Assessments Needed for Dental Hygiene Diagnosis

Why are assessments important?
Gathering assessments is the first step in the dental hygiene process of patient care. They are necessary to help us arrive to a diagnosis and create a treatment plan that will lead to improved oral health for our patients.

Medical History- It is important to have an updated medical history for all patients to make sure the patient is safe and healthy to receive treatment. It helps the clinician to evaluate systemic diseases that may lead to oral manifestations and affect the response of the periodontium. It also aids in the detection of systemic or infectious disease that may cause for a treatment modification or require special precautions to protect the patient or clinician.
Dental History-It is important to ask the patients chief complaint or the reason they are seeking treatment, so we can develop a treatment plan that meets their needs. The dental history includes; past dental treatment, frequency of treatment, last date of the patient’s most current cleaning, x-rays, and dental visit. Dental history should include questions regarding the patients past and present history , such as; bleeding gums, pain in teeth or gums, loose teeth, sensitivity to cold/hot/pressure, bad taste, and oral habits like clenching or grinding. All questions require additional information like; location, date of when a symptom started or ended, frequency of occurrences, and any changes in the problem. We should also note the patient’s oral health knowledge and oral hygiene routine.
Extraoral & Intraoral Exam- The head, neck and oral cavity is examined for evidence of diseases, cancers, and to record anatomy that may deviate from normal. Lymph nodes should be palpated for any swelling to identify the presence that the body is fighting an infection. Also the patient’s lips, floor of the mouth, oral mucosa, palate, osseous, tongue, and throat should be examined for any signs of inflammation, abnormalities, lesions, or lumps. All findings should be addressed with the patient and further questioning to determine if the patient is aware of the findings.
Temporomandibular disorder (TMD): Any findings such as pain, popping, or clicking of the jaw upon opening or closing should be noted. It is important to note any condition because it can cause limited opening and discomfort during the appointment or during the patient’s oral hygiene routine
Maximum opening: Identifies if the patient has limited opening that may correlate with TMD.
Facial profile & Angles classification: helps recognize malocclusion. This is important because it will help us modify OHI with different techniques to adapt to the teeth that are not in the ideal position. Also helps with planning the frequency of re-care appointments to help with the areas of plaque retention or areas that are hard for the patient to reach or keep clean.
Salivary Flow: The flow and consistency is important to note because a reduction in saliva can be due to certain diseases or may be a side effect of certain drugs. A concern with decreased salivary flow is the increased risk of caries. It is important to note in changes and if a reduction is noted, we should recommend saliva substitutes and fluoride should be added in the patient’s treatment.
Gingival description: It is important to describe the color, size, shape (contour), consistency, and texture of the gingiva. This will help to recognize signs and effects of inflammation or identify the health of the patient’s gingival tissue. There may either be localized or generalized areas of inflammation. Gingival description should be done at all re-care visits to help evaluate the improvement or decline in the patient oral health status.
Marginal Bleeding Index: Is important to help recognize and record the presence of early inflammatory gingival disease. Each tooth has 6 surfaces, each area that bleeds is marked, and the sum is than divided by the total number of surfaces present. The goal of healthy gingiva is below 10%.
Examination of teeth- When gathering our assessments teeth should be examined for tooth wear; like abrasion, attrition, erosion, and abfraction.
Periodontal Exam: Probing Depths – The purpose of measuring probing depths is to assess the status of the periodontal health. They are used in conjunction with radiographs. The process of probing measures the distance from the gingival margin to the base of the pocket, which is called the pocket depth. Healthy probing depths are considered to be 1-3 mm. Anything higher indicates the presence of inflammation and bone loss. When inflammation is present, the probe can easily go into the tissue, which can result in false readings. These are referred to as pseudo-pockets.
Bleeding on Probing – BOP indicates disease progression at any particular site that continues to bleed over time. It may result from plaque build-up at the margin of the gingiva. Systemic factors can also contribute to bleeding on probing. Some examples of systemic factors are diabetes, leukemia, hormonal imbalances, and pregnancy. Patients that are taking anti-coagulants may display more signs of bleeding because of reduced clotting due to the medication. The goal is to have less than 10% bleeding on probing. Absence of bleeding indicates stability of the periodontium.
Recession – When the gingival margin migrates apically from the crown of the tooth, it is called recession. When this migration goes beyond the CEJ, the patient may experience sensitivity due to exposed cementum. This also causes susceptibility for root caries. Recession can be localized to 1 or more teeth, or generalized. When added to probing depths, it estimates the clinical attachment loss.
Clinical Attachment Loss – The amount of tooth support that has been lost is referred to as Clinical Attachment Loss, or CAL. This is measured by subtract 2mm from the attachment level, which is determined by measuring the distance from the depth of the pocket to the CEJ. This is approximately equal to the average sulcus depth. The attachment loss may extend to the area of the tooth apex. Teeth become loosened due to loss of bone support. It measures the progression of loss over time. This determines bone loss and the degree of periodontal disease severity. When active disease is present, the junctional epithelium migrates toward the root surface of the tooth.
Furcations Furcations are located on the root of a tooth, where the root divides. Furcations should not be clinically visible on health periodontium. They are present when there is attachment loss. The Nabers probe is used to detect furcations that may be present. Furcations can only present on 2-rooted mandibular molars. The extent of the furcations is a factor in diagnosis and treatment planning. There are 4 classes of furcations:1) Class I – Early stage of involvement, the interradicular bone is intact.2) Class II – Can affect 1 or more furcations on a tooth. It is identified as a cul-de-sac with a horizontal loss. Bone loss is present but the furca does not go through the opposite side.3) Class III – Complete loss of interradicular bone with the probe extending through the opposite side.4) Class IV – Loss of attachment and recession with the furca clearly visible clinically. Teeth with furcations are at a greater risk for further bone and tooth loss.Since these areas are difficult to get access to, the hygienist needs to spend more time when cleaning these areas. It is important to demonstrate to a patient how to use interproximal brushes so they can maintain these areas at home.
Mucogingival Defects – Recession extends into the alveolar mucosa. Less than 1 mm of band width is considered a defect.
Mobility Mobility refers to either pathological or physiological movement of the tooth. Physiological movement is considered to be normal and is generally less than 1mm. When mobility extends beyond the physiological range, it is termed pathological. Pathologic mobility is due to factors that affect the PDL and bone loss from periodontal disease. Mobility is measured using the ends of 2 metal instrument handles. There are 3 major types of mobility beyond the normal physiological range, which is noted with a plus sign.1) Class I – Shows slight pathological movement, about 1mm buccal-lingually.2) Class II – Demonstrates moderate pathological movement, which is about 2mm buccal-lingually, with no vertical displacement.3) Class III – Demonstrates severe pathological movement, greater than 2mm buccal-lingually or mesio-distally, including vertical displacement.
Fremitus Vibrations or movements of the teeth when in contacting position. A tooth with fremitus has excess contact. It is used in conjunction with occlusal analysis and is results from the patient’s own occlusal forces. It is diagnosed by placing fingers placed along the facial aspect of the cervical 1/3 of the maxillary teeth while the patient taps teeth together rapidly. This can also be observed visually.
Calculus Code – Calculus code is determined by determining whether the patient is a light, light-medium, medium, medium-heavy, or heavy. An explorer is used to determine the amount of sub- or super-gingival calculus. Depending on the amount detected a classification is determined for the patient. This enables the clinician to determine whether the patient requires local anesthesia during their cleaning. Typically anesthesia is for medium or heavier cases, but some lighter patients require anesthesia because of extreme sensitivity.
ADA Classification ADA classification is the severity of attachment loss as determined by the American Dental Association classifications. Radiographs are used in conjunction with the assessments gathered to classify the patient into the appropriate case type. There are 4 types of ADA Classification:1) Class I – Gingivitis with no attachment or bone loss2) Class II – Early periodontitis3) Class III – Moderate periodontitis4) Class IV – Severe periodontitis
AAP Classification – The American Academy of Periodontology classifies periodontal disease into categories based on their etiology. Some factors that may contribute are age of onset, rate and progression of disease, microbial flora, or systemic influences.
Plaque Index - The purpose of the plaque index is to identify the plaque on all tooth surfaces. This is done by using a disclosing agent. This is an excellent learning tool for patient education. The goal is to have the patient display less than 10% on the plaque index score.