What is the primary purpose of advanced fulcrums?  

–    Stability and control

–    Power through principles of leverage

–    Improve adaptation

–    Improve angulations

–    Improve lateral pressure and/or control especially with reinforced fulcrums

Name 5 types of advanced fulcrums

–    extra oral

–    cross arch

–    opposite arch

–    finger on finger

–    reinforced fulcrum

•      thumb

•      finger

When using the gracey 13/14 what type of stroke would you use when scaling the buccal or lingual surfaces?

–    Turning the toe down and using horizontal and/or oblique strokes at the line angles

Where is the best place to adapt a gracey ½ or ¾ and how would you adapt the blade?

–    Cutting edge toward buccal or lingual

–    Toe third toward direct surface

–    Pointing toward root surface

–    Horizontal and/or oblique strokes

–    Excellent for calculus under CEJ

When is it indicated to use ultrasonics? (8)

–    Removal of supragingival calculus

–    Removal of tenacious stain

–    Subgingival periodontal debridement

–    Initial debridement - NUG/NUP

–    Debridement of furcations

–    Debridement of deposits prior to oral surgery

–    Removal of orthodontic cement and debonding

Removal of overhanging margins of restorations

 When would you use the ultrasonic subg?

–    Subgingival periodontal debridement

        Calculus

        Attached biofilm

        Endotoxins

        Unattached biofilm

What are some contraindications for using the ultrasonic scaler? (11)

–    Communicable disease

–    Susceptibility to infection:  Chemotherapy, uncontrolled diabetes, debilitation, kidney or other organ transplant

–    Respiratory risk: Septic material and microorganisms from biofilm and periodontal pockets can be aspirated into lungs

–    History of chronic pulmonary disease, active asthma, emphysema, cystic fibrosis

–    History of  CVD with secondary pulmonary disease or breathing problems

–    Swallowing difficulty: Amyotrophic lateral sclerosis, muscular dystrophy, paralysis, multiple sclerosis, stroke

–    Cardiac pacemaker

–    Deminieralized areas

–    Exposed dentinal surfaces

–    Children

–    Precautions – porcelain crowns, amalgams, composites, titanium implant abutments

How would you operate an air polisher

–    Circular motion                              

–    4-5 mm away from surface

–    Exposure time - .5-1 second

–    Keep away from gingival margin

–    Direct spray to middle third of tooth

What type of steps need to be in place before using the air polisher?

–    Self Barriers

•      Face shield

•      Goggles

–    Patient Barriers

•      Goggles

•      Towel /damp

•      Lubricant for lips

What angles does the operator need to be aware of when using the AP?

–    Anteriors –

•      Buccal and Lingual - 60 degrees

–    Posteriors

•      Buccal and Lingual - 80 degrees

•      Occlusal - 90 degrees

Step by step procedures for using the AP….

–    Review health history

–    Review dental history

–    Explain procedure

–    Googles Protect eyes - remove contact lenses

–    Pre-procedural rinse

–    Apply lubricant to lips

–    Damp towel

–    Set patient up 45 degrees

–    Patient head turned slightly towards

–    Use direct vision as much as possible

–    Use external fulcrum, light modified pen grasp

–    Hold nozzle 3 to 4 mm from tooth surface

–     Use constant circular sweeping motion

–    Alternate powder and water every 2 to 3 teeth

–    Removal of heavy, tenacious tobacco stain

–    Removal of CHX-induced stain

–    Orthodontics

–     Dental Implants

–    Prior to bonding procedures

–    Root detoxification for periodontally diseased roots

When is the AP contraindicated? (14)

–    Physician-directed low sodium diet

–    Xerostomia

–    Respiratory conditions

–    Any condition that limits swallowing or breathing

–    Renal dialysis

–    Hemodialysis

–    Medications effecting electrolyte balance

–    Pediatric application

–    Immediately after deep debridement

–    Routine root debridement

–    Areas already hypersensitive

–    Demineralized areas

–    Rampant caries

–    Gingivitis

What are some physical addictions of tobacco? (6)

–    Nicotinic acetylcholine receptor

–    Stimulates release of dopamine

–    Produces pleasure that reinforces repeat administration

–    Develops tolerance

–    Abrupt discontinuation – withdrawal symptoms

Higher addiction than alcohol, cocaine and heroine

What are some psychological addictions of tobacco?

–    Stress

–    Relaxation

–    Rewards

Describe the health of a smoker 20min after smoking a cig?

–    Blood pressure decreases

–    Pulse rate drops

–    Body temperature of hands and feet increases

Describe the health of a smoker 8hrs after smoking a cig?

–    Carbon monoxide level in blood drops to normal

–    Oxygen level in blood increases to normal

Describe the health of a smoker 24hrs after smoking a cig

Chance of heart attack decreases

Describe the health of a smoker 48 Hours After Quitting

–    Nerve endings begin repairing

–    Ability to smell and taste is enhanced

Describe the health of a nonsmoker 1yr after quitting?

–    Circulation improves

–    Walking becomes easier

–    Lung function increases

–    Coughing, sinus congestion, fatigue, shortness of breath decreases

–    Excess risk of coronary heart disease is decreased to half that of a smoker

Describe the health of a nonsmoker 5yrs after quitting?

–    Stroke risk is reduced to that of people who have never smoked

Describe the health of a nonsmoker 10yrs after quitting?

–    Risk of lung cancer drops to as little as one-half that of continuing smokers

–    Risk of cancer of the mouth, throat, esophagus, bladder, kidney, and pancreas decreases

–    Risk of ulcer decreases

Describe the health of a nonsmoker 15yrs after quitting?

–    Risk of coronary heart disease is now similar to that of people who have never smoked

–    Risk of death returns to nearly the level of people who have never smoked

AUTISM- Treatment considerations

–    Treatment considerations

•      Poor communication skills.

•      May not responds to his/her own name

•      May not make eye contact  

•      Reduced  response to pain

•       Heightened sensitivity to touch, sound, or other stimulation 

•      Caregivers can provide info to assist to avoid triggers that cause neg. reactions

•      Calm through repetitive familiarization.

•      Rewards or “bribes” work well for children with autism.

•      More susceptible to oral stimuli  making treatment difficult, more hyperactive. 

•      If safety cannot be assured; “sleep dentistry” may be necessary.

•      Plan a desensitization appointment to familiarize the patient to the office

•      Use a toothbrush first to gain access to the patients mouth because it is something they are familiar with.

•      Make appointments short and positive.

•      Try to gain cooperation with least restrictive manner.

•      Try to reduce unnecessary sights, sounds, and odors.  This could be disruptive stimuli.

•      Allow time for the patient to adjust.

AUTISM- oral implications

•      Damaging oral habits:  bruxism, tongue thrusting, self injurious behavior: picking at gingival, biting lips.

•      Tooth eruption might be delayed due to medications.

AUTISM-dental management

•       some modifications to the treatment plan,

•      Mild manifestations = successful tx in the general dental setting.

•      Severe may require sedation, general anesthesia, or immobilization in a special setting.

•      Be aware that dental care may have had low priority.

Down’s syndrome- Treatment considerations

•      Xerostomia

•      Macroglossia, increased secretions, enlarged tonsils and adenoids

•      Susceptibility to periodontal disease related to Altered immune response

   Down’s syndrome- oral implications

•      Xerostomia

•      Macroglossia, increased secretions, enlarged tonsils and adenoids

•      Susceptibility to periodontal disease related to Altered immune response

Down’s syndrome- dental management

–    Treatment considerations

•      Dental treatment should start at an early age with “happy visits”

•      Tighter recare schedule due to their susceptibility to periodontal disease related to Altered immune response

•      Mouth breathing which will cause Xerostomia

•      Airway obstruction: macroglossia, increased secretions, enlarged tonsils and adenoids

•      chair position, fluid suctioning, and gag reflex

•      Congenital Heart Lesions: Antibiotic premed related to high incidence of Mitral valve prolapse  

 Treatment considerations for spina bifida

•      Plan on being very patient with them and go at their pace.

•      A strong gag reflex is sometimes associated with this disability and a fluoride regimen may be needed.

•      There are also balance problems so reclining the operatory chair back too far may be uncomfortable for the patient as well as trigger their gag reflex with saliva pooling in their mouth

•      None, unless concurrent encephalopathy or Chiari II malformation, rare (but common with myelomeningocele where the cerebellum and brainstem protrude into the spinal canal or neck area.

•      This can lead to compression of the spinal cord leading to a variety of symptoms including trouble feeding, swallowing, and breathing, choking and arm stiffness.

•      encephalopathy or Chiari II malformation( cerebellum and brainstem protrude into the spinal canal or neck area compressing of the spinal cord leading to a variety of symptoms including trouble feeding, swallowing, and breathing, choking and arm stiffness.)

•      They may need caregiver help if Spina Bifida is in conjunction with encephalopathy or Chiari II.

•      Upper extremities usually not affected and typically does not exhibit communication, cognitive or perceptual deficits

Treatment considerations for cerebral palsey

•      May have mental retardation (<50%)

•      May have learning disabilities (<50%)

•      May have seizures (25-30%)

•      Seeing & hearing problems are common

•      Opening mouth presents difficulty during dental-home & office

•      Many special adaptations needed-patient specific

•      Disturbances of muscle movement-facial grimacing, abnormal muscle function, facial asymmetry, problems with mastication and swallowing are common

•      Malocclusion

•      Attrition

•      Fractured teeth - often from  falling

•      High Caries risk related to soft food  and lacking the ability to remove biofilm

•      Periodontal infections-high incidence of induced gingival hyperplasia ( Phenytoin)

•      Heavy calculus BU related to mouth breathing, biofilm BU  & lack of proper OHI

•      Patience needed-sudden movements & inability to communicate

•      Address patient directly-not care giver

•      Consider use of mouth prop, sedation, premedication

•      Assistance through out appointment needed by family/caregivers

Treatment considerations for BLINDNESS

•      maintain neutral tone

•      Offer the option of wearing  their own glasses

•      Describe all procedures, instruments, flavors, material

•      Have patient feel but avoid handing the patient sharp instruments.

•      Avoid light in eyes because of sensitivity as with all patients

•      Speak before touching them.

•      Warn patients before using air, water, and power driven instruments

•      Watch position of patient because glaucoma patients may experience increased pain and pressure in the eyes if chair is tilted.

Oral implications for BLINDNESS

•      Clear pathway and guide patient with arm without pushing or pulling

•      Tell them when leaving and entering the room to avoid embarrassment of speaking to no one

•      Glaucoma patients have no peripheral vision, so speak to these patients straight on.

•      Use toothbrushes with built-up handles (or cut a small slit in the sides of a tennisball and slide it onto the handle of the toothbrush)

•      use flossing tools

•      consider electric toothbrushes and flossing devices

•      Sit to brush and floss, if standing at the basin is tiring.

•      Floss in the morning if you are too tired at night. Since flossing at bedtime is preferable because it removes bacteria that will multiply while you sleep, try flossing in bed.

•      Allow a family member or personal assistant to help with tooth brushing/flossing.

•      Manage tremors by wearing a weighted glove while brushing.

•      People with a chronic disease may neglect their general health and wellness which may divert people’s attention from appropriate dental care.

•      People with significant fatigue and/or mobility impairment may find office visits  particularly difficult to manage but it is important to remember  healthy teeth and gums are essential for preventing infections, which may cause MS symptoms to increase.

•      There are several symptoms of MS that can interfere with adequate care of the teeth and gums.

•      Fatigue

•      Spasticity

•      Weakness

•      Tremor

•      facial pain (trigeminal neuralgia)

Treatment considerations for a pts Rheumatoid/arthritis

•      Side effects medications.

•      Stomatitis: Folic acid can help.

•      Steroids for an extended period of time although the  immune response may be altered

•      Daily use of Listerine or periodic use of CHX may help lower their bacterial load.

•      Toothbrushes with wider handles- such as electric toothbrushes for those with dexterity problems.

•      The TMJ may be joints involved.

•      Talk to patients about a soft diet, night guard, and physical therapy.

•      Refer to specialist. If bone loss in the TMJ area is seen on a panoramic radiograph.

•      May develop Sjogrens syndrome

Help keep the patient comfortable in your chair by offering pillows under their knees, back, neck etc; and blankets to keep them warm.

•      Try to keep appointment times to a minimum.

Treatment considerations for a pt with anorexia/nervosa

•      Periodontal Disease

•      Has a potential affect on body health:

•      Cardiovascular Disease

•      Stroke

•      Pulmonary Disease

•      Kidney Disease

•      Osteoporosis

•      Rheumatoid Arthritis

•      Diabetes

Pregnancy Outcomes

Oral implications of bulimia and anorexia

•      Bulimia – erosion of tooth enamel, causing cavities, discoloration and tooth loss.

•      Anorexia – semi-starvation deprives the body of the nutrients, and osteoporosis can develop, weakening the bones in the jaw that support teeth, leading to tooth loss.  Also, nutritional deficiencies can cause soft tissue lesions like angular cheilitis, candidosis, glossitis and mucosa ulcerations.

 Dental management of a pt with bulimia/anorexia

•      We may be the first medical professional to notice symptoms, especially of bulimia (tooth erosion).

•      If diagnosed and treated at an early stage, enamel loss may be replaced with composite resins. 

•      In some cases, more extensive work such as overlays, crowns or veneers may be necessary.

•      Therapy is crucial.  Its goals are to identify the negative thoughts and feelings about weight and the self that are behind the anorexic behaviors, and to replace them with healthier and less distorted attitudes.

What are the AAP recommendations ?

–    A periodontal evaluation of patients with atherosclerotic CVD should include a comprehensive examination of periodontal tissues…visual signs of inflammation and bleeding on probing, loss of connective tissue attachment….and bone loss assessed radiographically.  If patient have untreated or uncontrolled periodontitis, they should be treated with a focus on reducing and controlling the bacterial accumulations and eliminating inflammation.

What are primary secondary and tertiary interventions?

–    Primary: Community Fluoride

•      Prevention strategies aimed at health promotion directed towards life changes

–    Secondary: Sealants

•      Aimed at screening for the presence of undiagnosed disease

–    Tertiary: Resin restorations

•      Aimed at minimizing the loss

What diseases are bidirectional?

–    Diabetes Mellitus - defined

–    Mutual Risk Factors with Periodontal Disease

•      CVD

•      CKD

•      Rheumatoid Arthritis

•      Respiratory Diseases

•      Osteoporosis

•      Pre-term, low birth weight infants

–    A – Assessment

•      HH and vitals

•      Pre med if indicated, type and time taken

•      Chief complaint/chief concern !

•      Subjective Info                         

•      Objective Information

•      Subjective Information

•      Obtained by observation and interaction w/patient

•      Patient’s perception of healthcare and value placed on health care

•      Date and type of RADS if brought from another office

•      Pain or sensitivity, concerns per patient

•      Document if patient is late

•      Current homecare methods

•      Objective Information

•      Physical and oral assessment

•      RI findings

•      Assessment information such as stain, calculus and plaque descriptions

•      Include items that should be prioritized or need follow up from the data that you have collected

•       (highlight or reiterate unmet needs/ areas that need improvement!)

•      Risk assessment

–    D- Diagnose

•      Dental Hygiene Diagnostic Statement

•      The “related to” statements

•      Must include patient classification

•      Interpretation of data

•      Validation (verify accuracy with the patient

•      Plan designed to resolve the problem based on data

•      Individualized per patient

•      Based on unmet needs

•      Procedures that you actually completed

•      UR,  #9-13, scaled all quads etc

•      OHI- document specific OHI

•      Kvp, Ma of RADS and type

•      Type of fluoride 

•      (tray -4 min appl. time)

•      Referrals

•      Attending DDS

•      Documentation is the complete and accurate recording of all collected data, treatment planned and provided, recommendations, and other information relevant to patient care and treatment.

1.  Documents all components of the dental hygiene process of care (assessment, dental hygiene diagnosis, planning, implementation, and evaluation).

2. Objectively records all information and interactions between the patient and the practice (i.e. telephone calls, emergencies, prescriptions).

3. Records legible, concise and accurate information (i.e. dates and signatures, clinical info that subsequent providers can understand, ensure all components of the patient record are accurately labeled). 

Why is it important to have an informed consent?

1)   Disclosure

2) Competence

3) Understanding

4) Voluntariness

5) Decision making

Mosby’s pg40

Legal ramifications of not following through with treatment?

Informed Consent

                                         i.    Additional procedures – if not consented

      Liable for Technical Assault and Battery

                                       ii.    Reasonable time and within Standard of

       Care – Liable for Breach of Contract

Dental Hygiene Considerations for Atherosclerosis/CAD/PAD/Aneurysm

• None directly related 
• Xerostomia due to hypertension medication.
• Dizziness/orthostatic hypotension due to hypertension medication.

Treatment  considerations for

Atherosclerosis/CAD/PAD/Aneurysm?

Evidence indicates that eliminating infection and sources of inflammation in the oral cavity and throughout the body can decrease the presence, size, and scope of atheromas and slow the evolution of atherosclerotic plaques.

Albuterol can cause xerostomia and candidiasis

Prednisolone can cause Ulcerative esophagitis

Oral Complications for Chronic Bronchitis

• Halitosis
• Nicotine stomatitis
• Periodontal infections
• Oral cancer
• Extrinsic tooth stains

Clinical care of pt with Lower Respiratory Disease

•  
  • Ultrasonic, or air polisher, Nitrous oxide may be contraindicated
  • No LA with epi

Oral complications ofAlzheimers

—  Xerostomia is a common side effect of meds. prescribed treat Alzheimers or Dementia.

—  If medication is syrup-based there is an increased danger of caries.
The dentist may also be able to apply chlorhexidene and fluoride varnishes 

Some antipsychotic drugs can cause increased tongue and jaw movements, making it difficult to wear dentures, particularly in the lower jaw.

Oral Complications of Cystic Fibrosis

• Candidiasis
• Increased risk of caries
• Increased osteoclast activity

Dental considerations and management of pts with Cystic Fibrosis

• Clinical Care – Patients may need breaks from being reclined and may also need to be treated in a more upright position.
• Patients with Cystic Fibrosis Related Diabetes will need to be treated in a similar manner to patients with Type I Diabetes. 

Oral consideration for pt with Multiple Sclerosis

• Some of the medications they may be taking may cause complications such as xerostomia

Dental considerations of a pt with MS

• As the disease progresses, a person with MS may become wheelchair bound, and have difficulty  with swallowing or breathing
• Pt and caregiver to know that a shorter recall visit between dental appointments may be recommended    

Oral Complications of Lupus:

§  Increased bleeding due to blood cell dyscrasias, especially thrombocytopenia, and anemia.  Increased chance of infection due to leucopenia.

§  Half of these individuals have extensive superficial erosions affecting the mouth, esophagus, larynx, trachea, genitalia, and eyes.

§  Sjorgen’s syndrome – dry eyes, mucous membranes and xerostomia.

 Premedication

Oral care for pts that have suffered a Heart attack, MI, Stroke, and Angina

    Elective dental treatment is usually not advised until 6 months or more after a stroke, but preventive measures and biofilm control procedures are introduced or reinstated as early as possible.

Name 15 Oral complications of Kidney disease

1.    gingival hyperplasia

a.   Secondary to drug therapy such as cyclosporine and calcium channel blockers

2.  increased bleeding/bruising/ petechaie

a.   Secondary to Heparin treatment for hemodialysis and platelet dysfunction 

3.  periodontal disease

4.  inflammation of the salivary glands

5.  Stomatitis

6.  Erythema

7.  Edema

8.  Candidiasis

9.  Pallor of gingival tissue

10.               Due to anemia

11. Xerostomia

12.               r/t to drug therapy and/or hemodialysis

13.               Oral Malodor

14.               Ammonia-like oral odor in 1/3 of hemodialysis pts

15.               Altered tasted/sensation

16.               Pts with chronic renal failure may complain of unpleasant/metallic taste, or sensation of enlarged tongue

17.               Dental erosion

18.               r/t frequent vomiting

19.               Attachment loss

r/t hypocalcemia

Possible Premed needed