Transcript for:
Hard Tissue Examination and Dental Health

in this video we are going to be discussing Wilkins chapter 16 which reviews The Hard tissue examination of the dentition so let's first look at the um course objectives so um the objectives for this actual um chapter in Wilkins is being able to identify the three divisions of human dentition explaining the Developmental and non-carious lesions describing different types of dental injuries and tooth fractures to be able to list the classifications of dental curious lesions to explain the development of early childhood caries we are not really going to get into pulp Vitality at this point so I know Wilkins goes into that but we are not going to really get into that um only um just kind of brush the surface of Pulp Vitality you'll get um deeper into this when you um are in Dental materials in the spring and you'll be able to do um Hands-On pulp testing so um we are also going to look at listing different factors to observe during Dental charting explaining um the basic principles of occlusion um classifying occlusion um according to angle's classification um and over the reading you should be able to you know just look at the difference between functional and parafunctional contacts and give examples of those parafunctional habits um and then also we're going to discuss Wilkins in this chapter is going to discuss the types of occlusal trauma that you might see we're going to just kind of briefly talk about study models and the purposes of study models so let's first look at primary dentition so primary dentition is um the formation of those primary teeth and that typically begins in utero um the weeks when in utero is when the primary teeth actually begin to mineralize and then the average age after birth when the enamel is completely formed before the date of eruption is going to be discussed more in another chapter so hopefully you understand this this is that um dentition where we're using more of the letters to determine the teeth um the teeth actual you know what the teeth are called instead of the numbers so these are the teeth that are exfoliated once the permanent teeth begin to erupt so here we have our matte Solari and our mandibular primary teeth um let's see let's go into our mixed dentition so our mixed dentition can also be called transitional dentition so that's where we're transitioning into you know getting um exfoliating or losing those primary teeth and then those permanent teeth erupting and taking their place so this usually typically starts to occur at the age of six and usually extends on to about 12 years of age and then of course those wisdom teeth follow um some years later usually around um 18 you know 17 years old yeah the next phase of dentition is going to be our permanent dentition so here we're looking at the eruption of all the permanent teeth in the dentition so um here this picture just shows the maxillary teeth it shows the mandibular teeth I know that in your anatomy class you are going to go over all the different characteristics of each of those teeth and what makes them identifiable so permanent dentition mineralization of the permanent teeth usually starts at Birth and concludes into the Adolescent so during that time um these teeth are forming and they are starting to erupt into the mouth so Roots um normally are completed about three years after eruption so know that once you see that tooth clinically there is probably still some work going on on that route it usually isn't completely formed until um two years after actual eruption of the tooth so here we look at the teeth um what this picture is just kind of depicting is clinical Crown length so um we do look at clinical crown and we look at clinical Roots so when we discuss clinical Crown it's important for you to know what part of the tooth is above the attached periodontal tissues so it can be considered part of the tooth that is visible not covered um with gingiva when in the mouth and where restorative treatments are performed so it's what we're actually clinically seeing when we look into the mouth okay and so it can be different for different patients depending on how much of that is um actually exposed so when we look at clinical roots that is the part of the tooth that is not visible because it's below the base of the gingival sulcus or periodontal pocket so it's not visible when you look into the mouth it's the part of the root to which periodontal fibers are attached so we know that that part that is that is down in here right is actually the clinical root so here the the or the root that is obviously attached in the with the sulkit so so that is part of the tooth that is not visible but when we talk about clinical Crown we are talking about that part which is a visible and keep in mind that some of that Crown in some patients can sometimes be covered with um actual gingiva all right so the part of the tooth that is above the attached periodontal tissues so a here in this picture is um kind of showing a periodontal pocket that's developed and the clinical Crown extends to a position at which the clinical Crown length is greater than the clinical root length the clinical root is the part of the tooth with the attached periodontal tissues okay so that's kind of the difference that we're looking at and then in B is when the clinical attachment level is at the cej or cemento enamel Junction and the clinical crown and the atomical crown are actually the same okay so we can look at clinical Crown we can look at anatomical crown so anatomical Crown is the part of the tooth that is covered by enamel all right anatomical root is the part of the tooth covered by cementum so does it really matter what is visible or what is not visible that really doesn't come into play when we talk about anatomical versus the word clinical all right so hard tissue examination procedure so let's talk about the things that we actually um look at when we're doing a hard tissue examination we're looking at teeth and existing Restorations and we are assessing for non-carious and curious lesions keep in mind that that word curious means Decay or a cavity okay um and there are also lesions of the teeth that can be non-carious so I'm not related to an actual cavity which is caused by different microorganisms we're also looking at when we do a hard tissue examination we're looking at occlusion an occlusion is the way the teeth fit together okay so we're looking at what teeth are there what Restorations are there what kind of lesions being curious or non-clarious and we're looking at occlusion and and a lot of times when we're looking at occlusion we think of study models so if anyone has had any kind of orthodontic treatment you know that when you go to the orthodontist one of the things they do is take a study model and that is so that they can look at the way your teeth fit together and they can educate you with this replica of your teeth typically they will do another study model once you are at the end phases of your orthodontic treatment so they can then show how the changes are heard um in your dentition and the way those teeth fit together so Dental charting of teeth and Restorations so let's look a little more deeply at that so when we're charting um teeth and Restorations we want to look first at which teeth are missing okay so we're going to go around and say what is not there either because it's extracted or because um it was not developed then we're going to look at supernumerary team so supernumeric teeth might be extra teeth right so in some cases some patients will develop supernumerary teeth or extra teeth and then we will also look at teeth that could be unerrupted and the way we would know that obviously is to look at radiographs so we would look at those radiographs and see that they were waiting you know to come down but yet they are not erupted okay so those are things we would um look at and chart first when we're looking at teeth and Restorations the next thing we would do is we would look at existing Restorations so when I say existing restoration I'm saying existing fillings so where in the mouth have fillings or Restorations been um been applied so Restorations can be Composites they can be um amalgams they can be crowns they can be root canals um so this is a really very big category when I talk about Restorations um then we're going to look at developmental enamel lesions we're going to look at non-carious cervical lesions we are then going to look at carious lesions and then we're going to look at any other pathology that we might have noticed during the radiographic or clinical examination so seeing that radiographic and clinical examination and seeing those terms should kind of ha give you this light bulb moment that radiographs are necessary when we are charting dental teeth to get a very accurate um final result of our Dental chart okay so it is important that each clinician developed a systemic approach to talk to charting Restorations so that you don't have errors so important to look at you know let's start with tooth number one and go all the way to 216 and look at what is missing or what is unerrupted or if there are any super super numeric teeth okay then do the same thing for the mandibular starting with tooth number 18 and going to 32 all right and then we want to go back to number one and we want to say okay now let's look at those existing Restorations okay and go through the map and do that and then those enamel lesions and then those non-carious cervical lesions those curious lesions and then any other pathology that we might have noticed so those are the things we really want to look at when we're looking at the teeth and creating a dental chart of those teeth so assessment of non-carious and curious Dental lesions so how do we do that so really we want to use a visual examination procedure so we want to carefully and visually inspect so this is really just looking okay um with maybe our Dental mirror all right and our eyes just looking at things using our light our overhead light so carefully visually inspect each surface we might even incorporate air all right so we might pick up the air to actually dry the teeth um and use that overhead light to kind of look around at everything observe changes in color in translucency of the actual two surface comparing one tooth to another to see if there's differences um note if there's any changes that um we saw on the radiographs that we need to now review clinically and then there is something that we can do called transillumination so trans illumination is when we actually take our Dental mirror and then we direct the light to our Dental mirror and reflect that light through anterior teeth and unrestored posterior teeth and we can see through those teeth to see if there are areas of light and dark transition within a tooth because sometimes that can indicate that there might be a um something that we need to add to our Dental chart so um radiographic examination so we talked about the visual and now we have the radiographs so we want to carefully review those radiographs and interpret the radiographic findings that we're identifying and then use those during the clinical examination so first we're visually looking at the mouth then we're looking at the radiographs okay so the radiographs nor the clinical without each other are complete all right so we really need to have those both to be able to do a thorough job so in addition to looking for Curious lesions on those radiographs it's important to look for other things on those radiographs such as anomalies impactions of teeth fractures internal root resorption any kind of radiolucencies near the roots so periapical radiolucencies we can use panoramic radiographs we can use extra oral or occlusal radiographs sometimes to detect these anomalies we can use those periapical radiographs we can use those bite Wing radiographs so a lot of different radiographs can be used when we're doing our Dental chart to help us get that complete picture so the clinical examination so if carries cannot be converted visually or on the radiograph then we're going to gently use our shepherd's hook Explorer so so hopefully you remember from when we were um going through our kits what that shepherd's hook explorer was if you don't that's okay we're gonna talk more about that shepherd's hook but if you pick that instrument up it actually looks like a shepherd's hook all right so um you have this very thin wire that forms what looks like a shepherd's hook and we use that to confirm visual findings it is essential when we use that explorer that we're not putting a lot of pressure that we're just very gently exploring those pigs and Fishers and grooves and those smooth areas of the teeth um but we don't want to be actually taking that Explorer and removing any um re-mineralized areas of the tooth so intraoral images are another tool that can be used to document existing conditions and provide a visual um for treatment needs and that can be used for documentation in the patient's chart and to educate the patient so when I'm talking about intraoral images here I'm not talking about those digital images those radiographs that you're taking I'm talking about actual interoral images with an intraoral camera and actual pictures of um different types of conditions so that can be a very useful tool during this clinical examination so that we can make part of the patient's chart and use for patient education purposes so occlusion and study models so assessment of occlusion actually includes looking at normal occlusion looking at malocclusion looking at Mal relations of groups of teeth and then malpositions of single teeth so study models again I'm going to just talk about those as another tool that can be created to assess and document the occlusal relationships and their actual lead also a very important part of patient education so let's talk about developmental enamel lesions so the ones we're going to discuss in this chapter are enamel hypoplasia hyper mineral maturation and hypo mineralization so let's first talk about enamel hypoplasia okay so enamel hypoplasia is a defect that occurs as a result of a disturbance during formation of the organic enamel Matrix there are different types in etiologies and hopefully you know that ideology means cause so there's different types and causes of enamel hypoplasia so first we have um genetic okay or hereditary all right so um the enamel is thin in this case it or absence and the enamel may also have surface pitting or vertical grooves so an example of this could be ameliogenesis imperfecta so hopefully you've talked about ameliogenesis imperfecta in your histology class this summer but it is a um it is a malformation of enamel so Emilio blasts are actually the cells that start to form enamel and so ameliogenesis we're talking about the formation of enamel and it being imperfect so systemic so now we're looking at conditions contributing to tooth um enamel hypoplasia during to development so systemic conditions can be metabolic disturbances such as celiac disease okay um maybe something from an infection okay that could have occurred so maybe um you've talked about in your histology class you might have talked about a mulberry molars okay um and that being from congenital syphilis so things that might have happened during development because of a condition um such as an infection and then you can have local um enamel hypoplasia so that's going to be like something that actually happened to this development mentally developmenting tooth or developmental tooth um such as trauma or inflammation of a primary tube that could have actually affected that permanent tooth so next we're going to look at some pictures of these different types of um enamel hypoplasia so the appearance can really depend on the type and the cause so first we have that genetic okay so um I told you Amelia Genesis imperfecta is a really good example of that um and then we have local where we just have it you know just on a couple of teeth and then we have that systemic that was due to an acquired um infection of the mother at Birth so this is our um this is actually our Mulberry molars and our Hutchinson's incisors that we're seeing here and the developments changes that we see are due to the mother having that infection while um the baby was in utero this kind of um this this infection actually was transmitted to the fetus and then we have the the um the changes in the development of the tube so now we look at hypomineralization and this occurs during the mineralization stage of the enamel so there's different causes and types so children with celiac disease you might see this in um chronic liver kidney disease acquired infections chemical and Drug exposure could also cause this hypomineralization so remember it doesn't have to be the actual child ingesting it can be the um mother ingesting okay because those teeth of course those primary teeth are developing but those permanent teeth are all the buds are also developing as well so different types can be brown or a yellowish color and you can see like a little demarcated areas and depending on when they were exposed is the teeth they're going to affect so if it was something that they were exposed to all during you know the um developmental stages of all their teeth then you might see this more generalized but if they were exposed at different times okay of development then you will see it only affecting the teeth that we're developing during that time so hypomineralization yellowish or brownish spots on the teeth all right so the other thing we can look at is hypo mattress maturation and this can really occur as a result of either any of the um different conditions that we're talking about and this actually occurs during those last stages of mineralization of the teeth and it results in the enamel just being very fragile and fracturing very easily so if you look at this picture this is a picture of this ameliogenesis imperfecta so the enamel was not formed properly um in those last stages of mineralization you can see that the enamel is very thin and if I used an Explorer or some kind of sharp instrument around these teeth and started picking at that enamel it would easily um like off okay so we have to be really careful about those types of conditions when we're using our instruments all right so now let's look at developmental defects of Dentin so we're focused on enamel and now we're looking at denzin so hopefully these terms are not something that you know are new to you but um we can look at genetic as different causes and those would be like dentinogenesis imperfecta Dentin dysplasia which is the inherited form of rickets and the appearance traditionally is going to look like this brown discoloration and uh and you could have that Progressive pulp obliteration so um the next thing we're going to look at is non-carious Dental lesions so these are things that happen to the teeth um after they've been erupted in the mouth so the things we look at before are things that are more Developmental and now we're looking at things that um Can Happen um after the teeth are erupted over time sometimes so first we can look at attrition so attrition is the wearing away of it too due to two to two contact so in the image that you're seeing here you're seeing a flattening of those incisal edges um know that it can be more widespread than just the mandibular anterior teeth you can see this also in posterior teeth um you can see this on occlusal surfaces on cusp tips and and all of that but the location is typically those occlusal or incisal surfaces the age really um depends on the bruxism that's involved but it's usually going to be cumulative so you know you're going to see this more frequently in in patients where those teeth have been present in there for a while but yes you can see those this attrition also on primary teeth okay so those teeth can also show where um gender we do see it more commonly in men than women of comparable ages so I'm not saying that we see attrition more in men than in women but we see it at a worse State at the same age as in women so if we can if we would sit on a 30 year old man and a 30 year old woman next to each other and we would look at we would probably find some attrition in both of their mouths but the men um might be more advanced at that age Than a Woman and that's not always the case but that is that's more common so causes of this condition this attrition um can be stressed sometimes people will brux they're or grind their teeth together in times of stress it can be tension um we see this in people who do a lot of weight lifting sometimes so Brooks or grind their teeth together when they're lifting weights um and do that you know just as a subconscious thing and then they're seeing effects on their teeth and sometimes it can be occlusal interferences so just the way their teeth are fitting together so predisposing factors so I think of predisposing factors as kind of like risk factors so um maybe course Foods chewing tobacco can be a risk factor um culture related to chewing habits so chewing different things um abrasive dust associated with certain occupations can also contribute to attrition so the next thing we're going to look at is these non-cert non-carious so again attrition was also non-curious but these now lesions are going to be more on the cervical part of the tooth so when we talk about these I will tell you that erosion is typically on it can be on the cervical area but sometimes it can't extend down into the middle third of the tooth but we're not seeing it as much on the incisal edge like we do with the attrition so we're going to look at erosion abrasion and a fraction so erosion is the loss of two substance by a chemical process so instead of having it being two teeth that are rubbing together now we know that there has to be a chemical involved but um not necessarily A bacterial action so we think of Decay as being more of a bacterial action so there is a chemical involved but really not the same bacteria that we would see present in the Decay process so the location is the facial or lingual surfaces are usually the most commonly affected the causes are either extrinsic acids or intrinsic acids so extrinsic acids means it's coming from an external Force so um occupational acid exposure acidic Foods acidic drugs that the patient might be taking intrinsic acids would be you know things that come from within the body so acids that are formed as a result of Eating Disorders um so patients that may have um bulimia who might be binging and purging right eating a lot and then throwing up that acid that's coming from the stomach is the in intrinsic acid that is actually causing an erosion to the teeth and then we have conditions such as gastrointestinal reflux disease where the patient is getting this up flow of acid into the oral cavity which is affecting the teeth also alcohol abuse can cause this gastrointestinal reflux disease and contribute to on that acid getting up into the teeth so the appearance so usually it's going to look smooth that surface can be very smooth it's going to be shallow it's going to be hard it's going to be shiny the shape is going to vary from a shallow saucer-like depression to deep wedge-shaped grooves the marsh the margins are not sharply demarcated and it may progress to actually involve the Dentin underlying layer and if it does that then it usually will stimulate secondary Dentin production in order to protect that pulp okay because we know that that's what Dentin does it protects the pulp so I'm sorry I'll go back to that picture so here we see it on the facial surfaces you see that um erosion okay around the tooth here these two teeth here we see the erosion but we see that part of the tooth was restored right so you see this white area here so the dentist probably placed a composite restoration to protect that area because we know that Dentin is not as resistant to Decay as enamel is and we're also getting a weakening of that tooth because it's thin at the cervical area so dentists will a lot of times cover that area up with a composite restoration to protect it and then over time if we have not um resolved the issues that are causing the erosion we are still going to get erosion of the tooth around that composite so that's what you're seeing here so kind of interesting here in this picture you're seeing the same thing you're seeing erosion but you're seeing it on those lingual surfaces and you can see now it's not just um you know uh localized to that cervical area but you're seeing it over that whole lingual surface you're even seeing how smooth these occlusal surfaces are due to that um wearing away of the tooth so as you learn in anatomy all the difference on grooves and fossas and cusps and characteristics of each teeth you see that erosion kind of smooth those surfaces so that we don't have now all of those grooves and things we have this very smooth area all right now let's look at um abrasion so the mechanical wearing away of two surfaces by forces other than mastication so we're wearing a way of the tooth and it's usually the location is along those exposed root surfaces so over time we will sometimes see that the gingival margin of the tooth will move apically to expose the root surface of the tooth into the oral cavity when that is exposed we sometimes will see abrasion on those areas we can also see abrasion on the incisal edges in occlusal surfaces of teeth okay so what are the causes so an abrasive agent so it is very commonly caused we see this a lot this abrasion along the root surface okay or along the cervical surface of the tube and as you usually from vigorous horizontal tooth brushing with a very abrasive Dent of risk so adenopress is a toothpaste okay so something very abrasive along that root surface with those horizontal um toothbrushing motion will over time cause tooth abrasion there can also be occupational causes so for example it could be um you know I could be a carpenter and maybe I hold nails or tacks in my teeth you know and then over time that is going to match out or upgrade that incisal edge um pins by dressmakers so um if you've ever went to get alterations sometimes the dressmakers you know they'll be pinning the areas that they're going to be adjusting in the garments and they will sometimes put the pins in there um between their teeth and hold them there as they're working so that can also over time Notch out those teeth habits so if someone is smoking or using some sort of a pipe and holding that between their teeth and they're doing it in the same area over many years that can also cause abrasion in those um incisal edges of the teeth so what does it look like so typically um and different than abrasion you will see more of this defined margin okay so you'll definitely see where it stops and starts um and it will be clearly demarcated those those margins so it is going to be shiny it is going to be smooth it is going to be hard just like with the erosion but instead of it being over a diffuse area a bigger area you're going to see it just in those incisal area or I'm sorry cervical areas except for those incisal biting habits that can occur on the incisal edge so next we're going to look at a fraction and I'm going to warn you when we look at a fraction it is going to look exactly the same as abrasion it really is only finding out what caused it that is going to help us know if it is abrasion or a fraction okay and typically we do error on the side of caution and call it's abrasion whether it's a fraction or abrasion typically we do error on the side of caution and call it abrasion but I do want to point out this word to you and go over it because there are um quite a few practitioners who um do use it quite regularly so a fraction is going to be um a breakaway and um a breakaway of those enamel rods those Hydro oxy appetite crystals of enamel and Dentin and it's going to cause a micro fracture in that cervical area of the tooth okay so we're looking at primarily the buccal surfaces of teeth okay and we're looking right along that cervical area just like we did with our abrasion and so what are the causes so really multi-factorial so that means there's a lot of different causes okay and research has not really confirmed that occlusal trauma is the cause but a lot of times that is what it is linked to okay so debt and demineralization may actually increase the risk of that fraction and the occlusal forces may increase the progression so if someone's occlusal forces if they have malocclusion and they are putting a lot of pressure on their teeth then what they're saying is that there is a breakdown of those hydroxyapatite crystals near that cervical Edge and then we get this result which looks a lot like abrasion all right so my appearance all of this information is exactly the same as abrasion all right so at this point in your career you're not going to be able to tell is it a fraction or is it abrasion so we're going to call it abrasion but I want to let you know as you go further on in your career you're going to hear this word of fraction and it is a lot of times going to be linked to um occlusal forces okay and the brought breakdown of those um hydroxyapatite crystals all right so now let's talk about so those are our non-carious Dental lesions that we are looking for um when we check the teeth so now let's look at fractures of the tooth okay so this is not Decay but fractures so what are the causes of tooth fractures so it could be an automobile accident a bicycle accident a diving accident I mean we could go on and on it could be you know some kind of ski accident some kind of snowboarding accident right roller skating we could we could go on and on um contact Sports so that's another thing when they're when when um our athletes are not wearing mouth protectors they will um sometimes suffer from fractures of the tea on different blows to the face so if someone gets hit in the face um maybe they get into an argument or a fight that becomes physical then obviously we can have fractures to the tooth and some of balls okay so maybe they're not doing any of these types of sports but they're walking and they have uneven cement and they fall okay so another another um cause of the tooth fracture so the description so the line of fracture so when we get a fracture of a tooth it can be a horizontal line it can be a diagonal line or it can be a vertical okay so the fractures can go in all different directions so radiographic signs of recent trauma so sometimes we'll just look in the mouth clinically and we'll see all of this but we really need to take a radiograph to see the different signs of trauma and how that's affected the the tooth underneath of what we can see clinically so usually when we see um trauma in a tooth we'll see a widening of the periodontal ligament space around that tooth all right so when we look at the radiographs that periodontal ligament space will be wider um sometimes we can see radiolucent fracture lines on the on the x-rays typically those are going to be more on the root of the tooth than on the enamel because when it's on the enamel it usually does fracture off but on the root we might see these radiolucent lines where the root is actually fractured radio opaque areas where fracture segments overlap and sometimes we're going to see tooth displacements okay so where the tooth has kind of moved into a different spot um and sometimes you know the tooth actually becomes evolved or actually falls out right but we're looking more at um when the two actually fractures so different fractures of the teeth so fractures are actually classified okay according to how much of the different tooth structures are involved in the chip okay or in the fracture so we look at the fracture of enamel of the tooth such as chips and cracking we look at fracture of the crown of the tooth with or without pulpal involvement um we look at fracture of the crown and the roots of the tooth with or without Popple involvement we look at just fracture of the root of the tooth we can look at something called luxation which is dislocation of the tooth a loosening of the tooth with displacement we can look at intrusion Extrusion or Emulsion of the tooth so intrusion is when it is actually hit right and it actually is kind of pushed down into the alveolar bone and and now sit it's lower than it wants did and usually that can be accompanied by a fracture of the actual alveolar socket Extrusion from the socket which is when um the tooth has actually kind of popped up it hasn't came all the way out of this out of the sulcus okay or it came out of the socket but now it actually sits higher and sits at a um different spot than it did initially in the socket and then we have a version of tooth where that's just complete displacement of the tooth and that's when it actually comes out of the socket so those are different things we can look at when we look at um classification of dental injuries so recommendations for treatment so what what do we do well we really have to do a clinical diagnosis an immediate emergency treatment so um sometimes we have to do that immediate immediate emergency treatments and clinical diagnosis and then we have to have follow-up appointments to actually come up with long time long-term treatment for the tooth um we definitely need to get a radiograph to detect if there are any root fractures present because sometimes we can't clinically see those we also need to see if there's any two fragments that are around the area we want to do pulp testing which is where we can either take some take some Endo ice okay and actually touch the tooth to see if we get a response or we can use electronic on Pulp testing to actually see if we get a response out of the tooth um we want to see if there's any Mobility with the tooth If It Moves if there's any tenderness and then obviously we want to follow up for additional requirements but in this picture here you're seeing the different fractures of the tooth as what we talked about in the previous slide so if you look at a right you should see that a is an enamel fracture so we're just seeing you know the tip of the enamel that is fractured in B you are seeing the the crown fracture okay so you're seeing this enamel fracture we're into the debt in just a bit right of that tooth but we're still not into the pulpal part of the tooth okay and then we're seeing C which is a crown fracture with pulpal involvement so now we have enamel we have Dentin and we have pulp that is involved in this fracture so then we have D which is a fracture of the crown and root near the neck of the tooth okay so we're having this whole portion that is fractured and then an e we're having actual root fractures all right that involve the cementum the Dentin and the pulp and may occur in the apical the middle or the coronal third of the root so it could be in one or multiple spots on this root but we're now seeing that you know not only do we have fracture in here but we have fracturing along the Route so that just kind of shows you the different types of um of fractures and obviously depending on the type of fracture you have is going to really in the way your body responds is going to determine the type of treatment that will need to be indicated long term all right so now we're doing our dental exam and we've looked at all of this stuff right and now we're looking for dental caries now as a hygienist we are not actually diagnosing Dental caries but we are looking for areas that um raise our suspicion and might be considered dental caries and we are pointing these areas out to the dentist when they come to do the dental exam we're pointing these areas out to our instructor when they are coming to do our hard tissue charting so that um we are aware of areas of concern in the patient's mouth so the who which hopefully you guys know who that is but um that is the World Health Organization they Define Dental caries as a localized post-erruptive pathologic process of external origin involving the softening of the hard tissue and proceeding to the formation of a cavity some things to keep in mind when we look at Dental caries is Dental caries is a preventable disease okay so Dental caries is preventable that's where we come in to do a lot of Education with our patients when especially before they ever get any kind of dental caries and then even after they get it to help prevent it in the future so Dental caries is a preventable disease characterized by demineralization of the hard components and um dissolving of the organic Matrix of the tooth the requirements for the development of dental caries are the presence of microorganisms fermentable carbohydrates in a susceptible tooth so we have to have all of those elements for a tooth to actually um begin the dental caries process so I have a fun little picture here that just kind of depicts that right so we have bacteria in our mouth okay and then we eat food drinks sugary sweets and we get the formation of these fermentable carbohydrates okay and from these two things together we are now producing an ambassy okay so the environment is more acidic so we put that acid with a healthy tooth and over time we can develop a cavity so hopefully if you are not a stranger to the dental office and you've been there for um just Dental Care even not even being employed in a dental office you have seen something like this before from your dentist or dental hygienist or dental assistant just kind of educating you on the dental process and it really is very accurate okay so that is that is how the Dental on Decay process happens so it is our job to um try to eliminate some of these factors right and if we can either get our patients eating healthier or decrease bacteria that is present in the mouth through brushing and flossing and taking care of her teeth then we can eliminate that acid production or at least reduce that acid production and then of course um impact the Decay process so Dental caries so Dental caries are classified according to GB blacks classification okay so that is how carries are identified and we actually use this same process okay or same classification to um then talk about our cavity preparations so cavity preparations are when the dentist is actually removing the Decay and preparing the tooth okay we will use these same these same categories and then actually the finished restoration we use these same categories so this is used very frequently not just to discuss the carious lesion but also the cavity preparation and the finished respiration okay so we can put these different um um things into categories based on the location of where they are so let's look here at the classifications um so we have a class one carry so when I say class one okay carries or class one restoration I'm talking about the um cavities that are in the pits and fissures of the occlusal surfaces of premolars and molars so just here in the occlusal surfaces okay that is it or the facial and lingual surfaces of molars okay so they might just be straight on the facial straight on the lingual or you might see these on the lingual surface of the maxillary incisors so we have um in different different um individuals have deeper grooves and in these areas but we can have little Pits on fissures and grooves and these anterior teeth and we get these small Restorations and these are all considered our class one according to CB Black's classification you can look at um class two all right and so class two is going to involve the proximal surface of molars and premolars so class two is um specific to posterior teeth okay so and this is just involving that proximal surface a class 3 then is going to have to do with classifying the proximal surface of incisors and canines that do not involve The incisal Edge okay so class three we're looking at those interproximal surfaces just like we were in two right but now we're looking at just those anteriority okay class 4 is looking at cavities in the proximal surface of T and now we're actually involving that incisal edge so we're still just talking about anterior so that's what I want you to keep in mind so three and four okay are looking very very closely at anterior teeth only class three being just that in our proximal surface and class four being that inner proximal surface and now you know extending onto that incisal edge so in this picture um it almost looks like it's just going deeper in our proximal but it is supposed to be showing involvement of that incisal edge surface class five all right so these are going to be cavities in the cervical third of facial or lingual surfaces not the pit and fissure so now we're going back to anterior teeth again okay and we're going but we're just looking at that cervical third so just that bottom half so not the pit here because remember we talked about pits and what do pits what classification are pits pits are up here right those are class ones all right so lingual surfaces of Max are in sizes facial and lingual surfaces of molars so when they're just in a buckle pit on the Buckle of a posterior teeth or they'll you know lingual pit of a posterior teeth and we're going to call them a class one but if they're down along the gum line right down along the cervical third we are going to call them a class 5 restoration and we're also going to look at those and classify those same type of restorations on anterior teeth so we're looking at the posterior and the anterior teeth now the last one we're going to look at is class six okay and these are cavities on the incisal edges of anterior teeth and cusp tips of posterior teeth so we are looking at both anterior and posterior teeth okay but would we would be just looking at just the very tip not into those grooves because those grooves would be a class one all right we're just looking at the cusp tips and then if we had we you could probably draw in here a um an incisor or an anterior tooth because this does talk about anterior teeth as well and we're talking about just those edges of the incisal surface so maybe someone who has a lot of attrition and so we want to just protect that or maybe they've developed a cavity there because they had a lot of attrition and we're seeing those underlying layers of tooth and they have a restoration just in that inside of age then we're calling that a class six okay and then if you look at this last category it will just kind of go over the method of examination like how you can see these so in our class one you can see these with direct Vision or indirect visual radiographs okay so you could use radiographs um but they're not going to be as useful to see those carries but they are going to be very useful if it is a restoration okay so it just depends on if we're looking at a restoration or if we're looking at actual queries and in this example they're really focusing on carries all right so director indirect visual examination the radiographer really might not see these curious lesions as often so class two early carries um probably going to see these mostly on the radiographs moderate carries not broken through from the proximal to the occlusal you might see visual changes in color when you're looking at the tooth clinically and that loss of translucency and you might see extensive carries involving the occlusal through direct visual so it just depends really where we are in that decay process as to how much um where you're going to be able to see that and which tool you're going to be able to use so now looking at class three we have early carries are really going to be more um picked up on radiographs or using that trans illumination where we're taking our Dental mirror and we're directing the light through the teeth the seed color changes moderate carries not broken through to the lingual or facial you might see some changes in tooth color you might see some darkening into that in our proximal area and then radiographs um you are going to see that extensive carries and also you can usually see those extensive carries directly just using visual examination um class four is going to be more Visual and using that trans illumination method class five okay is going to be direct so we're looking at that straight Buckle um straight lingual surface I'm usually better to dry that surface for vision um usually that dull probe or shepherd's hook um to distinguish if it's demineralized or if it's actually um Decay but something to keep in mind with these areas when you are using an instrument is they they could be very sensitive so you have to be very careful and then we have our class six which is those incisal edges um or our cusp tips and those are really going to be visual direct with direct Vision because you might see some discoloration you're probably not going to see these so much on the radiographs all right so let's get into the discussion on enamel carries um there are different stages in the formation of a curious lesion okay so we have initial we have moderate and we have more advanced curious lesions and there are different carries classifications um that are used to kind of group them and we have two systems that are used we have the carious classification system so if you see CCS that's what we're talking about and we have the international carries management system so iccms so both of these are um are pretty much the same but one obviously the Curious classification is more for the United States and what we use international is more you know broader so that's the system that's kind of used worldwide so first we can look at the initial carries lesions so sometimes people will also chain interchange some terms for that and they'll say early carry lesions or they might say incipient lesions so those are those first initial curious lesions so first we're getting that subsurface demineralization um we might get some clinical evidence of that and then green mineralization so sometimes these areas will actually start to remineralize which means that the body will actually start to heal them and they will not become you know as we know it today carries okay so these might be like an area that a certain clinician might decide to watch or keep an eye on to see if it progresses you know they might put the patient on certain prescription fluorides to try to um control this so the first clinical evidence usually of this is going to be usually like a wider area um of the tooth and there's usually no breakthrough of the enamel surface um with time it might start to stain um and things like that but low concentrations of fluoride can sometimes remineralize these areas which is which is really nice so then we can look at um the moderate category so that category is going to show breakdown of enamel um we are going to be able to um visually observe that um and irregularities might be detected when we use that Explorer over that area Okay and then progression of the carious lesions so sometimes you'll see spread of that lesion from that initial area it will start spreading on the teeth and know that decay does spread not only within one tooth but it can also also spread to a neighboring tooth all right and then we have the advanced okay so then the advanced carries um description is actually getting into more of cavitation that is exposing that Dentin surface and radiographically you're seeing it extend into the Dentin or into the pulpal surface or tissues of the tooth so here we can see um a chart that is actually in your Wilkins textbook that goes over these different classifications so we have our sound surfaces so these are our healthy surfaces right and then we have our initial stage carries so um just kind of maybe some white spots um no no incidents on the radiographs at all no shadowing um but we might say that enamel might be starting to break down a bit so we might give them some some um preventative type measures that they can actually get these areas to remineralize um and then we have our moderate stage where we are seeing some color change we are seeing breakdown of the enamel all right and then obviously that extensive stage carries where we are visually able to see you know these areas where the enamel and Dentin and sometimes called is actually involved and um in being you know destroyed so nomenclature buys surfaces so we can have a simple cavity which is going to involve one tooth surface we can have a compound cavity which is going to involve two surfaces and we can have a complex cavity which is going to involve more than two surfaces so when we look at these um just keep in mind it's how you read them off right so if I said I have an occlusal cavity you know that's a simple cavity that's just a melting one surface but if I'm saying I have a mesial occlusal or an Mo cavity I'm saying that I now have two surfaces that are involved right and if I have a complex cavity I'm involving more than two surfaces and so now I could say this is a mesial occlusal distal restoration or dental caries and it is involving the mod surfaces so there are different types of dental caries um there are pit and Fisher there are smooth surface they're primary there are recurrents they're arrested um and there are uh rampant carries so arrested really and rampant should be two separate categories here so um so let's look at Pitt and Fisher so Pitt and Fisher carries begin in a um default or into a pit or fissure um so where those irregularities are um we do get an accumulation of microorganisms and sometimes we will get um carries in those areas so smooth surface so these are carries that begin in smooth surfaces where there really isn't a pit there isn't a group there isn't a defect right it occurs where Dental biofilm is protected from removal such as maybe proximal surfaces so you think of like smooth surface and you might think of just the Buckle and lingual but no no we're actually talking about the mesial and distal as well because those are smooth surfaces but yet removal is kind of tough because we have a you know teeth up against them so cervical thirds of teeth can sometimes be areas that are difficult to clean for people so sometimes there will get carries so primary um occurring on a Surface not primary previously effective so an area that is um a cavity that is in a virgin tooth that's never had a cavity before so we can also call this initial carries or incipient carries um recurrent so this occurs on a Surface adjacent to a restoration so maybe we have already had a curious lesion in a tooth and it's been restored and now we have recurrent carries we have carries now developing around the existing restoration so um those can be difficult to detect clinically and radiographically at times especially when they're first starting because we have that restoration when we look at the um when we look at the tooth and so sometimes we'll miss you know where that is um leaking in so it is important to kind of check our margins on our Restorations to see like how smooth or how rough they are because that can sometimes give us an indication of it if that area is susceptible to recurrent carries so arrested arrested is stopped right so curious lesion that has become stationary and doesn't really show any progression so frequently this um has a hard surface and it does take on like a brownish color um and then we have rampant carries so rampant carries is really that sudden spreading of carries and it usually does involve early pulp involvement in which 10 or more lesions occur each year on a two surface that's usually not typically affected so the three types include Early Childhood you find rampant carries adolescent rampant carries and then rampant carries in those patients who have xerostomia so xerostomia is dry mouth um so the restoration Restorations of this are pretty challenging due to the nature of the decay in how widespread it is through the mouth all right so now let's look at Early Childhood caries so this is the formation of carries found in very young children the causes are typically um we see this a lot in the use of that nursing bottle um with milk or sweetened but um beverages when the child is going to sleep or maybe prolonged at will breastfeeding um there are usually high levels of streptococcus mutans that are present um that is the the really predominant Decay causing bacteria so that's definitely a type of bacteria that you want to think of when you think of um the Decay process that strep mutans um but in these Early Childhood carries patients sometimes we will see lactobacilli in Canada um also involved in the progression of Early Childhood carries so clinical parents what's it going to look like um demineralization areas might be noted along that cervical area of the maxillary teeth looking like white spot and as it progresses that can actually start to turn a brown color and it can spread to the maxillary and the mandibular molars but typically first we're seeing it in those anteriority right along that gum line so now we're going to kind of shift our Focus to root carries root carries is a soft Progressive lesion of the cementum and Dentin that involves bacterial infection and Invasion so you can see here in the picture it's not always going to be this black color but this makes it kind of easy to identify right when we see it down here on that root surface that root carries so usually we see this more commonly in patients at an advanced age but really this doesn't occur because of age it usually occurs because there's gingival recession present okay because that has to be present so that means there could be some kind of periodontal involvement going on with our patients and um a lot of times we see it in our patients that are on many different types of medications causing um dry mouth xerostomia so our patients have xerostomia they have exposed root surfaces those root surfaces don't have enamel on them to protect them and so they are very um very susceptible to the Decay process so steps in the formation of a root um carries is gingival recession is exposed exposing that it's a mental surface the dental care starts near that cej where the cementuminum will start together the cementum is very thin and it's soon destroyed and the Dentin is then invaded um clinical recognition how are you going to find it lesions and root peries are described as soft kind of leathery and sometimes that they've been there for a little while sometimes they will start to harden those lesions will harden so this is just kind of another like illustration of root carries you see here very early and then you know obviously more Progressive but you see it kind of starting at that cej next thing we're going to talk about is occlusion so we looked really hard at teeth and now we want to look at how teeth fit together which is occlusion so um when we look at occlusion we look at the normal occlusion we look at the facial profile we look at the North the molar relation and we look at canine relation so here we can see like that facial profile um so mesonathic that we have them fitting together in that normal occlusion that we call it and then we have retronetic where we have that maxillary that is protruding over the mandible and then that prognathic we're having that mandible that is protruding over the maxilla so the classification of occlusion and malocclusion so we do classify occlusion and we do classify malocclusion so we're going to look at that you're going to talk pretty extensively about this also in Dental Anatomy so I definitely um would you know pay attention and hopefully this you know the combination of this information from both classes will help you to better understand this so we classify occlusion as to class one two and three okay and we're going to focus really on adults right now we look at open bite overjet under jet we look at Cross bytes edge to edge bytes and to end bytes we look at overbytes and then we classify those as normal moderate or severe so let's just kind of look at all of that so here we go so this is this is how we're looking at occlusion and classifying occlusion all right so our normal occlusion or our ideal occlusion um we typically will call that um we could call that normal idea occlusion but we also call that class one occlusion okay so that is where the the molar relationship is the same as normal with malpositioning or individual teeth or groups of teeth so we typically don't just say normal okay we either say class one two or three okay with occlusion we don't typically get into the different um divisions so normal occlusion is going to be where the molar relationship so we're going to look at the molars first okay it's going to be our go-to is those first permanent molars and we're going to look at the mesiobuckle cusp of the max layer first premolar okay so this is the mesial buccal cusp and it occludes with the buccal Groove of the mandibular first permanent molar okay so this cusp fits into the buccal group of the mandibular so if you see in this perfect this ideal or this class one occlusion we are seeing that it it um the mandibular um first molar is sitting just a bit in front of that maxillary first molar all right so then we're going to go down to our class two okay so our our class 2 is going to be a little different our class 2 is going to be when looking at the molar relation the buccal group of the mandibular first Primal or first permanent molar is distal to the mesial buccal cusp of the maxillary first permanent molar by at least the width of a premolar so what we're seeing here if I look at this and compare it to this we're seeing a switch right instead of seeing the mandibular first molar just sitting a little in front of the maxillary for a smaller we're now seeing the opposite right and so this is going to be our class 2 and then as you look towards the interior you see that that clue Class 2 must be that pragmaphic right that when that um that um those anterior teeth sit up in front of so actually if we look back at this page we call it retro naphic okay because then our mandibular jaw is actually setting back okay so we're looking at when we look at the facial profiles we're really looking at that as um and we're basing those terms on our lower jaw all right so don't don't be confused by that all right so class two all right and this is the way we are having the molars um sit together all right so then we can look down here at our class three okay so our class three is going to be when the Buckle groove of the mandibular first permanent molar is mesial to the mesial buccal cusp of the maxillary first premolar by at least the width of a premolar so when I look at class three and I compare it to class one that ideal occlusion what I hope you're seeing is now instead of just being a little bit in front of okay we are seeing that mandibular molar almost completely in front of that maxillary molar causing a prognathic profile right of the mandibular jaw okay whereas this is called causing a retro automatic of the lower jaw okay all right so we will be classifying people's occlusion so when you go into the clinic and you get out those big giant blue books know that there is this picture that you can refer to as you look at the molars so we're always going to try to look at those first molars if the first molars if one of them is missing then we'll look at the canines and look at how rows actually fit together okay all right so now let's look at Cross bites so typically all right like in a we will see that um the mandibular teeth are lingual to the maxillary teeth okay so this is normal I would not call this a crossbite I would say this is the way the teeth are supposed to be aligned right but when I look at B okay I look at the mandibular teeth facial to the normal position so the mandibular teeth are out okay and then the maxillary teeth are sitting more lingual so now we have a posterior crossbite okay so it's crossing over where it should be and then in our picture C we are seeing that on one side we have a normal position okay where we have the maxillary sitting to the outside of the mandibular but then we look at um the other side we are seeing just the opposite so we are seeing a cross bite just on one side so we will look at our teeth and see that the maps layer are coming to the outside of our mandibular and if they're not then we will need to identify is there a cross bite and if there is where is that all right then we can look at the interiors and if there is a cross bite okay so in this picture here you are seeing a crossbite okay so even in the anterior we will have the maxillary right sitting on the outside of the mandibular so when we have that opposite positioning we have a cross bites okay we have an anterior crossbite then another deviation of occlusion is edge to edge bite so instead of having one on the outside and one on the inside we have the two incisal edges coming together at the tips and because of that we call that an edge to edge bite and that is specific to the anterior teeth next we can look at end-to-end bite and that is when we have two posterior teeth that instead of the maxillary sitting to the outside of the mandibular teeth right we have them right on top of each other right right on top and we called it end to end bite another thing that we might see is when our patient bites their teeth together all of the teeth touch except for a certain area so in this picture we're looking at an anterior open bites okay so we don't have a crossbite we don't have an end to end we don't have an edge to edge right we have an open bite so I would say I have an anterior open bite so you might ask can I have a posterior open like and absolutely if we put the teeth together and there is an area where there is space okay between where the teeth should occlude and we would call that an anterior open bite now if teeth are missing that isn't that is not what we're talking about okay we're talking about when the teeth bite down whether there's teeth missing or not right is it open or is it um is it into the correct position all right so now let's look at over jet so this is definitely something that we assess in our Clinic okay so we assess when we bite the teeth together okay and the anterior teeth do come over the mandibular teeth how far out do they sit so hopefully by looking at the second picture you can see now here I would maybe get a millimeter right I would maybe get a millimeter they're not edge to edge because they're not tip to tip but maybe a millimeter but here if I was using a probe to measure and we had one millimeter two millimeters three millimeters four and five millimeters I would actually use this probe to measure okay so this big um line being five I would actually say that I have five millimeters of over Jets okay where the teeth come out from the mandibular teeth so this would be an under jet okay so an under jet is just the opposite so now we're seeing where the maxillary teeth are coming out over you could call this a cross bite as well or an under Jet and then we could measure the under jet how far this mandibular tooth is coming out from that maxillary tube so after we look at that relationship the relationship of over Jets we can look at over byte and we will look at over byte we are looking when the teeth come together how much of the mandibular teeth are being covered by the maxillary maxillary teeth okay and we typically will look towards the anterior and instead of taking a measurement with this we would say a would be normal okay so we're just covering that incisal incisal uh third of the tooth okay not quite to the middle in B all right we are covering more than half the two okay or half the two length and we would say that we have a moderate overrides in C we are seeing little to none of the mandibular tooth being exposed when they bite their teeth together and so in this case we would classify as a severe overbite all right so one other thing that we do look at is we look at the primary teeth now all of the concept that I just talked about um apply for both um primary mixed permanence okay the only thing that sets outside the box is the way we determine the classification of occlusion so the class one two and three so when we look at we look at primary teeth we can again look at um the molars or we can look at the canines okay just like we can with um permanent teeth um typically we'll go straight to the primary molars and both of those are if all four of those are present but if they're not then we'll look at the canines um a lot of the relationship is going to depend on if there are if there's primary primate space or not between the teeth so primate space is um you might have noticed when um deciduous teeth start or primary teeth start to erupt there's natural spaces in between each tooth right so sometimes that happens and sometimes you don't get that space okay so in this picture right here you're seeing a the mandibular primate space between the canine and the first molar and then you're seeing the maxillary primate space between the lateral incisor and the canine so sometimes that is present and sometimes you don't have that primate space but as far as classification of occlusion what we're really going to be looking at is we're going to be using some different terms than we do with our adults so we are going to use the term either mesial step flush terminal plane or we might say ends on end okay or end on or we might say distal step so we're looking at how those molars fit together again so a in this picture below really looks a lot like what we might think of as class one in adults okay so that's our mesial step so B is our flush terminal plane and on so I think with everything we've reviewed already you should understand that's just the molars kind of you know right on top of each other and then C right looks almost like what we would have said our class 2 looks like in adults right where we have an opposite effect that's the distal step all right so that is where we have that maxillary first primary molar sitting in front of that mandibular instead of the opposite with a right so that's just something to think about um obviously we're going to get into um classifying each other's occlusion in the clinic when we start doing our intraoral extra oral exams and and we are not going to be looking at pediatric molars because all of us don't have those anymore but there is going to be a time when you are going to have pediatric patients in your chair and you are going to have to look at this in a little different way so I just want you to kind of be aware of that and really um listen in um when you are in your anatomy class on how to classify all these different types of occlusion all right so this whole chapter is really about documentation because what are we doing during this is we are looking we are um you know visually clinically radiographically and we are documenting all of this so what are the things we want to document existing and missing teeth existing Restorations white spots and cavitated carious lesions non-carious lesions fractures occlusal habits and um will always you know ask questions about previous orthodontic treatments and have those in our patients notes so hopefully um this kind of cleared up or gave you some more information about chapter 16 in Wilkins and as always if you have questions concerns anything like that you can always reach out to me and let me know