Volume II
2024-2025
Dental Hygiene Department Manual
CC DH Department Manual 2024-2025
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Table of Contents-Volume II
DEPARTMENTAL & CLINICAL EMERGENCY SITUATION PROTOCOL ......................................... 4
Management of Emergency Situations............................................................................................ 5
Emergency Equipment Location and Contents.................................................................................5-7
DEPARTMENTAL EMERGENCY TREATMENT PROTOCOL…………………………………………….8
Contacting Life Support Team Instructions …………………………………………………………………8
CLINICAL MEDICAL EMERGENCY PROTOCOL……………………………………. ......................... 9
Code Red Emergency Guidelines……………………………………………………… ......................... 10
Emergency Care Report…………………................................................ ................................ 11-12
AED Use Reporting………………………………………………………….................................. 13-16
SPECIFIC EMERGENCY CONDITIONS AND TREATMENT RESPONSES ......................................... 17
Debris in Eye……………………………………………............................................................... 17
Neurogenic Shock………………………………………………………………. ................................ 17
Acute Hyperventilation Syndrome………………………………………………… .............................. 17
Allergic Reactions……………………………………………………………….. ............................... 18
Severe Hypotension…………………………................................................ ............................... 18
Angina Pectoris………………………………………………………………….. .............................. 19
Myocardial Infarction……………………………………………...................... ............................... 19
Cardiac Arrest…………………………………………………………………... .............................. 19
Adrenal Crisis…………………………………………………………………… .............................. 20
Insulin Shock……………………………………………………………………. ............................... 20
Acute Asthma Attack…………………………………………………………… ................................. 21
Convulsions Due to Epilepsy……………………………………………………. ................................. 21
Mandibular Subluxation…………………………………………………………. ................................ 21
CAMPUS EMERGENCY PREPAREDNESS…………………………………………............................. 22
Inclement Weather Emergency Procedures……………………………………… ................................. 23
Departmental Active Shooter Protocol….……………………………………….. ................................ 24
DEPARTMENTAL RADIATION POLICY AND RADIOGRAPHIC EXPOSURE PROTOCOL………….. 25
Policy on the Use of Ionizing Radiation General Guidelines……………………… .............................. 26-27
Indications for Radiographic Examination
……………………………………….. ........................ 27
Retaking Radiographs Criteria………………………………………………….. ................................. 28
Radiology Procedures…………………………………………………………. .................................. 29
Safe Use of Radiographs in Dentistry…………………………………………… .................................. 30
Use of Ionizing Radiation: ALARA……………………………………………… ............................. 31-32
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DENTAL HYGIENE CLINIC PATIENT HEALTH HISTORY GUIDELINES……………… .................... 33
Health History Guidelines………………….................................................................................. 34
Glucose Monitoring Protocol………………......................................................... .................... 35-36
Prevention of Infective Endocarditis……….......................................................... ..................... 37-40
Special Needs/Accommodations……………………………………………………….. ........................ 40
ASA Physical Status Classification System………………………………………………. ........................ 41
Blood Pressure Guidelines (Adults)………............................................................. ....................... 42
Blood Pressure Guidelines (Pediatric/Adolescent)…………………………………… ............................ 43
ORAL DISEASE RISK MANAGEMENT, PERIODONTAL DIAGNOSIS AND DENTAL HYGIENE CARE
PLANNING PROCESS……………………………………………………………………………………. 44
Oral Disease Risk Management Protocols Scope and Purpose of Guidelines…………….. .......................... 45
Dental Caries Risk Management………………………………………………………. ..................... 45-47
Periodontal Disease Risk Management……………………………………………….... ..................... 48-50
Oral Pathology/Cancer Risk Management………………………………………………………… ...... 51-53
Assessment Phases .............................................................................................................. 54-62
AAP Classification/DHDX……………...................................................... ............................. 63-79
Calculus Accretion Classification……………………………………………….................................... 80
Dental Hygiene Care Plan………………................................................... .............................. 81-82
Guidelines for Screening Patients………………………………………. ............................................ 83
STANDARDS OF CLINICAL PRACTICE AND CLINICAL ASSESSMENT PROCESS ............................ 84
Clinical Process of Care Evaluation (TalEval)……………..... ...................................................... 85-101
Percentage Weights for Clinical Courses…….………………………………………… ....................... 102
Radiology Assessment and Evaluation Process……………....................................... ....................... 103
Clinical Skill and Competency Evaluations………………………………………….. ........................... 104
Clinical Proficiency Contract……………………………………………………….... ....................... 105
Manual Statement…………………………………………………………………………………….... 106
CC DH Department Manual 2024-2025
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Departmental and Clinical
Emergency Situation Protocol
2024-2025
Dental Hygiene Department Manual
CC DH Department Manual 2024-2025
4
Management of Emergency Situations
Refer to Managing Emergency Situations: Located in the Collin College Dental Hygiene Department Manual, Clinic,
Radiology Laboratory, and Simulation Laboratory.
SDS Manual: Electronic Manual loaded on all computers in Clinic, Radiology Laboratory, and Simulation Laboratory.
SDS Posters: Located in the Clinic and Simulation Laboratory.
Emergency Equipment and Location
Clinic Crash Cart
•
Clinic area/Sterilization 1: located to the left of the restroom
•
CPR Board located behind cart, against wall
Defibrillator
•
Mounted on wall above crash cart
Emergency Kit and Oxygen:
•
Emergency kit is placed on the crash cart each clinic day; a portable oxygen tank is located next to the crash
cart in Sterilization 1 area and next to filing cabinet in Sterilization 2 area.
Fire Extinguisher:
•
Main clinic hallway (accessible to clinic and radiology lab)
Emergency Spill Kit:
•
Storage room in clinic hallway
•
Compressor room #1 in clinic
Emergency Telephone:
•
Cordless telephone located in clinic Sterilization 1, desk phones located at faculty tables and radiology
laboratory.
Emergency Statement
For unusual or disruptive behavior observed with a patient or outside visitor: “Colleen’s phone keeps ringing,
would you please let her know?” Then that person will call 5555 (on-campus phone) or 972.578.5555 (offcampus phone) and describe the situation and location.
Dental Hygiene Clinic Emergency Equipment
The emergency equipment/crash cart is in the center of the clinic near the patient restroom. A First Aid
Sign is posted above the emergency cart and first aid kit and is kept against the wall next to the patient
restroom.
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Emergency Cart
Emergency Red Bag
Resuscitator Kit
Non-rebreather Mask
First Aid Kit
First Aid Kit
Band-Aids (various sizes)
Instant Cold Pack (1 pack)
Tape (1 roll)
Scissors/Tweezers
Ophthalmic Solution Eyewash
Sterile Gauze Pads
Neomycin Antibiotic Ointment
First Aid and Burn Cream
Antiseptic Alcohol Pads
Nitrile Exam Gloves (2 pairs)
Emergency Red Bag
Blood Pressure Cuff and Stethoscope (1 Pedo and 1 Adult)
Emergency Oral Airway (1)
Penlight (1)
Tourniquet (1)
Probe Covers (1 box)
Thermometer (1)
Bite Block (1)
4X4 Sponges (1 box)
Tape (1 roll)
Hemostats (1)
Pocket Mask (1)
Rescue Blanket (1)
Safety Glasses (1)
Nitrile Gloves (2 pairs)
Bandages
Alcohol Swabs
Pulse Oximeter (1)
Emesis Basin (1)
Contents of Emergency Kit (Red Box)
Epinephrine pen (1 of each)
*Adult-.3mg
*Child-.15 mg
Pro-Air Rescue Inhaler (1)
Aspirin 325 mg (2 tablets)
Instant Glucose (1 pouch)
Nitrolingual tablets (1 bottle)
Syringe and tourniquet (1)
Pocket mask with oxygen inlet valve (1)
Contents of Emergency Cabinet
Benadryl (1 bottle)
Advil 200 mg and Aspirin 325 mg
Amoxicillin 500 mg (1 bottle)
Pro-Air Rescue Inhaler (1)
Oraquick HIV-1/2 (4 tests)
Pocket Mask (1)
Alcohol Wipes
Glucometer (2) and Testing Strips (Sterile 1 and 2)
Reli-On Glucose Tablets
Lancets (Sterile 1 and 2)
Emesis Basin, Splint, Instant Cold Packs
Electronic Blood Pressure Cuffs (Reg/L/XL)
(Sterile 1 and 2)
Pediatric Cuff and Stethoscopes
*Any prescription medications dispensed by the supervising clinical dentist must be recorded on the “Medication Dispensed
Record” and included in the patient notes history. The “Medication Dispensed Record” is located on the cabinet door of the
emergency medicine cabinet. The patient’s name, medication, amount, dosage, and supervising clinical dentist’s name must be
included on the record.
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Oxygen Liter Flow Guidelines*
The oxygen tank is in the clinic next to the emergency crash cart in Sterilization 1 and next to the filing cabinet in
Sterilization 2. The following is a guideline used to determine liter flow but in an emergency, turn the valve to
maximum flow:
HISTORY
No Past Lung Hx
4-6 LPM Cannula
CYANOTIC
10-15 LPM Mask
Emphysema or any Hx of chronic
Obstructive pulmonary disease
(COPD)
2-3 LPM Cannula
4-6 LPM Mask
Smoking: pack-year HX of 20*
(# of packs/day X # of years
smoking) per Tobacco Use Form
3-4 LPM Cannula
7-8 LPM Mask
Patient on oxygen
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The usual liter flow and delivery device
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Departmental Emergency Treatment
Protocol
Basic Emergency Procedures to be taken in all emergencies unless otherwise noted:
A. Call for help, from a student or faculty closest to you
B. Assess breathing, check airway, manage airway
C. Check vital signs
D. Move the emergency kit and AED to the site of the emergency; open it and prepare for use
E. Be prepared to administer CPR to support circulation and respiration
F. Be prepared to send for emergency help
G. Supervising clinical dentist will determine if there is a need to administer medications
Contacting Life Support Team Instructions:
CALL 911 and provide the following information to the operator:
1.
2.
3.
4.
Your name.
State that a life support team is needed.
State the type of emergency (heart attack, shock, etc.)
Location of clinic: 2200 West University Drive, A118, McKinney, Main Building, South End, A
Wing, First Floor
5. Any other information requested by the operator.
DO NOT hang up until after the operator disconnects.
If so, directed by the operator, go outside near the entry of the parking lot and wait for the emergency team. Direct
the team and police to the clinic/site of the emergency. If the operator asks you to remain on the line until the
emergency team arrives, send another person to the entrance to the parking lot to wait for the emergency team and
direct them to the clinic/site of the emergency.
Emergency Numbers
911
Medical Emergency
Fire Emergency
Police Emergency
AND---------------------------------------5555 (on campus phone) Campus Security
972.578.5555 (off campus phone)
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Clinical Medical Emergency Protocol
Preparation for Medical Emergencies
•
All students and faculty will:
1. Know where all emergency supplies are located.
2. Periodically review the use and administration of emergency drugs.
3. Have telephone numbers of emergency services (911), physicians, hospitals, and ambulance services
readily available.
•
Faculty will:
1. Conduct practice scenarios annually for various emergency scenarios. All faculty and students should
know what to do in an emergency.
2. Regularly check supplies and equipment to ensure that no expired drugs are present in the emergency
kit and that all emergency equipment works properly. Expired drugs and supplies will be replaced as
needed.
•
Student Responsibility in Prevention of Medical Emergencies
1. Check the patient’s medical history thoroughly and be familiar with any medical condition the
patient may have. Make note of the history of allergic responses.
2. Check to determine that information regarding health history and primary health care provider is
current.
3. Check all prescription and non-prescription medications the patient is taking. Identify purpose of
the medication, possible side effects and potential effects of the medication to dental treatment.
4. Determine if patient has taken required medications the day of the appointment. Required
medications include the patient’s regular medications and an antibiotic if pre-medication is
required.
5. Be certain that the patient has required medication on hand for existing medical conditions
(medication/inhaler for asthma, medication for angina, etc.)
6. Check the patient’s vital signs (blood pressure, pulse, respiration rate).
7. Schedule appointments to best meet the patient’s health care needs.
8. Be aware of the signs and symptoms of allergic reactions and other emergencies.
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Code Red Emergency Guidelines
1. The student closest to the emergency location will assess the patient.
2. Render aid and request that nearby student report the emergency and the appropriate operatory number to
the clinical assistant (CA) on duty.
3. If an emergency location is in the Radiology Lab or Simulation Lab, the dental hygiene student will request
the nearest student to report the emergency and the room number to the CA on duty.
4. The CA will notify the clinical faculty and the DDS immediately.
5. The CA will immediately notify the program director of the emergency.
6. The clinical faculty and DDS will report to the emergency site and determine if an advanced life support unit
needs to be initiated by calling 911.
7. If 911 is called, contact Campus Police at 5555 from any college telephone or 972-578-5555 from any other
phone. (There are college telephones in the Sterilization 1 area, radiology lab, and at all clinic faculty
workstations).
8. The CA will bring emergency equipment to the emergency site (oxygen tank and crash cart, AED if
requested).
9. The CA is responsible for completing the “Collin College Emergency Care Report” (copies located in the
filing cabinet behind the faculty tables in the clinic) and submitting it to the clinical faculty.
10. The dental hygiene student who is responsible for treating the emergency patient will stay at the site to cotreat as needed and summon appropriate emergency personnel.
11. The dentist will consult with the clinical faculty and administer necessary medications.
12. It is requested that all other faculty and students remain away from the emergency.
13. The CA should be present to record pertinent information, such as time of onset, vitals, etc.
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Collin College
Dental Hygiene Department
2200 W. University Drive, Suite A118
McKinney, TX 75071
972-548-6535
Emergency Care Report
Date
Site of Emergency
Personal Data
Name
Address
Telephone Number
Age
Description of Incident
Vital Sign
Time
1st Reading
Time
2nd Reading
Pulse
Respiration
Blood Pressure
Treatment Administered at Scene
Equipment Used
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Appraisal of Patient Condition
How did the patient leave Collin College Dental Hygiene Department?
Ambulance
By him/herself
Family
Other
Security
Referral Information
Additional Information
Collin College Personnel at Scene
Clinical Faculty Signature
Date
Clinical Coordinator Signature
Date
Supervising Clinical Dentist Signature
Date
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Indications for AED Use
The AED Defibrillator should be used only on a patient who is:
•
•
•
Unconscious
Not Breathing
Has No Pulse
*Apply the AED if:
•
•
•
•
Unconscious
Non-breathing, pulseless victim
For children ages 1-8, utilize the pediatric attenuated pads
For children over 8 years old, utilize the adult pads
** Apply the AED with caution if:
•
•
Nitroglycerin patch on chest (remove nitroglycerin patch carefully, then apply AED)
Implantable Pacemaker (pacemaker may interfere with rhythm analysis, do not place electrodes directly over
pacemaker.)
Procedure
I. Assess scene safety
Is the scene free of hazards?
Rescuers make sure there are no hazards to them. Some examples are:
•
•
•
•
•
Electrical Dangers (downed power lines, electrical cords, etc.)
Chemical (hazardous gases, liquids or solids, smoke)
Harmful People (anyone that could potentially harm you)
Traffic (make sure you are not in the path of traffic)
Fire, flammable gases such as medical oxygen, cooking gas, etc.
II. Open AED Case
Turn on the AED.
III. Follow Voice Prompts
A. Place Electrodes:
• AED says: “Place electrodes”
B. Analyze Rhythm
• AED says: “Do not touch patient. Analyzing rhythm”
C. Charges
• AED says: “Charging”
D. Delivers Defibrillation Pulse
• AED says: “Stand clear. Push flashing button to Rescue.”
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The Rescuer will state “clear” and makes a visual head-to-toe check of the patient making sure that he/she and any other rescuers
are “clear” of contact with the patient. Once this is accomplished, the rescuer will press the “rescue button” to deliver a
defibrillation pulse:
E. Analyze/Change/Pulse
After the first defibrillation, the AED will re-analyze the patient’s heart rhythm.
The AED says: “Do not touch patient. Analyzing rhythm”
If shockable rhythm is detected, the AED will charge and prompt the rescuer to deliver another defibrillation, the
voice prompt says “Check pulse. If no pulse, give CPR.”
* If at any time during this cycle the AED detects a heart rhythm that does not require defibrillation, the voice prompt
will say “Check pulse. If no pulse, give CPR.”
**Remember that the AED will not advise to defibrillate all pulseless patients. Some cardiac rhythms do not respond
to defibrillation.
*** Call “911” at this time, if not already done. ***
F. Rescuer Gives CPR for One Minute
After the 3rd defibrillation, the voice prompt will say:
“Check pulse. If no pulse, give CPR.”
G. Repeat Analyze/Charge/Defibrillation Pulse
After one minute of CPR, the voice prompt will say:
“Do not touch patient, analyzing rhythm.”
If the cardiac rhythm is shockable, the AED will guide the rescuer through another 3-defibrillation pulse sequences, followed by
one minute of CPR. This sequence should continue until:
•
•
•
No shockable rhythm is detected; or
The electrodes are disconnected; or
Until Ambulance personnel arrive on the scene.
H. Patient Converts to a Non-Shockable Rhythm
If at some point during the rescue the patient converts to a heart rhythm that does not require defibrillation, the voice
prompt will say:
“Check pulse. If no pulse, give CPR.”
At this point, call “911” or the local emergency access phone number if not already done.
If a pulse is found on the patient and the patient is not breathing, continue rescue breathing, leave electrodes in place and follow
voice prompts.
If the patient regains consciousness, make the patient as comfortable as possible until ambulance personnel arrive on scene.
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IV. Post Incident Procedure
The steps should be completed as soon after the incident as possible:
1.
2.
3.
4.
Replace the electrode pads.
Close lid of AED and view the status indicator for GREEN indicator.
Retrieve rescue data and forward it to Physician.
Complete “AED Use Report Form.” (copies in the clinic filing cabinet located across from the Dental
Materials Lab)
V. DDS Oversight
DDS oversight for this department will be provided by the Supervising Clinical DDS. DDS oversight will include the following
items:
•
•
Review of response documentation and rescue data for all uses of the AED.
Provide advice regarding the medical care of those in need of such care.
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VI. AED Use Reporting
The following form must be completed when the AED is used:
AED REPORT FORM
Date: _________________
Patient Information
Name: _____________________________
Address: ___________________________
Age:
Gender: Male [ ]
Female [ ]
Site of Incident:
Witnessed Arrest: Yes [ ] No [ ]
Breathing upon arrival of designated responders: Yes [ ] No [ ]
Pulse upon arrival of designated responders:
Yes [
] No [ ]
Bystander CPR: Yes [ ] No [ ]
Cardiac Arrest after Arrival: Yes [ ] No [ ]
Defibrillation: Yes [ ] No [ ]
Number of Defibrillations:
Efforts terminated in the Field? Yes [ ] No [ ]
Any complications? Yes [ ] No [ ]
Comments:
Additional Comments:
User’s Name:
User’s Signature:
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Specific Emergency Conditions and
Treatment Responses
Debris in the Eye
Eyewash systems are located at the sink on the “clean” side in Sterilization 1 and 2 and in the Simulation Lab. One student
or faculty must escort the injured individual to the eye wash station. Student must turn on the eye wash unit
(injured individuals will have difficulty seeing). Flush the eye for 15 minutes.
Neurogenic Shock (Vasovagal Syncope, Syncope)
Symptoms:
• Patient will state they feel faint or dizzy and may state they feel cold while perspiring.
•
They appear pale, pupils are dilated, blood pressure drops, and they may lose consciousness. Causes include fatigue,
fear, emotional stress, pain, poor ventilation, and acute loss of blood.
Treatment:
• Complete basic emergency procedures.
•
Place patient in Trendelenburg position-recline chair to improve venous return, cardiac output, and blood flow to the
brain.
•
Check carotid pulse.
If patient loses consciousness:
•
If patient loses consciousness, promptly call 911.
Acute Hyperventilation Syndrome
Symptoms:
• Rapid respiration with increased oxygen intake leading to decreased carbon dioxide levels.
•
Patient feels short-of-breath, experiences “air hunger” seen as gasping; may experience tingling of fingers, hands, toes,
lips; numbness of extremities, faintness. Frequently seen in anxiety-induced states, but is also found in asthma,
metabolic acidosis, and pulmonary disorders such as pulmonary embolism and pulmonary edema. Can produce cerebral
hypoxia.
Treatment:
• Complete basic emergency procedures except do not administer oxygen.
• Decrease rate of CO2 loss by having the patient breathe through only one nostril with the mouth closed. Patient can
close one nostril by placing a finger against that side of the nose. Another method is to have patient breathe into paper
bag, which decreases CO2 loss. Pace respirations by counting from 1 to 10 for patient and having patient inhale on ten.
• Reassure patient.
• Monitor vital signs.
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Allergic Reactions
PREVENTION IS THE BEST TREATMENT, REVIEW PATIENT HISTORY OF ALLERGIES PRIOR TO ANY TREATMENT; NOTE
ALLERGIES ON CHART; BE ALERT TO CROSS-SENSITIVITIES IN MEDICATION CATEGORIES; CONSULT PATIENT’S PHYSICIAN IF
NECESSARY, PRIOR TO ANY TREATMENT.
Symptoms: Type I (immediate reactions are a local systemic anaphylaxis.)
•
•
Local responses include urticaria (hives), allergic rhinitis, asthma, and swelling of mucous membranes of nose and
throat.
Systemic responses are life-threatening. The allergen in the bloodstream releases chemical mediators that produce
severe bronchial obstruction and vasodilation leading to pulmonary edema and/or shock.
Treatment:
• Complete basic emergency procedures
• Supervising dentist will inject epinephrine pen if needed
• Monitor carotid pulse and blood pressure.
• Call for emergency medical help (911).
If patient loses consciousness:
•
Be prepared to render CPR to support cardiopulmonary function. Continue CPR until respirations and heartbeat are
restored or medical help arrives.
Severe Hypotension
Symptoms:
Severe decrease of systolic and diastolic blood pressure below normal range. Generally, consider 90/60 and below in adults to
be hypotension, although some normally have a blood pressure at or below this level. Most frequently seen in the dental clinic
as a sign of shock, because of a drug interaction (local anesthetic when patient is taking other medications or in hemorrhage).
*PLEASE NOTE: BE ALERT FOR HYPOTENSION IN PATIENT’S WHO EXPERIENCE ANAPHYLACTIC SHOCK AND ARE TAKING
CHLORPROMAZINE (THORAZINE) OR PRAZOCINI (MINIPRESS) WHEN EPINEPHRINE IS NOT EFFECTIVE.
Treatment:
• Place patient in Trendelenburg position; head lower than body to improve venous return, cardiac output and improve
blood flow to head.
• Carry out basic emergency steps.
• Call for emergency help. (911)
• Administer CPR if necessary.
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Angina Pectoris
KNOW THE PATIENT’S HISTORY. IF PATIENT HAS A HISTORY OF ANGINA PECTORIS, DO NOT BEGIN TREATMENT UNTIL THE
PATIENT’S NITROGLYCERN IS AT HAND. BE AWARE THAT PATIENT MAY WEAR A NITROGLYCERIN TRANSDERMAL PATCH.
Symptoms:
Severe pain and a feeling of constriction about the heart. Pain typically radiates to the left shoulder and down left arm (in rare
situations patient experiences pain radiating from the heart to the abdomen.) Pain may also radiate to the back or to the jaw.
Pain is steady; patient may experience great anxiety; face will be pale, ashen or bright red. Patient may experience dyspnea,
pulse is usually rapid and blood pressure raised.
Treatment:
• Have patient take their nitroglycerin as prescribed, noting time of first dose.
• Monitor pulse and blood pressure.
• If three doses of nitroglycerin at 5-minute intervals have not relieved pain, seek immediate medical attention.
• If nitroglycerin brings relief, allow patient to rest before resuming procedure. If the procedure is at a point that it can
be discontinued, patient may stop treatment and re-schedule appointment.
Myocardial Infarction
MEDICAL TREATMENT MUST BE INSTITUTED WITHOUT DELAY, IF SYMPTOMS INDICATE MYOCARDIAL INFARCT, CALL 911
IMMEDIATELY.
Symptoms:
Prolonged heavy pressure or squeezing pain in the center of the chest behind the sternum; may spread or localize to shoulder,
neck, arm and 4th and 5th fingers of the left hand, back, teeth or jaw. Patient may experience nausea, vomiting, sweating and
shortness of breath. Blood pressure may be elevated or patient may be hypotensive.
Treatment:
• Complete basic emergency procedures.
• Call 911, monitor vital signs until emergency help arrives.
• Loosen tight clothing and make patient comfortable; patient may have less respiratory distress if in upright position; if
patient experiences hypotension, place in Trendelenburg position.
• Administer oxygen under positive pressure. The pressure should approximate the patient’s respiratory volume (6 liters
per minute for adult males, 5 liters per minute for females, children 1-2.5 liters per minute) total lung capacity is based
on patient size. These are approximate measures and must be used with consideration of patient size. A small adult
male or female will require less oxygen just as a large adolescent will require more than listed for children.
• Be prepared to initiate CPR if pulse and respirations stop.
Cardiac Arrest
Symptoms:
Absence of pulse, blood pressure and respiration, pupils dilated, skin cyanotic.
Treatment:
• Complete basic emergency procedures.
• Start CPR.
• Call for emergency medical help (911), continue until respiration and pulse return or emergency medical help arrives.
• Supervising dentist will administer medications if needed.
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Adrenal Crisis
PATIENTS WHO ARE UNDERGOING TREATMENT WITH STEROIDS (I.E. HYDROCORTISONE) OR WHO HAVE BEEN TREATED WITH
STEROIDS IN THE LAST TWELVE MONTHS ARE VERY SUSCEPTIBLE TO STRESS AND MAY EXPERIENCE ADRENAL CRISIS. REVIEW MEDICAL
HISTORY CAREFULLY. BE ALERT TO POTENTIAL FOR ADRENAL CRISIS IF PATIENT HAS HAD STEROID TREATMENT.
A CONSULTATION MUST BE MADE WITH THE PATIENT’S PHYSICAN PRIOR TO DENTAL TREATMENT.
BEFORE BEGINNING TREATMENT, NOTIFY SUPERVISING DENTIST AND CLINICAL FACULTY THAT THE PATIENT IS SEATED AND
POTENTIAL FOR ADRENAL CRISIS EXISTS.
Symptoms:
Headache, nausea, vomiting, abdominal cramps, weakness, mental confusion, hypertension, cardiac arrest.
Treatment:
• Complete basic emergency procedures.
• Start CPR if pulse and respirations are absent;
• Call for emergency medical help, (911) continue CPR until pulse and respirations return or emergency medical help
arrives.
Insulin Shock
KNOW IF THE PATIENT IS DIABETIC. PRIOR TO BEGINNING ANY TREATMENT, REVIEW THE PATIENT’S USE OF INSULIN AND MEALS PRIOR
TO COMING TO THE DENTAL CLINIC. IF PATIENT TOOK INSULIN AND HAS FASTED YOU MAY NEED TO RE-SCHEDULE THE APPOINTMENT.
CHECK WITH FACULTY AND SUPERVISING DENTIST IN THIS SITUATION. IF PATIENT HAS TAKEN INSULIN AND FOLLOWED REGULAR MEAL
PATTERNS, CHECK TO SEE IF THEY HAVE CANDY OR OTHER GLUCOSE WITH THEM. KEEP THEIR GLUCOSE SUBSTANCE AT HAND OR HAVE
A SWEETENED JUICE NEARBY. FOLLOW GLUCOSE MONITORING PROCEDURES.
IF PATIENT HAS NOT TAKEN THEIR INSULIN AS PRESCRIBED OR SKIPPED MEALS PRIOR TO COMING TO THE CLINIC, CONSULT WITH
SUPERVISING DENTIST BEFORE BEGINNING ANY TREATMENT.
Symptoms:
Rapid pounding pulse, pale moist skin, weakness, trembling, headache, nausea, disorientation. In severe cases patient may lose
consciousness and convulsions may occur.
Treatment:
•
•
•
Complete basic emergency procedures.
Have patient eat candy or other glucose preparations they have with them or give them a sweetened soda.
If patient loses consciousness, supervising dentist may administer oral glucose. Call for emergency medical help if
patient loses consciousness.
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Acute Asthma Attack
IF PATIENT HAS ASTHMA, ASK PATIENT ABOUT THEIR ATTACK HISTORY. CHECK TO SEE IF PATIENT HAS MEDICATION WITH THEM AND
PUT IT IN A PLACE THAT IS READILY ACCESSIBLE DURING DENTAL TREATMENT.
Symptoms:
Difficulty in breathing, wheezing.
Treatment:
•
•
•
•
Keep patient in upright position. The patient may find it easier to breathe in a hunched forward position which they
naturally assume during an attack.
Have the patient use their inhaler with prescribed medications.
Complete basic emergency procedures.
If relief is not obtained, call for emergency medical help.
Convulsions Due to Epilepsy
KNOW THE PATIENT’S MEDICAL HISTORY. IF PATIENT HAS EPILEPSY, AVOID SEATING THE PATIENT IN CLINIC AREAS WERE FLASHING
LIGHTS OR SUDDEN NOISES ARE PRESENT AS THESE MAY TRIGGER AN EPILEPTIC SEIZURE IN SOME INDIVIDUALS.
Symptoms:
Some patients experience an aura before a seizure; other patients may have no warning of impending seizure.
Treatment:
•
•
•
•
If patient tells you they are experiencing an aura, stop treatment, lower patient to floor away from dental unit to prevent
injuries to patient, place a pillow or cushion under their head. Do not use tongue blades between teeth. Cradle head if
on hard surface and pillow is not available quickly enough.
If there is no warning, place all parts of the dental unit as far away from the patient as possible to prevent injuries. Restrain
patient gently by holding them to prevent them from falling out of chair.
If seizure lasts more than 5 minutes, call for emergency medical help.
After seizure stops, allow patient to sleep or rest. Monitor respiration and pulse.
Mandibular Subluxation
Symptoms:
Patient is unable to close mouth because spasm in the muscles of mastication prevent the condyle from moving over the articular
eminence. Spasms are very painful.
Treatment:
• Keep patient in upright position.
• Clinical faculty or supervising clinical dentist will:
1. Place thumbs inside mouth on the buccal surfaces of the mandibular bone and as far back as possible. Thumbs
are not to be placed over the occlusal surfaces.
2. Grasp lower border of mandible with the rest of the fingers.
3. Push the mandible down and back until the teeth snap into occlusion.
Reference of Emergency Procedures:
Little and Falace. Dental Management of the Medically Compromised Patient, 2024. Elsevier, 10th ed
https://www.merckmanuals.com/professional/resource, retrieved May 15, 2024
Elena Bablenis Haveles. Applied Pharmacology for the Dental Hygienist, 2024. Mosby, 9th ed
Wilkins’ Clinical Practice of the Dental Hygienist, 2024, Jones & Bartlett, 14th ed
CC DH Department Manual 2024-2025
21
Campus Emergency Preparedness
In the event of a fire, earthquake, or other disaster, the steps listed below should be followed to ensure employee, student or
patient safety.
First aid kit: The Dental Hygiene Department’s first aid kit is inspected by appointed faculty at the beginning of every
semester to confirm that necessary items are in the kit and all pharmaceuticals are current. The first aid kit is located in the
sterilization area of the dental hygiene clinic on the medical cart. The Dental Hygiene Simulation Lab also has a first aid kit on
the wall to the right of the right exit.
Oxygen tank: An oxygen tank is always ready for an emergency and checked once a week (Monday morning) by the
appointed faculty. Attachments (i.e., masks and hoses) are clean and stored with the tank. The oxygen tank is stored in the
sterilization area of the dental hygiene clinic next to the clinic crash cart as well as on the C side of the clinic in Sterilization
Area 2.
Automated External Defibrillators (AED): An AED is located in the sterilization area of the dental hygiene clinic on the
wall above the clinic crash cart. It is inspected weekly (every Monday) by appointed faculty and monitored by the emergency
services department.
EARTHQUAKES: An earthquake can happen anytime, anywhere. In the event of a disaster, emergency services may not be
available. FEMA recommends the following steps for increasing safety during an earthquake:
• Drop, Cover, then Hold On. Drop to your hands and knees. Cover your head and neck with your arms. Hold on
to any sturdy furniture until the shaking stops. Crawl only if you can reach better cover without going through an
area with more debris.
• If in bed, stay there and cover your head and neck with a pillow.
• If inside, stay there until the shaking stops. DO NOT run outside.
• If in a vehicle, stop in a clear area that is away from buildings, trees, overpasses, underpasses, or utility wires.
• If you are in a high-rise building, expect fire alarms and sprinklers to go off. Do not use elevators.
FIRE: A fire extinguisher is in the dental hygiene clinic's hallway just outside the instrument locker room. The Dental Hygiene
Simulation Lab also has a fire extinguisher located on the wall to the left of the right exit. A professional company, regulated
by the Texas Fire Marshal inspects and updates the fire extinguishers every 12 months. In the event of a fire, dial 911 from any
phone.
EVACUATION: In the event of an evacuation, dental hygiene students, patients, staff, and faculty will exit through the closest
door that leads to either the east, west, or south parking lot. Everyone will attempt to remain together if possible and move as
far away from the building as possible or as directed by College Police. If exiting through the west door, walk towards
Community Drive (near the fire station). If exiting the east door, walk towards the creek. If exiting the south door inside the
clinic, walk towards the tree lined path of the parking lot closest to University Drive/Hwy. 380. If College Police are giving
directions, ALWAYS default to police instructions.
Be prepared: Annual training is provided to faculty, staff, and students. This includes practice drills and written plans.
Everyone in the clinic is trained and notified where the first aid kit locations, emergency medical supplies, oxygen tank, and
fire extinguisher.
CC DH Department Manual 2024-2025
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McKinney Campus: Weather Emergency Procedures
During severe weather, College Police and Administration will monitor the National Weather Service, radio, and local
television for current weather information.
1. If an emergency develops, the campus will be notified by emergency warning sirens and/or College Police and
Administration.
2. When a weather emergency is ordered, occupants will vacate upper levels of all campus buildings and move to
st
designated 1 Floor Recommended Severe Weather Areas (e.g., interior halls, classrooms, bathrooms, and offices;
Pike Hall, locker rooms, etc.) Clear all atrium areas and any other spaces exposed to exterior glass. (Employees
should inform and assist students and visitors.)
3. Occupants are to remain in the Recommended Severe Weather Areas until the “all clear” is communicated by College
Police or Administration.
4. The closest Recommended Severe Weather Area to the dental hygiene clinic is in the “A” wing hallway outside of
Dental Hygiene Simulation Lab (A109) and the faculty office suite (A105).
For Police, Fire & Medical Emergency
1. Call 911 for medical emergencies. 911 can be dialed directly from any campus phone.
2. Call 972-578-5555 for College Police. 5555 can be directly dialed from any campus phone.
3. Dental hygiene students, faculty, and staff are advised to save the College Police phone number in cell
phones.
First Aid Kit Locations (McKinney Campus)
Andrea-Mennen Welcome Center: First (1st) Floor at the Information Desk in the Atrium
Conference Center
Main Building:
•
•
•
•
•
•
•
Collin College Police Department Room C-121 and All Patrol Vehicles
Facilities and Plant Operations
Fitness Center
Information Desk
Science Labs in All Buildings
Dental Hygiene Clinic A118
Dental Hygiene Simulation Lab A109
Automated External Defibrillators (AED) Locations (McKinney Campus)
Andrea-Mennen Welcome Center: First (1st) floor, South Hallway Outside the Men’s Restroom
Conference Center
Library
Main Building:
• B Wing on the Third (3rd) floor
• Dental Hygiene Clinic A118
• Fitness Center
• All Collin College Police Department Patrol Vehicles
CC DH Department Manual 2024-2025
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Collin College Police Department and Office of Emergency Management:
https://www.collin.edu/campuspolice/
Inclement weather and closing of the College: Collin College Dental Hygiene Department schedules its instruction to comply
with the Common Calendar published by the Texas Higher Education Coordinating Board. College faculty meet all scheduled
classes as published in the class schedule. If severe weather or emergencies make it advisable to discontinue classes, the college
makes every effort to notify its students on the college website, through the CougarAlert system, and local television stations.
An official closing of the college delays all work until the next class meeting or until a date determined by the faculty. Makeup days for official college closings will be scheduled as needed. If a student is in an area experiencing severe weather and the
college has not officially closed, it is that student’s responsibility to exercise caution and decide whether to attend class. The
student must contact the faculty immediately in the event the college has not cancelled classes. Make-up assignments must be
completed in a timely fashion according to the faculty’s directions.
Active Shooter Protocol for Dental Hygiene Department
See the following link for Collin College Police Department for protocol and training in the event of an active shooter on
campus.
https://www.youtube.com/watch?v=QvI-aMm5QSo
The dental hygiene clinic has 4 exits (reception area, radiology hallway, clinic between Op’s 4 and 5, and through Sterilization
Area #2). 3 exits lead to 2 exterior door exits and one exit is an emergency exit that leads directly to the south-end parking
lot. In the event of an active shooter, many scenarios are possible and unpredictable. The following are things to consider in
the event of an active shooter:
•
•
•
•
•
•
•
•
•
Avoid, Deny, Defend: Choose the options that best protect you in the situation.
If you run, get as far away from the building as possible. Go to the fire station on Community Drive across the street
from the clinic or go to the creek just outside the east doors. ALWAYS default to police instructions.
If a Cougar Alert or police order is activated, follow instructions accordingly.
Remember that if shots can be heard while inside the dental hygiene clinic, the shooter is likely very close. Activate
the dental hygiene protocol hiding areas as presented in training.
Doors inside the dental hygiene clinic with a Collin College logo are safe areas to hide.
Remain still and quiet until directed by police.
You have the right to defend yourself by any means in the event of an active shooter.
If you have a license to carry and choose to carry on campus and have drawn your weapon during an incident when
the police arrive drop your weapon and show your hands. DO NOT get mistaken as the suspect.
All faculty, staff, and students are trained in the dental hygiene active shooter protocol every semester.
Sign up for Cougar Alert’s, through CougarWeb, to receive the most updated school
closure and emergency information.
CC DH Department Manual 2024-2025
24
Departmental Radiation Policy
and
Radiographic Exposure Protocol
2024-2025
Dental Hygiene Department Manual
CC DH Department Manual 2024-2025
25
Policy on the Use of Ionizing Radiation
General Guidelines
The following policy has been developed, in the interest of establishing a consistent standard concerning the use of
ionizing radiation as a diagnostic tool, and to minimize, as much as possible, any potential risk from adverse biological
effects to patients, students, faculty and staff. The Radiation Safety Control Officer for Collin College dental
hygiene program is Jennifer Swetmon, MS, RDH.
Radiography, together with symptoms and clinical signs, are an adjunct to the dentist in diagnosis and treatment planning.
Radiographs are exposed when indicated and ordered by the dentist, following a thorough clinical/medical history,
examination of signs and symptoms and consideration of the dental history, including study of existing radiographs.
Patients of the Collin College Department of Dental Hygiene are then classified into high or low risk groups, considering
the pattern of oral hygiene, exposure to fluoride, CAMBRA, family dental health, developmental abnormalities, tooth
eruption pattern, frequency of dental visits and the clinically observed condition of existing tooth surfaces and
restorations.
NOTE: All regulations concerning conduct, attendance and dress apply equally to all radiology procedures. Radiographs
will be taken for diagnostic purposes only. Patients will not be exposed to ionizing radiation for the purpose of training or
demonstration.
1. Ionizing radiation should be used in dentistry specifically as an aid for diagnostic purposes. Therefore, the
recommendations of the ADA Council on Scientific Affairs (CSA) are employed. The patient’s welfare is always
considered. Collin College Department of Dental Hygiene follows the ADA policy of the frequency of exposing
radiographs is outlined in Table 1. It is the general policy of the school to take the appropriate number of
periapical radiographs individualized according to patient’s needs on adult patients. These radiographs will be
authorized following a medical/dental history, clinical evaluation, and when the patient will derive direct benefits
from such radiograph. A follow-up session with a dentist is strongly recommended.
2. Dental exposure of patients to radiation shall be kept at the minimum level consistent with ALARA
recommendations and the clinical requirements of each individual patient. Therefore, a maximum of two
retakes per FMX, bitewing, or periapical examination is allowed following dentist
recommendation and assistance. If prior radiographs are available, they should be evaluated before new
radiographs are ordered. Only those additional views needed for complete diagnosis and care planning should be
ordered and exposed. Professional judgment should be used in this determination.
3. Recare radiographic examinations of patients should be based on the needs of the individual after a thorough health
history review and oral examination of the patient. Follow-up FMX’s are taken when indicated clinically. Such
radiographs are exposed no sooner than a five-year interval unless significant clinical changes are observed. The
radiographic examinations may be needed for diagnosis of other conditions which may be evidenced before clinical
symptoms, e.g., apical changes, un-erupted teeth, developmental abnormalities, trauma to maxillofacial region
and inflammatory, degenerative, or neoplastic processes.
4. All students must demonstrate proficiency in radiographic techniques on skulls and manikins before they will be
allowed to expose radiographs on patients.
5. Digital radiographs are utilized for all patient exposures to radiation. Only the patient should be present in the
radiology room or dental operatory during x-ray exposure. When radiographs are exposed in the radiology
laboratory, the student should close the door and observe the patient through the leaded glass window as the
exposure is made.
6. Radiographs shall be exposed only when the patient is capable of cooperating and when a faculty is present in the
clinic.
7. All radiographic patients (or parent/guardian if a minor) must complete and sign the Medical History and Consent
forms prior to radiographic exposure. If requested, radiographs will be forwarded to the patient’s dentist following
completion of the form “Authorization Form for Use or Disclosure/Release of Patient Information”.
8. The student must obtain the radiographic prescription from the DDS and make a radiographic rationale entry into
the Notes History prior to exposure. If retakes are to be taken, they must be approved and recorded in the Retake
Log with DDS signature, along with the DDS radiograph retake approval in the patient’s notes history.
CC DH Department Manual 2024-2025
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9. A digital panoramic radiograph and 4 digital bitewings should be taken according to patient needs and dentist’s
approval whenever an FMX is not possible. When indicated, edentulous patients may receive either a panoramic
radiograph or a combination of occlusal and periapical radiographs as deemed appropriate. Nevertheless,
edentulous surveys will usually contain fewer films than comparable radiographic surveys.
10. Pediatric and adolescent patients may receive a panoramic radiograph with bitewings and individually selected
periapical views, when indicated.
11. The number of radiographs in an FMX will vary according to individual patient needs. Factors such as the status of
third molars, premolars, number of extracted teeth and jaw size will result in reduction in exposure.
12. Protective shield and thyroid collars must be used for all radiographic exposures. Thyroid shields should fit
snuggly around the patient’s neck. Failure to utilize the protective shield will result in a grade zero for the
radiographs taken. Panoramic radiographs require the use of a protective shield without a cervical collar. Use of a
cervical collar will produce a non-diagnostic radiograph.
13. The paralleling technique and the use of rectangular collimation must be used whenever possible. Film holding
devices should be used routinely to stabilize films, minimize distortion, and reduce cone cutting.
14. Following exposure of radiographs, position the x-ray tube head against the wall with the PID pointing down.
15. The Nomad hand-held x-ray device may be utilized for radiograph exposure in place of the PID and will require
the use of a protective shield. This device may be disinfected and shared between operators. After use, the Nomad
will be turned into faculty for proper storage.
16. After all radiographic procedures have been performed, the patient’s protective shield should be removed,
disinfected according to manufacturer’s recommendation, and hung on the designated hooks. It should never
be folded.
17. Dental charting should be revised following evaluation of radiographs.
18. Radiographs or copies of radiographs should NEVER leave the clinic unless forwarded to the patient’s dentist or
released to patient. Radiographs must be kept in the patient’s record if traditional film. Radiographs or copies
of radiographs will not be allowed in lockers or clinic drawers and must not leave the clinical area.
Indications for Radiographic Examination
A. The following patient will require written approval from their physician and/or dentist prior to radiographic
exposure:
1. Pregnant women: Radiographs should be based on the individual needs of the patient according to ADA
Recommendations. The patient must be draped with a protective shield designed for pregnant patients
and the absolute minimum number of radiographs should be exposed to establish a diagnosis.
Discretionary x-rays examination of pregnant women will be delayed until after the third month. At the
time, only bitewings and individually selected periapical views will be taken, if indicated. Patients with
periodontal disease needing NSPT should have diagnostic radiographs prior to receiving treatment
(FMX preferred, BWX & PANO substitution acceptable for pregnant patient
2. Patients undergoing radiation therapy within the last 12 months must have a diagnostic need and will
not be exposed to radiographs without prior written approval of their physician.
3. Patients in the first nine months of implant treatment will need written approval by the dentist
performing the implant procedure.
B. Examples of periapical films often indicated:
1.
2.
3.
4.
5.
6.
7.
8.
Periodontal involvement
Suspected impaction
Congenitally missing teeth
Restorative work
Localized sensitivity
Suspected pathology
Injury to the oral cavity
Endodontic therapy
CC DH Department Manual 2024-2025
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C. Examples of full mouth series often indicated in the following situations: (Number of exposures prescribed
according to individual patient needs.)
1. No history of previous radiographs
2. Diagnosis being made for care planning
3. Patient needs extensive restorative therapy
4. Patient requiring oral surgery, periodontal, orthodontic or endodontic procedures
5. When requested by DDS for an edentulous patient
6. Patient’s dentist written request
D. Examples of panoramic radiographs indicated in the following situations:
1. Suspect implications (when planning 4 or more periapicals or when discovered on BWX series)
2. Edentulous patients
3. Orthodontic patients
4. Trauma to head or neck
5. No history of radiographs
6. Greatly delayed eruption
7. Patient’s dentist written request
8. TMJ symptoms
9. Patient’s unable to tolerate periapicals
E. Examples of Horizontal Bitewings (interproximal)
1. Carious lesions
2. Localized periodontal involvement
3. No history of radiographs
4. Patient’s dentist written request
F. Examples of Indications for Vertical Bitewings (4 or 7 series)
1. AAP Stage III patients/Periodontal Maintenance
2. New patient with copies of films from general dentist exposed within 12 months
Radiograph Retake Criteria
1. A maximum number of two retakes may be taken on a patient following dentist approval and
supervision.
2. Excessive overlapping resulting in inability to view interproximal areas.
3. Apical areas from particular teeth not visible on any periapical films.
4. Specific region incompletely represented due to improper placement of film i.e., third molars not visible.
5. Cone cutting resulting from improper placement of PID if diagnostic quality is compromised.
6. Radiograph exposed backward (improper sensor placement).
7. Double exposures.
8. Excessive elongation or foreshortening.
9. Overexposure or underexposure (proper unit setting).
10. For panoramic radiograph only:
a) Image not centralized in the film from left to right.
b) Parts of the oral cavity not visible in the film due to improper patient positioning.
REMINDER: DO NOT RETAKE ANY RADIOGRAPH UNTIL AUTHORIZED BY A DENTIST.
All radiographs must be checked for diagnostic acceptability by a dentist before the patient is dismissed.
CC DH Department Manual 2024-2025
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Radiology Procedures
*NOTE: RADIOGRAPHS SHOULD BE TAKEN AT THE BEGINNING OF THE APPOINTMENT
1. After reviewing the patient’s health and dental history, the student must establish the rationale for exposing
radiographs and must present to DDS for approval the number and type of exposures. Radiographs must not be
exposed unless ordered by the dentist.
2. Aseptic technique must be always maintained while exposing radiographs.
3. Each set of radiographs must be self-evaluated and reviewed by the DDS.
4. Patient radiographs should be displayed on computer screen. The supervising dentist will assist the student in the
interpretation of the radiographs.
5. The supervising dentist evaluates radiographic images and determines the need for retakes. If retakes are
necessary, the dentist completes entry into retake log and enters retakes in the patient notes history.
Faculty and Clinic Assistant Responsibilities for Radiology Laboratory
The Clinic Assistant (CA) will:
1. Clean and disinfect the panoramic room (if applicable) before and after radiographs are exposed on a patient.
• The panoramic unit requires only plastic covering on the patient bite block.
2. Report radiology equipment problems to a clinical/radiology faculty or the supervising dentist.
3. The counters must be cleaned and free of supplies for the evening.
4. The CA will make every effort to assist in the setting up/breaking down of panoramic room. It is ultimately the
responsibility of each student scheduled in the clinic that day.
Pregnancy Policy for Students and Faculty
1. Since the student/faculty member may not be aware of being pregnant, all radiological safety precautions are to be
always followed to prevent any unnecessary operator exposure to ionizing radiation.
2. When a student/faculty becomes pregnant, the Director must be notified immediately so that measures can be taken
to minimize exposure to ionizing radiation. Laboratory and/or clinical schedules may require modification.
3. The following procedures will be followed for pregnant student or faculty:
a. The pregnant student/faculty must obtain written clearance from her obstetrician to expose radiographs on a
patient or work in the radiology department.
b. Pregnant students/faculty must follow guidelines.
c. The pregnant student/faculty must wear an operator lead shield while exposing radiographs.
Concern exists for the safety of dental X-rays in pregnant patients and operators. The ADA recommends the use of aprons
and thyroid shields for pregnant patients, and dosimeters and work practice controls for pregnant
operators. Studies of pregnant patients receiving dental care have affirmed the safety of dental treatment. The
American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women
reaffirmed its committee opinion in 2022: “Patients often need reassurance that prevention, diagnosis, and
treatment of oral conditions, including dental X-rays (with shielding of the abdomen and thyroid) … [is] safe during
pregnancy.”
https://www.ada.org/en/resources/practice/practice-management/radiation-safety-for-pregnant-dentalstaff-and-patients, retrieved May 15, 2024.
https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/08/oral-health-careduring-pregnancy-and-through-the-lifespan, retrieved May 15, 2024.
CC DH Department Manual 2024-2025
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Safe Use of Radiographs in Dentistry for the Patient and Operator
1. Deliberate exposure of an individual to dental diagnostic radiographic procedures for training or demonstration
purposes shall not be permitted unless there is a documented diagnostic need for the exposure. The use of filmholding devices, bite tabs, or other methods are appropriate to position the film during exposure.
2. The dental hygiene student shall not hold the sensor in place for the patient during the exposure. The use of the
appropriate film-holding devices is recommended.
3. The operator must close the door to the x-ray operatory or leave the clinical operatory and directly observe the
patient during each exposure.
4. The x-ray tube housing or the cone must never be held during the exposure. If the equipment is not stable, report the
problem to the radiology faculty and go to another operatory, if needed.
5. Only shielded open-end cones will be used with rectangular Position Indicating Devices (PID) to minimize scattered
radiation. Pointed or closed-end cones are never used.
6. Rectangular collimated position indicating devices will be utilized whenever possible. In this manner, the rectangular
beam striking the face will be appropriate for the receptor size. The use of rectangular collimation utilized along with
the department’s radiographic selection criteria significantly reduce the patient’s unnecessary radiation exposure and
result in obtaining quality images (increased subject contrast of radiographic images) that result in improved diagnoses
and treatment.
7. All intraoral radiographs and panoramic radiographs will be exposed with digital radiography.
8. Each dental x-ray unit should contain filtration of 2mm of aluminum equivalent, if operating at less than 70 kilovolt
peak (kvp) and 2.5 mm of aluminum equivalent, if operating at 70 kvp or above.
9. The Nomad hand-held x-ray device may be utilized for radiographic exposure. It is equipped with a lead impregnated
acrylic shield which protects the operator from scatter radiation. An internal housing encases the x-ray tube to block
backscatter radiation and leakage.
10. The Nomad must be held at mid-torso level and the lead acrylic shield extended down the cone as far as possible
towards the patient. This creates a ‘safe zone’ for the operator. If the operator is not able to stand perpendicular fully
behind the patient, a protective shield should be utilized.
11. Protective shields and cervical collars will be used on all x-ray patients as an additional precaution to prevent
unnecessary scatter radiation exposure to the body of the patient. Aprons are hung up, when not in use.
Recommendations for the use of a thyroid collar are applicable for all patients.
12. A quality assurance program will be observed with daily, weekly, and monthly task schedules. In addition, periodic
radiation protection surveys and inspections will be made by state radiation inspectors and calibration experts. All
recommendations by the radiation safety officer will be implemented and/or corrected, e.g., collimation, filtration,
beam alignment, roentgen output, radiation leakage, etc.
13. Autoclavable or disposable positioning devices will be used on patients. Strict enforcement of infection control
measures will be observed.
CC DH Department Manual 2024-2025
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Collin College Department of Dental Hygiene Policy on the Use of Ionizing Radiation and
ALARA Guidelines are consistent with the ADA CSA as described below and in Table 1:
Patient Selection and ALARA
The ADA CSA 'Recommendations for Patient Selection and Limiting Radiation Exposure' are categorized by the
types of patient encounters: new patient being evaluated for oral disease; recare patient with caries or who is at risk
of caries; recare patient with no caries and is at no increased risk of caries; recare patient with periodontal disease;
recare patient who needs monitoring of dentofacial growth and development and/or assessment of dental or skeletal
relationships; and patients with special circumstances, such as implants, other pathology, endodontic needs, etc.4
The age and dental developmental stage of children, adolescents, adults, and edentulous individuals have specific
recommendations, based on these encounter categories (Table 1). Although the guidelines state that radiographs
should not be based on time alone, intervals between 6 months and 3 years are suggested for specific clinical
situations. The table of recommendations is subject to clinical judgment and may not apply to every patient, as the
decision to prescribe X-rays should be made by dentists only after reviewing the health history and completing a
clinical examination. When the decision has been made that radiographs are necessary in the Collin Dental Hygiene
Clinic, the number and location are selected carefully, and the DDS will prescribe the lowest dose options needed
for diagnostic needs.
The guiding principle in radiation is: ALARA – As Low As Reasonably Achievable
In dentistry, the ALARA principle can be applied during many phases of the radiographic process:
•
•
•
determining the need for and type of radiographs;
using “best practices” during the actual making of images, including the application of office quality control
procedures;
Interpreting the images completely and accurately to obtain all the diagnostic information they contain.
CC DH Department Manual 2024-2025
31
Reference Table 1: Council on Scientific Affairs. American Dental Association, US Department of Health and Human Services, Food and Drug Administration. Dental radiographic examinations:
patient selection and limiting radiation exposure. 2012.
CC DH Department Manual 2024-2025
32
Recommendations for
Dental Hygiene Department
Patient Health History Guidelines
2024-2025
Dental Hygiene Department Manual
CC DH Department Manual 2024-2025
33
Health History Guidelines
Patient’s Health History/Risk Assessment
When reviewing the health history with a patient who has indicated systemic medical conditions that could be
affected by the treatment a dental hygienist would provide, you must be sure to have a thorough understanding of
the patient’s medical problem and status of treatment. The information gained from the questions you ask the
patients will help you and your faculty plan the appropriate dental treatment for that patient and determine the need
for medical clearance and/or pre-medication.
Medical Clearance Requirements
In some cases, a medical clearance from the patient’s physician may be indicated for patients with medical history
concerns. It is necessary to consult with a DDS/faculty before treating patients with a history of any of the
following conditions:
• AIDS/HIV
• Asthma-severe or persistent
• Bone Plates (less than 2 years from date of surgery)
• Breast Implants-history of post-surgical infection or complications
• Cardiac conditions associated with complications and/or stents (less than 2 years from date of
surgery); heart attack (6 months or less)
• Heart valve replacement, history of rheumatic heart disease
• COPD
• End Stage Renal Disease
• Epilepsy
• Hepatitis (B, C,D,E)
• History of being told by physician to take antibiotics before dental treatment
• History of infective endocarditis
• Immunosuppression due to organ transplant
• Joint Replacement (history of infection, diabetic)
• Leukemia
• Marfan’s syndrome
• MRSA
• Other autoimmune deficiencies
• Pacemakers/Defibrillator-shielded/unshielded
• Patients currently on dialysis (shunts/fistulas)
• Recent chemotherapy/radiotherapy (facial)
• Uncontrolled diabetes
• Sickle Cell Anemia
• Traumatic Brain Injury/Transient Ischemic Attack/Stroke (6 months or less)
• Systemic steroid/corticosteroid medication/therapy
• Tuberculosis-active within 5 years
• Diabetes (medical clearance with most recent A1C, within the past three months, is ideal prior to
completion of assessments for proper dental hygiene diagnosis and care planning; See Glucose
Monitoring Protocol, pg. 35)
CC DH Department Manual 2024-2025
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Glucose Monitoring Process
Blood glucose levels will be performed on all pre-diabetic and diabetic patients and documented. If glucose levels
are at or below 200mg/dl during a morning appointment but rise to 201-250 mg/dl the same day after lunch, the
supervising clinical dentist can evaluate the patient on a case-by-case basis. Diabetic patient glucose levels vary
depending on the patient. A blood glucose level that is 200 or greater may be normal for that patient. It is
recommended that a medical clearance be obtained to determine what a safe level is for dental treatment. Obtaining
a blood glucose level is a real time test and does not indicate how well the patient is controlled over certain period.
There are several factors that can influence a blood glucose test. It is best to obtain a medical clearance citing the
patient’s most recent A1C and proceed with asking for any precautions and if the patient is cleared for non-surgical
periodontal therapy. Diabetic patients should be seen in the morning when glucose levels are normally at their best.
Possible Uncontrolled Diabetics and/or high glucose (>200 mg/dl):
• Wait 10-15 minutes and obtain a new glucose level. If glucose is still >200 mg/dl:
o Invasive care should be postponed (Radiographs, dental exam, EIOE, and gingival
assessment may be completed, but a medical clearance will need to be obtained before
continuing elective treatment)
The protocol is as follows and will be monitored by a faculty/DDS:
1. Obtain required materials according to protocol;
• Student should obtain a glucometer, lancet, and glucose strip
• Student should obtain a sterile package of 2X2 gauze and an unopened alcohol wipe
2. Obtain approval to begin
3. Verbalize this patient’s individualized need for glucose monitoring;
• Student should verbalize whether the patient has diabetes (and if it is Type I or Type II), pre-diabetes, or
other reason for use of glucometer.
4. Explain procedure and rationale to patient;
• This step should be completed in the presence of the faculty
• Explain the importance of diabetes as it relates to oral health.
• Describe the glucose testing in layman’s terms.
• Inform the patient that we are performing procedures that can put them at high risk for infection if blood
glucose levels are above normal range.
5. Disinfect the patient’s finger according to protocol;
• Must use new alcohol wipe
• Must wipe for at least 10 seconds
• If finger is excessively dirty, must repeat with a new alcohol wipe for an additional 10 seconds
• Wait for alcohol to dry completely. Wet alcohol can alter the test results and cause burning sensation to
the patient when pricked.
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6. Enhance blood flow to the finger and use correct technique to prick finger with lancet;
• Rub the finger to warm and enhance blood flow
• A warm finger will help the blood flow more easily and lessen the pain of the injection; Place the lancet
firmly against the tip of the finger and press to inject.
7. Prepare the glucose meter for use and expel a drop of blood onto the test stick before the meter times out;
• Place the correct end of the test strip in the meter.
• When the meter is ready to accept blood, rub and squeeze the finger to expel a small drop of freshly
squeezed blood on the test strip.
8. Apply pressure to the test site with sterile gauze;
• Ask the patient to hold the sterile gauze against the finger for a few minutes to stop the bleeding
9. Properly dispose of lancet;
• Place in the sharps container
10. Disinfect meter and return to assigned area. Properly document blood glucose results on the medical history
form in the comments section with appropriate mg/dl.
Example: “HHX reviewed, patient ate breakfast one hour ago, 2 eggs and some black coffee, took Metformin at
the same time, Blood glucose 154 mg/dl, no changes to history since last appt, ASA II, EHenderson.”
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American Dental Association/American Heart Association Guidelines
Preventive antibiotics prior to a dental procedure are advised for patients with:
Antibiotic prophylaxis with dental procedures is reasonable only for patients with cardiac conditions associated with
the highest risk of adverse outcomes from endocarditis, including:
• Prosthetic cardiac valve or prosthetic material used in valve repair or implantable cardiac devices such as a
transcatheter aortic valve
• Previous, relapse, or recurrent infective endocarditis
• Congenital heart disease (CHD) only in the following categories*:
– Unrepaired cyanotic CHD, including those with palliative shunts and conduits
– Completely repaired congenital heart defect with prosthetic material or device, whether
placed by surgery or catheter intervention, during the first six months after the procedure†
– Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or
prosthetic device (which inhibit endothelialization)
• Cardiac transplantation recipients with valve regurgitation due to a structurally abnormal valve and/or cardiac
valvular disease
* Except for the conditions listed above, antibiotic prophylaxis is not recommended for any other form of CHD.
† Prophylaxis is reasonable because endothelialization of prosthetic material occurs within six months after the
procedure.
All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth, or perforation of
the oral mucosa* *Antibiotic prophylaxis is NOT recommended for the following dental procedures or events:
routine anesthetic injections through noninfected tissue; taking dental radiographs; placement of removable
prosthodontic or orthodontic appliances; adjustment of orthodontic appliances; placement of orthodontic brackets;
and shedding of deciduous teeth and bleeding from trauma to the lips or oral mucosa.
References:
The 2021 American Heart Association Statement on prevention of infective endocarditis - The Journal of the American Dental
Association (ada.org)
https://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis
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Total Joint Replacement
In 2014, the ADA Council on Scientific Affairs assembled an expert panel to update and clarify the clinical
recommendations found in the 2012 evidence report and 2013 guideline, Prevention of Orthopaedic Implant Infection in
Patients Undergoing Dental Procedures.1, 2American Academy of Orthopaedic Surgeons/ American Dental Association
Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures Evidence-Based Clinical Practice
Guideline. https://www.aaos.org/dentalcpg Published December 12, 2012. Accessed May 15, 2024.
“As was found in 2012, the updated systematic review undertaken in 2014 and published in 2015 found no
association between dental procedures and prosthetic joint infections.3 Based on this evidence review, the 2015
ADA clinical practice guideline states,3 "In general, for patients with prosthetic joint implants, prophylactic
antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.” The ADA
encourages dental professionals to review the full 2015 guideline3 and take this recommendation into account,
consult with the patient's orthopedic surgeon as needed, and consider the patient's specific needs and preferences
when planning treatment.
According to the ADA Chairside Guide found at https://www.ada.org/en/resources/research/science-andresearch-institute/oral-health-topics/antibiotic-prophylaxisin cases where antibiotics are deemed necessary, it is
most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and, when reasonable,
write the prescription.
You can access the updated AAOS Information Statement and dental prophylaxis decision tree at
https://www.aaos.org/globalassets/quality-and-practice-resources/dental/dental-prophylaxis-auc-decision-tree-1.pdf
These guidelines were developed by the American Academy of Orthopedic Surgeons and the American Dental
Association. They are designed to help practitioners make decisions about preventive antibiotics for dental patients
with artificial joints. They are not a standard of care or a substitute for the practitioner’s clinical judgment.
Practitioners must exercise their own clinical judgment in determining whether preventive antibiotics are
appropriate. Pediatric doses may be different. Antibiotic prophylaxis is not recommended for patients with pins,
plates, and screws, or routinely for patients with total joint replacement.
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Antibiotic regimens for dental procedures
(single dose administered 30 min to 60 min before the procedure)
Situation
Agent
Adults
Children
Able to take oral medication
Amoxicillin
2g
50 mg/kg
Unable to take oral medication
Ampicillin
2 g IM or
IV
50 mg/kg IM or
IV
Cefazolin or ceftriaxone
1 g IM or
IV
50 mg/kg IM or
IV
Cephalexin
2g
50 mg/kg
Azithromycin OR
clarithromycin OR
500 mg
15 mg/kg
Doxycycline
100 mg
Cefazolin or ceftriaxone
1 g IM or
IV
OR
Allergic to penicillin or ampicillin
OR
Allergic to penicillin or ampicillin and unable to
take oral medication
50 mg/kg IM or
IV
IM Intramuscular; IV Intravenous
Total children’s dose should not exceed adult dose.
** Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria,
angiodema, or anaphylaxis) to penicillins.
Retrieved from Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the
American Heart Association (ahajournals.org)
May 15, 2024.
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*ALWAYS RECORD THE TYPE, DOSAGE, AND TIME THE DRUG WAS TAKEN IN THE PATIENT’S
MEDICAL HISTORY IN THE COMMENTS SECTION:
“Patient took prescribed premedication of Amoxicillin 500 mg X 4 tabs at 7:30 am”
AND MAKE ENTRY IN NOTE HISTORY STATING “Premed taken as indicated in HHX”
The supervising clinical dentist may dispense the medication the first time the patient is treated. Inform the patient
that it will be his/her responsibility to get the medication for subsequent appointments if needed, and for future
appointments. A prescription must be obtained from the patient’s physician.
Precautions/Variations for Patients Requiring Special Needs or Accommodations
Herpes Simplex I
•
•
If patient has an active, oral lesion, reappoint patient.
For all other patients, take standard precautions.
Conjunctivitis
•
Dismiss patient and reschedule when the patient has been cleared by physician.
Pacemaker/Defibrillator
•
Ultrasonic instrumentation is contraindicated unless pacemaker is shielded. Most pacemakers placed after 2005 are
shielded; however, a Piezo scaler may be utilized. Clearance is required for an initial visit and does not need to be
updated annually unless there have been changes to the patient’s current health status.
In all cases, health is the most important factor and adjustments may be necessary to provide safety and comfort for both
patient and operator.
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ASA PHYSICAL STATUS CLASSIFICATION SYSTEM
Last amended on December 13, 2020
Retrieved May 15, 2024 https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
Although pregnancy is not a disease, the parturient physiologic state is significantly altered from when the woman is not pregnant, hence the assignment of ASA 2 for a woman with uncomplicated
pregnancy.
**The addition of “E” denotes Emergency surgery: (An emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part)
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Blood Pressure Guidelines for Adult Patients
This blood pressure chart reflects categories defined by the American Heart Association. Understanding Blood
Pressure Readings American Heart Association Retrieved May 15, 2024.
Collin College Dental Hygiene Department Dental Therapy Considerations
Blood Pressure
(MM/HG)
<140 and <90
Dental Therapy Considerations
1. Routine dental management
1. Re-check in 10 minutes
2. If exceeds 140/90, medical consultation is indicated
3. Routine dental management if approved by physician/dentist and DDS
140-160 and/or 90-95
signature required
4. If there is no DDS available, a medical clearance is required before treatment,
including the taking of radiographs*
5. Stress reduction protocol if indicated
1. Re-Check blood pressure in 10 minutes. If still elevated, medical consultation
is indicated
161-200 and/or 96-115 2. A medical clearance is required before treatment, including the taking of
radiographs*
3. Stress reduction protocol
>201 and/or >116
1. Immediate medical consultation
*Patients with a BP of 161/96 will not be seen for treatment without a medical clearance form. Verbal
authorization for treatment will not be accepted.
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Blood Pressure Guidelines for Pediatric Patients
http://pediatrics.aappublications.org/content/early/2017/08/21/peds.2017-1904.figures-only
Blood Pressure Categories for Adolescent Patients
Flynn JT, Falkner BE. New clinical practice guideline for the management of high blood pressure in children and adolescents.
Hypertension. 2017;70: 683–686
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Oral Disease Risk Management
Periodontal Diagnosis,
and
Dental Hygiene Care Planning Process
2024-2025
Dental Hygiene Department Manual
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Oral Disease Risk Management Protocols Scope and Purpose of Guidelines
Modern methodology for the prevention of progressive oral disease includes identification of those patients who
have a high probability of developing disease. These individuals are distinguished by demographic, physical, lifestyle,
or other risk factors associated with the disease. Identification of these factors comes from clinical examination,
laboratory tests, and surveys of disease incidence and prevalence. Prevention is the most effective means for
controlling oral disease and attaining an improved state of oral health. Cost effective prevention requires a
standardized risk management protocol which directs appropriate treatment and education based on level of risk.
The treatment protocols, based on the best available evidence, are intended to help guide treatment decisions
regarding diagnosis, management, and treatment of oral diseases, including dental caries, periodontal disease, and
oral cancer. These protocols provide a framework for the delivery of quality oral healthcare/preventive services,
and to sustain continuous improvement of dental hygiene practice. They are not intended to restrict individual
clinical judgment. Oral health risk assessment forms are not intended to include all possible risk factors. The risk
factors selected are intended to provide patients with information that may help them lower their oral disease risk
over time, while also providing dental health providers with the information required to assign patients into
recognized risk categories and identify treatment options and therapies to achieve and maintain oral health.
Dental Caries Risk Management Guidelines Risk Factors for Dental Caries
Caries risk assessment currently involves a combination of factors including diet, fluoride exposure, a susceptible
host, and microflora that interplay with a variety of social, cultural, and behavioral factors. Caries risk assessment is
the determination of the likelihood of the incidence of caries (i.e., the number of new cavitated or incipient lesions)
during a certain time period or the likelihood that there will be a change in the size or activity of lesions already
present.
It is now known that surgical intervention of dental caries alone does not stop the disease process. Additionally,
many lesions do not progress, and tooth restorations have a finite longevity. Therefore, modern management of
dental caries should be more conservative and includes early detection of noncavitated lesions, identification of an
individual’s risk for caries progression, understanding of the disease process for that individual, and “active
surveillance” to apply preventive measures and monitor carefully for signs of arrestment or progression. Active
surveillance (prevention therapies and close monitoring) of enamel lesions is based on the concept that treatment of
disease may only be necessary if there is disease progression, that caries progression has diminished over recent
decades, and that many proximal lesions, even in dentin, are not cavitated.
History of Caries
Although the best tool to predict future caries is past caries experience, it is not particularly useful in young children
due to the importance of determining caries risk before the disease is manifest. Children with white spot lesions
should be considered at high risk for caries since these are precavitated lesions that are indicative of caries activity.
Plaque accumulation is also strongly associated with caries development in young children.
Cariogenic Diet
While there is no question that fermentable carbohydrates are a necessary link in the causal chain for dental caries, a
systematic study of sugar consumption and caries risk has concluded that the 1-2-1relationship between sugar
consumption and caries is much weaker in the modern age of fluoride exposure than previously thought. However,
there is evidence that night-time use of the bottle, especially when it is prolonged, may be associated with early
childhood caries. The effect of sugar substitutes on caries rates has been evaluated in several populations with high
caries prevalence. Studies indicate that xylitol can decrease streptococcus mutans microorganism levels in plaque
and saliva and can reduce dental caries.
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Exposure-Antimicrobial Therapy
Dentistry has increasingly incorporated the medical mode of treatment, turning to pharmacological agents to arrest
and reverse the disease process, instead of relying solely on surgical interventions (as in the past) to repair dentition
after the disease has taken its toll. Presently, several methods are employed for the prevention and remineralization
of caries, including the application of fluoride, chlorhexidine (CHX), xylitol, and casein phosphopeptide amorphous
calcium phosphate (CPP-ACP). The protocols promote the application of topical fluoride therapy since there is
consistent and strong evidence of its effectiveness, based on a sizable body of evidence from randomized controlled
trials. Evidence-based clinical recommendations for professionally applied fluoride in caries prevention, among
moderate- and high-risk adults, call for the application of fluoride gel or varnish every 3 to 6 months, depending on
the caries risk levels. Fluoride toothpaste, if used as recommended, is safe to use irrespective of fluoride exposure
from other sources. Additional use of fluoride mouth rinses may be indicated for individuals at risk of developing
caries: both daily rinsing with 0.05% NaF (226 ppm F) and once-a-week or once-every-two-weeks rinsing with
0.2% NaF (909 ppm F) were found to be effective. CPP-ACP (Recaldent) and ACP products are available in
toothpaste, such as Arm and Hammer Enamel Care and Mentadent. These compounds are also marketed in prophy
pastes, such as MI Paste and Enamel Pro. The chewing gum, Trident White, also contains Recaldent. These
products are most useful when saliva production is less than ideal.
Xerostomia
Reduced saliva flow that results in a dry mouth is a common problem. It is caused by certain medical disorders and
may be a side effect of more than 400 medications. Without saliva’s cleansing effects, tooth decay and other oral
health problems become more common. Medications that may reduce salivary flow include anti-allergy
medications, antihistamines, decongestants, sedatives, cardiovascular medications (angiotensin-converting enzyme
(ACE) inhibitors and calcium channel blockers); muscle relaxants, drugs for urinary incontinence, Parkinson’s
disease medications, antidepressants, antacids and many others. A saliva test may be considered if there is suspicion
of high bacterial challenge. Antimicrobials such as fluorides and chlorhexidine gluconate, along with dentifrices or
gels containing calcium phosphate, mints or gum containing xylitol, and pH modifying products should be
considered if saliva flow is inadequate.
Caries Management by Risk Assessment (CAMBRA) is an evidence-based approach to preventing and
managing cavities at the earliest stages. Developed at the University of California, San Francisco (UCSF) in the early
2000s, CAMBRA considers a patient’s health and lifestyle risk factors, such as the presence of harmful bacteria, low
levels of saliva, and poor diet. It then weighs these factors against protective measures like living in a community
with fluoridated water, using fluoride toothpaste, and practicing good oral hygiene.
Here are some key points about CAMBRA:
1. Risk Assessment:
o Dentists assess a patient’s risk for developing caries (tooth decay) based on individual factors.
o Risk factors include acid-producing bacteria, frequent consumption of fermentable carbohydrates,
and abnormal saliva flow.
o Protective factors include using fluoride products, antibacterial mouth rinses, and maintaining
adequate saliva flow.
2. Treatment Strategies:
o Dentists develop a personalized management strategy based on the patient’s risk assessment.
o Treatment may include:
 Remineralization: Using fluoride and/or antibacterial therapies (e.g., chlorhexidine,
xylitol) to strengthen teeth.
 Minimally Invasive Restorative Procedures: Preserving tooth structure while addressing
caries.
 Regular Follow-Up: Monitoring progress and adjusting treatment as needed.
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3. Clinical Benefits:
o CAMBRA can prevent a lifetime of oral pain and discomfort.
o It saves patients thousands of dollars in dental bills over their lifetimes.
o For dentists, it serves as a powerful practice builder, especially in an era focused on preventive
care12.
Remember that CAMBRA is a standard of care that involves early risk assessment, diagnosis of the caries disease
process, and minimally invasive treatment. Dentists worldwide have embraced CAMBRA to manage patients’ oral
health effectively3.
Dental Caries Risk Management
The treatment protocol for patients at risk for caries includes three components: patient education, treatment, and
continuing care.
1. Patient Education Component
a. Inform the patient that carious lesions are not the disease, but the aftermath of a disease process caused by
elevated bacterial levels in his or her mouth. Placing a filling restores the damaged tooth structure but may have
little effect on the activity of the cariogenic bacteria or disease progression. Therefore, in addition to tooth
restoration, dental caries treatment must address bacterial etiology.
b. Inform the patient that they will be receiving antibacterial treatment and oral hygiene instruction designed to
control the cariogenic bacteria in his or her mouth. Success will depend largely on their compliance with the
prescribed treatment.
2. Treatment Component
a. Eliminate active caries
(1) Refer for restoration of any cavitated lesions
(2) Seal remaining deep, retentive pits, and fissures
b. Implement preventive measures
(1) Survey and recommend diet modifications
(2) Provide oral health instruction (disease etiology and oral hygiene instruction)
(3) Evaluate salivary flow (High Caries Risk)
(4) Provide two in-office fluoride treatments over a 12-month period (Moderate Caries Risk), or
four in-office fluoride treatments over a 6-12 month period using either gels or varnishes as per
current professional guidance
(5) Implement prescription strength home fluoride usage as per current professional guidance
(6) Discuss benefits of Xylitol chewing gum and provide a sample if available
3. Recare Component
a. Six to Twelve Month Intervals: Low Caries Risk
(1) Monitor and reinforce preventive measures
(2) Monitor sealant retention
b. Four to Six Month Intervals: Moderate Caries Risk
(1) Monitor and reinforce preventive measures
(2) Monitor sealant retention
c. Three to Four Month Intervals: High Caries Risk
(1) Monitor and reinforce preventive measures
(2) Monitor sealant retention
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Periodontal Disease Risk Management Guidelines
Risk Factors for Periodontal Diseases
Numerous experts have published recommendations for assessing risk and managing periodontal diseases. The goal
of a periodontal therapy and maintenance program is to preserve the dentition, while maintaining health, comfort,
esthetics, and function for the patient. No one treatment can provide the single best outcome, so different options
may be chosen for different cases or time periods in treatment plans. The periodontal disease risk assessment
estimates the risk for (or susceptibility to) periodontal disease. It consists of an assessment of the level of infection
(full mouth bleeding scores), the prevalence of periodontal pockets, tooth loss, an estimation of the loss of
periodontal support, an evaluation of the systemic conditions of the patient, and an evaluation of environmental and
behavioral factors such as smoking.
Oral Hygiene
Since bacterial plaque is by far the most important etiologic agent for the occurrence of periodontal diseases, it is
evident that the full mouth assessment of the bacterial load must have a pivotal impact in the determination of the
risk for disease. Studies to date have not identified the level of plaque compatible with periodontal health.
However, clinically, a percentage of tooth surfaces covered by visible plaque of 20-40% might be tolerable in most
patients. It is important to realize that the full mouth plaque score must be related to the host response of the
patient, i.e. compared to inflammatory parameters.
Bleeding on Probing
Bleeding on gentle probing represents an objective inflammatory parameter which has been incorporated into index
systems for the evaluation of periodontal conditions and is used as a parameter by itself. Although there is no
established acceptable level of prevalence of bleeding on probing above which a higher risk for disease exists, a
bleeding on probing (BOP) prevalence of 25% has been the cut-off point between patients who maintain
periodontal stability and those who do not. The BOP percentages reflect a summary of the patient’s ability to
perform proper plaque control, the patient’s host response to the bacterial challenge, and the patient’s compliance
with recommended preventive measures.
Periodontal Pockets
The enumeration of probing depths greater than 4 mm, in conjunction with other parameters such as bleeding on
probing and/or suppuration, will reflect existing ecological niches from and in which infection might occur. The
presence of high frequencies of deep pockets has been associated with high risk for periodontal disease progression.
Tooth Loss
Although the reason for tooth loss may not be known, the number of remaining teeth in a dentition reflects the
functionality of the dentition. If more than 8 teeth from a total of 28 teeth are lost, oral function is usually
impaired. Since tooth loss also represents a true end point outcome variable reflecting the patient’s history of oral
disease and trauma, it is logical to incorporate this risk indicator in the assessment.
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Clinical Attachment Loss
Interdental clinical loss of attachment (recession plus pocket) is the most prevalent indicator in determining the
presence and risk of periodontal disease and is the first clinical indicator used by the AAP Classification System.
when related to the patient’s age. Radiographic bone loss is important in the assessment of staging and grading but
only gives a history of the alveolar bone loss and does not always align with what is seen clinically. The estimation of
the loss of bone is performed in the posterior region on either periapical radiograph, in which the predominant sites
affected are grossly estimated in percent of the root length or on bitewing radiographs, in which the predominant
sites are estimated in millimeters.
On bitewing radiographs, one millimeter is considered equal to 10% bone loss. An estimation of 20% bone loss is
considered the critical value in determining greater periodontal disease risk.
Diabetes/Systemic and Genetic Aspects
The most substantiated evidence for modification of disease susceptibility and/or progression of periodontal disease
arises from studies on Type I and Type II diabetes mellitus populations. Although the impact of diabetes on
periodontal diseases has been documented in patients with untreated periodontal disease, it is reasonable to assume
that the influence of diabetes may affect the risk for periodontal disease. In recent years, genetic markers have
become available to determine various genotypes of patients regarding their susceptibility to periodontal diseases.
Research on the Interleukin-1 (IL-1) polymorphisms has indicated that IL-1 genotype positive patients show a
greater risk for periodontal disease and higher tooth loss.
Tobacco Use
Consumption of tobacco, predominantly in the form of smoking rather than snuffing or chewing, increases the
susceptibility of patients to periodontal disease. The association of smoking and periodontal disease risk has been
shown to be dose dependent. The equivalent of 10-20 cigarettes a day represents a higher risk for periodontal
disease and increases the rate of progression.
Periodontal Disease Risk Management
Clinical management protocols are documents designed to assist in clinical decision-making; they provide criteria
regarding diagnosis and treatment and lead to recommended courses of action. The protocols are based on evidence
from current peer-reviewed literature and the considered judgment of expert panels, as well as the clinical
experience of practitioners. The treatment protocol for patients at risk for periodontal disease includes three
components: patient education, treatment, and continuing care.
1. Patient Education Component
a. The first step in treating periodontal disease is to tell the patient that he/she has an infection in his/her
mouth. The patient should be kept informed of diagnosis, prognosis, treatment plan, changes in
periodontal prognosis and risk factors.
b. Inform the patient that they will be receiving antibacterial treatment and oral hygiene instruction
designed to control the bacteria in his or her mouth. Success will depend largely on their compliance with
the prescribed treatment.
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2. Treatment Component
a. Eliminate local etiologic factors
(1) Nonsurgical removal of supragingival and subgingival plaque and calculus
(2) Refer for surgical interventions designed to reduce or eliminate periodontal pockets
(3) Refer for surgical interventions designed to regenerate periodontal tissues
a. Refer to physician for assistance with management of periodontal-systemic interrelationships.
b. Refer for therapy designed to establish and maintain occlusal health
c. Apply root desensitizing agents
d. Implement preventive measures
(1) Survey and recommend diet modifications
(2) Provide oral health instruction (disease etiology and oral hygiene instruction)
(3) Discuss periodontal disease risk factors, with appropriate referral if needed
(4) Implement antimicrobial therapy to reduce, eliminate, or change the quality of
microbial pathogens or to alter the host response:
Chlorhexidine Gluconate (0.12%) rinse, Locally delivered antibiotics/antimicrobials,
Systemic antibiotics
(5) Evaluate salivary flow
3. Recare Component: Monitor and reinforce preventive measures
a. Six Month Intervals: No history of periodontal disease
b. Three Month Intervals: History of periodontal disease
Periodontal Disease Risk Management Protocol
The protocol for managing periodontal disease risk factors represents appropriate preventive and therapeutic
interventions to achieve optimal results for at-risk patients. Determining individual treatment plans, including
whether a patient should be referred to a specialist, is dependent on your clinical judgment.
1. Counseling on control or elimination of risky behaviors, such as tobacco use or a highly stressful lifestyle
2. Oral hygiene instruction and oral disease education
3. Construction of an occlusal splint or occlusal adjustment
4. Patient-specific nutritional counseling
5. Evaluation of salivary flow
6. Medical consultation
7. Removal of supragingival and subgingival biofilm
8. Use of chemotherapeutic agents to reduce, eliminate, or change the quality of microbial pathogens, or to
alter the host response, through local or systemic delivery
9. Root desensitization, if indicated
10. Referral for surgical periodontal therapy
11. Recare interval of 3 months.
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Oral Pathology/Cancer Risk Management Guidelines
Risk factors for oral cancer with the stereotypical oral cancer patient (an elderly male, who abuses tobacco and
alcohol), late diagnosis may be related to the fact that an increasing number of oral cancer patients who do not fall
into the “high risk” group are not recognized by health care practitioners as being at risk of developing oral cancer.
This concept is exemplified by the rise of the female population that is affected by oral cancer. In the 1930’s the
male to female ratio for oral cancer was 10:1. With increases in tobacco and alcohol use by women that ratio has
changed to 2:1. The relative risk is much higher in women at all levels if smoking. Moreover, it has also been
suggested that women may be more susceptible to cancers that are provoked by alcohol. Nearly 30,000 new cases
of oral cancer are found every year in the US.
Tobacco
Studies of oral cancer have consistently demonstrated that smoking and other uses of tobacco are the most
consistently identified risk factors. Smokers have been found to have a 6 to 14 times greater risk of oral cancer
compared to non-smokers. The risk of oral cancer associated with smoking diminishes with elapsed time since
quitting. Among Americans, another factor that has been advocated as causative for developing cancer has been the
use of spit tobacco. Increased popularity of the use of this form of tobacco, and the fact that American women have
shown significant increases in tongue cancer with a low rate of smokeless tobacco use (0.3%) raises doubt as to the
significance of these products in accounting for this form of tongue cancer. The incidence of non-tongue oral cancer
(cheek and gingival), areas that harbor smokeless tobacco, has remained constant in the United States.
Alcohol
Alcohol abuse, defined as more than 21 standard drinks for men and 14 for women in one week, is the second
largest risk factor for the development of oral cancer. Individuals who use both alcohol and tobacco are at an
especially high risk of contracting the disease. Scientists now believe that these substances act synergistically,
increasing each other's harmful effects. Alcohol's effect on the mouth may be the key to understanding how it works
with tobacco to increase the risk of developing cancer. The dehydrating effect of alcohol on cell walls enhances the
ability of tobacco carcinogens to permeate mouth tissues; additionally, nutritional deficiencies associated with heavy
drinking can lower the body's natural ability to use antioxidants to prevent the formation of cancers.
Lesions
Several oral lesions and conditions precede oral carcinoma and the most common of these are leukoplakia and
erythroplakia. Leukoplakia has many clinical variants but is much less likely to progress to malignancy than
erythroplakia. It has recently been estimated that the annual transformation rate of oral leukoplakia to oral
squamous cell carcinoma may not exceed 1%. Erythroplakia is rare and mainly occurs in people aged over 60.
Chronic irritation to the lining of the mouth, due to poorly fitting dentures, faulty restorations, cheek chewing or
other oral habits, may increase a person’s risk for oral cancer. Evidence of this chronic trauma may be seen as
ulcerations or soft tissue masses. An ulcer which occurs with no evidence of trauma is also a risk factor for oral
cancer.
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Viral Infection
Recently, human papilloma virus (HPV) infections have been found to cause cancer of the oropharynx, including the
soft palate, the base of the tongue, and the tonsils. HPV infections are the most common sexually transmitted
infections in the United States. In fact, more than half of sexually active people are infected with one or more HPV
types at some point in their lives. High-risk or oncogenic HPVs can cause cancer. At least a dozen high-risk HPV
types have been identified. Two of these, HPV types 16 and 18, are responsible for many HPV-caused cancers. In
the United States, more than half of the cancers diagnosed in the oropharynx are linked to HPV-16. The incidence
of HPV-associated oropharyngeal cancer has increased during the past 20 years, especially among men. It has been
estimated that, by 2020, HPV will cause more oropharyngeal cancers than cervical cancers in the United States.
Ultraviolet Radiation
Lip cancer is linked to excessive sun exposure. Many patients who have cancer of the lip have outdoor jobs
associated with prolonged exposure to sunlight. In fact, more than 30 percent of lip cancer diagnoses are in persons
with outdoor occupations. Lip cancer occurs in men six times more often than in women. A history of exposure to
sunlight growing up, especially a history of frequent sunburns, is the most important cause of all squamous cell skin
and lip cancers. Most lip cancer forms on the lower lip. Lip cancer on the upper lip is rarer, but also more
dangerous.
History of Oral Cancer
People with a previous oral or pharyngeal cancer have a more than 30-fold increased risk of second oral or
pharyngeal cancer, and risk remains 20-fold higher 10 or more years after the first diagnosis. An almost seven-fold
increase in risk of oral and pharyngeal cancer has been shown after a diagnosis of squamous cell carcinoma of the
esophagus, with risk remaining higher five or more years after the first diagnosis.
Xerostomia
Xerostomia is defined as dry mouth resulting from reduced or absent saliva flow. Xerostomia may be a symptom of
various medical conditions, a side effect of radiation to the head and neck, or a side effect of a wide variety of
medications. Xerostomia is a common complaint found often among older adults, affecting approximately 20
percent of the elderly. The absence of adequate salivary flow may indicate the need for biopsy of major salivary
glands when malignancy is suspected. With xerostomia, the mucosal surface lining the oral cavity does not receive
the protective qualities of saliva and is at risk for the development of oral cancers. Poor Diet Research has suggested
that fruits and vegetables, which contain antioxidants that can “trap” harmful molecules, can decrease the risk for
oral cancer. Thus, it is speculated that people with a low intake of these types of foods are at an increased risk for
oral cancer. A meta-analysis showed a significant risk reduction of about 50% for each additional daily serving of
fruit or vegetables. However, there is considerably more uncertainty about the links between diet and oral and
pharyngeal cancer than for other risk factors, such as smoking and alcohol.
Oral Cancer Risk Management
The identification of one or more oral cancer risk factors calls for prompt patient education and treatment
protocols. Prevention or early detection of oral cancer can save many lives. The treatment protocol for patients at
risk for oral cancer includes three components: patient education, treatment, and continuing care.
1. Patient Education Component
a. Inform patients of the importance of early diagnosis of oral cancers
b. Explain patients’ important role in primary prevention of oral cancers
(1) Risk factors which can be modified or eliminated
(2) Risk factors which cannot be changed:
• Age of 55 or more years, Male gender, African American race
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2. Treatment Component
a. Perform biopsy or refer for biopsy of existing suspicious lesions
b. Refer for removal of existing factors which irritate oral mucosal surfaces
c. Implement protective measures
(1) Offer or refer to Tobacco Cessation program
(2) Recommend avoidance or prudent use of alcohol
(3) Recommend safety measures to be adhered to during sun exposure
(4) Survey and recommend diet modifications
(5) Refer for counseling regarding HPV vaccine
3. Recare Component: Perform annual oral cancer screening and provide oral cancer risk education yearly.
Oral Cancer Risk Management Protocol
Health histories and clinical exams reveal risk factors associated with oral cancer. Understanding these risk factors is
essential for all dental health care providers. Early detection and intervention of oral cancer risk can save patient
lives.
1. Oral cancer risk education, including all relevant factors
2. Counseling on control or elimination of tobacco use
3. Refer to physician for counseling on minimizing potential HPV exposures and/or HPV vaccine
4. Refer for treatment of alcohol addiction/abuse
5. Patient-specific nutritional counseling
5. Removal of factors causing physical irritation to mucosal tissues
6. Follow-up on potentially cancerous oral lesion in 7-10 days
7. Refer for biopsy any potentially cancerous oral lesion that remains unchanged after 7-10 days
8. Perform annual oral cancer screening.
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Radiographic and Clinical Assessment
Radiographic Assessment
Radiographically determining changes in the alveolar bone associated with periodontal disease is based on the
appearance of the crestal lamina dura and the alveolar bone. In a healthy periodontal environment, the crestal lamina
dura radiographically appears as a continuous, radiopaque line running parallel to an imaginary line drawn between
the CEJs of the adjacent teeth. In a healthy periodontium, the difference in the distance between the normal alveolar
bone crest and the CEJ can range from 0.4 to 2.9 mm. In general, however, a distance greater than 2 mm from the
CEJ to the crestal bone is considered evidence of disease. An early radiographic change associated with periodontal
disease is a fuzziness or break in the continuity of the lamina dura at the mesial or distal aspect of the interdental
area. This change results from a loss of crestal density. As inflammation spreads, a wedge-shaped widening of the
PDL occurs, exhibiting a radiolucent area between the tooth and the crestal bone, known as triangulation. The V of
the wedge of the triangle points apically. As inflammation spreads deeper into the connective tissue, bone
degenerates with a subsequent reduction in bone height.
The pattern of bone loss is described as either horizontal or vertical. The CEJ of adjacent teeth can be used to
determine the type of bone loss.
• When bone loss is >2 mm and is parallel to the CEJ of the adjacent teeth, horizontal bone loss is present

When bone loss is >2 mm and is diagonally oriented to the CEJ of adjacent teeth, vertical bone loss is
present.
If the teeth have erupted at varying levels or are tilted, the lamina dura crest will be slanted to match the variation in
crown level. Normal slanting may be confused with bone loss. Bone loss resulting from the inflammation of
periodontitis typically does not uniformly occur throughout the mouth, the quadrant, or even on the same tooth;
loss in one area may be more severe than in another. Severity is assessed as a percentage loss of the normal amount
of bone. To obtain a percentage loss, the radiographic image and probe are used to measure the total root length—
from the CEJ to the root apex. Next, the distance from the CEJ to alveolar crest is determined. The percentage of
bone loss is a ratio of these two measurements; that is, the distance from the CEJ to alveolar crest is divided by the
total root length. For example, a 6-mm distance from the CEJ to the crest of the bone with a 17-mm root length
would equal a 25% bone loss (6 mm divided by 17 mm).
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Distribution of bone loss should be described as localized or generalized, including the type, vertical or horizontal,
as well as a statement of its severity—mild, moderate, or severe (e.g., periodontitis, with generalized mild
horizontal bone loss and localized moderate vertical bone loss).
Normal bone is parallel with the bone level and the cementoenamel junctions (arrows) on teeth 2, 3, 4, and 5 and is
often confused with bone loss.
Clinical significance: A patient with short, blunted roots and 6-mm periodontal pockets would not have the same
ratio of root-to-bone support as a patient with long roots and a 6-mm pocket. The alveolar support for teeth with
short roots would increase the risk of tooth loss from periodontitis; the root length would be less, increasing the
risk of tooth loss from periodontitis.
Blunted roots in maxillary anterior teeth
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Radiographic Furcation Involvement
Radiographic images are used to detect changes to interradicular bone in the furcations of multirooted teeth. When
bone in a furcation is destroyed, it appears as a radiolucency in the furcal area. Lack of radiolucency in the furcation
does not mean that the disease has not spread to the area. However, the presence of radiolucency in the furcal area
does indicate bone loss. The absence of radiographically visible bone loss does not rule out the possibility of
furcation involvement. More often, interradicular bone loss is clinically greater than what is radiographically visible.
Clinical examinations must always be included to ensure a true representation of furcation involvement. Exposing
radiographic images at differing angles also may assist in detecting furcation involvement.
*Vertical bitewing image shows a triangular radiolucency in the bifurcation area of the mandibular first molar,
indicating furcation involvement (arrows).
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Clinical Assessment
Clinical gingival and periodontal disease classifications are useful to help establish a diagnosis, determine prognosis,
and facilitate treatment planning. A diagnosis of gingival diseases and/or periodontitis is determined by risk
assessment, radiographic assessment, clinical assessment of the gingiva, including gingival description, and a full
mouth periodontal assessment including bleeding points, recession, furcation, and mobility.
Gingival Characteristics
Color
Erythematous
Shape of Margin
Rolled
Cyanotic
White or pale pink
Thickened
Irregular
Position of Margin
More than 2mm coronal to
CEJ
Apical to CEJ (recession)
Edematous
Shape of Papilla
Edematous
Consistency
Soft
Texture
Smooth
Bulbous
Spongy
Shiny
Blunted
Leathery, not resilient
No Stippling
Cratered
Firm or nodular (fibrotic)
Missing
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Periodontal Charting Components and Disease Indicators
Healthy gingival epithelium acts as a barrier to bacterial plaque biofilm and irritants. As a result of the inflammatory
processes, the sulcus’ gingival epithelial lining becomes ulcerated. Consequently, capillary beds in the underlying
connective tissue are exposed. During probing, the instrument contacts the ulcerated epithelium, which causes
bleeding. As a predictor of future periodontal breakdown, BOP alone has minimal value. Bleeding is not a predictor
of future attachment loss; however, BOP, in combination with increasing pocket depths, increases the risk for
continued periodontal destruction. Bleeding is the key feature of dental biofilm–induced gingivitis. Repeated
absence of BOP, especially on two or more occasions, generally indicates good periodontal health. Cessation of
bleeding correlates with reduced gingival inflammation, repair of gingival connective tissue, and pocket reduction.
The use of a periodontal probe to measure the depth of a healthy sulcus (i.e., one with an intact layer of sulcular
epithelium) yields no bleeding. BOP is one of the earliest clinical signs of the presence of inflammation and
gingivitis. However, false positive readings may occur if a clinician uses heavy force during probing, resulting in a
punctured JE. This instrumentation error could result in bleeding from healthy gingival tissues. In most cases, the
more severe the inflammation is, the more severe the bleeding, except in tobacco users where bleeding may be
reduced by associated vasoconstriction and altered immune response.
•
•
•
•
•
BOP predicts attachment loss approximately 30% of the time. Furthermore, fibrotic tissue resulting from
long-term, chronic inflammation may bleed little or not at all.
Gingival bleeding occurring at several sequential continued-care visits is associated with an increased risk for
loss of attachment.
Bleeding can be minimized or masked in tobacco users.
Absence of bleeding is associated with a lack of disease progression; however, the mere presence or absence
of bleeding does not predict periodontal breakdown.
BOP sites are recorded in the patient record and monitored at each appointment.
Periodontal pockets are classified as follows:
•
•
•
Gingival pocket occurs when the gingival margin is coronal to the CEJ due to edema, there is no bone
loss. A pseudopocket can be used to describe and anatomical irregularity due to aspects such as impacted
third molars effecting the distals of second molars. These are not taken into consideration when
determining a dental hygiene diagnosis.
Suprabony periodontal pocket occurs when the JE has migrated below the CEJ but remains above the
crest of the alveolar bone. Suprabony pockets are most commonly associated with horizontal bone loss.
Intrabony periodontal pocket, also known as infrabony pocket, occurs when the JE has migrated
below the crest of the alveolar bone. Intrabony pockets are associated with vertical bone loss.
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Clinical Attachment Levels
In cases of gingival inflammation or hypertrophy, when the gingival margin is coronal to the CEJ, CAL is less than the
pocket depth. To obtain an accurate CAL, enlarged gingival margins above the CEJ must be measured and subtracted
from the periodontal pocket measurement. For example, if a patient has generalized 6-mm probe readings but 4 mm
of the enlarged gingiva is coronal to the CEJ, then the actual CAL is 2 mm. If this 2 mm is not subtracted from the
probe reading, then a realistic assessment cannot be obtained. In this situation, a patient with only 2 mm of attachment
loss may be misclassified as having more bone loss than has actually occurred. This measurement is achieved with
periodontal probe measuring from the CEJ to the gingival crest. Using radiographic images and careful
instrumentation will help determine the subgingival location of the CEJ.
Attachment loss (disease activity), not periodontal pocket readings, indicates the progression of periodontal disease
and is considered its defining feature. Consequently, regular documentation of comprehensive periodontal assessment
in the patient record is important to track periodontal disease activity.
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Furcation Involvement
Furcation involvement (or loss of the interradicular bone and PDL attachment of multirooted teeth) is
identified, classified, and monitored. The patient is informed about areas of furcation involvement and taught homecare techniques to manage these areas. The Nabers furcation probe often is used to detect and measure furcation
involvement. Radiographic images confirm but do not always accurately reveal this condition until they are severely
involved. Attention to root morphologic structure and instrumentation are important considerations for providing
effective periodontal therapy in furcation areas. Furcation can be presented as “Class or Grade.”
**Blue arrow indicating Nabers probe used for clinical assessment.
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Tooth Mobility
Tooth mobility is the degree to which a tooth can move in a horizontal or apical direction. Although caused by the
loss of PDL and bone support in periodontitis, tooth mobility varies according to diet and stress. Children, young
adults, and some women exhibit more tooth movement than individuals in other groups. Although tooth mobility is
not a cause of periodontal disease, it may contribute to it. Therefore, mobility is evaluated and documented as an
important aspect of periodontal assessment. To test for mobility, the practitioner places an instrument handle on the
lingual surface of the tooth and gently applies pressure from the fulcrum finger on the facial surface with another
instrument, and then vice versa, to rock the tooth in a horizontal motion (e.g., the handles of a periodontal probe
and a mouth mirror). The feeling of movement is most acute at the contact points between two teeth. Mobility
classification should be recorded on the dental chart to allow comparative readings at successive appointments.
Classification of Mobility
CLASS I
CLASS II
CLASS
CLASS III
DESCRIPTION
Tooth can be moved <1mm in any direction
Tooth can be moved >1mm in any direction but is not
depressible in the socket
Tooth can be moved in a buccolingual direction and its
depressible in the socket
Fremitus
Fremitus is the vibration or movement of the teeth when in contacting positions from the patient's own occlusal
forces. To assess fremitus, the clinician places his or her index finger along the facial aspects of the cervical one third
of each maxillary tooth, and the patient is asked to tap the teeth together. Teeth that are displaced are then
identified. At times, a widened PDL space also will be visible radiographically due to excessive occlusal forces.
Radiograph shows a widening of the periodontal ligament associated with occlusal trauma (arrow).
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Mucogingival conditions and inadequate attached gingiva
Mucogingival conditions are assessed through clinical examination for recession, frenum pulling on the gingiva, and
the width of the attached gingiva. A periodontal probe is used as needed to measure the attached gingiva where a
potential problem is observed. (A) Irregular gingival contours and recession are evident with severe gingival
inflammation. (B) Gingival recession, proximal crater formation, and chronic inflammation with fibrotic tissue are
exhibited. The bottom of the pocket is beyond the mucogingival junction. (C) Recession on the maxillary canine
with a shallow sulcus is present and attached gingiva is absent. (Courtesy Dr. Kenneth Marinak, Adjunct Clinical
Faculty, Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University, Norfolk, Virginia.)
Measuring Attached Gingiva
(A) Total width of the attached gingiva is 6 mm. (B) Depth of sulcus is 3 mm with no clinical attachment loss.
Therefore 3 mm of attached gingiva is still evident. (C) Total width of attached gingiva is 3 mm. (D) Depth of
pocket is 3 mm, and 6 mm of clinical attachment loss is evident. Therefore, no attached gingiva is demonstrated. (E)
Diagram illustrates how attached gingiva is determined.
Areas with a limited zone of attached gingiva, termed inadequately attached gingiva (IAG), are noted, shown
to the patient, and explained during the periodontal assessment. To measure the amount of attached gingiva, a
periodontal probe is used to measure the total width of the gingiva from the free gingival margin to the MGJ. Next,
the periodontal probing depth is obtained and subtracted from the total width of the gingiva.
The width of attached gingiva is not measured on the palatal side of maxillary teeth because of the inability to
differentiate between where attached gingiva ends and palatal tissues begin. IAG exists when less than 1 mm of
keratinized attached gingiva is present. Areas with IAG are often sensitive to the patient, are difficult to maintain,
and can develop into a mucogingival problem because the thin zone of attachment usually reflects a reduced blood
supply and a potential for quick loss of supporting bone and connective tissue. Recession and high frenum or muscle
attachments may add to the reduction of alveolar mucosa. These chronic conditions must be recorded and
monitored. Although good oral hygiene can maintain periodontal health with almost no alveolar gingiva, high
frenum attachments or the use of the tooth as a crown and bridge abutment may indicate surgical intervention to
widen the zone of attached gingiva.
Once the clinician has completed a full risk assessment, radiograph assessment, periodontal assessment, including
assessment and charting of hard tissue and existing restorations, collaboration with the dentist regarding a
periodontal status and diagnosis can begin.
All text, figures, and images above were retrieved from Pieren, D.B. J. Darby and Walsh Dental Hygiene. [Pageburstls].
Retrieved from https://pageburstls.elsevier.com/#/books/9780323477192/
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Dental Hygiene Diagnosis
AAP Classification of Periodontal and Peri-Implant Diseases and Conditions
Classification Systems
The 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and
Conditions resulted in a new classification of periodontitis characterized by a multi-dimensional
staging and grading system.
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Periodontal Health, Gingival Diseases and Conditions
Periodontal Health
Periodontal Health (In-tact Periodontium): No signs of inflammation which include redness, clinical
swelling, edema, and pain. Clinical periodontal health is clearly distinct from pristine dental health. Although it is
rare, it is a realistic entity.
Periodontal Assessment/Treatment Recommendations:
• Clinical Attachment Loss (CAL): Mostly 0-1mm
• Radiographic Bone Loss (RBL): None
• Bleeding on Probing (BOP/BI): <10%
• Probing Depths (PD): 1-3mm
• Treatment Recommendations: Prophylaxis (D1110)
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Periodontal Health (Reduced Periodontium): Gingival health can exist in an intact or a reduced
periodontium due to existing attachment loss from other factors (i.e. recession, orthodontics, endodontic lesion,
surgery, trauma, clenching/bruxism, malocclusion, etc.) or after successful nonsurgical and/or surgical treatment.
Health on a Reduced Periodontium (Non-Periodontitis Patient): Existing attachment loss from other
factors (i.e. recession, orthodontics, endodontic lesion, surgery, trauma, clenching/bruxism, malocclusion, etc.)
Periodontal Assessment/Treatment Considerations:
• Clinical Attachment Loss: Variable
• Radiographic Bone Loss: Variable
• Bleeding on Probing (BOP/BI): <10%
• Probing Depths: 1-3 mm
• Modifying/Predisposing factors: Controlled
• Treatment Recommendation: Prophylaxis (D1110)
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Health on a Reduced Periodontium (Stable Periodontitis Patient): Existing attachment loss due to
periodontal history (i.e. nonsurgical periodontal therapy including scaling and root planning and/or periodontal
surgery)
Periodontal Assessment/Treatment Considerations:
• Clinical Attachment Loss: Variable
• Radiographic Bone Loss: Variable
• Bleeding on Probing (BOP/BI): <10%
• Probing Depths: 1-4 mm
• No new bone loss (monitor for 1-2 years)
• Modifying/Predisposing factors: Controlled
• Treatment Recommendation: Periodontal Maintenance (D4910)
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Gingival Diseases and Conditions
Biofilm (Plaque-Induced) Gingivitis
Gingivitis (In-tact Periodontium): Sight specific inflammatory condition initiated by dental biofilm
accumulation and characterized by gingival redness, edema and the absence of periodontal attachment loss.
• Reversible with the removal or disruption of biofilm
• Systemic modifying/predisposing factors-biofilm induced gingivitis is associated with bacterial dental
biofilm only, although it can be mediated or modified by systemic or local factors.
These factors include the following:
o Systemic conditions exacerbating periodontal destruction:
 Hormones-puberty, menstruation, pregnancy, oral contraceptives
 Hyperglycemia (undiagnosed or poorly controlled diabetes)
 Leukemia
 Smoking
 Malnutrition
o Oral factors enhancing plaque accumulation
 Subgingival restoration margins
 Hyposalivation
 Drug-influenced gingival enlargement
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Gingivitis is identified based on the extent and the severity of a patient’s bleeding index (bleeding on probing)
and the condition of the gingiva:
Extent:
• Incipient Gingivitis: <10% BOP (variant of health, not considered bio-film induced)
• Localized Gingivitis: 10-30% BOP
• Generalized Gingivitis: >30% BOP
Severity: BOP is not definitive evidence of the severity of gingivitis, you must take into
consideration the gingival description including color, size, shape, texture, and consistency.
• Mild: 10% BOP
• Moderate: 11-30% BOP
• Severe: >30%
Periodontal Assessment/Treatment Considerations:
• Clinical Attachment Loss (CAL): Mostly 0-1mm
• Radiographic Bone Loss (RBL): None
• Bleeding on Probing (BOP/BI): >10%
• Probing Depths (PD): 1-4mm (4mm PDs may be present in the absence of CAL, gingival margin in
coronal to the CEJ creating a “suprabony” bony pocket.
• Treatment Options:
o Prophylaxis (Localized mild inflammation; D1110)
o *Scaling in the Presence of Gingivitis (diagnosis must be generalized moderate or
severe not completely dependent on bleeding index, gingival tissue must exhibit
generalized moderate or severe erythema and edema per the ADA CDT code
description, D4346). This code is not to be considered for localized mild,
moderate, severe, or generalized mild cases.
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Gingivitis (Reduced Periodontium-Non-Periodontitis Patient): Existing attachment loss from other
factors (i.e. recession, orthodontics, endodontic lesion, surgery, trauma, clenching/bruxism, malocclusion, etc.)
Periodontal Assessment/Treatment Considerations:
• Clinical Attachment Loss: Variable
• Radiographic Bone Loss: Variable
• Bleeding on Probing: >10%
• Probing Depths: 1-3mm
• Modifying/Predisposing factors: Uncontrolled
• Treatment Recommendation: Prophylaxis (D1110) based on severity and extent; this type of patient could
present with initial signs of periodontitis per the periodontal assessment.
Gingivitis (Reduced Periodontium-Periodontitis Patient): Existing attachment loss due to periodontal
history (i.e. nonsurgical periodontal therapy including scaling and root planning and/or periodontal surgery)
Periodontal Assessment/Treatment Considerations:
•
•
•
•
•
•
•
Clinical Attachment Loss: Variable
Radiographic Bone Loss: Variable
Bleeding on Probing: >10%
Probing Depths: 1-3mm
Some new bone loss may be evident
Modifying/Predisposing factors: Controlled
Treatment Recommendation: Periodontal Maintenance (D4910) based on severity and extent; this type of
patient could regress and require retreatment based on bleeding and probing depths; take into consideration
modifying and predisposing factors, pocket depth, and bleeding on probing before considering nonsurgical
periodontal therapy retreatment. Periodontal Maintenance description includes localized scaling and root
planning as needed.
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Periodontal Disease Remission: Existing attachment loss due to periodontal history (i.e. nonsurgical periodontal
therapy including scaling and root planning and/or periodontal surgery)
Periodontal Assessment/Treatment Considerations:
•
•
•
•
•
•
•
Clinical Attachment Loss: Variable
Radiographic Bone Loss: Variable
Bleeding on Probing: >10%
Probing Depths: >4 mm
Some new bone loss may be evident
Modifying/Predisposing factors: Uncontrolled
Treatment Recommendation: Periodontal Maintenance (D4910) based on severity and extent; this type of
patient could regress and require retreatment based on bleeding and probing depths; take into consideration
modifying and predisposing factors, pocket depth, and bleeding on probing before considering nonsurgical
periodontal therapy retreatment. Periodontal Maintenance description includes localized scaling and root
planning as needed.
Non-Biofilm (Not Plaque-Induced) Gingivitis
Less common and are often manifestations of systemic conditions. Non-biofilm induced diseases and conditions are
usually not resolved by mechanical plaque removal. They can be classified into eight general categories:
• Genetic/development disorders
• Specific infections-bacterial, viral, or fungal
• Inflammatory or immune conditions and lesions
• Reactive processes
• Neoplasms
• Endocrine/nutritional/metabolic disease
• Traumatic lesions
• Gingival pigmentation
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Periodontitis
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Periodontitis:
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Periodontitis is classified based on extent, stage, and grade.
Extent: Number of teeth affected (with greatest severity) as a percentage of total teeth present
• Extent of Periodontitis: TEETH
• Extent of Gingivitis: SITES
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Stage (Diagnosis): There are four stages and are based on areas with most severity according to the level of CAL, amount
and percentage of radiographic bone loss, probing depths, presence of furcation involvement, and mobility, as well as the
number of teeth lost due to periodontitis, complexity, and extent of distribution.
•
•
•
Stage I-early/initial
Stage II-moderate
Stage III/IV-severe with increasing complexity
*The entire oral cavity receives one stage; clinicians do not assign different stages for varying
degrees of the mouth. (1) The area of the mouth with the most destruction determines the stage
because this requires a more complex case management. (1).
Grade (Rate of Progression/Prognosis): Indicates the rate of progression based on risk factors affecting progression,
general health status, and other considerations such as smoking or the level of control of diabetes.



Grade A-slow rate
Grade B-moderate rate
Grade C- high rate
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Indirect Evidence Guide for calculating the ratio for Bone Loss/Age:
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Periodontitis: Initial Diagnosis and Treatment Planning/Recommendations:
*SRP (Scaling and Root Planing;
part of NSPT)
CDT Codes: D4341/4342
Nonsurgical periodontal therapy: Encompasses the control of oral biofilm through self-care and professional
periodontal debridement (scaling and root planing), supplemented by adjunctive therapy with antimicrobials or host
modulation agents, as needed, for the treatment of periodontal diseases involving natural teeth or implant
replacements. For more involved cases in which NSPT does not resolve the disease process and achieve health,
periodontal surgery is recommended.
Treatment Options:
•
NSPT (4341)- perio scaling on 1-3 teeth in quad
•
NSPT (4342)-perio scaling on 4+ teeth in quad
*Note
•
NSPT is recommended for any sites with PDs of 5mm + (at least 2 non-adjacent teeth should be present),
whether BOP is present or not.
•
NSPT can be justified treatment for any sites with PDs of 4mm with initial bone loss or CAL if they are a
smoker, whether BOP is present or not.
Necrotizing periodontal disease (NPD)-NPD have three key clinical features; papillary necrosis, bleeding, and
pain, usually with rapid onset. NUG rarely progresses to NUP, both are associated with a compromised host
immune response such as HIV/AIDS, immunosuppression, severe malnutrition, severe viral infection.
Periodontal Assessment/Treatment Considerations
• Necrotizing ulcerative gingivitis (NUG)
o Limited to the gingiva
• Necrotizing ulcerative periodontitis (NUP)
o Affects periodontal attachment and bone
• Necrotizing stomatitis (NS)
o Affects the oral mucosa
• Treatment Considerations: Consult with DDS for appropriate treatment and medicament
recommendations.
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Periodontal Manifestations of Systemic Diseases and Development and Acquired
Conditions
•
Systemic Diseases or Conditions Affecting Periodontal Supporting Tissues
o Rare disorders such as Papillon-Lefevre syndrome, Down Syndrome, cyclic neutropenia,
leukocyte adhesion deficiency, hypophosphatasia)
o Oral cancer
• Periodontal abscesses and endodontic-periodontal lesions-characterized by rapid onset and rapid
destruction of the periodontium and pain or discomfort.
• Mucogingival Deformities and Conditions
o Gingival recession
o Mucogingival defects or conditions without gingival recession may be attributed to:
 Tooth position
 Frenum pulling
 Lack of adequate vestibular depth
• Traumatic Occlusal Forces-defined as any occlusal force that damages the teeth and/or periodontal
attachment tissues.
o Occlusal trauma-injury to the periodontium, no evidence traumatic force causes CAL, and
limited evidence suggest that it results in inflammation. Occlusal trauma is associated with the
severity of periodontitis but does not influence the rate of progression of periodontitis.
o Signs of Occlusal Trauma:
 Tooth pain or discomfort on chewing or percussion
 Tooth migration
 Wear facets exceeding expected levels
 Fremitus
 Chipped enamel
 Tooth mobility
 Root fracture
 Widening of the PDL space
 Loss of lamina dura
 Radiolucency at tooth apices in a vital tooth
 Root resorption
• Tooth-and Prosthesis-Related Factors-infringement by a tooth or prosthesis-related factor such as:
o Nonoptimal fixed or partial dentures
o Rough or overhanging margins of restorations
Less common tooth anomalies such as:
o Enamel pearls
o Close root proximity
o Abnormal root fractures
o Tooth position
• Treatment Recommendations: Patient that present with any of the above conditions that are
contributing to loss of periodontium are not to be considered a periodontitis patient in which Stage and
Grading is utilized as the diagnosis unless they present with 2 more or nonadjacent teeth that present
with active disease. These patients will require a detailed description of what the condition is that is
contributing to the loss of periodontium, potential treatment for the condition, and a diagnosis and
treatment recommendation based on the overall condition of the oral cavity.
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Peri-Implant Diseases and Conditions
•
•
•
•
•
Peri-implant health: the absence of erythema (inflammation), bleeding on probing (BOP), swelling, and
suppuration with no bone loss (BL) < 2.0 mm
Peri-implant mucositis: inflammation, presence of BOP, swelling, no BL < 2.0 mm, and strong evidence
that plaque (biofilm) is the etiologic factor
Peri-implantitis: inflammation, plaque-associated pathological condition in tissue, probing depth (PD) ≥ 4–
8 mm, and subsequent progressive BL ≥ 2–3 mm
(Peri-implantitis in absence of previous examination: patient records should include previous radiographs,
PD at one-year post-load. In the absence of a previous exam, refer to the guidelines for peri-implantitis, PD
≥ 6 mm, BOP, and BL ≥ 3 mm with concurrent peri-implantitis diagnosis)
Peri-implant soft-and hard-tissue deficiencies: conditions following the normal healing process of tooth loss
that leads to diminished dimensions of the alveolar process/ridge, resulting in both hard-and soft-tissue
deficiencies.
You must state the overall health of the natural dentition present along with the diagnostic
statement regarding the health of the implant(s).
In our clinic, we take a very conservative approach to implant care because we are not working with or in
collaboration with the dentist/oral surgeon/periodontist who may have placed the implant and the final
restoration. Treatment recommendations are either Prophylaxis (D1110) or Periodontal Maintenance (D4910).
The implant procedure codes D6081is not to be used in conjunction with D1110, 4910, 4346. Consult the DDS
regarding treatment of peri-implantitis in conjunction with D4341/4342.
•
•
•
•
•
Evaluate radiographically and clinically first to determine if there are concerns with the health of
the implant.
Assess mobility the same way we would with a natural tooth but keep in mind that an implant is not held in
by periodontal ligaments like natural teeth. Periodontal ligaments allow for some
movement. Since implants are osseointegrated, there should be no movement if the implant has been
successfully integrated. If there is movement, the implant has failed. However, the implant crown could be
loose and could cause you to think the abutment was loose. This takes careful evaluation to determine this.
Again, radiographic evaluation would need to be done.
Determine whether we need to probe and get updated measurements. As far as what to use to probe, there
is no evidence that the use of a plastic probe is necessary. There must be consistency in the type of probe
and angulation used to validate changes in the probing depths. This is very difficult to do in an educational
environment with the number of students and faculty that the patient may see in any given series of
appointments.
Calculus does not occur as frequently on implant abutments as it does on natural teeth, but plaque biofilm
does, and it is important to know that we cannot treat the implants as we do natural teeth. We need to
assess whether the implant surface needs mechanical instrumentation at all or if we need to take a minimally
invasive approach.
Air polishing (Guided Biofilm Therapy) using glycine powder, the use of titanium curets, and the use of
ultrasonic inserts with specialized tips are the best choices for biofilm disruption. The titanium abutment
surface can easily be abraded so that is why stainless steel and metal tips are not to be used. Plastic
instruments have been shown to leave deposits behind, a smear layer, that may do more harm than good. It
is also contraindicated to rubber cup polish with abrasive paste, overall, not a therapeutic treatment.
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•
If the patient shows no signs or symptoms of peri-implant mucositis (reversible, like gingivitis) or periimplantitis (progression and surgical intervention needed) we like to use Super floss dipped in Listerine and
debride or use C shaped method around the neck of the implant to mechanically remove light plaque and to
have some antimicrobial effects. If a patient does show signs of either of the above implant diseases, we will
determine care based on their diagnosis. Home care is the most important aspect of our care.
References for Pages 61-80
Various pictorials, graphs, and text utilized from:
• Professor RDH course on AAP Classification presented by Lisa Mayo, RDH, BSDH, MHA, Academic Chair for
•
Dental Hygiene, Dental Assisting, and Surgical Technology at Dallas College
1. Chapple, I., Mealey, B., Van Dyke, T., Bartold, P., Dommisch, H., Eickholz, P., Geisinger, M., Genco,
R. Glogauer, M., Goldstein, M., Griffin, T., Holmstrip, P., Johnson, G., Kapila, Y., Lang, N., Meyle, J.
Murakami, S., Plemons, J., Romito, G., Shapira, L., Tatakis, D., Teughels, W., Trombelli, L., Walter,
C., Wimmer, G., Xenoudi, P., & Yoshie, H. (2018, March 12). Periodontal health and gingival diseases
and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017
World Workshop on the Classification of periodontal and peri-implant diseases and conditions. J Periodontol,
89, Suppl 1, S74-84. doi:10.1002/JPER.17-0719
2. Gehrig, J., Shin, D., & Willmann, D. (2019). Periodontics for the dental hygienist. (5th ed.). Burlington,
MA: Jones & Bartlett.
Case Calibration on AAP presented by Tulsi Patel, RDH, MHA, Associate Professor & Director of Health
Promotion at the UTHSC School of Dentistry
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Calculus Accretion Classification
Class A
• Slight supragingival calculus and/or stain
• Ex: lingual surfaces of the mandibular anteriors
• Facial surfaces of the maxillary molars
• Slight sub-gingival calculus not more than 1mm
Class B
• Moderate supragingival calculus limited to the cervical 3rd of the teeth
And/Or
• Light subgingival calculus, not more than 3mm deep in 2 or more areas
Ex: lingual surfaces of the mandibular anteriors or facial surfaces of the maxillary molars
Class C
• Generalized moderate, with some localized heavy, subgingival calculus involving 2-3 surfaces on most teeth
And possibly
Moderate to heavy supragingival calculus
Class D
• Heavy to gross deposits of supragingival and subgingival calculus on most teeth Ex: moderate to heavy
subgingival on maxillary anterior interproximal surfaces is present in addition to heavy subgingival on
posterior teeth. Radiographically visible.
CALCULUS FORMATION: REFERENCE GUIDE (Created by Jill Gehrig)
Granular
Nodule
Spicule
Band
Finger-Like Projection Proximal Ledge
Class A
Simple
Supragingival calculus extending only slightly
below the free gingival margin
Class B
Light/Moderate
Moderate amount of supragingival and light
subgingival calculus, or light subgingival calculus
only
Class C
Moderate
Abundance of supragingival and subgingival
calculus, or subgingival calculus only
Class D
Heavy
Generalized gross/heavy supragingival and
subgingival ledges around cervical thirds of
crowns and bands on most root surfaces
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Dental Hygiene Care Planning
CC Guidelines for developing the Dental Hygiene Written Care Plan and Treatment
Plan for patients with either gingival health, gingivitis, or periodontal disease:
Dental Hygiene Care Planning
Care planning starts with:
• Complete Assessment (medical, dental, periodontal health)
• Analyze collected data from:
o Health history
o Dental history
o Radiographs
o Periodontal assessment
o Dental chart/tooth condition (vitality, caries, mobility, any abnormalities)
o Caries Assessment Management by Risk Assessment (CAMBRA)
o Dental awareness and practices (oral hygiene knowledge, practices, habits, attitudes, etc.)
o Oral Disease Risk Assessment/ODRA (utilize the risk assessment resources on pgs. 45-53)
• Dental Hygiene Diagnosis/Complete the Care Plan Worksheet and Eaglesoft treatment plan
• Discuss care plan with faculty for faculty approval and obtain approval entry
• Present proposed treatment plan to patient and obtain an electronic signature for patient informed consent
from patient/parent following faculty discussion and approval
• Give copy of the approved Patient Informed Consent Agreement to patient
** Do Not overlook reasonable alternatives when writing your care plan, the written care plan guidelines are just
guidelines, care plans need to be tailored to fit the individual patient’s needs**
Dental Hygiene Diagnosis:
Each care plan should include the following information related to:
o Health (In-tact/Reduced), Gingivitis (Biofilm/Non-Biofilm Induced, In-tact/Reduced, Non-Perio, Perio,
Perio Remission), or Periodontitis
o If disease is present, include the following:
o Extent of disease (Gingivitis and Periodontitis)
 Localized
 Generalized
o Severity of disease
 Mild, Moderate, or Severe (Gingivitis)
 Stage I, II, III, IV (Periodontitis)
o Prognosis (Periodontitis only)
 Grade A, B, C
o Implant assessment
o Calculus accretion
o Bone loss radiographically (if appropriate)
o Mobility/Furcation Involvement
o Bleeding index
o Contributing causes/risk factors - i.e. smoking/diabetes/orthodontic treatment
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General Goal of Periodontal Therapy:
The goal of periodontal therapy is to help our patients preserve, maintain, and improve their natural dentition,
implants, periodontium, and peri-implant tissues. It is our intention to achieve periodontal health, comfort,
aesthetics, and function.
o Pieren, D.B. J. (2020). Darby and Walsh Dental Hygiene (5th ed.). Elsevier - Evolve.
*Dental Hygiene therapy frequently includes most, but not necessarily all, of the following:
Dental Hygienist
1. Patient education and training in personal oral hygiene; behavior modification
2. Thorough scaling and periodontal debridement to remove microbial deposits that might act as reservoirs for
microbial infection
3. Use of local and/or systemic antimicrobial agents
4. Re-evaluation and Periodontal Maintenance
DDS (possible treatment options in private practice dental office)
1. Elimination or correction of defective restorations and other local factors that might interfere with oral hygiene
efforts or act as retention sites for periodontal pathogens
2. Surgical therapy
3. Extraction of severely involved teeth
4. Occlusal therapy
5. Local Anesthesia as needed
Pediatric/Adolescent Care Plan (Ages 0-19)
Dental Hygiene Diagnosis/Indications of Periodontal disease:
Generalized healthy tissue/Generalized or localized biofilm or non-biofilm induced gingivitis
Dental Hygiene Goal: To maintain gingival health/to restore gingival health/prevent recurrence
Prognosis: Good to excellent with compliance
Recare Interval – 4-6 month
*Adolescent patients (ages 10-19) should be carefully planned according to assessment findings.
Exceptions are made for adolescents with severe gingivitis and/or periodontal involvement.
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Guidelines for Screening Patients
Patients will be screened to determine an estimated classification of case type, including accretion level, based on
the screening form below. Screening is not used for patients seeking treatment for pain, lost fillings, consultations,
radiographs, etc.
Screening Process:
A. Conduct a health history review and take patient vital signs.
B. Get faculty permission to proceed.
C. Check for any obvious dental and/or EIOE findings and have DDS/faculty evaluate.
D. Classify the patient with these characteristics by using an estimation, not tooth by tooth evaluation:
1. Calculus Deposits-visual (use air), explore proximal surfaces only for estimate
2. Periodontal Level-gen overall condition of gingiva, probe all surfaces of #’s 3,14,19,30 for estimate,
looking for bleeding and/or mobility. If unable to determine classification from teeth noted above,
proceed to probe all surfaces of the second molars
3. Note any significant restorative or hard tissue pathology that is present
4. Note total number of teeth present in each quadrant
5. Provide dental referral, if needed
6. Obtain medical clearance, if indicated, this is the responsibility of the student/faculty who is
screening.
7. Note treatment considerations such as need for anesthesia
8. Inform patient of approximately how many appointments will be necessary, the length of each
appointment and the importance of keeping each appointment
Significant Restorative Needs:
# of Teeth Present in Each Quadrant (missing molars/premolars?):
UR:
LR:
Estimated Periodontal Status
Circle One: Health
Comments:
UL:
LL:
Gingivitis
Estimated Accretion Level
A B C D
E. Treatment Considerations: Indicate by placing X after each consideration:
Immediate referral to a physician for medical concern
Immediate referral to an oral surgeon for a suspicious lesion
Immediate referral to general dentist
Periodontitis
Please select one:
Add to Call List:__________
OR
Scheduled by:
_____
(CA/Student Name)
Appropriate for Clinic: I II III
(Circle all that apply)
Possible patient case study
Possible Clinical Competency patient
Radiographs Recommended (Check Type Indicated): FMX___ Panorex___ BWX____
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Standards of Clinical Practice
and
Clinical Assessment Process
2024-2025
Dental Hygiene Department Manual
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Clinical Process of Care Evaluation
Guide to the TalEval Grading and Outcomes Assessment System
TalEval is a major component of our ongoing outcomes assessment and quality assurance in the patient care
assessment plan. Both plans are necessary for meeting ADA accreditation guidelines.
It is of primary importance that the faculty be calibrated on this clinical evaluation process to determine specific
areas of strength and weakness in students’ performance. The validity of the assessment is contingent upon
adherence to the evaluation procedures described in this guide.
Directions for TalEval:
TalEval is a sequential listing of items to evaluate in each category of all the aspects of dental hygiene patient care.
Each item is assigned a mark of evaluation by the faculty:
+ for accuracy
for a single minor error
X
for multiple or major errors
N
indicates item: not performed OR not observed
At the time of the evaluation, the faculty does not know the weights of evaluation marks as they are determined
until the final week of the semester when the findings are presented on a master grid and calculated according to
class performance in each category.
The evaluation at each clinic session is objective rather than subjective, as no grade is assigned at each clinic. Every
category of dental hygiene care is evaluated on the Daily Clinic Appointment Tracking Form (yellow) at each patient
appointment. Each student’s performance is plotted on a grid to provide data collection that serves as an assessment
tool for determining individual student performance and total class performance. The following categories and
items are evaluated. Refer to this guide for the determination of errors and scoring of each item.
Categories: Assessment, Planning, Implementation, Evaluation (all categories include documentation)
Competencies: Risk Assessment/History, Radiography, Hard Tissue, Extr/Intral Oral Exam, Gingival
Assessment, Accretion, Periodontal Assessment, Care Planning, Preventive/Supportive Treatment, Pain Control,
Instrumentation, Calculus Removal, Quality Assurance, and Professionalism
Critical errors are the most crucial part of evaluating individual student clinical performance and students are not
compared to one another in the critical error component of TalEval. TalEval counts the number of times all the
students make this type of error and that affects the mean, but the additional points lost for critical errors only affect
the grade of the student who makes the error(s). Critical Error point deductions are determined by the number of
infractions, meaning the error was either marked with a or X. Critical Error point deductions range from .5-1
point per infraction based on the category. Infection control and professional conduct are weighted heavier.
TalEval grades students using two methods simultaneously, individual student performance by Critical
Errors and comparison of expected performance at level of DH Clinical education with comparison to class
performance. Critical error points range from one half a point to one point based on single/multiple errors and
competency. Some competencies are considered an X for a single error (Infection control, patient safety, and
professionalism).
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ASSESSMENT
Competency I – Risk Assessment and History
Item 1
Critical
Further questions findings, HHX comments section (HHX Questions 1-52)
Further questions patients about those items on questionnaire and enters in comments +
Failure to enter answers in comments or further question patients about a yes answer
Errors on more than one “yes” answer X
Item 2
Documents medications & conditions
Enters all conditions and medications including dosage in medical history, presents drug
information to faculty upon check-in +
Missed one condition or medication drug card
Failed to complete more than one medication drug card/condition entry X
Item 3
Vital Signs (Initial visit, subsequent, and recare visits)
Uses proper technique and accurately records vital signs +
Uses inaccurate technique or does not record vital signs correctly on one vital sign
Uses inaccurate technique or does not record vital signs correctly on more than one vital sign or
fails to take vitals and proceeds with appointment or does not retake if outside of clinical guidelines,
wait 10 minutes and note both readings, prior to check-in. X
Item 4
Notifies faculty of contraindications to treatment
Student notifies faculty if vital signs or medical history findings require a consult with patient’s
physician prior to treatment +
Failure to notify faculty of patient condition or disease that is a risk for treatment
Failure to notify faculty of more than one risk factor X
Item 5
Documents pertinent information in General, History, Habits Tabs, including Reason
for Visit
Completes all tabs and documents all lifestyle risk factors +
Incomplete by the omission of reason for visit or risk factors(s) X
Item 6
Request for medical consult/clearance completed
Completion of appropriate form and referral to physician with faculty signature +
Failure to complete appropriate form X
Item 7
Faculty reviews history findings prior to start of treatment
Faculty checks in patient and gives permission to proceed +
Begins treatment without permission to proceed on health history X
Critical
Item 8
Critical
Consent Forms (SMART Docs, if applicable)
All SMART Doc forms (including initial consent, patient bill of rights, HIPAA receipt,
Authorization to Release Records) are complete and signed by patient+
Fails to complete one or more than one of the above X
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Competency 2 – Radiology
Item 9
Critical
Item 10
Critical
Obtains prescription prior to taking radiographs
Obtains radiographic prescription from DDS prior to taking films +
Fails to obtain prescription prior to exposing radiographs X
Technique, process/retake approval/excessive need for retake
Uses correct technique and receives retake approval (2 max) from faculty/DDS +
Failure to complete one or more of the above or due to technique errors, requires more than 2
retakes for radiographs to be deemed diagnostic X
Item 11
Interpretations/correlations: Hard tissue, EIOE, Perio exams
Uses radiographs to interpret and correlate films with assessments +
Error in one of the above
Error in more than one of the above X
Item 12
Discusses radiographic findings with DDS on diagnosis
Discusses findings with DDS on diagnosis and DDS documents radiographic review in notes history
+
Fails to notify DDS for diagnosis and no treatment notes entry X
Competency 3 – Dental Assessments/Hard Tissue
Item 13
Missing Teeth Identified
Correctly identifies & charts which teeth are missing (including extracted or unerupted) +
Omits one chartable missing tooth
Omits more than one chartable missing tooth X
Item 14
Restoration Identification
Correctly identifies & charts restoration material+
Omits one chartable restoration
Omits more than one chartable restoration X
Item 15
Correctly identifies suspicious carious lesions and documents correctly
Correctly identifies & charts suspicious carious lesions +
Omits one chartable lesion
Omits more than one chartable lesion X
Item 16
Abnormality Identification
Correctly identifies any findings not noted other than caries, missing teeth, or restorations, such as:
fractures, erosions, abrasions, attrition, hypocalcification, mottled enamel, rotations,
imperfections, supernumerary teeth and any anomalies +
Omits one abnormality
Omits more than one abnormality X
Item 17
Angle’s Classification (entered in Occl Tab prior to DDS exam)
Angle’s classification of I, II, or III correctly documented +
Left or right side inaccurate
Both left and right side inaccurate or occlusion not assessed by student X
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Item 18
Overjet
Documented correctly +
Documented incorrectly X
Item 19
Overbite
Documented correctly +
Documented incorrectly X
Item 20
Crossbite – records teeth numbers of specific areas affected
Documented correctly +
Documented incorrectly X
Item 21
Deviations
Documented correctly +
Documented incorrectly X
Item 22
Midline Shift
Documented correctly +
Documented incorrectly X
Item 23
End to End / Edge to Edge
Documented correctly +
Documented incorrectly X
Item 24
Verbal presentation to DDS of all findings using proper terminology
Presents effectively and accurately +
Ineffective presentation and/or inaccurate X
Item 25
Critical
Updates at recare appointments, as needed, for annual exam+
Failure to update annual exam X
Competency 4- EIOE (Extra/Intra Oral Exam)
Item 26
Identifies potentially pathological abnormalities (referrable conditions only)
Identifies all findings present +
Failure to identify one finding
Failure to identify more than one finding X
Item 27
Measures, describes, and documents pathological findings
Measures, describes, and documents pathology +
Omits one of the following: measure, description, or documentation
Omits more than one of the above X
Item 28
Updates at subsequent and recare appointments, as needed
Updates at subsequent and/or recare appointments +
Fails to update at subsequent and/or recare appointments X
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Competency 5 – Gingival Assessment/Description
Item 29
Critical
Item 30
Patient should be free of any disclosing solution prior to faculty assessment
Free of disclosing solution +
Not free of disclosing solution, faculty unable to assess gingival health X
Gingival Description
Includes color, size, shape, texture, & consistency documented as well as Generalized or
Localized +
Omits one of the above descriptions
Omits more than one of the above descriptions X
Competency 6 – Accretion (Hard and Soft Deposit)
Item 31
Biofilm (soft plaque) assessment (exploration, visual)
Correctly identifies and documents +
Misses any one of the following: identification, documentation
Misses more than one of the following: identification, documentation X
Item 32
Hard deposit (calculus) assessment
Complete, identifies and documents hard deposit/completes calc detection chart; 2nd year (full
mouth on all C/D accretion) +
Does not complete, identify, or document calculus detection as stated above X
Competency 7-Periodontal Assessment
Item 33
Periodontal Probing Measurements
Accurate measurements of pocket depths (6 sites per tooth) +
Misses one area by more than 1mm
Misses more than one area probing by 1mm X
Item 34
Gingival Margin – (Recession and/or Inflammation)
Measures and records all areas (highest reading from line angle to line angle unless otherwise
indicated) of recession and/or denotes inflammation where margin is coronal to the CEJ, identifies
areas of “Clinical Attachment Level” (CAL) +
Omits one of the above descriptions
Omits more than one of the above descriptions X
Item 35
Bleeding Points
Records all areas of bleeding on probing (BOP) with red notations on periodontal chart +
Omits recording one bleeding point
Omits recording more than one bleeding point X
Item 36
Mobility
Accurately identifies & records all mobile teeth according to classifications I, II, III +
Omits identifying or misclassifying one mobile tooth
Omits identifying or misclassifying more than one tooth X
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Item 37
Furcation
Records all furcation involvement according to classification I, II, III, IV utilizing
Nabers probe +
Omits recording one area of furcation involvement or Nabers probe not utilized
Omits more than one area of furcation involvement; Nabers probe not utilized X
Item 38
Current radiographs are in view during all aspects of periodontal assessment.
Radiographs are in view during all aspects of periodontal assessment+
Fails to have in view during patient care X
Critical
Item 39
Accuracy of Summary Statement of Periodontal Status and Gingival Health
Correctly summarizes statement of periodontal status – Classification and gingival health
description summary +
Fails to correctly summarize either periodontal status or gingival health description summary
Fails to correctly summarize periodontal status and gingival health summary X
Competency 8 – Care Planning
Item 40
Critical
PLANNING
Performs and calculates a BCR % (biofilm control record) to educate patient on
conditions, where applicable, prior to care planning approval for new patient
appointment, re-evaluation, and recare.
Calculates BCR% prior to care planning for faculty evaluation and explains findings to
patient +
Omits BCR % X
Item 41
Formulates and presents Dental Hygiene Care Plan
Correctly formulates and presents Care Plan Worksheet and Eaglesoft treatment plan to faculty
prior to beginning treatment phase of care +
Omits one of the above
Fails to correctly formulate and present the Care Plan Worksheet and Eaglesoft treatment plan
prior to faculty approval/beginning treatment phase X
Item 42
Completed ODRA which includes caries risk assessment prior to faculty approval
(CAMBRA)
CAMBRA completed prior to faculty approval +
CAMBRA not completed prior to faculty approval X
Item 43
Prioritizes patient needs and updates as needed
Prioritizes patient needs +
Fails to prioritize patient needs X
Item 44
Plans and has realistic goals for the process of care
Prepares a realistic care plan, the proper sequence of treatment procedures, including realistic
number of appointment, and appropriate educational interventions +
Omits one of the above on care plan
Omits more than one of the above on care plan X
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Item 45
Plans for pain control and stress reduction
Plans for pain control when indicated +
Does not plan for pain control when indicated X
Item 46
Plans time frame for recare/re-eval appointments
Appropriate timeframe for recare/re-eval included in initial therapy plan +
Inappropriate timeframe stated for recare/ or re-eval not included in initial therapy plan
No recare/re-eval appointment planned X
Item 47
Includes and explains the need for referral to a specialty provider (dental, perio,
other)
Appropriate referrals are made +
Does not plan for referral or give referral form to patient when indicated X
Item 48
Explains plan, alternatives, and expected outcomes/prognosis
Correctly explains plan, alternatives and expected outcomes to patient +
Incorrectly explains plan or does not explain alternatives and outcomes X
Item 49
Patient consent of plan confirmed with signatures, following approval
Patient signature is recorded on informed consent prior to beginning treatment +
Informed consent not completed or approved or signed by patient X
Critical
IMPLEMENTATION
Competency 9 – Preventive and Supportive Treatment
Item 50
Educates patient on conditions, needs, and commitment
Completes all education on condition, needs, and commitment+
Misses one of the above
Misses more than one of the above or no presentation given to the patient X
Item 51
Overall health condition considered in instruction
Overall health conditions consider in instruction +
Failure to consider health problem placing patient at risk X
Item 52
Correct toothbrush and technique taught
Correct toothbrush and technique are taught +
One of the above is omitted or incorrect
Does not complete X
Item 53
Appropriate auxiliary aids recommended and demonstrated
Selects appropriate auxiliary aids for patient needs, especially when pocket depths are greater than
4mm, diastemas, or crowding of teeth that make biofilm removal more difficult - recommended
and demonstrated, according to BCR+
Fails to recommend or demonstrate appropriate auxiliary aids
Fails to address use of appropriate auxiliary aids X
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Item 54
Presentation – Delivery, lay terms, visual aids, etc.
When educating the patient, visual aids are used to explain progression of the disease, uses
terminology that is appropriate for the patient’s age, and educational level. Defines terms and/or
presents in lay terms as needed. +
Fail to address one of the above appropriately
Fails to address more than one of the above appropriately. X
Item 55
Tobacco Cessation as needed utilizing current methodology
Completes Tobacco questionnaire and Eaglesoft Tab on patient that uses any form of tobacco and
documents in notes history any discussion. +
Completes tobacco questionnaire but fails to document in tab and in notes history any discussion
with patient.
Fails to complete Tobacco questionnaire on patient that uses any form of tobacco (including noncombustible tobacco products) X
Item 56
Nutritional counseling and lifestyle concerns
Utilizing CAMBRA as a guide, formulates a plan for nutritional analysis and counseling specific to
patient needs +
Completes plan for counseling but is not aligned with patient need
Fails to complete a plan and does not discuss any nutritional modifications needed per analysis X
Item 57
Fluoride self-care instruction if indicated
Utilizing CAMBRA and assessments as a guide for need; instructs patient on home fluoride
treatments and documents discussion in treatment notes +
Fails to instruct or document when home fluoride therapy is indicated
Fails to instruct and document when home fluoride therapy is indicated X
Item 58
Care of restorations and oral appliances (partials, dentures, retainers)
Cleans and instructs patient on proper homecare of oral appliances +
Does not clean or address homecare on oral appliances X
Item 59
Pit and fissure Sealants as prescribed
Acquires prescription from DDS for application of sealants, places sealants on prescribed
teeth only, uses correct technique & product, documents in notes history date, tooth
numbers sealed, and product use +
Fails to do one of the above
Fails to do more than one of the above X
Item 60
Antimicrobial/Chemotherapeutic agents (Arestin)
Places agent correctly and documents in notes history product used and each tooth and every site
placed +
Places agent and fails to document in notes history
Places agent incorrectly and fails to document correctly X
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Item 61
Desensitizing indications, products, techniques
Uses agent correctly and documents in notes history product used and each tooth/area used as well
as reason for utilization of product +
Uses agent and fails to document in notes history
Uses agent incorrectly and fails to document correctly X
Competency 10 – Pain Control
Item 62
Identifies the need for pain control, explains the need, procedure, post-op
precautions
Explains the need, procedure, post-op precautions +
Omits one of the above
Omits more than one of the above X
Item 63
Local anesthetic set-up and breakdown/Topical anesthetic application
Properly prepares syringe, needle, correct anesthetic for patient need, recapping device according
to set-up photos provided in clinic, properly and safely dissembles syringe and needle according to
manual+
Omits one of the above
Omits more than one of the above X
Critical
Critical
Item 64
Critical
Critical
Local/topical anesthesia consent completed: documents in patient record
Consent complete with patient signature and typed DDS name; Documents type of anesthetic,
amount used, effectiveness, and any reactions in notes history+
Omits one of the above
Omits more than one of the above X
Competency 11 – Instrumentation
Item 65
Critical
Critical
Current radiographs and periodontal chart are in view during patient care
Radiographs and perio chart are in view during all aspects of patient care+
Radiographs or perio chart are not in view during all aspects of patient care
Radiographs and perio chart are not in view during all aspects of patient care X
ULTRASONIC SCALING:
Item 66
Appropriate indications for ultrasonic use
Appropriate indications considered for use: deposits, health status, risks +
Fails to consider one of the above
Fails to consider more than one of the above X
Item 67
Explanation of procedure to patient
Describes procedure and explains need for suction and avoidance of swallowing water and debris +
Failure to explain procedure to patient X
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Item 68
Equipment preparation, tip selection and patient/operator protection and safety
Correctly sets up ultrasonic equipment, correct tip is selected, drapes patient, gives patient towels,
and safety glasses worn by patient and operator +
Fails to prepare one of the above
Fails to prepare more than one of the above X
Item 69
Patient/Operator positioning
Utilizes correct patient and operator positioning during instrumentation (retraction and fluid
control) +
Incorrect operator or patient positioning
Incorrect operator and patient positioning X
Item 70
Technique – placement and movement of tip
Places side of tip on deposit and moves continuously to avoid heating up tooth surface and
does so with fulcrum maintained +
Fails to complete one or more of the above or causes burns to gingiva X
Critical
HAND INSTRUMENTATION:
Item 71
Patient-Operator Positioning
All aspects of positioning are correct + (neutral wrist, clock positions, etc.)
One aspect of patient or operator positioning are incorrect (chin up or down, head turned
toward/away, chair height appropriate, proper illumination, etc.)
Both patient and operator positioning are incorrect X
Item 72
Indirect Vision
Uses indirect vision with dental mirror +
Isolated incidence of not using indirect vision where needed to assure proper positioning and good
visibility
Repeated incidents of not using indirect vision where needed X
Item 73
Instrument Selection–correct instrument for task, correct end/edge;
sharpness
Selects appropriate instrument and correct end/edge for specific areas and tooth surfaces +
Isolated incidence of not selecting appropriate instrument and end/edge
Repeated incidents of not selecting appropriate instrument and end/edge X
Critical
Item 74
Grasp
Grasp is correct (fingers together, no splits, fulcrum finger advanced, thumb and index forming
“C”, space between thumb and index, no hyper flexed joints) +
Grasp is incorrect in one circumstance or with one instrument
Grasp is incorrect in more than one area of the mouth with instrument X
Item 75
Fulcrum
Fulcrum is rigid (support beam), fixed (not traveling), proper position and correctly used
throughout instrumentation +
Inability to employ fulcrum, or using weak fulcrum (bent, traveling, too far/too close to tooth)
Repeatedly failing to employ fulcrum in correct manner X
Critical
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Item 76
Parallelism
Terminal shank is parallel to long axis of the tooth during instrumentation +
Isolated incidence of not placing instrument parallel to long axis of the tooth
Repeatedly failing to employ fulcrum in correct manner X
Item 77
Insertion (starts in “Get Ready Zone (middle 1/3rd) to prepare for insertion)
Correctly inserts instrument with closed blade to avoid tissue trauma +
One isolated insertion error
More than one insertion error X
Item 78
Exploratory Stroke
Uses light exploratory stroke with scaling instrument to locate and detect calculus, and positions
1/3rd of instrument working end under deposit before activating +
One isolated insertion error
More than one insertion error X
Item 79
Adaptation
Toe or tip 1/3rd is consistently adapted with correct angulation (60-80 degrees) during
instrumentation +
Isolated area of not adapting instrument to tooth
Repeatedly failing to adapt instrument to tooth X
Item 80
Angulation
Instrument is inserted with closed angle then activation is initiated with face of instrument opened
to 60-80 degrees +
Isolated area of not inserting with closed angle or not opening to 60-80 degrees (staying closed)
Repeatedly incorrect angulation X
Item 81
Activation
Employs fulcrum while opening to proper angle +
Fails to employ fulcrum while opening to proper angle X
Item 82
Lateral Pressure During Activation
Uses appropriate (firm) pressure, no scraping or heavy pressure during activation+
One incidence of scraping instead of short, controlled bite or longer,
lighter shaving stroke
Repeated incidents of scraping instead of short, controlled bite or longer, lighter shaving stroke X
Item 83
Stroke Control
The scaling stroke is less than 2mm long and ends with instrument on tooth +
Lifts instrument off tooth at stroke’s end
Repeatedly lifts instrument off the tooth at stroke’s end X
Item 84
Working Strokes
Uses vertical, oblique, horizontal/circumferential, working strokes to remove calculus deposits. +
Failure to use productive working strokes for calculus removal in one area
Failure to use productive working strokes for calculus removal in more than one area X
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Item 85
Hand Steady – Not Shaking When Performing Instrumentation
Does not shake during instrumentation, regardless of nervousness during performance; hands are in
control when performing instrumentation +
Isolated incidence of shaking during instrumentation
Repeatedly shaking during instrumentation X
Item 86
Selective coronal polishing: explains procedure, uses correct technique,
patient is plaque and stain free
Explains procedure and uses correct technique +
Fails to explain or uses incorrect technique
Fails to explain, uses incorrect technique, patient is not plaque or stain free X
Item 87
Guided biofilm therapy (air polishing): explains procedure and uses correct
technique
Explains procedure, uses correct technique+
Fails to explain or uses incorrect technique
Fails to explain and uses incorrect technique X
Item 88
Finishes by flossing
Finishes by flossing +
Failure to floss X
Item 89
Topical fluoride varnish treatment
Explains procedure, correct data and uses correct technique to apply varnish +
Fails to explain or uses incorrect technique
Fails to explain and uses incorrect technique X
Competency 12 – Calculus (Hard Deposit) Removal
ALLOWABLE AREAS OF MISSED CALCULUS REMOVAL
BY QUADRANT AND CLINICAL LEVEL:
Clinic I
Pedo/Adol/A
B
C
Clinic II
Pedo/Adol/A
B
C
D
Clinic III
Pedo/Adol/A
B
C
D
+
1
2
4
+
0
1
3
4
+
0
0
2
3
CC DH Department Manual 2024-2025

2
3
5

1
2
4
5

1
1
3
4
X
3+
4+
6+
X
2+
3+
5+
6+
X
2+
2+
4+
5+
Missed areas of calculus by clinical level are less as
progression through the program occurs. Students
are required to re-scale and correct all errors and be
re-evaluated by faculty before proceeding to the next
quadrant(s), per faculty discretion.
Accretion Pedo/Adol/A scaling: all four
quadrants can be completed at one time
Accretion B scaling: two quadrants can be
completed at a time (faculty discretion)
Accretion C and D scaling: one quadrant is
completed at a time
96
Item 90
QUAD UR – see grid above
Item 91
QUAD LR– see grid above
Item 92
QUAD UL– see grid above
Item 93
QUAD LL– see grid above
Item 94
Tissue Trauma – no lacerations
No lacerations present +
One laceration present, per quadrant
More than one laceration present, per quadrant X
Critical
Critical
Item 95
Self-evaluates (air, explores)
Uses explorer and air to self-evaluate prior to faculty check +
Does not self-evaluate with explorer or air prior to faculty check
Fails to self-evaluate X
EVALUATION
Competency 13 – Quality Assurance
Item 96
Notes History; proper documentation completed
Treatment Summary Autonote is complete and in a sequence with the specific treatment provided,
assessment findings if applicable, anesthesia provided, oral hygiene interventions, referrals, next
visit information and or recare noted, student initials +
One of the above is not complete
More than one of the above is not complete X
Item 97
Organization and sequence of appointment
Organized and appointment sequencing in procedures is correct +
Fails to follow proper sequence during appointment or is unorganized
Fails to follow proper sequence during appointment and is unorganized, or proceeds without
permission X
Critical
Item 98
Care plan followed to completion; modifications made as needed
Patient treatment followed to completion as planned or modified +
Patient care is fragmented, not modified, and not according to timeline
Patient’s treatment is not completed X
Item 99
Student evaluation of care
Treatment results are documented and all entries in notes history are detailed, correct, and signed
by student +
One error in documentation in notes history
More than one error in documentation in notes history X
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Item 100
Continued comprehensive care (referrals)
Proper referrals are made, and forms completed with recommendations and appropriate signatures
(perio, dental, other) +
Fails to provide appropriate referrals X
Item 101
Completes student QA chart review, Daily Clinic Form completed as the
appointment sequence progresses
Completes student chart audit review utilizing checklist in operatory folder, daily clinic form
completed as needed +
Fails to complete student QA chart review in its entirety X
Competency 14 – Professionalism
*Any errors incurred due to unprofessional behavior, patient safety, or HIPAA policy are subject
to the professional and safe practice infraction policy as outlined in the CC DH Department
Manual, Volume I.
Item 102
Critical
Punctuality; Arrives to clinic at start time and is ready for huddle (Clinic start time is
7:15 am, Huddle is at 8:00 am)
Student is on time and does not leave early +
Student arrives late or leaves early (w/o faculty permission) X
Item 103
Equipment/operatory preparation setup & break down
Appropriate equipment and armamentarium set up in operatory, clinic binder, correct daily
form(s) in op folder prior to seating patient; operatory cleaned and broken down by end of clinic
day dismissal time of 5 pm +
One of the above is not completed
More than one of the above is not completed X
Item 104
Time management during clinic sessions
Student is using time wisely in the best interest of the patient and student, does not dismiss patient
prior to dismissal time without faculty approval or past the dismissal time
(AM: 11:15 am; PM: 4:00 pm) +
Student is not using time wisely and/or dismisses patient prior to or past the dismissal time X
Critical
Item 105
Critical
Item 106
Critical
Infection control, clinical and patient safety including following proper clinic PPE
guidelines as outlined in the CC DH Department Manual, Volume I
Student follows all protocols for infection control, clinical and patient safety +
Student fails to follow one or more than one protocol for infection control or patient safety, or the
student endangers clinician or patient safety X
Professional conduct; appearance, demeanor, attitude, composure, and judgment
Student is professional in all ways +
Student is unprofessional in anyway in appearance, demeanor, attitude or composure, or judgment
according to the CC DH Department Manual, Volume I X
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Item 107
Critical
Item 108
Critical
Item 109
Critical
Item 110
Critical
Item 111
Critical
Patient management, rapport, and compassion
Student establishes patient rapport and shows compassion +
Student fails to establish any patient rapport and/or does not show compassion X
Patient management during appointment, patient comfort
Takes every precaution to prevent patient from swallowing blood or loose calculus/debris
by using gauze and suction to absorb/remove blood/debris.
Rinses and uses suction to avoid patient swallowing blood/debris and create clear working field. +
Failure to do one or more than one of the above X
Team player, self-directed, helps others, work ethic, shows initiative
Student helps where needed without having to be told +
Student wants to be helpful, but does not realize what he/she needs to do
Student is not self-directed or not a team player X
Accepts fair, constructive feedback from faculty
Student welcomes fair, constructive feedback +
Student does not accept constructive feedback, argues or defies faculty X
Acknowledges and corrects errors
Student acknowledges errors and makes corrections +
Student refuses to acknowledge errors or make corrections X
Item 112
Practices effective communication skills
Communicates with patient at their level of understanding +
Uses technical terms when lay terms are necessary or uses lay terms when patient has a background
to understand technical terms
Fails to clarify conditions, procedures to patient on a level they understand X
Item 113
Proper grammar spoken and written
Uses correct grammar when speaking, writing, or spelling +
One error in grammar or spelling
More than one error in grammar and/or spelling X
Item 114
Practices within limits of knowledge and skills – Public health and safety
issues
Stays within limits of knowledge and skills+
Practices beyond the limits of knowledge and skills or is deemed unsafe X
Critical
Item 115
Critical
Item 116
Critical
Follows all HIPAA policies
Student is very discrete and protects patient privacy +
Student is indiscrete or not protective of patient privacy; HIPAA violation according to the CC DH
Department Manual, Volume I X
Completes requirements on time, within assigned clinical hours
Completes all requirements on time as outlined in the clinic schedule +
Fails to complete one or more requirements in the time allotted, utilizes additional clinic hours or
completes requirements during finals week X
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Points Gained from Productivity in Treatment of Each Patient Classification
Points lost are offset by points gained from productivity through treatment of a specific number and classification of
patients. Patient points are determined according to level of periodontal involvement and calculus deposits
combined with the clinical skill level. The semesters of clinic in the two-year dental hygiene program include one
semester of pre-clinical and three semesters of patient treatment clinics named Clinic I, II and III respectively.
Students are expected to be more proficient in clinical skills as they progress through clinical education. As the
student becomes more competent through experience, they are required to provide care to more periodontally
involved patients with a greater degree of accuracy in assessment, planning, implementation, and continuing care
and recare of patients. A daily clinic form is utilized to track progress/errors for that patient treated in that clinic
session and for faculty to enter feedback at the end of the clinic session.
Table of Patient Point Values Per Clinic Course
DHYG 1261-Clinic I
Periodontal Skill
Level
Pedo/Adol
Health/Gingivitis
Stage I
Stage II
Stage III
Points Per Patient
.25
.25
.50
.75
1.00
Calculus/Accretion
Level
Pedo/Adol
A
B
C
D
Points Per Patient
Calculus/Accretion
Level
Pedo/Adol
A
B
C
D
Points Per Patient
Calculus/Accretion
Level
Pedo/Adol
A
B
C
D
Points Per Patient
.25
1.00
2.00
2.25
N/A
DHYG 2361-Clinic II
Periodontal Skill
Level
Pedo/Adol
Health/Gingivitis
Stage I
Stage II
Stage III
Stage IV
Points Per Patient
.25
.20
.40
.50
.75
1.00
.25
.50
1.00
2.00
2.50
DHYG 2363-Clinic III
Periodontal Skill
Level
Pedo/Adol
Health/Gingivitis
Stage I
Stage II
Stage III
Stage IV
Points Per Patient
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.20
.35
.45
.50
.55
.25
.30
.50
1.00
1.50
100
COLLIN COLLEGE DENTAL HYGIENE PROGRAM DAILY CLINIC APPOINTMENT TRACKING FORM
Student Name: ________Patient Name: ______________Date: _________Appt #:___ Recare Pt.: Y / N ASA: ____
Age:____ Special Need(s):_______Health Health Red Perio Ging. Red. Perio Gingivitis: Loc. Gen. Biofilm/Non
Perio: Loc. Gen. Stage: _____ Grade: _____ Accretion: _____ Implantitis______
TalEval Competencies
ASSESSMENT
1) Risk (comments, RFV, drug
cards, SmartDocs)
2) Radiographs (prescription,
retake limit)
3) Dental Exam/Hard Tissue
(DDS exam, occlusion)
4) EIOE (pathology noted)
Comments/Errors
Faculty
5) Gingival Description
(No disclosing)
6) Accretion (hard and soft
deposit; calc detection sheet)
7) Periodontal Assessment
(xrays in view)
PLANNING
8) Care Planning (BCR,
worksheet and coded plan
complete, consent)
IMPLEMENTATION
9) Preventive and Supportive TX
10) Pain Control
(documentation, safety)
11) Instrumentation (xray/perio,
biofilm/stain removal, polish)
12) Calculus Removal
URQ
LRQ
C:
C:
S:
S:
C:
C:
S:
S:
ULQ
LLQ
EVALUATION
13) Quality Assurance
(notes and audit)
14) Ethics and
Professionalism (time,
IC, behavior)
Recommended Recare/Reevaluation Interval:____________
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Percentage Weights for Clinical Courses
DHYG 1431: Preclinical Dental Hygiene
(Didactic and Laboratory)
25% Exams (Written)
DHYG 1261: Clinical I-Dental Hygienist
40%
Clinical Evaluation (Process)
25%
Pre-Clinical Skill Evaluation (Product)
45%
Competency Evaluation (Product)
20%
Objectively Structured Clinical Exam
(OSCE)
10%
Radiology Technique/Interpretation
Evaluation
15%
Quizzes
5%
Clinical Self-Assessment Logs (SWOT)
10%
Assignments
5%
Clinical Self-Assessment Logs (SWOT)
DHYG 2361: Clinical II-Dental Hygienist DHYG 2363: Clinical III- Dental Hygienist
50%
Clinical Evaluation (Process)
60%
Clinical Evaluation (Process)
30%
Competency Evaluation (Product)
15%
Competency Evaluation (Product)
10%
Radiology Technique/Interpretation
Evaluation
10%
Clinical Competency Examination
5%
Minor Activity Site Evaluation
5%
Radiology Technique/Interpretation
Evaluation
5%
Clinical Self-Assessment Logs (SWOT)
5%
Minor Activity Site Evaluation
5%
Clinical Self-Assessment Logs (SWOT)
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Radiology Assessment and Evaluation Process
First Year Radiology Laboratory Assessment:
•
•
•
Completion of radiology requirements as described in the DHYG 1304 syllabus
Points will be deducted according to guidelines described in the “self-assessment” form
Grades are established on a product competency evaluation based on radiographic technique, exposure, and
interpretation of radiographs.
Clinical I, II, and III Radiology Assessment:
•
•
•
•
•
•
All radiographs must be evaluated within 10 school days of exposure. A ten (10) point deduction from the
technique grade WHEN THE EVALUATION PERIOD EXCEEDS 10 DAYS.
Any infraction of the retake and/or infection control protocol will be deducted in TalEval for the
appointment session.
Radiographs not evaluated by DDS on the day of exposure will result in a 25-point deduction from the
technique grade.
The following are error codes used for grading periapical and bitewing radiographs, the maximum
obtainable technique grade is 100, and points deducted for errors are based on clinical level.
Interpretation maximum obtainable grade is 100. The grade is based on the charted visible anatomical
landmarks and the charted visible conditions viewed on the radiographs.
The technique and interpretation grades are averaged together to determine the total grade.
Technique Evaluation for Intra-Oral Radiology Self-Assessment
D
-
Density (exposure)
MA -
Missing apices (Periapicals)
VF
-
Vert. ang. (foreshortening)
DR
-
Dropped Receptor Corner
VE
-
Vert. ang. (elongation)
CC
-
Cone cut
OL
-
Horizontal angulation (Overlap)
MT -
Image mounted incorrectly
M
-
Movement
R
-
Retakes (2 retakes allowed)
RP
-
Receptor placement
O
-
Other (specify)
•
Panoramic maximum obtainable grade is 100. The grade is based on the following:
o Process/Proper Technique
o Patient Preparedness
o Documentation
o Landmarks/Soft Tissue Identification
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Clinical Skill and Competency Evaluations
Pre-clinical skill evaluations and clinical competencies are to determine the student’s level of competency at the
developmental stage. Each skill evaluation and competency have a set number of criteria that are required to be met
by the student with no faculty intervention. Each skill/competency evaluation will have its own grading scale based
on the number of criteria and an appropriate level for the course. Skill sets to be demonstrated within a
skill/competency evaluation are graded as either acceptable or unacceptable. The student will self-assess their
performance on the particular skill/competency and will assign an “A” for acceptable or a “U” for unacceptable for
each objective. The student is to self-assess once skill/competency is complete prior to the faculty assessment. The
faculty will assess the student’s performance and will assign an “A” for acceptable or a “U” for unacceptable for each
objective.
Satisfactory completion (grade of 75% or higher) of all skill evaluations and competencies must be attained in order
to successfully pass DHYG 1431, DHYG 1261, DHYG 2361, and DHYG 2363. No more than three (3) attempts
are allowed to pass a skill evaluation or competency. Every effort must be made by the students and faculty to
complete skill evaluations and competencies by the scheduled date unless it is deemed by the faculty that the student
is not clinically ready.
For DHYG 1431 and DHYG 1261, if after the first attempt, the student does not pass, a clinical proficiency
contract will be formulated by the student and First Year Clinical Coordinator. If the student fails the second
attempt, a proficiency contract will be established with Second Year Clinical Coordinator and the student. If the
student does not pass 3rd attempt (final), the student will be dismissed from the program by the Director.
For DHYG 2361 and DHYG 2363, if after the first attempt, the student does not pass, a clinical proficiency
contract will be formulated by the student and Second Year Clinical Coordinator. If the student fails the second
attempt, a proficiency contract will be established with First Year Clinical Coordinator and student. If the student
does not pass the 3rd attempt (final), the student will be dismissed from the program by the Director.
** Second and third attempts to pass a competency will result in a grade no higher than the grade
earned on the first attempt, regardless of the student’s performance on the competency.
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Clinical Proficiency Contract
The clinical proficiency contract is in place to assist students who experience difficulty or who are performing below
required clinical competency level in any skill area. Proficiency contracts are specific to student’s areas of weakness.
Student is to use the SWOT analysis to complete the proficiency contract. Clinic Coordinator will approve of
student’s plan before implementation begins. For instructions on how to use SWOT analysis,
visitwww.mindtools.com/rs/SWOT.
Student Name: _______________________
Date Approved: ______________
Student Signature: _____________________________
Clinic Coordinator/Faculty___________________________________
1. Identify reason for proficiency:
_________________________________________________________
In a few sentences, identify the weaknesses or threats, that are affecting your
performance of the skill.
2. Plan: Make a step-by-step plan, including resources you will use, as to how you will use your strengths and
opportunities to improve the issue and decrease the area of weakness and/or threat.
Include a timeframe when this will be completed: _________________________________
3. Implementation: What resources did you use to help implement the plan above?
4. Evaluation: Was the plan outlined in #2 successful and did it allow you to reach the goal?
Passed competency:
Passed skill eval:
Other: _____________________________________
5. Coordinator/Faculty Feedback/Observation:
Date proficiency was completed: ___________________
Student Signature: _______________________________
Clinical Coordinator/Faculty Signature: ______________________
Program Director Signature: ________________________________
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This manual is a living document and may be subject to change as needed by the Collin College
Dental Hygiene Department.
This manual is intended to be a resource on how the department manages the clinic regarding
department expectations, legal, ethical, and safe practices, professional conduct, student
evaluation of the process of care, and student proficiency.
This manual is not intended as a resource to include course material and skills learned in didactic,
laboratory, or clinical courses.
It is the student's responsibility to come prepared with the knowledge and clinical skills learned in
didactic, laboratory and preclinical courses.
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