AQ

Hard Tissue Exam and Related Concepts (Flashcards)

Hard Tissue Examination and Dental Charting

  • Hard tissue exam is performed to document the health of the teeth and supporting structures and guide treatment planning.
  • Core components include:
    • Dental charting of missing teeth and existing restorations.
    • Charting of carious and noncarious lesions.
    • Radiographs to identify caries and other pathologies.
    • Evaluation and documentation of occlusion.
    • Use of study models (optional but useful) to aid treatment planning.

Dentition: Types and Development

  • Three divisions of the human dentition:
    • Primary (Deciduous) dentition
    • Mixed (transitional) dentition
    • Permanent dentition
  • Primary dentition (Deciduous):
    • Baby teeth begin forming in utero.
    • There are 20 primary teeth, labeled A–T.
  • Mixed dentition:
    • Occurs roughly between ages 6-12 years.
    • Primary teeth are shedding while permanent teeth are erupting.
  • Permanent dentition:
    • Consists of 32 teeth.
    • Mineralization starts at birth and continues into adolescence.
    • Typical sequence includes: central incisor, lateral incisor, canine, first premolar, second premolar, first molar, second molar, third molar (wisdom tooth).
  • Developmental timeline references:
    • Primary dentition (A–T) present in early childhood.
    • First permanent molars erupt around age ~6 years (eruption patterns discussed later).
    • Permanent dentition reaches full eruption by adolescence.
  • Example ages for dentition stages:
    • Primary dentition: up to around age 6.
    • Mixed dentition: around 6-12 years.
    • Permanent dentition: typically complete by early adulthood.

Tooth Counting, Numbering, and Diagrams

  • Permanent dentition numbering: 1-32 (viewed as if looking into the mouth, upper right to upper left then lower left to lower right).
  • Primary dentition labeling: letters A-T.
  • Quadrant reference (as depicted in typical diagrams):
    • Top Right (TR) – Quadrant I
    • Bottom Right (BR) – Quadrant IV
    • Top Left (TL) – Quadrant II
    • Bottom Left (BL) – Quadrant III
  • Notation examples:
    • Permanent dentition: teeth numbered 1–32; e.g., 1 = maxillary right first molar, 32 = mandibular right third molar.
    • Primary dentition: teeth labeled A–T; e.g., A = maxillary right primary canine, T = maxillary left second molar (varies by charting convention).
  • Clinical crowns vs anatomic crowns:
    • Clinical crown length varies with gingival level; anatomic crown is the full crown anatomy.
    • Important for charting tooth morphology and estimating restorability.

Radiographic and Clinical Examination Procedures

  • Radiographic examination is used to complement clinical findings.
  • Stepwise approach:
    • Start with a radiographic survey to evaluate missing teeth, impactions, unerupted teeth, root structure, and bone support.
    • Use radiographs to assist caries detection, periapical status, and eruption patterns.
  • Clinical examination procedures include:
    • Visual inspection with good illumination and drying of surfaces.
    • Tactile assessment using appropriate explorers/probes (e.g., to detect caries, grooves, calculus).
    • Intraoral camera as an adjunct tool for documentation and patient education.

Caries Classification and Lesions

  • Caries classification systems used in diagnosis, treatment planning, and restorations:
    • G.V. Black classification (carious lesion location): Class I–VI
    • Class I: Cavities in pits and fissures (occlusal surfaces of premolars/molars, facial/lingual surfaces of molars, lingual surfaces of maxillary incisors).
    • Class II: Cavities on proximal surfaces of premolars and molars.
    • Class III: Cavities on proximal surfaces of incisors/canines that do not involve incisal edge.
    • Class IV: Cavities on proximal surfaces of incisors/canines that involve incisal edge.
    • Class V: Cavities in the cervical 1/3 of facial or lingual surfaces (not pits/fissures).
    • Class VI: Cavities on incisal edges of anterior teeth or cusp tips of posterior teeth.
    • American Dental Association (ADA) Caries Classification System (clinical presentation of caries):
    • Sound: No clinically detectable lesion; enamel appears normal.
    • Initial: Demineralization limited to enamel or shallow dentin demineralization; may be visible only after drying.
    • Moderate: Enamel breakdown or dentin demineralization is evident but not fully cavitated.
    • Advanced: Enamel fully cavitated with dentin involvement.
    • Variants include Surface-specific terms like “noncavitated,” “microcavitation,” etc., and radiographic correlates (E1, E2, D1, D2, D3, etc.).
    • International Caries Detection and Assessment System (ICDAS) and ICCMS caries categories:
    • ICCMS categories combine ICDAS scores with radiographic findings to stage caries as: Sound, Initial, Moderate, and Extensive.
    • ICCMS caries categories definitions (summary):
      • Sound: No evidence of caries (enamel translucency intact, after cleaning and air-drying).
      • Initial stage caries (ICDAS 1–2): First visual changes in enamel without surface breakdown or dentine shadowing; may show opacity or discoloration.
      • Moderate stage caries (ICDAS 3–4): White/brown spot with localized enamel breakdown or underlying dentine shadowing.
      • Extensive stage caries (ICDAS 5–6): Distinct cavity with visible dentine.
      • A diagnostic probe (e.g., WHO/CPI/PSR ball-end probe) may be used very gently to test surface breakdown and to confirm enamel or dentine involvement.
  • Other important caries concepts:
    • Initial caries: Demineralization of enamel; may appear whitish or yellow; may dry to dull appearance; remineralization possible.
    • Early childhood caries (ECC): Strongly associated with bottle feeding practices; high levels of Streptococcus mutans increase risk.
    • Root caries: Occurs on cementum/dentin, often in exposed root surfaces; typically soft, progressive, and spreads laterally; common in aging populations.
    • Proximal caries: Detected via radiographs and visual examination; may progress from incipient to cavitated lesions.
    • Caries management emphasizes preventive strategies (fluoride, diet modification) and remineralization when possible.

Noncarious Dental Lesions (NCCLs)

  • NCCLs include attrition, abrasion, and erosion (A, B, C in some diagrams):
    • Attrition: Wear caused by tooth-to-tooth contact; cumulative with time; commonly associated with bruxism (grinding); early signs include wear facets.
    • Abrasion: Mechanical wear of tooth structure from external agents (e.g., aggressive brushing, chewing on pens, pipe smoking); often at cervical areas.
    • Erosion: Chemical dissolution of tooth structure; affects facial and lingual surfaces; can be intrinsic (gastric reflux) or extrinsic (acidic foods/beverages).
  • Implications of NCCLs include reduction in tooth integrity and esthetics, potential plaque retention in irregular lesions, and hypersensitivity. Treatment considerations include hygiene modifications, desensitizing agents, appropriate dentifrices, and sealants or restorations as needed.

Fractures and Traumatic Injuries

  • Fractures of teeth can involve enamel, enamel-dentin, enamel-dentin-pulp, crown-root fractures (with or without pulp involvement), root fractures, and alveolar fractures.
  • Traumatic dental injuries include a range of injuries to permanent teeth:
    • Concussion, Subluxation
    • Extrusion, Lateral luxation, Intrusion
    • Avulsion
  • Radiographic signs help diagnose trauma and determine treatment; classification systems assist in documenting severity and prognosis.

Pulp Vitality and Restorations

  • Testing for pulp vitality helps determine whether a tooth is alive, reversibly affected, or non-vital:
    • Cold testing and heat testing are common methods.
    • A lack of response indicates non-vital pulp (possible need for root canal therapy, RCT).
    • An exaggerated or prolonged response indicates pulpitis (reversible or irreversible depends on clinical context).
  • Restorations and root canal therapy (RCT) considerations:
    • Documentation of existing restorations is essential for treatment planning.
    • Implants and RCT may be discussed as options for missing teeth.

Occlusion: Principles, Classification, and Profiles

  • Occlusion refers to how the teeth come together during closure and function.
  • Basic concepts:
    • An ideal contact pattern and tooth alignment, with dissipation of forces during chewing.
    • Occlusal trauma is trauma to teeth and supporting structures caused by excessive functional or parafunctional forces.
  • Angular (Angle’s) classification:
    • Class I: Normal molar relationship with some malocclusion variations (crowding, rotation, protrusion, crossbite may occur).
    • Class II: Distocclusion (mandible retruded relative to maxilla).
    • Division 1: All maxillary incisors proclined.
    • Division 2: One or more maxillary incisors retroclined.
    • Class III: Mesocclusion (prognathic profile; mandible ahead of maxilla) with potential underbite.
  • Facial profiles associated with occlusion:
    • Retrognathic: Retruded mandible.
    • Mesognathic: Neutral/normal jaw relationship.
    • Prognathic: Protrusive mandible.
  • Functional vs parafunctional contacts:
    • Functional contacts: Normal contacts that occur during typical function.
    • Parafunctional contacts: Deviations during clenching, grinding, nail biting, or chewing on hard objects; can accelerate tooth wear and contribute to occlusal trauma.
  • Proximal contacts: Important for force dissipation, preventing tooth migration, food impaction, and maintaining interdental bone health.
  • Occlusal trauma types:
    • Primary occlusal trauma: Excessive biting force on a tooth with normal bone support.
    • Secondary occlusal trauma: Normal or abnormal forces applied to a tooth with bone loss.
  • Clinical findings associated with occlusal trauma:
    • Tooth mobility and fremitus, sensitivity to pressure, drifting, pathologic migration, and fractured teeth.
    • Radiographic signs include thickening of the lamina dura and widening of the periodontal ligament (PDL) space, and potential root resorption.
  • Study models and interocclusal records are used to assess occlusion and serve as part of the patient’s permanent record.
  • Interocclusal records: Bite registrations that help relate upper and lower models; useful for open bites, crossbites, or missing teeth affecting occlusion.

Study Models and Interocclusal Records

  • Study models serve as a permanent patient record of:
    • Existing/missing teeth, tooth position and anatomy, gingival/papillae morphology, frena, and occlusion.
  • Interocclusal records aid in correct model mounting and occlusal analysis.
  • Uses include planning for orthodontic therapy, restorative work, and tracking progress over time.

Patient Education and Practice Considerations

  • Key educational points for patients include:
    • Benefits of orthodontic care and improving chewing efficiency and diet.
    • Habits that affect occlusion (e.g., teeth grinding, cheek/lip biting) and strategies to modify them.
    • Space maintenance in the primary dentition and monitoring occlusion during growth.
    • Importance of biofilm control, especially in crowded or misaligned dentition.
    • Use of appropriate self-care aids and regular maintenance appointments.
  • For patients undergoing orthodontic treatment, emphasize ongoing care and follow-up.

Equipment and Tools for Hard Tissue Examination

  • Essential tools include:
    • Mouth mirror, Shepard Hook, bright light, proper patient positioning.
    • Loupes for magnification (preferred).
    • Radiographs for diagnostic support.
  • Additional technique tips:
    • Use air to dry teeth to enhance visualization of caries, calculus, and demineralization (inform patient prior to using air).
    • Maintain patient comfort and avoid applying air to cervical areas or carious lesions if painful.

Practical Charting Procedures and Documentation

  • Charting order and methodology:
    • Record missing teeth first using radiographs for confirmation.
    • Follow a systematic sequence around the mouth: 1–16 (upper arch) and then 17–32 (lower arch).
  • Documentation to include:
    • Existing restorations and their locations.
    • Developmental enamel lesions and NCCLs (noncarious cervical lesions).
    • Carious lesions using the recognized classification system (G.V. Black, ADA, ICDAS/ICCMS).
    • Any other pathology observed during radiographic or clinical examination.
  • Occlusion documentation should note functional and parafunctional contacts, intraoral relationships, and any deviations from ideal occlusion.

Pulp Vitality Testing and Root Health

  • Pulp vitality testing helps determine pulp status (vital, reversible pulpitis, irreversible pulpitis, or non-vital).
  • Testing methods include thermal tests (cold/heat) and occasional electric pulp testing as adjuncts.
  • Loss of vitality may lead to root canal therapy (RCT) or extraction if tooth structure and prognosis are poor.

Summary of Key Caries and Lesion Concepts

  • Caries progression involves a balance of three factors: microorganisms, fermentable carbohydrates, and susceptible tooth surface, over time.
  • Key caries timelines and stages include:
    • Initial demineralization (enamel changes, possible white spot lesions).
    • Moderate progression with enamel breakdown or dentin shadowing.
    • Extensive cavitation with dentin involvement.
  • Root caries and ECC require special attention due to unique etiologies and progression patterns.

Practice Questions Preview (Sample Review Prompts)

  • Classify a given malocclusion using Angle’s system (Class I, II, III; with Divisions 1 and 2 for Class II).
  • Identify which type of noncarious lesion is most likely given a description (attrition, abrasion, erosion, or abfraction).
  • Determine the ICCMS stage for a lesion described as a white opacity with no dentin exposure and confirm with radiographs if needed.
  • Describe the steps you would take to complete a hard tissue exam for a new patient and the rationale for each step.

Figures and Diagrams (Study Notes)

  • Tooth development and eruption figures illustrating permanent dentition layout and eruption sequence.
  • Diagrammatic representations of occlusion classifications (Class I, II, III) and facial profiles (retrognathic, mesognathic, prognathic).
  • Examples of occlusal trauma signs on radiographs and clinical exam.
  • Illustrations of noncarious lesions (attrition facets, NCCLs, wedge-shaped abfractions).

References to Classifications and Codes (Summary for Quick Review)

  • G.V. Black’s Caries Classification: Class I–VI (pit/fissure to incisal/cusp tip lesions).
  • ADA Caries Classification System (clinical): Sound, Initial, Moderate, Advanced.
  • ICDAS/ICCMS Caries Categories:
    • Sound (ICDAS 0)
    • Initial (ICDAS 1–2)
    • Moderate (ICDAS 3–4)
    • Extensive (ICDAS 5–6)
  • Radiographic correlates (e.g., E1, E2 for enamel, D1, D2, D3 for dentin – specific to radiographic scoring in some schemes).
  • Occlusion terminology: Normal Class I alignment, Class II Distocclusion (Division 1 vs Division 2), Class III Mesiocclusion; facial profiles: retrognathic, mesognathic, prognathic.
  • Common NCCL terms: Attrition, Abrasion, Erosion, Abfraction.
  • Pulp vitality notes: cold testing, heat testing, and reactions indicating reversible or irreversible pulpitis.

Quick Reference Dates and Timelines (From the Slides)

  • Primary dentition present in early childhood; 20 teeth labeled A–T.
  • Mixed dentition between ages 6-12; transition from primary to permanent.
  • Permanent dentition consists of 32 teeth; mineralization begins at birth and continues through adolescence.