POHS II: Final Exam

Objectives:

• Pedo/Ado → 5

• Effective Communication → 9

• Home Care → 6

• Dentifrice/Mouth-rinse → 6

• Fixed/Removable Appliances → 5

• Instrument Sharpening → 6

• Advanced Periodontal Instrumentation → 4

• Power Scaling → 5

• Air-polishing → 6

• Professionalism → 8

Instrument Sharpening

Dull Vs Sharp Periodontal Instruments

List visual and tactile ways to test instruments for sharpness/dullness:

• Position the terminal shank:

  • Area-specific: slightly tilted away

  • Universal/scaler: perpendicular to the floor

• Motion:

  • up-and-down motion (end on a downward stroke)

  • Focus on the heel, middle, and toe (tip third)

• Pressure:

  • light to moderate

  • Listen for a “squeak”

  • 3–5 strokes

Check Your Work

• Test all thirds for a “bite”

List characteristics of each:

• Ceramic: Fine grit; maintains cutting edge

• Arkansas Stone: Moderately coarse; oil recommended; restores partially dull blades

• Carborundum Stone:  irregular particles that restore dull blades

• Diamond-Coated (Card/Steel): Most aggressive; for completely dull instruments

• automated sharpeners

Advanced Periodontal Instrumentation

Extended Gracey Curets:

After Five:

• Terminal shank 3 mm longer

• Blade 10% thinner

• Designed for pockets ≥ 5 mm

Mini Five Curettes

• Terminal shank 3 mm longer

• Blade 10% thinner

• Blade length 50% shorter

• Best for:

  • Deep pockets (≥ 5 mm)

  • Concavities

  • Longitudinal depressions

  • Furcations

Micro Mini 5

• 50% shorter

• 20% thinner

• 3mm longer and thicker

• APPLICATION SAME AS STANDARD GRACEY

Advanced Instrumentation:

Instrument	Primary Uses	Key Design Features	Stroke Style
Chisel Scaler	Anterior teeth with type III embrasures lingual calculus bridges	45° angle to the terminal shank	Facial-to-lingual push stroke
Hoe	large SUPRA-gingival calculus NOT for subgingival (gouging risk)	Straight edge 99°	Vertical pull stroke ONLY
Debridement Curette	Smoothing root surfaces removing residual deposits in deep pockets	1.5mm disc blade long shank (15mm)	Multidirectional strokes with feather-light pressure; push-pull motion
Periodontal Files	Crushing heavy or burnished calculus ultrasonics are contraindicated	Multiple cutting edges at 90° followed by a curette.	Moderate lateral pressure; pull stroke only
Finishing files	smooths amalgam, root surfaces and CEJ furications	no blade; paired end	multidirectional in push-pull motion
Vision Curvette	furcation deep anterior pocketing narrow root structure tight pocketing	blade 50% reduced 5mm, and 10mm in the terminal shank; X on the handle	same as Standard Gracey
Laser Therapy	Enhance pocket disinfection (bactericidal) promote wound healing control bleeding root debridement	Wavelength: 635–10,600 nm;	insert laser into pockets directed to soft tissue horizontal and vertical strokes water/HVE clears debris and fumes

Power Scaling

Power Vs. Traditional Instruments

Terms to Know:

• Dysphagia

  • difficulty swallowing

• acoustic turbulence    

  • agitation in the fluid surrounding the vibrating tip

• cavitation

  • creation and collapse of vapor-filled bubbles due to pressure variations

• oscillation

  • going back and forth between two positions

• lavage

  • washing of the pocket surface to remove endotoxins and loose debris

• transducer

  • device that converts energy from one form to another

• sonic scaler

  • Driven by compressed air with a handpiece attached to the dental unit tubing

• ultrasonic scaler

  • converts high-frequency electrical currents to mechanical vibrations

• magnetostrictive

  • generates a magnetic field and produces tip vibration by stack or rods

• stack

  • acts as an antenna to pick up the magnetic field and cause vibrations

• rod

  • ferromagnetic material with high magnetic permeability

• piezoelectric

  • activated by a change in the crystals in the handpiece

Sonic vs. Magnetostrictive vs Pizeoelectric

Oral Contraindication:

• Demineralized enamel

• Exposed dentin

• Restorations

• Titanium implants

• Primary teeth (large pulp chambers → increased sensitivity)

Systemic Contraindications:

• Communicable diseases: TB, COVID-19

• Immunocompromised patients: uncontrolled diabetes

• Respiratory conditions: COPD,  Asthma, Emphysema, Cystic fibrosis

• Dysphagia/gag reflex conditions: ALS, Parkinson’s, MS, stroke, and Pacemaker

Clinician/Patient PPE:

• Clinician:

  • level 3 mask

  • face shield

• Patient:

  • preprocedural rinse → 0.12% chlorhexidine

  • Apply Vaseline to the lips

Risk to Clinicians And/or Patients:

• hearing changes

• Vibration-related nerve sensitivity

• Overheating tip → thermal damage to pulp/gingiva

• Children are more sensitive to vibration

• Waterline contamination risk

Insert Types

Summary:

Condition / Deposit	Recommended Insert Tip(s)
Biofilm	Perio Thinsert and contra-angled
Heavy supra and sub Calculus / Heavy Stain	Universal, Triple Bend & Beavertail
Light/Moderate Calculus	Perio Thinset, Universal (supra) or contra angle (sub)
Furications and concavities	contra-angled and Furcation
Implants / Veneers	Implant
Developmental concavities	contra-angle and furcation

Air Polishing

Purpose & Key Features:

• Efficient removal of stains and biofilm

• Delivers slurry: air + water + powder

• Propels abrasive particles to tooth surface

Pressures:

• Air pressure: 40–100 PSI

• Water pressure: 20–60 PSI

Advantages:

• NO heat generation

• ergonomic

• Powders are less abrasive than polishing paste

Uses:

• Preferred for orthodontic appliances

• Acceptable before sealant placement

Powders

• Sodium Bicarbonate (SB)

  • Original powder: salty taste and may sting

  • Use: anatomical crown only

  • Compatible: amalgam, gold, porcelain; NOT for some restorations or root surfaces

  • Mohs hardness: 3.0 size: 74 µm

• Aluminum Trihydroxide

  • Alternative to SB

  • Use: anatomical crown only; not for restorations

  • Mohs: 4.0 size: 80 µm

• Calcium Carbonate

  • Main ingredient in antacid

  • Use: anatomical crown only; effect on restorations unknown

  • Mohs: 3.0 size: 45 µm

• Calcium Phosphosilicate

  • Bioactive glass — researchers warn against use (destructive to enamel/root)

  • Mohs: 6.0 size: 120 µm

• Glycine

  • Amino acid powder

  • Reduces abrasiveness to the root by ~80%

  • Use: supra- and subgingival; safe on all restorations

  • Also detoxifies the root surface

  • Mohs: 2.0 size: 20 µm

• Erythritol

  • Water-soluble polyol (sweetener)

  • Use: supra- and subgingival; safe on all restorations

  • Detoxifies the root surface

  • Mohs: <2.0 size: 14 µm

Oral Contraindications:

ALL:

• open wounds

• ≤3 mm supporting alveolar bone → risk of subcutaneous emphysema

  • Caused by angulation into sulcus

  • Symptoms: swelling, tenderness, crackling sensation, and extreme pain

  • Management: emergency treatment, observation, antibiotics, and analgesia

Prophy-jet Polishing:

• Root surfaces, Soft, spongy, or inflamed gingiva

Systemic Contraindications:

ALL:

• Communicable airborne diseases: cold, flu, and COVID.

• Respiratory disease or breathing disorders: asthma, COPD, cystic fibrosis, and pulmonary hypertension

• Very immunocompromised patients: AIDS, cancer treatment, uncontrolled diabetes, immunosuppressive meds, hemophilia, neutropenia, agranulocytosis

Prophy-Jet ONLY:

• End-stage renal disease, Addison’s disease, Cushing’s disease, metabolic alkalosis

• Patients on potassium, antidiuretics, or steroid therapy

Sodium Bicarbonate ONLY:

• sodium-restricted diet, high blood pressure, kidney disease, heart problems

Supragingival Use with Prophy-Jet

Preparations:

1. cup lips or cheek to control aerosols

Procedure:

• Nozzle 4–5 mm from the tooth

• Anterior teeth: 60° to the facial/surfaces

• Posterior teeth: 80° to buccal surfaces

• Occlusal surfaces: 90° to occlusal surfaces

Method:

• constant circular motion

• 1-2 seconds per tooth

• rise and floss

Supragingival with Airflow

Procedure:

• Nozzle 2–5 mm from tooth

  • heavier → closer

  • far → aerosol

• Angulation: use between 15°–80° (avoid 90°)

method:

• constant circular motion

• 1-2 seconds per tooth

• rinse and floss

Subgingival with Air-Flow

Procedure:

• Insert inactive tip until contact with JE, withdraw 1 mm coronally (away from base)

• Activate for 5 seconds with overlapping vertical strokes

Note:

• FDA: approved for pockets ≤5 mm (Canada: ≤10 mm)

• tip directs to root surface, NOT base of pocket

Professionalism:

Function of Mid-level Providers:

Purpose:

• bridge the gap to care

• expand functions:

  • caries removal

  • place composites and amalgam

  • place space maintainers

  • Fabricate a stainless steel and a temporary crown

  • pulpotomies and pulp vitality testing

  • Extract erupted primary teeth

Core values

• autonomy

  • respect for persons ability to make a choice

• confidentiality

  • protect privileged communication

• societal trust

  • bond between DH, patients, professionals, and the public

• non-maleficience

  • avoidance of harm to others

• beneficence

  • act of doing good

• justice/fairness

  • fair treatment

• veracity

  • tell the truth when information is disclosed to patients

Process of Care:

• assess:

  • collect subjective/objective data

• diagnose:

  • critical thinking to interpret data

• plan:

  • strategies that meet patient needs

• implement:

  • activation of care plan

• evaluation:

  • determines patient needs to be retreated, referred, or placed on a continuing care schedule

• documentation:

  • details of assessment data, diagnosis, care plan, treatments, patient education, and evaluation

Services

• primary prevention: → reverse progression of disease BEFORE it begins

  • oral evaluation

  • prophylaxis

  • sealants

  • fluoride as a preventative agent

  • health education/promotion

• secondary treatment → treat early disease

  • restoration

  • endodontics

  • fluoride and sealants on incipient caries

• tertiary treatment: → replace lost structure

  • prosthodontics

  • implant

  • oromaxillofacial surgery

• educational: → promotes change in individuals

  • link oral to systemic health

  • creates partnership

• therapeutic: → arrest and control disease AFTER it exists

  • periodontal debridement (scaling)

Roles

• Clinician: This role involves providing direct patient care through clinical services. Examples include working in private practice, dental specialties (like orthodontics or pedodontics), and hospitals.

• Public Health: These professionals focus on enhancing access to care within the community, often in programs funded by governments or non-profits. Work settings include community clinics, schools, and the armed forces.

• Corporate: This role centers on the promotion of product development and services. Examples include product sales or acting as a corporate educator.

• Researcher: Researchers conduct studies to test new products, procedures, and theories. They typically work for universities, corporations, or government agencies.

• Educator: Educators use educational theory and methodologies to train oral healthcare professionals. They may work in traditional clinical education, continuing education, or corporate education.

• Administrator: This role involves applying organizational skills to manage resources and evaluate programs. An example is a program director in a clinical, educational, or corporate setting.

• Entrepreneur: Entrepreneurs initiate new oral health-related enterprises. Their work can include practice management, consulting, developing new products, or being a professional speaker.

Level of Supervision

• Direct Supervision: dentist is required to be physically present while procedures are performed

• Personal Supervision: dentist authorizes procedure, present, and check the work before patient is dismissed

• General Supervision: dentist authorize procedure for patient, but they do not need to be present when hygienist carries out work

• Direct Access Supervision: hygienist provides services without specific authorization

  • limited to preventative services provided in public health or alternative practice settings, such as schools, nursing home facilities, or free clinics

• Collaborative Supervision: Services are provided without supervision, but works in collaboration with dentist

• Remote Supervision: dentist supervises work through use of technologies, such as tele-dentistry

• Independent Practice: practice without any authorization from a dentist

Effective Communication, Interviewing and Counseling:

Terms:

• Health Literacy: Ability of a patient to understand and respond to health info and make decisions

  • Personal: ability to make health-related decisions

  

  • Organizational: ability of organizations in finding and using health information

• Feedback: receiver’s direct response to a message

• Affirmation: to validate a patient’s effort toward change

• Ambivalence: conflict feelings towards making a change

• Elicit: to draw forth or bring out

• Evocation: Drawing out thoughts through open-ended questions

• Active listening: being fully engaged and demonstrating that you are listening

• Reflective listening: responding with a summary or statement that shows understanding (not just repeating words)

• Preventative counseling: guidance to help patients improve oral health using motivational interviewing

• Sustain talk: patients argument for not changing

• Change talk: Patients self-expressed arguments for change

• Social Determinants of Health: conditions in which people are born, grow, live, work, play and age

Encode Vs Decode

• Encode – communicators’ translation of thought into words, gestures, or signs

• Decode – receiver’s ability to take in words to recreate encoded thought

Foundations of Communication

Types of Communication

• Verbal: based on language and words

  • Verbal/vocal – spoken language

  

  • Verbal/non-vocals – signs or signals: writing, braille, sign language

Nonverbal: based on characteristics of language

• Nonverbal/vocal

  • qualifiers: volume, pitch, tempo, cadence

  • characteristics: crying, laughing

• Nonverbal/non-vocal

  • body language, movement of body and eyes, facial expressions

Barriers to Communication:

• Dysarthria – a motor disorder that paralyzes muscles of the face, mouth, larynx, and vocal cords

  • resulting in slurred, difficult-to-understand speech

• Aphasia – loss of power of expression and comprehension of language

• Physical barrier – noise levels, not positioned face-to-face

• Physiological barrier – inability to see, hear, touch, or vocalize to communicate

• Psychosociological barrier – emotional factors, pain, or fear

Motivational Interviewing

Purpose: A tool used to elicit and strengthen patient motivation for positive behavior change

Core Processes

• Engaging

  • connection and working relationship

• Focusing

  • direction about change

• Evoking

  • eliciting movitation for change

• Planning

  • commitment to a plan of action

Spirit of MI – PACE

• Partnership

  • Create a positive, non-intimidating environment

  • Listen more → talk less

• Acceptance

  • Absolute Worth: respect the patient as a human being

  • Accurate Empathy: understand the patient’s perspective

  • Autonomy Support: respect patient choice

  • Affirmation: encourage hope and belief in change

• Compassion

  • Prioritize patient needs over clinician's agenda

  • Builds trust

• Evocation

  • Draw out patient strengths, thoughts, and ideas

  • Build on what the patient shares

Guiding Principles – RULE

• Resist the Righting Reflex

  • Avoid the urge to “fix” the patient

• Understand the Patient’s Motivation

  • Identify their reasons for change

• Listen to the Patient

  • Practice active listening

• Empower the Patient

  • Support autonomy

  • Outcomes improve with patient involvement

Core Skills – OARS

• Open ended questions

• Affirmations

  • validate efforts

• Reflective listening

• Summary

Assess Commitment to Change

Low-Level:

• I’ll think about it

• I’ll consider it

• I plan to

• I hope to

• I’ll try to

High-Level:

• I will

• I am ready

• I promise

• I intend to

Dentifrice and Mouth-washing

Active Ingredients:

1. Cavity Protection and Remineralization:

• prevents caries and ↑ remineralization

• Fluorides: sodium fluoride, stannous fluoride, sodium monofluorophosphate

• Others: xylitol, ACP, CPP-ACP

2. Biofilm and Gingivitis Reduction:

• ↓ inflammation and bleeding

• Ingredients: Stannous fluoride and zinc citrate

3. Sensitivity Protection:

• occludes dentin tubules and block nerves

• Potassium: 5% Potassium nitrate, potassium citrate, potassium chloride

• Others: stannous fluoride, strontium chloride, strontium acetate, arginine calcium carbonate, novamin

4. tartar control:

• ↓ supragingival calculus

• Pyrophosphate: pyrophosphate, sodium hexametaphosphate, tetrapotassium pyrophosphate

• Others: zinc chloride, zinc citrate, tetrasodium

5. malodor control:

• ↓ VSCs

• Ingredients: essential oils, chlorine dioxide, cetylpyridinium chloride, sodium hexametaphosphate, stannous fluoride

6. Stain Reduction/Whitening:

• ↑ whitening effect, ↓ stain embedded in acquired pellicle

• Phosphate: tetrasodium pyrophosphate, sodium tripolyphosphate, sodium hexametaphosphate

• Peroxide: hydrogen peroxide, carbamide peroxide

Inactive Ingredient:

• Detergent (surfactant): foam and cleanse

  • sodium lauryl sulfate

  • sodium N-lauryl sarcosinate

• Abrasive: clean and polish

  • silica and silicate

  • calcium carbonate

  • calcium pyrophosphate

  • aluminum oxide

  • bicarbonate

• Binder: thickener/stabilizer

  • mineral/seaweed colloid

  • xanthan gum

  • carrageenan

  • synthetic cellulose

• Humectant: moisture stabilizer

  • glycerol

  • sorbitol

  • synthetic cellulous

  • vegetable oils

• Preservation: prevent bacterial growth

  • alcohol

  • benzoates

  • dichlorinated phenols

• Flavoring: sweeteners

  • essential oils (peppermint, cinnamon, wintergreen, clove)

  • artificial non-cariogenic (xylitol, glycerol, sorbitol)

Mouth-rinse Active Ingredients:

• sodium fluoride:

  • ↓ demin

  • ↑ hypersensitivity

• stannous fluoride: taste alternation, may stain

  • ↓ demin, hypersensitivity

  • ↑ remin, staining

• chlorehexidine

  • ↓ biofilm, gingivitis

  • 8-12 hr substantibity

  • ↑ supragingival calculus

  • DO NOT USE AFTER BRUSHING WITH SLS

• cetylpyridinium

  • 0.05-0.07% OTC rinse

  • burning sensation

  • tissue sloughing

• sanguinarine

  • risk of oral leukoplakia

  • potential carcinogen

• phenolic related essential oils

  • contradicted for recovering alcoholics

  • burning sensation

• oxygenating agents

  • reduce NUG/NUP

• oxidizing agents

  • reduction of malodor

  • short term

Case Studies

Case Study 1:

1. Mrs. Thomas ASA Classification is…

a. I

b. II

c. III

d. IV

ANSWER: gen. healthy but smoker → mild systemic disease

2. Sign language is a form of __ communication

a. nonverbal, non-vocal

b. nonverbal, vocal

c. verbal, non-vocal

d. verbal, vocal

ANSWER: verbal → communication; non-vocal → no noise

3. What explains absence upon bleeding?

a. mid biofilm induced gingivitis, does NOT bleed

b. healthy with no signs of disease in oral cavity

c. blood vessels have been constricted by smoking cigarettes

d. early stages of periodontal disease does not bleed, only moderate and severe forms bleed

ANSWER: nicotine causes vasoconstriction in gum tissues, supressing blood flow

4. Which clinical service includes providing education on importance of routine dental care and smoking cessation?

a. educational

b. therapeutic

c. preventative (primary)

d. preventative (secondary)

ANSWER: education is to make positive changes in patients (via dental care and smoking cession to improve health; preventative is to arrest diseases BEFORE it occurs.

5. Which instrument would remove subgingival calculus?

a. air-polish with sodium bicarbonate

b. cavitron with universal and slime line insert

c. chisel slacer around mand. anterior teeth

d. detect with 11/12 exploerer

e. scale with gracey 11/12 and 13/14

6. __ from cavitron will scatter calculus from surface of the tooth

a. acoustic turbulence

b. cavitation

c. irrigation

d. mechanical vibration

ANSWER: cavitrons functions to convert electrical frequency to mechanical vibrations

7. Which statement is FALSE regarding use of cavitron?

a. start at base of pocket

b. use slow to medium stroke

c. light tapping motion on larger deposit

d. explore and follow up with hand-instruments after use

ANSWER:

8. What is the BEST choice for polishing the stains Mrs. Thomas teeth?

a. air polisher with calcium sodium phosphosilicate

b. air polisher with sodium bicarbonate powder

c. cleaning paste with the RDH handpiece

d. coarse polishing paste with the RDH handpiece

ANSWER: by process of elimination, calcium phosphosilicate is destructive to enamel; handpiecings arent desidgned to remove stains, polishing paste can be abrasive compared to air polishing (function to remove biofilm and staining)

9. What is the BEST dentrifice to help her control supragingival calculus formation?

a. potassium nitrate

b. sodium hexametaphosphate

c. sodium fluoride

d. stannous fluoride

ANSWER: tartar control functions to reduce supragingival calculus; sodium hexametaphospahte is an ingredient under such

10. A humectant in the dentifrice you choose:

a. moisture stabilizer

b. polishing agent

c. thickener

d. lowers surface tension