College of Dental Hygienists of Manitoba
COMPETENCY ASSESSMENT
INFORMATION GUIDE
Ensuring the public has access to safe, competent dental hygiene care that contributes to improved oral and overall health
Competency Assessment (CA) Information Guide The intent of the Competency Assessment (CA) is to evaluate dental hygienists for safe, competent practice. Competence is judged to a level of entry-level dental hygienists in Manitoba and evaluates a candidate’s ability to utilize professional knowledge, skills, attitudes and judgment in providing oral health care competently and safely. To qualify for the Competency Assessment, candidates must meet the eligibility criteria established by the College of Dental Hygienists of Manitoba (CDHM). Once your application for assessment has been approved, written confirmation will be sent to you along with further information and documentation. Introduction The CDHM Competency Assessment (CA) has been developed as a Prior Learning and Recognition (PLAR) tool for:
Individuals who have been out of dental hygiene practice for more than three years;
Individuals who have not met the minimum practice hours required in the three year period immediately preceding when registration is sought; or
Graduates of International dental hygiene programs. This Information Guide has been developed to assist candidates in understanding the Competency Assessment (CA) process. It includes the following:
1. Dates 2. Location 3. Documents and Fees 4. Format 5. Evaluation & Results 6. Clients 7. Supplies and Equipment 8. Clinical Procedures 9. Resources 10. Questions 11. Clinical Records 12. Clinic Manual/ Infection Control Manual 13. Criteria for Clinical Evaluation
*This Competency Assessment has been based on the Dental Hygiene Clinical Examination of the CRDHA
College of Dental Hygienists of Manitoba 109-420 Des Meurons, Winnipeg, MB R2H2N9 T: 204-219-2678 F: 204-219-2679 email: [email protected]
1. (CA) DATES Determination of dates depends on the number of candidates involved and availability of clinic space and resources. 2. (CA) LOCATION The CA will be held at the School of Dental Hygiene, University of Manitoba, Bannatyne Campus - 780 Bannatyne Avenue, Winnipeg. It is the responsibility of the CA candidate to make appropriate travel arrangements that ensure arrival to the Competency Assessment (CA) session on time. Late arrivals will not be permitted to continue the Competency Assessment (CA) process and will forfeit the Competency Assessment (CA) fees.
3. (CA) DOCUMENTS AND FEES Those individuals who wish to take the CA must:
1. Submit a complete Application for Registration with the CDHM, including all the supporting documentation and requirements, including:
Official transcript sent directly to the CDHM by the granting institution
Notarized copy of the National Dental Hygiene Certification Board Examination (NDHCE) certificate
Evidence of holding professional liability insurance in the amount of $1,000,000 per claim, $3,000,000 aggregate
2. Submit a completed Application for Competency Assessment form; 3. Enclose payment (personal or certified cheque acceptable)
Competency Assessment (CA) Fee: approximately $2,500.00 Request for withdrawal from the examination, for any reason, must be made in writing a minimum of five working days before the first day of the CA. Withdrawal for any reason, in the specified notice period, will result in a cancellation fee of $300.00. Withdrawal without the minimum specified notice or failure to appear for the examination will result in forfeiture of the entire CA fee. All fees are subject to change without notice. Once a candidate’s application for Competency Assessment has been approved, a Candidate Package will be provided that further details the assessment and the criteria measured.
4. (CA) FORMAT The Competency Assessment (CA) has been developed by a group of dental hygiene instructors at the School of Dental Hygiene, University of Manitoba. The Competency Assessment (CA) represents the basic knowledge and skills needed to practice safely and competently as a dental hygienist in Manitoba.
The Competency Assessment (CA) is offered over two days: Part 1: Day One (AM) – Jurisprudence The jurisprudence exam will consist of 25 multiple choice questions that review the legislation and jurisprudence that applies to dental hygiene practice in Manitoba. The duration of the exam will be 60 minutes. A score of 80% is required for successful completion. Orientation: to the School of Dental Hygiene clinical facility.
Materials Available for the Jurisprudence Examination The following materials will be available to the candidate for study prior to the examination:
1. The Dental Hygienists Act 2. The Dental Hygienist Regulations 3. The CDHM Bylaws 4. The CDHM Practice Standards 5. The CDHM Competencies 6. The CDHM Continuing Competency Program Package
Part 2: Day One (PM) – Radiography During Part Two of the examination, competence in both the taking and interpretation of radiographs will be assessed. Section 1: Radiographic Survey Technique includes exposing, processing and mounting films; answering questions related to radiography theory and radiation hygiene; evaluation of the quality of radiographs including identifying technical errors and the need for retakes, and interpretation of radiographs (eg. anatomical landmarks, abnormal conditions, artifacts, restorative care, technical errors). Candidates will be required to take a full mouth series of periapical and bite wing radiographs (16 projections plus 2-4 bitewings) on a DxTR mannequin, as directed by the assessor. The maximum allotted time will be 90 minutes. The choice of using either film-based or digital radiographic equipment will be determined by candidate and assessor. Section 2: Radiographic Survey Interpretation assesses competence in the interpretation of radiographs through completion of an objective simulated clinical examination (OSCE). The examination will consist of a maximum of 60 questions, based on a series of radiographs to be projected on a screen in a classroom-style examination setting. The exam questions require short-answer written responses. The maximum allotted time will be 90 minutes. No backpacks, textbooks, study materials, cell phones and other electronic devices or other unauthorized materials are permitted during the examination period. Equipment and Materials Available for the Radiography Examination In addition to digital radiography equipment, the following film-based equipment will be available in the radiography clinic:
- X-ray Units: 70-100 kv (adjustable) Collimation – Extended Target to Film (16” long cone) Open Ended Cylinders
- Automatic Processor - Timers - Films: Intraoral size, 1, 2, Periapicals, Bite Wing Films
- Holders: Rinn XCP Instrument Package, Bite Wing Tabs, Cotton Rolls - Full Survey Mounts - Electronic View Boxes
Part 3: Day Two (AM & PM) – Clinical Therapy - Full day in the clinic with a client The candidate’s competence will be assessed relating to the fo llowing clinical areas of dental hygiene practice: Medical & Dental History, Extra/Intraoral Exam, Periodontal Assessment & Charting, Hard Tissue Charting & Occlusal Analysis, Dental Hygiene Diagnosis including client-specific Radiographic Interpretation, Care Planning, Oral Hygiene Instruction, Clinical Conduct & Management, Instrumentation Procedures, Polishing & Adjunctive Therapies (e.g. Fluoride, Desensitization) and Evaluation. The candidate must supply their own client for Part Two of the examination, however if there are challenges around finding clients the CDHM will endeavour to support the applicant in this regard. Criteria for client selection are provided later in this guide. Additional Skills – Local Anaesthesia/Restorative If a candidate requires assessment regarding the administration of local anaesthesia and/or restorative skills, the candidate will be required to successfully complete the University of Manitoba School of Dental Hygiene anaesthetic and/or restorative modules offered throughout the year. The cost incurred will be at the additional expense of the candidate, and not included in the cost of the competency assessment. The administration of local anaesthetic is still an optional skill and not required by candidates to practice dental hygiene in the province of Manitoba. Information can be obtained by contacting the School of Dental Hygiene.
5. EVALUATION & RESULTS Evaluation criteria for each clinical procedure are specified in the CA Handbook provided to candidates once registration for the exam is complete. Candidates must successfully complete all parts of the clinical components of the Competency Assessment (CA) to pass. Results and Registration to Practice Successful candidates will be notified in writing of the results of their CA. Successful completion of the CA must be followed by completion of all processes for registration with the CDHM. Successful candidates must not engage in the practice of dental hygiene in Manitoba until the CDHM has issued a registration number and a practicing license in the person’s name. Unsuccessful candidates are advised in writing of the detailed results of the competency assessment. Assessment Re-takes Unsuccessful candidates may apply for re-examination at the next scheduled examination session. Payment of the set examination fee is required for re-examination.
A candidate will be allowed a maximum of three attempts to pass the clinical examination. After the second unsuccessful attempt, the candidate must provide evidence of completing a refresher, remedial or upgrading course prior to being allowed a third and final attempt at the clinical examination.
6. CLIENTS Selection of an appropriate client is a critical factor in the Competency Assessment (CA). The candidate must supply a client. The CDHM, its staff or examiners cannot assist candidates in obtaining clients before or during the examination. One adult client who can attend for a full day is required for the CA. All clinical procedures are performed on the same client. Medically compromised clients are not suitable for the clinical examination. Specific client criteria are required in order to assess the candidate’s clinical competence. To ensure suitability, the candidate should obtain a current medical history and do a screening check to verify that the client meets the examination criteria prior to appearing at the examination. An alternative client is strongly suggested if a candidate is unsure of the client’s acceptability or reliability. Incomplete procedures cannot be evaluated. Therefore, an additional consideration in client selection is the cooperative attitude of the client. A client who is apprehensive, hypersensitive or who is unable to remain until the CA is completed should not be selected. If your client refuses certain aspects of the treatment to be assessed or refuses to be examined by three examiners at any evaluation check-point, the examination will be determined a “fail”. Examination clients must meet all of the following criteria:
Adult client (minimum 18 years of age)
Must not be a dentist, a dental hygienist, a dental assistant or a student of a dentistry, dental hygiene or dental assisting program.
Must have a minimum of 20 teeth, with teeth in at least three quadrants. At least three of the teeth in a quadrant must be bicuspids and molars.
Must have bite wing radiographs taken within the last two years. Radiographs must be available, clear and exhibit minimal distortion. Radiographs may be horizontal or vertical. Interproximal bone level must be visible on all radiographs. If possible, please make duplicates, if necessary, as one set of radiographs must be left in the client chart as part of the permanent clinical exam records.
Must have supra and subgingival calculus (SP/SB 2 or 3 as defined below).
Must present with written medical clearance and antibiotic prophylaxis from a physician or dentist if the client has any significant medical problem requiring antibiotic coverage (e.g. joint prosthesis, artificial heart valves, history of infective endocarditis, serious congenital heart conditions, cardiac transplant). The medical clearance must indicate the specific medical concern.
Must have a blood pressure reading of 160/100 or below. A client with a blood pressure between 160/100 and 180/110 is accepted only with the written consent of the client’s
physician. The CDHM does not allow treatment of any client with a blood pressure greater than 180/110.
Must not have orthodontic bands (bonded lingual arch wires are acceptable).
Must not have had a heart attack, stroke or cardiac surgery within the past six months.
Must not have active tuberculosis. Clinical signs would include: a bad cold that has lasted longer than two weeks, pain in the chest, coughing up blood or sputum. A client who has tested positive for TB, or is being treated for TB but does not have the clinical symptoms, is acceptable.
Must not have orofacial herpes at the prodromal, vesicle, or ulcerated vesicle stages.
Must not have any condition or medication/drug history that might be adversely aggravated by the length or nature of the examination procedures.
Must not have been treated with intravenous bisphosphonates (e.g. Zometa or Aredia) for bone cancer or severe osteoporosis.
A calculus classification of SP/SB 2 or 3 is required for the Clinical Examination. A candidate will not be permitted to continue with the examination if his/her client does not meet these criteria.
SP2 - moderate amount of supragingival calculus covering 1/4 to 1/2 of the tooth
SP3 - heavy amount of supragingival calculus covering more than 1/2 of the tooth
SB2 - moderate amount of subgingival calculus (e.g. ledges, rings, or readily detectable interproximal deposits burnished calculus)
SB3 - heavy amount of subgingival calculus (e.g. finger-like or fern-like projections down the
roots, or continuous rings surrounding the cervical portion of the tooth surface) which are radiographically visible.
* Other factors may be taken into consideration when determining the deposit classification
at the evaluators’ discretion.
Candidates are advised not to select clients that have:
Generalized probing depths greater than 6mm
Class III furcations, Class III mobility
A number of temporary or faulty restorations or overhangs that extend subgingivally.
Gross caries that extend subgingivally or will interfere with calculus removal and/or patient comfort.
Crowns with rough or poor subgingival margins (smooth and/or supragingival margins are acceptable).
If a client brought to the Competency Assessment does not meet the stated criteria and is not suitable for assessment of the candidate’s clinical skills, or is not medically suitable for dental hygiene care, the client will be disqualified as an assessment client. An acceptable alternative client should be available in enough time for the candidate to continue with the assessment as scheduled. Inability to provide a suitable alternative client will result in termination of the assessment and forfeiture of the assessment fee.
SCHEDULE FOR PART 3: CLINICAL THERAPY
Candidate Schedule
Assessor Evaluation
Procedures
8:30 – 9:00 a.m.
Candidate Set-up of Clinical Unit
9:00 – 9:20 a.m.
Seat Client Complete Medical/Dental History
9:20 – 9:30 a.m.
Assessor checks: Medical/Dental History and Client Suitability
9:30 – 10:00 a.m.
Extraoral/Intraoral Exam & Observations (15 minutes) Deposit Assessment (5 minutes) Interpretation of client radiographs (10 minutes)
10:00 – 10:10 a.m.
Assessor checks: Extraoral/Intraoral Exam & Observations, Deposit Assessment, Client Radiographs Assessor assigns: specific areas to be probed, charted, and instrumented
10:10 – 10:50 a.m.
Periodontal Charting, Periodontal Diagnosis, Occlusal Analysis, Hard Tissue Charting, Caries Risk Profile
10:50 – 11:10 a.m. Assessor checks: Periodontal Charting, Periodontal Diagnosis, Occlusal Analysis, Hard Tissue Charting, Caries Risk Profile
11:10 – 11:25 a.m.
Care Plan
11:25 – 11:30 a.m. Assessor Checks: Care Plan
11:30 – 11:50 a.m.
Evaluation will occur at the time OH instruction is provided to client
Oral Hygiene Instruction, Dismiss Client
Candidate Schedule
Assessor Evaluation
Procedures
11:50 – 12:00 p.m.
Clean up of clinical unit
12:00 – 1:00 p.m. Lunch break
1:00 – 3:30 p.m. Power Instrumentation assessment will occur at 15-20 minute intervals
Instrumentation Power Instrumentation: Class 2 deposit: 15-20 minutes per quadrant Class 3 deposit: 15-20 minutes per sextant Assessors may allot more time depending on complexity of case Hand Instrumentation: Depending on the complexity of the case, specific areas assigned for instrumentation will be evaluated at time frames set by the assessors. Time adjustment will be made in overall time allotted if client requires anaesthetic
3:30 – 4:00 p.m. Evaluation will occur at the time adjunctive procedure are being performed
Adjunctive therapies (stain removal, polishing, fluoride, desensitization, etc.)
7. SUPPLIES AND EQUIPMENT The Competency Assessment (CA) facility is a modern, fully equipped dental clinic at the Faculty of Dentistry, University of Manitoba. Candidates are expected to provide:
- Sterilized hand instruments. Kit must include mirror, explorers, probes, and scalers including sickle scalers H6/7, S204 and any additional choice (eg. Nevi or Montana Jack) and curet scalers including a universal curet and a selection of area-specific Graceys
- An extra exam kit – mirror, explorer and probe, which is sterilized and packaged separately from all other instruments
- Sterilized instrument sharpening stone - Sterilized acrylic testing stick to assess instrument sharpness - Personal safety glasses - Any other equipment that the candidate thinks will be necessary - A combination lock to secure personal items in an assigned locker
The following equipment will be available at the examination site: Candidates may wish to bring their own preferred items.
- Bib clips - Hand mirror - Client Safety Glasses - Sterilizing & Disinfecting Supplies and
Equipment
- Hand pieces and Prophy angles - Rubber cups & Brushes - Instrument Trays - Self-aspirating Anaesthetic Syringe
and Hemostat - Anaesthesia Agents - Saliva Ejectors &/or Suction Tips - Air/Water Syringe Tips - Sphygmomanometer
- Stethoscope - Bite Block - Model 3000 Series (30k) Cavitron &
Inserts - Cotton Rolls - Cotton Tip Applicators - Gauze - Kleenex - Dappen Dishes - Disclosing Solution - Polishing Agents - Gloves - Masks - Fluoride Trays - Fluoride Gel
All instruments brought to the Competency Assessment (CA) must be sterilized . There is no time to sterilize instruments prior to the Competency Assessment (CA). All instruments brought to the Competency Assessment (CA) must be sharpened prior to the clinical session. Candidates will also be expected to demonstrate instrument sharpening skills and maintain sharp instruments during debridement.
8. CLINICAL PROCEDURES Detailed Competency Assessment (CA) information, including a schedule, sample charts, Clinic Manual, Infection Control Guidelines and Evaluation Criteria for Competence, are included in this package. General Information
Examiners will be using the International Tooth Numbering System
The Competency Assessment (CA) is divided into three parts and candidates are required to complete all parts within a specified time period. Times will be strictly adhered to.
Some procedures are evaluated at their completion; others are evaluated while they are being performed and also at completion.
Examiners evaluate each procedure by comparing the candidate's practice to specific written criteria. These criteria are included in the CA Handbook.
9. RESOURCES The following reference texts are recommended to assist candidates with Competency Assessment (CA) preparation:
Daniel, S. & Harfst, S. (2002) Mosby’s Dental Hygiene – Concepts, Cases and Competencies
Darby, M. & Walsh, M. (2009). Dental Hygiene Theory and Practice. 3rd Ed., St Louis, Saunders.
Haring, Joen I. & Lind, Laura J. (1993) Radiographic Interpretation for the Dental Hygienist. Login Brothers.
Nield-Gehrig, Jill S. (2008) Fundamentals of Periodontal Instrumentation. 6th Ed., Lippincott Williams & Wilkins.
Weinberg, M (2001) Comprehensive Periodontics for the Dental Hygienist Dental hygiene textbooks are not commonly found in local libraries. Textbooks may be available in bookstores of universities and community colleges with dental hygiene programs. They may also be available as a library loan, for a fee. In Winnipeg, dental hygiene education is offered at the School of Dental Hygiene, University of Manitoba, Bannatyne Campus. The Neil John Maclean Health Sciences Library, is located at 770 Bannatyne Avenue, Bannatyne Campus.
10. QUESTIONS Questions concerning the Competency Assessment (CA) process should be directed to the College office: College of Dental Hygienists of Manitoba 109-420 Des Meurons Street Winnipeg, MB. R2H2N9 T: 204-219-2678 F: 204-219-2679 [email protected] www.cdhm.info
11. CLINICAL RECORDS The following records comprise the Client Chart. Candidates are expected to complete the following records during, but not prior to, their clinical assessment.
1. Client Consent/ Release Form 2. History
I. Dental History II. Medical History
3. Dental Hygiene Assessment Summary – Periodontal and Hard Tissue Record I. Health History
II. Client’s Chief Concern III. Oral Health Behaviours IV. Tobacco Use History V. Extra-Oral Observations
VI. Intra-Oral Observations VII. Assessment Data
VIII. Periodontal Charting IX. Periodontal Diagnosis X. Occlusal Analysis
XI. Dentures/Appliances XII. Caries Risk Profile
XIII. Hard Tissue Charting 4. Dental Hygiene Care Plan/ Human Needs Assessment Reference form 5. Daily Treatment Record
12. CLINIC MANUAL A selection of information required for the completion of the client ’s chart: Medical/Dental History and Vital signs Health history and dental history must be accurately completed by the candidate. All “Yes” responses to health history questions must be clarified in writing. Candidates are expected to accurately record vital signs including blood pressure, respiration and heart rate on the Dental Hygiene Assessment Summary. The health history must be reviewed by an examiner before any form of treatment is performed. Once the health history is cleared, the examiners will do a cursory assessment to determine client suitability. Vital Signs It is expected that the candidate will:
1. Check the medical/dental history for pertinent information, and if any, note and act
appropriately upon it. 2. Assemble the armamentarium: blood pressure cuff and bulb, sphygmomanometer,
stethoscope, timepiece with second hand. 3. Explain procedure and rationale to the client. 4. Take vital signs on all individuals who are 18 years of age and older or when it is deemed
necessary due to medical conditions.
A. Respiration i) Observe client's chest for 60 seconds unobtrusively and measure respiration rate. ii) Determine respiratory rate, rhythm, depth, and sound, and record findings.
B. Pulse
i) Palpate accessible artery a) Radial artery - place 2 fingers over radial artery at wrist b) Carotid artery - place 2 fingers gently below the mandible c) Temporal artery - place fingers on artery at a temporal fossa
ii) Evaluate and record rate/minute, rhythm, and quality. C. Blood Pressure
i) Prepare Client - seat client with right brachial artery at level of heart - or if client is lying down be sure to record this as client position. - request client to roll up sleeve or remove clothing restricting access to brachial artery - position arm in slightly flexed position with hand open and relaxed
ii) Manometer Gauge - should be vertical and less than 3 feet away from observer - eye should be level with upper end of mercury column.
iii) Place Cuff
- locate brachial artery on medial aspect of antecubital fossa - wrap cuff firmly and evenly around arm (lower border of cuff 1" above pulse site) - situate rubber tubing medially, straddling brachial artery - place gauge in position to be easily viewed
iv) Inflate Cuff - place earpieces of stethoscope in ears with earpieces directed forward - close air cut-off valve (turn clockwise)
Technique: - place diaphragm on brachial pulse site so entire surface contacts arm - pump air into cuff until brachial pulse can no longer be heard - at this point observe the reading - continue pumping bulb until pressure is 20-30 mm. HG. above level at which brachial pulse disappears. Determine Systolic Pressure - open cut-off valve (turn counter clockwise) - allow pressure to decline 2 to 3 mm. Hg./second - listen attentively through stethoscope - listen for Korotkoff sounds as pressure approaches level where radial -brachial pulse disappeared - note pressure reading when first sound occurs Determine Diastolic Pressure
- continue decreasing pressure - note pressure reading when last sound occurs - open valve slowly to release remaining air in cuff - record systolic over diastolic - compare blood pressure with normal range for client - if reading is not near normal, repeat to verify (allow at least 5 minutes between readings if reevaluation is necessary) - advise client about the reading. For a client with blood pressure significantly above or below normal, advise him/her to see his/her physician to have it checked out.
Remove Cuff and Stethoscope
- disinfect earpieces (wipe with gauze. Do not spray directly on or into earpieces) - remove and rewrap cuff
5. Correlate information concerning vital signs with medical/dental history findings, and determine their significance to the delivery of oral care. If unable to interpret the findings, or
if an abnormal or unusual condition is identified, seek additional advice. When indicated, modify treatment plan.
6. Make complete, accurate, dated chart entry in ink.
Vital Signs
Values of Significance in dental and dental hygiene appointments
Pulse Rate
Normal Adult Range 60 to 100 per minute Normal Child Range 70 to 120 per minute
Respiration
Normal Adult Range 14 to 20 per minute Child Average 20/minute Accelerated >28 per minute Dangerous >60 per minute
Blood Pressure (taken on all Adults 18 years old plus) (always taken on a child who is medically compromised)
Systolic/ Diastolic/
Range Range (mm Hg) Adult Low <100 <70 Normal <130 <85 High Normal 130-139 85-89 1. Mild Hypertension 140-159 90-99 2. Moderate Hypertension 160-179 100-109* 3. Severe Hypertension 180-209 110-119** Child/Age Averages 3 year old 108/70 mm Hg 6 year old 114/74 mm Hg 12 year old 122/78 mm Hg
* Refer for additional medical evaluation within one month ** Refer for immediate medical evaluation; reappoint for dental
or dental hygiene therapy
Dental Management of Hypertensive Adults <140/90- Routine dental treatment can be provided; recommend lifestyle modifications (diet, exercise, quit smoking). Retake blood pressure at continuing appointments. 140-159/90-99- Retake blood pressure in 5 minutes to ensure accuracy of first reading. Inform client of blood pressure status; recommend lifestyle modifications. Routine dental treatment can be provided. Limit vasoconstrictor. 160-179/100-109- Retake after 5 minutes. If still elevated inform client. Refer for medical evaluation within 1 month; delay treatment if client is unable to handle stress or if procedure is stressful. Limit vasoconstrictor-use 1:200,000 or no vasoconstrictor. Routine treatment can be provided. Employ stress reduction strategies. >180/>110- Retake after 5 minutes. Delay treatment until pressure controlled. Refer to physician prior to dental treatment. If emergency treatment is required, it should be done in a setting with emergency life support equipment available such as a hospital setting. Extraoral & Intraoral Examination An inspection is made of the extraoral and intraoral features using visual and tactile examination methods. The candidate is to identify all existing conditions which deviate from normal and record the appropriate information in the chart. Although tori, Fordyce granules and linea alba are not abnormal conditions, it is to your benefit to make note of their existence so the examiners know that you have recognized and identified them. Extraoral Exam
a) visually examine face for asymmetry, swelling, skin blemishes, pigmentations, etc.
b) for the submandibular glands, stand behind the client, have them tilt their head to the side being palpated. With the opposite hand pull tissues taut, away from area to be palpated. With palpation, hand roll tissue over the border of the mandible. Palpable nodes will “pop” over the bone and be easily detectable. Use a similar roll for the submental glands.
c) palpate anterior, inferior, and posterior auricular nodes using circular compression against
tissues.
d) palpate occipital lymph nodes, located at the base of the skull at the back of the head. With client leaning forward apply bilateral digital circular compressions beginning at the back of the neck extending horizontally to the sternocleidomastoid muscle.
e) palpate sternocleidomastoid muscle unilaterally. Client's head is turned to the side, and chin
is slightly down, resting in clinician's free hand. Palpate using bidigital compression starting from below ear and continue the entire length of muscle to clavicle.
f) palpate superficial anterior and posterior cervical chain of lymph nodes bilaterally. With client's head upright and in a forward position apply digital compression and circular movement along the anterior and posterior aspects of the sternocleidomastoid muscle.
g) palpate the parotid gland (including parotid nodes) bilaterally using digital compression and circular motion. Begin anterior to tragus of the ear, extending forward to cheek area, and downward to the angle of the mandible.
h) palpate masseter muscle bilaterally beginning at the angle of the mandible and extend up
onto the cheek. Have client clinch several times to facilitate complete examination.
i) palpate temporomandibluar joint bilaterally. Finger tips are placed bilaterally just anterior to outer meatus (opening) of the ear. Client should be asked to open and close several times, perform right and left lateral movements of the mandible with the mouth open, and perform protrusive movements of the mandible with the teeth occluded and then apart. Temporomandibular disorders such as muscle and joint pain, limitation of mandibular movement, clicking/crepitus sounds during condyle movement, history of clenching or bruxism, pain in TMJ area, and client's past history of headaches and TMJ sensitivity is also recorded under E/O.
j) palpate thyroid gland (located vertically between the cricothyroid ligament and the fourth
tracheal ring and horizontally between the sternocleidomastoid muscle and the trachea). Using one hand to displace the tissue of the thyroid gland to one side of the trachea, the fingers of the opposite hand apply circular digital compressions of these areas. Having the client swallow will aid in examining the thyroid gland for changes in shape, size, or lack of movement.
Gingival Assessment The gingival assessment is part of the preliminary data collection. Inspection is made using visual and tactile examination methods and existing conditions are recorded.
Candidates are to use assessment criteria which includes colour, contour, consistency, texture, size, bleeding, exudate, etc. A list of commonly used terms for describing the clinical signs and symptoms of the free and attached gingiva is provided on the next two pages. Candidates are to identify all existing conditions which deviate from the normal and record this information on the gingival assessment form.
Gingival Examination
Appearance in Health
Changes in Disease Clinical Appearance
Causes for Changes
Colour
Uniformly pale pink or coral pink Variations in pigmentation related to complexion, race
Acute: bright red
Inflation: capillary dilation increased blood flow
Chronic: bluish pink bluish red
Vessels engorged Blood flow sluggish Venous return impaired Anoxemia Increased fibrosis
Attached gingiva: colour change may extend to mucogingival line
Deepening of pocket, muco-gingival involvement
Size
Not enlarged Fits snugly around the tooth
Enlarged
Edematous: inflammatory fluid cellular exudate vascular engorgement hemorrhage Fibrotic: new collagen fibers
Shape Marginal gingiva: knife-edged, flat follows a curved line about the tooth Papillae: 1. normal contact papilla is pointed and pyramidal; fills the interproximal area 2. space (diastema) between teeth: gingiva is flat or saddle-shaped
Marginal gingiva: rounded rolled Papillae: bulbous flattened blunted cratered
Inflammatory changes edema or fibrosis Bulbous with gingival enlargement (see edematous and fibrotic, above) Cratered in necrotizing ulcerative gingivitis
Consistency Firm Attached gingiva firmly bound down Limited zone of attached gingiva
Soft, spongy: dents readily when pressed with probe Associated with red color, smooth, shiny surface, loss of stippling, bleeding on probing
Edematous: fluid between cells in connective tissue
Firm, hard: resists probe pressure Associated with pink color, stippling, bleeding only in depth of pocket
Fibrotic: collagen
Surface Texture
Free gingiva: smooth Attached gingiva: stippled
Acute condition: smooth shiny gingiva Chronic: hard, firm with stippling, sometimes harder than normal
Inflammatory changes in the connective tissue: edema, cellular infiltration Fibrosis
Examination of the gingiva, Clinical Reference Chart (continued)
Appearance in Health
Changes in Disease Clinical Appearance
Causes for Changes
Position of Gingival Margin
Fully erupted tooth: margin is 1-2 mm above cemento- enamel junction, at or slightly below the enamel contour
Enlarged gingiva: margin is higher on the tooth, above normal, pocket deepened Recession: margin is more apical; root surface is exposed
Endematous or fibrotic Junctional epithelium has migrated along the root; gingival margin follows
Position of Junctional Epithelium
During eruption: along the enamel surface Fully erupted tooth: the junctional epithelium is at the cementoenamel junction
Position, determined by use of probe, is on the root surface
Apical migration of the epithelium along the root
Mucogingival
Make clear demarcation between the pink, stippled attached gingiva and the darker alveolar mucosa with smooth shiny surface
No attached gingiva: (1) colour changes may extend full height of the gingiva; mucogingival line obliterated (2) Probing reveals that that the bottom of the pocket extends into the alveolar mucosa (3) Frenal pull may displace the gingival margin from the tooth
Deepening of the pocket Apical migration of the junctional epithelium Attached gingiva decreases with pocket deepening Inflammation extends into alveolar musosa
Bleeding
No spontaneous bleeding or upon probing
Spontaneous bleeding Bleeding on probing: Bleeding near margin in acute condition; bleeding deep in pocket in chronic condition
Degeneration of the sulcular epithelium with the formation of pocket epithelium Blood vessels engorged Tissue edematous
Exudate
No exudate on pressure
White fluid, pus, visible digital pressure Amount not related to pocket depth
Inflammation in the connective tissue Excessive accumulation of white blood cells with serum and tissue fluid makes up the exudate (pus)
Deposit Classification
Deposit classification is based on the amount of plaque, stain and calculus present and the periodontal condition of the client. Three parameters are utilized to describe stain and calculus deposits. The first is a label, indicating the type of deposit. The second is a numerical scale, indicating the extent of the deposit. The third parameter is a description of whether the deposit is localized (L) or generalized (G).
Type of Deposit Numerical Scale Location
Stain = ST 0 = deposit free * Localized Supragingival deposit = SP 1 = light * Generalized Subgingival deposit = SB 2 = moderate 3 = heavy *Definitions Localized = 1, 2 or 3 areas of 1 or 2 teeth Generalized = in 2 or more sextants involving more than 2 teeth
Description of Stain ST0 - no stain visible
ST1 - light stain (eg. located on the cervical portion of the tooth; covering
< ¼ of the surface)
ST2 - moderate stain (covering > ¼, < ½ of tooth surface)
ST3 - heavy stain (covering > ½ of tooth surface)
Description of Supragingival Deposits SP0 -no calculus present
SP1 -light amount of supragingival calculus covering not more than 1/4 of the tooth
SP2 -moderate amount of supragingival calculus covering 1/4 to 1/2 of the tooth
SP3 -heavy amount of supragingival calculus covering more than 1/2 of the tooth
Description of Subgingival Deposits
SB0 - no subgingival deposit
SB1 - light amount of subgingival calculus (e.g. flecks, spicules and/or small
nodules)
SB2 - moderate amount of subgingival calculus (e.g. ledges, rings, or readily detectable interproximal deposits burnished calculus)
SB3 - heavy amount of subgingival calculus (e.g. finger-like or fern-like
projections down the roots, or continuous rings surrounding the cervical portion of the tooth surface) which are radiographically visible.
* Other factors may be taken into consideration when determining the deposit classification at the instructors’ discretion.
Level of Difficulty Level I no obvious difficulties (cooperative child with no calculus)
Level II minor difficulty (i.e. very little calculus, no posterior teeth, no restorations)
Level III moderate difficulty (i.e. some calculus, restorations, furcations,
recession, etc)
Level IV very difficult increases with amount and tenacities of
Level V extremely difficult calculus plus other factors as listed below
Clinicians are often faced with additional challenges when providing debridement for their client in clinic. The following are examples of some of the items taken into consideration when determining the Level of Difficulty:
Tooth rotations (e.g. lingual version)
Crowded dentition
Excessive salivary flow
Deep pockets
Limited opening
Mobility
Sensitivity
Gagging
Excessive bleeding
Furcations
Tenacity of deposits
Need for local anesthetic
Periodontal Assessment
All teeth are to be evaluated in sequences using the following parameters: Missing teeth: Cross out missing teeth with a vertical line. 18 17 16
B
L
Periodontal Probing During probing, six measurements must be recorded for each tooth (DL, L, ML, DB, B, MB). All measurements 4mm or greater are to be charted. Bleeding on probing sites will be recorded at the same time. Bleeding on Probing
Bleeding on probing will be recorded as present, if the gingival unit (pocket) bleeds within 30 seconds after initial probing (Vander-velden, 1979). The location of the bleeding is done in red. The total number of bleeding sites (n) is divided by the total number of units probed (n ÷ # teeth X 4) to obtain the PBI. Correlate information with other pertinent data. Utilize information to assist formulation of care plan.
Eg. 18 17
B
L
Mobility: recorded for each tooth. Normal = movement of the crown of the tooth, less than .5 mm in buccal-lingual direction Class I = movement of the crown of the tooth .5 mm to 1.0 mm in buccal-lingual direction Class II = movement of the crown of the tooth 1.0 mm to 2.0 mm in buccal-lingual direction Class III = movement of more than 2.0 mm in mesial-distal or buccal-lingual direction and/or
vertical depression.
Eg. 18 17
I II
Furcation: Classification of furcation involvement should be recorded in the following manner: Class 1 = up to 3 mm (horizontal) [dip] Class 2 = over 3 mm (horizontal) [cave] Class 3 = through and through between 2 roots [tunnel]
Eg.
B
L
1
1
1
2
Minimal Attached Gingiva: Record all sites with less than 2 mm of attached gingiva.
a. On the surface of the gingiva, measure from the gingival margin to the mucogingival junction. This measurement represents the total width of the gingiva.
b. Measure the pocket depth. c. The width of the attached gingiva equals the total width of the gingiva minus the
pocket depth.
Recession (CEJ to GM- gingival margin): Apparent gingival recession should be recorded for each tooth. The extent of recession is measured from the CEJ to the free gingival margin. The greatest mm reading for the Buccal and for the Lingual is recorded.
Eg. 18 17
B
L
2 mm
3 mm
2 mm
2 mm
Clinical Attachment Loss/ Level (CAL): Refers to the estimated position of the structures that support the tooth as measured with a
periodontal probe. The CAL provides an estimate of a tooth’s stability and the loss of bone support. CAL is determined using the three possible relationships of the gingival margin to the CEJ. (Illustrations from Fundamentals of Periodontal Instrumentation by Jill S. Nield-Gehrig)
Periodontal Classification The Periodontal classification is based on: the periodontal disease or condition; the severity of the disease or condition (based on the CAL measurement); whether the disease is localized (<30%) or generalized (> 30%). Classification is based on the 199 American Academy of Periodontology Classification of Periodontal Diseases and Conditions. Following is an abbreviated classification list:
I Gingival Diseases A Dental plaque-induced gingival diseases B Non-plaque-induced gingival lesions
II Chronic Periodontitis A Localized (< 30% of sites involved) B Generalized (>30% of sites involved) C Slight = 1-2 mm CAL, Moderate = 3-4 mm CAL, Severe = 5 mm CAL
III Aggressive Periodontitis A Localized (< 30% of sites involved) B Generalized (>30% of sites involved) C Slight = 1-2 mm CAL, Moderate = 3-4 mm CAL, Severe = 5 mm CAL
IV Periodontitis as a Manifestation of Systemic Disease A Associated with hematological disorders B Associated with genetic disorders C Not otherwise specified
V Necrotizing Periodontal Diseases A Necrotizing ulcerative gingivitis B Necrotizing ulcerative periodontitis
VI Abscesses of the Periodontium A Gingival abscess B Periodontal abscess C Periocoronal abscess
VII Periodontitis Associated with Endodontic Lesions A Combined periodontic-endodontic lesions
VIII Developmental or Acquired Deformities and Conditions A Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis B Mucogingival deformities & conditions around teeth C Mucogingival deformities & conditions on edentulous ridges
Dental Hygiene Diagnosis The dental hygiene diagnosis states the client’s actual or potential (at -risk) problem related to oral health and disease. The dental hygiene diagnostic statement allows the dental hygienist to focus care on the client problems and individualize care. The following terminology should be used when making a diagnostic statement: Disease Entity Gingivitis: -acute (short duration, rapid onset, severe symptoms)
-chronic (long, slow duration, low intensity symptoms)
Periodontitis: -chronic
-aggressive
Severity
An evaluation of the degree to which the client has disease. Includes changes from normal (for
periodontitis only, gingivitis is not quantified):
early (4-5 mm probing depth with CAL), moderate (5-6 mm probing depth with up to 4 mm CAL) or
advanced changes (>6 mm probing depth with > 4mm CAL).
Distribution
Localized – confined to a single tooth or a group of teeth (< 30% of sites involved)
Generalized – distributed throughout most or all of the mouth or arch (>30% of sites involved)
Examples of a dental hygiene diagnosis:
Generalized moderate chronic periodontitis with localized history of bone loss (reduced periodontium)
Generalized gingivitis with localized areas of early chronic periodontitis
Care Plan The care plan is part of the preliminary data collection, and will outline the proposed total dental hygiene therapy for the client Candidates are to provide observations, objectives and specific intervention information on the care/treatment plan form prior to examiner evaluation. Specific alterations to procedures must be noted and discussed with the examiners. The care/treatment plan must be presented to the client who is asked to sign the consent form prior to any implementation. The Human Needs Baseline Assessment form is included as a reference only , and in the interest of time, does not need to be completed.
Caries Risk Assessment Please refer to the Journal of the American Dental Association, Vol. 126, 8-S, 1995 for information regarding Caries Risk Classification Guidelines.
Dentition Assessment At a minimum, candidates will be requested to chart all teeth which have been selected for instrumentation.
Hard tissue Charting Chart all conditions according to the following key: Missing teeth Draw vertical red line through any missing teeth. If known to be congenitally missing, mark with C.M. Unerupted teeth Draw blue line (indicating gingival contour) "around" occlusal/incisal surface to indicate coverage by tissue. Caries - suspect Outline the area(s) on the surface(s) in red.
Amalgam Restorations Fill in solid black the exact area(s) of the surface(s) that are restored. Gold (or metal) crown, inlay or foil Outline area in black, draw diagonal lines through restored area.
Fill in the area(s) of the surface(s) in black. If resin restoration, mark with "R" Sealants Outline Sealant in green and place an "S" on Sealant
PR2 Fill in cavity prep area in solid black, and outline sealant area in green. Indicate PR2 above this restoration Temporary Restoration Outline area(s) of the surface(s) in black and mark "Temp" Porcelain Crown Outline crown in black. Mark with P. Cr.
Porcelain bonded to metal Outline crown in black. mark with P.B.M. Draw diagonal lines through area restored with metal Stainless Steel Crown Outline crown in black. Mark with SSC
Fixed Bridge Draw vertical red line through missing teeth. Draw bracket from abutment to abutment in black. Crowns -Outline crown in black. Draw diagonal lines through areas restored with metal including pontics.
Root Canal
Draw vertical black line through root mark with R. C. Amalgam Overhang Draw triangle in black on Facial view
Non-vital tooth Mark with n. v. Non-carious cervical lesion Mark with NCCL
Implants Draw an X through the missing tooth
and label with IMPL Attrition Mark with att.
Inadequate Embrasure Indicate in red by triangle symbol.
(Darby, Michele
Leonardi. Dental
Hygiene: Theory and
Practice, 3rd Edition.
W.B. Saunders
Company, 032009.).
<vbk:9781416053576
>
Over-eruption Indicate with black arrow on facial aspect Diastema Indicate with symbol in black on all aspects. Open Contact Indicate with symbol in black on all aspects. Fractured Tooth Outline the area(s) of the surface(s) in black and mark "F"
Deficient margin Mark with d. m. Recurrent caries Mark with r. c. in red Rotation Indicate rotation with arrows in black on occlusal aspect of tooth involved. Drifting Indicate with black arrows on occlusal aspect.
Occlusal Analysis:
The occlusal analysis should proceed as follows: Angle's Classification: Using the first molars when possible and the canines when needed,
classify the occlusion into Angle's Class I, Class II, Division I, Division II, or Class III for the client's right and left sides.
Overjet: Express excessive overjet in mm (millimeters). Overbite: Express in percentage and mm the overlap of maxillary incisors over mandibular incisors ( a positive measurement). Openbite: Express this as a negative amount. Crossbite: Stipulate which teeth are involved. Faceting: Estimate whether the amount of occlusal and incisal
wear is normal or excessive for the client and indicate tooth number involved. Habits: Rule out habits such as pipe chewing, pencil biting, nail biting, etc. or any habit
which would place excessive forces on the periodontium
