|Standard Clinical Procedures
I. Coronal Caries.
Historical perspective. Caries diagnosis by clinical means has traditionally used a combination of visual, tactile, and radiographic means. The use of a dental explorer for tactile examination has been a controversial issue over the past few years, because of the possibility of Mutans Streptococcus cross-contamination caused by inoculating a healthy pit and fissure system (Loesche, 1998) and because “routine use of the explorer…is likely to damage the enamel matrix of noncavitated lesions where remineralization is taking place (Burt and Eklund, 1999).” In addition, newer diagnostic tools such as the DiagnoDENT have conflicting results that make their use as a diagnostic tool secondary at best (Kidd, Ricketts, Pitts, 1993). Caries is found to be more prevalent in different teeth, and there are definite demographic and behavioral risk factors. Teeth most susceptible to dental caries in the general population are (in order): mandibular first and second molars, maxillary first and second molars, mandibular second biscuspids, maxillary first and second bicuspids, maxillary central and lateral incisors, maxillary canines and mandibular first bicuspids, mandibular central and lateral incisors, and mandibular canines (Klein and Palmer 1941). Demographic risk factors include age (caries risk experience is directly linked to the presence of early childhood caries [Kaste, Marianos, Change, Phipps, 1992]), gender (females tend to have higher DMF scores than males of the same age [U.S. Public Health Service, 1971]), socioeconomic status, familial and genetic patterns, and race and ethnicity. Behavioral variables are well understood by dentists, and include diet, consumption of fluoridated water or lack thereof, oral hygiene, and, especially in early childhood caries development, the age of inoculation of M. Streptococcus. In light of all of these factors, the clinician must use a visual and radiographic examination in combination with an adequate history to make a diagnosis of coronal caries and, more importantly, the treatment needs of the patient.
Standardization. The Schurz Service Unit Dental Program will employ a comprehensive dental examination, to include a visual examination, limited tactile examination by dental explorer, radiographic examination, and dental history and prevention assessment. See A1 – Dental Examination Record – for correct documentation. The use of the D1-D3 scale (WHO) will be utilized to define treatment needs for service unit dental patients:
Criteria for Diagnosing Coronal Caries (D1-D3 Scale)
0. Surface sound. No evidence of treated or untreated clinical caries (slight staining allowed in an otherwise sound fissue).
Treatment modalities. Place a pit and fissure sealant containing fluoride in all primary and permanent posterior teeth, and, if necessary, the palatal pits of maxillary lateral incisors. In the Schurz Service Unit, this is to be done regardless of caries risk classification.
D1. Initial caries. No clinically detectable loss of substance. For pits and fissures, there may be significant staining, discoloration, or rough spots in the enamel that do not catch the explorer (if the explorer is used), but loss of substance cannot be positively diagnosed. For smooth surfaces, these may be white, opaque areas with loss of luster. This diagnosis includes interproximal caries radiographically confined to the enamel.
Treatment modalities. In our population, this presents the greatest challenge to us, since we often tend to err on the side of caution and treatment plan operative dentistry for the incipient lesion. However, the Schurz Service Unit will treat initial caries, as defined above, by use of both fluoride application (varnish or rinse) and pit and fissure sealant application. The patient will be recalled at least every six months for re-evaluation.
Note about DiagnoDENT. If the clinic utilizes the DiagnoDENT to aid in caries diagnosis, it is important to realize that this transillumination tool is most effective over several readings; in other words, a diagnosis should not be made on the basis of a single DiagnoDENT score. However, if the DiagnoDENT score progressively increases at each recall (and is recorded in the Dental Progress Notes), the DiagnoDENT can be an effective tool in caries diagnosis.
D2. Enamel caries. Demonstrable loss of tooth substance in pits, fissures, or on smooth surfaces, but no softened floor or wall or undermined enamel. The texture of the material within the cavity may be chalky or crumbly, but there is no evidence that cavitation has penetrated the dentin.
Treatment modalities. This diagnosis requires the use of a dental explorer, and, as previously stated, the explorer should be used less frequently than in the past. Therefore, if there is visual evidence of loss of tooth substance but the caries does not extend past the dentin-enamel junction, the treatment of choice is a preventive resin restoration (unfilled resin) and fluoride application.
D3. Caries of dentin. Detectably softened floor, undermined enamel, or a softened wall, or the tooth has a temporary filling. On approximal surfaces, the explorer point must enter a lesion with certainty.
Treatment modalities. Prior to the use of the explorer, there should be clear visual and/or radiographic evidence of dentinal caries. Treatment of D3 caries is amalgam or composite restorations.
D4. Pulpal involvement. Deep cavity with probable pulpal involvement. Pulp should not be probed.
Treatment modalities. See endodontic diagnosis and treatments.
It is important to make a distinction between a dental caries diagnosis and the proposed treatment on the Dental Examination Record. For example, if only the mesial surface of tooth #8 is caries, the dentist should not record MFL caries, but only mesial caries, but should clearly mark the treatment plan as an MFL (or ML or MF) composite, should that be the proposed treatment.
If a dentist uses ADA Code 0150, he/she must fulfill all of the requirements of a comprehensive dental examination, which include (and should be documented on the Dental Examination Record):
Coronal caries examination
Root caries examination (adults)
Periodontal Screening and Recording (PSR, or CPITN), ages 15 and higher
Soft tissue examination
Fluorosis examination, to include documentation of any enamel defects
A written, signed proposed treatment plan (signed by the patient and dentist)
Radiographs, as appropriate
Review of the patient’s medical history
If all of the above procedures are not performed during the examination appointment, the dentist did not perform a comprehensive dental examination and must enter an ADA Code of 0140 or 0120.
The Dental Examination Record is an extremely important medico-legal document, and should be completed fully by all service unit dentists. The Prevention Assessment in the right column must be completed on each patient at the initial examination and annual recall (see example), and a Periodontal Screening and Recording (PSR, or, alternatively, the CPITN) should be recorded at each initial and recall examination. The proposed treatment plan must be completed by the treating dentist, not the dental assistant, and should list proposed treatment by appointment (i.e., “Appointment 1 – Seal #19, Amalgam #20, Appointment #2 – Composite #24, 25”). Alternative treatments should be both verbally discussed with the patient and documented on the Dental Examination Record as well. Most importantly, the patient and dentist must sign the Dental Examination Record for it to be a valid medico-legal document.
II. Periodontal Diseases.
Historical perspective. “Plaque-induced periodontal diseases are mixed infections associated with relatively specific groups of indigenous oral bacteria (American Academy of Periodontology, 2003).” The clinical dentist utilizes several objective assessments in making a periodontal diagnosis, including the presence or absence of clinical signs of inflammation – bleeding upon probing, cyanotic gingival color, a purulent gingival sulcus, and loss of interdental papilla – a radiographic examination to determine the percent loss of horizontal bone and possible vertical defects, and assessment of probing depths and attachment loss (and a PSR). In addition, subjective criteria that aid in the diagnosis of periodontal diseases arise from the dentist taking a medical history, dental history (to include reasons for previous tooth loss, current oral hygiene, and tobacco use), and the presence of other signs and symptoms of periodontal disease, such as pain, observable plaque and calculus, etc. A diagnosis of periodontitis based solely on periodontal pocket depth, solely on gingival inflammation, or, in some cases even when both are present, is not always entirely accurate. For example, deeper periodontal pockets without the presence of inflammation may the result of certain systemic diseases, occlusal trauma, or even previous periodontitis but now a stable periodontium, or even pseudopockets resulting from hyperplastic gingival or partially erupted teeth. Gingival inflammation without corresponding pocket depths only indicates gingivitis, when there is no loss of connective tissue attachment. Finally, in some cases where a patient had a history of periodontitis and now exhibits gingival inflammation, the clinical dentist must ascertain whether it is recurrent periodontitis or simply gingivitis superimposed on a stable periodontium.
Standardization. The Schurz Service Unit Dental Program will provide a periodontal assessment on all patients seeking comprehensive oral health care, through conducting a Periodontal Screening and Recording (PSR, or alternatively, a CPITN) for patients over 12 years of age, for permanent teeth excluding third molars, and will schedule and perform a full-mouth periodontal probing for all patients with at least two sextants of a “3” score or a single sextant with a “4” score, using the guidelines set forth below. In addition, the service unit dental program will employ the most recent Classification of Periodontal Diseases and Conditions by the American Academy of Periodontology (1999), which are listed below.
Periodontal Screening and Recording (PSR, using a WHO probe)
Code 0. Health. No clinical evidence of clinical signs and symptoms of gingival inflammation, and no periodontal pockets greater than 3.5 millimeters (the beginning of the black band on the WHO probe). This code is not affected by the amount of plaque evident on the tooth surfaces.
Treatment modalities. Adult prophylaxis (by dentist, dental assistant, or dental hygienist), customized oral hygiene instructions to include demonstration models, and 6 month to one year recalls, depending also on caries risk assessment.
Code 1. Gingivitis. Clinical evidence of inflammation, as evidenced by bleeding upon skimming or bleeding upon probing, with no pocket measurements greater than 3.5 millimeters (the beginning of the black band on the WHO probe).
Treatment modalities. Customized oral hygiene instructions to include demonstration models, rubber-cup prophylaxis if desired by dentist or patient (performed by dentist, dental assistant, or dental hygienist), and 6 month to one year recalls, depending also on caries risk assessment.
Code 2. Gingivitis, calculus present. Clinical evidence of inflammation, as evidenced by bleeding upon skimming or bleeding upon probing, with calculus either visually observed by the dentist or felt by the periodontal probe, with no pocket measurements greater than 3.5 millimeters (the beginning of the black band on the WHO probe).
Treatment modalities. Adult prophylaxis (by dentist, dental hygienist, or dental assistant), to include isolated subgingival or supragingival scaling, customized oral hygiene instructions to include demonstration models, and six-month hygiene recalls.
Code 3. Mild to Moderate Periodontitis. Periodontal pocket depth measurement greater than 3.5 millimeters but less than 5.5 millimeters on at least one tooth in the sextant. It is important to note that clinical signs of inflammation nor subgingival calculus need to be observed in order to assign this code; it is reflective only of the periodontal probing measurement.
Treatment modalities. The dentist must ascertain whether the patient has periodontitis (pocket depths greater than 3.5 mm and less than 5.5 mm, with concurrent signs and symptoms of inflammation and possible calculus) or whether the probing depth is a result of a pseudopocket, hyperplastic tissue, occlusal trauma, or partially erupted tooth. If the dentist makes a diagnosis of periodontitis (see disease classifications), treatment may involve scaling and root planing by quadrant or half mouth – if scaling and root planning is indicated, then it should be done with local anesthesia. The treatment plan must be detailed in the Dental Examination Record by the treating dentist. Scaling and root planing may be performed by the dentist or dental hygienist, while other procedures not requiring anesthesia (prophylaxis with isolated supra- and sub-gingival scaling) may be performed by the dentist, dental hygienist, or dental assistant. Following periodontal therapy, the patient should be recalled at 3-6 month intervals as determined by the dentist or dental hygienist.
Code 4. Moderate to Advanced Periodontitis. Periodontal pocket depth measurement greater than 5.5 millimeters (past the first black band on the WHO probe)on at least one tooth in the sextant. Once a Code 4 is called on a sextant, the dentist need not bother probing the rest of the sextant. It is important to note that clinical signs of inflammation nor subgingival calculus need to be observed in order to assign this code; it is reflective only of the periodontal probing measurement.
Treatment modalities. The dentist must ascertain whether the patient has periodontitis (pocket depths greater than 5.5 mm, with concurrent signs and symptoms of inflammation and possible calculus) or whether the probing depth is a result of a pseudopocket, hyperplastic tissue, occlusal trauma, or partially erupted tooth. If the dentist makes a diagnosis of periodontitis (see disease classifications), treatment may involve a gross debridement (with or without local anesthesia) prior to scaling and root planning, full-mouth periodontal probing before or after the debridement, and scaling and root planing by quadrant or half mouth – with local anesthesia. This treatment plan must be detailed in the Dental Examination Record by the treating dentist. Scaling and root planing may be performed by the dentist or dental hygienist. Following periodontal therapy, the patient should be recalled at an individualized recall based on response to care, no more than 6-month interval (and it can be shorter) as determined by the dentist or dental hygienist.
Treatment for the diabetic patient. Pursuant to the service unit (and IHS) protocol for treating the diabetic dental patient, if a diabetic patient has two sextants of a Code 3 or a single sextant of a Code 4, the patient qualifies as a “protocol” patient. For those patients that do not qualify as a protocol patient, treatment modalities are identical to those of the non-diabetic patient as described above. For the diabetic protocol patient, treatment consists of:
Appointment #1 – Comprehensive dental examination, full-mouth radiographic series, panoramic radiograph if available, preliminary oral hygiene instructions (brushing, flossing). Prescribe Doxycycline, 100 mg tablets, with instructions to take 1 tablet twice daily beginning on the day of the second appointment, for 14 days (28 tablets total).
Appointment #2 – Scaling and root planing, utilizing only the Piezon Master 400 (in other words, very little hand scaling and root planing), under local anesthesia. This procedure should last no more than one hour in length, and should consist of two quadrants. At the appointment, a glycated hemoglobin level (HbA1C) should be ascertained either by referring the patient to the medical department or reviewing the patient’s medical record (the HbA1C must be no more than 30 days old). At this appointment, periodontal probing should be performed and charted on the anesthetized two quadrants, oral hygiene instructions should be customized to the patient (to include an interproximal brush, chlorhexidine rinse, and other hygiene aids), hopeless teeth in the two quadrants should be extracted, and the visit should be recorded on the Diabetic Data Form. At the conclusion of this visit, the patient should be scheduled to return to the dental clinic in two weeks or less (while still under antibiotic coverage).
Appointment #3 -- Scaling and root planing, utilizing only the Piezon Master 400 (in other words, very little hand scaling and root planing), under local anesthesia. This procedure should last no more than one hour in length, and should consist of the remaining quadrants. At this appointment, periodontal probing should be performed and charted on the anesthetized quadrants, oral hygiene instructions should be customized to the patient (to include an interproximal brush, chlorhexidine rinse, and other hygiene aids), hopeless teeth in the remaining anesthetized quadrants should be extracted, and the visit should be recorded on the Diabetic Data Form. At the conclusion of this visit, the patient should be scheduled to return to the dental clinic in 6-8 weeks for re-evaluation.
Appointment #4 – Re-evaluation of the patient, to include isolated spot probing, periodontal maintenance cleaning with the Piezon Master 400, reinforcement of oral hygiene, and the dentist’s determination as to whether the patient’s periodontal status has improved or not (and documented on the Diabetic Data Form). Following this appointment, the patient should be recalled every 3-6 months, depending on the stability of the periodontium, patient compliance, etc. If the periodontal status has improved, the patient can be scheduled for routine restorative procedures.
Appointment #5 – Annual recall of the patient, to include full-mouth periodontal probing, obtaining a HbA1C measurement (by chart review or ordering the test), periodontal maintenance visit, and completing the Diabetic Data Form. If clinically stable with no signs and symptoms of inflammation, the patient can be placed on a 6-month recall program; if not clinically stable, the patient should continue to be recalled every 1-3-6 months until clinically stable. If not clinical stable, the patient should continue to be recalled every 3-6 months and Periostat or local antibiotics should be considered, as well as the patient should be recommended for referral to a periodontist for further treatment.
The Classification of Periodontal Diseases by the American Academy of Periodontology is below. This is the diagnosis that should be entered into diagnosis space on the Dental Examination Record, and should not be confused with Case Types (Case Type I – gingivitis, Case Type II – mild periodontitis, Case Type III – moderate periodontitis, Case Type IV – advanced periodontitis, and Case Type V – refractory periodontitis).