09 Dentistry and Oral Medicine

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).

• 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
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 =

= (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

• not scoreable: X

Interproximal Areas of Maxillary Teeth	Code	Code	Interproximal Areas of 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:

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, papilla, or both)	1
	moderate gingivitis involving both free and attached gingiva	2
	severe gngivitis with hypertrophy and easy hemorrhage	3
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 formation one side not over one half of root length	2
	bone loss about one half of root length, or pocket formation one side not over three fourth root length; mobility slight	3
	bone loss about three quarters of root length, or pocket formation one side to apex; mobility moderate	4
	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:

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 proximal surface	M	3
plaque in contact with gingival tissue on facial or lingual surface	G	2
plaque in contact with gingival tissue on distal proximal surface	D	3
plaque on facial or lingual surface of tooth surface but not in contact with gingival tissue	R	1

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

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.

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 the tooth. Tooth is firm and no exudate is present.	0
Inflammatory changes are present but do not completely encircle the tooth.	1
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 over 5 mm.	5
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)

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 tooth surface, AND/OR the presence of extrinsic stain without other debris regardless of surface area covered	1
soft debris covering more than one third, but not more than two thirds, of the exposed tooth surface	2
soft debris covering more than two thirds of the exposed tooth surface	3

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 third of the exposed tooth surface	1
supragingival calculus covering more than one third 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	2
supragingival calculus covering more than two thirds of the exposed tooth surface AND/OR a continuous heavy band of subgingival calculus around the cervical portion of the tooth	3

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.

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:

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 overhang	inflammation	pocket depth	Class
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

• 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 calculus and overhangs	30 minutes per quadrant for 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

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 margin of the tooth	2
a band of plaque wider than 1 mm coering less than one third of the crown of the tooth	3
plaque covering at least one-third but less than two thirds of the crown of the tooth	4
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 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 color and no swelling	bleeding on probing	1
change in color due to inflammation; no swelling or macroscopic edema	bleeding on probing	2
change in color due to inflammation; slight edematous swelling	bleeding on probing	3
obvious swelling	bleeding on probing	4
spontaneous bleeding; changes in color; marked swelling with or without ulceration	bleeding on probing	5

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.

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 mild edema with slight change in texture	no bleeding	mild	1
redness, hypertrophy, edema and glazing	bleeding on probing/pressure	moderate	2
marked redness, hypertrophy, edema, ulceration	spontaneous bleeding	severe	3

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)

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 inflammation in the investing tissues, nor loss of function due to destruction of supporting tissues)	radiographic appearance normal	0
mild gingivitis (overt area of inflammation in the free gingivae, but this area does not circumscribe the tooth)		1
gingivitis (inflammation completely circumscribes the tooth, but there is no apparent break in the epithelial attachment)		2
(not used in field study)	early, notchlike resorption of the alveolar crest	4
gingivitis with pocket formation (the epithelial attachment is broken, and there is a pocket. There is no interference with normal masticatory function, the tooth is firm in its socket, and has not drifted.	horizontal bone loss involving the entire alveolar crest, up to half of the length of the tooth root (distance from apex to cemento-enamel junction)	6
advanced destruction with loss of masticatory function (tooth may be loose; tooth may have drifted; tooth may sound dull on percussion with a metallic instrument; the tooth may be depressible in its socket)	advanced bone loss, involving more than half of the length of the tooth root, or a definite intrabony pocket with definite widening of the periodontal membranes. There may be root resoprtion, or rarefaction at the apex	8

(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.

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

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?

(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

(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:

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:

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

• 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.

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

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 destroying the soft tissue of the palate	X, and score no further
3	crossbite of individual anterior teeth, when destruction of soft tissue is present	X, and score no further
4	severe traumatic deviations (attach description of condition)	X, and score no further
5A	Overjet greater than 9 mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory and speech difficulties.	X, and score no further
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 molars	*(count) 3, see note below**
10	anterior crowding: Score one point for maxilla, and/or one point for mandible; two points maximum for anterior crowding	*(0, 1 or 2) 5, see note below**
11	labiolingual spread in mm	(mm)
12	posterior unilateral crossbite (must involve 2 or more adjacent teeth, one of which must be a molar)	4

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)

• 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

(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.

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

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, canine and premolar teeth	6
crowding in incisal segments	number of segments crowded	1
spacing in incisal segments	number of segments spaced	1
diastema	in millimeters	3
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; 0.5 cusp = 1, >= 1 cusp = 2	3

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

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 perspective)	USA	Europe	FDI	Set 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 perspective)	USA	Europe	FDI	Set 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 perspective)	USA	Europe	FDI	Set 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 (bicuspid)	13	+5	25	5
left maxillary first premolar (bicuspid)	12	+4	24	4
left maxillary dibular cuspid (canine)	11	+3	23	3
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 (bicuspid)	5	4+	14	4
right maxillary second premolar (bicuspid)	4	5+	15	5
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 perspective)	USA	Europe	FDI	Set 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 (bicuspid)	20	-5	35	5
left mandibular first premolar (bicuspid)	21	-4	34	4
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 (bicuspid)	28	4-	44	4
right mandibular second premolar (bicuspid)	29	5-	45	5
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

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 Maxilla	Center of Body of Mandible	Center of Symphysis of Mandible	Levels Aligned	Type of Asymmetry
midline	midline	midline	all 3	none (normal)
midline	midline	asymmetric	maxilla and body of mandible	I
midline	asymmetric	asymmetric	body and symphysis of mandible	II
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 Asymmetry	Genioplasty	Mandibular Surgery	Maxillary 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
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)

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
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 between meals	high intake of snacks
microflora	low numbers of S. mutans and lactobacilli	high numbers of S. 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

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 penetrated by dental explorer	light tan to brown
II (shallow)	< 0.50 mm in depth	soft or irregular, rough, can be pentrated by a dental explorer	tan to dark brown
III (cavitation)	cavitation >= 0.50 mm in depth, no pulpal involvement	soft, can be penetrated by a dental explorer	light brown to dark brown
IV (pulpal)	deeply penetrating with pulpal or root involvement		brown to dark brown

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.

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)

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.

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:

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 reduction	none	0
	minor	1
	marked	2
undefined occlusion	none	0
	minor	1
	marked	2
difficult soft tissue coverage	none	0
	minor	1
	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

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 Failure	Intercept
4 to 10	0%	3.8333
	25%	2.8333
	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)

(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

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

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

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

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 airway	none	1
	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:

14 Dental Health Surveys

14.01 The Geriatric Oral Health Assessment Index (GOHAI)

Overview:

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:

Response	Points if Positively Directed	Points if Negatively 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.

• Factors associated with lower scores include having fewer teeth, wearing a removable denture, and perceiving the need for dental treatment.

References:

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:

(1) male gender

(2) younger children

(3) mothers having less education

(4) lack of dental care in the previous 2 years

(5) symptom driven dental visits rather than for routine examinations

References:

14.03 Importance of Dental Behaviors Questionnaire

Overview:

The Importance of Dental Behaviors questionnaire can help separate patients depending on how well they understand the behaviors required to maintain good dental hygiene. A person scoring low on the questionnaire may benefit from educational interventions and closer dental monitoring.

Instructions:

In this section, I will read to you some statements about various oral health behaviors. Looking at this rating scale from very important to not at all important (show the 5-point rating scale), tell me how important each of these behaviors is.

Questions:

(2) How important is it to you to floss your teeth for a healthy mouth?

(3) How important is it to you to get good nutrition for good oral health?

(4) How important is it to you to get dental checkups even when there is nothing wrong?

(5) How important is it to you to improve your looks by having healthy teeth and gums?

(6) How important is it for you to learn about proper care for your mouth?

(Question 7 applies for complete denture wearers only)

(7) As a denture-wearer, how important is it for you to get regular dental checkups for a healthy mouth?

(Questions 8 through 10 are for respondents with any natural teeth):

(8) How important is it to you to keep your natural teeth?

(9) How important is it to you to have your teeth cleaned by a dentist or hygienist for a healthy mouth?

(10) How important is it to you that sweet foods might decay your teeth?

Response	Points
not at all important	1
slightly important	2
somewhat important	3
important	4
very important	5

total score =

= SUM(points for all questions that apply)

percent of ideal response =

= ((total score for patient) - 5) / ((maximum number of points) – 5) * 100

Interpretation:

• minimum total score is 7 if no natural teeth and 9 if any natural teeth are present

• maximum total score is 35 if no natural teeth and 45 if any natural teeth are present

• The higher the total score, the better the person's understanding of behaviors required to maintain oral health.

NOTE: Representing the response as a percent of ideal is not included in the reference.

References:

15 Halitosis and Oral Malodor

15.01 Clinical Evaluation of Halitosis

Overview:

Halitosis (bad breath, oral malodor) can be characterized by clinical examination.

Clinical examinations:

(1) whole mouth breath

(2) breath odor while speaking (counting to 20)

(3) odor from anterior dorsum of tongue (wrist lick)

(4) odor from posterior dorsum of tongue

(5) nasal odor

(6) malodor of dental floss passed through the interdental areas

Whole mouth breath test

• The patient exhales briefly through the mouth at a distance of 10 cm from the nose of the judge.

• Malodor is scored using the table below.

Breath odor while speaking (counting to 20)

• The patient is instructed to count from 1 to 20 at a distance of 10 cm from the nose of the judge.

• The first number at which bad breath is detected is recorded.

Odor for anterior dorsum of tongue

• The patient is asked to lick his or her wrist with tongue extended.

• 5 seconds later the observer holds the wrist at 5 cm and assesses the odor.

• Malodor is scored using the table below.

Odor from posterior dorsum of tongue

• The posterior of the tongue is scraped with a plastic spoon or spatula.

• 5 seconds later the observer holds the scarper at 5 cm and assesses the odor,

• Malodor is scored using the table below.

Nasal odor

• The patient exhales briefly through the nose at a distance of 10 cm from the nose of the judge.

• Malodor is scored using the table below.

Malodor of dental floss passed through the interdenta areas

• Unwaxed floss is passed between the posterior teeth.

• The observer holds the floss at a distance of 3 cm and inhales.

• Malodor is scored as present/positive or absent/negative.

Observer Scoring of Malodor	Points
no appreciable odor	0
barely noticeable odor	1
slight but clearly noticeable odor	2
moderate odor	3
strong odor	4
extremely foul odor	5

Limitations:

• Grading of malodor varies between observers.

• A single observer may show variability in grading.

• Scoring of intermediate grades of malodor may be inconsistent.

• Extremely foul odor may be hard to characterize.

• Variability in malodor with time of day, time in menstrual cycle, diet and other factors.

References:

16 Differential Diagnosis of Tooth Discoloration

Overview:

The cause of tooth discoloration can often be determined based on the color, dental examination and clinical history.

Location of the discoloration in or on the teeth:

(1) extrinsic: with exterior of the tooth cleaned, the discoloration is reduced

(2) instrinsic: discoloration persists despite cleaning

Number of teeth involved:

(1) localized: one or a few teeth involved, with others unaffected

(2) generalized: all or most teeth affected

Etiology	Instrinsic vs Extrinsic	Color	Comment
poor oral hygeine	extrinsic	brown, black	generalized
smoking	extrinsic	brown, black	generalized
coffee or tea	extrinsic	brown	generalized
wine	extrinsic	red, purple	generalized
drugs (iron, antibiotics, etc.)	extrinsic	brown, black	generalized
betel nut chewing	extrinsic	brown, black	generalized
trauma	instrinsic	yellow, brown	localized
caries	instrinsic	brown, black, white	localized
restorative material	instrinsic	black, silver, gold	localized
internal resorption	instrinsic	pink	localized
tetracyclines	instrinsic	brown	generalized
excessive fluoride	instrinsic	brown, white	generalized
amelogenesis imperfecta	instrinsic	brown	generalized
dentinogenesis imperfecta	instrinsic	brown, purple	generalized
bilirubin (kernicterus, etc)	instrinsic	green	generalized
porphyria	instrinsic	red	generalized

References:

17 Tongue Size and Macroglossia

17.01 Identification of Pseudomacroglossia

Overview:

Pseudomacroglossia describes the condition in which the tongue appears relatively large but is normal in size. Identification is important, since correction needs to target areas extrinsic to the tongue, rather than the reducing tongue volume itself.

Causes of pseudomacroglossia:

(1) habitual posturing of tongue anteriorly

(2) displacement

• hypertrophy of tonsils and adenoids

• extrinisic cysts or tumors

(3) reduced oral cavity volume

• low palatal vault

• transverse, vertical or anterioposterior deficiency in the maxillary or mandibular arches

(4) severe mandibular deficieny

Optimal correction of pseudomacroglossia depends on the cause.

• Orthognathic surgery can be used to advance the mandible, which can increase the oral cavity volume.

• Anterior posturing of the tongue may be reduced by behavioral counseling.

References:

17.02 Clinical and Cephalometric Features of Macroglossia

Overview:

Macroglossia may be associated with a number of clinical and radiographic findings. The findings may vary between individuals, but patients with true macroglossia will have several findings present.

Clinical Findings (after Table I, page 171)

General appearance

(1) The tongue is grossly enlarged and/or wide, broad and flat.

Changes in arches and/or dentition:

(3) Mandibular prognathism.

(4) Class III malocclusion with or without anterior and posterior crossbite.

(5) Buccal tipping of posterior teeth (increased curve of Wilson in maxillary arch, reverse curve in mandibular arch).

(6) Accentuated curve of Spee (or curve of occlusion; the curved line determined by the occlusal surfaces and incisal edges of teeth when viewed from the side) in the maxillary arch.

(7) Reverse curve of Spee in the mandibular arch.

(8) Decreased transverse width of mandibular and maxillary arches.

(9) Diastemata (space between teeth) in the mandibular or maxillary dentition.

(10) Asymmetry in the maxillary or mandibular arches associated with an asymmetric tongue.

(11) Instability in orthodontic mechanics or orthognathic surgical procedures that in usual circumstances would be stable.

Changes associated with the tongue

(12) Crenation (scalloping) on the tongue.

(13) Glossitis from excessive mouth breathing.

Functional changes

(14) Speech articulation disorders.

(15) Difficulty in eating and swallowing.

(16) Airway difficulties, such as sleep apnea, due to oral or oropharyngeal obstruction.

(17) Drooling

Cephalometric features in Radiographs (after Table II, page 171)

(2) Dentoalveolar protrusion, either mandibular or bimaxillary.

(3) Overangulation of anterior teeth, involving maxillary and/or mandibular dentition.

(4) Disproportionately excessive mandibular growth with dentoalveolar protrusion.

(5) Decreased oropharyngeal airway.

(7) Increased mandibular plane angle

(8) Increased mandibular occlusal plane angle.

References:

18 Measurements of Mouth Opening

Overview:

Several measures of the oral opening are available. Some deal with the distance between the teeth, while others try to measure the opening delimited by the lips. Because of the variability associated with oral opening, a measure may be more useful for monitoring changes for the individual over time rather than for comparison to population norms.

Situations where the extent of oral opening may be measured:

(1) disorders of the temporomandibular joint

(2) prior to tracheal intubation or endoscopy

(3) with scleroderma

(4) following burns of the face or other scarring conditions

One measurement of the oral opening is the distance between the bottom of the upper incisor and the top of the lower incisor with the patient asked to open her or his mouth as wide as possible (Pope, 1995).

The oral aperture is the measurement in millimeters from the outer vermillion borders of the lips when the mouth is maximally opened (Furst, 1979). To measure the dimensions of the oral opening, the horizontal distance between the corners of the mouth (intercommissural distance) is also measured.

If the mouth opening is taken to be an ellipse, then:

approximate circumference of the mouth opening =

= 2 * _ * SQRT((((vertical semiaxis)^2) + ((horizontal semiaxis)^2)) / 2)

area of the mouth opening =

= _ * (vertical semiaxis) * (horizontal semiaxis)

where:

• Semiaxis = half the length of the axis diameter; this is the radius in a circle.

Cephalometry can be used to measure the angle of the opening and the internal distances between bony landmarks.

Limitations on the inter-incisor distance:

(1) This may need to be estimated if the person is missing key incisors.

(2) The inter-gingival distance might be used in an edentulous person for most situations.

(3) A person with abnormal dentition may need to use estimates of incisor location for some situations.

References:

Pope JE, Baron M, et al. Variability of skin scores and clinical measurements of scleroderma. J Rgeumatol. 1995; 22: 1271-1276.

DentAl Algorithms

Dentistry and Oral Medicine

Evaluation of Malocclusion and Need for Orthodontic Treatment

Score

Points

Points

Nasal Obstruction Index

Degree of Obstruction on X-rays

Points

Points