clinic theory III exam 2

stage I

• initial periodontitis

  • SRP quad D4341 (four teeth or more)

  • SRP quad D4342 (three teeth or less)

  • Perio maintenance D4910

stage II

• moderate periodontitis

  • SRP quad D4341 (four teeth or more)

  • SRP quad D4342 (three teeth or less)

  • Perio maintenance D4910 /3 months

  • periodontist referral

Stage III

• severe periodontitis with potential for additional tooth loss

  • SRP quad D4341 (four teeth or more)

  • SRP quad D4342 (three teeth or less)

  • Perio maintenance D4910 /3 months

  • periodontist referral

stage IV

• severe periodontitis with potential for loss of the dentition

• need for complex rehabilitation

  • SRP quad D4341 (four teeth or more)

  • SRP quad D4342 (three teeth or less)

  • Perio maintenance D4910 /3 months

  • Periodontist referral and surgical evaluation

grade A

• slow rate of disease progression

grade B

• moderate rate of disease progression

grade C

• rapid rate of disease progression

staging

• intends to classify the severity and extent/ complexity of a patients disease

grading

• aims to indicate the rate of periodontitis progression

• generally more important

periodontium

• a functional system of tissues that surrounds teeth and attaches them to the jaw bone

• attachment and supportive apparatus of teeth

periodontitis

• a bacterial infection of all parts of the periodontium including the

  • gingiva

  • periodontal ligament

  • bone

  • cementum

• results in irreversible tissue damage

• a type of periodontal disease

horizontal pattern of bone loss

• is the most common pattern of bone loss

• results in fairly even, overall reduction in the height of bone

• inflammation spreads in this manner because it is the path of least resistance

vertical bone loss

• less common pattern

• leaves a trench-like area of missing bone alongside the root

• occurs when the crestal periodontal ligament fibers are weakened and no longer act as an effective barrier to inflammation

• Stage I periodontitis severity

• interdental CAL: 1-2 mm at site of greatest loss

• RBL: coronal third (<15%)

• no tooth loss

Stage I periodontitis complexity

• maximum probing depth of ≤ 4mm

• mostly horizontal bone loss

Stage II periodontitis severity

• interdental CAL: 3-4 mm

• RBL: coronal third (15%-33%)

• no tooth loss

Stage II periodontitis complexity

• max. probing depth ≤5 mm

• mostly horizontal bone loss

Stage III periodontitis severity

• interdental CAL: ≥ 5mm

• RBL: extending to middle third of root and beyonf

• ≤4 teeth lost

Stage III periodontitis complexity

• probing depths of 6mm or more

• vertical bone loss of 3 mm or more

• furcation involvement class II or III

• moderate ridge defects

  • (in addition to Stage II complexity)

Stage IV periodontitis severity

• interdental CAL: ≥ 5mm

• RBL: extending to middle third of root and beyond

• ≥ 5 teeth lost

Stage IV periodontitis complexity

• probing depths of 6mm or more

• vertical bone loss of 3 mm or more

• furcation involvement class II or III

• moderate ridge defects

• need for complex rehabilitation due to

  • masticatory dysfunction

  • secondary occlusal trauma

  • bite collapse, drifting, flaring

  • < 20 remaining teeth (10 opposing pairs)

Grade A periodontal disease

• RBL: no loss over 5 years

• % bone loss/ age: <0.25

• case phenotype: heavy biofilm deposits with low levels of destruction

• non smoker

• normoglycemic/ no diagnosis of diabetes

Grade B periodontitis

• RBL: < 2 mm over 5 years

• % bone loss/ age: 0.25 to 0.50

• case phenotype: destruction commensurate with biofilm deposits

• < 10 cigarettes a day

• HbA1c < 7.0% in patients with diabetes

Grade C periodontitis

• RBL: ≥ 2 mm over 5 years

• % bone loss/ age: > 1.0

• case phenotype: destruction exceeds exceptions given biofilm deposits; specific clinical patterns suggestive of periods of rapid progression and/or early onset disease

• ≥ 10 cigarettes a day

• HbA1c ≥ 7.0% in patients with diabetes

initial periodontal lesion

• bacterial colonization near the gingival margin

• increased vascular dilation

• PMN migration to gingival sulcus

• gingival tissue looks clinically healthy

early periodontal lesion

• bacteria penetrate into connective tissues

• more PMNs attracted to site and release cytokines causing more localized destruction of the connective tissue

• macrophages are first recruited to the connective tissue

  • release cytokines, PGE2, and MMPs

• clinically, edema and redness of gingival marginal tissue is observed

• Sulcular epithelium forms epithelial ridges and JE cells proliferate

established lesion (established gingivitis)

• plaque biofilm extends subgingivally into the sulcus, disrupting attachment of coronal-most portion of the JE from the tooth surface

• macrophages and lymphocytes are most numerous in connective tissues; PMNs continue to fight bacteria in the sulcus

• host cells produce more toxic chemicals

• collagen breakdown, gingivitis is present clinically

advanced periodontal lesion (periodontitis)

• plaque biofilm spreads laterally as well as apically along the root surface

• chronic inflammation causes harm to the periodontium

• macrophages produce high concentrations of cytokine, PGE2 and MMPs that destroy alveolar bone

• PMNs, macrophages cause destruction of connective tissue and PDL fibers

• immune response becomes chronic; intense inflammation begins to harm the periodontium

C-reactive protein

• protein produced in the liver, usually during acute inflammation that increases in blood when there is inflammation in the body

• activates complement system and leads to phagocytosis

• high levels when there is infection, trauma, or inflammation

• periodontitis may trigger body to produce elevated levels

phase 1 urgent/diagnostic

• emergency care

• consultations with other medical providers are needed

• dental hygiene diagnosis

phase 2 disease control

• biofilm control/calculus removal

• preventive measures (diet, fluoride, mouthguard)

• restorative needs

phase 2 evaluation

• evaluation of treatment, biofilm control of patient

• complicance with treatment recommendations?

phase 3 corrective therapies or rehabilitation

• periodontal surgery

• endodontics

• orthodontics

• fixed or removable prosthesis

• implant placement

phase 4 maintenance or support therapy

• continuing care intervals and evaluation

• refining biofilm control techniques and modifiable risk factors

CDT codes in dentristry

• A set of standardized codes used to ensure consistency and accuracy in reporting dental procedures to third-party payers (insurance),  in Electronic Health Records (EHR), and in submission fees for the patient estimate of care/financial responsibility.

• D0100-D0999

diagnostic category of CDT code

• D1000-D1999

preventative category of CDT code

D2000-D2999

• restorative category of CDT code

D3000-D3999

• endodontic category of CDT code

D4000-D4999

periodontics category CDT code

D5000-D5899

prosthodontics- removable

D5900-D5999

maxillofacial proshtetics

D6000-D6199

implant services

D6200-D6999

• prosthodontics fixed

D7000-D7999

• oral and maxillofacial surgery

D8000-D8999

• orthodontics

D9000-D9999

adjunctive general services

D0171

• post-op 4-6 week follow-up <90 days

D0170

• chronic conditioning/monitoring

% bone loss / patient age

• Calculation of bone loss percentage

maconutrients

• proteins, fats, carbohydrates, water

micronutrients

• vitamins, minerals, bioflavonoids (antioxidants)

fat soluable

Vitamins A, D, E, and K

• associated with the structure and calcification of hard tissues

• are absorbed with the other fats from the foods you eat

water soluable

• B and C vitamins

• Not stored in the body

• enter the bloodstream, and what the body doesn’t need is eliminated through urine

folic/ folate acid (B9)

• Necessary for pregnant females to prevent neural tube defects (spinal bifeda)

• Deficiency may also lead to megaloblastic anemia: a deficiency of _ affecting red blood cell production

nutrigenomics

• personalized nutrititon that studies how genes respond to food

nonmaleficience

• having the duty to do no harm

• refraining from action that cause injury, pain, or suffering

beneficence

• acting for the good of others to promote well-being

• taking active steps to help, comfort, or improve situations of others

nutritional assessment

•  A Systematic collection of information to identify the need for nutritional counseling and make appropriate recommendations and referrals.

targeted patients for nutritional counseling

• at high risk for dental caries or periodontal disease

• exhibiting oral manifestations of a possible nutritional deficiency

• undergoing periodontal or oral and maxillofacial surgery

• at risk for osteoporosis

• diagnosed with osteopenia

body mass index (BMI)

• divide patients weight in kilograms by his/her height in meters

• important components of health history

• provides measurement associated with health risks such as heart disease, hypertension, diabetes, and cancer

• Normal range ~18.5-24.9, with 25-29.9 being overweight and over 30 considered obese

waist circumference

• Can be used to indicate health risk. Determines central obesity and health risks

• men- 40 in

• women- 35 in

• most accurate method because it does not take age, race, or frame size into consideration

exercise patterns

• acitivity levels may be used to determine daily caloric need

• activity levels can be entered into online interactive tools

• approximate daily caloric expenditure can be useful

• primary goal in a dental setting is to identify nutritional concerns that may contribute to systemic/oral disease

my plate

• foods are categorized into five good groups (grains, vegetables, meats/beans, fruits, dairy)

• individual caloric needs are determined based on age, gender, and activity level

• each sugar exposure is circled in red (cariogenic potential)

• most programs provide information on caloric intake as well as deficient or excess nutrient amounts

• once energy needs are established, dental hygienist can compare an individuals intake to the specified amount recommended by _ to assess the patients dietary adequacy

D1310

• listed as “other preventive services” and receives no compensation when provided in dental practice

• Although not compensated by insurance companies, it is NOT a justification to eliminate nutritional counseling from the DH process of care

nutritional counseling

Using the information obtained from health history and dietary assessment, dental hygienist and patient fromulate a plan

• useful for patient education and motivation

• use motivational interviewing techniques

• explain how positive lifetyle changes can benefit overall health

• discuss health, nutrient-dense snack foods

• identifying nutritional deficiencies (cultural sensitivity)

• cariogenic foods vs cariostatic foods

• food insecurities

pregnant patients

• have an increased need for nutrients and energy intake

• Calcium intake for fetal tooth development

• Folic/folate acid (vitamin B9) to prevent neural tube malformations

veracity

conformity with truth or fact

• devotion to being truthful

primary nutritional deficieny

• Inadequate intake of a nutrient

• can be corrected once identified

• counseling and proper intake of the nutrient

secondary nutritional deficiency

• due to a systemic disorder that interferes with absorption, transport, digestion, or ingestion of the nutrient

• complex care; refer to a physician and dietitian for treatment

vitamin K

• clotting factors

• deficiency blood can clot slowly and cause excessive bleeding

• patients may bruise easily

iodine

• necessary to prevent hypothyroidism, graves disease (supplied via iodized salt)

nutritional needs of infancy and childhood

• Nutritional intake and food choices during this time may influence growth patterns

• Nutrient-dense foods (osteomalacia prevention, enamel hypoplasia) with offered variety of food groups

nutritional needs older adult patients

• need more vitamins/minerals

• possible need for increased protein in a segment of the population

• specifically need for vitamin D, E, B6, B12, folate, calcium, magnesium, iron, and zinc

periodontal and oral maxillofacial surgical patients

• often unable to consume adequate amount of recommended nutrients owing to loss of function

• chronic alcoholics, extremely underweight individuals, those taking steroids, or immunosuppressents may have depleted stores of nutrients

osteopenia

• a loss of mineralized bone tissue

• regardless of cause, is considered to be a precursor to osteoporosis

osteoporosis

• is a disease characterized by low bone mass, microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk

• Monitor patients' vitamin D intake, as deficiency reduces calcium absorption and can worsen bone loss

obesity

• Associated with many chronic diseases, including periodontal disease

• having a BMI of greater than or equal to 30

• While it is beyond the role of the dental hygienist to create diet plans for use in weight loss, it is the hygienist's responsibility to educate patients on health promotion, disease prevention techniques, and habits that will benefit oral health as well as overall health.

• Caries risk may elevate with bariatric surgery as the frequency of meals is increased; deficiency is also possible due to meal portions

pharmacologic assessment

• An assessment of ingestion of prescription medications, as well as common OTC supplements, provides insight into oral manifestations or effects of these medications on oral tissues that may interfere with dental care such as

  • xerostomia

  • lichenoid reactions

  • candidiasis

  • chelitits

  • and glossitis (inflamed tongue)

vitamins associated with hard tissues

• Vitamin A (fat-soluble)

• Vitamin D (fat-soluble)

• Vitamin E (fat-soluble)

• Vitamin K (fat-soluble)

• Vitamin C (water-soluble)

vitamin A

• fat-soluble vitamin

• synthesized in the intestinal tract

• only found in animal foods (beef liver is excellent source)

• beta form (carotene):

  • carrots, melon, squash, sweet potatoes, spinach

• excess may cause headache, vomiting, severe liver damage, defect in long-bone formation, and fetal birth defects

vitamin A manifestations of deficiency

• fat-soluble vitamin

• growth failure, xerosis, keratomalacia

• enamel hypoplasia, defective dentin formation (hard tissue)

• decreased salivary secretion and xerostomia; delayed or impaired wound healing (soft tissue)

vitamin D

• fat-soluble vitamin

• Synthesized in skin exposed to sunlight

• excess may cause vomiting, diarrhea, and hypercalcemia

vitamin D deficiency

• rickets, osteomalacia

• enamel hypoplasia, loss of lamina dura

vitamin E

• fat-soluble vitamin

• synthesized in the intestinal tract

• Found in vegetable seed oils widely distributed among foods

• Excess may inhibit vitamin K functions→ causing problems with blood clotting

  • can act as an anticoagulant

vitamin E deficiency

• anemia, neuropathy, myopathy

• loss of oral resistance to inflammation in the periodontium (hard tissue)

• loss of integrity of cell membranes of mucosa (soft tissue)

vitamin K

• fat-soluble vitamin

• Synthesized by intestinal bacteria

• found in green leafy vegetables, soybeans, and beef liver

• high doses of synthetic form may cause oxidation of membrane lipids and severe jaundice in infants

vitamin K deficiency

• defective blood clotting

• may be involved in bone formation

vitamin C

• water-soluble vitamin

• synthesized in intestinal tract

• Found in citrus fruits, papaya, cantaloupe, broccoli, potatoes, and strawberries

• Excess can cause GI distress, and interfere with vitamin B12 absorption

• overdose may cause diarrhea and kidney stones

vitamin C deficiency

• survy

• inhibition of the formation of fibroblasts, osteoblasts, and odontoblasts (hard tissue)

• weakened collagen formation, leading to gingivitis and poor oral wound healing (soft tissue)

minerals associated with hard tissues

• calcium

• phosphorus

• magnesium

• fluoride

calcium

• found in milk and milk products, sardines, clams, turnip and mustard greens, broccoli

• excess may cause constipation

• deficiency may result in rickets, osteomalacia, osteoporosis, stunted growth

• oral manifestations of deficiency may include tooth exfoliation due to osteoporosis in alveolar bone

phosphorus

• found in meat, poultry, fish, eggs, milk products, and chocolate

• symptoms associated with excess are rare; problems appear to occur only when calcium-to-phosphorus ratios are altered significantly in infants.

• Deficiency may result in rickets and osteomalacia

• oral manifestations of deficiency may result in possible failure of reparative dentin formation

magnesium

• Found in nuts, legumes, cereal grains, chocolate, blackstrap molasses, and spinach

• acute toxicity from excessive intravenous administration results in nausea, depression, and paralysis

• deficiency may result in growth failure, neuromuscular dysfunction, personality changes, muscle spasms

• oral signs of deficiency may include reduced formation of alveolar bone, hypoplasia of enamel, widening of PDL space, and gingival hyperplasia

fluoride

• Naturally found in mackerel, salmon, shrimp, meat, potatoes, wheat, and sardines

• Excess results in fluorosis

• deficiency may result in osteoporosis or osteosclerosis

• oral manifestations of deficiency may include dental caries

vitamins associated with soft tissue

• vitamin B1

• vitamin B2

• vitamin B6

• vitamin B12

• Niacin

• folate

• pantothenic acid

• biotin

• vitamins C, A, and E

vitamin B1

• thiamine, water-soluble vitamin

• found in pork, sunflower seeds, and legumes

• Excessive doses may cause headache, convulsions, cardiac arrhythmia, and anaphylactic shock.

• deficiency may include Beriberi, muscle weakness, tachycardia, enlarged heart, edema, anemia, neuropathy, and myopathy

• oral manifestations of deficiency include Glossitis, gingival tissue discoloration

vitamin B2

• water-soluble riboflavin

• found in Beef liver, lean steak, mushrooms, ricotta cheese, milk

• no toxicity symptoms reported

• Deficiency may result in Photophobia, dermatitis, anemia

• Oral manifestations of deficiency may include Cheilosis, glossitis, edema of pharyngeal and oral mucous membranes, angular stomatitis

vitamin B6

• water-soluble, pyridoxine

• found in Sirloin steak, navy beans, potatoes, bananas

• excessive causes sensory and peripheral neuropathy; minimal dose, at which toxicity occurs, is not defined.

• defiency may result in Dermatitis, neurologic symptoms of confusion, drowsiness, neuropathy

• Oral manifestations of deficiency may include Glossitis and cheilitis

vitamin B12

• water-soluable

• found in Meat, fish, shellfish, poultry, milk

• no effects from excessive doses

• deficiency may result in Megaloblastic anemia (pernicious anemia), degeneration of peripheral nerves, skin hypersensitivity

• oral manifestations of deficiency may include glossitis, eventual disappearance of the filiform and fungiform papillae; glossopyrosis