition controlled? Effecting patients oral condition? Does
condition/medication increase risks of dental trt? how?
Plan - decrease risks
Medical consultations as needed
i.
Patient is poor historian
ii.
Suspicion of occult dz
iii.
Dz appears to be poorly controlled
iv.
Unusual condition

4.

Be able to assign Physical Status (ASA) Classification

*Global assessment of the patients health
a. ASA I: No systemic disease
b. ASA II: Mild systemic disease that doesnt interfere with daily activities, or healthy with
risk factors
c.
ASA III: Moderate to severe systemic disease, limits daily activity but not lifethreatening
d. ASA IV: Incapacitating disease, constant threat to life
e. ASA V: Pt not expected to survive 24 hours
f.
ASA VI: Pt brain dead organs to be removed

5.

How does Functional Capacity affect the ASA Classification?

a. Adequate functional capacity = ability to perform at 4 METs without
i.
Shortness of breath
ii.
Fatigue
iii.
Chest tightness or pain
b. Energy requirements in metabolic euqivalents : 1~13 //
c. Test these MET to determine ASA ? Must be III+ if it affects cardiac activity?

6. What is the bottom line for the medical/medication SOAPs and what questions should this
answer?
Medical
S: any information not obtained through your examination of the pt,
provided by pt/guardian, lab results from pt physician
O: only information from your own examination/observation of the pt
ex. vital signs, extra/intraoral signs or manifestations (none appropriate)
A: (most important, none NEVER appropriate)
Does the disease appear to be controlled?
What risk that this condition may affect or be affected by dental tx?
P: planned modification to lessen health/medication related risks

(none appropriate)
Medication
S: information from patient, physician, and reference materials (lexi)
generic/brand name, pharmacologic category, local anesthetic/vasoconstrictor
precautions, effects on dental tx, effects on bleeding, cardiovascular adverse fx
O: information from clinical exam
ex. vital signs abnormalities, oral manifestations if seen
A: how the medication is currently affecting/the risk that it may affect the pt oral health
effects of the medication
P: modifications to the treatment plan to allow for safe treatment and maintenance of
oral health
Lecture 3 Vital Signs (11)
1. Sources of error for BP and whether each error will increase or decrease the BP
Avoid auscultatory gap error by taking palpatory BP before auscultatory BP Leads
to inaccurate BP recordings
Bladder too narrow for arm Inaccurate high reading
Bladder too wide for arm Inaccurate low reading
Leaky tube or bulb Inaccurate reading
Pt arm not at heart level Inaccurate reading
Pt legs dangling Inaccurate high reading
Back unsupported Inaccurate high reading
Cuff wrapped too loosely Reading too high
Applied over clothing Inaccurate
Amplifying device applied too firmly Diastolic reading too low
Failure to palpate brachial pulse Underestimation of systolic
Inflation level too low Underestimation of systolic
Inflation too slowly Overestimation of diastolic
Cuff pressure released too fast Underestimate of systolic, over estimate of
diastolic
Intra-arm difference Pressure difference of more than 10mm Hg between arms
Tiime of day: BP usually lowest in morning and can increase 10mm Hg later
Postion: lower when lying down
Arm: pressure difference of more than 10 mm Hg between arms in 6% of HTN pts
Eating: BP slightly higer after meal, especially if it is high in salt
Exercise: strenuous activity will temporarily increase systolic blood pressure
Stress: anxiety, fear, or pain will temporarily raise a persons blood pressure
2.

Procedure for taking vital signs

a. Temp (3M Tempa DOT procedure)
i.
Remove outer package
ii.
Place at base of tongue in posterior sublingual pocket
iii.
Have patient press down with tongue

iv.
v.
vi.
vii.
viii.

Time for 60 seconds

Remove and wait 10 seconds before reading
Read the last blue dot
Ignore any skipped dots
Retake if left in the mouth > 2 mins

b. Pulse/ HR
(Wrist- radial artery)
ii.
Patient rotates hand into palm up position
iii.
Use distal pads of index and middle fingers not thumb!
iv.
Pulse can be felt just above the wrist behind the thumb
(neck- carotid artery)
v.
Anterior to the SCM muscle
vi.
At the level of the thyroid cartilage
vii.
Use the distal pads of the index and middle fingers
(Nextfor both wrist and carotid)
viii.
Apply firm pressure until you feel pulsation
ix.
Count the beats for 30 seconds and multiply by 2
x.
Retake for 30 seconds if it is abnormal (rate, amplitude, irregular)
c.

3.

Respiration
i.
Two techniques
1. Immediately after taking pulse, leave fingers on wrist, surreptitiously
observe the rise and fall of chest/abdomen
2. From behind, where patient cant see you, observe the rise and fall of
chest/abdomen
3. ABOVE ALL, do not tell the patient you are going to measure their
breathing!
ii.
Count respirations for 30 seconds and multiply by 2
iii.
Record as # respirations/minute (14/minute)

Advantages and disadvantages of different types of equipment

a. Temp
i. Glass-mercury thermometer
1. Advantages
a. Inexpensive ($1-3)
b. Still in wide use
c. No batteries needed
2. Disadvantages
a. Breakable hazardous substance
b. Technique sensitive
c.
Shake it down to below 94 F or 34.4 C
d. Hold by stem, not bulb
e. Difficult to read

f.
Wait 3-5 minutes for a reading
ii. Electronic
1. Advantages
a. Quick 30 seconds
b. Automatic timer
c.
Digital read-out
d. Some beep when done
2. Disadvantages
a. More expensive ($ 5-10)
b. Battery operated
c.
Disposable sheaths required
iii. 3M Tempa-DOT
1.
Advantages
a. Single use
b. Unbreakable
c.
Inexpensive
d. Easy to keep in the mouth
e. No batteries or covers
f.
May cost no more than sheaths for reusable thermometers
2. Disadvantages
a. 60 seconds
b. Sensitive to high temps
c.
Difficult to interpret
b.

4.

BP
i. Mercury sphygmomanometer
1. advantage
a. More accurate than anaeroid
2. disadvantage
a. fixed or difficult to tranposrt
b. more fragile than anaeroid
c.
hazardous compound (mercury colum)
d. 0 at level of heart
ii. Automatic blood pressure
1. Adv
a. Home units no stethoscope ( Fully automatic/ semi-automatic)
b. Most accurate invasive (catheter in artery), arm band-type
(manual or automatic) , brachical artery best (as opposed to finger or
wrist)
2. disadv.
a. expensive. many automatic devices do NOT provide accurate
readings

Normal ranges for vital signs adults

a.
b.
c.
d.

5.

Temp: Oral 96-99.6 F (avg 98.6)

Pulse/heart rate: 60-100 bpm
Respiration: 14-20/ min
Bp : 120/80 (mmHg)
systolic: 90-119 mmHg
diastolic: 60-79 mmHg

Children: 90-100 bpm

Management of abnormal findings

a. Temp
Above 99.6 F infection or neoplasm
compare with baseline measures.
Is patient aware? (determine duration, causes)
oral examination oral infection or tumor? Treat cause.
Unexplained cause- refer to physicians
Above 105 F heat stroke or dmg to hypothalamus (not infection)
Medical EMERGENCY
>106 F in children - convulsions
>108 F - irreversible brain damage
Causes in adults
Not infection
Heat stroke
Damage to hypothalamus
b.

HR
i. weak, thready pulse heart failure, hypovolemia, aortic stenosis
correlate with medical history
is patient aware
medical consultaion
ii. Bounding pulse heavy exercise, stress, medication, rec. drugs, hyperthyroidism,
severe hypertension, bradycardia, hypervolemia
correlate with bp/medical history
current medications, recreational drug use, stress/fear level
medical consultation
patient education regarding recreational drugs
iii. Tachycardia fever, anemia, CHF
normal variation?
Correlate with health history/temp
oral infection?
Is pts aware?
Medical consultation

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iv. rhythm irregularities (pulsus alterans, PVC)

correlate with health history
med consult
c.

Respiration
i. Tachypnea (increase breathing, > 20/min) - anxiety, hypervent., metabolic acidosis
is patient in immediate distress? Call EMS (8333),
normal variation?
Correlate with medical history and vital signs,
assess for fear/ anxiety,
medical consultation
ii. Bradypnea (decrease breathing, <12/min) - coma, narcotic OD
assess mental status,
elicit history of injury or drug use,
activate EMS
iii. Cheyes/strokes respiration (1-3 min cycle, apnea increase in intensity)
correlate with medical history/
obtain medical consultation
iv. Kussmaul respiration (heavy, labored breathing, diabetes)
correlate with medical history/
activate EMS if pt in immediate distress
v. Dyspnea (difficulty in breathing , shortness of breath, obstruction)
pt in immediate distress? EMS,
correlate with medical history,
asses for fear/anxiety,
medical consultation

d.

Blood pressure
i. Below normal findings- <90/<60
pt in immediate distresss?
Evaluate cognitive function.
Correlate with medical history,
medical consult
ii. Above normal findings: >140/>90
immediate distress?
Correlate with medical history and medications,
assess fear/stress,
medical consultation

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1. ALWAYS start by retaking the measurement

2. Explain the findings to your patient. Is patient aware of this abnormality?
3. Questions to ask yourself
1. Is this normal variation?
2. Is the patient in distress?
3. Does this finding correlate with any finding in health history or side effect of
medications?
4. Is the finding associated with an oral condition?
5. Is the finding associated with dental anxiety or fear?
6.

Auscultatory gap
a. Korotkoff sounds sounds caused by turbulent flow in artery
Systolic phase 1,2,3 1st diastolic phase 4 2nd diastolic phase 5
(silence)
b. Auscultatory gap = The disappearance of the Phase 1 Korotkoff sounds in systole
with reappearance above the diastolic pressure
c.
Avoid auscultatory gap error by taking palpatory BP before auscultatory BP
palpatory BP estimate SYSTOLIC not diastolic
d. Cause: unknown (atherosclerotic plaque)
e. 20% of elderly patients
f.
Leads to inaccurate BP recordings
Silence systolic p 1,2,3 (GAP=silence)- false systolic 4- diastolic p- 5 (silence)

7.

Causes of blood pressure variability

a. Normal variation
i. Typical diurnal pattern: peaks at midmorning, falls progressively throughout the
day, lowest at 3-4 am
b. BP rises slightly as patient ages
c. Wrong size cuff (4)
d. Wrong arm position (dont rest on chair)
e. Failure to have the patient relax before measurement
f.
Too rapid deflation of the cuff
g. Rounding values off to nearest 0 or 5 mm instead of to the closest 2 mm
h. Cuff too loose
i.
Pressure released too slowly or too quickly
j.
Amplifying device not applied correctly and not positioned correctly
k. Cuff applied over thick clothing

8.

White coat hypertension

a. Increased BP at the time of dental exam or treatment (or physicians exam) when
compared to other values
b. Seen in 10 40% of patients with borderline hypertension
c. Usually not seen when patient has normal blood pressure
d. Difference in measurements may be > 20 mm Hg

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e.

Primarily seen with dentist/physician and not with other staff members

Lecture 4 & 5 Orthodontics and Occlusion (4)

1. Difference between abrasion, attrition, erosion
abrasion - tooth brushing, rounded
attrition - clenching, angled
erosion - chemical wear (lemons, GERD, bulimia)
2.

Indications and benefits of orthodontic treatment

can the pt benefit from ortho treatment?
improved position and improved restorative options/outcomes
psychosocial improvement
occlusal function
esthetics
reduced caries risk
improved periodontal health

3. Types of malocclusion, Angles classification

Class I (or neutrocclusion) In this classification, the maxillary first molar is
slightly back to the mandibular first molar; the mesiobuccal cusp of the maxillary first
molar is directly in line with the buccal groove of the permanent mandibular first
molar. The maxillary canine occludes with the distal half of the mandibular canine and
the mesial half of the mandibular first premolar. The facial profile is termed
mesognathic.
Figure 11a.

Normal Occlusion
Class II (or distocclusion) In this classification, the maxillary first molar is even
with, or anterior to, the mandibular first molar; the buccal groove of the mandibular
first molar is distal to the mesiobuccal cusp of the maxillary first molar. The distal
surface of the mandibular canine is distal to the mesial surface of the maxillary canine
by at least the width of a premolar. The facial profile of both divisions is termed
retrognathic.
Figure 11b.

Class II Malocclusion
Class II, Division 1 occurs when the permanent first molars are in Class II and the
permanent maxillary central incisors are either normal or slightly protruded out
toward the lips.
Class II, Division 2 occurs when the permanent first molars are in Class II and the
permanent maxillary central incisors are retruded (pulled backward toward the oral
cavity) and tilting inwards towards the tongue.
Figure 11c.

Figure 11d.

Class II Division 1

Class II Division 2

Class III (or mesiocclusion) In this classification, the maxillary first molar is more
to the back of the mandibular first molar than normal; the buccal groove of the
mandibular first molar is mesial to the mesiobuccal cusp of the maxillary first molar.
The facial profile is termed prognathic.
Figure 11e.

Figure 11f.

Class III

Class III Anterior Bite

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Lecture 6 Medical History Evaluation (2)

1. General questions to ask re: conditions or symptoms
is it a current condition?
is the condition controlled?
what is the magnitude of risk?
for a positive response for a disease ask:
when were you first diagnosed?
are you currently being treated for this disease? what tx?
do you have current problems related to this disease?
Be sure to write in dates where requested (heart attack, stroke, cancer)
BEMAD
Ask about:

Bleeding
Have you had any episodes where you didnt stop bleeding, for example after
surgery or after you cut yourself?
Exercise
What do you do for exercise?
Can you climb a flight of stairs with groceries or walk 4 mph on a treadmill?
Medications
Are you taking any prescribed, over-the-counter or herbal/nutriceutals?
Allergies
Are you allergic to anything?
Doctor/Disease
Have you seen a doctor in the past 5 years?
Have you had any medical problems (diseases) in the past 5 years?

2. Risks with Dental Treatment Table (also flash cards)

(see assignment)
3. Allergies questions to ask
when did the reaction occur?
what happened? what type of reaction did you have?
medication allergies? latex allergies? metal allergies?
4. Difference between negative reaction and allergic reaction
Negative Rxn (adverse)
vs.
Allergic rxn (type I hypersensitivity)
- diarrhea
- rash
- upset stomach
- hives
- fainting, dizzy
- difficulty breathing
(psychogenic rxn)
- throat closed up

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- swelling
- lower BP
5. Medical consultations when are they required
- significant past or present health problems which may impact dental tx for which the pt
does not provide important information
- evidence presents of potentially serious health problems
a) pt not being treated
b) treatment appears to be inadequate
- unexplained symptoms
6. For which conditions is antibiotic prophylaxis indicated? will there be BLOOD?
a) Before dental treatment that might cause bacteremia (bacteria in the blood)
b) Particularly susceptible to certain infections (infective endocarditis, immune comp.)
c) Cardiac indications: prosth. heart valves, previous infective endocarditis, hx of
congenital heart dz, cardiac transplant with valve pathology
d) orant transplant and on immunosuppressants
e) cancer pt also on chemotherapy
f) uncontrolled diabetic
g) advanced AIDS
7. Know the prescriptions for the 1st choice medication for heart and first choice for patients allergic
to penicillin.
Amoxcillin - 1st choice medication for heart
Condition: Heart & Other
Clindamycin - 1st choice for patients allergic to penicillin
Condition: Heart & Other
8. Know conditions where local anesthetic with vasoconstrictor should be used with caution.
unstable angina
uncontrolled severe hypertension
arrhythmias
cocaine/meth use
tricyclic antidepressants
previous MI or stroke
9. List seven ways to reduce patient stress.
proper rest
sedation
morning appt
short appt
avoid tx in hot/humid weather
adequate post-op pain and anxiety control
phone pt the evening after appt
10. List four ways to locally control hemostasis

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Pressure = bite on gauze

Suture
Gelfoam
Tranexamic acid (oral, topical rinse, IV)
Lecture 7 Chief Complaint/Dental History (2)
1. Importance of identifying the chief complaint
identifies the patients first priority
early discussion (not necessarily treatment)
pt feels his/her problems have been recognized
help determine focus of the initial interview and exam
DOESNT mean it MUST be treated first
essential diagnostic procedures should not be circumvented to rush tx
2. Types of chief complaints (and examples) and when each should be treated
Urgent - requires immediate attention
ex. pain, acute infection, bleeding, trauma
COE should become limited to provide tx as quickly as possible
Tx provided before completing the examination
Moderately urgent
ex. Lost filling, chipped tooth
COE become limited to determine if immediate tx is warrented
Non-urgent
ex. Need teeth cleaned, whitened, new crowns
Complete COE
Provide estimated timetable for tx
3. Define palliative vs curative care and give examples
Palliative care = attempt to control symptoms rather than cure
sometimes only way to treat urgent complaints
Examples:
pulpotomy when no time for endo tx
antibiotic Rx when swelling is present that could affect local anesthetic
sedative (temp) filling when no time for permanent
flipper for missing front tooth while an implant is being planned
Curative (definitive) care = elimination of the problem
Examples:
extraction or endo tx on an abscessed tooth
replacing a missing filling with amalgam or composite
placing a permanent crown on a fractured tooth

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4. Which medical problems can be worsened by dental anxiety/fear

angina
seizures
asthma
hypertension
hyper/hypothyroid
adrenal insufficiency
taking steroids
diabetes
post heart attack
post stroke
fainting
5. Identify signs of an anxious patient
increased BP and pulse rate
trembling
excessive sweating
dilated pupils
unnaturally stiff posture
white-knuckle syndrome
may be overly willing to cooperate
may talk a lot/quickly
Lecture 8 Drug Information (0)
Know what information from Lexi.com is important
(see above)
Be able to SOAP medications
(see above)
Know how to determine an assessment for a medication vs the assessment for a medical condition
Medical SOAP assesses the medical condition
Medication SOAP assess the effects of the medication
Lecture 9 Extraoral Examination (7) ** - Michael?
1. Definitions of examination methods
Visual
Anatomy - normal structure?
Border - shape/symmetrical?
Color - normal?
Dimension - right size?
Type - if abnormal, what type of lesion?
Palpatory
Consistency - hard, soft, rubbery?

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Surface texture - smooth, lumpy, papillary?

Pain upon palpation - sinuses, lymph nodes, TMJ, musc of mast.
Temperature - inflamm. present?
Auscultation
Abnormal sounds? TMJ during fxn
Evaluation of function
TMJ during max opening, excursives
Deviation or pain during opening?
2. Which examination methods are used with each structure.
General Assessment
visualize
Facial form
visual (look for unilateral or bilateral swellings)
Skin
visual (and palpation if needed)
Extraoral muscles of mastication
palpation of masseter/temporalis
(Lateral/Medial pterygoid)
NOT PART of extraoral exam (supplementary TMJ exam)
palpation
Frontal sinuses
palpation
Maxillary Sinuses
palpation
TMJ
palpation + visualization + asculatate
measure vertical range + excursives (subtract negative overlap, add postive)
Parotid
palpation during exam of masseter/TMJ, preauricular LN
Abnormal findings: swelling may cause elevation of ear lobes
Lymph nodes
Palpation (and visualization if sufficiently enlarged)
Submandibular (healthy nodes are DETECTABLE), submental, anterior/posterior
cervical chain, suboptical, supraclavicular, posterior auricular, preauricular
Muscles of neck
SCM - palpation
Trapezius - palpation
Thyroid gland
visualization (palpate if enlarged)

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3. Location of structures
see above/should know from anatomy
4. Abnormal findings of lymph nodes
tender, palpable lymph nodes = recent infection
large, well defined = acute infection
node boarders less defined = chronic infection
firm enlarged, non tender, immobile = possible malignancy
three or more node groups involved = autoimmune dz or neoplasm

Lecture 10 Intraoral Examination (10) **

1. Definitions of examination methods (i.e., visualization, Bidigital palpation)
Lips:
Visual look at lips for changes in color, texture, structure of vermillion border
Bidigital palpation press lip btwn thumb & index/middle finger & go across upper/lower lip
Variations of normal: Very little vermillion border present (loss of vertical dimension), non path
developmental pits in comissures of lips, fordyces granules (ectopic sebaceous glands),
Vestibule:
Visual look at frenae, retract lip out up/down
Palpate run index finger over the bone in the depth of the vestibule (check for
swellings/tenderness)
Variations of normal: fibroepithelial polyps - caused by trauma and healing
Buccal Mucosa:
Bidigital palpation press mucosa btwn thumb and index finger
Visualize pull cheeks out w/ index finger
Variations of normal: Linea alba (white line), leukodema (white or gray thin surface film in dark ppl
& disappears when mucosa is stretched), Fordyces granules (ectopic sebaceous glands,
slightly raised, yellowish spots often clustered together and present in 80% of population)
Palate:
Visualize mouth mirror & reflected light
Palpation hard/soft palate w. index finger & press upward (dont touch base of tongue)
Variations of normal: Tori palatinus {Bony hard swellings ALWAYS in MIDLINE of palate (2035%), frequently inherited, benign tumor, hard to take radiographs}
Oropharynx:
Visualize mirror upside down on tongue dorsum, push it down and forward, ask pt to say ahh
Digital Palpation only if indicated, palpate anterior tonsillar pillar
Tongue:

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Visualize have patient simply open wide, or stick their tongue out
Bidigital palpation press all surfaces of anterior between thumb and index finger; use
topical/local anesthetic for posterior
Variations of normal fissured tongue has multiple fissures of dorsal surface on anterior (1-4%
of population), loss of filiform/fungiform papilla
Dorsum-->Visualize Pt. open wide or stick out toungue
Lateral Visualize Pt. w/ tongue out, use a 2X2 fold around it, pull tongue to the left and right to
see the backlateral or posterolateral sides. NOTE: this is the most common place lesion occurs
Ventral Visualize Pt. touch the roof of the mouth w. tongue.
Normal variations lingual varicosities (venous dilations, red-blue to purple color)
Floor of mouth:
Visualize pt lifts the tongue to roof of mouth, use mirror to reflect light to the anterior part of
mouth floor, to see the back of the floor of the tongue use the mirror to retract the tongue
Bimanual palpation index finger in pts mouth & fingers of the other hand outside the pts mouth
in the submandibular area. Submandibular glands (towards the back of the mouth), sublingual
gland (mid and anterior part of mouth),
Variations of normal mandibular tori (bilateral bony hard swellings, 5-40% of population)
Pathology Ankylglossia (tongue-tied) - very short lingual frenum, may cause speech difficulties,
easily treated w/ frenectomy (removal of frenum)
2. Which examination methods are used with each structure.
3. Location of structures
4. Variations of normal
see above
Oral cancer is 6th deadliest type of cancer: = oral cavity, = oropharynx
We can save our patients life if it is detected EARLY.
Most common oral cancer = squamous cell carcinoma (9/10 oral cancer cases)
most common site for oral cancer = lower lip
most common site for intra oral cancer = lateral tongue
Cause/most common risk factor: Tobacco use
Lecture 11 TMD (4)
1. Understand the rationale behind the TMD questions
Severity of patients symptoms may require special care (frequent rest periods during the dental
appointment, bite block, NSAIDs) or referral to specialty clinic or private practice for dental care or
treatment of TMD by specialist
Questions about jaw getting stuck, locked or go out indicate anteriorly displaced disc,
subluxation, or previous trauma and may require treatment by a TMD specialist.
2. Know when to SOAP a TMD problem

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3. Difference between subluxation, disc displacement, crepitus

Subluxation
partial or incomplete condylar dislocation during wide mouth opening
usually accompanied by a joint sound (soft pop or click)
may result from anatomical difference, habit, or trauma
Disc displacement - see below = clicking and popping
Crepitus - grinding (arthritic changes)

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4. Be able to identify terms and normal measurements for TMD examination

Range of Motion
Normal Opening: 40-60mm
Normal R/L Lateral: 9-12mm
Maximum Pain Free Opening = 20mm + overbite
Maximum Unassisted Opening = 41 mm + overbite
Myalgia:
1. one or more of the following
a. muscle pain report
b. muscle pain on opening
c. muscle pain on excursion
2. muscle pain on palpation that does NOT refer to a different location
Myofascial Pain
1. Regional dull, aching muscle pain aggravated by mandibular function
2. Trigger points are present that increase the pain complaint and REFER the pain
Arthralgia
1. one or more of the following
a. joint pain report
b. joint pain on opening
c. joint pain on excursion
2. joint pain on palpation
3. absence of crepitus noises
4. absence of degenerative changes on Panorex or other imaging of TMJ
Osteoarthritis
1. one or more of the following
a. joint pain report
b. joint pain on opening
c. joint pain on excursion
2. joint pain on palpation
3. crepitus (grinding noise) in joint during any movement MAY be present
4. degenerative changes evident on Panorex or other imaging of TMJ
Osteoarthrosis
1. NO joint pain report or joint pain on palpation
2. Crepitus (grinding noise) in joint during any movement
Anterior Disc Displacement with Reduction (suspected)

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1. Click on opening and/or closing

2. Corrected deviation of mandible to affected side on mouth opening/closing (if unilateral)
3. MRI would reveal an anteriorly displaced disc which reduces (sets onto condyle) w/ mouth
opening
Anterior Disc Displacement without Reduction (suspected)
1. Limited mouth opening (assisted) of <35mm
2. Deflection of mandible to affected side on mouth opening (if unilateral)
3. MRI would reveal an anteriorly displaced disc which does NOT reduce (seat onto condyle)
w/ mouth opening
Lecture 12 Dental Exam -- Existing Restorations (3)
1. Be able to identify various restorations (be sure to look closely at restorations that look alike)
clinically and radiographically
Sealants
can be opaque or translucent - not color matched
will follow grooves of teeth
usually on occlusal surfaces, sometimes on lingual and buccal
Not always seen on radiographs
Composite Resins
Are color matched so they may be hard to find
They can be found by drying off tooth and running explorer over surface. Composite may
mark grey.
Can be found on any surface of tooth
Usually have prepped outline
Can be radiopaque or radiolucent on radiograph
Intracoronal Restorations: Composite Resins
restorations within crown, old composites turn yellow over time
Composite resin on radiograph
more radiopaque than tooth structure
Note: Ghost (slide 6) = have no BaF so many of them dont show up on radiographs
Amalgam
Appears silver or grey on clinical examination
Very radiopaque on radiographs
Similar radiopacity as gold/metal
Amalgam on radiograph
only include MD in MO/DO/MOD preps if they involve the proximal contact
Extracoronal Restorations: Full Gold & Porcelain crowns
Shave off 1mm tooth take impression temp crown lab makes crown
All porcelain = 1 piece porcelain ceramic w/ no metal
Porcelain fused to metal = metal at the base w/ porcelain stacked on top for esthetics
Metal over porcelain is BETTER for occlusion
Extracoronal Restorations: Stainless Steel and Base metal crowns
Preformed stainless steel crown are not custom made and usually for primary teeth and
sometimes for adults in temporary crowns

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 Prep childs tooth, cement and place crown

Custom cast crown = base metal
Extracoronal Restorations on radiograph
Cant tell if base metal or gold
Stainless steel not as radiopaque
Base metal fused to porcelain (does not show up very well)
All porcelain vs. Metal restorations on radiograph
Cement
MO Max 1st molar composite
Extracoronal Restorations: Onlays and Partial Coverage Crowns
Onlays: cover 1-2 cusps (2 or 3) & usually have 1 cusp thats not covered
Partial Coverage Crown: bigger than onlays
Intracoronal Restorations: Gold or Ceramic Inlay
Ceramic/Porcelain or Composite Veneer
cover buccal/facial/interproximal surfaces
prep tooth by shaving buccal and interproximal areas
Implants
one way of replacing missing tooth
Fixed Partial Denture (Bridge)
2 crowns with fake tooth in the middle cemented in
Acrylic Removable Partial Denture (Stayplate/Flipper)
Quick fix
not made to chew
Removable partial Denture - Cast metal base/Resin base
Fake teeth attached, metal base or acrylic
Complete Dentures
KNOW: 10% of function vs. Natural teeth
Endodontic Radiographs
Root canals - silver rods to fill canals
look for PA lesion which needs new root canal
Other things you may see on your patients
Cantilever bridge - used when there are adjacent teeth on only one side of the missing
tooth or teeth. Not very common and is not recommended in the back of the mouth where it
can put too much force on other teeth and damage them.
Fracture & infection on tooth
Cemented retainers
Cemented diamond
2. Be able to list the seven criteria for assessing existing dental restorations and be able to identify
deficits in an image of a restoration
Criteria for Assessing Dental Restorations
1. Structural integrity
Are portions of the filling fractured or missing?
Are fracture lines or voids present? cavities can start

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Ask if fractures weaken the restoration, cause risk for further deterioration or
recurrent caries
Is there already plaque accumulation or decay?
2. Margins
Few perfect margins - there really are none and it is rare to have margin that is
completely smooth and undetectable - Use explorer for examination
Marginal openings - amalgam
Marginal ditching or an open margin alone is not an indication for
replacement
Indications for replacement - marginal ditching/open margin with
Recurrent caries at the margin
Large accumulation of plaque at the margin
Marginal openings - composite
Marginal gap in which explorer tip can be placed has increased susceptibility
to caries (vs. amalgam or glass ionomer) - restoration should be replaced (tin
chloride produced w/ GI)
Marginal openings - gold or metal ceramic restorations
Marginal discrepancy is not necessarily an indication for replacement
Indications for replacement
Recurrent caries
Large accumulation of plaque
Tip of explorer can be placed up underneath the crown - high risk so
replace this
3. Anatomical form
The degree to which the restoration duplicates the original contour of the intact tooth
Problems
Overcontour/undercontour (BIGGEST problem you will see decay or
periodontal disease)
Uneven marginal ridges
Inadequate facial/lingual embrasures
Lack of occlusal or gingival embrasures
Replacement indicated
Current periodontal disease or decay - usually periodontal pathosis
Carious or periodontal pathosis is very likely
Anatomic form - poor contour: overcontouring a big problem at the apical end as you
see gums are red, if probing performed cause bleeding
4. Periodontal health
Restoration defects which affect perio health
Anatomic abnormalities (previously mentioned)
Surface roughness of the restoration
Interproximal overhangs
Impingement on the zone of attachment - biological width (2 mm or so)
attachment tooth to bone
5. Occlusal and interproximal (proximal) contacts

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Overhangs - Replace them

Proximal Contacts
Assess with thin dental floss - replace/adjust those that do not allow smooth
passage of floss
Open or excessively light contacts - leave and monitor if not troubling patient
Assess for pathosis, food impaction or annoyance to patient
Occlusal Contacts
Hyperocclusion WORSE - may cause periodontal pathosis and TMD
problems
Adjust or replace the restoration
Infraocclusion - may cause supraeruption and subsequent malalignment
of teeth
Replace restoration if significant
6. Caries around existing restorations
Recurrent Caries - Caries around existing amalgam
Grey or gray-yellow, opaque area at margin
Margins should be probed for changes in texture - sticks
Grey color change alone does NOT equal caries
Corrosion product form amalgam - increases caries resistance
Physical presence of amalgam
Recurrent Caries - Caries around existing composite resin
Staining at the margin or undermining stain adjacent to the filling may indicate
caries
If no change in texture (stick) or open margin, polish first
7. Esthetics
Esthetic conditions which may indicate replacement:
Discoloration or poor shade match
Poor periodontal tissue response
Poor restoration contour
Display of gold or amalgam in esthetic areas
Patient however may be fine and like how they look
If patient desires replacement be sure patient understands
Risks of replacing a serviceable restoration (e.g. amalgam filling replacement
causes more mercury to be released)
Educated in regard to material pros and cons
Obtain a consent form/Document their decision

Lecture 13A Diagnostic Tests (2)

1. What are the four possible outcomes of a diagnostic test?
True Positive
Person has the disease and tests (+)
True Negative
Person does not have the disease and tests (-)
False Positive

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 Person does not have the disease but tests (+)

False Negative
Person has the disease but tests (-)
2. Define sensitivity and specificity and the calculation used to determine each
Sensitivity: ability of a test to detect people who actually have the disease
Sensitivity = (TP)/(TP+FN)
TP + FN = all people who HAVE the disease
Specificity: ability of a test to detect people who do NOT have the disease
Specificity = (TN)/(FP+TN)
FP + TN = all people who DO NOT HAVE the disease
3. Interpret the sensitivity and specificity for a caries test.
(Sensitivity = .40 and Specificity = 0.40; would this test undertreat, overtreat or treat just right?)

A test with LOW sensitivity leads to increased number of missed diagnoses and
UNDERTREATMENT
Sensitivity = 40/40+60 = 0.4 = 60 people with the disease were missed
A test with LOW specificity leads to increased number of over diagnosis and OVERTREATMENT
Specificity = 40/40+60 = 0.4 = 60 healthy people were diagnosed with the disease
Lecture 13B Dental Exam -- Caries (13) ** - Shawn might do this one
1. Relate the diagnostic methods used to the areas of the tooth
Histological examination = gold standard for caries diagnosis
Dental ExamCaries (13):
Diagnostic methods used to the areas of the tooth:
Occlusal

Proximal

Facial/Lingual

Root Surface

Recurrent

Visual

Tactile

X*

X*

Radiographic

(X)

FOTI

*Only when cavitation is present

Techniques:
Visual:
- Teeth should be dry and free from plaque, calculus, and other debris. There must be
adequate lighting and having loupes is very helpful.
- Take note of gray/gray-yellow, opaque areas and white, frosty, opaque appearances (initial
caries).

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- Occlusal: Larger lesions may appear black at base, look for changes in occlusal opacity
around the pit or fissure. halo
- Proximal: Initial lesions of proximal surfaces will not be clinically visible; however, large
proximal lesions may be noticed. Proximal lesion may remineralize when the environment
changes. Arrested decay
- Facial/Lingual: May find initial white/brown/black spots on the facial and lingual smooth
surfaces, these may be active or arrested. Dry the tooth surface,
if rough/chalky/matte surface => demineralization or cavity present
If smooth, shiny surface => remineralization.
-Root surface: Early stage- one or more small, well-defined, discolored areas adjacent to or
below the gingival margin. Later stage- discolored area areas may be yellow, light to dark
brown, or almost black. (ROOT DECAY does not remineralize)
-Recurrent: gray, gray-yellow, opaque areas at the margins of the existing restoration.
Amalgam: gray change alone is not a reliable indicator of caries present. (corrosion,
physical presence of silver restoration). Composite: staining at the margin or undermining
stain is not a reliable indication of caries present.
-Incisal and cuspal: Only when Xerostomia is present(not very common)

Tactile:
Caries is determined to be present if the explorer sticks (provides resistance to
removal). The tactile method should be used if cavitation is detected on visual inspection.
Used to obtain information about the texture of the margins and base of the lesion.
Proximal: explorer is often used to determine the extend of the lesion
Should be used to determine the texture of both cavitated and non-cavitated lesions
Recurrent: marginal area should be clean, dry and free from debris. Areas of ditching
should be probed for change in texture/consistency and size of discrepancy.

Explorer:
1.This method allows you to obtain information about the texture of the margins and base of
the lesion.
2. To detect secondary caries in the presence of restoration
3. To evaluate marginal acceptability.
4. To evaluate discolored cementum for possible root caries. For roots, it should be used to
determine the texture of both cavitated and non-cavitated lesions. For recurrent decay, the
presence of narrow ditching alone is not an indication for restoration replacement.

Radiographic: Be wary of the risk factors of ionizing radiation.

Somatic effects - cancer, leukemia, and cataracts.
Genetic effects - defects passed to future generations.
The likelihood of damage is very small, but present. Radiographs should be prescribed only after
careful assessment of patients needs, including caries risk.
o Demineralization of the enamel and dentin is noted as areas of relative radiolucency.
E0= Sound, no caries
E1= Caries in the outer of enamel

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 E2= Caries into the inner of enamel

D1= Caries through DEJ, into the outer 1/3 of dentin
D2= Caries into the middle 1/3 of the dentin
D3= Caries into the inner 1/3 of the dentin
o Occlusal: lesions are usually not seen until the DEJ is reached and the lesion spreads in
all directions. Do not see where it comes into enamel
o Proximal: You will find the initial proximal lesion just below the contact area. Initial lesions
often first seen in enamel(not always) then in dentin. (ideally, the triangle of decay has apex
towards the dentin, and subsequent triangle has apex towards pulp).
o Facial / lingual: Difficult to differentiate buccal from lingual. The lesions appear welldefined due to the angulation of the enamel rods. Round, kind of tapers. Occlusal lesions
would be more of a saucer than round shape.
o On the root surface: radiolucent areas appear saucer-shaped or cupped out in the
proximal areas. Initially the areas appear just apical to the CEJ. Larger lesions may progress
till they undermine the enamel.
FOTI (fiberoptic transillumination): Non-invasive technique used to supplement the visual
examination. Intraoral fiberoptic light source placed buccal to the tooth surface and the transmitted
light is examined.
Criteria: A carious lesion has a lowered index of light transmission and will appear as a darkened
shadow.
Risk factors to watch out: You can use an explorer on root surfaces because root surfaces do not
remineralize. You do not want to use an explorer just anywhere because it will prevent
remineralization. Cavitation may be created at the site of a superficial lesion, which might otherwise
be remineralized. Probing may accelerate the rate of caries progression. Pathogenic bacteria may
be transferred from one site to another.
DIAGNO-dent or KaVo (a quantitative laser fluorescence device): when you can tolerate a low
specificity. DIAGNO-dent has a significant number of false positives; therefore you will have over
treatment. It may be valuable for longitudinal monitoring of caries progression and remineralization.
The amount of fluorescence is proportionate to the degree of caries present. Used on occlusal,
facial and lingual surfaces.
Lecture 14 CRA and Tx planning (4)- shawn is doing this one
1. Understand how the CRA is calculated
- (Disease indicators+Risk factors+Dietary assessment) Protective factors = CRA
- CRA provides better allocation of available resource with low cost
CRA Calculation
Low

-99

to

23

Moderate

24

to

59

25

High

60

Extreme

> 450

to

449

If patient has 2 cavities - only add once so only 75 not 75+75

2. Which disease indicators or risk factors will, on their own, cause the caries risk to be extreme
- If the patient is using recreational drugs
If the patients mouth appears dry or complains of a dry mouth.
3. Which disease indicators or risk factors will affect the CRA least
DISEASE INDICATORS
Cavities/Radiograph to dentin
Clinically - Cavitated lesions
Radiographically - D1 or deeper
Approximal enamel lesions (by radiograph)
E1 or E2 lesions
White spots on smooth surfaces
Rough, matte finish
NOT remineralized lesions
Having restorations placed within 1 year due to caries
Attempts to consider caries incidence in a new patient, and rate of progression
Does NOT include sealants
Having more than 3 carious teeth in the mouth
Attempts to predict prevalence of caries
Having more than 5 filled surfaces
Presence of existing restorations predisposes to increased risk for recurrent caries
PFM or FGC = 5 surfaces
RISK FACTORS
Visible heavy plaque on teeth
Deep pits and fissures
Recreational drug use
Methamphetamine
Marijuana
Mouth appears dry or patient complains of dry mouth
Xerostomia and salivary dysfunction rampant decay due to lack of salivary
defense
Saliva reducing factors
Medications - cause xerosomia
Radiation to the head and neck
Systemic diseases
Sjogrens syndrome: dry mouth
Diabetes: high glucose in saliva feed bacteria
Exposed roots
Cementum is more susceptible to caries

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Orthodontic Appliances or Removable Partial Denture (RPD)

Increases plaque retention and the difficulty of plaque removal

4. How much do the protective factors affect the CRA

- The protective factors do not affect the CRA by much.
Only by a maximum of -2, and a minimum of -1, yet a combined total of -15.
5. What are the typical treatments for: low salivary pH, exposed root surfaces, xerostomia, low
buffering capacity
Low salivary pH: Nuvora Lozenges, baking soda
Exposed root surfaces: chlorohexidine varnish or fluoride varnish
Low buffering capacity: MI paste

Xerostomia: Biotene or Oasis products, MI paste, Nuvora Lozenges, pilocarpine lollipops

Cervitec Plus Ivoclar (chlorhexidine varnish)
1% chlorhexidine and 1% thymol in a homogenous solution, transparent clear varnish
Fluoride varnish: use 1-2% silinated varnish, better than the 23,000 ppm varnish
Can kill S. Mutands (+ ion) and can inhibit metalloproteases (perio)
Sodium Fluoride
Low doses of fluoride (<1000ppm) may help arrest early lesions
High doses of fluoride (>1200ppm) should be antibiotic
Baking Soda

Xylitol

Sodium Bicarbonate
Gently abrasive (good for staining)
Antimicrobial properties
Increases oral pH

Interferes w/ cell metabolism

Bacteria cant process it, non fermentable
6-10 grams per day
Anticariogenic
Reduces adhesion of bacteria
Ice breaker cubes and Mentos Pure gum
Nuvora Lozenges
pH changer (saliva substitute)
Lozenges can last up to 7 hours
Contain Xylitol and essential oils
Elevates the pH for as long as the lozenge is in the mouth by adding extra bicarbonate
MI Paste

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 Casein Phosphopeptide Amorphous Calcium Phosphate

No inherent antimicrobial properties
Increases buffering capacity
Provides protein substrate for healthy plaque
Encourages remineralization - has reversed incipient lesions in VIVO
DO NOT give to people with milk protein allergy
Pilocarpine Lolipops
Pilocarpine is a parasympathomimetic, stimulating muscarinic acetylcholine receptors
Pilocarpine is absorbed through oral mucosa, some is also swallowed
Stimulates patients own saliva
5-30 sec prn
Made by compounding pharmacy
Biotene and Oasis products

Oral lubricants
Found in drug stores, widely available
BIotene: lysoszyme, lactoferrin and peroxidase
BIOTENE PBF
Oasis: cetylpyridinium chloride

ETC
Resting salivary pH=6.8-7.2 (average of initial spit and salivary gland duct values)
Stimulated salivary pH= 7.0 or greater
Stimulated salivary flow= .7ml/min or greater
Salivary buffer capacity= 10 or greater (red=0, purple=1, blue=2, teal=3, green/grey4)

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