Examination Procedures Preclinic

Examination Procedures PreClinical Skills Reference Wilkins Ch 13

Mouth Mirrors
Has 3 parts  handle, shank, & working end
Surfaces
Plane (flat) may produce a double image
Concave- Magnifying
Front surface-eliminates “ghost image”
Handles
Thicker handles  comfortable grasp, greater control
Wider handles are useful for mobility determination

Purpose/Use
Indirect vision
Indirect illumination
Transillumination
Retraction
Grasp of Mirror
Modified pen grasp with finger rest on a tooth surface wherever possible to provide stability and control.

Retraction
Use a water based lubricant on dry or cracked lips & corners of mouth
Adjust the mirror position so that the angles of mouth are protected from undue pressure of the shank of the mirror
Insert & remove carefully to avoid hitting the teeth because this can be very disturbing to the client

Maintain Clear Vision
Warm mirror with water, rub along buccal mucosa to coat mirror with thin transparent film of saliva, & request the client to breather through their nose to prevent condensation of moisture on the mirror
Use detergents or other means for keeping a CLEAR surface while working in the client’s mouth
Discard scratched mirrors

Application of Air
Purpose-clear saliva & debris and/or dry the tooth surfaces
Improve & facilitate examination procedures  dry supragingival calculus to facilitate exploring & scaling; small deposits may be light in color & not visible until they are dried. Dried calculus appears chalky & presents contrast to tooth color.

AIR WATER SYRINGE - AIR

Purpose for AIR
Improve visibility of the treatment area during instrumentation  dry area for finger rest to provide stability during instrumentation; minimize appointment time; evaluate complete removal of supragingival calculus after instrumentation
Prepare teeth and/or gingiva for certain procedures  ex. Are to dry surfaces for application of caries-preventing agents; make impressions for study casts; apply topical anesthetic

Procedure for Use
Palm grasp about the handle of the syringe; place thumb on release lever or on button on handle
Test the air flow so that the strength of flow can be controlled
Make controlled, relatively short, gentle applications of air
Supplement air drying with use of saliva ejector & folded gauze sponge placed in vestibule

Precautions
Avoid sharp blasts of air on sensitive cervical areas of teeth or open carious lesions; such areas may be dried by blotting with a gauze or cotton roll to avoid causing discomfort
Avoid applying air directly into a pocket; subgingival biofilm may be forced into the tissues & may create a bacteremia
Avoid forceful application of air which can direct saliva & debris out of the oral cavity, contaminating the working area, clinician & create aerosols.
Air directed toward the posterior region of the client’s mouth may cause coughing/gagging
Avoid startling the client, forewarn when air is be applied

Probes

Guide
A pocket is a diseased gingival sulcus; the use of a probe is the only accurate, dependable method to locate, assess and measure sulci & pockets
Periodontal disease (gum disease) is one of the most pervasive dental diseases in older adults. It involves the loss of connective tissue attachment with subsequent destruction of tooth-supporting bone, leading to loss of teeth. At present there are no reliable clinical indicators of periodontal disease activity and the best available diagnostic aid, conventional periodontal probing, is only a retrospective analysis of attachment already lost. Subtraction radiography (x-rays) may be of value in detecting small changes in alveolar bone mineralization but does not evaluate periodontal ligament attachment. In addition, changes in bone have been shown to lag behind connective tissue loss by several months

Unlike the previous two mentioned, the Naber's probe is curved, and it is used for measuring into the furcation area between the roots of a tooth.

The Treatment of Gum Disease (Periodontitis)
The treatment of gum disease varies depending on the degree of involvement with the disease. The following is an overview of the treatment of gum disease:
a. What is normal? b. What is the appearance of gum disease? c. Non-surgical therapy. d. Surgical therapy.

What is Normal? (Healthy!)
Normal healthy gums are usually described as "coral pink" in color and usually fit to a nice sharp point as they approach the point where the teeth come together and contact.
The healthy gums have a "pebble grain" appearance which is called "stippling".
When gums become disease, they:
1. change in color from coral pink to a more reddish color
2. change in form from a nice sharp, tapered form into a rounded,swollen, less tapered form
3. lose their appearance of stippling and become shiny as well as reddened

The Cause of Gum Disease
When the gums are infected, they detach from the teeth and form the probing depths that are deeper than 3 millimeters.
The following case types will show probing being done and you will see the silver periodontal probe. Healthy gums look healthy and probing into the "sulcus" only goes to a depth of 1-3 millimeters.
Disease gums show changes in color, form and texture, and also show a probing depth deeper than 3 millimeters.

Healthy Gums You can see the "coral pink" color, the form where the gums fit into a nice sharp tapered point between the teeth and where the "stippling" exists.

Periodontal Probe This print shows the probe outside of the gum "sulcus" in order to show just how deep it would have gone (2-3 mm) in this healthy "sulcus"

What is the Appearance of Gum Disease?
Periodontitis (gum disease) looks different in different patient's mouths.
However, changes in color, form and texture are good visual clues to look for when you are looking for the presence of gum disease.
These next photos will show how a deep pocket may actually appear.

A Diseased Area (All diseased areas don't look the same) The gum tissue is slightly redder than normal and there are slight changes in the gum tissue form. There is some yellow pus on the gum margin where the periodontal probe will be inserted in the next photo.

Probe in the Pocket This print shows the probe in the pocket to a depth of 8 mm.

Probe Outside of the Pocket You can see how deep the probe did actually go into this disease pocket. This is approximately 8 millimeters and shows how much gum and bone destruction has occurred

Probing a 5 mm. Pocket (pre-treatment) Here you can see the silver periodontal probe which goes 5 mm. into the pocket.There is much bleeding and infection present.

ATER debridement …The gum tissues are pink in color and there has been some tissue shrinkage. The gums are healthier with a probing depth of 3 mm.

That's 192 measurements in a mouth with every tooth present!

Guide to Probing
Pocket is measured from the base of the pocket (top of attached periodontal tissue) to the gingival margin
Pocket or sulcus is continuous around the entire tooth & the entire pocket/sulcus must be measured. “SPOT” probing is inadequate.
The depth varies around an individuals tooth; probing depth rarely measures the same all around the tooth or even around 1 side of a tooth
Proximal surfaces must be approached by entering from both the facial & lingual aspects of the tooth

Anatomic features of the tooth-surface wall of the pocket influence the direction of probing
Examples are concave surfaces, anomalies, shape of the cervical third, and position of furcations
During the movement of the probe, calculus & tooth surface irregularities can be felt & evaluated

The general objective of probing are accuracy & consistency so that recordings are dependable for comparison with future probings as well as with colleagues in practice together; at the same time client discomfort & trauma to the tissues must be minimal

Probing is influenced by factors such as:
Severity & extent of periodontal disease
Normal healthy tissue; the probe is at the base of the sulcus or crevice, at the coronal end of the junctional epithelium
Gingivitis & early periodontitis. The probe tip is within the junctional epithelium
Advanced periodontitis. The probe tip penetrates through the junctional epithelium to reach attached connective tissue fibres

Probing Procedures
Insertion
Grasp probe with modified pen grasp
Establish the finger rest on a neighboring tooth, preferably in the same dental arch
Hold side of instrument tip flat against the tooth near the gingival margin
The cervical third of a primary tooth is more convex

Gently slide the tip under the gingival margin
Healthy of firm fibrotic tissue-insertion is more difficult because of the close adaptation of the tissue to the tooth surface; underlying gingival fibres are strong & tight
Spongy, soft tissue-gingival margin is loose & flabby because of the destruction of underlying gingival fibres. Probe inserts readily & bleeding can be expected on gentle probing

Advance probe to base of pocket…
Hold the probe tip flat against the tooth surface
Slide the probe along the tooth surface vertically down to the base of the sulcus or pocket
Maintain contact of the side of the tip of the probe with the tooth
Gingival pocket-side of probe is on enamel
Periodontal pocket-side of probe is on the cemental or dentinal surface when inserted to a level below the CEJ
As the probe is passed down the side of the tooth, roughness may be felt
When obstruction by calculus deposit is encountered, lift the probe away from the tooth & follow the edge of the calculus until the probe can move vertically into the pocket again

FIG 13-3 IN WILKINS
The base of the sulcus or pocket feels soft & elastic
Slight pressure, the tension of the attached periodontal tissue at the base of the pocket can be felt
Position the probe for reading-bring the probe to position as nearly parallel with the long axis of the tooth as possible for reading the depth
Interference of the contact area does not permit placing the probe parallel for the measurement directly beneath th contact area.
Hold the side of the shank of the probe against the conotact to minimize the angle. FIG 13-3 in WILKINS

READ THE PROBE
MEASUREMENT for a probing depth is made from the gingival margin to the attached periodontal tissue
Count the millimetres that show on the probe above the gingival margin & subtract the number from the total number of mm marked on the probe being used
When the gingival margin appears at the level between the probe marks, use the higher mark for the final reading
Dry the area being probed to improve visibility for specific reading

HOMEWORK
Read Wilkins
Make notes on Clinical Attachment Level, Mucogingival Examination, Periodontal Charting
Read Chapter 14-20
Make notes on Plaque Indices, biofilms, calculus & plaque
Read Chapter 26 and make notes on Interdental care

Examination Procedures Preclinic

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