Transcript Suggested Protocol

STAFF SCRIPTS FOR THE
FOUR FOOD GROUPS
The words just roll off my tongue!
Jenna R. Derango R.D.H.
When to approach the patient
Dr’s new exam patients
 New patients in hygiene
 Consult patients
 Patient checks
 Cleaning & Recall patients
 Restorative patients
 Esthetic patients

Dr’s New exam Patients


“Mrs. Jones, our exam today is going to be a lot
like you would have at your medical doctors in
that we will be discussing risk factors. Dental risk
factors are three main reasons or risks that could
cause you to lose or severely damage your teeth.”
“Mrs. Jones I know your main concern today is
that you have a broken tooth. When doctor comes
in he will be discussing with you dental risk
factors. Three of the risk factors are reasons you
could lose or break your teeth. So at the end of
your appointment you will have a pretty good idea
of the chances or odds you have of keeping the
rest of your teeth.”
New Patient in Hygiene
“Mrs. Jones before we start your cleaning I
would like to discuss with you what I will
be evaluating during your appointment.
The first thing I will be doing is an oral
cancer screening. Even patients who do
not smoke, drink, or chew tobacco can
acquire oral cancer. The other thing we
will be assessing is four dental risk
factors. Three of these risk factors could
cause you to lose or break your teeth.”
Consult Patients

“Today as we evaluate your concern
we will also make note of your
dental risk factors. In our office we
evaluate four dental categories.
Three of these categories could
cause you to lose or break your
teeth.”
Patient in office for a “check”


“Mrs. Jones, while that x-ray is being
developed I would like to review your four
dental risk factors. Three of these risks
could cause you to lose or break your
teeth.”
“Mrs. Jones, it appears that the large
filling in the tooth we x-rayed has broken.
Large fillings put your teeth at risk. If
you remember at your last cleaning your
hygienist discussed with you the dental
risk factors. Biomechanics or the
individual tooth structure is one of the
three reasons you could lose or break
your teeth.”
Cleaning and Recall Patients


“Mrs. Jones, as I’m cleaning your teeth I
will be discussing with you the dental risk
factors. Dental Risk factors, as you may
remember, are four categories that affect
treatment, three of the categories are
reasons you could lose or damage your
teeth.”
“Mrs. Jones, I notice you have several
large fillings. Did you know that because
of those fillings you are more at risk to
fracture, break, or lose those teeth. In
our office we evaluate dental risk factors.
Risk factors are reasons you could lose
your teeth.”
Restorative Patients


“Mrs. Jones, today Dr. will be removing decay
from your tooth and replacing it with a filling.
Caries is one of the categories of dental risk
factors. There are three main risk factors that
could cause you to lose or break your teeth.”
“Mrs. Jones, today we will be placing a permanent
crown on the tooth on the bottom right where you
had a large broken down filling. Although crowns
are stronger than fillings, because it is not a
completely natural tooth, it has the potential to
break in the future. Restored teeth, or the
structure of a tooth is one of your dental risk
factors. Risk factors are three main reasons you
could lose your teeth.”
Esthetics patients

“Mrs. Jones, today we will be
placing six veneers on your front
teeth. Although esthetics are
important, your mouth is like
building a house. You must have a
great foundation in order for the
house to be strong. In dentistry we
evaluate risk factors. These risk
factors allow us to evaluate the type
of foundation in your mouth.”
Risk Factors
“In each category of risk you will
be receiving a low, medium, or
high risk. Each risk is indicated
by a green, yellow, or red dot.
A low risk or green dot is the
best and indicates no
treatment necessary and a
state of health. A yellow dot is
usually a warning or a
moderate risk. With treatment
a moderate risk gives you a
fairly good potential to keep
your teeth. A high risk or red
dot, indicates that even with
treatment you could potentially
break or lose teeth. Things
can be done in most categories
to decrease your risk factors.
As I go through each category
I will describe these options to
you.”
For Example
“Think of the degrees of dental risk factors as a stop
light. Low risk is like going through a green light.
Chances are you will pass the intersection safely,
however, there is the slight chance someone could
come through the opposite light and cause an
accident. It is the same with your dental risks.
Although you may have a green dot or low risk it does
not mean you have no risk. LOW RISK DOESN”T
MEAN NO RISK. A yellow light or dot indicates some
caution is necessary. Most of the time you may be
safe running a yellow light, however, you are putting
yourself at a higher risk every time you attempt to run a
yellow light. Finally, running a red light or proceeding
with out treatment with a red dot immensely increases
your risk to lose or break your teeth.”
Periodontal Risk

“The first reason you could lose your
teeth is from periodontal disease. There
are many different factors that play a role
in periodontal disease. Patients with a
personal or family history of the disease
or another systemic disease along with
patients who smoke are at an increased
risk to developing the disease.”
What are pocket depths?

“At every hygiene
appointment, today included,
we will be checking your
pocket depths. Pocket depths
are natural occurring spaces
next to every tooth in your
mouth. This pocket can be
measured using a periodontal
probe. The probe is marked
off in sections by millimeters,
each indicating different levels
of health or disease.”
Does it hurt?
“Since the pocket already exists and
is a natural occurring space, most
patients just feel a slight amount of
pressure on their gums.
Occasionally patients with gum
irritation or gum disease may feel a
slight pinch with the pressure.”
Healthy Gums

Neck of Tooth
“This is a picture of a
normal healthy
mouth. Notice the
tissue is pink and
tightly bound to the
tooth. The bone is
very close to the neck
of the tooth. If you
were to brush and
floss there would be
very little to no
bleeding.”
Gingivitis

Neck of
Tooth
“In this picture you
can see right away the
red color to the tissue.
This indicates a
swelling of the gum
tissue. The
periodontal probe is
now indicating 4 or
5mms. Notice,
however, that the
bone is still close to
the neck of the tooth.”
How it happens & what to do about it
“Plaque and bacteria can become trapped underneath the
gums causing irritation. Your body responds by
sending blood into your tissue to try and remove the
plaque and bacteria for you. If you were to brush,
floss, or get your teeth cleaned your tissue would
bleed. The reason you are bleeding is not necessarily
because you are hurting your gums by being too
aggressive, but because they are not healthy. The
good news is, it can be easily healed. Proper brushing
and flossing for at least 10-14 days along with regular
cleanings can completely eliminate the irritation and
your gums will return to a state of health. When you
look at your gums later, or when we measure your
pockets at your next visit, we will not be able to tell
where the diseased areas were.”
For example…
“Think of it as a sliver in your finger.
Your bodies response is to swell up
around the sliver and try and work
it out of your system. Once the
sliver is removed you are unable to
tell where it was before and your
finger is completely healthy again.”
Periodontal disease
“The next
we begin
“Our
next thing
picture
to indicates
see is the aloss
of some
stage
of
of the
tissue and
bone.
periodontal
disease.
The
tissue
loss although
is on the
The
tissue,
inside
thenot
tooth,
not next
pink,towill
notnecessarily
on the outside
like
you
be as
red
would
with
recession.
as itsee
was
in the
last
Some
patients
can have
stage,
gingivitis.
periodontal disease and not
Sometimes the tissue
even know it because it
can almost appear
does not usually cause any
normal and healthy.”
pain.”
Advanced Periodontal Disease
“In this last picture we
see a very advanced
case of periodontal
disease. The tissue is
receded away from
the gums and the
pockets that remain
measure well over
5mm. The bone has
been lost as well,
leaving little to no
support for the
existing teeth. Teeth
maybe extremely
loose or even fall out.”
Radiograph importance
“The x-rays taken at your
appointment are used to help us
detect, diagnose, and monitor
periodontal disease. It is essential,
if gum problems exist that every
year we take new x-rays to monitor
your bone and periodontal health.”
Decreasing your Periodontal Risks

In order to decrease your risk of
developing periodontal disease:




Maintain good oral care by brushing a
minimal of twice daily, flossing nightly,
and using an antiseptic mouth rinse
(Listerine)
Return for regular cleaning visits
See your medical doctor regularly
Do not smoke
Biomechanical Risk

“The second risk factor is biomechanical.
The biomechanical category has two sub
categories: caries and structure.”
Caries
“Caries is another word for cavities or
tooth decay. If you have decay in
your mouth, your tooth is breaking
down. If left alone the bacteria
from the cavity can be spread to
other teeth or even other people by
sharing saliva. Eventually the tooth
maybe lost if the decay is not
treated in time.”
Pre-cavities

“There are also areas on your teeth called
decalcifications. These white areas can
be weak and turn into cavities or with the
help of fluoride, calcium, and phosphate
they can be made strong again.”
Detection of Caries
“In our office we use three
different methods to detect
and diagnose dental caries.
X-rays, an intra oral exam, and the
Diagnodent. The Diagnodent looks like a
pen with a red light as the ink. We hold the
instrument over your teeth and it gives us a
number reading 1-99. 99 being the most
likely chance you have a cavity and 1 as not
likely. Together using these three methods
we can accurately detect and diagnose
caries in very early stages.”
Decreasing your Caries Risk

In order to decrease your risk of
developing dental caries:




Maintain good oral care by brushing a minimal
of twice daily, flossing nightly, using an
antiseptic mouth rinse (Listerine), and an anticavity mouth rinse (ACT).
Return for regular cleanings
Limit the frequency you eat sugary foods or
using straws for sugary beverages.
Do not share food, beverages, or saliva with
someone that has the caries bacteria.
Structure
“The second sub category of Biomechanical
risk is structure. Structure deals with the
condition of the existing teeth. Teeth are
made up of different materials, one of
which is enamel. Enamel is the hardest
substance in the body. When enamel is
weakened by caries, although a filling or
dental restoration can restore the tooth,
some of the tooth’s strength is lost.”
Structure risks
“Patients with large
fillings or dental work on every tooth are at
a higher risk to potentially lose, break, or
form caries around their teeth. This is the
risk of the tooth because of the filling.
Although, your tooth may look fine today, it
always has the potential to break at any
time. That is the inherited nature of a
restored tooth.”
Breakdown process

“As we chew a lot of force is
generated upon our teeth. The
tooth has some flexibility to move in
and out to absorb the forces
whereas the filling will not move as
much. The constant pull in opposite
directions may cause either the
tooth or filling to break.”
For Example

“You may leave here today feeling
fine, having no problems with your
teeth, and we may not see anything
that looks suspicious, however, you
could being eating a piece of bread
later this afternoon and break any
of those teeth with large fillings in
them. Once again, that is because
those teeth are structurally
compromised.”
Decreasing your Structure Risks

In order to decrease your risk of
structurally compromised teeth:


Place crowns on teeth with large
fillings.
Replace broken or extremely
compromised teeth with implants.
Radiograph importance

“The x-rays taken at your
appointment are used to help
us detect and diagnose caries, as
well as, monitor your existing dental
work. It is essential for patients with
caries, or that have previously had
several teeth restored, to have new
x-rays taken every year to insure
that there are no new caries
beginning.”
Functional Risk

“The last category has a lot to do with
your jaw and how your teeth come
together. I will be looking for shifted or
worn teeth. Some patients can grind
their teeth and wear them away, yet,
others that do not clench or grind can
have wear as well. When a patient
speaks or chews their teeth can rub
together and wear away. I will also feel
your joint as you open and close and
check for popping or clicking in your jaw.”
Patient Questionnaire





Do you ever hear or feel your jaw
popping, clicking, or locking?
Do you clench or grind your teeth during
the day or at night?
Does your jaw become tired or fatigued
while chewing?
Do you ever have pain in your joint, ear,
or side of your face?
Have you noticed your teeth shifting,
moving or becoming worn?
Decreasing your Functional Risk

In order to decrease your functional
risk:



Avoid chewing gum or chewy foods
such as bagels.
Wear night guards when recommended
by your dentist.
Receive orthodontics or braces as
recommended by your dentist.
Dentofacial

“The last category I wish to speak
to you about is called dentofacial or
esthetics. Esthetics is another word
for the appearance of your teeth, or
how you think they look. Has there
ever been anything you have
wanted to change about your teeth
or anything you are unhappy with?”
Patient options




Invisalign
Whitening
Bonding
Veneers
Important things to Remember



If at any point during the risk factor
presentation a patient asks a
question…Answer it.
If teeth are missing, Ask if the
patient remembers how or why the
teeth were lost.
Show the patients corresponding
pictures to each category. Use the
intra-oral camera.
Breakdown of the Profile Stickers
After rating a patient low, med, high, a
brief note must be written to give further
detail.
Charting Abbreviation Key

Perio






PP1- Perio protocol 1
PP2- Perio protocol 2
PP3- Perio protocol 3
PP4a- Perio protocol 4a
PP4b- Perio protocol 4b
Stanke- Patient is alternating with the
periodontist. Note: Copy of x-rays and
pocket depths must be sent at the C/R.
Charting Abbreviation Key

Biomechanical: Caries




Fl2 @ q C/R- Patient must receive a
fluoride treatment at every cleaning
appointment regardless of recall
intervals.
CP1- Caries protocol 1
CP2- Caries protocol 2
CP3- Caries protocol 3
Charting Abbreviation Key

Biomechanical: Structure


MR- Patient with Mostly Restored teeth
IBD- Insurance Based Dentistry
Patient would like to replace old or
broken dental work slowly with
insurance. Note: In September the
hygienist and dentist should discuss
teeth to be done by end of the year.
Secretaries should have insurance
information ready before recall
appointment.
Charting Abbreviation Key

Functional
RR- Risk to Restorative
 Patients that are a risk to the dentist to
do restorative work. Such as patients
with:
Anterior open bite
CCP or dysfunction patients
Strong tongue and lips that would
interfere or slow the restorative
process.

Charting Abbreviation Key

Esthetics



A4- Any number and letter pairing
indicates the shade of a patients teeth.
LLL- Patient with a low lip line.
GUM- Patient with a gummy smile.
Classifying and Treatment of Patients


Guidelines to determine status of
risk
Guidelines for treatment of each
risk category
Classifying Low Risk Perio Patients
AAP Case Type 0
Clinical Definition
Gingival tissue is coral pink, firm and
resilient without evidence of inflammation,
bleeding or exudate. Gingival sulci 1-3 mm
without muco- gingival defects.
Periodontal Pockets
Junctional epithelium at or above CE
junction
Alveolar Bone Loss
None
Furcation Involvement
None
Tooth Mobility
None
Classifying Low Risk Perio Patients
AAP Case Type I
Clinical Definition
Inflammation of gingiva with hyperplasia,
edema, retractability and/or bleeding with
gentle probing
Color of gingiva is red to reddish blue
No exudate
Periodontal Pockets
Pockets or gingival pockets less than 4 mm
Alveolar Bone Loss
None
Furcation Involvement
None
Tooth Mobility
None
Classifying Low/ Moderate
Risk Perio Patients
AAP Case Type II
Clinical Definition
Periodontal Pockets
Alveolar Bone Loss
Furcation Involvement
Tooth Mobility
Progression of gingival inflammation into
alveolar bone crest and early bone loss,
resulting in moderate pocket formation.
Enlargement and loss of stippling of
gingiva. Moderate bleeding and slight
exudate.
Pocket depth 4-6mm
Color of gingiva is reddish-blue
Junctional epithelium apical to CE
junction, but above bulbous crestal alveolar
bone.
Supra bony pockets 4-6 mm.
Slight, usually up to 2 mm horizontal
patterns.
Grade I or II
Slight (Class I)
Classifying Moderate / High
Risk Perio Patients
AAP Case Type III
Clinical Definition
Periodontal Pockets
Alveolar Bone Loss
Furcation Involvement
Tooth Mobility
A more advanced state of periodontitis
with increased destruction of structures,
moderately deep pockets measuring 5-8
mm, moderate to severe bone loss
Gingival inflammation changes
Generalized exudate and generalized
moderate bleeding
Junctional epithelium apical to CE
junction, and apical to crest of alveolar
bone, supra bony and/or infra bony
periodontal pockets
Pocket depth 5-8mm
Moderate, 2-4 mm horizontal pattern
Grade II-IV
Moderate (Class II)
Classifying High Risk Perio Patients
AAP Case Type IV
Clinical Definition
Periodontal Pockets
Alveolar Bone Loss
Further progression of periodontitis with
severe destruction of periodontal
structures, increased pocket depth greater
than 7 mm, increased tooth mobility with
possible immediate tooth loss, gingival
inflammation, moderate bleeding and
moderate exudate
Junctional epithelium apical to CE
junctions and apical to crestal alveolar
bone, both supra and infra bony pockets
Advanced/Severe, > 4mm horizontal
pattern
Furcation Involvement
Grades II-III
Tooth Mobility
Moderate to severe (Class II or III)
Treatment of Periodontal Low Risk



Regular Cleaning and Recall: 6,9, or 12
month
Reinforce good oral home care
Continued periodontal probing at recall
appointments
Protocol 1 for Perio Treatment
Patient name:
Date:
Hygienist: Vicki / Jenna / Christina
Dr:
Derango / Mueller
A) Documentation




4 – 7 VBWS
Pano
FMX
Full Perio charting including mcj,
Recession, pus, and bleeding points
Visit
Date
1
2
3
4
4381
4381
Ins code
Fee
B) Diagnosis
AAP Type
Risk Factor
Prognosis
II
Moderate
Good
Date
Risk Factor
Prognosis
C) Surgery / Referral Option

No referral necessary
Date
Referral
D) Controlling Local Factor
1.
2.
Mechanical

6 unit full mouth prophy

Reinforced oral hygiene instructions,

Mechanical brush(sonicare)

Oral irrigators
Antimicrobial

Commercial Mouthwash

Chlorhexidine
F) Recall Frequency

4 Month recall 6 units
G) Evaluation

Full Perio Re-Evaluation every 16 months
(after 4th visit) At 4th visit renew all
documentation, review with patient at an 8
unit hygiene appointment



Stimudents
Proxy brush
Rubber tip
Date
Antimicrob
Ins code
Fee
Date
Ins code
Fee
4381
4910
$54
4381
4910
0120
$54
$18
4910
$54
Re-evaluation apt.
Date
Ins code
Fee
4910
$54
0120
$18
9999
$25
Re-eval
Re-eval
Re-eval
Protocol 2 for Perio Treatment
Patient name:
Date:
Hygienist: Vicki / Jenna / Christina
Dr:
Derango / Mueller
A) Documentation




4 – 7 VBWS
Pano
FMX
Full Perio charting including mcj,
Recession, pus, and bleeding points
B) Diagnosis
AAP Type
Risk Factor
Prognosis
II Early type III
Moderate
Good
C) Surgery / Referral Option
A. No referral necessary
Visit
Date
1
2
3
4
5
4381
4381
Ins code
Fee
Date
Risk
Prognosis
Date
Referral
D) Controlling Local Factor
1.
2.
Mechanical

6 unit full mouth prophy

Reinforced oral hygiene instructions,

Mechanical brushing

Oral irrigators

Antimicrobial

Commercial Mouthwash

Chlorhexidine

Atridox

Periochip
F) Recall Frequency

3 Month recall 6 units
G) Evaluation

Full Perio Re-Evaluation every 15 months
(after 5th visit) At 5th visit renew all
documentation, review with patient at an 8unit hygiene appointment. After hygiene a
separate Dr. Exam of 2 units.



Stimudents
Proxy brush
Rubber tip
Date
Antimicrob
Ins code
Fee
Date
Ins code
Fee
4381
4910
0120
54
18
4381
4910
54
4381
4910
0120
54
18
Re-evaluation apt
Date
Ins code
4910
9999
0150
Fee
$54
$20
$35
4910
54
eval
eval
eval
Protocol 3 for Perio Treatment
Patient name:
Date:
Hygienist: Vicki / Astrid /___________________
Dr:
Derango / Mueller
A) Documentation




4 – 7 VBWS
Pano
FMX
Full Perio charting including mcj,
Recession, pus, and bleeding points
B) Diagnosis
AAP Type
Risk Factor
Prognosis
Visit
Date
Ins code
Fee
1
2
3
4
5
4381
4381
Date
II III
Moderate
High
Good Fair
Risk
Prognosis
C) Surgery / Referral Option
Date

Recommended unless good prognosis
Referral
D) Controlling Local Factor
1.
2.
Mechanical

7 unit with deep cleaning 1 quad / visit

Reinforced oral hygiene instructions,

Mechanical brush

Oral irrigators
Antimicrobial

Commercial Mouthwash

Chlorhexidine

Atridox

Periochip
F) Recall Frequency

3 Month recall 7 units

S&R plane 1 quad/visit
G) Evaluation

Full Perio Re-Evaluation every 15 months
(after 5th visit) At 5th visit renew all
documentation, review with patient at an 8unit hygiene appointment. After hygiene a
separate Dr. Exam of 2 units.



Stimudents
Proxy brush
Rubber tips
Date
Antimicrob
Ins code
Fee
4381
4381
4381
Date
Quads
Ins
code
Fee
Re
4355
4341
0120
4355
4341
4355
4341
0120
4355
4341
Re
54
49
18
54
49
54
49
18
54
49
Re
Re-evaluation apt
Date
Ins code
Fee
4910
$54
9999
$20
0150
$35
Protocol 4 for Perio Treatment
Patient name:
Date:
Hygienist: Vicki / Jenna / Christina
Dr:
Derango / Mueller
A) Documentation




4 – 7 VBWS
Pano
FMX
Full Perio charting including mcj,
Recession, pus, and bleeding points
B) Diagnosis
AAP Type
Risk Factor
Prognosis
II III IV
Moderate
High
Good Fair Poor
C) Surgery / Referral Option

Recommended. Must sign release
unless AAP II with good prognosis
Visit
Date
Ins code
Fee
Antimicrobial

Commercial Mouthwash

Chlorhexidine

Atridox

Periochip

Perio Stat during 4 quads(active disease)
F) Sequence and Recall Frequency

3 Month recall from 1st
appointment in series
G) Evaluation

Re-evaluate at 1st 3 month recall for referral or
new protocol. Protocol 4 can only be used
once
2
3
4
5
4381
4381
Date
Risk
Prognosis
Date
Referral
D) Controlling Local Factor
1. Mechanical

7 unit scaling and root planning by quads
4 visits within a 6-8 week period

Reinforced oral hygiene instructions,

Mechanical brush

Oral irrigators
2.
1



Stimudents
Proxy brush
Rubber tip
Date
Antimicrob
Ins code
Fee
Date
Quads
Ins code
Fee
4381
4341
$125
Re-evaluation apt
Date
Ins code
4910
Fee
$54
4381
4341
$125
4381
4341
$125
4341
$125
Re-ev
Re-ev
Re-ev
Re-ev
Protocol 4B for Perio Treatment
Patient name:
Date:
Hygienist: Vicki / Jenna / Christina
Dr:
Derango / Mueller
A) Documentation




4 – 7 VBWS
Pano
FMX
Full Perio charting including mcj,
Recession, pus, and bleeding points
B) Diagnosis
AAP Type
Risk Factor
Prognosis
II III IV
Moderate
High
Good Fair Poor
C) Surgery / Referral Option

Recommended. Must sign release
unless AAP II with good prognosis
Visit
Date
Ins code
Fee
Antimicrobial

Commercial Mouthwash

Chlorhexidine

Atridox

Periochip

Perio Stat during 4 quads(active disease)
F) Sequence and Recall Frequency

3 Month recall from 1st
appointment in series
G) Evaluation

Re-evaluate at 1st 3 month recall for referral or
new protocol. Protocol 4 can only be used
once
2
3
4
5
4381
4381
Date
Risk
Prognosis
Date
Referral
D) Controlling Local Factor
1. Mechanical

8/9 unit scaling and root planning by
arches 2 visits within a 2-3 week period

Reinforced oral hygiene instructions,

Mechanical brush

Oral irrigators
2.
1



Stimudents
Proxy brush
Rubber tip
Date
Antimicrob
Ins code
Fee
Date
quads
Ins code
Fee
4381
4341
$65
Re-evaluation apt
Date
Ins code
4910
Fee
$54
4381
4341
$65
4381
4341
$65
4341
$65
Re-ev
Re-ev
Re-ev
Re-ev
Protocol 5 for Perio Treatment
Patient name:
Date:
Hygienist: Vicki / Jenna / Christina
Dr:
Derango / Mueller
A) Documentation




4 – 7 VBWS
Pano
FMX
Full Perio charting including mcj,
Recession, pus, and bleeding points
Visit
Date
Ins code
Fee
1
2
3
4
5
4381
4381
4381
6
B) Diagnosis
AAP Type
Risk Factor
Prognosis
III IV
Moderate
High
Fair Poor
Date
Risk
Prognosis
C) Surgery / Referral Option

Storngly Recommended.
Must sign release
Date
Referral
D) Controlling Local Factor
1.
2.
Mechanical

Protocol 2 or 3

Reinforced oral hygiene instructions,

Mechanical brush

Oral irrigator
Antimicrobial

Commercial Mouthwash

Chlorhexidine

Atridox

Periochip
F) Recall Frequency

Recall every 3 months

Protocol 2 or 3
G) Evaluation

Full Perio Re-Evaluation every 18 months
(after 6th visit) At 6th visit renew all
documentation, review with patient at an 8
unit hygiene appointment. After hygiene a
separate Dr. Exam of 2 units.



Stimudents
Proxy brush
Rubber tips
Date
Antimicrob
Ins code
Fee
4381
4381
Date
Quads
Ins code
Fee
4381
Eval
Eval
Eval
Re-evaluation apt
Date
Ins code
4910
9999
0150
Fee
$54
$20
$35
Points
Risk Factors
Number
Number
Number
Number
Number
Number
of
of
of
of
of
of
smooth surface lesions
occlusal lesions
recurrent decay
caries restored in the past year
rough white spot lesions
interproximal watches
_______ x 1.5
_______ x 1.0
_______ x 1.0
_______ x 1.0
_______ x 0.5
_______ x 0.5
Each of the following answers = 1 point
Caries restored in the past 3 years
Heavy plaque
Frequent sugary/starchy snacks
Saliva reducing facotors:
- Medications
- Head / Neck Radiation
- Systemic Disease
- Dry Mouth (other)
Occlusal or Diagnodent watches
Orthodontic appliances or partial dentures
Deep pits & fissures / developmental defects
Exposed root surfaces
Classifying and Treating Caries
Risk
Notes:
Notes:
Notes:
TOTAL
Protocol 1 (4-8 pts)
Oral Hygiene / Diet Review
Prevident Toothpaste
Spry Gum or Mints
Fee
Protocol 2 (9-12 pts)
Oral Hygiene / Diet Review
Prevident Toothpaste
Spry Gum or Mints
Chlorhexidine Mouth Rinse
Fluoride Tx @ q C/R
MI Prophy Paste & home usage
Fee
Protocol 3 (>12 pts)
Oral Hygiene / Diet Review
Prevident Toothpaste
Spry Gum or Mints
Chlorhexidine Mouth Rinse
Fluoride Tx @ q C/R
MI Prophy Paste & home usage
Fluoride Varnish 3x within 10days
GC Saliva Test
Bacterial Test @ 3 month recall
Fee
$
$
$
Treatment of Caries Low Risk



Regular Cleaning and Recall: 6,9,12
months
Review of Oral Hygiene
Radiographs as necessary
Caries Protocol Components







Oral Hygiene instruction / Plaque removal
Diet counseling and Saliva education
Restorations / Sealants
Anti-bacterial mouth rinse/Chlorhexidine
Xylitol Gum / Mints
Fluoride: Prevident / Fluoridex toothpaste
Duraphat / Cavity shield
MI Paste
DIET
Reducing the number of sugary and starchy
foods, snacks, drinks, or candies can help
reduce the development of tooth decay.
That does not mean you can never eat
these types of foods, but you should limit
their consumption particularly when eaten
between main meals. A good rule is three
meals per day and no more than three
snacks per day. It is also important to
note that eating small amounts of sugary
foods throughout the day is more likely to
cause decay than a large amount of
sugary snacks all at once.
SALIVA
Saliva is critical for controlling tooth decay. It neutralizes acids
and provides minerals and proteins that protect the teeth. If
you cannot brush after a meal or snack, you can chew some
sugar-free gum. This will stimulate the flow of saliva to help
neutralize acids and bring lost minerals back to the teeth.
Sugar-free candy or mints could also be used, but some of
these contain acids themselves. These acids will not cause
tooth decay, but they can slowly dissolve the enamel surface
over time (a process called erosion). Some sugar-free gums
are designed to help fight tooth decay and are particularly
useful if you have a dry mouth (many medications can cause
a dry mouth). Some gums contain baking soda, which
neutralizes the acids produced by the bacteria in plaque. Gum
that contains xylitol as its first listed ingredient is the gum of
choice. If you have a dry mouth, you could also fill a drinking
bottle with water and add a couple teaspoons of baking soda
for each 8 ounces of water and swish with it frequently
throughout the day. Toothpastes containing baking soda are
also available from several companies.
RESTORATIONS / SEALANTS
Restorative work includes any type of dental work that
reconstructs tooth structure after all the decay has been
eliminated. Fillings or crowns can come in composite,
porcelain, or metal material depended on what is needed
to completely return the function of your tooth. Sealants
are plastic coatings bonded to the biting surfaces of back
teeth to protect the deep grooves from decay. In some
people, the grooves on the surfaces of the teeth are too
narrow and deep to clean with a toothbrush, so they may
decay in spite of your best efforts. Sealants are an
excellent preventive measure for children and young
adults at risk for this type of decay.
Suggested Protocol: All decay must be removed before any
other treatment or preventative measures are taken.
Since decay is a bacterial process that is transmissible
complete elimination of the decay is necessary so new
decay is unable to form.
ANTI BACTERIAL MOUTH RINSE
Rinses that your dentist can prescribe are able to
reduce the number of bacteria that cause tooth
decay and can be useful in patients at high risk
for tooth decay. The reviewed literature showed
that chlorhexidine is effective in reducing the
incidence of dental caries in the populations
tested.
Suggested Protocol: After normal brushing and
flossing in the morning, pour some Chlorhexidine
in a cup. Dip your clean toothbrush into the
mouth rinse and briefly brush it around you
mouth. Then take the remaining mouth rinse left
in the cup and rinse for 30 seconds. Repeat daily
until the bottle is gone or as directed by your
dentist.
XYLITOL PRODUCTS
Xylitol is a sugar substitute with sweetness equal to that of table
sugar. Xylitol has a number of effects on S. mutans (bacteria
responsible for the decay process) that may account for some
of its clinical effects in caries reduction. Short-term
consumption of xylitol is associated with decreased S. mutans
levels in both saliva and plaque.5 Long-term habitual
consumption of xylitol appears to have a selective effect on S.
mutans, resulting in selection for populations less adherent to
tooth surfaces. These colonies, therefore, are shed more
easily from plaque into saliva.6 this effect may not only be
important to the individual’s decay experience, but may also
influence the transmission of S. mutans from mothers who
consume xylitol to their children.
Suggested Protocol: Xylitol comes in mint and gum form.
Chew or use saliva to dissolve two pieces of the product
three to five times daily.
FLUORIDES
Fluorides help make teeth more resistant to being dissolved by
bacterial acids. Fluorides are available from a variety of sources
such as drinking water, toothpaste, over-the-counter rinses, and
products prescribed by your dentist such as brush-on gels used at
home or gels and foams applied in the dental office. Daily use is
very important to help protect against the acid attacks.
Suggested Protocol: Prevident or Fluoridex toothpaste is to be
used nightly immediately before bed. Apply paste to a dry
toothbrush, brush as normal and spit. DO NOT rinse your mouth
with water. In order for the prescription fluoride to work at full
strength it is essential not to eat, drink, or rinse, your mouth for
30 minuets after use.
Suggested Protocol: Cavity Shield or Duraflor fluoride varnish can
be applied at home or n office. Both types must be applied to all
teeth three times within a 10 day period. Patients should not eat
or drink for an hour to an hour and a half after application.
MI PASTE
Casein Phosphopeptide (CPP) are natural occurring molecules
which are able to bind calcium and phosphate ions and
stabilize Amorphous Calcium Phosphate (ACP) Replaces
lost minerals, improves the protective qualities of saliva,
improves fluoride uptake, and soothes sensitive surfaces.
Strengthens tooth enamel, Reduce sensitivity, Buffer plaque
acid Prophy cup application , Custom tray application, athome follow-up applied daily MI Paste is indicated for
post-bleaching sensitivity, root planing and scaling, as well
as during prophylaxis.
Suggested Protocol: Apply a pea sized amount to the tip of
your finger. Use finger to rub on to the surfaces of your
teeth. Once the paste is gone from you finger, use your
tongue to rub paste across every tooth surface until it is
dissolved completely. Since the product is made
completely of animal products it is safe to swallow,
however, if you prefer you may spit the excess paste into
the sink. Do Not eat, drink, or rinse for 3 minuets after
using the paste. Apply 2-3 times daily.
Classifying Function
1.
2.
3.
4.
5.
Acceptable Function
Dysfunction
Constricted Chewing Pattern
Parafunction
Neurological disorders
Recognizing Acceptable function




Minimal to no signs or symptoms of
pain or joint problems
Physiological wear i.e.: diet or age
Pathological wear from chemical
erosion
Risk Category: LOW
Recognizing Dysfunction




Posterior interference or avoidance
Wear patterns on posterior teeth
Can not find their “Home” in chewing or
bite pattern
Risk Category:
MODERATE
HIGH
Recognizing Constricted Chewing
Patterns





Also called restricted envelope
Maxillary arch locks lower teeth
Anterior wear patterns
Wear on maxillary lingual and mandibular
facial
Usually minimal posterior wear
MODERATE

Risk Category:
HIGH
Recognizing Parafunction

Horizontal wear patterns-irregular and
advanced
Wear patterns on night guard match teeth
wear patterns
Sleep disturbances
Possible TMD

Risk Category:



HIGH
Recognizing Neurologic Function



Recognition by medical history
Due to disease
Ex: Epileptics
Drug induced
Ex: Ecstasy
Risk Category:
HIGH
Treating Acceptable Function

No treatment necessary
Treating Dysfunction


Joint position that allows teeth, muscles
and joint to work in harmony
Equilibration- bite adjustment


Helping patients find a “home” with equal
intensity and simultaneous bilateral contacts
Anterior Guidance- teeth the guide to
home that is not too steep nor too
shallow
Treating Constricted Chewing Patterns


Orthodontics- maxillary teeth out
and or mandibular teeth in
Open bite orthodontically or
restoratively
Treating Parafunction
Force management principleshallow guidance- no deep overbite
Treating Neurologic Disorders


No solution for patients with genetic
or systemic diseases
Replace or remove patient from the
drug inducing the functional
problem if possible