Patient Classification

Patient Classification

The conversion of patient difficulty into a classification system

What is the two-tier classification system?

DHI (calculus classification -A,B,C, or D)

and

Periodontal Classification (based on attachment loss and bone loss - S/G = staging and grading)

DHI stands for

Dental Hygiene Index

Dental Hygiene Index (DHI) represents

Calculus Classification

P stands for

Periodontal

Periodontal (P)

Periodontal Classification

S stands for

Staging

Staging options (S)

- Healthy

- Gingivitis

- Stage (I - IV)

G

Grading

Grading option (G)

A, B, C

DHI options

A, B, C, D

Calculus Assessment/DHI procedure (2)

-Explore the dentition with ODU 11/12 explorer

-Determine the amount, location, severity, and extent of calculus by exploring the M, D, F, & L surfaces (4 surfaces).

ODU 11/12 use

calculus detection

What is the appearance of SUPRAGINGIVAL dehydrated calculus?

white and chalky

You can see it best by blasting air on it

Where are calculus deposits located in supragingival calculus?

in the gingival margin

Instruments for the Detection of Subgingival Calculus (3)

Mirror

Explorer

Dental Light

What skill is required for the detection of subgingival calculus?

Tactile Sensitivity

Calculus Classification (Supragingival - C1)

Light = 1

Moderate = 2

Heavy = 3

Very Dense = 4

ABCD

A = light (0-3 DHI pts)

B = moderate (4-5)

C = Heavy (6-8)

D = Very Dense (9+)

The number assigned for calculus classification is known as

Deposit Points

Light Supragingival Calculus location

mandibular anteriors due to proximity to wharton's/bartholins duct

(if you have plaque on your teeth the saliva from the duct puts Ca++ and P into the plaque and soon the organic portion calcifies)

What is the requirement for moderate supragingival calculus deposit points?

both anterior AND posterior supragingival calculus

(mandibular anteriors and buccal of maxillary molars)

Moderate Supragingival Calculus (Location)

mandibular anteriors due to wharton's/bartholin's duct and buccal of maxillary molars due to proximity of Stenson's duct.

(requires both anterior and posterior teeth)

What is the requirement for moderate subgingival calculus deposit points?

requires interproximal posterior calculus on at least two posterior teeth in every quadrant

(instructor/student negotiation required for score of 4 or 6 on subgingival calculus)

Light Subgingival Calculus (Location) (2)

- At gingival Margin + slightly subgingivally

- Slight Interproximal roughness located in the concavities

(**Difficult to find, requires a great deal of tactile sensitivity)

The light subgingival calculus is...

difficult to find and requires a great deal of tactile sensitivity

The light subgingival calculus is described as feeling like...

sandpaper (ie. grainy)

c1 refers to

supragingival

c2 refers to

subgingival

Plaque is primarily found in...

1. Gingival Margin

2. Interproximal Spaces

Grade A

Severity Points = 0 to 3

Type of Appointment = Prophy

Number of Appointments = 1

Requirements of Moderate Subgingival Calculus

interproximal posterior calculus on at least two teeth in every quadrant

(Minimum of 8 deposits)

Moderate Subgingival Calculus (Location)

The mesial of first molars and distal of last tooth in the arch

Grade B

Ant and post calculus

minimum of 8 deposits

Severity Points = 4 to 5

Type of Appointment = Prophy

Number of Appointments = 1

Requirements of Heavy Supragingival Calculus

sheet or layer of supragingival calculus covering multiple surfaces

The appearance of (dehydrated) heavy supragingival calculus is described as...

dull and smooth

It becomes yellow when you dry it

Heavy Supragingival Calculus (Location)

mandibular anteriors due to wharton's duct and buccal of maxillary molars due to stenson's duct

(same location as moderate)

Requirements for Heavy Subgingival Calculus

interproximal calculus on at least 12 surfaces in a half mouth (minimum of 24 deposits)

Heavy Subgingival Calculus (Location)

The buccal and/or lingual surfaces with definite spicules (speed bumps) in interproximal spaces

(doesn't require as much tactile sensitivity)

Heavy subgingival calculus and tactile sensitivity relationship

does NOT require as much tactile sensitivity as there are definite spicules and no guessing involved

Grade C

Severity Points = 6 to 8

Type of Appointment = Periodontal Debridement (w/ anesthesia)

Number of Appointments = 2 - Half mouth w/ anesthesia (quad 1+4 or quad 2+3)

Number of Reappointments = 1 (for reevaluation)

What is the difference between D4342 and D4341?

D4342 = 1-3 teeth have 4mm+ pockets per quad

D4341 = 4 or more teeth have 4mm+ pockets per quad

D4341

4 or more teeth have 4+ mm pocket depths per quadrant.

D4342

1 - 3 teeth have 4+ mm pocket depths per quadrant.

Requirements for Very Dense Supragingival Calculus

ledges that weld the teeth together forming a bridge that prevents flossing.

Very Dense Supragingival Calculus (Location)

mandibular anteriors due to wharton's duct and buccal of maxillary molars due to stenson's duct.

(same as modeate and heavy)

Requirements for Very Dense Subgingival Calculus

Generalized interproximal ledges/rings of calculus on at least 12 surfaces per quadrant (48 deposits minimum)

Wall to wall calculus

Very Dense Subgingival Calculus (Location)

heavy, long-standing definite rings/deposits that encircle the tooth and are very difficult to remove

ADA Code for Grade "D"

4341 & 4342

4342 & 4341 (Grade "D")

Severity Points = 9+

Type of Appointment = Periodontal Debridement

Number of Appointments = 4 - Quadrant (w/ anaesthesia)

Number of Reappointments = 1 (1 month)

Conversion of Deposit Points to DHI

The total score for supragingival and subgingival calculus to determine the overall DHI

A (Light)

0 - 3

B (Moderate)

4 - 5

C (Heavy)

6 - 8

D (Very Dense)

9+

Periodontal Classification (3)

Healthy/Gingivitis (Type I)

Stage I-IV

Grading A-C

What is periodontal classification based on?

attachment loss and bone loss

(probe depth and recession, review radiographs to determine bone loss)

Type I

Gingivitis

Type I (Gingivitis)

A. NO bone loss

B. NO attachment loss

C. Changes in Color

D. Changes in consistency

E. Changes in texture

F. Changes in contour

G. The presence of bleeding and/or exudate.

How do you view bone loss?

Review radiographs

What are the two primary risk factors for the development of periodontal disease? (2)

Smoking

Diabetes

What is the critical amount of bone loss?

> 15% and 33% <

P

Periodontal Classification

(based on attachment loss and bone loss)

How do you determine periodontal classification? (3)

Review the patient's medical history.

Review the patient's attachment loss.

Review the patient's radiographs.

Why do you review the patient's medical history?

To determine if the patient is a smoker or has diabetes

How do you determine the patient's attachment loss?

Probe Depth + Recession

Why do you review the patient's radiographs?

To determine the amount of bone loss.

CAL

Clinical Attachment Loss (AKA Total Attachment Loss)

RBL

Radiographic Bone Loss

What is the purpose of the RBL?

To determine the percentage of bone loss.

Stage I-IV

Identify the SEVERITY of disease at presentation and COMPLEXITY of disease management.

Stage I

-Initial Periodontitis

-less than 15% bone loss

Stage II

Moderate Periodontitis

15 - 33% bone loss

Stage III

Severe Periodontitis w/ potential for additional tooth loss (greater than 6mm).

greater than 33% bone loss

Stage IV

Severe Periodontitis w/ potential for loss of dentition

greater than 33% RBL

Grading (G) - what you are looking for

Identify the rate of disease progression, relation of plaque to destruction, and risk factors (modifiers).

Based on smoker (# of cigs) and A1c classification

radiographic bone loss diagram

2 mm from CEJ is normal

What is easier to deal with: horizontal bone loss of vertical bone loss?

horizontal

(vertical bone loss means greater pocker depths; first you get horizontal bone loss and then it can progress into vertical)

Staging - Stage I list

SEVERITY:

CAL: 1-2mm

RBL: less than 15%

Tooth loss: None

COMPLEXITY:

Probe depth: greater than or = 4

bone level: horizontal

NO furcation involvement

Staging - Stage II

SEVERITY:

CAL: 3-4mm

RBL: 15-33%

Tooth loss: None

COMPLEXITY:

Probe depth: greater than or = 5

bone level: horizontal

NO furcation involvement

Staging - Stage III

SEVERITY:

CAL: greater than or equal to 5mm

RBL: greater than 33% of root

Tooth loss: less than or = to 4 teeth

COMPLEXITY:

Probe depth: greater than or = 6

bone level: vertical

furcation involvement can be II or III

ridge defects

Staging - Stage IV

SEVERTIY:

CAL: greater than or = 5mm

RBL: greater than 33% of root

Tooth loss: greater than or = 5 teeth

COMPLEXITY:

masticacy disfuncation, 20 or less teeth remain, bite colapse