DentAl Algorithms
Dentistry and Oral Medicine

Indices for Evaluating Dental Health Status
01.01 Calculus Surface Index
01...
09.01 Risk Factors for Caries Development
09.02 Severity Grades of Root Surface Caries
09.03 Root Caries Index (RCI) of Ka...
• Each surface with calculus is scored 1 point.

calculus surface index =
= SUM(calculus points on the 16 surfaces surveye...
no signs of periodontal disease                      0

Treatment recommendation
• maximum score 0: no need for additional...
= (number of interdental spaces that bled) / (number of interdental spaces studied)

Interpretation
• minimum score: 0
• m...
• not scoreable: X

  Interproximal Areas of          Code        Code       Interproximal Areas of
     Maxillary Teeth  ...
The gingival bone count is a composite score based on the gingival condition and degree
of bone loss affecting a person's ...
The Navy Plaque Index (NPI) was developed as part of the Navy Periodontal Screening
Examination, along with the Navy Perio...
tooth score =
= (facial points) + (lingual points)

NPI score =
= MAX(all 6 tooth scores)

NPI total =
= SUM(all 6 tooth s...
Gingival Score

Each tooth is examined for evidence of inflammatory change, which constitutes one or
more of the following...
Interpretation
• minimum tooth score: 0
• maximum tooth score: 10
• minimum NPDI score: 0
• maximum NPDI score: 10
• minim...
tooth surface, AND/OR the presence of extrinsic
stain without other debris regardless of surface area
covered
soft debris ...
09.01.09 Periodontitis Severity Index

Overview:
The Periodontitis Severity Index (PSI) was developed to assess the severi...
periodontal severity index (PSI) =
= (clinical inflammation score) * (bone loss score)

mean periodontal severity index =
...
• a pocket deeper than 5 mm mesially to the central incisors is not scored as C, if it is the
    only C pocket in that qu...
Modified Plaque Scoring System of Turesky et al                     Score
no plaque                                       ...
the "PM Index", but the name was changed to prevent confusion with the "PMA
Index".

Number of teeth examined: 16 (the ant...
Engelberger T, Hefti A, et al. Correlations among papilla bleeding index, other
   clinical indices and histologically det...
Average Gingival Index     Interpretation
         2.1 - 3.0           severe inflammation
         1.1 - 2.0           mo...
circumscribes the tooth, but there is
 no apparent break in the epithelial
 attachment)
 (not used in field study)        ...
02.01 Jaw Symptom Questionnaire for Evaluating Patients with
    Temporomandibular Joint Disorders

Overview:
A Jaw Sympto...
(5) Is your bite uncomfortable?

Patient Responses
• no (score = 0)
• maybe a little (score = 1)
• quite a lot (score = 2)...
(4) jaw opening
(5) sleeping
(6) chewing
(7) swallowing
(8) talking
(9) pushing and pulling
(10) resting
(11) driving
(12)...
Periodontal osseous resective surgery should be delayed or not performed in certain
clinical situations. Surgery usually c...
• granulation tissue: present
• incision margin: not epithelialized, with connective tissue exposed

Healing Index 3: Good...
Traumatic deviations include:
• loss of premaxilla segment due to burns or by accident
• effects of extensive osteomyeliti...
Overview:
The evaluation and management of severe malocclussion is difficult and expensive.
Patients must demonstrate medi...
• 5B: This is recorded with the patient's teeth in centric occlusion and measured
    from the labial portion of the lower...
(c) date of onset of the illness or condition, and etiology if known
(d) clinical significance or functional impairment ca...
Pre-normal or post-normal occlusions with no other anomalies. Includes up to half a
   unit discrepancy.

                ...
Increased overjet > 9 mm

Extensive hypodontia with restorative implications (more than 1 tooth missing in
   any quadrant...
anterior irregularity in maxilla      largest irregularity in mm                 1
anterior irregularity in mandible     l...
Usually diagrams are from the examiner's perspective
• The rightmost position is the patient's final left molar.
• The lef...
left maxillary lateral incisor           10        +2        22          2
left maxillary medial incisor             9    ...
Overview:
Facial asymmetry involving the maxilla and mandible may be congenital or
acquired. The type of asymmetry determi...
C                                         yes                   yes
(after Table page 351)

The specifics for the techniqu...
Overview:
Xerostomia refers to a dry mouth caused by a decreased salivary gland flow in a
patient with adequate hydration....
medications                   none                      medications with saliva
                                          ...
Overview:
Caries on the dental root involve destruction of the cementum and penetration of
the dentine. They can be graded...
root caries index =
= ((number of teeth showing gingival recession with decay) + (number of teeth
showing gingival recessi...
Kitamura M, Kiyak HA, Mulligan K. Predictors of root caries in the elderly in the
   elderly. Community Dental Oral Epidem...
marked                                         2

Systemic factors
• history of seizure disorders
• psychiatric diagnoses
...
Overview:
The probability of successfully restoring a positive overjet in a child or adolescent
with unilateral cleft lip ...
50%                    1.8333
                                 75%                    0.8333
                             ...
(2) clinical features (C)
(3) pathologic features on biopsy (P)

Parameter                    Finding                     ...
Findings                          Stage
no lesion                           0
any L, C1, P1 or P2                 1
any L,...
Limitations
• Other leukoplakic lesions may clinically mimic oral hairy leukoplakia.
• Histologic features like hyperkerat...
In addition, the anterior nasopharynx is examined.

 Parameter                          Finding                 Points
 na...
The Geriatric Oral Health Assessment Index is a self-reported, screening
instrument for identifying problems with oral hea...
• Factors associated with lower scores include having fewer teeth, wearing a
    removable denture, and perceiving the nee...
/~landon/TeleDentAL/Dentistry and Oral Medicine.DOC
/~landon/TeleDentAL/Dentistry and Oral Medicine.DOC
/~landon/TeleDentAL/Dentistry and Oral Medicine.DOC
/~landon/TeleDentAL/Dentistry and Oral Medicine.DOC
/~landon/TeleDentAL/Dentistry and Oral Medicine.DOC
/~landon/TeleDentAL/Dentistry and Oral Medicine.DOC
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  1. 1. DentAl Algorithms Dentistry and Oral Medicine Indices for Evaluating Dental Health Status 01.01 Calculus Surface Index 01.02 Community Periodontal Index of Treatment Needs (CPITN) 01.03 Eastman Interdental Bleeding Index 01.04 Gingival Bleeding Index of Carter and Barnes 01.05 Gingival Bone Count 01.06 Navy Plaque Index 01.07 Navy Periodontal Disease Index 01.08 Oral Hygiene Index 01.09 Periodontitis Severity Index 01.10 Periodontal Treatment Need System (PTNS) 01.11 Quigley and Hein's Plaque Index, as Modified by Turesky et al 01.12 Sulcus Bleeding Index 01.13 Gingival Index of Loe and Silness 01.14 Periodontal Index of Russell Temporomandibular Joint (TMJ) Disorders 02.01 Jaw Symptom Questionnaire for Evaluating Patients with Temporomandibular Joint Disorders 02.02 Activity Limitation Scale for Patients with Temporomandibular Joint Disorders Periodontal Surgical Therapy 03.01 Contraindications to Performing Periodontal Osseous Resective Surgery 03.02 Healing Index of Landry, Turnbull and Howley Evaluation of Malocclusion and Need for Orthodontic Treatment 04.01 Handicapping Labio-Lingual Deviation (HLD) Index 04.02 The California Modification of the Handicapping Labiolingual Deviation [HLD(CalMod)] Index 04.03 The Index of Orthodontic Treatment Need (IOTN) 04.04 The Dental Aesthetic Index (DAI) 05 Systems for Dental Notation 06 Using a Simple Classification System in Planning the Surgical Management of Maxillomandibular Asymmetry Cephalometric Analysis 07.01 Diagnosis of the Long Face Syndrome 08 Xerostomia (Dry Mouth) 09 Cariology
  2. 2. 09.01 Risk Factors for Caries Development 09.02 Severity Grades of Root Surface Caries 09.03 Root Caries Index (RCI) of Katz 09.04 Risk Factors for Root Caries in the Elderly 10 Mandibular Fracture Score Cleft Lip and Palate 11.01 Estimation of the Possibility to Restore a Positive Overjet in Patients with Unilateral Cleft Lip and Palate Oral Leukoplakia 12.01 LCP Classification and Staging System for Oral Leukoplakia 12.02 Criteria for the Diagnosis of Oral Hairy Leukoplakia Assessment of the Tonsils and Adenoids 13.01 Estimating Adenoidal Obstruction of the Nasopharyngeal Airway in Children Dental Health Surveys 14.01 The Geriatric Oral Health Assessment Index (GOHAI) 14.02 The Child Dental Neglect Scale 14.03 Importance of Dental Behaviors Questionnaire Halitosis and Oral Malodor 15.01 Clinical Evaluation of Halitosis 16 Differential Diagnosis of Tooth Discoloration Tongue Size and Macroglossia 17.01 Identification of Pseudomacroglossia 17.02 Clinical and Cephalometric Features of Macroglossia 18 Measurements of Mouth Opening Indices for Evaluating Dental Health Status 01.01 Calculus Surface Index Overview: The Calculus Surface Index is a measure of dental calculus formation. It can be used to quantitate the accumulation of dental calculus in short-term testing programs to evaluate the effectiveness of preventive care. Method • Each of the 4 mandibular incisors is assessed on 4 surfaces (one labial, one lingual and two proximal).
  3. 3. • Each surface with calculus is scored 1 point. calculus surface index = = SUM(calculus points on the 16 surfaces surveyed) Interpretation • minimum score: 0 • maximum score: 16 References: Ennever J, Sturzenberger OP, Radike AW. The calculus surface index method for scoring clinical calculus studies. J Periodontol. 1961; 32: 54-57. 01.02 Community Periodontal Index of Treatment Needs (CPITN) Overview: The Community Periodontal Index of Treatment Needs (CPITN) is an epidemiologic tool developed by the World Health Organization (WHO) for the evaluation of periodontal disease in population surveys. It can be used to recommend the kind of treatment needed to prevent periodontal disease. Teeth examined: 2 methods of selection (1) sextants: 14 teeth on the maxilla and 14 teeth on the mandible, divided into 3 segments on each • FDI notation maxilla: (1) 17, 16, 15, 14; (2) 13, 12, 11, 21, 22, 23; (3) 24, 25, 26, 27 • FDI notation mandible: (4) 47, 46, 45, 44; (5) 43, 42, 41, 31, 32, 33; (6) 34, 35, 36, 37 • third molars are not used unless they function in place of the second molars (2) use of index teeth: 5 teeth on the maxilla and 5 teeth on the mandible • FDI notation maxilla: (1) 17, 16; (2) 11; (3) 26, 27 • FDI notation mandible: (4) 47, 46; (5) 31; (6) 36, 37 Dental evaluation (1) A special probe is used to to evaluate the depth of the dental sulcus. (2) The teeth are examined for supragingival or subgingival calculus. (3) Any bleeding after gentle probing is noted. Evaluation • The worst finding in each sextant is coded according to the table below.. • The maximum code for the entire mouth is used for the treatment recommendation. Findings Code pathologic pockets >= 6 mm deep 4 pathologic pockets 4-5 mm deep 3 supragingival or subgingival calculus 2 gingival bleeding after gentle probing 1
  4. 4. no signs of periodontal disease 0 Treatment recommendation • maximum score 0: no need for additional treatment • maximum score 1: need to improve personal oral hygiene • maximum score 2: need for professional cleaning of teeth, plus improvement in personal oral hygiene • maximum score 3: need for professional cleaning of teeth, plus improvement in personal oral hygiene • maximum score 4: need for more complex treatment to remove infected tissue References: Ainamo J, Barmes D, et al. Development of the World Health Organization (WHO) Community Periodontal Index of Treatment Needs (CPITN). International Dental Jounral. 1982; 32: 281-291. Ainamo J, Parviainen K, Murtomaa H. Reliability of the CPITN in the epidemiological assessment of periodontal treatment needs at 13-15 years of age. International Dental Journal. 1984; 34: 214-218. Cutress TW, Hunter PBV, Hoskins DIH. Comparison of the Periodontal Index (PI) and Community Periodontal Index of Treatment Needs (CPITN). Community Dental Oral Epidemiol. 1986; 14: 39-42. Gaengler P, Goebel G, et al. Assessment of periodontal disease and dental caries in a population survey using the CPITN, GPM/T and DMF/T indices. Community Dent Oral Epidemiol. 1988; 16: 236-239. Lewis JM, Morgan MV, Wright FAC. The validity of the CPITN scoring and presentation method for measuring periodontal conditions. J Clin Periodontol. 1994; 21: 1-6. 01.03 Eastman Interdental Bleeding Index Overview: Gingival bleeding after a defined method of interproximal stimulation is a valid indicator for the presence of inflammation in the midinterproximal gingival tissues. The interdental bleeding index is a simple procedure for monitoring the gingival health of a patient. It can be used by patients to monitor their own gingival status between visits to the dentist. Procedure (as devised at the Eastman Dental Center in Rochester, New York): (1) A wooden interdental cleaner is inserted between the teeth from the facial aspect. (2) The path of insertion is horizontal, with care taken not to direct the point of the cleaner apically. (3) The cleaner is used to depress the interdental papilla 1-2 mm, then removed. (4) The process is repeated until the interdental cleaner has been inserted and removed a total of 4 times. (5) The presence or absence of bleeding within 15 seconds is then recorded. interdental index =
  5. 5. = (number of interdental spaces that bled) / (number of interdental spaces studied) Interpretation • minimum score: 0 • maximum score: 1.00 • The higher the value, the greater the extent of gingivitis. References: Caton JG, Polson AM. The interdental bleeding index: A simplified procedure for monitoring gingival health. Compendium Contin Educ Dent. 1985; 6: 88-92. Caton J, Polson A, et al. Associations between bleeding and visual signs of interdental gingival inflammation. J Periodontol. 1988; 59: 722-727. 01.04 Gingival Bleeding Index of Carter and Barnes Overview: The Gingival Bleeding Index is a measure of gingivitis as indicated by bleeding following dental flossing. It can be used either for initial patient evaluation or over time to assess response to interventions to improve periodontal health. Procedure • The mouth is divided into 6 segments (upper right, upper anterior, upper left, lower left, lower anterior, lower right). • The American dentition notation is used, with maxillary dentition numbered 1 to 16 going from right to left, and mandibular dentition going 17 to 32 from left to right. • Areas involving the third molars are not scored because of variations in arch position, access and vision. • Unwaxed dental floss is alternately passed interproximally into the gingival sulcus on both sides of the interdental papillae. With the floss extended as far as possible towards the buccal and lingual, the floss is carried to the bottom of the sulcus. The floss is then moved in an inciso-gingival motion for one double stroke. Care is taken not to cause laceration of the papillae. • A new length of clean floss is used for each interproximal unit. • Bleeding is generally immediately evident in the area or on the floss, but 30 seconds are allowed for reinspection of each segment. If bleeding is copious, the patient should rinse between segments. • An area is nonscoreable when tooth positions, diastemas or other factors compromise the desirable interproximal relationships. Bleeding assessment • no attempt is made to quantify the degree of bleeding • bleeding is assessed only as present or absent Coding • not bleeding: none (blank) • bleeding: B
  6. 6. • not scoreable: X Interproximal Areas of Code Code Interproximal Areas of Maxillary Teeth Mandibular Teeth 2-3 30 - 31 3-4 29 - 30 4-5 28 - 29 5-6 27 - 28 6-7 26 - 27 7-8 25 - 26 8-9 24 - 25 9 - 10 23 - 24 10 - 11 22 - 23 11 - 12 21 - 22 12 - 13 20 - 21 13 - 14 19 - 20 14 - 15 18 - 19 total scoreable areas = = 26 - (number of nonscoreable areas) Gingival Bleeding Score = = total bleeding areas = = SUM(number of bleeding areas) total nonbleeding areas = = SUM(number of nonbleeding areas) = (total scoreable areas) - (total bleeding areas) Interpretation • The fewer the number of bleeding sites, the less the extent of gingivitis. Ideally the score should be 0. • If the patient is to be followed over time, previous bleeding sites are monitored to see if they become nonbleeding. The goal of interventions is to reduce the score as much as possible. References: Carter HG, Barnes GP. The gingival bleeding index. J Periodontol. 1974; 45: 801. Ciancio SG. Current status of indices of gingivitis. J Clin Periodontol. 1986; 13: 375-378. 01.05 Gingival Bone Count Overview:
  7. 7. The gingival bone count is a composite score based on the gingival condition and degree of bone loss affecting a person's teeth. This can be used to evaluate periodontal health, especially in epidemiologic studies. Scoring • The gingival score is based on the clinical examination. • The bone score is based on the clinical examination and evaluation of dental X-rays. • A single gingival score and a single bone score is generated for each tooth studied. • A mean for each score is then computed for the whole mouth. Parameter Finding Score gingival score negative 0 mild gingivitis involving the free gingiva (margin, 1 papilla, or both) moderate gingivitis involving both free and attached 2 gingiva severe gngivitis with hypertrophy and easy 3 hemorrhage bone score no bone loss 0 incipient bone loss or notching of alveolar crest 1 bone loss about one fourth of root length, or pocket 2 formation one side not over one half of root length bone loss about one half of root length, or pocket 3 formation one side not over three fourth root length; mobility slight bone loss about three quarters of root length, or 4 pocket formation one side to apex; mobility moderate bone loss complete; mobility marked 5 gingival bone score = = SUM((gingival score) + (bone score)) / (number of teeth examined) = = (mean gingival score) + (mean bone score) Interpretation • minimum score: 0 • maximum score: 8 • The higher the score, the more serious the periodontal disease. References: Dunning JM, Leach LB. Gingival-bone count: A method for epidemiological study of periodontal disease. J Dent Research. 1960; 39: 506-513. 01.06 Navy Plaque Index Overview:
  8. 8. The Navy Plaque Index (NPI) was developed as part of the Navy Periodontal Screening Examination, along with the Navy Periodontal Disease Index. It reflects the plaque control status of the patient and emphasizes plaque in the cervical portion of the tooth which is in contact with the gingiva margins. Comparison of scores over time can help guide intervention to prevent periodontal disease. Teeth examined •3 •9 • 12 • 19 • 25 • 28 Substitutions • If 3, 12, 19 or 28 is missing, then substitute the next most posterior tooth. • If 9 or 25 is missing, then substitute the nearest incisor in the arch. If all of the incisors are missing from the arch. If all incisors are missing from the arch, then substitute a cuspid. Surfaces examined on each tooth • facial • lingual Plaque Status Designated Points plaque in contact with gingival tissue on mesial M 3 proximal surface plaque in contact with gingival tissue on facial or G 2 lingual surface plaque in contact with gingival tissue on distal D 3 proximal surface plaque on facial or lingual surface of tooth surface R 1 but not in contact with gingival tissue For each tooth facial points = = (M points on facial aspect) + (G points on facial aspect) + (D points on facial aspect) + (R points on facial aspect) lingual points = = (M points on lingual aspect) + (G points on lingual aspect) + (D points on lingual aspect) + (R points on lingual aspect) Generating the NPI
  9. 9. tooth score = = (facial points) + (lingual points) NPI score = = MAX(all 6 tooth scores) NPI total = = SUM(all 6 tooth scores) Interpretation • minimum score for a surface: 0 • maximum score for a surface: 9 • minimum tooth score: 0 • maximum tooth score: 18 • maximum NPI score: 18 • minimum NPI total: 0 • maximum NPI total: 108 References: Grossman FD, Fedi PF Jr. Navy Periodontal Screening Examination. J Am Soc Prevent Dentistry. 1973; 3: 41-45. Hancock EB, Wirthlin MR Jr. An evaluation of the Navy periodontal screening examination. J Periodontol. 1977; 48: 63-66. 01.07 Navy Periodontal Disease Index Overview: The Navy Periodontal Disease Index Index (NPDI) was developed as part of the Navy Periodontal Screening Examination, along with the Navy Plaque Index. It is composed of a gingival and a pocket scores. The NPDI score can be used to determine the level of treatment required by the individual patient. Teeth examined •3 •9 • 12 • 19 • 25 • 28 Substitutions • If 3, 12, 19 or 28 is missing, then substitute the next most posterior tooth. • If 9 or 25 is missing, then substitute the nearest incisor in the arch. If all of the incisors are missing from the arch. If all incisors are missing from the arch, then substitute a cuspid.
  10. 10. Gingival Score Each tooth is examined for evidence of inflammatory change, which constitutes one or more of the following findings: • any change from normal gingival color • loss of normal density and consistency • slight enlargement or blunting of the papilla or gingiva • tendency to bleed upon palpation or probing Gingival Score Points Gingival tissue is normal in color and tightly adapted to 0 the tooth. Tooth is firm and no exudate is present. Inflammatory changes are present but do not completely 1 encircle the tooth. Inflammatory changes completely encircle the tooth. 2 Pocket Score With a calibrated periodontal take 6 measurements of each designated tooth: • mesial facial surface • middle facial surface • distal facial surface • mesial lingual surface • middle lingual surface • distal lingual surface Pocket Measurements Points Probing reveals sulcular depth not over 3 mm. 0 Probing reveals pocket depth greater than 3 mm but not 5 over 5 mm. Probing reveals pocket depth greater than 5 mm. 8 pocket score = = MAX(score taken at the 6 probing sites) Generating the NPDI tooth score = = (gingival score) + (pocket score) NPDI score = = MAX(all 6 tooth scores) NPDI total = = SUM(all 6 tooth scores)
  11. 11. Interpretation • minimum tooth score: 0 • maximum tooth score: 10 • minimum NPDI score: 0 • maximum NPDI score: 10 • minimum NPDI total: 0 • maximum NPDI total: 60 References: Grossman FD, Fedi PF Jr. Navy Periodontal Screening Examination. J Am Soc Prevent Dentistry. 1973; 3: 41-45. Hancock EB, Wirthlin MR Jr. An evaluation of the Navy periodontal screening examination. J Periodontol. 1977; 48: 63-66. 01.08 Oral Hygiene Index Overview: The Oral Hygiene Index is a method for classifying the oral hygiene status of a patient. It can be used over time to monitor progress in corrective interventions. Dental segments • upper right posterior: distal to the right cuspid on the maxillary arch • upper anterior: mesial to the right and left first bicuspids on the maxillary arch • upper left posterior: distal to the left cuspid on the maxillary arch • lower right posterior: distal to the right cuspid on the mandibular arch • lower anterior: mesial to the right and left first bicuspids on the mandibular arch • lower left posterior: distal to the left cuspid on the mandibular arch Surfaces on each segment • buccal (outer) • lingual (inner) Evaluating teeth • Only fully erupted (occlusal and incisal surface has reached the occlusal plane) permanent teeth are scored. • Third molars and incompletely erupted teeth are not scored because of the wide variations in heights of clinical crowns. • The buccal and lingual debris scores are both taken on the tooth in a segment having the greatest surface area covered by debris. • The buccal and lingual calculus scores are both taken on the tooth in a segment having the greatest surface area covered by supragingival and subgingival calculus. Grading Debris Points no debris or stain present 0 soft debris covering not more than one third of the 1
  12. 12. tooth surface, AND/OR the presence of extrinsic stain without other debris regardless of surface area covered soft debris covering more than one third, but not 2 more than two thirds, of the exposed tooth surface soft debris covering more than two thirds of the 3 exposed tooth surface debris index = = (SUM(points along buccal surface for all segments present) + SUM(points along lingual surface of all segments present)) / (number of segments present) Grading Calculus Points no calculus present 0 supragingival calculus covering not more than one 1 third of the exposed tooth surface supragingival calculus covering more than one third 2 but not more than two thirds of the exposed tooth surface, AND/OR the presence of individual flecks of subgingival calculus around the cervical portion of the tooth supragingival calculus covering more than two 3 thirds of the exposed tooth surface AND/OR a continuous heavy band of subgingival calculus around the cervical portion of the tooth calculus index = = (SUM(points along buccal surface for all segments present) + SUM(points along lingual surface of all segments present)) / (number of segments present) oral hygiene index = = (debris index) + (calculus index) Interpretation • The minimum number of points for all segments in either the debris or calculus portions is 0. • The maximum number of points for all segments in either the debris or calculus score is 36. • Since there are up to 6 segments, the individual indices range from 0 to 6. • Since the oral hygiene index is the sum of the two indices, its range of values is from 0 to 12. • The higher the score, the poorer the oral hygiene. References Greene JC, Vermillion JR. The oral hygiene index: a method for classifying oral hygiene status. J Am Dental Assoc. 1960; 61: 172-179.
  13. 13. 09.01.09 Periodontitis Severity Index Overview: The Periodontitis Severity Index (PSI) was developed to assess the severity of periodontitis and distinguishes between clinically healthy and inflamed sites. Periodontitis is diagnosed on the concurrence of clinically apparent marginal inflammation and vertical loss of supporting periodontium. In the presence of marginal inflammation, the PSI is directly proportional to the percentage of bone loss. The severity of the associated clinical inflammation does not seem to be related to the severity of the tissue loss. Clinical Inflammation Score Signs of gingival inflammation: ANY of the following • edema • suppuration • bleeding upon provocation • increased crevicular fluid flow • color deviation If none of these findings are present, the clinical inflammation score is 0. If any one of the these findings are present, the clinical inflammation score is 1. Bone Loss Score A Schei ruler is used to determine the percentage of bone loss for a tooth surface from the radiograph. Bone Loss in percent Bone Loss Score 0 0 1-10% 1 10-20% 2 20-30% 3 30-40% 4 40-50% 5 50-60% 6 60-70% 7 70-80% 8 80-90% 9 90-100% 10 Periodontal Severity Index For each mesial (medial) and distal tooth surface, the following is calculated:
  14. 14. periodontal severity index (PSI) = = (clinical inflammation score) * (bone loss score) mean periodontal severity index = = SUM (all PSI scores) / (total number of surfaces) Interpretation • A PSI of 0 can occur if either no bone loss has occurred or if the gingiva is healthy. • maximum PSI: 10 References Adams RA, Nystrom GP. A periodonitis severity index. J Periodont. 1986; 57: 176-179. 01.10 Periodontal Treatment Need System (PTNS) Overview: The Periodontal Treatment Need System (PTNS) can be used to determine the periodontal therapeutic needs in a population. It can be used to estimate the manpower and costs needed to address the problems found on examination. Classification Criteria plaque calculus and/or inflammation pocket depth Class overhang no no no not applicable 0 yes no yes <= 5 mm A yes yes yes <= 5 mm B yes yes yes > 5 mm C Patient Assessment Classes 0 and A are assigned based on assessment of the entire mouth. Classes B and C are assigned based on oral quadrants. • Normally the mouth is divided into 4 quadrants (left maxillary, right maxillary, left mandibular, right mandibular). • If less than 8 teeth are present on the maxilla or mandible, then this is taken as one quadrant. • If 4 teeth or less are in the mouth as a whole, then the mouth is considered to have one quadrant. Probing: • each tooth is probed on all surfaces • if a pocket deeper than 5 mm is found, then the whole quadrant is scored as C
  15. 15. • a pocket deeper than 5 mm mesially to the central incisors is not scored as C, if it is the only C pocket in that quadrant, AND if the other quadrant on the same jaw has been scored as C. Treatment Plan Class Treatment Time to Complete 0 no treatment needed 0 A oral hygiene instructions 60 minutes B scaling and removal of 30 minutes per quadrant for calculus and overhangs scaling C surgery 60 minutes per quadrant for surgery A patient with Class B disease also requires Class A management. A patient with Class C disease also requires Class A and Class B management. The maximum time estimates for a person with all teeth present and severe periodontal disease involving all quadrants would be 7 hours (1 hour for each quadrant for surgery, 30 minutes for each quadrant for cleaning, and 1 hour for training, or 4 + 2 + 1). Limitations • The time estimates seem overly generous except for the surgery on severely affected areas. References: Johansen JR, Gjermo P, Bellini HT. A system to classify the need for periodontal treatment. Acta Odont Scand. 1973; 31: 297-305. 01.11 Quigley and Hein's Plaque Index, as Modified by Turesky et al Overview: Quigley and Helm proposed a system for scoring dental plaque. This was modified by Turesky et al to more explicitly describe mild to moderate plaque deposits. Plaque Scoring System for Quigley and Hein Score no plaque 0 flecks of stain at the gingival margin 1 definite line of plaque at the gingival margin 2 gingival third of surface 3 two thirds of surface 4 greater than two thirds of surface 5
  16. 16. Modified Plaque Scoring System of Turesky et al Score no plaque 0 separate flecks of plaque at the cervical margin of the tooth 1 a thin continuous band of plaque (up to 1 mm) at the cervical 2 margin of the tooth a band of plaque wider than 1 mm coering less than one third 3 of the crown of the tooth plaque covering at least one-third but less than two thirds of 4 the crown of the tooth plaque covering two-thirds or more of the crown of the tooth 5 Scoring by the Turesky modification • all teeth assessed except third molars (maximum number 28) • a staining solution is used to show plaque deposits (Quigley and Turesky used basic fuchsin, Gordon used erythrosine) • both the facial and lingual surfaces examined (maximum number 56) • a score is assigned to each facial and lingual nonrestored surface total score = SUM(scores for all facial and lingual surfaces) index = (total score) / (number of surfaces examined) Interpretation • A score of 0 or 1 is considered low. • A score of 2 or more is considered high. References: Fischman SL. Current status of indices of plaque. J Clin Periodontol. 1986; 13: 371-374. Gordon JM, Lamster IB, Seiger MC. Efficacy of Listerine antiseptic in inhibiting the development of plaque and gingivitis. J Clin Periodontol. 1985; 12: 697-704. Mandel ID. Indices for measurement of soft accumulations in clinical studies of oral hygiene and periodontal disease. J Periodontal Res. 1974; 9 (supplement 14): 7-30. Marks RG, Magnusson I, et al. Evaluation of reliability and reproducibility of dental indices. J Clin Periodontol. 1993; 20: 54-58. Quigley GA, Hein JW. Comparative cleansing efficiency of manual and power brushing. J Am Dental Assoc. 1962; 65: 26-29. Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of Victamine C. J Periodontol. 1970; 41: 41-43. 01.12 Sulcus Bleeding Index Overview: The Sulcus Bleeding Index (SBI) can be used to assess a patient for gingivitis, which can be important in the prevention of periodontal disease. This was initially called
  17. 17. the "PM Index", but the name was changed to prevent confusion with the "PMA Index". Number of teeth examined: 16 (the anterior 4 in each quadrant, 2 on maxilla and 2 on mandible) Teeth in each quadrant (1) medial incisor (2) lateral incisor (3) cuspid (4) first premolar Surfaces on each tooth probed: 4 (1) M labial (2) M lingual (3) P mesial (4) P distal Total number of readings: 64 Each surface is examined grossly for color and swelling, then a probe is gently placed in the sulcus to see if bleeding occurs. Appearance Sulcus Probing Points healthy no bleeding 0 apparently healthy with no change in bleeding on probing 1 color and no swelling change in color due to inflammation; bleeding on probing 2 no swelling or macroscopic edema change in color due to inflammation; bleeding on probing 3 slight edematous swelling obvious swelling bleeding on probing 4 spontaneous bleeding; changes in bleeding on probing 5 color; marked swelling with or without ulceration Interpretation • The total number of surfaces showing each of the scores (0 to 5) is used to evaluate the distribution of changes associated with gingivitis. • minimum sum of all SBI scores: 0 • maximum sum of all SBI scores: 320 References: Ciancio SG. Current status of indices of gingivitis. J Clin Periodontol. 1986; 13: 375-378.
  18. 18. Engelberger T, Hefti A, et al. Correlations among papilla bleeding index, other clinical indices and histologically determined inflammation of gingival papilla. J Clin Periodontol. 1983; 10: 579-589. Muhlemann HR, Son S. Gingival sulcus bleeding - A leading symptom in initial gingivitis. Helv Odont Acta. 1971; 15: 107-113. 01.13 Gingival Index of Loe and Silness Overview: The Gingival Index (GI) was developed by Loe and Silness to describe the clinical severity of gingival inflammation as well as its location. Appearance Bleeding Inflammation Points normal no bleeding none 0 slight change in color and no bleeding mild 1 mild edema with slight change in texture redness, hypertrophy, bleeding on moderate 2 edema and glazing probing/pressure marked redness, spontaneous severe 3 hypertrophy, edema, bleeding ulceration Teeth examined" (1) maxillary right first molar (2) maxillary right lateral incisor (3) maxillary left first bicuspid (4) mandibular left first molar (5) mandibular left lateral incisor (6) mandibular right first bicuspid Surfaces examined on each tooth (1) buccal (2) lingual (3) mesial (4) distal Gingival Index for a specific tooth = = AVERAGE (points for the 4 surfaces) Gingival Index for type of tooth (first molar, first bicuspid, lateral incisor) = = AVERAGE (Gingival Indices for the 2 teeth) gingival index for patient = = AVERAGE (Gingival Indices for all 6 teeth)
  19. 19. Average Gingival Index Interpretation 2.1 - 3.0 severe inflammation 1.1 - 2.0 moderate inflammation 0.1 - 1.0 mild inflammation < 0.1 no inflammation Limitations: • Several subsequent modifications were made to better describe milder forms of inflammation or to eliminate the need to perform probing. References: Bollmer BW, Sturzenberger OP, et al. A comparison of 3 clinical indices for measuring gingivitis. J Clin Periodontol. 1986; 13: 392-395. Ciancio SG. Current status of indices of gingivitis. J Clin Periodontol. 1986; 13: 375-378. Lobene RR, Mankodi SM, et al. Correlations among gingival indices: A methodology study. J Periodontol. 1989; 60: 159-162. Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontologica Scand. 1963; 21: 533-551. Loe H. The Gingival Index, the Plque Index, and the Retention Index. J Periodontol. 1967; 38: 610-616. Marks RG, Magnusson I, et al. Evaluation of reliability and reproducibility of dental indices. J Clin Periodontol. 1993; 20: 54-58. 01.14 Periodontal Index of Russell Overview: Russell developed an index for measuring periodontal disease that could be used in population surveys. It can be based solely upon the clinical examination, or it can make use of dental X-rays if they are available. It places greater emphasis on advanced disease. Scoring: (1) Each tooth is scored separately according to the following criteria. (2) Rule: When in doubt, assign the lower score. Criteria for Field Studies Additional X-Ray Criteria Score negative (neither overt radiographic appearance 0 inflammation in the investing normal tissues, nor loss of function due to destruction of supporting tissues) mild gingivitis (overt area of 1 inflammation in the free gingivae, but this area does not circumscribe the tooth) gingivitis (inflammation completely 2
  20. 20. circumscribes the tooth, but there is no apparent break in the epithelial attachment) (not used in field study) early, notchlike resorption of the 4 alveolar crest gingivitis with pocket formation (the horizontal bone loss involving 6 epithelial attachment is broken, and the entire alveolar crest, up to there is a pocket. There is no half of the length of the tooth interference with normal root (distance from apex to masticatory function, the tooth is cemento-enamel junction) firm in its socket, and has not drifted. advanced destruction with loss of advanced bone loss, involving 8 masticatory function (tooth may be more than half of the length of loose; tooth may have drifted; tooth the tooth root, or a definite may sound dull on percussion with a intrabony pocket with definite metallic instrument; the tooth may widening of the periodontal be depressible in its socket) membranes. There may be root resoprtion, or rarefaction at the apex (Table I, page 352, Russell) individual score = = AVERAGE(scores for all of the teeth in the mouth) population score = = AVERAGE(individual scores in population examined) Interpretation: • minimum score: 0 • maximum score: 8 • The higher the score, the more marked the periodontal disease. References: Ciancio SG. Current stagus of indices of gingivitis. J Clin Periodontol. 1986; 13: 375-378. Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontologica Scand. 1963; 21: 533-551. Russell AL. A system of classification and scoring for prevalence surveys of periodontal disease. J Dental Research. 1956; 35: 350-359. Shapiro S, Pollack BR, Gallant D. A special population available for periodontal research. Par II. A correlation and association analsyis between oral hygiene and periodontal disease. J Periodontology. 1971; 42: 161-165. 02 Temporomandibular Joint (TMJ) Disorders
  21. 21. 02.01 Jaw Symptom Questionnaire for Evaluating Patients with Temporomandibular Joint Disorders Overview: A Jaw Symptom Questionnaire developed by Clark et al can be used to monitor patients with temporomandibular joint disorders and to measure the effect of therapeutic interventions. It consists of two parts, the first dealing with jaw pain and the second jaw function. Part A: Jaw Pain Questions (1) Does it hurt when you open wide or yawn? (2) Does it hurt when you chew, or use the jaws? (3) Does it hurt when you are not chewing or using the jaws? (4) Is your pain worse on waking? (5) Do you have pain in front of the ears or ear aches? (6) Do you have jaw muscle (cheek) pain? (7) Do you have pain in the temples? (8) Do you have pain or soreness in the teeth? Patient Responses • doesn't hurt at all (score = 0) • hurts a little (score = 1) • hurts a lot (score = 2) • almost unbearable (score = 3) • unbearable pain without relief (score = 4) jaw pain score = = SUM(points for all 8 responses) Part B: Jaw Function Questions (1) Do your jaw joints make noise so it bothers you or others? (2) Do you find it difficult to open your mouth wide? (3) Does your jaw ever get stuck (lock) as you open it? (4) Does you jaw ever lock open so you cannot close it?
  22. 22. (5) Is your bite uncomfortable? Patient Responses • no (score = 0) • maybe a little (score = 1) • quite a lot (score = 2) • almost all the time (score = 3) • all the time without stopping (score = 4) jaw function score = = SUM(points for all 5 responses) Interpretation Scores • minimum score for both parts: 0 • maximum score for jaw pain questions: 32 • maximum score for jaw function questions: 20 References: Clark GT, Moody DG, Sanders B. Chapter 7: Analysis of arthroscopically treated TMJ derangement and locking. pages 1xx-130 (pages 122-132). IN: Sanders B, Murakami K-I, Clark GT. Diagnostic and Surgical Arthroscopy of the Temporomandibular Joint. WB Saunders Company. 1989. Yatani H, Kaneshima T, et al. Long-term follow-up study on drop-out TMD patients with self-administered questionnaires. J Orofacial Pain. 1997; 11: 258-269. 02.02 Activity Limitation Scale for Patients with Temporomandibular Joint Disorders Overview: The pain associated with temporomandibular joint disorders can interfere with the activities of daily living. The Activity Limitation Scale can be used to semiquantitate the impact of this pain. It can be used to monitor disease severity over time and to assess the impact of therapeutic intervention. Patient Instructions: Please indicate how much these activities USUALLY CAUSE PAIN (does not include unusual or prolonged activity, e.g., driving on a long trip). Activities (1) walking (2) eating soft food (3) eating hard food
  23. 23. (4) jaw opening (5) sleeping (6) chewing (7) swallowing (8) talking (9) pushing and pulling (10) resting (11) driving (12) dressing (13) sports (14) reading (15) watching television (16) household chores (17) gardening (18) employment Responses Points doesn't hurt at all 0 hurts a little 1 hurts a lot 2 almost unbearable 3 unbearable pain prevents activity 4 activity limitation scale = = SUM(points for all 18 activities) Interpretation • minimum score: 0 • maximum score: 72 References: Clark GT, Moody DG, Sanders B. Chapter 7: Analysis of arthroscopically treated TMJ derangement and locking. pages 1xx-130 (pages 122-132). IN: Sanders B, Murakami K-I, Clark GT. Diagnostic and Surgical Arthroscopy of the Temporomandibular Joint. WB Saunders Company. 1989. Yatani H, Kaneshima T, et al. Long-term follow-up study on drop-out TMD patients with self-administered questionnaires. J Orofacial Pain. 1997; 11: 258-269. 03 Periodontal Surgical Therapy 03.01 Contraindications to Performing Periodontal Osseous Resective Surgery Overview:
  24. 24. Periodontal osseous resective surgery should be delayed or not performed in certain clinical situations. Surgery usually can be done once the underlying conditions are corrected or controlled. Contraindications to Periodontal Osseous Resective Surgery (1) Patients with inadequate plaque control. (2) Uncontrolled or progessive systemic diseases, including: • recent myocardial infarction • acute leukemia • severe anemia • diabetes mellitus • severe neurologic disorders (3) Patients receiving the following therapy: • large doses of corticosteroids • history of long term use of corticosteroids • anticoagulation (4) Advanced cases where patients have not agreed to a restorative treatment plan following the surgical phase of their treatment. In this case, the surgical phase should be deferred until a restorative commitment is made. References: Silverstein LH, Kurtzman D, et al. Chapter 7A: Periodontal osseous surgery and root resective therapy. pages 1-25. IN: Hardin JF (editor). Clark's Clinical Dentistry, Volume 3. Revised Edition, 1998. Mosby. 03.02 Healing Index of Landry, Turnbull and Howley Overview: Landry, Turnbull and Howley described an index to describe the extent of healing after periodontal surgery. Healing Index 1: Very Poor Has 2 or more of the following: • tissue color: >= 50% of gingiva red • response to palpation: bleeding • granulation tissue: present • incision margin: not epithelialized, with loss of epithelium beyond incision margin • suppuration present Healing Index 2: Poor • tissue color: >= 50% of gingiva red • response to palpation: bleeding
  25. 25. • granulation tissue: present • incision margin: not epithelialized, with connective tissue exposed Healing Index 3: Good • tissue color: >= 25% and < 50% of gingiva red • response to palpation: no bleeding • granulation tissue: none • incision margin: no connective tissue exposed Healing Index 4: Very Good • tissue color: < 25% of gingiva red • response to palpation: no bleeding • granulation tissue: none • incision margin: no connective tissue exposed Healing Index 5: Excellent • tissue color: all tissues pink • response to palpation: no bleeding • granulation tissue: none • incision margin: no connective tissue exposed References: Landry RG, Turnbull RS, Howley T. Effectiveness of benzydamyne HCl in the treatment of periodontal post-surgical patients. Research in Clinic Forums. 1988; 10: 105-118. Masse JF, Landry RG, et al. Effectiveness of soft laser treatment in periodontal surgery. International Dental Journal. 1993; 43: 121-127. 04 Evaluation of Malocclusion and Need for Orthodontic Treatment 04.01 Handicapping Labio-Lingual Deviation (HLD) Index Overview: The Handicapping Labio-Lingual Deviation (HLD) Index was developed to fill the need for a simple, reproducible and valid method for identifying patients with a physical handicap arising from dental abnormalities. Examination: • Measurements are taken using a Boley gauge with results read to the nearest millimeter. • Overjet and overbite are measured with the teeth in the centric relationship. • Mandibular protrusion is read from the labial surface of the lower incisor to the labial surface of the upper incisor. • A reverse overbite is included with overbite. • Open bite = absence of occlusal contact in the anterior region; it is measured from dental edge to edge.
  26. 26. Traumatic deviations include: • loss of premaxilla segment due to burns or by accident • effects of extensive osteomyelitis • extensive surgery • other gross abnormalities Labio-lingual spread: • If only a single protruded or lingually displaced tooth are present, then the measurement is from the incisal edge of the tooth to the where that edge should be in the normal arch. • If one or more teeth protrude and a one or more teeth are lingually displaced, then the total distance between the incisal edges of the most protruding and most lingually displaced should be measured. • Only one labio-lingual spread should be entered for the index. If multiple teeth are affected, all should be measured but only the maximal value should be entered. This will give the patient the benefit of the greatest deviation. Parameter Points cleft palate 15 severe traumatic deviations 15 overjet in mm (mm) overbite in mm (mm) mandibular protrusion in mm (mm) * 5 open bite in mm (mm) * 4 ectopic eruption in anterior teeth (number) * 3 anterior crowding, maxilla (number) * 5 anterior crowding, mandible (number) * 5 labio-lingual spread in mm (maximum) mm HLD score = = SUM(all points assigned) Interpretation: • minimum score: 0 • maximum score: > 80 • A score >= 13 is considered to constitute a physical handicap. References: Draker HL. Handicapping labio-lingual deviations: A proposed index for public health purposes. Am J Orthodontics. 1960; 46: 295-305. 04.02 The California Modification of the Handicapping Labiolingual Deviation [HLD(CalMod)] Index
  27. 27. Overview: The evaluation and management of severe malocclussion is difficult and expensive. Patients must demonstrate medical necessity for programs such as Medicaid or Champus to provide reimbursement. The Handicapping Labiolingual Deviation (HLD) Index was developed as means to identify patients with handicapping malocclusion. This was modified by a lawsuit in California as the HLD (CalMod) Index. Procedure: • The observer should use a Boley gauge or disposable rule and an HLD scoresheet.. • The patient's teeth are positioned in centric occlusion. • All measurements are recorded in the order given and rounded off to the nearest millimeter (mm). • If a condition is absent, a 0 is entered. • The use of an assistant to record the findings is recommended. No. Condition Score 1 Cleft palate deformities X, and score no further 2 deep impinging overbite, when lower incisors are X, and score no destroying the soft tissue of the palate further 3 crossbite of individual anterior teeth, when X, and score no destruction of soft tissue is present further 4 severe traumatic deviations (attach description of X, and score no condition) further 5A Overjet greater than 9 mm with incompetent lips or X, and score no reverse overjet greater than 3.5 mm with reported further masticatory and speech difficulties. 5B overjet in mm (mm) 6 overbite in mm (mm) 7 mandibular protrusion in mm (mm) * 5 8 open bite in mm (mm) * 4 9 ectopic eruption: Count each tooth, excluding third (count) * 3, see molars note below 10 anterior crowding: Score one point for maxilla, and/or (0, 1 or 2) * 5, see one point for mandible; two points maximum for note below anterior crowding 11 labiolingual spread in mm (mm) 12 posterior unilateral crossbite (must involve 2 or more 4 adjacent teeth, one of which must be a molar) NOTE: If both anterior crowding and ectopic eruption are present in the anterior portion of the mouth, score only the most severe condition. Do not score both conditions. Additional scoring instruction (Figure 3, page 139)
  28. 28. • 5B: This is recorded with the patient's teeth in centric occlusion and measured from the labial portion of the lower incisors to thelabial of the upper incisors. The measurement may apply to protruding single tooth as well as to the whole arch. • 6: A pencil mark on the tooth indicating the extent of overjet facilitates this measurement. "Reverse" overbite may exist in certain conditions and should be measured and recorded. • 7: Score exactly as measured from the labial of the lower incisor to the labial of the upper incisor. A reverse overbite, if present, should be shown under 6 (above). • 8: This condition is defined as the absence of occlusal contact in the anterior region. It is measured from edge to edge in millimeters. In cases of pronounced protrusion associated with open bite, measurement of the open bite is not always possible; in these cases, a close approximation can be estimated. • 10: Arch length insufficiency must exceed 3.5 mm. Mild rotations that may react favorably to stripping or mild expansion procedures are not to be scored as crowded. • 11: A Boley Gauge or disposable ruler is used to determine the extent of deviation from a normal arch. Where there is only a protruded or lingually dusplaced anterior tooth, the measurement should be made from the incisal edge of that tooth to the normal arch line. Otherwise, the total distance between the most protruded tooth and the lingually displaced anterior tooth is measured. The labiolingual spread porbably comes close to a measurement of overall deviation from what would have been a normal arch. In the event that multiple anterior crowding of the teeth is observed, some deviation from the normal arch should be measured for the labiolingual spread, but only the most severe individual measurement should be entered on the index. • 12: The crossbite must be one in which the mandibular posterior teeth involved may either be both palatal or both completely buccal in relation to the mandibular posterior teeth. Scoring: • If conditions 1 through 5A are present, then further scoring is not needed. • If conditions 1 through 5A are not present, then total score = SUM(all the conditions present) Interpretation • "X" is scored in conditions 1 through 5A: these are considered to be handicapping malocclusion • scores >= 26: this is considered handicapping • If a person does not score an "X" or has a total score less than 26, then s/he may be eligible under the EPSDT exception if medical necessity is documented. EPSDT Exception: All of the following must be provided (a) principal diagnosis (b) prognosis
  29. 29. (c) date of onset of the illness or condition, and etiology if known (d) clinical significance or functional impairment caused by the illness or condition (e) specific types of services to be rendered by each discipline associated with the total treatment plan (f) the therapeutic goals to be achieved by each discipline and anticipated time for achievement of goals (g) the extent to which health care services have been previously provided to address the illness or condition, and results demonstrated by prior care (h) any other documentation available which may assist in making the required determination References: Draker HL. Handicapping labio-lingual deviation: a proposed index for public health purposes. Am J Orthod Dentofacial Orthop. 1960; 46: 295-305. Parker WS. The HLD (CalMod) index and the index question. Am J Orthod Dentofacial Orthop. 1998; 114: 134-141. 04.03 The Index of Orthodontic Treatment Need (IOTN) Overview: The Index of Orthodontic Treatment Need (IOTN) was developed as a means to objectively measure a person's need for orthodontic treatment. Components (1) dental health: 5 grades from none to very great (2) aesthetics: attractiveness of the patient's labial aspect ranked from 1 (close to normal) to 10 Dental Health Component Grade 1: None Extremely minor malocclusions including displacements < 1 mm. Dental Health Component Grade 2: Little Increased overjet 3.6 - 6.0 mm, with competent lips. Reverse overjet 0.1 -1.0 mm Anterior to posterior crossbite with up to 1 mm discrepancy between retruded contact position and intercuspal position. Displacement of teeth 1.1 - 2.0 mm Anterior or posterior openbite 1.1 - 2.0 mm Increased overbite >= 3.5 mm, without gingival contact.
  30. 30. Pre-normal or post-normal occlusions with no other anomalies. Includes up to half a unit discrepancy. Dental Health Component Grade 3: Moderate Increased overjet 3.6 - 6.0 mm, with incompetent lips. Reverse overjet 1.1 - 3.5 mm Anterior or posterior crossbites with 1.1 - 2.0 mm discrepancy. Displacement of teeth 2.1 - 4.0 mm Lateral or anterior crossbite 2.1 - 4.0 mm Increased and complete overbite without gingival trauma. Dental Health Component Grade 4: Great Increased overjet 6.1 - 9.0 mm. Reversed overjet > 3.5 mm with no masticatory or speech difficulties. Anterior or posterior crossbites with > 2 mm discrepancy between retruded contact position and intercuspal position. Severe displacement of teeth, > 4 mm Extreme lateral or anterior openbites, > 4 mm Increased and complete overbite with gingival or palatal trauma. Less extensive hypodontia requiring pre-restorative orthodontic space closure to obivate the need for a prosthesis. Posterior lingual crossbite with no functional occlusal contact in one or both buccal segments. Reverse overjet 1.1 - 3.5 mm with recorded masticatory and speech difficulties. Partially erupted teet, tipped and impacted against adjacent teeth. Supplemental teeth. Dental Health Component Grade 5: Very Great
  31. 31. Increased overjet > 9 mm Extensive hypodontia with restorative implications (more than 1 tooth missing in any quadrant) requiring pre-restorative orthodontics. Impeded eruptions of teeh (with the exception of the third molars) due to crowding, displacement, the presence of supernumerary teeth, retained deciduous teeth, and any pathological cause. Reverse overjet > 3.5 mm with reported masticatory and speech difficulties. Defects of cleft lip and palate. Submerged deciduous teeth. Aesthetic Component A patient's score is based on matching his or her dental appearance with one of a series of 10 photographs showing the labial aspect of different Class I or Class II malocclusions ranked according to their attractiveness. References: Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. European J Orthodontics. 1989; 11: 309-320. Mitchell DA, Mitchell L. Oxford Handbook of Clinical Dentistry, Second Edition. Oxford University Press. 1995. pages 134-135. Shaw WC, Richmond S, et al. Quality control in orthodontics: Indices of treatment need and treatment standards. Br Dent J. 1991; 170: 107-112. 04.04 The Dental Aesthetic Index (DAI) Overview: The Dental Aesthetic Index (DAI) is an orthodontic index which incorporates socially defined aesthetic standards. In addition, it provides a severity measure for psychologic and functional impairment. It consists of 10 components multiplied by weights based on regression coefficients, plus a constant. Component Finding Weight constant 13 missing teeth number of missing incisor, 6 canine and premolar teeth crowding in incisal segments number of segments crowded 1 spacing in incisal segments number of segments spaced 1 diastema in millimeters 3
  32. 32. anterior irregularity in maxilla largest irregularity in mm 1 anterior irregularity in mandible largest irregularity in mm 1 anterior maxillary overjet in millimeters 2 anterior mandibular overjet in millimeters 4 vertical anterior openbite in millimeters 4 antero-posterior molar relation largest deviation from normal; 3 0.5 cusp = 1, >= 1 cusp = 2 where: • diastema = the space between 2 adjacent teeth on the same dental arch DAI score = = SUM((finding) * (weight)) Interpretation • minimum score: 13 • maximum score encountered in reported series of 1306 study models: 66 • The further the score falls from the norm of most acceptable dental appearance, the more the occlusal condition may be judged socially or physically handicapping if left untreated. References: Jenny J, Cons NC, et al. Predicting handicapping malocclusion using the Dental Aesthetic Index (DAI). International Dental J. 1993; 43: 128-132. Monaco A, Boccuni M, Marci MC. Indices of treatment needs in orthodontics: the applicability of the DAI. Minerva Stomatologica. 1997; 46: 279-286 (in Italian). Otuyemi OD, Noar JH. Variability in recording and grading the need for orthodontic treatment using hte handicapping malocclusion assessment record, occlusal index and denta aesthetic index. Community Dentistry Oral Epidemiology. 1996; 24: 222-224. 05 Systems for Dental Notation Overview: Several systems exist for explicitly denoting a tooth's location in the dentition. Dentition • deciduous (child): 4 sets of 5 teeth = 20 • permanent (adult): 4 sets of 8 teeth = 32 Notation systems • American (USA) • European • FDI • Zsigmondy-Palmer, Chevron, or Set Square system
  33. 33. Usually diagrams are from the examiner's perspective • The rightmost position is the patient's final left molar. • The leftmost position is the patient's final right molar. Deciduous Teeth Upper Dentition (from patient's USA Europe FDI Set perspective) Square left maxillary second molar J +05 65 e left maxillary first molar I +04 64 d left maxillary cuspid (canine) H +03 63 c left maxillary lateral incisor G +02 62 b left maxillary medial incisor F +01 61 a right maxillary medial incisor E 01+ 51 a right maxillary lateral incisor D 02+ 52 b right maxillary cuspid (canine) C 03+ 53 c right maxillary first molar B 04+ 54 d right maxillary second molar A 05+ 55 e Lower Dentition (from patient's USA Europe FDI Set perspective) Square left mandibular second molar K -05 75 e left mandibular first molar L -04 74 d left mandibular cuspid (canine) M -03 73 c left mandibular lateral incisor N -02 72 b left mandibular medial incisor O -01 71 a right mandibular medial incisor P 01- 81 a right mandibular lateral incisor Q 02- 82 b right mandibular cuspid (canine) R 03- 83 c right mandibular first molar S 04- 84 d right mandibular second molar T 05- 85 e Permanent Teeth Upper Dentition (from patient's USA Europe FDI Set perspective) Square left maxillary third molar 16 +8 28 8 left maxillary second molar 15 +7 27 7 left maxillary first molar 14 +6 26 6 left maxillary second premolar 13 +5 25 5 (bicuspid) left maxillary first premolar 12 +4 24 4 (bicuspid) left maxillary dibular cuspid 11 +3 23 3 (canine)
  34. 34. left maxillary lateral incisor 10 +2 22 2 left maxillary medial incisor 9 +1 21 1 right maxillary medial incisor 8 1+ 11 1 right maxillary lateral incisor 7 2+ 12 2 right maxillary cuspid (canine) 6 3+ 13 3 right maxillary first premolar 5 4+ 14 4 (bicuspid) right maxillary second premolar 4 5+ 15 5 (bicuspid) right maxillary first molar 3 6+ 16 6 right maxillary second molar 2 7+ 17 7 right maxillary third molar 1 8+ 18 8 Lower Dentition (from patient's USA Europe FDI Set perspective) Square left mandibular third molar 17 -8 38 8 left mandibular second molar 18 -7 37 7 left mandibular first molar 19 -6 36 6 left mandibular second premolar 20 -5 35 5 (bicuspid) left mandibular first premolar 21 -4 34 4 (bicuspid) left mandibular cuspid (canine) 22 -3 33 3 left mandibular lateral incisor 23 -2 32 2 left mandibular medial incisor 24 -1 31 1 right mandibular medial incisor 25 1- 41 1 right mandibular lateral incisor 26 2- 42 2 right mandibular cuspid (canine) 27 3- 43 3 right mandibular first premolar 28 4- 44 4 (bicuspid) right mandibular second premolar 29 5- 45 5 (bicuspid) right mandibular first molar 30 6- 46 6 right mandibular second molar 31 7- 47 7 right mandibular third molar 32 8- 48 8 References: Mitchell DA, Mitchell L. Oxford Handbook of Clinical Dentistry, Second Edition. Oxford University Press. 1995. page 752. 09.06 Using a Simple Classification System in Planning the Surgical Management of Maxillomandibular Asymmetry
  35. 35. Overview: Facial asymmetry involving the maxilla and mandible may be congenital or acquired. The type of asymmetry determines the surgical procedures which may be needed for correction. There are three anatomic planes in the maxillmandibular region: (1) maxilla (2) body of mandible (with dentition) (3) symphysis of the mandible Center of Center of Body Center of Levels Aligned Type of Maxilla of Mandible Symphysis of Asymmetry Mandible midline midline midline all 3 none (normal) midline midline asymmetric maxilla and I body of mandible midline asymmetric asymmetric body and II symphysis of mandible midline asymmetric asymmetric none III asymmetric asymmetric asymmetric none IV (after Figure 1, page 349) If the 3 anatomic levels show an occlusal cant discrepancy (not horizontal), then the type is designated type C as follows: • if normal symmetry: C • with asymmetry type I: IC • with asymmetry type II: IIC • with asymmetry type III: IIIC • with asymmetry type IV: IVC The type of asymmetry determines which surgical procedures should be used for correction. Type of Genioplasty Mandibular Maxillary Surgery Asymmetry Surgery I yes II yes III yes yes IV yes yes yes IC yes yes yes IIC yes yes IIIC yes yes yes IVC yes yes yes
  36. 36. C yes yes (after Table page 351) The specifics for the technique used to correct a deformity must be determined individually. When treating transverse occlusal cant discrepancies it is important to consider the vertical relationship of the maxillary incisors to the upper lip. References: Reyneke JP, Tsakiris P, Kienle F. A simple classification for surgical treatment planning of maxillomandibular asymmetry. Br J Oral Maxillofacial Surg. 1997; 35: 349-351. 07 Cephalometric Analysis 07.01 Diagnosis of the Long Face Syndrome Overview: The diagnosis of the long face syndrome can be confirmed by cephalometric measurements from the lateral radiograph of the skull. Some problems associated with the long face syndrome • excessive eruption of the posterior teeth • excessive eruption of the anterior teeth • short posterior facial height • steep mandibular plane angle Landmarks on lateral skull radiographs to be identified: (1) S: sella (mid-point of sella turcica) (2) N: nasion (most anterior point on the frontal nasal suture) (3) Go: gonion (most posterior inferior point on angle of mandible) (4) Gn: gnathion (5) Me: menton (lowermost point on the mandibular symphysis) Criteria for diagnosis of long face syndrome (1) angle of the gonion-to-gnathion line and the sella-to-nasion line: >= 37 degrees (2) (sella-to-gonion length) to (nasion-to-menton length) ratio <= 0.65 References: Mitchell DA, Mitchell L. Oxford Handbook of Clinical Dentistry, Second Edition. Oxford University Press. 1995. pages 140-143. Prittinen JR. Orthodontic diagnosis of long face syndrome. General Dentistry. 1996 (July-August); (no volume): 348-351. Viazis A. Atlas of Orthodontics: Principles and Clinical Applications. WB Saunders. 1993. page 66. 08 Xerostomia (Dry Mouth)
  37. 37. Overview: Xerostomia refers to a dry mouth caused by a decreased salivary gland flow in a patient with adequate hydration. It may occur as an isolated finding or as one of the findings in Sjogren's syndrome. Objective criteria for the diagnosis of xerostomia: at least 2 of the following: (1) reduced unstimulated salivary flow, with <= 1.5 mL saliva collected in 15 minutes (2) lymphoplasmocytic infiltrate in an adequate biopsy of labial salivary glands (sialoadenitis) (3) abnormal salivary gland imaging studies (scintigraphy): • decreased uptake • decreased spontaneous secretion • decreased secretion after citrus stimulation Problems in diagnosis: • Some patients complain of a dry mouth despite evidence of adequate saliva flow. • An inadequate biopsy may miss or insufficiently sample a minor salivary gland. • While biopsy of the parotid gland may be diagnostic, this can result in facial nerve damage, scarring or a cutaneous fistula if not performed carefully. Differential diagnosis (1) Sjogren's syndrome (2) dehydration (3) obstruction to saliva flow (stone, tumor) (4) drug effect or infection References: Daniles TE. Chapter 6: Benign lymphoepithelial lesion and Sjogren's syndrome. pages 83-106. IN: Ellis GL, Auclair PL, Gnepp DR (editors). Surgical Pathology of the Salivary Glands. Volume 25 in Major Problems in Pathology. WB Saunders Company. 1991. Manthorpe R, Oxholm P, et al. The Copenhagen criteria for Sjogren's syndrome. Scand J Rheumatol. 1986; Supplement 61: 19-21. 09 Cariology 09.01 Risk Factors for Caries Development Overview: Certain factors can increase or reduce the risk for development of caries in an individual. Parameter Positive Factor Negative Factor health good serious systemic diseases
  38. 38. medications none medications with saliva affecting drugs or medicines containing sucrose working hours regular working hours shift work mental status relaxed stressed fluoride supplementation present no fluoride DMFT low high number of caries none or few many location of any caries on surfaces at risk on surfaces not normally affected carious lesions hard and pigmented soft and whitish saliva secretion normal decreased saliva buffering capacity normal decreased diet well balanced deficient sucrose low intake especially high intake of snacks between meals microflora low numbers of S. mutans high numbers of S. and lactobacilli mutans and lactobacilli oral hygiene good large amount of plaque Quantitation of bacteria: Streptococcus mutans • S. mutans reflect a caries producing microflora • high levels in saliva: > 1,000,000 per µL saliva • low levels in saliva: < 100,000 per µL saliva • high levels in dental plaque: > 10% • low levels in dental plaque: < 1% Quantitation of bacteria: lactobacilli • lactobacilli reflect a caries-promioting diet • high levels: > 100,000 per µL saliva • low levels: < 1,000 per µL References: Fejerskov O, Manji F. Reactor paper: Risk assessment in dental caries. pages 215-217. IN: Risk Assessment in Dentistry. Proceedings of a Conference. June 2-3, 1989. Chapel Hill, North Carolina. Krasse B. Caries Risk. A Practical Guide for Assessment and Control. Quintessence Publishing Co. Inc. 1985. pages 45-51, 85-89. (Table 5, page 51) Krasse B. Microbiological and salivary risk factors. pages 51-61. IN: Risk Assessment in Dentistry. Proceedings of a Conference. June 2-3, 1989. Chapel Hill, North Carolina. 09.02 Severity Grades of Root Surface Caries
  39. 39. Overview: Caries on the dental root involve destruction of the cementum and penetration of the dentine. They can be graded based on the degree of severity. Features (1) surface defect (2) surface texture (3) pigmention Grade Surface Defect Surface Texture Pigmentation I (incipient) none soft, can be light tan to brown penetrated by dental explorer II (shallow) < 0.50 mm in depth soft or irregular, tan to dark brown rough, can be pentrated by a dental explorer III cavitation >= 0.50 soft, can be light brown to dark (cavitation) mm in depth, no penetrated by a brown pulpal involvement dental explorer IV (pulpal) deeply penetrating brown to dark with pulpal or root brown involvement References: Newbrun E. Problems in caries diagnosis. International Dental J. 1993; 43: 133-142 (Table 2, page 136) 09.03 Root Caries Index (RCI) of Katz Overview: The Root Caries Index (RCI) was developed by Katz to report the severity of a person's caries. Since gingival recession is usually present before a root surface lesion can occur, only teeth with gingival recession are recorded. When multiple types of root surfaces are exposed, the most severely affected surface should be recorded for that tooth (Katz, page 12). An alternative method of recording would be score each surface (up to 4 per tooth) of teeth with gingival recession. total number of teeth showing gingival recession = = (number of teeth showing gingival recession with decay) + (number of teeth showing gingival recession with all root lesions filled) + (number of teeth showing gingival recession with intact surface)
  40. 40. root caries index = = ((number of teeth showing gingival recession with decay) + (number of teeth showing gingival recession with all root lesions filled)) / (total number of teeth showing gingival recession) * 100 Interpretation: • minimum score: 0 • maximum score: 100 • The higher the score the more severe the caries. The index can be modified to report the attack rate for a given tooth or tooth class (premolar, molar, etc.). There are at least 2 sources for underscoring: (1) A root caries may occur at the base of a true periodontal pocket without gingival recession. (2) Gingival swelling may obscure a root caries. References: Katz RV. Assessing root caries in populations: The evolution of the root caries index. Journal of Public Health Dentistry. 1980; 40: 7-16. Kitamura M, Kiyak HA, Mulligan K. Predictors of root caries in the elderly in the elderly. Community Dental Oral Epidemiol. 1986; 14: 34-38. 09.04 Risk Factors for Root Caries in the Elderly Overview: An elderly patient who has retained her or his teeth may be at risk for root caries. An elderly patients with risk factors for dental caries should be targeted for dental examination and care. Risk factors for root caries in the elderly: (1) number of teeth remaining (2) presence of calculus (3) presence of plaque (4) xerostomia from medication and/or disease (5) history of poor dental care (6) difficulty in receiving dental care Distribution for caries: (1) more likely to be found on mandibular teeth than maxillary (2) more likely to affect molars and premolars (3) xerostomic medications increase the risk for caries, particularly in the maxillary teeth References:
  41. 41. Kitamura M, Kiyak HA, Mulligan K. Predictors of root caries in the elderly in the elderly. Community Dental Oral Epidemiol. 1986; 14: 34-38. 10 Mandibular Fracture Score Overview: The Mandibular Fracture Score is a numeric scoring system which gives an objective and standardized assessment for the severity of a mandibular fracture. The score was developed at the University of Munster in Germany. Parameters used for score (1) preoperative • anatomic location • amount of displacement • complex fractures • systemic factors (2) intraoperative • difficult positioning and reduction • undefined occlusion • difficult soft tissue coverage Parameter Finding Points anatomic location symphysis 0 premolar region 1 molar region 2 angle 3 ramus 3 amount of displacement none 0 minor 1 marked 2 complex fractures none 0 minor 1 marked 2 systemic factors none 0 one or more present 2 difficult repositioning and none 0 reduction minor 1 marked 2 undefined occlusion none 0 minor 1 marked 2 difficult soft tissue none 0 coverage minor 1
  42. 42. marked 2 Systemic factors • history of seizure disorders • psychiatric diagnoses • abnormal calcium metabolism • poor oral hygiene • immunodeficiency • severe malnutrition • significant metabolic or endocrine abnormality mandibular fracture score = = SUM(points for the 7 parameters) Multiple fractures • Each fracture is scored individually. • My assumption in the implementation is that the points for systemic factors is added to each score. • Each of these scores is then added together to give a cumulative score. Interpretation • minimal score for a single fracture: 0 • maximum score for a single fracture: 15 • The higher the score, the more severe the fracture. Complications seen after fracture • malocclusion • infection • disturbed wound healing • fifth nerve dysfunction • temperomandibular joint complications From Figure 3, the estimated rate of complications: • for scores 0-4: 2 out of 15 (about 1 in7 = 14%) • for scores 5-9: 4 out of 28 (about 1 in 7 = 14%) • for scores 10-14: 13 out of 27 (about 1 in 2 = 50%) • for scores > 14: 2 out of 3 (66%) References: Joos U, Meyer U, et al. Use of a mandibular fracture score to predict the development of complications. J Oral Maxillofac Surg. 1999; 57: 2-5 11 Cleft Lip and Palate 11.01 Estimation of the Possibility to Restore a Positive Overjet in Patients with Unilateral Cleft Lip and Palate
  43. 43. Overview: The probability of successfully restoring a positive overjet in a child or adolescent with unilateral cleft lip and palate can be predicted based on the patient's age and cephalometric measurements. Patient population • Children and adolescents from 4 to 18 years with unilateral cleft lip and palate. Measurement of the interalveolar relations using cephalometrics: • prosthion (Pr): The point of gingival contact with the upper central incisors • infradentale (Id): The point of gingival contact with the lower central incisors • PL = line through the anterior and posterior nasal spine • ML = the tangent to the mandibular body thorugh the gnathion • modified occlusal plane: plane originating at the point of meeting for the PL and ML lines, and passing through the center between the cusps of the upper and lower incisors during centric occlusion. • Pr line = distance in mm from the Pr to the modified occlusal plane, using a line drawn perpendicular to the modified occlusal plane • Id line = distance in mm from the Id to the modified occlusal plane, using a line drawn perpendicular to the modified occlusal plane NOTE: To get the negative values for (Pr + Id) shown in the figures, one or both of the values for Pr and Id must be negative. sum Pr + Id = = (Pr line in mm) + (Id line in mm) Nomogram (Figure 7, page 120) • Plot of sum of Pr+Id vs age. • This shows 5 parallel sets of lines for 0% (K), 25%, 50%, 75% and 100% probability to FAIL in being able to restore the positive overjet. • Age range is from 4 to 18 years. • Change in slope occurs at 10 and at 15 years. Age Range Slope of Lines with X = age 4 to 10 -0.3333 10 to 15 -0.500 15 to 18 -0.16667 Age Range Probability of Intercept Failure 4 to 10 0% 3.8333 25% 2.8333
  44. 44. 50% 1.8333 75% 0.8333 100% -0.1667 10 to 15 0% 5.5 25% 4.5 50% 3.5 75% 2.5 100% 1.5 15 to 18 0% 0.5 25% -0.5 50% -1.5 75% -2.5 100% -3.5 The location of the sum Pr + Id relative to the probability lines can result in the following likelihood of FAILING in attempts to correct the positive overjet: • 0% (100% success) • 1-24% • 25% • 26-49% • 50% • 51-74% • 75% • 76-99% • 100% (0% success) References: Smahel Z. The prediction of restoration of a positive overjet in unilateral cleft lip and palate. Acta Chirurg Plasticae. 1994; 36: 42-47. Smahel Z. Nomogram for assessment of restoration of a positive overjet in unilateral cleft lip and palate. Acta Chirurg Plasticae. 1997; 39: 117-120. 12 Oral Leukoplakia 12.01 LCP Classification and Staging System for Oral Leukoplakia Overview: The LCP classification and staging system can be used to characterize lesions of oral leukoplakia. A provisional diagnosis can be made when the external appearance cannot distinguish between the different causes of a white mucosal lesion. A definitive diagnosis can be made when an etiologic cause is identified, which usually requires histologic examination of a biopsy. Parameters (1) size in diameter (L)
  45. 45. (2) clinical features (C) (3) pathologic features on biopsy (P) Parameter Finding Code lesional size (L) <= 2 cm L1 > 2 to <= 4 cm L2 > 4 cm L3 not specified Lx clinical aspect (C) homogeneous C1 non-homogeneous C2 not specified Cx pathologic features (P) no dysplasia P1 mild dysplasia P2 moderate dysplasia P3 severe dysplasia P4 not specified Px where: • homogeneous lesion = predominantly white lesion of uniform flat, thin appearance that may exhibit shallow cracks and has a smooth, wrinkled or corrugated surface with consistent texture throughout. • non-homogeneous lesion = predominantly white or mixed white-red lesion that may be irregularly flat, nodular or exophytic. The nodular lesions have a slightly raised, rounded, red and/or white excrescences . The exophytic lesions have irregular blunt or sharp projections. • erythroplakia are reddish lesions of the oral mucosa for which the etiology cannot be identified based on external examination. Mixed red and white lesions are termed erythroleukoplakia. Use: (1) A provisional diagnosis of oral leukoplakia can be made based on size (L) and clinical (C) features. (2) A definitive diagnosis of oral leukoplakia usually requires histologic examination of a biopsy (P) from the lesion. (3) If there is doubt as to which code should be assigned for a given finding, the lower category should be used. (4) Staging is done only for lesions which have been examined histologically. (5) If more than one lesion is present, the L code is based on the largest lesion present and the code is designated "(m)". For example, multiple lesions with the largest one measuring 3 cm would be termed L2(m). (6) If multiple lesions are present, the C code reported is the maximum for all the lesions present. (7) If multiple biopsies from (a) multiple lesions or (b) a single lesions were done, then the highest pathologic code should be reported. (8) The oral subsite for the lesions should be given, according to the ICD-DA
  46. 46. Findings Stage no lesion 0 any L, C1, P1 or P2 1 any L, C2, P1 or P2 2 any L, any C, P3 or P4 3 References: Axell T, Holmstrup P, et al. Internaional seminar on oral leukoplakia and associated lesions related to tobacco habit. Comm Dental Oral Epidem. 1984; 12: 145-154 Axell T, Pindborg JJ, et al. Oral white lesions with special reference to precancerous and tobacco-related lesions: Conclusions of an international symposium held in Uppsala, Sweden, may 18-21 1994. J Oral Pathol Med. 1996; 25: 49-54. Suarez P, Batsakis JG, El-Naggar AK. Leukoplakia: Still a gallimaufry or is progress being made? - A review. Adv Anat Pathol. 1998; 5: 137-155. 12.02 Criteria for the Diagnosis of Oral Hairy Leukoplakia Overview: Oral hairy leukoplakia is a lesion of the lateral tongue that is typically seen in HIV- positive patients. The lesion usually is white, poorly demarcated, and corrugated ("hairy"). Epstein-Barr virus (EBV) can be demonstrated in the lesions by a number of techniques. Parameter Findings clinical usually in high risk category for HIV-disease unilateral or bilateral tongue involvement, rarely on buccal mucosa lack of complete regression after topical or systemic antifungal therapy histolopathology hyperkeratosis, band-like or projections presence of balloon cells usually absence of inflammatory cell infiltrate (inflammation sometimes present) Epstein-Barr viral DNA on in-situ hybridization evidence of herpes-type virus particles on electron microscopy laboratory usually HIV-positive, may be negative High risk populations • intravenous drug abusers • homosexual and bisexual men (men who have sex with men) • hemophiliacs exposed to non-recombinant, pooled plasma concentrates untreated for viral inactivation • females who are sex workers or who have sex with men who are intravenous drug abusers or who have sex with other men
  47. 47. Limitations • Other leukoplakic lesions may clinically mimic oral hairy leukoplakia. • Histologic features like hyperkeratosis are nonspecific. • Morsicatio lingue (tongue biting) may share both clinical and histologic features, but evidence of EBV would be lacking. References: Ficarra G, Gaglioti D, et al. Oral hairy leukoplakia: Clinical aspects, histologic morphology and differential diagnosis. Head & Neck. 1991; 514-521. Suarez P, Batsakis JG, El-Naggar AK. Leukoplakia: Still a gallimaufry or is progress being made? - A review. Adv Anat Pathol. 1998; 5: 137-155. 13 Assessment of the Tonsils and Adenoids 13.01 Estimating Adenoidal Obstruction of the Nasopharyngeal Airway in Children Overview: Children with adenoidal obstruction of the nasopharyngeal airway will show increased mouth breathing and hyponasality in speech. A clinical index based on mouth breathing and nasality of speech correlates with the degree of obstruction seen on X-ray. The study was done at the University of Pittsburgh. Parameters for nasal obstruction index: (1) mouth breathing: The degree of mouth breathing was observed throughout the clinical assessment and included times when the patient was distracted or in repose. The lips are closed when there is no mouth breathing, slightly apart with mild mouth breathing, and widely separated with marked mouth breathing. (2) hyponasality in speech during alternating opening and closing of the nares: With normal speech, nasal resonance is heard when phrases are spoken with the nares open; this is markedly reduced when the nares are pinched close. With hyponasal speech, resonance is poor when the nares are open; little change is noted when the nares are pinched close. Parameter Finding Points mouth breathing none 1 slight 2 moderate 3 marked 4 hyponasality none 1 mild 2 moderate 3 marked 4 nasal obstruction index = = ((points for mouth breathing) + (points for hyponasality)) / 2
  48. 48. In addition, the anterior nasopharynx is examined. Parameter Finding Points nasal secretions none 1 slight 2 moderate 3 marked 4 mucosal edema none 1 mild 2 moderate 3 marked 4 erythema of the nasal mucosa none 1 mild 2 moderate 3 marked 4 compromise of the intranasal none 1 airway mild 2 moderate 3 marked 4 Interpretation: • minimum nasal obstruction index: 1.0 • maximum nasal obstruction index: 4.0 • The anterior nasopharynx should show no or minimal change in order to ascribe evidence of nasal obstruction to enlarged adenoids. • The higher the nasal obstruction index, the greater the degree of adenoidal obstruction. Nasal Obstruction Index Degree of Obstruction on X-rays 1.0 and 1.5 low 2.0 and 2.5 intermediate 3.0, 3.5 and 4.0 high References: Paradise JL, Bernard BS, et al. Assessment of adenoidal obstruction in children: Clinical signs versus roentgenographic findings. Pediatrics. 1998; 101: 979-986. 14 Dental Health Surveys 14.01 The Geriatric Oral Health Assessment Index (GOHAI) Overview:
  49. 49. The Geriatric Oral Health Assessment Index is a self-reported, screening instrument for identifying problems with oral health in an older person. In the past 3 months: (1) How often did you limit the kinds or amounts of food you eat because of problems with your teeth or dentures? (2) How often did you have trouble biting or chewing any kinds of food, such as meat or apples? (3) How often were you able to swallow comfortably? (4) How often have your teeth or dentures prevented you from speaking the way you wanted? (5) How often were you able to eat anything without feeling discomfort? (6) How often did you limit contact with people because of the condition of your teeth or dentures? (7) How often were you pleased or happy with the looks of your teeth and gums, or dentures? (8) How often did you use medicates to relieve pain or discomfort from around your mouth? (9) How often were you worried or concerned about the problems with your teeth, gums, or dentures? (Y or N) (10) How often did you feel nervous or self-conscious because of problems with your teeth, gums or dentures? (11) How often did you feel uncomfortable eating in front of people because of problems with your teeth or dentures? (12) How often were your teeth or gums sensitive to hot, cold, or sweets? Response Points if Positively Points if Negatively Directed Directed always 5 0 very often 4 1 often 3 2 sometimes 2 3 seldom 1 4 never 0 5 Positively directed (high points indicate good oral health): 3, 5, 7 Negatively directed (high points indicates poor oral health): 1, 2, 4, 6, 8, 9, 10, 11, 12 GOHAI = = SUM(points for all 12 questions) Interpretation: • minimum score: 0 • maximum score: 60 • The higher the score the better the oral health.
  50. 50. • Factors associated with lower scores include having fewer teeth, wearing a removable denture, and perceiving the need for dental treatment. References: Atchison KA, Dolan TA. Development of the Geriatric Oral Health Assessment Index. J Dental Education. 1990; 54: 680-687. 14.02 The Child Dental Neglect Scale Overview: The Child Dental Neglect Scale is an interview instrument to be used with parents. It measures a child's level of dental care and can help identify children with a greater need for intervention. The authors are from the University of Adelaide and the South Australian Dental Services. Statements for parents: (1) Your child maintains his/her home dental care. (2) Your child receives the dental care he/she should. (3) You child needs dental care, but you put it off. (4) Your child needs dental care, but he/she puts it off. (5) Your child brushes as well as he/she should. (6) You child controls between meal snacking as well as he/she should. (7) Your child considers his/her dental health to be important. Questions indicating good care: 1, 2, 5, 6, 7 Questions indicating poor care: 3, 4 The responses are graded so that a higher score indicates poorer care. Responses Poor Care Good Care definitely no 1 5 somewhat no 2 4 neutral 3 3 somewhat yes 4 2 definitely yes 5 1 neglect scale = = SUM(points for all 7 statements) Interpretation: • minimum score: 7 • maximum score: 35 • A higher score for all the questions indicates greater dental neglect. • A high score for questions 3 and/or 4 indicates avoidance behavior. A high score for dental neglect was associated with:

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