2

Darby's Comprehensive Review of

Dental Hygiene

EIGHTH EDITION

Christine M. Blue, DHSc, MS, BSDH

Associate Professor and Director, Division of Dental Hygiene, School of
Dentistry, University of Minnesota, Minneapolis, Minnesota

3
4
Table of Contents

Instructions for online access

Cover image

Title page

Copyright

Contributors
Subject matter consultants (Chapter 18)

Preface
“Client” vs. “Patient”

Organization

Simulated national board dental hygiene examinations/electronic resources

Acknowledgments

Chapter 1: Preparing for National, Regional, and State Dental Hygiene

Board Examinations
Dental hygiene licensure

State boards of dentistry or dental hygiene and professional associations

Joint commission on national dental examinations

National board dental hygiene examination

Clinical testing

Examiner selection and training

5
 Examination administration

Clinical facilities

Examination instruments

Examination forms

Examiner selection and training

Client recruitment

Clinical examination formats

Examination results

Ethical and legal issues

Content and organization of this review book

Chapter 2: Histology and Embryology

General histology

Cell Replication

General embryology

Oral histology

Chapter 3: Anatomy and Physiology

Basic concepts

Cells

Tissues

Systems of the body and their components

Chapter 4: Head and Neck Anatomy and Physiology

Anatomic nomenclature

Osteology

Paranasal sinuses

The muscular system

6
 Temporomandibular joint

The circulatory system

The lymphatic system

Glands of the head and neck region

The nervous system

Chapter 5: Clinical Oral Structures, Dental Anatomy, and Root

Morphology
Clinical oral structures

Dental terminology

Dental anatomy

Eruption

Intra-arch and interarch relationships

Summary of tooth dimensions

Chapter 6: Oral and Maxillofacial Radiology

General considerations

Radiation biology and protection

Dental x-ray film

Film-processing errors

Quality assurance

Digital imaging

Radiology techniques: intraoral and extraoral

Radiographic errors: intraoral and extraoral

Film mounting

Radiographic interpretation

Chapter 7: General Pathology

7
 Inflammation1–3

Regeneration and wound healing1–3

Regenerative medicine4

Genetics2,5

Differential diagnosis6

Chapter 8: Oral Pathology

Benign lesions of soft tissue origin

Inflammatory tumors (Granulomas)

Benign intraosseous neoplasms

Gingival fibromatosis

Ulcerative diseases

Minor aphthous ulcers

Major aphthous ulcers

Skin diseases

White lesions

Neoplasia

Pleomorphic adenoma (benign mixed tumor)

Cysts

Developmental cysts

Odontogenic cysts

Blood disorders

Human immunodeficiency virus (HIV)

Fibrous dysplasia

Endocrine disorders

Abnormalities of teeth

Conditions of oral soft tissues

8
Chapter 9: Microbiology and Immunology
General microbiology

Microbiology of the oral cavity

Chapter 10: Infection Control and Prevention of Disease Transmission in

Oral Health Care
Disease transmission

Infection control procedures for dental health care personnel

Oral health care environment and promotion of infection control

Governmental agencies and infection control

Chapter 11: Pharmacology

General considerations

Autonomic nervous system agents

Local anesthetic reversal agent

General anesthetics

Sedative-hypnotic medications

Anti-infectives (antibiotics)

Cardiovascular agents

Antiarrhythmics

Psychotherapeutic agents

Endocrine agents

Respiratory system agents

Gastrointestinal agents

Antineoplastic agents

Substance abuse

Drug use during pregnancy

9
Chapter 12: Biochemistry, Nutrition, and Nutritional Counseling
Six major classes of essential nutrients

Specialized cells of oral tissues: effects of nutrients

Energy balances and weight control

Nutritional assessment and counseling

Chapter 13: Biomaterials

Introduction

Direct preventive and restorative materials

Indirect preventive and restorative materials

Chapter 14: Periodontics

Basic features of the periodontium

Diseases of the periodontium

Changes in the periodontium associated with disease

Bacterial dental biofilm1,3

Clinical assessment of the periodontium1,4

Systemic effects of periodontal disease1,3

Treatment1,3,6

Postoperative care

Dental implants

Chapter 15: Dental Hygiene Process of Care

Basic concepts

Health history evaluation

Extraoral and intraoral assessment

Assessment of dentition

10
 Periodontal assessment

Radiographic evaluation

Oral hygiene assessment

Risk factor assessments

Diagnosis

Prognosis

Evidence-based decision making22,23

Planning

Case presentation

Informed consent

Implementation

Client management with effective communication

Evaluation

Documentation

Ethical, legal, and safety issues

Chapter 15 review questions

Chapter 16: Strategies for Oral Health Promotion and Disease Prevention
and Control
Preventive care planning

Behavior change theory1

Dental plaque biofilm detection

Mechanical plaque biofilm control on facial, lingual, and occlusal tooth surfaces

Interdental plaque biofilm control

Dentifrices

Controlling oral malodor12

Oral irrigation

11
 Care of fixed and removable prostheses

Caries management

Mouthrinses or chemotherapeutics22,23

Dental sealants

Tobacco use interventions

Periodontal disease risk assessment29

Oral cancer risk assessment

Diagnostic tools for oral cancer detection

Assessment of dentinal hypersensitivity

Etiology

Pulpal vitality and testing devices

Ethical, legal, and safety issues

Chapter 17: Periodontal Instrumentation for Assessment and Care

Instrument design

Hand-activated instruments

Principles of instrumentation

Steps for calculus removal with hand-activated instruments

Instrumentation for assessment

Concepts in periodontal instrumentation

Sharpening of Hand-Activated Instruments

Ultrasonic and sonic instrumentation

Advanced instrumentation techniques

Selective stain removal

Ethical, legal, and safety issues

Chapter 18: Management of Pain and Anxiety

12
 Characteristics and physiology of pain

Local Anesthesia Armamentarium

Local anesthetic agents (Table 18-1)

Local anesthesia injections

Trigeminal nerve: maxillary nerve, second division (V2)

Trigeminal nerve: mandibular nerve, third division (V3)

Computer-controlled Local Anesthesia Delivery Device (CCLADD)

Local Anesthesia Complications

Conscious sedation with nitrous oxide–oxygen

Chapter 19: Dental Hygiene Care for Clients with Special Care Needs
General considerations

Specific conditions

Overall dental management considerations for special care clients

Chapter 20: Community Oral Health Planning and Practice

Basic concepts

Epidemiology

Epidemiology and research

Epidemiology of oral diseases and conditions

Measurement of diseases and conditions in oral epidemiology

Preventing and controlling oral diseases and conditions

Community intervention

Program evaluation

Provision of oral health care

Financing oral health care

Need for, demand for, and utilization of dental services

13
 Oral health care challenges affecting community oral health practice

Ethical and legal issues

Chapter 21: Medical Emergencies

General considerations1–3

Medical history1–3

Vital signs1–5,8

The emergency kit2

Emergency care1,2,4,6–8

Management of medical emergencies

Conclusion

Chapter 22: Ethical and Legal Issues

Ethical considerations

Professionalism

Ethical issues in public policy

Legal concepts

Civil law and the dental hygienist

Dental records and record keeping

Employer and employee rights and responsibilities

Risk management and avoiding litigation

Appendix A: Medical Terminology

Prefixes

Suffixes

Combining forms

Terminology frequently used to designate body parts or organs

14
Appendix B: Professional Organizations of Interest to Dental Hygienists

Appendix C: American Dental Hygienists Association and Canadian

Dental Hygienists Association Codes of Ethics
The american dental hygienists’ code of ethics

The canadian dental hygienists association code of ethics

Index

15
16
Copyright

3251 Riverport Lane

St. Louis, Missouri 63043

DARBY’S COMPREHENSIVE REVIEW OF DENTAL HYGIENE

978-0-323-31671-2

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Previous editions copyrighted 2012, 2006, 2002, 1998, 1994, 1991, 1986.

All rights reserved. No part of this publication may be reproduced or

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This book and the individual contributions contained in it are protected

under copyright by the Publisher (other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As
new research and experience broaden our understanding, changes in
research methods, professional practices, or medical treatment may
become necessary.

Practitioners and researchers must always rely on their own experience

and knowledge in evaluating and using any information, methods,
compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional
responsibility.

17
With respect to any drug or pharmaceutical products identified, readers
are advised to check the most current information provided (i) on
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administered, to verify the recommended dose or formula, the method
and duration of administration, and contraindications. It is the
responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages
and the best treatment for each individual patient, and to take all
appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors,
contributors, or editors, assume any liability for any injury and/or
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Library of Congress Cataloging-in-Publication Data

Mosby's comprehensive review of dental hygiene.

Darby's comprehensive review of dental hygiene/[edited by] Christine M.
Blue. – Eighth edition.
p. ; cm.
Comprehensive review of dental hygiene
Preceded by Mosby's comprehensive review of dental hygiene/[edited by]
Michele Leonardi Darby. 7th ed. c2012.
Includes bibliographical references and index.
ISBN 978-0-323-31671-2 (hardcover : alk. paper)
I. Blue, Christine M., editor. II. Title. III. Title: Comprehensive review of
dental hygiene.
[DNLM: 1. Dental Prophylaxis–Examination Questions. 2. Dental
Prophylaxis–Outlines. WU 18.2]
RK60.7
617.6′01–dc23
2015037283

Content Strategist: Kristin Wilhelm

Content Development Manager: Billie Sharp
Associate Content Development Specialist: Samantha Dalton
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Cindy Thoms
Design Direction: Ashley Miner

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Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

19
20
Contributors
Jeanne M. Anderson, BSDH, MPA Adjunct Professor, Division of
Dental Hygiene, University of Minnesota, Minneapolis, Minnesota

Brenda Armstrong, BSDH, MDH Assistant Professor, Dental Hygiene

Department, Dixie State University, St. George, Utah

Stephen C. Bayne, MS, PhD Professor and Chair, Cariology,

Restorative Sciences, and Endodontics, School of Dentistry, University of
Michigan, Ann Arbor, Michigan

Christine French Beatty, RDH, BS, MS, PhD Professor Emeritus,

Dental Hygiene, Texas Woman's University, Denton, Texas

Connie E. Beatty, RDH, MS Assistant Professor, Division of Dental

Hygiene, Department of Dental Medicine, University of New Mexico,
Albuquerque, New Mexico

Denise M. Bowen, RDH, MS Professor Emeritus, Department of

Dental Hygiene, Idaho State University, Pocatello, Idaho

Charlene B. Dickinson, RDH, BSDH, MS Assistant Clinical Professor,

Dental Hygiene, Texas Woman's University, Denton, Texas

Barbara Leatherman Dixon, RDH, BS, MEd Assistant Professor,

University of Utah School of Dentistry, Salt Lake City, Utah, Dental
Hygiene Board Examiner, WREB, CDCA

Jill S. Gehrig, RDH, MA Dean Emeritus, Division of Allied Health and

Public Service Education, Asheville-Buncombe Technical Community
College, Asheville, North Carolina

JoAnn R. Gurenlian, RDH, MS, PhD Professor and Graduate Program

Director, Dental Hygiene, Idaho State University, Pocatello, Idaho

Elena Bablenis Haveles, BS Pharmacy, PharmD, RPh Adjunct

Associate Professor of Pharmacology, School of Dental Hygiene, Old
Dominion University, Norfolk, Virginia

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Gwen L. Hlava, RDH, MS Professor and Chairman, Dental Hygiene,
University of Nebraska Medical Center, College of Dentistry, Lincoln,
Nebraska

Laura Jansen Howerton, RDH, MS Instructor, Dental Hygiene, Wake

Technical Community College, Acquisition Technologist, Carolina OMF
Imaging, Raleigh, North Carolina

Olga A.C. Ibsen, RDH, AAS, BS, MS

Adjunct Professor, Department of Oral and Maxillofacial Pathology,
Radiology, and Medicine, New York University College of Dentistry, New
York, New York
Adjunct Professor, Fones School of Dental Hygiene, University of
Bridgeport, Bridgeport, Connecticut

Kim T. Isringhausen, BSDH, MPH Associate Professor, Chair, Oral

Health Promotion and Community Outreach, Virginia Commonwealth
University, School of Dentistry, Richmond, Virginia

Todd N. Junge, RDH, BS Assistant Professor, Dental Hygiene,

University of Nebraska Medical Center, Lincoln, Nebraska

Leslie Koberna, RDH, BSDH, MPH/HSA, PhD Associate Clinical

Professor, Dental Hygiene Program, Texas Woman's University, Denton,
Texas

Lisa F. Harper Mallonee, BSDH, MPH, RD, LD Associate Professor,

Dental Hygiene, Baylor College of Dentistry, Texas A&M University,
Dallas, Texas

Laura Mueller-Joseph, EdD, RDH Associate Provost, Professor Dental

Hygiene, Farmingdale State College of New York, Farmingdale, New York

Darnyl M. Palmer, RDH, MS Clinical Instructor, Department of Dental

Hygiene, Georgia State University, Dunwoody, Georgia

John M. Powers, PhD

Clinical Professor of Oral Biomaterials, Restorative Dentistry and
Prosthodontics, University of Texas School of Dentistry at Houston,
Houston, Texas
Senior Vice President and Senior Editor, The Dental Advisor, Dental
Consultants, Inc., Ann Arbor, Michigan

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Maureen Dotzel Savner, MS, RDH Professor of Dental Hygiene,
Dental Health Department, Luzerne County Community College,
Mountain Top, Pennsylvania

Jessica Peek Scott, RDH, DHSc Department Chair of Allied Health

Sciences, Allied Health, Central Carolina Community College, Sanford,
North Carolina

M. Anjum Shah, BSDH, MS Assistant Professor and Chair of Dental

Hygiene Program Admissions, Oral Health Promotion and Community
Outreach, Dental Hygiene Program, Virginia Commonwealth University,
Richmond, Virginia

Rebecca A. Sroda, MS Dean, Health Sciences, South Florida State

College, Avon Park, Florida

Susan Lynn Tolle, BSDH, MS Professor, University Professor, School of

Dental Hygiene, Old Dominion University, Norfolk, Virginia

Pamela Zarkowski, JD, MPH, BSDH Provost and Vice President for
Academic Affairs, Professor in the Department of Patient Management,
School of Dentistry, University of Detroit Mercy, Detroit, Michigan

23
Subject matter consultants (Chapter 18)
Margaret J. Fehrenbach, RDH, MS Oral Biologist and Dental Hygienist,
Adjunct Instructor, Bachelor of Applied Science Degree, Dental Hygiene
Program, Seattle Central College, Educational Consultant and Dental
Science Writer, Seattle, Washington
Demetra Daskalos Logothetis, RDH, MS Professor Emeritus and
Professor and Graduate Program Director, Department of Dental
Medicine, School of Medicine, University of New Mexico, Albuquerque,
New Mexico

24
25
Preface
The transforming health care environment, new knowledge gained
through research, and the need for evidence-based education and
practice serve as the prime forces guiding the development of the eighth
edition of Darby’s Comprehensive Review of Dental Hygiene. Publishing a
book that comprehensively reviews the foundation for dental hygiene
competencies is a challenge. Demographic, societal, and educational
trends, issues surrounding access to care for all citizens, and new health
care delivery and finance systems require successful dental hygienists to
possess competence in the biological, social, behavioral, and dental
hygiene sciences and in general education. The book and the
accompanying Evolve website offer a complete learning package to:
• assist individuals in reviewing the theory, skills, and judgments
required on national, regional, and state dental hygiene board
examinations;
• prepare dental hygienists for reentry into professional dental hygiene
roles—clinician, educator, advocate, researcher, and
administrator/manager;
• provide educators with salient information used for course and
curriculum development and outcomes assessment.

26
“Client” vs. “Patient”
Throughout the book, “client” (instead of “patient”) is used
predominantly because the term is congruent with the profession’s
disease prevention, health promotion, and wellness focus. Most
important, the term “client” conveys dental hygiene’s partnership with
consumers and communities inclusive of individuals, families, and target
groups who are fast becoming the focus of community-based dental
hygiene practice. Both the American Dental Hygienists’ Association and
the Canadian Dental Hygienists’ Association have embraced the term
“client” in their policies and actions. When the client is debilitated by
disease or disability, the term “patient” is used.
A special effort was made to design testlets for the community oral
health content and case-based questions that include client health;
dental, pharmacologic, and cultural history; and dental charts,
radiographs, and photographs. Other multiple-choice test items mimic
the various types used on the actual National Board Dental Hygiene
Examination.

27
Organization
The eighth edition of Darby’s Comprehensive Review of Dental Hygiene is
divided into 22 independent, interrelated chapters. Chapter 1 provides
guidance and confidence-boosting recommendations for anyone
preparing for a board examination. Emphasis is on understanding board
examinations, test-taking strategies, and trends in standardized board
examinations. Chapters 2 to 22 cover subject areas found on the National
Board Dental Hygiene Examination and contain theoretical and applied
information in an outline format. End-of-chapter review questions, with
rationales on Evolve, explain why the correct answer is appropriate and
why each incorrect choice is wrong. The rationales for the correct and
incorrect answers provide an additional strategy for efficient board
preparation. This information enables the reviewer to assess both
decision making and judgment in integrating professional knowledge,
and facilitates mastery of each chapter ’s content, further increasing the
likelihood of success on examination day.
Internet links and a comprehensive index that enables users to locate
information quickly and easily are included. Illustrations and the
appendices minimize the need to search alternative sources; however,
reference lists and website resources are provided for those who desire
more in-depth study or enrichment.

28
Simulated national board dental hygiene
examinations/electronic resources
Resources for Students and Faculty
Providing four simulated National Board Dental Hygiene Examination—
style exams gives you and your students the practice opportunities
needed to ensure test-taking confidence and exam-day success. The
examinations are located on the Evolve companion site (see inside front
cover for access information), and students have the ability to take each
exam in practice and study modes. Practice mode displays the answer
and rationale after the student answers each question, whereas exam
mode mimics a realistic testing experience with timer functionality and
end-of-exam results and feedback. Questions are scrambled each time,
and students can take them as many times as they want. In addition,
faculty members who have adopted this text can enroll students into
their class to monitor progress, publish class syllabi and lecture notes,
and enable communication with and among students.

29
30
Acknowledgments
Christine Blue
Almost everyone can recall a special individual - a tough but caring
coach, a friend who went beyond the call of duty - someone who left an
imprint on us for the rest of our lives. For me, that individual is Michele
Darby. So first, I want to pay tribute to her, the creator of this work. I
would not have had the wonderful career in dental hygiene education if it
were not for Michele. As her graduate student, she taught me how to be a
teacher, a writer, and a researcher. She inspired me with her vision of
what the dental hygiene profession could become and we know now her
vision was way ahead of its time. Throughout my professional career,
Michele continued to be a wonderful mentor to me, always taking the
time to listen and help whenever I needed it. She so often encouraged me
to lead change, to take on challenges. And, when she could hear my
reluctance, she calmly said, “You can do it” and “make it better.” Michele
taught me to strive for excellence in all I do. I am both honored and
humbled to carry on as editor of this book for Michele.
I would like to express my sincere appreciation to those who helped
make this edition of Darby’s Comprehensive Review of Dental Hygiene a
reality. Detailed outlines, board questions, answers, and rationales were
developed by renowned experts identified in the table of contents.
Comments and suggestions from students, faculty, and returning dental
hygienists who have used the book are embodied in this edition. The
exemplary work of these contributors has made Darby’s Comprehensive
Review of Dental Hygiene a board-preparation experience that is second to
none.
My special thanks go to Kristin Wilhelm, Content Strategist; Billie
Sharp, Content Development Manager; Samantha Dalton, Associate
Content Development Specialist; and Cindy Thoms, Senior Project
Manager, who facilitated the many steps of the publication process at
Elsevier. Also acknowledged are the authors, corporations, and
publishers who granted permission to use quotes, concepts,
photographs, figures, and tables. Since the work of those who
contributed to the earlier editions remains central to this revision, I want
to gratefully acknowledge their efforts, particularly the work of Dr.
Eleanor Bushee and Linda E. DeVore, whose competence and good
humor as oral health professionals, teachers, administrators, colleagues,

31
and friends will forever be missed, and Marilyn Beck, Dr. Marcia Brand,
Kristin Calley, Patricia Regener Campbell, Karen Caspers, Marie A.
Collins, Patricia Damon-Johnson, Judith A. Davidson, Dr. Catherine C.
Davis, Mary-Catherine Dean, Susann Duncan, Diane M. Frazier,
Jacquelyn L. Fried, Barbara Heckman, Jan Shaner Greenlee, Charlotte
Hangorsky, Kara Hansen, Beverly Entwistle Isman, Dr. Donald E.
Isselhard, Sandra Kramer, Mary M. Lee, Shirley Kuhn, Kathy Macciocca,
Sally Mauriello, Susan Schwartz Miller, Cara Miyasaki, Dr. Marlene Moss-
Klyvert, Lynn Ray, Dr. Peggy Reep, Dr. Lindsay Rettie, Danielle Leigh
Ryan, Michelle Sensat, Dr. Lynn Utecht, Venkat Varkala, Nancy Webb, K.
Cy Whaley, and Susan Zimmer. Without the earlier contributions of these
talented people, the current edition of Darby’s Comprehensive Review of
Dental Hygiene would not be possible.
The eighth edition appropriately has a new title, that being Darby’s
Comprehensive Review of Dental Hygiene, and I dedicate this edition to
Michele—a person who made a lasting imprint on my life.

32
C HAPT E R 1

33
Preparing for National, Regional,
and State Dental Hygiene Board
Examinations
Barbara Leatherman Dixon

Preparing for board examinations requires deliberate planning, study

and review, time management, organization of information and
schedules, and a positive “can-do” attitude. Conscientious dental
hygienists will organize a plan for success well in advance and will be
prepared to satisfy board requirements with confidence in their
professional knowledge and skills. This book is a guide through the
evidence-based knowledge on which dental hygiene practice is based.
Systematic use of this book enables one to reinforce professional
education, integrate concepts and ideas from many dental hygiene
educators, and identify subject areas in which additional study is
warranted.
The introductory chapter is a primer in navigating the licensure system
—whether a new graduate, a practicing dental hygienist who is moving to
another licensing jurisdiction, or a dental hygienist returning to practice
after a lapse of activity—to prepare for both didactic and clinical board
examinations. A dental hygienist must master all subject matter and
skills necessary for practice; therefore, each subsequent chapter focuses
on different aspects of such knowledge and skills. Success on board
examinations also relies on being psychologically, emotionally, and
physically prepared to demonstrate competence. It is essential to become
thoroughly familiar with the format, logistics, and requirements of any
preparatory examination for licensure.
This chapter discusses the multi-faceted licensure structure and
explains the roles and interactions of the numerous organizations within
the system. Information on both the National Board Dental Hygiene
Examination (NBDHE) and clinical board examinations is provided. The
chapter concludes with an overview of this review book, including its
purpose and organization, as well as instructions on how to use the text
effectively.

34
Dental hygiene licensure
In the United States, licensure falls under the authority of an individual
state or jurisdiction. Licensure of dental hygienists is a means of
regulation to protect the public from unsafe practice of the profession
and unqualified individuals. Each state has a state practice act that defines
the practice of dental hygiene, establishes educational and testing
requirements for licensure, sets parameters for enforcement of the law
within that jurisdiction, and creates a state board of dentistry or dental
hygiene to serve in accordance with the statute. A certificate for
successful completion of an examination is not authorization to practice.
Beginning practice without a license is illegal. Dental hygiene licensure
requirements vary from state to state, but almost every state has the
following three requirements:
• Graduation from a dental hygiene program accredited by the
Commission on Dental Accreditation (CODA) or, based on reciprocity,
by the Commission on Dental Accreditation of Canada (CDAC)
• Successful completion of the NBDHE
• Successful completion of a regional or state clinical board examination
Recognition of an accrediting agency is a governmental function. In
health care fields with a domain of specialized education, accreditation is
conducted by a dedicated agency within the profession. In dentistry, the
U.S. Department of Education (USDE) has recognized the CODA of the
American Dental Association (ADA) as the official accrediting body for
schools of dentistry, dental hygiene, dental assisting, and dental
laboratory technology. The CODA is also listed in the publications of
accreditation agencies by the Council for Higher Education Accreditation
(CHEA). A diploma, certificate, associate’s degree, or baccalaureate
degree in dental hygiene indicating graduation from an accredited
program is an essential component for licensure that is based on the
accreditation system carried out under the auspices of the CODA. States
that provide for licensure of a dental hygienist from a non-accredited
school generally require evidence of an educational program approved by
the state board. The NBDHE is developed and administered by the Joint
Commission on National Dental Examinations (JCNDE). Client-based
clinical examinations are conducted by five regional testing agencies
(Boxes 1-1 and 1-2). Currently three regional testing agencies (CITA,
NERB, and SRTA) administer the American Board of Dental Examiners
(ADEX) dental hygiene licensure examination. ADEX is strictly a test
development corporation; it does not administer any examinations. The
licensure boards of California, Delaware, and the Virgin Islands of the

35
United States administer independent examinations. Clinical
examinations accepted for initial dental hygiene licensure are shown in
Figure 1-1.

Box 1-1
Membership in the Five Regional Testing
Agenc ies in the United States*
CITA
Alabama
Kentucky
Louisiana
North Carolina
West Virginia
Puerto Rico

CRDTS
Alabama
Colorado
Georgia
Hawaii (dental hygiene only)
Illinois
Iowa
Kansas
Minnesota
Missouri
Nebraska
New Mexico
North Dakota
South Carolina
South Dakota
Washington
West Virginia
Wisconsin
Wyoming

NERB
Connecticut
District of Columbia

36
Florida
Hawaii
Illinois
Indiana
Kentucky
Maine
Maryland
Massachusetts
Michigan
Mississippi
Missouri
Nevada
New Hampshire
New Jersey
New Mexico
New York
Ohio
Oregon
Pennsylvania
Rhode Island
Vermont
West Virginia
Wisconsin

SRTA
Arkansas
Kentucky
Mississippi
South Carolina
Tennessee
Virginia
West Virginia

WREB
Alaska
Arizona
California (dental only)
Hawaii (dental hygiene only)
Idaho
Illinois

37
Kansas
Kentucky
Missouri
Montana
Nevada
New Mexico
North Dakota
Oklahoma
Oregon
Texas
Utah
Washington
West Virginia
Wyoming

* CITA, Council of Interstate Testing Agencies; CRDTS, Central Regional Dental Testing
Service, Inc. NERB, Northeast Regional Board of Dental Examiners, Inc. SRTA,
Southern Regional Testing Agency, Inc. WREB, WREB: A National Dental and
Dental Hygiene Testing Agency.

Box 1-2
Regional Testing Agenc ies and Contac t
Information*
Central Regional Dental Testing Service, Inc. (CRDTS)
Central Regional Dental Testing Service, Inc.
1725 Gage Boulevard
Topeka, KS 66604-3333
Phone: 785-273-0380
Fax: 785-273-5015
www.crdts.org

Council of Interstate Testing Agencies (CITA)

1003 High House Road, Suite 101
Cary, NC 27513
Phone: 919-460-7750
Fax: 919-460-7715
www.citaexam.com

38
Northeast Regional Board of Dental Examiners, Inc.
(NERB)
Northeast Regional Board of Dental Examiners, Inc.
8484 Georgia Avenue, Suite 900
Silver Spring, MD 20910
Phone: 301-563-3300
Fax: 301-563-3307
www.nerb.org

Southern Regional Testing Agency, Inc. (SRTA)

Southern Regional Testing Agency, Inc.
4698 Honeygrove Road, Suite 2
Virginia Beach, VA 23455
Phone: 757-318-9082
Fax: 757-318-9085
www.srta.org

WREB: A National Dental and Dental Hygiene Testing

Agency
23460 North 19th Avenue, Suite 210
Phoenix, AZ 85027
Phone: 602-944-3315
Fax: 602-371-8131
www.wreb.org

* Current information about examination policies, procedures, criteria, locations,

dates, registration, and frequently asked questions can be accessed at the
respective agency’s website.

39
 FIG 1-1 Clinical examinations accepted for initial dental hygiene
licensure.

A license is applicable only within the geographic boundaries of the

issuing state. However, most states have provisions for granting dental
hygiene licensure by credentials or endorsement. Requirements
generally include an active license in good standing, recent practice
experience, graduation from an accredited program, successful
completion of the NBDHE, and successful completion of a clinical
examination. Specifics differ from state to state and are subject to
change. For example, some states only accept NBDHE results within the
last 5 years, or limit recognition of clinical board examination scores to
those from particular testing agencies.
Applicants for dental hygiene licensure must contact the individual
state licensing board for current requirements and information. The
American Association of Dental Boards (AADB) website
(http://www.dentalboards.org/states/index.htm) features a map of the
United States with direct links to state board offices. State board
websites are also readily accessible through an online search listing the
state and “dental/dental hygiene board.”

40
State boards of dentistry or dental
hygiene and professional associations
State boards of dentistry or dental hygiene are governmental agencies
that control and manage dental hygiene licensure in accordance with
laws adopted by the legislature of the states. Boards have the power or
influence to grant, deny, and revoke licenses. Board members are charged
with the following duties:
• Enforcing the state practice act and its rules and regulations
• Conducting or recognizing examinations for competence
• Reviewing and investigating complaints concerning unlawful or
unprofessional conduct by licensees
Significant variations exist from jurisdiction to jurisdiction in
regulatory board organizational structure, in scope of power and
authority, and even in title. For the purpose of clarity in this text, the term
state board or state board of dentistry is used to refer to the regulatory body
in a respective legal jurisdiction that is empowered to determine
prerequisites for licensure and issue licenses to practice dental hygiene.
Frequently, licensure candidates and even licensed practitioners
confuse the state board with the state professional association. Although
strong ties may exist between a state board and the state professional
association, distinct legal differences exist between these two bodies. The
state board of dentistry is a governmental agency, established by law,
which functions as an arm of the state legislature to regulate the practice
of dentistry and/or dental hygiene. Its sole purpose is to protect the
public from incompetent or unethical practitioners. In contrast, a state
dental hygiene or dental association is a voluntary organization of
practitioners, who join together to advance the profession and promote
the oral health of the public.
Practitioners need to understand both this distinction and the
interaction between state boards and professional associations.
Professional associations do not determine requirements for licensure or
regulate practice; this is founded by law and implemented through state
boards. Professional associations do, however, initiate programs and
research projects, and propose legislative changes that may ultimately be
incorporated into the legal requirements for practice. In most states,
state board members are appointed by the governor. Alabama, Nebraska,
North Carolina, Oklahoma, and the District of Columbia are the
exceptions, with designation through election by members of the
profession or through appointment by another governmental body.

41
Typically, professional associations nominate and influence these
appointments.
All states have some form of dental hygiene representation on the
board. Recent years have seen a trend toward self-regulation, with the
establishment of separate dental hygiene state boards and advisory
committees. Currently, 18 states have varying degrees of self-regulation
for dental hygienists (Arizona, California, Connecticut, Delaware,
Florida, Iowa, Maine, Maryland, Michigan, Missouri, Montana, Nevada,
New Hampshire, New Mexico, Oklahoma, Oregon, Texas, and
Washington). In Canada, over 99% of dental hygienists are self-regulated
(in all provinces except Prince Edward Island and the three territories).
The legislative and political arenas in dentistry are constantly
changing, as are technologic advancements in health. As a result,
revision to state practice acts—including the definitions of dental hygiene
and the scope of practice—is ongoing. Likewise, as the standards of
competence in dental hygiene are redefined in terms of requisite
professional skills and knowledge, examinations undergo continual
updating. Although this places demands on the individual practitioner,
the educational system, and the agencies responsible for evaluating
competence, it is the pathway for the advancement of professional
standards, increasing access to care and improving the oral health status
of populations. State practice acts charge the state board with conducting
or sanctioning both didactic and clinical examinations to determine
competence for entry into the profession. Some state laws even define
the examination content and specify a passing score. The majority of
practice acts authorize the state board to recognize multiple
examinations (see Figure 1-1). Although other agencies are part of the
licensure process, the fundamental authorization to recognize
qualifications for licensure lies with the individual state regulatory
board.

42
Joint commission on national dental
examinations
The JCNDE is the agency responsible for the development and
administration of the NBDHE. It includes a 15-member panel of
representatives, as follows:
• American Dental Association, ADA (3)
• American Dental Education Association, ADEA (3)
• American Association of Dental Boards, AADB (6)
• American Dental Hygienists Association, ADHA (1)
• Public Member (1)
• American Student Dental Association, ASDA (1)
A standing committee of the JCNDE, the Committee on Dental
Hygiene (CDH), consists of five dental hygienists (including the ADHA
Commissioner)—two educators and two practitioners and a dental
hygiene student representative appointed by the ADHA—plus one
Commissioner from the ADA, the ADEA, and the AADB. The CDH’s
responsibilities relate primarily to the NBDHE and include the following:
• Examination content and specifications
• Test construction procedures, including nomination of test constructors
• Information to publicize or explain the testing program
• Examination regulations that affect dental hygiene examinees
• Matters pertaining to finances, the ADA and the Joint Commission
Bylaws, and the Joint Commission Standing Rules that affect the
NBDHE
The Commission has final authority to act on committee
recommendations, but historically, the CDH has been the guiding force
of the dental hygiene examination program.

43
National board dental hygiene
examination
Examination Format
The NBDHE is designed to “assess the ability of an examinee to
understand important information from biomedical, dental, and dental
hygiene sciences, and to apply such information in a problem-solving
context.”1 The examination is computer based and includes
approximately 350 multiple-choice items in independent, case-based, and
testlet formats. The NBDHE is a comprehensive examination with two
components. Component A presents 200 discipline-based items in three
major areas, as follows:
• Scientific basis for dental hygiene practice
• Provision of clinical dental hygiene services
• Community health/research principles
Component B presents 150 case-based items, which relate to 12 to 15
dental hygiene patient cases. Case material includes dental and health
histories, dental charting, radiographs, and clinical photographs. Every
examination includes one or more of the following patient types:
geriatric, adult–periodontitis, pediatric, special needs, and medically
compromised. The case-based items address knowledge, skills, and
judgments necessary for the following:
• Assessing client characteristics
• Obtaining and interpreting radiographs
• Planning and managing dental hygiene care
• Performing periodontal procedures
• Using preventive agents
• Providing supportive treatment services
• Professional responsibility
The NBDHE tests the examinee’s ability to apply the essential
knowledge and skills as a beginning safe practitioner to solve oral health
care problems and answer questions related to dental hygiene care. The
examination is based on practice competencies underlying entry-level
dental hygiene practice as defined by the ADEA, the ADHA, the
Accreditation Standards published by the CODA, and other communities
of interest. As part of its validity analyses to verify that the examination
content supports these competencies, the JCNDE conducts a nationwide
practice survey every 5 years. For more information, read the NBDHE
Technical Report available on the ADA’s website,
http://www.ada.org/~/media/JCNDE/pdfs/nbdhe_technical_report.ashx.

44
The NBDHE Test Specifications document, accessible in the National Board
Dental Hygiene Examination Guide, is the blueprint for test development.
The outline lists the specific categories of subject matter included in the
examination, with an itemization of the number of items devoted to each
area. It should be referenced as a guide for study and review.
Examination items are written and selected by test construction
committees in accordance with the NBDHE Dental Hygiene Test
Specifications. The test construction committees are composed of
individuals who represent locations across the country and are selected
on the basis of their expertise in six areas: (1) basic sciences, (2) radiology,
(3) periodontics, (4) dental hygiene curriculum, (5) clinical dental
hygiene, and (6) community dental health. Test construction committees
author new examination items and develop new cases, revise and clone
test items, create multiple versions of the examination, and review
examination drafts before publishing. Committees strive toward higher
cognitive levels—understanding, application, and reasoning—in test
development.

Item Format
The multiple-choice items on the NBDHE consist of a stem, which poses
a problem, and a list of three to five possible responses. The stem is
usually either a question or an incomplete statement. Key words in the
stem such as best, most, first, not, except, or least are usually highlighted or
italicized. Only one response is correct or clearly the best choice by
universally accepted standards of care.
A variety of item formats are used in the NBDHE. Descriptions of
formats as well as sample items from the National Board Dental Hygiene
Examination Guide are provided next.

Completion
As indicated by the name, completion items necessitate the correct
completion of a theory or idea. For example:

The sensation of touch, pain, pressure, or temperature is determined by

the:
a. Specific nerve fiber stimulated
b. Method of stimulation of a nerve fiber
c. Degree of myelinization of a nerve fiber
d. Strength of the stimulation to a nerve fiber

45
e. Frequency of the stimulation to a nerve fiber

Question
A question item poses a problem or set of circumstances. Response
choices include only one best answer. For example:

Which of the following is innervated by the phrenic nerve?

a. Diaphragm
b. Abdominal muscles
c. Sternocleidomastoid muscle
d. Internal intercostal muscles
e. External intercostal muscles

Negative
A negative item is characterized with words such as except, least, or not in
the stem. These key words are emphasized by capitalization, italics, or
both. For example:

Each of the following is affected by saliva EXCEPT one. Which one is the
exception?
a. Swallowing
b. Dental caries
c. Oral microflora
d. Protein digestion
e. Carbohydrate breakdown

Paired True-False
In a paired–true-false item, the stem consists of two sentences on the
same topic. The examinee is asked to determine whether the statements
are true or false. For example:

Protection from excessive exposure to radiation is aided by use of

aluminum filters and a lead diaphragm. The filters reduce the amount of
soft radiation reaching the patient’s face, and the diaphragm controls the
area exposed.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE, the second is FALSE.

46
d. The first statement is FALSE, the second is TRUE.

Cause and Effect

In cause-and-effect items, the stem includes a statement and a reason
joined by the word “because.” This item requires judgment of both the
accuracy and the relationship between the two statements. First, the
examinee should determine whether each statement is correct or
incorrect and then how the statements are related. For example:

A traumatic injury can cause the pulp space to calcify because the
accident can trigger odontoclasts into accelerated activity.
a. Both the statement and the reason are correct and related.
b. Both the statement and the reason are correct but NOT related.
c. The statement is correct, but the reason is NOT.
d. The statement is NOT correct, but the reason is correct.
e. NEITHER the statement NOR the reason is correct.

Testlet
Testlet items are used for testing knowledge and application of
community health and research principles; they are also used in the case-
based section of the examination. A short scenario describing a situation,
event, or problem is followed by a set of associated multiple-choice
items. For example:

A dental hygienist employed at a public health clinic in a rural county of

the United States is assigned the project of developing a preventive
dental health program for a subgroup of the population.

Community Profile
The primary employers in this county have been coal-mining companies.
The unemployment rate in the county has increased by 32% since the
closing of the coal mines.
The median age of the population is 46 years. In the county, there are
five general dentists, three dental hygienists, and one public health–
centered dental clinic. The clinic employs a full-time dentist and dental
hygienist. The public health clinic sees low-income children and senior
citizens on a sliding-fee schedule.
The dental hygienist employed by the public health clinic conducts
dental screenings for the kindergarten (K) students each year. The mean

47
deft (decayed, extracted, filled teeth) scores for the K students for the
last 3 years are d = 1.02, e = 0.87, and f = 4.22.
The community does not have water fluoridation because of multiple
water sources. The state funds a 0.2% sodium fluoride rinse program in
grades K through 5. The state mandates that a dentist or a dental
hygienist perform deft/dmft (decayed, missing, filled teeth)/DMFT and
Gingival Index (GI) scoring on all students in grades 1, 2, 3, 5, 7, and 10.
On a yearly basis, all pathology is brought to the parent’s attention and
referred to a dental professional.
1. Which population group is dentally underserved in this community?
a. Adult age
b. Geriatric age
c. Adolescent age
d. Early-childhood age
e. Elementary school age
2. What would be the next step for the dental hygienist to take in
program planning after selecting the target population?
a. Appraise the program.
b. Define goals for the program.
c. Compile data on the target group population.
d. Develop educational components.
e. Identify manpower resources in the community.
3. Each of the following is perceived as a barrier to dental care for this
community EXCEPT one. Which one is the exception?
a. Geographic isolation
b. Lack of water fluoridation
c. Maldistribution of providers
d. Lack of affordable services
e. Loss of income and insurance
4. What can be stated about the deft scores of the kindergarten students?
a. Early exfoliation
b. High decay rate
c. Increased referrals
d. Late eruption pattern
e. Treatment needs are being met.
5. How often should the fluoride rinse for grades K through 5 be
performed?
a. Daily
b. Weekly
c. Monthly
d. Three times a week

48
 e. Based on the caries rate of the child

Case Based
The case-based portion of the examination presents 12 to 15 dental
hygiene patient cases, including social, medical, and dental histories; a
chief complaint; dental and periodontal charting; radiographs; and
clinical photographs. Items based on observations and judgments about
the client’s clinical conditions and needs follow. These items may be
presented in any of the test formats previously described.
Examples of cases and other items are provided in the NBDHE
samples at the end of this book and on the Evolve website. Sample
Examination Items can also be accessed from the ADA/JCNDE website.

National Board Dental Hygiene Examination

Eligibility and Application
Eligibility for the NBDHE requires qualification through one of the
following stipulations:
• A student in an accredited dental hygiene program is eligible when
certified by the program director to be prepared for the examination.
• A graduate of an accredited dental hygiene program is eligible
following the JCNDE’s receipt of evidence of graduation.
• A graduate of a non-accredited program is eligible only if the program
is deemed equivalent to an accredited program by an independent
auditing agency (e.g., length of study, curriculum content, hours of
clinical instruction).
• A dental student from an accredited dental school is eligible if the dean
of that school certifies that the student has completed the equivalent of
a dental hygiene program.
• A dentist is eligible if the National Board Dental Examination (NBDE)
eligibility requirements have been met.
Applications must be submitted electronically to the Joint
Commission. The steps involved in the application process include the
following:
• Read the NBDHE Guide before applying
• Obtain a Dental Personal Identifier Number (DENTPIN) from the
ADA. The DENTPIN is a unique number to identify students and
examinees for secure reporting, transmission of test scores, and
tracking of academic data in the educational system of the United
States.

49
• Apply for the examination. Confirm and agree to the rules and
regulations. Include requests for score reporting to state boards where
seeking licensure. If applicable, submit appropriate documentation of
a disability to support an appeal for testing accommodation. Also,
indicate whether the NBDHE was previously taken.
• After processing the application, the Joint Commission will send
notification of eligibility.
• Schedule an appointment to take the examination at a Pearson VUE
Testing Center. The computer-delivered NBDHE is scheduled and
administered on an individual basis year-round.

Examination Day
Candidates for the NBDHE must present two original, current forms of
identification (ID) to the testing center, as follows.
• One government-issued ID with a photograph and signature
• One secondary ID with a signature
No personal items (e.g., cell phones, study materials, backpacks or
purses, watches, “good luck charms,” food or water bottles) are allowed
in the secure testing area. The testing schedule begins with an optional
15-minute tutorial. Three and a half hours are allowed for the first
session, Component A (200 discipline-based items), and 4 hours are
allowed for the second session, Component B (150 client case-based
items). An optional 1-hour break is scheduled between the sessions.
Examinees may provide feedback in a 15-minute post-examination survey
on completion of the examination and will receive a Notice of Completion
before leaving the testing center.

Examination Results
The examinee’s total score is calculated by the number of correct answers
selected. On the NBDHE, there is no penalty for selecting an incorrect
response. The total score is converted to a scale score, ranging from 49 to
99, which adjusts for any minor differences in difficulty across NBDHE
forms. A score of 75 represents the minimum passing score. The NBDHE
is “criterion referenced,” that is, the minimum passing score is
determined by experts through standard setting activities to ensure that
scores accurately and fairly reflect the entry-level practitioner ’s ability to
solve oral health care problems and to answer items relating to dental
hygiene practice on the examination. Detailed specifics on the scoring
system are outlined in the Technical Report on the Joint Commission’s

50
website. All examination results are audited for decision accuracy of the
pass/fail point before being reported.
Results on the NBDHE are reported as pass/fail only. The status of
“pass” is reported if a standard score of 75 or higher is achieved. The
status of “fail” is reported if a standard score below 75 is achieved. For
remediation purposes, examinees who fail receive numerical scores for
each of the major subject areas covered on the test. Official results are
available approximately 3 weeks after the examination. The examinee
receives an individual score report, and by virtue of signing the NBDHE
application, express permission is granted to give the dental hygiene
program director a score report as well. Reports are sent directly to state
licensing boards specified on the examinee’s application.
Examinees who have passed the NBDHE may not retake the
examination unless required by a state board or regulatory jurisdiction.
An unsuccessful examinee may reapply after 90 days from the date of the
previous examination attempt. After three failures, the examinee must
wait 12 months before reapplying. Examination attempts on or after
January 1, 2012, are restricted by the JCNDE’s 5 Years/5 Attempts
Eligibility Rule, which mandates examinees must pass the examination
within 5 years of their first attempt or five examination attempts,
whichever comes first.

Ethical and Legal Issues

The Joint Commission maintains a program to identify any irregularities
or cheating on the examination. As professionals, applicants for the
NBDHE are obliged to uphold ethical standards of behavior. All
examinees are expected to pass the examination on individual merit,
without assistance or prior knowledge of examination items. The
National Board’s Rules of Conduct are regulations that prohibit retaining
or sharing test items so that no examinee has an unfair advantage.
Maintaining the confidentiality of the examination protects the integrity
of the examination process and ensures valid outcomes in determining
satisfactory achievement to practice safely and responsibly. Violating the
Confidentiality Agreement by distributing or seeking unreleased
examination items is a legal infraction with stiff penalties, including
voiding of examination results and civil liability or criminal penalties or
both. In some cases, misconduct is reported to school or licensing
authorities. Unethical conduct carries the risk of delay, denial, or loss of
licensure. When the Joint Commission discovers, or is informed, that a
breach of examination regulations has occurred, the examinee’s results

51
are withheld or invalidated. In some cases, the examinee must wait up to
2 years to be considered eligible for retesting.
In addition to unauthorized access, or the written or oral distribution
of confidential exam content, other irregularities include the following:
• Falsifying information on the application
• Attempting to take the examination for someone else
• Bringing prohibited items (e.g., pens, cell phones, candy/gum,
medicines, religious items) to the test center or the testing area
• Creating a disturbance of any kind
• Taking unscheduled breaks during the examination
Study the rules of conduct in the NBDHE Guide, and follow all
regulations.
The JCNDE’s systematic security control procedures to identify and
investigate irregularities preserve the examination’s legitimacy.

Preparing for the National Board Dental Hygiene

Examination
Studying for a comprehensive, high-stakes licensure examination is
intensive and unique from studying for other tests. The following are
suggested steps in preparing for the NBDHE:
1. Organize a study plan 4 to 6 months in advance to allow an orderly,
progressive review without undue pressure.
2. Obtain the NBDHE Guide and application materials provided by the
JCNDE. Study the information thoroughly to gain a clear understanding
of the examination’s format, design, and administration. View the online
tutorial for the NBDHE at http://www.pearsonvue.com/nbdhe/.
3. Obtain a copy of the most recently released NBDHE items from the
Joint Commission. Released examinations, protected by copyright and
available for a fee, are valuable as examples. However, retired
examinations may contain out-of-date subject material and should not be
relied on as the sole study activity. Simulated board examinations, such
as the ones in this text and on the Evolve website, may also prove
beneficial during review.
4. Outline areas of weakness. Be guided by school experience, as
indicated by grades or difficulty in certain subjects and by the items from
the released or simulated examinations missed or marked as
questionable. Dental hygienists who have been out of school or practice
for some period should focus on basic science material and any
developments in dental technology or procedures that have expanded or
changed evidence-based practice since graduation.

52
5. Gather a personal resource library for reference throughout the review
process. Properly used, this book should be the mainstay study guide;
directions for its use are included at the end of this chapter. This book is
designed to direct a comprehensive review of dental hygiene, provide
questions to assess mastery of the subject material, and offer
documentation for correct and incorrect responses. This review book may
be supplemented with textbooks, class notes, pertinent journal articles,
and websites for further study in focused areas. Ensure all textbooks and
reference materials are current resources. The JCNDE does not approve
or recommend any particular texts or review courses. Programs or
conferences that profess to be “National Board Review Courses” are not
affiliated in any way with the JCNDE.
6. If considering a study club, recruit three to five colleagues whose study
habits, personal style, and self-discipline complement group efforts for
collaboration. Otherwise, study alone.
7. If a study group is formed, do not rely exclusively on someone else for
your preparation for the examination. Organize a schedule and
procedures for operation. Content areas can be assigned to individuals
for specific study and research, and then members of the group can pool
information and notes. Discussion of items or content areas can
contribute to the review process.
8. Create an orderly system to guide the review, and establish target dates
to complete each area. Set deadlines for the review of each chapter in this
book. Alternatively, organize review around the NBDHE test
specifications. Another option is to assess and prioritize perceived needs.
The point is to plan a system of review with goals and deadlines to
monitor progress.
9. Launch, and then stay with the plan. If progress slows, assess the
obstacles and make modifications to continue comprehensive review.
Aim to complete study at least 3 to 5 days before the examination date.
10. Take positive steps to manage examination anxiety (Box 1-3).

Box 1-3
Tips for Managing Examination Anxiety
• Be well prepared. Nothing boosts confidence like good advance
preparation.
• Study over several weeks. Do not rely on last-minute cramming.
• Maintain a positive attitude when preparing for the examination.
• Get physical exercise prior to the test day—it will help reduce stress.
• Eat nutritious foods, and get plenty of rest in the days leading up to the

53
 examination.
• Avoid negative thoughts and messages. Anxiety is contagious.
• Plan a relaxing activity the evening before the examination.
On the day of the examination:
• Allow plenty of time for traffic, parking challenges, and bad weather.
• Dress comfortably, and layer clothing in case the room temperature is
too hot or too cold.
• Bring the admission card and proper identification to the examination
site.
• Leave study materials and cell phones at home or outside the
examination center.
• Stay relaxed. If nervous, take a few deep breaths, and keep focused.
• Read the directions slowly and carefully. Follow all instructions.

Fundamental Guidelines for Taking Multiple-Choice

Tests
A system for reading and responding to test items facilitates
performance. Some general strategies for dealing with multiple-choice
examination items follow:
A. Read the stem of the item carefully and completely before looking at
the responses.
1. Determine what the item is asking; identify key words; and try to
formulate the answer before looking at the responses.
2. Consider each response carefully, and determine whether the
response is appropriate and complete.
3. Immediately eliminate responses that are obviously incorrect;
attempt to narrow the choices to no more than two.
4. For combination items, consider only those choices confidently
known to be correct.
5. When the choices have been narrowed as much as possible and the
correct answer is still not clear, make an educated guess.
B. Exercise caution in selecting any response that contains words such as
always, never, none, all, or every. Unconditional responses are frequently
incorrect.
C. Look for the answer that best applies to the conditions presented in the
item.
1. Avoid selecting responses based on isolated rules, are applicable
only to certain locales or regions, or refer to procedures and
techniques not universally accepted.
2. If the item asks for an immediate action, such as the first thing one

54
 would do, all the options may be correct. The best answer would be
based on identified priorities and conditions stipulated in the item.
D. The approach to case-based items encompasses a slightly different
strategy.
1. Case-based items require time to read and assimilate pertinent
information; good time management is of critical importance. Before
beginning a case-based section, estimate a reasonable amount of
time that can be dedicated to each case and still complete the entire
examination (divide the total time allowed by the number of cases in
the section). If a case requires extra time, confidently answer as
many items as possible, then flag remaining items and return to
them when the other cases have been finished.
2. When beginning a case, review all of the case material—client
history; health, dental, and pharmacologic histories; chief complaint;
clinical charts; radiographs; and photographs. Make a mental note of
significant findings, and begin formulating a concept of specific
problems or concerns about the case before attempting to answer
the test items. Answering items before reviewing all the case material
will result in overlooking important aspects of the case and
subsequent incorrect responses.
3. A well-constructed case requires referencing the case material to
make clinical decisions and respond to the items. Before marking a
response, consider what information is essential to answer an item
correctly and where that information is documented in the case. For
example, an item on an artifact in a radiograph may require looking
only at a specific radiograph to determine the nature of the artifact.
In contrast, an item on clinical attachment loss may necessitate
review of periodontal probing depths, radiographs, and perhaps
clinical photographs or client history. Items asking for disease
classification or appropriate care plans are more likely to require
consideration of all available information before responding.
E. Watch for grammatical clues. A well-edited item will offer responses
that are grammatically consistent with the stem. If the item indicates a
plural response, all the options should be in plural form. Any response
that is incompatible with the flow of the question may be an indication of
an incorrect response.
F. Take heed of the words not, least, and except in the item’s stem. Read the
stem carefully.
G. Carefully review questions that include “all of the above” or “none of
the above.” These responses impose broadly inclusive and exclusive
conditions.

55
H. Avoid becoming upset over challenging items. Negativity and
obsessing over a past difficult item affect the ability to concentrate on the
current item. Also, remember, on any given test, up to 10% of the items
are “seeded” or pretest items that will not count toward the final score.

Future Trends in the National Board Testing Program

In its mission to develop and conduct reliable, state-of-the-art
examinations that assist regulatory boards in making valid decisions
regarding licensure of dental hygienists and dentists, the JCNDE
periodically incorporates modifications to its policies for the fair and
secure administration of its examinations. Website and software updates
enable the electronic release of secured score reports to examinees,
dental hygiene schools, and state boards. In addition to an expanded and
more robust item bank, as well as ongoing forensic analyses to audit
quality control and monitor trends in examinee performance, actions to
enhance examination security and reduce stress on the item pool are
continually under investigation.

56
Clinical testing
The emphasis of the examinations conducted by regional and state
boards is on evaluating entry-level clinical competence. The methodology
for assessing clinical ability involves hands-on clinical treatment of
clients. In addition, some testing agencies include a computer-delivered
clinical simulation component. Testing agencies are obliged to adhere to
published psychometric guidelines such as those from the AADB, the
American Psychological Association (APA), the National Council on
Measurement in Education (NCME), the American Educational Research
Association (AERA), and others in the development and administration
of their examinations. Committees of examiners and educators
collaborate to determine the appropriate criteria, standards, and
technical aspects of clinical testing. Examination content and format are
similar among regional and state board examinations. An examinee’s
performance on the examination is reported to any of the regulatory state
boards accepting that particular examination (see Figure 1-1 and Box 1-1.)
Every state has a practice act, which delineates all provisions for
licensure, including the authority for approval of performance on an
examination as meeting its requirements for licensure to practice. A
license must be obtained before beginning practice.
Regional examining boards are corporate agencies composed of
individual dental and dental hygiene state boards. Regional agencies
have no authority over state boards and cannot implement policy that
supersedes the statutory powers of its member state boards. The state
board makes the determination to accept the results of the regional
board as satisfaction of its requirements for licensure. A regional agency
consists of states that have opted to standardize clinical testing
requirements and pool resources to develop and administer reliable
clinical examinations. Regional examinations are developed with the
consensus of the member states (see Boxes 1-1 and 1-2).
The membership of regional testing agencies fluctuates as states join
or withdraw. Many states belong to more than one regional board,
whereas other states belong to a single regional board but accept the
examination results of one or more of the others (see Box 1-1 and Figure
1-1). The five existing regional testing agencies are similar in their
organization and structure. Each maintains an office and employs staff
separate from any of its member state board headquarters (see Box 1-2).
A board of directors, steering committee, or general membership is
responsible for determining agency policies and managing finances. A
second key organizational element is an examination review committee

57
or panel. Each member of a state board is represented in this group,
which may include a dental hygiene program director or faculty member
representing the region’s educational institutions. The examination
review committee oversees analysis, development, and administration.
At present, two regional testing agencies, NERB and SRTA, administer
the ADEX dental hygiene examination; CITA administers the ADEX
dental examination only. As an organization whose exclusive purpose is
examination development, ADEX formulates examination content, scoring,
and criteria for the testing agencies that elect to administer it. Member
state boards participate in ADEX examination development and
approval. A list of member state boards, information on governance, and
an overview of the dental and dental hygiene examinations are available
on the ADEX website, www.adex.org. However, specific inquiries about
the ADEX examination are directed to the administering testing
agencies.
For jurisdictions conducting an independent examination, the state
board is the testing agency.

58
Examiner selection and training
Typically, state board member dental hygienists and dentists serve as
examiners. The pool of examiners for regional testing agencies comes
primarily from its member state boards. Most state boards also have the
authority to designate additional examiners; these appointed examiners
are licensed practitioners who meet the testing agency’s defined
requirements. The number of examiners assigned to an examination is
based on the examination agency’s administrative protocols. Testing
dates and sites are scheduled in advance by the examining agency.
Training programs for examiners vary but typically emphasize
standardization and grading exercises to calibrate examiners in the
evaluation of examination criteria. Examiners do not use their personal
criteria to assess examinee performance. Most testing agencies have
some type of examiner performance review system to monitor scoring and
ensure compliance with the agency’s standards. The objective is to
achieve an accurate and uniform assessment of clinical competence.

59
Examination administration
Most clinical board examinations are administered anonymously or in a
double-blind manner. Examinees are identified only by a number and are
kept segregated from examiners. Clients are brought to the examiners’
clinics; examinees are not present when the examiners conduct their
evaluations. The purpose of this practice is to eliminate any potential for
examiner bias based on an examinee’s personality, race, gender, religion,
or personal background. Evaluations are focused solely on clinical
performance. Curious examinees might be tempted to seek information
from their clients for perceived outcomes about the grading assessments.
Examiners typically are prohibited from sharing any information on
scoring, so making assumptions based on the reports of clients, who
generally understand little about the examination process, will only lead
to misinformation and erroneous conclusions.

60
Clinical facilities
Testing agencies use school clinical facilities to administer board
examinations. Schools release their facilities for the days of the
examination. Accommodating examination requirements entails
scheduling adjustments, loss of clinic income, and increased demands on
faculty and staff. Most schools charge a “school use fee” for services and
supplies. This cost is added to the examination fee.
If testing will take place in an unfamiliar facility, visit the site before
the testing date, if possible. Most testing agencies schedule an
orientation session and clinic tour before the day of examination. The
clinical facility is not under the management and control of the board
examiners, and the school may have its own institutional requirements,
or record keeping, for which the examinee is responsible. After an
examination application has been processed, most testing agencies will
mail examination-related documents as well as an information package
from the school that includes a description of the clinic facilities, a list of
provided supplies, emergency and infection control protocols,
compatibility of handpieces, instrument rental policies, and so on.
Equipment rental is handled through the testing site. Many schools have
maintenance personnel on call during the examination to handle school
equipment breakdown.
Concerns must be directed to the appropriate source. The testing site,
or school, deals with questions about the facilities; the testing agency
addresses questions about the examination itself; and the state board
attends to jurisprudence and licensure applications.

61
Examination instruments
Because examiners are calibrated with select instruments, testing
agencies are likely to require specific instruments for the examination.
Although such requirements may present some inconvenience, they are
vital to help ensure standardization in the examination process. Typically,
instrument requirements pertain only to the examining instruments (e.g.,
mirror, explorer, periodontal probe). Handpiece and instrument selection
for performing treatment are left to the examinee’s discretion. Most
clinical examinations allow the use of power scaling devices.
If the required instruments are unfamiliar, obtain them and practice
with them in advance. Reference the instrument’s task analysis, seek
guidance in correct adaptation and usage, or do both.
Instruments should be in excellent condition and sharp. Examiners
may request replacements if instruments are incorrect or defective. Have
extra sets of sterile instruments in case a client is not accepted or an
instrument is dropped.

62
Examination forms
Forms are an important consideration in charting, record keeping, and
documentation required for the examination. Numerous systems for
charting and for taking client histories exist. Obtain examination forms
(or facsimiles) in advance, and study them carefully. Practice using them.
If forms are not available prior to the examination, take the time to read
and review them at the examination site to understand how to use the
forms before beginning any charting procedures. When charting
procedures are part of the examination, their function is to measure an
examinee’s ability to recognize and record oral conditions; copying from
previous notes is considered an exam violation and may be grounds for
dismissal. Familiarity with examination forms will help avoid confusion
and facilitate recording of data on clinical judgments in the appropriate
places. Follow exactly instructions on how and when to complete the
forms.

63
Examiner selection and training
Classification of Oral Conditions of Clients
The selection of a board client is the single most important factor in
preparing for and successfully completing a clinical examination. Testing
agencies detail specific oral conditions as criteria for client acceptability,
including the number of teeth and surfaces that must have subgingival
calculus, and acceptable ranges of sulcular probing depths. Most
examinations require a client with “moderate” to “heavy” subgingival
calculus deposits. Clients exhibiting only plaque biofilm or supragingival
deposits are probably inadequate to present a valid test of the examinee’s
skills. A client with grossly heavy calculus or severe periodontal disease
is likely too difficult for the purposes of a clinical examination.
Testing agencies develop and maintain highly defined and precise
criteria in an effort to equalize difficulty in the examination.

64
Client recruitment
Testing agencies do not provide clients. This responsibility belongs to the
examinee. Some schools assist their students in client recruitment and
may allow examinees who are not students to screen clients before a
board examination. Ultimately, however, it is the responsibility of the
examinee to present an appropriate client. Examiners make the final decision
regarding acceptability. Dental hygiene educators and other licensed
practitioners are not calibrated to testing agency standards. Client
selection is integral to the examination; it is part of the test. Success or
failure on the examination often hinges on submitting a client who meets
the criteria—this crucial decision must not be delegated to an instructor
or other licensed dental professionals. It is risky to present a marginally
qualifying client or to design the treatment selection by prescaling in
hopes of an “easier ” examination. Having a client rejected results in
enormous stress on the examinee, grading penalties or failure of the
examination, the loss of treatment time, or all these consequences.
Historically, examinees have exhibited incredible resourcefulness in
recruiting clients. Family and friends are primary sources. The college
campus or one’s personal dentist or dental hygienist also serves as a
potential client source. Students and staff at hospitals are frequently
recruited. Many examinees have contacted local police and fire stations.
Sometimes, graduating classes organize a collective effort to recruit
clients, as well as backup clients, for the entire class. Examinees have
been known to advertise online or in local newspapers to obtain clients.
Some examinees have resorted to literally “beating the streets.” Stories of
bizarre and unprofessional methods of client recruitment are directly
proportional to the examinees’ desperation. Stress can be avoided by
beginning a search for clients well in advance of the examination.
Maintain professionalism in all contacts with potential clients. The
pressures of a high-stakes board examination do not supersede ethical
considerations. A client’s personal, oral, and systemic health needs
extend beyond the day of the examination and therefore must be given
due consideration. Most testing agencies require some type of
“continuing care” form to advise the client of additional treatment that
may be necessary but not provided during the examination.
Client selection is dictated by the testing agency’s defined criteria.
Criteria may stipulate requirements for age; systemic health status;
minimum number of teeth; combination of molars, premolars, and
incisors; calculus deposits; periodontal conditions; radiographs; and
more. The requirements also include informed consent from the client

65
for treatment, confidentiality, and adherence to universal precautions for
infection control. Carefully review all prerequisites before recruiting
clients.
In addition to published criteria, take into consideration the attitude
and cooperativeness of the client. Ascertain the client’s pain threshold
and tolerance to treatment procedures. Advise the client of the time
commitment. Clinical examinations usually require long treatment
sessions, waiting periods, and evaluation and instrumentation by
multiple examiners. If clients are not adequately prepared for the
demands of the examination, difficult situations can develop. Refusing to
cooperate, threatening to leave, and actually leaving the examination are
potential scenarios that must be circumvented. Advise the client of the
purposes of the examination, its importance to your future career, the
treatment that will be provided, the examiners’ role, the examination
schedule, and delays that may arise. When clients understand the
purpose and format of the board examination, most are supportive of the
profession’s efforts to ensure the competence of practitioners and are
appreciative of the dental hygiene care to be received.
Finding the “perfect” client who satisfies all criteria is challenging. It is
prudent to recruit more than one client for backup purposes. Inform
these clients that they may not be needed for the examination, but if
willing, they may be able to sit for another examinee. Stay in contact with
any clients who have been recruited. Confirm the time and date,
transportation or parking arrangements, and exact meeting locations.

66
Clinical examination formats
Clinical examinations provide a reliable third-party assessment of
examinees’ client-focused skills and judgments. Each testing program
has distinct examination protocols, procedures, requirements, and forms.
Examinees preparing to take a clinical examination must contact the testing
agency responsible for administering the examination to obtain its test
specifications (see Box 1-2). This chapter provides only a general
overview.
Four basic categories of clinical competencies are typically included in
regional and state clinical examinations: (1) appropriate client and
treatment selection, (2) calculus detection and removal, (3) oral and head
and neck assessment, and (4) tissue management. Components within
these areas may include dental and periodontal charting, extraoral and
intraoral examination, charting the location of subgingival deposits, and
removal of extrinsic stain, plaque, and supragingival calculus. Root
debridement and removal of subgingival calculus are universal
requirements. As previously noted, specific requirements for case
difficulty vary among examinations. All regional examinations mandate a
treatment submission of a minimum of six teeth; some require the teeth
to be in one quadrant but allow for a limited number of additional teeth.
Client acceptability criteria also include a specific number of “qualifying”
subgingival deposits. Typically, the number of anterior teeth that may be
included in the treatment submission is limited, and a certain number of
posterior teeth in proximal contact must be included. Examiners evaluate
the treatment selection. If the client does not meet the criteria, at a
minimum, points are deducted; at a maximum, client rejection results in
failure of the examination.
Some examination requirements, although potentially affecting the
examination outcome, are not actually scored. Acceptable client age and
health criteria are prime examples of “nongraded” requirements.
Acceptable probing depths are another such requirement. Diagnostic-
quality radiographs must be submitted with the client, although the
radiographs may not be a graded feature. Some agencies require a full-
mouth series or panograph x-ray film (exposed within 3 years), and
bitewing radiographs (exposed within 1 year). Others require only
periapicals and bitewings (within 1 year) of the teeth in the treatment
submission. Radiographs of “nondiagnostic quality” will result in point
deductions, negative impact on client acceptance and the ability to
continue the examination, or both.
Allotted clinic time is another variable factor. Most board examinations

67
place specific time limits for the completion of assignments. If an
examinee has one or more treatment selections rejected, it is likely that a
point deduction, loss of treatment time, failure of the examination, or all
these consequences will be incurred.
Pain management for the client is addressed by various means. Most
testing agencies permit administration of local anesthetic agents by the
examinee in compliance with the host school’s state practice act. Testing
agency protocols range from confirmation of formal education in
administration of local anesthesia to successful completion of an
examination on local anesthesia delivery. Some agencies also have
provisions for “qualified” licensed practitioners to administer the local
anesthesia. Generally, clients must be accepted for treatment prior to
administering anesthetics. Verify the authorization for the delivery of
local anesthetics with the testing agency and the regulatory board before
the examination.
In addition to client-based testing in the clinic, some regional testing
agencies utilize assessment on simulated patient cases at computer
testing centers or at school testing sites. The knowledge, skills, and
judgments necessary to provide competent entry-level dental hygiene
care are evaluated in a standardized examination. Both the physical
client-based section and the simulation section must be passed for
successful completion of the examination.

68
Examination results
No uniform scoring system for regional or state board clinical
examinations exists. Scoring is linked to the content and design of each
examination. In general, clinical board examinations use a system of
“weighting” to emphasize the importance or recognize the complexity of
certain skills sets and treatment procedures. For example, dental hygiene
practice surveys show that competency in scaling and root planing is
more critical than competency in stain removal. Consequently, in
examination development, when both components are measured, scaling
and root planing are weighted with more point value than is stain
removal. An examinee should strive to demonstrate competence in all
skills that are evaluated in an examination but may choose to concentrate
time and effort on each area in proportion to the weighted significance
built into the examination.
The testing agency must be contacted for all performance criteria and
the defined cutoff point separating acceptable performance from
unacceptable performance (see Box 1-2).

69
Ethical and legal issues
Because professional conduct and ethical behavior are central to the
practice of dental hygiene, all testing agencies have stipulations for
penalties, such as point deduction or immediate failure of the
examination for infractions. Examples of improper and/or unethical
conduct include, but are not limited to, the following:
• Violating standards as defined in the Examination Guide
• Evidence of dishonesty or misrepresentation during the application or
course of the examination
• Misappropriation or damage of equipment during the examination
• Treatment of teeth other than those approved or assigned by examiners
• Receiving assistance from another practitioner or using unauthorized
aids
• Altering examination records or radiographs
• Improper record keeping or failure to properly document anesthetic
use
• Breach of infection control standards
• Causing excessive tissue trauma
• Rude or abusive behavior
• Continuing to work after the established cutoff time
• Disregard for client welfare or comfort
• Use of cell phones, cameras, or electronic devices
Examinees found to have engaged in improper or unethical conduct
may be denied reexamination for 1 full year. Testing agencies reserve the
right to take other reasonable actions as deemed appropriate. Infractions
are reportable to all state licensing jurisdictions, the examinee’s school,
other testing agencies, and professional organizations. Examinees failed
for dishonesty may be permanently ineligible for licensure.

Preparing for Regional or State Clinical Board

Examinations
Contact the state board office to obtain a licensure application. Note all
requirements, including which board examinations are accepted and any
related conditions or restrictions. Consult the current state dental
practice act as well as the rules and regulations for this information.
Some jurisdictions require successful completion of local anesthesia,
nitrous oxide, and restorative examinations in addition to the dental
hygiene examination. Prepare a scheduled timeline for satisfying all
licensure requirements. List pertinent examination dates, as well as the

70
testing agency’s published time frame for releasing examination results.
1. Obtain the testing agency’s examination schedule, application forms,
Examination Guide, and any official information pertaining to the
examination. Most testing agencies have this information available
online. Read the information carefully at least twice. Do this several
months before the examination.
2. Review all the application material, and flag the desired examination’s
application deadline. Note examination requirements, including
eligibility and documentation that must be provided, client
requirements, instruments, and supplies.
3. Assemble the credentials necessary to sit for the examination. These
credentials may include school transcripts, the NBDHE score, a copy of
the diploma, current cardiopulmonary resuscitation (CPR) certification,
evidence of malpractice or liability insurance, and a passport-quality
photograph. Retain copies of everything.
4. Check the testing agency’s website for Frequently Asked Questions. This
section can provide insights and coping strategies to enhance confident
preparation.
5. Begin searching for eligible clients. Present prospective clients with a
clear and professional explanation of the client’s role as well as your own
in the examination.
6. For examinees still in school, many dental hygiene programs conduct
“mock boards” as a trial practice run. Additional clinical experience with
clients whose difficulty level is commensurate with board requirements
is likely to be helpful as well.
7. Practicing dental hygienists can set up clinical simulations of board
requirements using the examination’s specified oral conditions and time
constraints to evaluate clinical skills through critical self-assessment.
8. For dental hygienists who have been out of practice, most dental and
dental hygiene schools offer continuing education programs. Review
courses need to be investigated and pursued well before the examination
date.
9. Obtain the required examination instruments, and practice using
them.
10. Obtain examination forms before the test, and become familiar with
them. If unavailable, study the Forms section of the Examination Guide.
11. Be observant of the tooth-numbering system used in the examination
—it must be applied accurately. Noncompliance can result in charting
errors or incorrectly identifying which teeth are assigned by examiners.
12. A few days before the examination, prepare your clinic attire, and
organize instruments and supplies. Confirm arrangements with the

71
client(s) regarding time, date, location, and relevant directions. Check in
with the client again the night before the examination.
13. If taking the examination at an unfamiliar testing site, tour the
clinical facilities before the examination.
14. Plan to arrive at the testing site on time, taking into consideration
traffic and parking difficulties as well as the time required for locating
the operatory, setting up, and orienting to the clinic. Avoid starting the
day feeling rushed and distracted.
15. At the examination, listen closely to instructions, and read thoroughly
all materials provided. Failure to read and follow instructions is a
common denominator in problems experienced by examinees.
16. Relax, and concentrate on the high-quality dental hygiene care that
you are able to provide because of your professional education and
experience. Test-coping mechanisms are provided in Box 1-3 and on the
websites presented in the Website Information and Resources table at
the end of this chapter.

Future Trends in Clinical Examinations and

Licensure
In response to a growing demand for greater portability of credentials in
dental hygiene and dentistry, most states long ago implemented
licensure by credentials for active practitioners. Increasingly, many states
now not only accept results of multiple clinical examinations for initial
licensure (see Figure 1-1), but also are members of multiple testing
agencies (see Box 1-1). An outcome of this overlap is increased
competition for the market share among the testing agencies. In states
where more than one examination is accepted for initial licensure,
schools have a choice of which examination to host. Regional agencies
have amped up public relations efforts and communications with state
boards, educators, and students, touting candidate-friendly measures,
sensitivity to escalating examination fees, and modifications to exam
content and scoring, to gain a strategic advantage. This competition may
result in enhancements to the examination process and, with the cross-
pollination of examiners, who examine for multiple agencies, could result
in an exchange of best practices and more standardized exam
procedures.
Debate continues on the appropriateness of the use of humans in
clinical examinations. As the National Council on Radiation Protection
and Measurement (NCRP) Report #145 states, “Administrative use of
radiation to provide information not related to the health of the patient

72
shall not be permitted.” A cohort of educators, students, and some state
boards advocate discontinuation of the use of humans, citing both ethical
and practical reasons. Some examination agencies have incorporated
computer-delivered “simulation exercises,” in addition to client-based
testing, for the evaluation of clinical skills. It is generally agreed that a
dental hygiene examination constructed, directed, and administered by
dental hygienists, based on current and relevant scientific evidence, both
benefits the dental hygiene community and provides protection of the
public.
Most testing agencies utilize electronic scoring systems to augment
efficiency in compiling and releasing examination scores, thus facilitating
obtaining licensure in a timely manner. Software tracking of statistical
data on examiner scoring and validation can be used to improve
examiner training. Some testing agencies are reluctant to publish
information on examiner calibration and therefore guard this
information.

International Requirements
In our global culture, interest in working outside the United States is
increasingly appealing. International licensure requirements vary
significantly. A dental hygienist contemplating employment in another
country should contact the ADHA, the ADA, and the International
Federation of Dental Hygienists (IFDH) for pertinent information and
potential connections. The IFDH has compiled a database with detailed
requirements for working as a dental hygienist in the following 28
countries:
• Australia
• Austria
• Canada
• Czech Republic
• Denmark
• Fiji
• Finland
• Germany
• Ireland
• Israel
• Italy
• Japan
• Korea
• Latvia

73
 • Malta
• Nepal
• Netherlands
• New Zealand
• Norway
• Portugal
• Russia
• Slovakia
• South Africa
• Spain
• Sweden
• Switzerland
• United Kingdom
• United States
The information is available by clicking the “Working Abroad” tab and
then the county of choice on the IFDH website
(http://www.ifdh.org/work_abroad.html). In addition to these countries,
other nations known to have formal dental hygiene education programs
and dental hygiene practice include the following:
• Bahrain
• Hong Kong
• Jamaica
• Jordan
• Kuwait
• Lithuania
• New South Wales
• Nicaragua
• Nigeria
• Puerto Rico
• Queensland
• Saudi Arabia
Individual resources or personal contacts within the country of
destination should also be pursued.
As a starting point, collect documentation of all credentials, including
passports or visas, school transcripts, diplomas, licenses, board
examination scores, and employment history. Some countries require
language proficiency before certification is granted; others require an
employment contract before issuing a work permit. Most countries require
proof of graduation from an accredited school and successful completion
of cognitive and clinical or case-based board examinations; other
counties request merely “reporting to employer.”2

74
 Special citation is warranted of the National Dental Hygiene
Certification Board of Canada (NDHCB), which was established in 1994
in response to a priority concern of Canadian dental hygienists for
portability of licensure. The NDHCB examination consists of 200
multiple-choice items designed to assess the requisite knowledge and
skills for entry into practice. It is accepted for licensure by all provinces,
except Quebec. Clinical practice evaluations are conducted by Canadian
dental hygiene regulatory authorities only for graduates of nonaccredited
dental hygiene programs.
The NDHCB delivers its examinations in both English and French,
three times annually (January, May, and September) at computerized
writing centers in numerous cities throughout Canada. Examination
information can be obtained directly from the NDHCB using the
following contact information:
National Dental Hygiene Certification Board
1929 Russell Road, Suite 322
Ottawa, Ontario K1G 4G3
Canada
Phone: 613-260-8156
Fax: 613-260-8511
General inquiries: [email protected]; http://www.ndhcb.ca/en/about.php
The rigors of a country’s requirements appear to be strongly correlated
with the number of dental hygienists in the country, how long dental
hygiene has been established, and the size and strength of its
educational system.

75
Content and organization of this review
book
This book presents a review, in outline form, of basic, dental, dental
hygiene, and clinical sciences. Each review outline is followed by related
questions that test the reader ’s knowledge of concepts, principles, and
theories underlying the practice of dental hygiene.
Each chapter contains a section on Evolve entitled “Answers and
Rationales,” which provides justification for the correct answer and every
response in the review questions covering the subject matter. The
rationale supporting the correct answer and explanations for incorrect
responses are specified. By reviewing these rationales, the reader will be
able to confirm facts and reinforce knowledge. An example is provided
below.

Website Information and Resourc es

Source Website Address

76
Source Website Address
State http://ub-counseling.buffalo.edu/stresstestanxiety.shtml
University of
New York at
Buffalo

University of http://www.uic.edu/depts/ace/strategies.shtml
Illinois at
Chicago,
Academic
Center for
Excellence

Dartmouth http://www.dartmouth.edu/~acskills/success/stress.html

Massachusetts http://web.mit.edu/uaap/learning/test/anxiety.html

Institute of
Technology

University of http://www.lsa.umich.edu/advising/academicsupport/strategiesforsuccess/preppingfortests/overcomingt
Michigan

77
References
1 American Dental Association. National board dental hygiene
examination guide. Chicago: American Dental Association,
Commission on National Board Dental Examinations; 2014.
2 Johnson P.M. International profiles of dental hygiene 2007: a 21-
nation comparison. Int Dent J. 2009;59(2):63–77.

Chapter 1 review question

How to Use This Book in Studying

A. Review one section of the content at a time. Study the material
outlined in the section. Refer to other textbooks, websites, and
references to research additional details if any area is unclear.
B. After reviewing the content, answer the review questions that
immediately follow. As each question is answered, write a few words
about why that response is correct; justify the response selected. If
your response is a guess, make a special mark to identify it as such.
This will enable ready identification of areas that need further review
and clarification. Remember to analyze a question, narrow the choices,
and select the correct or best answer.
C. Score yourself using the answers provided on the Evolve website. If
the item was answered correctly, compare the reason noted for
selecting that answer with the listed rationales. For each item
answered incorrectly, review the correct answer and its rationale. Go
back to the chapter pertaining to that subject, and research
information in your reference material. Carefully review all the
questions and rationales for the items identified as guesses to ensure
mastery of the material.
D. After an interval of several days or weeks, review the chapters and
answer the questions again. If the same items are missed, further
study of that content material is necessary.

Completion of the Review Process

Board examinations can be attempted with confidence and success after
completing the comprehensive review presented in this book; assessing
areas of strength and weaknesses with the aid of the chapter review
questions; reinforcing concentrated study of particular material

78
pinpointed by the review; becoming familiar with the board examination
process, protocol, and purpose; and following instructions for
preparation. Preparation for board examinations actually begins with the
accredited dental hygiene program’s first class and continues throughout
the educational process. This book is designed to present a cohesive,
comprehensive review of that professional educational base, to reinforce
existing knowledge, and to provide guidance for areas requiring more
concentrated study.

1. An isolated radiopaque area in the periodontal ligament space is

observed on a client’s radiographs. This radiopaque structure is most
likely a/an:
a. Denticle
b. Cementicle
c. Epithelial rest
d. Cementum spur
e. Exostosis of alveolar bone
Answers and Rationales to Chapter Review Questions are available on
this text’s accompanying Evolve site. See inside front cover for details.

79
C HAPT E R 2

80
Histology and Embryology
Maureen Dotzel Savner

During the process of care, a dental hygienist must distinguish normal

structures, variants of normal structures, and developmental
abnormalities from pathology. A clear sense of developmental processes
and tissue histology provides the background for competent assessment
and evaluation.
Knowledge of tissue components and embryologic tissue origin
supports an understanding of the physiologic changes that take place
during the course of disease progression. This knowledge also provides
insight into how tissue is capable of responding to a pathologic
condition. This chapter contains basic general histologic information,
with a focus on oral tissue components and oral and facial development.
A clinician uses this knowledge to formulate a dental hygiene care plan,
evaluate the outcomes of treatment, and make appropriate referrals to
dentists and physicians when necessary.

81
General histology
Cells
A. Smallest structures and functionally self-contained units in the body;
they vary in size, shape, and surface, depending on functional
specialization (Figure 2-1)

FIG 2-1 Typical cell. (From Chiego DJ: Essentials of oral histology and emb ryology: a
clinical approach, ed 4, St Louis, 2013, Mosby.)

B. Cells possess similar common physiologic properties that permit:

1. Excitability
a. Change in the environment stimulates the cell to bring about a
response to adapt to a change
b. Example—nerve cells conduct impulses
2. Synthesis
a. Cells must have the ability to form substances that produce

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 products to aid in the body’s function
b. Example—glands synthesize and secrete products to aid bodily
functions
3. Membrane transport
a. Fluids, chemical elements, and compounds must have the
ability to move both in and out of cells
b. Example—nutrients are transported across the epithelial lining
of the gastrointestinal tract
4. Reproduction
a. Cells must have the ability to preserve the species by giving rise
to offspring
b. Example—union of a sperm and ovum can lead to the formation
of an offspring
C. The building blocks of tissues in the body are attached to each other
and to noncellular surfaces by cell junctions; the structures of various
types of cell junctions depend on location and function; the types of
junctions are:
1. Desmosomes—cell-to-cell attachments; this type of attachment is
found between ameloblasts (enamel-forming cells) and cells of the
stratified squamous epithelium that lines the oral cavity
2. Tight junctions—cells attach to each other by fusion of their cell
membranes; adjacent odontoblasts (dentin-forming cells) form tight
junctions that prevent substances in the pulp from passing into the
dentin
3. Gap junctions—contain a channel that runs between cells for
communication of cell electrical impulses and passage of molecules;
this type of junction is present among some odontoblasts, allowing
them to coordinate their activity
4. Hemidesmosome—the attachment of a cell to a noncellular surface;
the basal layer cells of stratified squamous epithelium attach to the
basement membrane by hemidesmosomes; this attachment
mechanism is present in the epithelial attachment to the tooth; the
epithelial attachment refers to the basal lamina and
hemidesmosomes that connect the junctional epithelium of the soft
tissue to the tooth surface
D. Cells are surrounded by a cell membrane that separates them from
the extracellular environment; cell membrane encloses all components of
the cell:
1. Cytoplasm
2. Organelles
3. Inclusions

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 4. Nucleus

Specialization
A. Differentiation
1. Cells that recognize one another will group together
2. Cancer cells do not recognize each other
B. Organization of chemicals
1. Chemicals appear early in the development of the embryo
2. Endocrine substances are produced by one type of cell and can affect
other types of cells
C. Cells → tissues → organs → organ systems

Cell Membrane
A. Referred to as plasma membrane or plasmalemma; usually too thin to
be seen with a light microscope; average width is approximately 7
nanometers (nm); considered selectively permeable because it controls
passage of materials into and out of the cell
1. It surrounds the cell and is semi-permeable, allowing some
substances to pass through it and others to be excluded
2. Its permeability may vary selectively by porous openings
3. Selective permeability characteristics
a. Protecting cell from external environment
b. Permitting entrance and exit of selected substrates
c. Using active transport, passive transport, or facilitated diffusion
4. Its composition is a 3:2 ratio of proteins to lipids; lipids and proteins
are the major components
5. Its structure is trilaminar, with a bipolar membrane and a central
core of lipids between two layers of protein
6. The 0.8-nm pores in the surface allow diffusion of small, lipid-
insoluble substances
B. Trilaminar structure composed of two facing layers of lipid molecules,
into which large globular proteins are inserted (Figure 2-2)

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 FIG 2-2 Fluid mosaic model. Schematic, three-dimensional view of the fluid
mosaic model of membrane structure. The lipid bilayer provides the basic
structure and serves as a relatively impermeable barrier to most water-soluble
molecules. (Modified from Patton KT, Thibodeau GA: Structure and function of the human
b ody, ed 15, St Louis, 2016, Elsevier.)

Cytoplasm
A. Translucent, aqueous, homogeneous gel enclosed in the cell by the cell
membrane; organelles and inclusions are suspended in the cytoplasmic
gel
B. All metabolic activities of the cell occur in the cytoplasm, including:
1. Assimilation (digestion)
2. Synthesis of substances such as proteins, proteoglycans, and
glycoproteins
3. A transport medium in which all nutrients and metabolites are
carried from one organelle to another
4. Presence of enzymes and electrolytes, in which specific metabolic
reactions take place (e.g., glycolysis)

Nucleus
A. Controls the two major functions of the cell
1. Chemical reactions—synthesizing activities; determines nutrient
needs
2. Stores genetic information of the cell
B. Genetic information stored in chromosomes for cell duplication;
chromosomal deoxyribonucleic acid (DNA); the human nucleus contains
46 chromosomes

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C. Chromosomes are visible only during cell division, when they become
long, coiled strands; at other times, chromosomal material is dispersed in
granular clumps of material called chromatin
D. Each nucleus contains one or more round, dense structures referred to
as the nucleolus (plural, nucleoli); these produce ribosomal ribonucleic
acid (RNA)—protein plus RNA; the nucleus also is surrounded by a
nuclear membrane and contains nuclear matrix with chromosomes

Synthesis Activities
A. Three types of RNA are necessary for protein synthesis:
1. Messenger RNA (mRNA)—copies of short segments of DNA, the
genetic code
a. mRNA can be compared with a tape that contains all the genetic
information of proteins, but it must pass through the ribosomes
attached to the endoplasmic reticulum (ER)
b. As the tape passes through the ribosomes, transfer RNA
(tRNA) adds the exact amino acid to the newly forming proteins
(Figure 2-3)

FIG 2-3 Ribosomes showing protein synthesis on rough

endoplasmic reticulum. Messenger RNA is being passed through
ribosomes on endoplasmic reticulum, where transfer RNA
becomes incorporated in protein (being formed) that is assembled
in the ribosome. (From Gartner LP, Hiatt JL: Color textb ook of histology, ed
3, St. Louis, 2007, Saunders.)

2. tRNA—carrier of specific amino acids (building blocks of proteins)

3. Ribosomal RNA (rRNA)—found floating freely in the cytoplasm
(polyribosomes) or attached to the ER
B. Protein synthesis also can occur on polyribosomes floating freely in
the cytoplasm; proteins synthesized on the free polyribosomes are used
in cellular metabolic processes; proteins synthesized on the ribosomes

86
attached to the ER are transported out of the cell

Inclusions
A. Transitory, nonliving metabolic byproducts found in the cytoplasm of
the cell
B. May appear as lipid droplets, carbohydrate accumulations (e.g.,
mucopolysaccharides), or engulfed foreign substances

Lysosomes
A. Membrane-bound organelles responsible for the breakdown of
foreign substances that are engulfed by the cell by the process of
phagocytosis or pinocytosis
B. Produced by a budding process from the Golgi complex, lysosomes
form spherical vesicles containing powerful degradative or hydrolytic
enzymes; enzymes are first produced by the ER and then transported to
the Golgi complex
C. During phagocytosis, lysosomes fuse with engulfed substances to
form a secondary vesicle; the vesicle with digestive materials may remain
in the cell as a residual body or may be discharged outside of the cell
D. Vitamins A and E and zinc are important stabilizers for the lysosome’s
membrane

Golgi Complex
A. The structure consists of stacks of closely spaced membranous sacs, in
which newly formed proteins are concentrated and prepared for export
out of the cell (Figure 2-4)

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 FIG 2-4Golgi complex. A, Schematic representation of the Golgi complex
showing a stack of flattened sacs, or cisternae, and numerous small
membranous bubbles, or secretory vesicles. B, Transmission electron
micrograph showing the Golgi complex highlighted with color. (From Patton KT:
Anatomy and physiology, ed 9, St Louis, 2016, Elsevier.)

1. Small membrane-bound vesicles pinch off from the Golgi complex

and form secretory granules (newly formed proteins)
2. Secretory granules attach to the inside of the cell membrane and are
then discharged outside of the cell
B. Responsible for secreting to the external environment a variety of
proteins synthesized on the ER
C. Major site of membrane formation and recycling
D. Storage site for newly synthesized proteins
E. Site for packaging and transporting many cell products (e.g.,
polysaccharides, proteins, lipids)
F. Synthesis site for lysosomes

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G. Also involved in the production of large carbohydrate molecules and
lysosomes

Mitochondria
A. Membranous structure bounded by inner and outer cell membranes;
the membranes contain enzyme complexes in a particular array (e.g.,
tricarboxylic acid cycle enzymes)
1. The inner part is formed into folds (cristae) that extend, like shelves,
inside the mitochondria to provide an additional work surface area
for the organelle
2. More than one mitochondrion is usually present in a cell; the
number depends on the amount of energy required by the cell
B. This structure provides the chief source of energy for the cell
(“powerhouse of the cell” by oxidation of nutrients) through enzymatic
breakdown of fats, amino acids, and carbohydrates; transforms the
chemical energy bond of nutrients into the high-energy phosphate bonds
of adenosine triphosphate (ATP)
C. A single cell may contain 50 to 2500 mitochondria, depending on the
cell’s energy needs (Figure 2-5)

FIG 2-5 Mitochondrion. A, Cutaway sketch showing outer and inner

membranes. Note the many folds (cristae) of the inner membrane. B,
Transmission electron micrograph of a mitochondrion. Although some
mitochondria have the capsule shape shown here, many are round or oval.
(From Patton KT: Anatomy and physiology, ed 9, St Louis, 2016, Elsevier.)

Endoplasmic Reticulum
A. Extensive membranous system found throughout the cytoplasm of the
cell; composed of lipoprotein membranes existing in the form of

89
connecting tubules and broad, flattened sacs (cisternae); the outer
membrane may or may not be covered with ribosomes; the two types are:
1. Granular or rough-surfaced endoplasmic reticulum (RER)
a. Contains ribosomes that are attached to the cytoplasmic side of
the membrane
b. Site of protein synthesis
2. Agranular or smooth-surfaced endoplasmic reticulum (SER)
a. No ribosomes are present
b. Site of steroid synthesis
B. The membrane system functions to synthesize, circulate, and package
intracellular and extracellular materials
C. Proteins are synthesized on ribosomes attached to the ER and are
transported to the Golgi complex for packaging
D. The system contains enzymes involved in a variety of metabolic
activities (e.g., lipogenesis, glycogenesis)
E. SER has a number of diverse roles and is found in a variety of cell types

Filaments and Tubules

A. Thread-like structures approximately 7 to 10 nm thick; thicker
filaments are the same as those seen in muscle (protein myosin strands)
and have been associated with contractility in cells
B. Microfilaments act as a support system for the cell cytoskeleton
C. Bundles of microfilaments form tonofibrils and become part of the
attachment apparatus (desmosomes) between cells

Microtubules
A. Delicate tubes, 20 to 27 nm wide, found in cells that are undergoing
mitosis and alterations in cell shape (cell morphology)
B. Microtubules have an internal support function, particularly in long
cellular processes such as neurites or odontoblastic processes
C. Microtubules have the capacity to direct intracellular transport
through the cytoplasm

Centrioles
A. Cylindrical structures composed of microtubule-like components
B. Centrioles function in cell replication and the formation of cellular
extensions

90
Internal Environment and Homeostasis
A. Extracellular fluid
1. Fluid mass that circulates outside and between cells
2. Extracellular fluid composition must be regulated exactly:

B. Intracellular fluid
1. Fluid located inside the cells of the body
2. Intracellular fluid composition must be regulated exactly:

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C. Homeostasis—the delicate balance maintained between the two fluid
compositions

Transport through the Cell Membrane

A. Diffusion
1. Definition—continuous movement of molecules among one another
in liquids or gases
2. Molecules may move across a membrane
3. Direction of diffusion of a substance is from a region of high
concentration to a region of low concentration, which is the diffusion
gradient
4. If equal amounts of a substance are placed at either end of a
chamber such as a cell, they diffuse toward each other, and the net
rate of diffusion equals zero
B. Osmosis

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 1. Definition—process of net diffusion of water through a semi-
permeable membrane caused by a concentration difference
2. Osmotic pressure—pressure that develops in a solution as a result of
the net osmosis into that solution; pressure is affected by the
number of dissolved particles per unit volume of fluid
3. Isotonic solution—when placed on the outside of a cell, will not
cause osmosis (e.g., 0.9% sodium chloride)
4. Hypertonic solution—when placed on the outside of a cell, will cause
osmosis out of the cell (e.g., greater than 0.9% sodium chloride) and
lead to crenation (shrinking) of the cell
5. Hypotonic solution—when placed on the outside of a cell, will cause
osmosis into the cell (e.g., less than 0.9% sodium chloride) and lead
to cell lysis
C. Active transport
1. Process used by a cell when large quantities of a substance are
needed inside the cell and only a small amount of the substance is
present in the extracellular fluid
2. Involves pumping the substance against its concentration gradient
3. Uses a carrier system and energy (ATP)
4. Keeps sodium extra-cellularly (sodium pump) and potassium intra-
cellularly; important for the transmission of nerve impulses
5. Almost all monosaccharides are actively transported into the body
D. Phagocytosis—movement of a solid particle into the cell
1. Cell wall invaginates around the particle
2. Pinches off from the rest of the membrane and floats inward
E. Pinocytosis—movement of fluid into a cell; similar to phagocytosis,
except that the cell invaginates around fluid

93
Cell Replication
A. Mitosis—process of cell replication (Figure 2-6)

FIG 2-6 Phases of mitosis. (From Chiego DJ: Essentials of oral histology and
emb ryology: a clinical approach, ed 4, St Louis, 2013, Mosby.)

1. Interphase
a. The genetic material of each chromosome replicates
b. Chromosomes are dispersed as chromatin material in the
nucleus
2. Prophase
a. Chromosomes coil and contract; each chromosome consists of a
pair of strands called chromatids, which are held together by a
centromere
b. The nuclear envelope disappears
c. The centriole divides, and the two centrioles move to opposite
poles of the cell
d. Spindle fibers develop
3. Metaphase
a. Chromatids line up at the center
b. Spindle fibers attach at the centromere
c. The centromere replicates, allowing the separation of
chromatids
4. Anaphase
a. Spindle fibers pull the new chromosomes to opposite poles of
the cell
5. Telophase

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 a. A nuclear membrane forms around each set of chromosomes
b. Centrioles replicate in each cell

Concepts Relating to Dental Tissues

A. All calcified dental tissues are produced by secretory cells that require
a great amount of energy in producing their organic matrices, which
become calcified; organelles such as mitochondria play an important role
in providing energy
B. Mitochondria have been associated with the calcification
(mineralization) process that occurs in dental tissues
C. Cell organelles help maintain tissues after the initial formation by the
cell; fibroblasts (i.e., connective tissue cells that are present in all tooth
tissues except enamel) contain increased numbers of cell organelles;
these additional organelles aid fibroblasts in their synthesizing and
secretory functions

Basic Tissues
A. At the beginning of human development, individual cells multiply
and differentiate to perform specialized functions; groups of cells with
similar morphologic characteristics and functions come together and
form tissues
B. Tissue components
1. Cells
2. Intercellular substance—a product of living cells; a medium for the
passage of nutrients and waste within the tissue; the amount of
substance varies with different tissues
3. Tissue fluid—blood plasma that diffuses through capillary walls; the
fluid carries nutrients to the intercellular substance and waste
materials to capillaries
C. Tissues in the human body can be classified into four types:
1. Epithelial tissue
2. Connective tissue
3. Nerve tissue
4. Muscle tissue
D. Each of the four basic tissues may be further subdivided into several
variations

Epithelial Tissue
A. Main categories

95
 1. Surface epithelia
2. Glandular tissue
B. The epithelium consists exclusively of cells held together by
specialized cell junctions (minimal intercellular material is present
between cells); cells rest on an underlying connective tissue, the basement
membrane
C. Epithelial cells (keratinocytes) form continuous sheets (tissues) and
perform the following functions:
1. Protection—covering all outer surfaces of the body (e.g., skin)
2. Absorption—forming the lining of all inner surfaces of the body
(e.g., digestive tract)
3. Secretion—forming glands (glandular tissue)
D. Epithelial tissue varies, depending on function—it may have surface
specializations on its free surfaces
1. Microvilli—for absorption
2. Cilia—for surface transportation
E. Replicates through mitosis

Surface Epithelia
A. The epithelium is classified according to:
1. The shape of the most superficial cells
a. Squamous (flat)
b. Cuboidal (cubical)
c. Columnar (tall, narrow—cylindrical or prismatic)
2. Number of cell layers present
a. One cell layer—simple; found in areas of little or no friction
(e.g., lining of blood vessels)
b. Several cell layers—stratified; capable of withstanding more
functional use (e.g., mucous membranes)
B. Combined characteristics allow for six different types of epithelia
(Figure 2-7) and locations:

96
 FIG 2-7 Classification of epithelia according to morphologic shape and number
of cell layers. (From Patton KT: Anatomy and physiology, ed 9, St Louis, 2016, Elsevier.)

1. Simple squamous—found in the walls of vessels

2. Simple cuboidal—lines the ovaries
3. Simple columnar—lines the intestines and the cervix of the uterus
4. Stratified squamous—lines the oral cavity
5. Stratified cuboidal and
6. Stratified columnar—line the large ducts of the major salivary glands
C. Other, intermediate forms of epithelium
1. Pseudo-stratified columnar (e.g., trachea)—appears stratified but is,
in fact, only one layer
2. Transitional (e.g., urinary tract)—resembles both stratified
squamous and stratified cuboidal epithelia
D. Other cell types found in the epithelium
1. Melanocytes—produce melanin (pigmentation); intensity of brown
skin color is not caused by the difference in the number of
melanocytes present but by the difference in the rate of melanin
production, the size of pigment granules, and the length of time of
their preservation
2. Inflammatory cells—transient cells usually associated with
inflammation
3. Langerhans cells—antigen-presenting cells
4. Merkel cells—mechano-receptors
E. The epithelium lining the oral cavity (oral mucosa) and the skin

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(dermis) is an example of stratified squamous epithelium

Glandular Tissue
A. Most glands develop from the epithelium; the epithelial basal cell
grows downward into the underlying connective tissue
B. Types
1. Exocrine
a. Serous; mucous or seromucous secretions
b. Ducts carry secretions
(1) Simple—nonbranching duct
(2) Compound—branching duct
2. Endocrine
a. Hormone secretions directly into the bloodstream
b. The bloodstream carries secretions; no ducts

Connective Tissue
Connective Tissue Proper
A. All connective tissue proper develops from the embryonic
mesenchyme; contains large amounts and various types of intercellular
material and few cells; highly vascular; has two main functions:
1. Provides mechanical and biologic support (supports organs and
other structures)
2. Provides pathways for metabolic substances and thus aids in the
distribution of nutrients
B. Types of connective tissue
1. Bone—hard and calcified; serves supportive and protective functions
2. Cartilage—firm but flexible; serves a supportive function
3. Reticular—network of branching fibers; acts as a filter; loose and
elastic; provides a connection between structures
4. Bone marrow—site where blood cells are manufactured
5. Lymphoid tissue (tonsils and lymph nodes)
6. Fat or adipose (special type of connective tissue composed of fat
cells)—located under the skin; provides insulation
7. Dental tissues
a. Pulp
b. Dentin
c. Cementum
C. Types of connective tissues—differ in composition of cell products and
proportions of products present

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 1. Dense connective tissue—consists predominantly of heavy, tightly
packed collagen fibers; main function is to resist tension; this dense
collagenous connective tissue is present in the gingiva
2. Loose connective tissue—collagen and reticulin fibers extending in
all directions; the main function is to provide biologic support and
fill the spaces between organs and tissues

Connective Tissue Components

A. Cells
1. Types of cells normally present
a. Fibroblasts—produce the fibrous matrix and ground substance
of connective tissue
b. Macrophages—capable of digestive activity
c. Mast cells—contain vesicles filled with heparin and histamine
d. Mesenchymal cells—primitive cells with the capability of
differentiating into various connective tissue cells; they play a
key role in the replacement of connective tissue lost as a result
of injury or disease
2. Cells that are normally in the bloodstream but move in and out of
the blood vessels into surrounding connective tissue when needed
(wandering cells)
a. Monocytes
b. Polymorphonuclear leukocytes
c. Lymphocytes
d. Plasma cells
B. Fibrous matrix
1. Matrix of connective tissue composed of some or all of the following
fibers:
a. Collagen fibers—consist of three long polypeptide chains coiled
in a left-handed helix to form a tropocollagen unit, which is
assembled in a “quarter-stagger ” model outside of the cell;
fibers are highly resistant to tension and are part of the
anchoring mechanism by which the connective tissue attaches
the basement membrane (see Figure 2-20, B); the most abundant
fibers found in connective tissue
b. Reticulin fibers—comparable with collagen fibers in their
protein composition; usually found in the border areas between
connective tissue and other tissues
c. Elastic fibers—consist of long fibrous proteins that differ in
composition from collagen; are the branching fibers responsible
for recoiling tissues when they are stretched

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 d. Oxytalan fibers—resemble elastic fibers in morphology and
chemical composition; are believed to be immature elastic fibers
C. Ground substance
1. Amorphous substance that consists of many large, highly organized
carbohydrate chains attached to long protein cores (e.g.,
proteoglycans)
2. Molecular structure and composition are responsible for the ground
substance’s resistance to compression, or compressive loading, from
any direction

Types (Cartilage and Bone)

Cartilage
A. Cartilage and bone are sister tissues, both highly specialized forms of
connective tissue, whose intercellular substances have assumed
particular properties that allow them to perform support functions
1. Very “bouncy,” resilient tissue that is specialized to resist
compression; has a gel-like matrix in which the ground substance
predominates over the intercellular matrix
2. Relatively avascular tissue
3. In humans, most of the embryonic skeleton is preformed as hyaline
cartilage that is eventually replaced by bone (during endochondral
ossification); depending on the location and loading pattern
imposed on the cartilage, it may specialize to form fibrous or elastic
cartilage
4. All mature cartilage is surrounded by the perichondrium, a fibrous
connective tissue, which serves a biomechanical function; it acts as
an attachment site for muscles and tendons
B. Cartilage, as with all types of connective tissue, has three components:
1. Cells—chondroblasts and chondrocytes
2. Fibrous matrix—type II collagen fibers and, in some cases, elastic
fibers
3. Ground substance—proteoglycans, which have a protein core with
side chains of chondroitin sulfate and keratan sulfate
(glycosaminoglycans); because of the chemical nature and
organization of proteoglycans, the ground substance can readily
bind and hold water, which allows the tissue to assume a gelatinous
nature that can resist compression and also permit some degree of
diffusion through the matrix
C. Types
1. Hyaline cartilage

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 a. Found in the adult human
(1) Covering articular surfaces of movable long bones
(2) Forms the skeletal support parts of:
(a) Trachea
(b) Larynx
(c) External ear
(d) Nasal septum
(e) Ends of ribs
b. Most abundant type of cartilage; forms the embryonic skeleton
in humans; is best suited to resist compression; appears as a
homogeneous, translucent tissue because its intercellular matrix
dominates its collagenous fibers; the major type of fiber in
collagen
2. Fibrous cartilage (fibrocartilage)
a. Has a very sparse amount of intercellular substance dominated
by collagen fibers, which are in such proportion that they are
visible through a light microscope and are seen running
between the chondrocytic cells in the cartilage
b. Resembles tendons except for the presence of the chondrocytes
enclosed in lacunae
c. Usually found in areas that are subjected to both compression
and tension, as in:
(1) Intervertebral disc
(2) Temporomandibular joint of older adults
(3) Pubic symphysis
3. Elastic cartilage
a. In areas that are in need of elastic recoil, hyaline cartilage
becomes highly specialized, and elastic fibers are added to its
intercellular matrix, as in:
(1) External ear
(2) Epiglottis
b. Elastic fibers are highly branched and form a delicate fibrous
matrix, often obscuring the intercellular substance; fibers can be
seen only through a light microscope when stained with a
specific elastic stain

Bone
A. A specialized vascular connective tissue composed of a mineralized
organic matrix; the inorganic component of bone is hydroxyapatite:

101
B. Two main functions:
1. Provides skeletal support and protection of soft tissues
2. Acts as a reservoir for calcium and phosphorus ions; when these two
ions drop below a critical level in the blood (100 mg of calcium per
100 mL of blood, and 600 mg of phosphorus per/100 mL of blood),
they can be withdrawn from the bone
C. Characteristic of all bones
1. Compact bone—dense bone that appears as a continuous solid mass
2. Trabecular (cancellous or spongy) bone—composed of a central
medullary cavity filled with either red or yellow marrow and with
intervening spicules of bone (trabeculae); these trabeculae act to
reinforce bone by increasing in number with increased function
D. Bone morphology
1. Bone-forming cells (osteoblasts) are produced from undifferentiated
mesenchymal cells of the periosteum, the endosteum, and the
periodontal ligament
a. The periosteum is the connective tissue that covers the outer
aspects of bone
b. The endosteum is a more delicate connective tissue lining the
inner aspects of bone, the trabeculae, and Volkmann’s canals
(canals of the bone containing blood vessels)
c. The periodontal ligament is specialized periosteum because it
covers the outer aspects of the alveolar bone; it is also capable of
forming bone and of forming cells that produce cementum
(cementoblasts)
2. Osteoblasts become incorporated into bone during their formation;
they occupy a space called a lacuna (plural, lacunae)
3. Lacunae are connected to each other by means of a system of canals
named canaliculi; these canals house the cytoplasmic extension of
the osteocytes and provide a means for the transport of vascular
components
4. Both compact and trabecular mature bones are formed in layers, or
lamellae. Lamellae are found in three distinct types of arrangements
present in all mature human bones (Figure 2-8):

102
 FIG 2-8 Microscopic morphology of bone tissue. Haversian system bone
is composed of lamellae arranged in concentric circles around a canal.
Interstitial bone fills the space between the concentric circles.
Circumferential lamellar bone is found on the outer aspects of compact
bone; endosteal lamellar bone covers the inner aspect of compact bone.
Spongy bone is composed of trabeculae and marrow cavity. (From Avery
JK, Chiego DJ: Essentials of oral histology and emb ryology: a clinical approach, ed 3,
St Louis, 2006, Mosby.)

a. Concentric, or haversian system, bone makes up the bulk of

compact bone; it consists of lamellae arranged in concentric
circles around a blood vessel (haversian canal) to form an
osteon. An osteon, which consists of this concentrically
arranged bone and haversian canal, is the basic metabolic unit
of bone
b. Interstitial lamellae fill the space between the concentric circles
of the haversian system bone
c. Lamellar bone is not arranged in concentric circles and is found
on the surfaces of most bones. This bone is further defined by
its location. When found on the outer aspects or the
circumference of the bone underneath the periosteum, it is
referred to as circumferential, or (sub)periosteal, bone; when found
on the surfaces of trabeculae or the inner aspect of compact
bone, it is referred to as (sub)endosteal bone
E. Bone tissue
1. Bone, as with all connective tissues, has three main components:
a. Cells
(1) Osteoblasts—bone-forming cells

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 (2) Osteoclasts—bone-resorbing cells
(3) Osteocytes—osteoblasts that are embedded in the lacunae
of bone matrix and that maintain bone tissue
b. Fibrous matrix—collagen fibers (type I), which are the
dominant component of bone matrix
c. Ground substance—proteoglycans containing chondroitin
sulfates and seeded with the mineral salt hydroxyapatite
2. Bone is formed by osteoblasts developed in one of two ways:
a. Intramembranous ossification—mesenchymal cells move closer
together (condensation), differentiate into osteoblasts, and
begin to deposit bone matrix; this is how the maxilla and the
mandible are formed
b. Endochondral ossification—future bone is preformed in a
cartilage model that is eventually resorbed and replaced by new
bone formed by osteoblasts (Figure 2-9)

FIG 2-9 Stages of endochondral bone formation in long-bone

growth. A, Original hyaline cartilage is calcified in the center of the
diaphysis. B, Blood vessel invades the center of the shaft. C, The
marrow space appears in the center of the shaft, and bone forms
around the diaphysis. D, Bone formation continues in the shaft,
and secondary ossification sites appear in the heads (epiphyses)
of the bones. A disc of cartilage remains between bone forming in
the head and the shaft (epiphyseal line). (From Chiego DJ: Essentials of
oral histology and emb ryology: a clinical approach, ed 4, St Louis, 2013,
Mosby.)

(1) Cartilage must undergo two important changes before

being resorbed and replaced by new bone:
(a) Chondrocytic hypertrophy
(b) Calcification of the cartilage model
(2) Endochondral ossification is the process by which all long
bones in the human body are formed
(a) Bone growth in length—occurs in the cartilaginous

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 epiphyseal growth plate
(b) Bone growth in diameter—occurs in the cellular layer
of the fibrous covering of connective tissue periosteum,
which produces a periosteal bone collar on the outer
bone surface
F. Structure of long bones (macroscopic)
1. The typical long bone is composed of:
a. Diaphysis (shaft)—thick compact bone forming a hollow
cylinder with a central marrow cavity; this is the primary center
of ossification in a long bone
b. Epiphyses (ends)—spongy bone covered by a thin layer of
compact bone; these are the secondary growth centers
c. Metaphysis—transitional region between the epiphyses and the
diaphysis, where the cartilage growth plate is located
d. All articular surfaces of long bones are covered by articular
cartilage
2. While active, the epiphyseal growth plate usually has four zones,
proceeding from first to last:
a. Primary spongiosa with resorption
b. Hypertrophy and provisional calcification
c. Proliferation
d. Resting zone (see Figure 2-9)

Blood and Lymph

A. Vascular system
1. Develops embryonically from mesenchymal cells that come together
and form delicate tubular structures composed of endothelial cells
2. Consists of the heart, blood vessels, and lymphatics
a. Is a closed system that runs from the heart to the organs of the
body and back to the heart
b. Between the heart and the organs, the blood vessels branch
progressively into finer and finer vessels and finally enter the
organs
(1) Here a delicate network of capillaries forms, called the
capillary bed—the most essential part of the vascular system
(2) Exchanges of gases and substances occur in this capillary
bed
c. Blood is then carried back to the heart via larger vessels, the
veins
3. Functions

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 a. Carries nutrients, oxygen, and hormones to all parts of the body
b. Carries metabolic waste products to the kidneys
c. Transports inflammatory cells and antibodies
d. Maintains a constant body temperature
B. Lymph vessels empty into filtering organs (nodes) and generally flow
toward larger lymph vessels, the thoracic duct, and the right lymphatic
duct; lymph enters the venous branches of the circulatory system

Blood Vessels
A. Arteries—the largest of the blood vessels; walls are composed of:
1. A thick layer of smooth muscle cells
2. Elastic tissue—the largest amount is found in the large arteries close
to the heart
B. Veins—usually accompany arteries but carry blood in the opposite
direction
1. Walls are composed of:
a. A layer of endothelial cells
b. A connective tissue layer
c. Occasionally a few smooth muscle cells
2. Veins contain about 70% of total blood volume of the body at any
given time
C. Capillaries—the simplest of the blood vessels in the structure
1. Walls consist of a simple layer of endothelial cells and a basal lamina
2. Usually, the diameter of a capillary lumen is so small that only one
blood cell at a time can pass through it
3. Capillaries form a barrier between blood and tissues
4. Transport of substances occurs at the capillary level through:
a. Pores in the endothelial wall of the capillary
b. Openings between adjacent endothelial cells
c. Pinocytotic vesicles formed by the wall of the capillary

Microvasculature
A. Composed of the smallest arteries and veins located in the capillary
bed
1. At the end of the arterioles is a preferential channel that has several
side branches entering the capillary bed
2. Blood passes through the capillary bed from the arterial side to the
venous side
B. Selective openings and closings of the capillary bed occur in the
microvasculature to ensure regulation of the amount of blood
throughout the body at any given time

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Blood Components
A. Cells
1. Red blood cells—erythrocytes; most numerous
2. White blood cells—leukocytes (granular and nongranular)
3. Platelets—cell fragments of a specific cell type found in red bone
marrow; have no nuclei
B. Plasma—liquid portion of blood

Functions of Blood Cells

A. Red blood cells (erythrocytes) contain hemoglobin, which carries
oxygen from lungs to tissues
B. White blood cells (leukocytes) function chiefly to fight infection, to
scavenge foreign invaders, and to repair injured tissue
1. Granular leukocytes
a. Polymorphonuclear neutrophils (PMNs)—first line of defense
against bacterial invasion
b. Eosinophils—involvement in allergic reactions
c. Basophils—antigen involvement
2. Nongranular leukocytes
a. Monocytes—can become macrophages in connective tissue
b. Lymphocytes—produce antibodies
C. Platelets—promote blood clotting

Lymphatic System
A. Made up of a series of vessels that carry excess tissue fluid from the
capillaries to filtering organs such as lymph nodes on the return to the
bloodstream
B. Lymph nodes are found along the lymphatic pathway
1. Consist of masses of lymph tissue that serve as a filtering system for
the body
2. The tonsils and the spleen are both filtering organs for the body
3. Swollen and palpable lymph nodes may indicate that an infection is
present somewhere in the body
C. The function of lymph is to protect and maintain the internal fluid
environment of the body

Nerve Tissue
A. Main functions of the nervous system
1. Directs and maintains the complex internal environment of the body
2. Integrates and interprets incoming stimuli and directs appropriate

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 responses at a conscious or unconscious level
B. The nervous system can be classified as follows:
1. Central nervous system (CNS)
2. Peripheral nervous system (PNS)
3. Autonomic nervous system (ANS)
C. Afferent nerves transmit impulses (sensations) from the periphery to
the CNS (sensory input); efferent nerves transmit impulses (commands)
from the CNS to muscles and other organs (motor output) (Figure 2-10)

FIG 2-10 Cross section of a spinal cord showing pathways used to transmit
nerve impulses from the periphery to the central nervous system. (From Patton
KT: Anatomy and physiology, ed 9, St Louis, 2016, Elsevier.)

D. Divisions of the nervous system

1. Central nervous system
a. Includes the brain and the spinal cord

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 b. Main functions:
(1) Receives incoming information at a conscious or
unconscious level (sensory)
(2) Integrates outgoing responses (motor) that are
transmitted to various parts of the brain and the spinal cord
2. Peripheral nervous system
a. Composed of 31 pairs of spinal nerves and 12 pairs of cranial
nerves
b. All nerves transmit information to and from the CNS
c. Contains both sensory and motor nerves (neurons)
3. Autonomic nervous system (Figure 2-11)

FIG 2-11 Distribution of sympathetic nerves. (From Copstead LC, Banasik JL:
Pathophysiology, ed 5, St Louis, 2014, Elsevier.)

a. Controls, regulates, and coordinates visceral activities

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 (digestion, body temperature, blood pressure, and glandular
secretions) at an unconscious level
b. Is further subdivided into:
(1) Sympathetic division—acts to regulate and mobilize
activities during emergency or stress (flight activities);
activities that require high outputs of energy produce an
accelerated heart rate and increase in blood pressure
(2) Parasympathetic division—works in the opposite manner
of the sympathetic division; stimulates activities that
restore or conserve energy (e.g., decreased heart rate,
constricted pupils, contraction of ciliary muscle)
(3) These two divisions are seen as acting reciprocally rather
than antagonistically

Structural Components
A. Neurons (Figure 2-12)

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 FIG 2-12 Neuron with its cell body, axon, dendrites, and synaptic relationships
with the muscle tissue and another neuron. (From Avery JK, Chiego DJ: Essentials of
oral histology and emb ryology: a clinical approach, ed 3, St Louis, 2006, Mosby.)

1. Structural components of nerve tissue

2. Receive and transmit information
3. Highly specialized cells consisting of:
a. Cell body—contains the nucleus and organelles; located in the
ganglia in the CNS and the PNS
b. One or more cytoplasmic extensions
(1) Dendrites—conduct impulses toward the cell body
(2) Axons—conduct impulses away from the cell body
4. Classified according to the number of cell processes (Figure 2-13):

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 FIG 2-13 Classification of neurons based on the location of the cell body
and the relative length and number of dendrites and axons. (From
Copstead LC, Banasik JL: Pathophysiology, ed 5, St Louis, 2014, Elsevier.)

a. Multi-polar neurons—located in the CNS and autonomic

ganglia; usually, one process is the axon and the other processes
are the dendrites
b. Unipolar neurons—have a short cell process that leaves the cell
body and divides into two long branches; one branch goes to the
CNS, and the other goes to the PNS (sensory neurons)
5. Interneurons—lie within the CNS; receive and link sensory and
motor impulses to bring about appropriate responses in the body
B. Glial cells—provide structural support and nourishment for the
neurons; Schwann cells in the PNS and satellite cells in the ganglia

Definitions
A. Synapse—an area that occurs between two neurons or between a
neuron and its effector (muscle or gland); found between the cell
surfaces are:
1. Synaptic cleft—intercellular space separating a presynaptic and
postsynaptic membrane
2. Presynaptic membrane—situated before the synapse
3. Postsynaptic membrane—situated after the synapse
B. Neurotransmitters—chemicals released from the neuron as electrical

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impulses travel along the axon and reach the terminal end
1. Neurotransmitters increase the permeability of the cell membranes;
impulses are relayed to the effector; impulses can be excitatory or
inhibitory
2. Two-membrane junctions
3. Types of neurotransmitters
a. Acetylcholine—secreted by cholinergic fibers
b. Norepinephrine—secreted by adrenergic fibers
C. Myelin sheath—fatty layer surrounding the axon of the nerve
1. Myelinated—contains a fatty sheath
2. Unmyelinated—contains no fatty sheath
D. Neurilemma—continuous sheath that encloses the segmented myelin
sheath of some nerves
E. Neuroglia—extremely soft tissue that supports the nervous tissue of
the brain and the spinal cord
F. Free nerve endings—end portions of afferent (sensory) axons no longer
covered by a supportive Schwann cell; found in:
1. Dental pulp
2. Oral epithelium
G. Encapsulated nerve endings—composed of several portions of afferent
axons surrounded by a capsule of several Schwann cells without a myelin
sheath and some connective tissue; they are associated with:
1. Touch perception (Meissner ’s corpuscles) found in the lamina
propria of the oral mucosa
2. Periodontal ligament

Cranial Nerves
See the section titled “The Nervous System” in Chapters 3 and 4.
A. Twelve pairs of cranial nerves originate from the brain
1. Cranial nerves transmit information to the brain from the special
sensory receptors and regulate the functions of:
a. Smell
b. Sight
c. Hearing
d. Taste
2. Cranial nerves bring impulses from the CNS to the voluntary
muscles of:
a. Eyes
b. Mouth (masticatory muscles)
c. Face (facial expression)
d. Tongue (swallowing and speech)

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 e. Larynx
B. In oral health care, a local anesthetic agent is injected into a sensory
peripheral nerve; it diffuses through the nerve fibers and blocks the
transmission of impulses to the brain in an area of several teeth or in a
localized area of soft tissue (see the section “Characteristics and
Physiology of Pain” in Chapter 18).

Muscle Tissue
A. Composed mainly of cells called muscle fibers, which have
differentiated from the embryonic mesenchyme and have become highly
specialized in contracting (shortening)
B. Contracting ability of muscle fibers is a result of large amounts of
actin and myosin, which are intracellular, contractile protein filaments
C. The three muscle tissue types are:
1. Skeletal (striated) muscle
a. Under conscious control; referred to as voluntary muscle
b. Has rapid, short, strong contractions; requires a great deal of
energy
c. Innervated by motor nerves
d. Skeletal muscles of the head region:
(1) Muscles of mastication
(2) Muscles of facial expression
e. Muscle attachments are possible because of the connective
tissues surrounding the muscle, bone, or cartilage; connecting
tissues of the muscle run directly into the periosteum, cover the
bone or perichondrium, cover the cartilage or perimysium, or
cover the muscle. The exact nature of the attachment depends
on the site and function of the muscle. The intermediate
structures may be:
(1) Tendons
(2) Ligaments
(3) Aponeuroses
f. Muscles that change the shape of the tongue by their
contractions are attached on both sides to the lamina propria of
the oral mucosa of the tongue
2. Smooth muscle
a. Under the control of the ANS and not under conscious control
b. Contractions are slow and can be maintained over a long period
without the use of much energy
3. Cardiac muscle

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 a. Has some of both skeletal (striated) and smooth muscle
characteristics
b. Is involuntary; has fast, powerful contractions
c. Purkinje fibers—specialized cells present in heart muscle that
act like nerves to conduct messages through the heart
d. Bundle of His—a band of specialized cardiac muscle fibers

Muscle Contraction
A. Muscle can be stimulated to contract by one nerve or by many nerves
B. Each striated muscle contains bundles of highly organized contractile
proteins called myofibrils; each myofibril consists of regularly arranged
protein filaments: actin and myosin (Figure 2-14)

FIG 2-14 Muscle fiber. A, The epimysium runs continuously with the
endomysium and the perimysium. B, The arrangement of fasciculi varies
among muscles. C, The banding pattern apparent on microscopic inspection
of a muscle cell results from the organized structure of the proteins (myofibrils)
of the contractile apparatus. D, Thick and thin filaments are organized into
contractile units called sarcomeres. (From Copstead LC, Banasik JL: Pathophysiology,
ed 5, St Louis, 2014, Elsevier.)

C. Protein filaments are attached to a Z band; the section of a myofibril

between two Z bands is called a sarcomere, which is the contractile unit
D. As a muscle unit contracts, actin and myosin filaments slide past each
other, shorten the length of the individual sarcomere (sliding
mechanism), and cause total shortening of the muscle fiber

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General embryology
A. All human development begins by fertilization, the union of a female
germ cell (ovum) and a male germ cell (sperm)
B. Each germ cell contains 23 chromosomes (haploid number); during the
process of fertilization, the number of chromosomes is restored to 46
(diploid number)
C. The developing organism, called the zygote, goes through a series of
mitotic divisions
1. Morula—16 to 32 cells, appearance resembles that of a mulberry
2. Blastocele—a central cavity with an embryonic pole
3. Blastocyst—thin-walled hollow ball of cells that attaches to and
embeds in the uterine wall
a. Two distinct layers become visible:
(1) Epiblast (ectoderm) layer
(2) Hypoblast (endoderm) layer
b. These two layers constitute the embryonic disc, which will give
rise to the future embryo
D. Three distinct periods in human development:
1. Period of the ovum (first week)—fertilized ovum develops an
embryonic disc
2. Embryonic period (second week to eighth week)—most of the organs
and organ systems develop
a. A period of differentiation
b. At the end of this period, a recognizable individual has
developed
c. Most congenital malformations occur during this time
3. Fetal period (third month to ninth month)—growth of existing
structures takes place
E. Development of some facial and oral structures is dependent on a
group of cells (neural crest cells) derived from the ectoderm as the neural
tube is forming; these cells migrate cephalad and interact with the
cephalic ectoderm and mesoderm to result in the development of:
1. Facial skeleton—Meckel’s cartilage
2. Neck skeleton—hyoid bone
3. Connective tissue components
4. Tooth development
F. Neural crest cells migrate into each of the branchial arches and
surround the existing mesoderm; in each arch, the following components
develop:
1. Cartilage rod (skeleton of each arch)—first branchial arch, Meckel’s

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 cartilage
2. Muscular component—second branchial arch, facial musculature
3. Vasculature component
4. Nerve component—first branchial arch, trigeminal nerve
G. On the internal aspect of the branchial arches are corresponding
pharyngeal pouches that give rise to:
1. External auditory meatus
2. Pharyngotympanic tube
3. Palatine tonsils
4. Parathyroid glands

Facial Development
A. Initiation of the development of the oral cavity occurs in the third
prenatal week (embryonic period) and is complete in the twelfth week
B. The future facial region is located among the bulging forebrain, the
frontal nasal process, and the developing heart
C. At the beginning of the fourth week, five facial swellings, called
branchial arches, appear on the embryo
1. Located between the first branchial arch and the frontal process
(forebrain) is the oral stomodeum (primitive oral cavity) (Figure 2-
15); the stomodeum is the first sign of facial development

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 FIG 2-15 Facial development. A and B, Facial development begins with
the outgrowth of branchial arches. Note the relationship of the oral
stomodeum to the heart and the developing face. Nasal pits develop
from the frontal nasal process and grow to become nostrils. The nasal
pits separate the frontal nasal process into the medial nasal process and
the right and left lateral nasal processes. C, Note the developmental
processes and the lines of fusion on the adult face illustration. (B from
Chiego DJ: Essentials of oral histology and emb ryology: a clinical approach, ed 4, St
Louis, 2013, Mosby.)

2. The stomodeal ectoderm invaginates until it comes in contact with

the primitive foregut; the stomodeum and the foregut are initially
separated by the buccopharyngeal membrane, which is composed of
the ectoderm and the endoderm. It is located in the region that will
eventually house the palatine tonsils
3. Rathke’s pouch—a small invagination in the roof of the stomodeum;
deepens into the brain and forms the anterior lobe of the pituitary
gland
4. The maxilla and the mandible develop from the first branchial arch
5. The second to fifth branchial arches are involved in development of

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 the neck
D. On the lower aspect of the frontal process, nasal pits (nostrils) arise
from nasal placodes (see Figure 2-15, B) and separate the lower frontal
process into:
1. Medial nasal process (area between the nasal pits); this gives rise to:
a. The center of the nose and the nasal septum
b. The globular process that develops into:
(1) The center of the upper lip (philtrum)
(2) The primary palate (premaxilla)—the anterior portion of
the palate
2. Lateral nasal processes (area to the right and left of the nasal pits)
that form the sides of the nose
E. Maxillary processes arise from the superolateral border of the first
branchial arch; they grow:
1. Downward to merge with the mandibular processes and form the
closure at the corner of the mouth
2. Medially to form the sides of the upper lip, which unite with the
globular process (forms the center of the lip)
3. Inward to form the lateral palatine processes that fuse together with
the primary palate (premaxilla) to form the palate
F. The lower face is formed by the bilateral swellings (mandibular
processes) of the mandibular arch
G. Several facial or oral processes merge or fuse together during
development; incomplete merging or fusing can result in cleft formation
—cleft lip or cleft palate
1. A cleft lip occurs more often on the left side, more frequently in
males, and at the end of the second month in utero
2. A cleft palate occurs more often in females
3. Cleft lips and cleft palates can occur as isolated defects, meaning a
cleft lip can occur without a cleft palate; most cleft palates occur in
combination with a cleft lip

Palatal Development
A. The globular process develops as medial nasal processes grow
downward and gives rise to:
1. The philtrum of the upper lip
2. The primary palate (premaxillary process), which carries the incisor
tooth buds
B. During the sixth week of embryonic life, two lateral palatine processes
(palatal “shelves”) develop from each side of the maxilla and lie vertically

119
on each side of the tongue (these palatal shelves form the secondary
palate)
C. During the seventh week of embryonic life, the developing tongue
drops down, and the vertical lateral palatine processes flip up, assume a
horizontal position, and fuse with the primary palate
D. Where the two palatal processes (shelves) fuse in the midline, trapped
epithelium between the two processes may result in epithelial remnants,
which may produce cysts
E. The right and left lateral palatine processes (palatal shelves) fuse with
each other at the midline; anteriorly, they fuse with the primary palate in
an area between the right and left laterals and the right and left canines
1. A cleft palate occurs at the end of the third month in utero
2. Failure of fusion can occur at any of these lines of fusion
3. A cleft in the alveolar ridge could occur unilaterally (on one side) or
bilaterally (on both sides); this cleft occurs between the lateral and
the canine, so the lateral incisor is the tooth most often missing or
malformed
4. The right and left lateral palatal processes can fail to fuse with each
other at the midline, and the oral cavity would be open to the nasal
cavity

Tongue Development
During the fourth week of embryonic life, the tongue develops from
several swellings arising on the internal aspect of branchial arches 1 to 4
(pouches); these swellings eventually merge and form the body and root
of the tongue.
A. Branchial arch 1—two lateral swellings and one medial swelling
(tuberculum impar) merge to form the body of the tongue
B. Branchial arches 2, 3, and part of 4—copula merge to form the base of
the tongue
C. Branchial arch 4—site where the epiglottis is formed
D. Thyroid gland—develops from an invagination of ectoderm in the area
of the foramen cecum of the tongue; the thyroid gland eventually
migrates down to its position in the neck; thyroid tissue that remains
entrapped in the tissue of the tongue may result in a developmental
abnormality known as lingual thyroid nodule

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Oral histology
Tooth Development
A. Begins in the seventh week of embryonic life with the 20 primary
teeth; continues until the late teens with sequential exfoliation of the
primary dentition and development and eruption of the secondary
dentition—the 32 permanent teeth
B. Tissues of the tooth
1. Each tooth consists of four tissues (Figure 2-16):

FIG 2-16 Four tissues of the tooth: enamel, cementum, dentin, and pulp.
The periodontal ligament and alveolar bone are supporting tissues;
junctional epithelium is the area where the enamel or cementum of the
tooth and the epithelium of the gingival tissue form an attachment.

a. Enamel—calcified
b. Cementum—calcified
c. Dentin—calcified
d. Pulp—uncalcified
2. All tissues of the tooth are specialized forms of connective tissue,

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 except enamel
3. Each tooth is the product of two tissues that interact during tooth
development:
a. Mesenchyme (ectomesenchyme)—derived from neural crest
cells
b. Epithelium—oral epithelium derived from the ectoderm
C. Involves two major events:
1. Morphodifferentiation—shaping of the tooth
2. Cytodifferentiation—cells differentiating into specific tissue-forming
cells:
a. Ameloblasts—enamel-forming cells
b. Cementoblasts—cementum-forming cells
c. Odontoblasts—dentin-forming cells
d. Fibroblasts—pulp-forming cells (also capable of differentiating
into a chondroblast, collagenoblast, or osteoblast)

Morphodifferentiation
A. Oral epithelium and underlying ectomesenchyme are responsible for
shaping the tooth
1. Both primary and permanent tooth germs go through the same
stages of development
2. The oral epithelium grows down into the underlying
ectomesenchyme; small areas of condensed mesenchyme form
future tooth germs
B. Stages (Figure 2-17)

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 FIG 2-17 Sequential stages of tooth development. A, Bud stage. B, Cap stage.
C, Bell stage. D, Dentinogenesis. E, Amelogenesis. F, Appositional dentin and
enamel. G, Eruption and root development. H, Functional stage. (From Chiego
DJ: Essentials of oral histology and emb ryology: a clinical approach, ed 4, St Louis, 2013,
Mosby.)

1. Bud stage—condensed areas of ectomesenchymal cells that are

continuous with the oral epithelium; connection between the two is
referred to as the dental lamina
2. Cap stage—future shape of the tooth becomes evident; cells
specialize to form the enamel organ
3. Bell stage—final stage of morphodifferentiation; in the latter part of
this stage, cytodifferentiation begins in the enamel organ
4. Dentinogenesis—origin or initial stages of dentin formation
5. Amelogenesis—differentiated cells begin initial enamel formation
6. Apposition stage—formation of dental tissue matrix; this matrix will
then undergo maturation or calcification

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 7. Eruption and root development
8. Functional stage—the tooth is fully erupted in the mouth

Cytodifferentiation
A. Stages of cytodifferentiation and morphodifferentiation overlap; both
epithelial and mesenchymal components of the tooth germ become
organized
1. Epithelial components become the enamel organ, which is organized
into four distinct cell layers (Figure 2-18):

FIG 2-18 The four distinct layers of the enamel organ. A, Outer enamel
epithelium. B, Stellate reticulum. C, Stratum intermedium. D, Inner
enamel epithelium. (Modified from Avery JK, Chiego DJ: Essentials of oral histology
and emb ryology: a clinical approach, ed 3, St Louis, 2006, Mosby.)

a. Outer enamel epithelium (OEE)—outlines the shape of the

future developing enamel organ on the outer surface; composed
of small cuboidal cells, one cell layer thick
b. Inner enamel epithelium (IEE)—innermost layer of the enamel
organ on the concave side of the developing tooth germ; this
will become the future enamel-producing cells, the ameloblasts;
composed of cuboidal-type cells, one cell layer thick
c. Stratum intermedium (STI)—flat, supporting, squamous-type
cells, two to three cell layers thick, lying on top of the inner

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 enamel epithelial cells
d. Stellate reticulum (STR)—mechanically and nutritionally
supporting cells that fill the bulk of the developing enamel
organ; are star shaped with large amounts of intercellular space
between them
2. Mesenchymal components become subdivided into:
a. Dental sac (follicle)—surrounds the developing tooth germ and
provides cells that will form the periodontal ligament, which in
turn will produce the cementum and the alveolar bone proper
b. Dental papilla—condensed ectomesenchyme located on the
concave side of the enamel organ; peripheral cells facing the IEE
will differentiate into odontoblasts (dentin-forming cells)
c. The center of the dental papilla will become the dental pulp
B. Tooth development depends on a series of sequential cellular
interactions between the epithelial and mesenchymal components of the
tooth germ
1. First interaction—between the oral epithelium and the mesenchyme;
the ectomesenchyme instructs the epithelium to grow down into the
ectomesenchyme and shape the tooth
2. Second interaction—signal given by cells of the inner enamel
epithelium (preameloblasts) to the mesenchymal cells on the
periphery of the dental papilla to differentiate into odontoblasts and
begin the deposition of dentin
3. Third interaction—as soon as odontoblasts begin to deposit dentin,
preameloblasts become true secreting ameloblasts and begin the
deposition of enamel
4. Fourth interaction—occurs with the development of root dentin and
cementum

Dentin and Enamel Formation

A. Both enamel-forming and dentin-forming cells are polarized, tall,
columnar, secreting cells; just before ameloblasts and odontoblasts begin
to deposit enamel and dentin, organelles, especially the mitochondria,
increase in number; organelles move to the basal nonsecretory end of the
cell; both cells require tremendous amounts of energy for the production
of their calcified tissues
B. All dentin and enamel formation begins at the dento-enamel junction
(DEJ) of the cup or the incisal edge of the tooth and continues in an
apical direction
C. The permanent tooth germ grows off the primary (deciduous) tooth

125
germ by an epithelial attachment similar to dental lamina, called
successional lamina; this applies to all the developing permanent teeth
except the first, second, and third molars; these develop from the dental
lamina, which continues to grow back in oral arches
D. Dentin formation
1. Odontoblasts produce collagen fibers that unravel to produce a
fibrous connective tissue matrix (fibrillar matrix) of predominantly
collagen fibers with a rich proteoglycan ground substance; dentinal
tissue is calcified by the deposition of the crystals of the calcium salt
hydroxyapatite into the matrix
2. Each odontoblast has a long cell extension, the odontoblastic
process, left behind in the calcified dentin and enclosed in a dentinal
tubule (Figure 2-19)

126
 FIG 2-19 Odontoblasts and ameloblasts with their cell extensions. Tall,
secretory odontoblast with its cell extension (odontoblastic extension).
Tall, secretory ameloblast with its cell extension (Tomes’ process). (From
Fehrenbach MJ, Popowics T: Illustrated dental emb ryology, histology, and anatomy, ed
4, St Louis, 2016, Elsevier.)

3. Dentin remains a vital tissue throughout the life of the tooth; in a

vital tooth, cells continue to produce dentin when needed
E. Enamel formation
1. Ameloblasts produce an enamel matrix with protein components
called amelogenins and enamelins; the matrix is calcified immediately
by the deposition of the crystals of the calcium salt hydroxyapatite
2. Ameloblasts deposit enamel; each ameloblast has a secretory
process called Tomes’ process; Tomes’ process has a six-sided
pyramidal shape and is responsible for prism-shaped microscopic
patterns of enamel rods; unlike the odontoblastic process, Tomes’
process is not left behind embedded in the calcified tissue (see
Figure 2-19)

127
 3. When the tooth emerges into the oral cavity, the enamel has no vital
cells associated with the tissue; enamel is not a true tissue like other
dental tissues and is incapable of tissue growth or repair; once
formed, the mineral substance cannot be physiologically withdrawn
from the tooth
4. A final product of the ameloblasts is the primary enamel cuticle, a
calcified coating on the enamel surface
5. Secondary cuticle—a noncalcified coating; a product of the reduced
enamel organ
6. Nasmyth’s membrane consists of the primary enamel cuticle and the
secondary enamel cuticle; this membrane on the newly erupted
tooth can easily pick up extrinsic stain
F. Dento-gingival junction formation
1. After the enamel formation is complete, remains of the enamel
organ (OEE, IEE, STI, and STR) come together to form the reduced
enamel epithelium
2. Reduced enamel epithelium—plays an important role in the
formation of the dento-gingival junction as the tooth emerges into
the oral cavity
G. Cementum formation
1. Formation of root dentin and cementum follows after the formation
of the crown of the tooth is complete
2. Hertwig’s root sheath is formed by the joining of the outer enamel
epithelium and the inner enamel epithelium; the sheath continues to
grow down, shapes the root of the tooth and the formation of root
dentin, and is followed by differentiation of cells from the dental sac;
these cells produce:
a. Cementum
b. Periodontal ligament
c. Alveolar bone proper

Soft Tissue of the Oral Cavity

Oral Mucosa
A. Oral epithelium (Figure 2-20)

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 FIG 2-20 Basic structure of the oral epithelium. A, Two basic tissues comprise
the oral mucosa: the oral epithelium and connective tissue. Connective tissue
is composed of a papillary layer and a reticular layer. A submucosal layer may
or may not be present, depending on the location of the oral mucosa. Note the
arrangement of rete ridges (or pegs) and connective tissue papillae. B, Basal
lamina interface between oral epithelium and connective tissue. Note the
hemidesmosomes with attachment plaque between epithelial cells and the
basal lamina. (From Fehrenbach MJ, Popowics T: Illustrated dental emb ryology, histology,
and anatomy, ed 4, St Louis, 2016, Elsevier.)

1. Covered by a layer of the stratified squamous epithelium that:

a. Acts as a mechanical barrier
b. Protects the underlying tissues
2. Three types of stratified squamous epithelia are found in the oral
cavity:
a. Orthokeratinized
(1) Effective as a mechanical protector and barrier against
fluids
(2) Least common of the three types

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 (3) Layers
(a) Basal cell layer—deepest layer
(b) Prickle cell layer (stratum spinosium)
(c) Granular layer—contains the keratohyaline granules,
the precursor to keratin
(d) Keratinized layer (stratum corneum)—contains
degenerative cells with no nuclei or organelles; cells are
filled with keratin, become hard (cornified), and are
eventually lost from the surface epithelium
b. Nonkeratinized
(1) Functions as a selective barrier; acts as a cushion and as
protection against mechanical stress and wear
(2) Layers
(a) Basal cell layer
(b) Prickle cell layer
(c) Outer surface of nonkeratinized cells (squamae); no
distinctly recognizable layer above the prickle cell
layer; superficial cells in the outermost layer undergo a
gradual increase in size; look empty but are filled with
fluid sacs; cells act as a cushion and are firmly attached
to each other
c. Parakeratinized
(1) Intermediate form of the epithelium located between the
orthokeratinized and nonkeratinized oral mucosa
(2) Layers
(a) Basal cell layer
(b) Prickle cell layer
(c) Keratinized layer—no distinct granular layer present;
gradually becomes filled with keratin; nuclei and other
cell organelles remain until the cell becomes cornified,
and then they are eventually lost
3. The stratified squamous epithelium is constantly renewed by mitosis
at the basal cell layer; turnover time ranges from 5 to 16 days
B. Connective tissue—referred to as lamina propria
1. Subdivided into two layers:
a. Papillary layer—directly under the epithelial layer; tattoo dye is
injected into this portion of tissue
b. Reticular layer—dense fibrous layer located under the papillary
layer; wrinkles in the skin occur because of degradation of the
reticular layer
2. Forms a mechanical support system and carries

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 a. Blood vessels
b. Nerves
C. Submucosa
1. Layer of loosely organized connective tissue
2. Present only in areas that require a high degree of compressibility
and flexibility (e.g., cheeks, soft palate)
3. When present, submucosa is located between the lamina propria
and areas of muscle tissue
D. Interface
1. Area of interdigitation between the oral epithelium and connective
tissue
2. Epithelial extensions into connective tissue (lamina propria) are
called ridges or rete pegs (see Figure 2-20, A)
3. Connective tissue extensions into overlying epithelium are called
connective tissue papillae
4. Corrugated arrangement
a. Increases the surface area between the two tissues
b. Increases the strength of the junction between the two tissues
c. Decreases the distance between the blood supply and the
epithelium, which does not have its own blood supply; blood
vessels are carried to the epithelium in connective tissue
through connective tissue papillae
d. This rete peg arrangement is found in healthy attached gingiva,
the stippling of which is caused by this arrangement; healthy
sulcular epithelium does not have rete pegs
E. Basement membrane (see Figure 2-20, B)
1. Located between oral epithelium and connective tissue
2. Noncellular
3. Produced partly by epithelial cells and connective tissue cells
4. Composed of two layers:
a. The basal lamina is primarily the product of epithelial cells and
can be further divided into two layers:
(1) The clear layer adjacent to the epithelium is the lamina
lucida
(2) The denser layer closer to the connective tissue is the
lamina densa and is about 20 to 70 nm thick; it contains
some type IV collagen fibers that are produced by the
connective tissue
b. Reticular lamina is found below the basal lamina and is much
thicker than the basal layer; it contains collagen fiber produced
by connective tissue cells and plays a role in anchoring the basal

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 lamina to the underlying connective tissue
5. Epithelial cells form hemidesmosome attachments to the basal
lamina (see Figure 2-20)
F. Clinical changes in the oral mucosa
1. Inflammation, friction, heat, and chronic irritation produce changes
in the degree of keratinization
a. Inflammation causes a reduction in keratinization
b. Friction, heat, and chronic irritation cause an increase in
keratinization
c. Increased keratinization causes tissue appearance to be lighter
or whitish; in areas of the mouth that have minor salivary
glands, such as the soft palate, increased keratin may obstruct
the gland openings, producing the appearance of red dots on
hyperkeratinized tissue (nicotine stomatitis)
2. The appearance of the oral mucosa changes in response to
pathologic, dermatologic, systemic, allergic, and localized factors

Classifications of Mucosa
A. Masticatory—gingiva, hard palate (orthokeratinized epithelial
covering)
1. Histologic structure
a. Keratinized stratified squamous epithelium; rete pegs—
projections into the underlying connective tissue
b. No submucosa; no salivary glands
c. Fibrous connective tissue; gingival fibers
2. Clinical appearance
a. Coral pink; influenced by vascularity, the thickness and degree
of keratinization of the epithelium, and the presence of pigment
cells
b. Texture—stippled, the result of the rete peg arrangement
c. Consistency—firm, caused by the fibrous content (mostly
collagen) of the underlying connective tissue
B. Lining—lips, cheeks, floor of mouth, ventral surface (underside) of
tongue, soft palate, alveolar mucosa (nonkeratinized epithelial covering)
1. The floor of the mouth is the thinnest part of the nonkeratinized
squamous epithelial lining mucosa (100 µm)
2. Connective tissue of the lining mucosa has more elastic fiber than
that of the masticatory mucosa; fluid disperses readily in this area,
making it an ideal site for local anesthetic injections

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Specialized Mucosa of the Tongue
A. Specialized covering found only on the top of the tongue; covered with
lingual papillae
B. Epithelial layer—stratified squamous epithelium that varies in
thickness and degree of keratinization
C. Taste buds are epithelial organs of special sense (taste); most taste
buds are found on lingual papillae; isolated buds may be found on the
soft palate and on the walls of the pharynx
D. Connective tissue papillae form specialized lingual papillae
1. Fungiform papillae—located on the dorsal aspect of the tongue;
mushroom shaped; a single taste bud may be present on the top
surface
2. Filiform papillae—most abundant of papillae; found covering the
entire top surface of the tongue; have no taste buds; elongated in
cases of “hairy” tongue
3. Circumvallate papillae—large papillae located in a V-shaped groove
at the base of the tongue; encircled by a deep groove; mushroom
shaped; taste buds are located on their sides; small salivary glands
(Ebner ’s glands) empty into surrounding grooves of taste buds
4. Foliate papillae—located along the sides of the tongue, near the
base; taste buds may be located on only one of the sides
E. No submucosa is present

Tissues of the Tooth

Dentin
A. Mature dentin composition
1. Chemical composition
a. Organic matter, 18%
b. Inorganic matter, 70%
c. Water, 12%
2. Tissue composition
a. Cells—odontoblasts
b. Fibrous material—collagen fibers (type I)
c. Ground substance—proteoglycans and glycoproteins
3. Calcification—deposition of crystals of the calcium salt
hydroxyapatite in the dentin, fibrous matrix, and ground substance
B. Process of dentogenesis
1. Dentin begins to form in the late bell stage of the developing tooth
germ (see Figure 2-17)

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2. Newly differentiated odontoblasts deposit the dentin matrix;
odontoblastic processes become surrounded by predentin (a newly
deposited, uncalcified dentin matrix); predentin becomes calcified as
cells deposit more dentin; predentin is adjacent to the pulp in young
teeth
3. Each cell process in mature calcified dentin is enclosed in a dentinal
tubule (Figure 2-21)

FIG 2-21 Odontoblastic process with its cell process enclosed in dentinal
tubule. (From Chiego DJ: Essentials of oral histology and emb ryology: a clinical
approach, ed 4, St Louis, 2014, Elsevier.)

a. Dentinal tubules can run from the DEJ to the periphery of the
dental pulp, where cell bodies of odontoblasts are located
b. Tubules follow a primary S-shaped curve (pathway) and
secondary S-shaped curves along the length of the tubules

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 (1) Primary S-shaped curves are caused by the movement of
odontoblasts from a wider area to a narrower area, which
produces crowding of the odontoblasts; because of the S-
shaped–curved movement, odontoblasts adjust to the new
crowding while moving back toward the dental pulp
(2) Secondary S-shaped curves are seen along the length of the
dentinal tubule as small waves in the tubules, about 4 µm
apart; may possibly be reflecting changes in the movement
of the odontoblasts during night and day
c. Tubules tend to have more branching at their terminal ends in
the crown of the tooth than in root dentin; root dentin has more
lateral branching, with fewer primary S-shaped curves
d. Higher tubular density in peripheral dentin makes teeth
particularly sensitive when exposed, almost as sensitive as the
dentin near the pulp
e. The diameter of tubules changes during the process of dentin
formation; the widest dentinal tubules are found in children and
are about 4 µm wide
4. The first layer of dentin immediately adjacent to the DEJ is called
mantle dentin; the remainder of the deposited dentin is called
circumpulpal dentin (around the pulp)
a. Mantle dentin
(1) The layer of dentin that is about 10 to 30 µm thick
(2) Differs from circumpulpal dentin because in addition to
collagen fibers normally found in dentin, it contains a
second group of thicker and heavier collagen fibers
(a) These fibers are deposited perpendicular to the DEJ
(b) These heavier collagen fibers are referred to as Korff’s
fibers
(3) Mantle dentin is less calcified than is circumpulpal dentin
b. Circumpulpal dentin
(1) Contains finer collagen fibers than does mantle dentin
(2) Fibers are deposited parallel to the DEJ
5. Dentin that forms immediately around the odontoblastic process is
called peritubular dentin
a. Forms a sheath around each odontoblastic process about 1 µm
thick
b. Consists of a matrix of delicate collagen fibers
c. Is highly calcified
d. Is the first dentin to be decalcified by bacterial enzymes when
exposed to caries

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 6. The remainder of dentin is called intertubular dentin
a. Consists of large, coarse collagen fibers
b. The matrix is less calcified than that of peritubular dentin
c. Produced first by the odontoblast; then the odontoblast
produces its peritubular dentin
7. Once dentin is deposited, it does not undergo any remodeling
C. Types
1. Primary dentin—refers to dentin deposited before completion of the
apical foramen
2. Secondary dentin—refers to dentin formed after completion of the
apical foramen; tends to be more calcified than primary dentin;
forms at a slower rate
3. Reactive (reparative) dentin—forms rapidly in localized areas where
dental tubules have been exposed to external traumas such as:
a. Dental caries
b. Attrition or bruxism (enamel has been mechanically worn away)
c. Thermal extremes
4. Sclerotic dentin—forms when the dentinal fibers have degenerated
and the tubules become filled with calcium salts
5. Dead tracts—dentinal tubules that remain unfilled after dentinal
fiber degeneration
6. Interglobular dentin—small areas of unmineralized dentin near the
DEJ
7. Tomes’ granular layer—small unmineralized areas of dentin beneath
the cementum (may play a role in root sensitivity)
D. Sensory conduction
1. Nerves associated with dentin are located in the dental pulp, but it is
believed that they monitor the changes in the environment of
odontoblasts, which allows for the perception of pain
2. When dentinal tubules become exposed to the outside environment,
a direct contact is made with the dental pulp; fluid in open, exposed
tubules begins to evaporate, and the movement of fluid caused by
evaporation may stimulate the nerves closest to odontoblasts to
produce pain (dentinal hypersensitivity) (see the section “Control of
Dentinal Hypersensitivity” in Chapter 16)

Pulp Tissue
A. Structure
1. Most centrally located tissue in the tooth
2. Loose connective tissue

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 3. Cells
a. Fibroblasts—undifferentiated mesenchymal cells
b. Histiocytes—found along blood vessels; sometimes referred to
as macrophages when filled with ingested materials
c. Lymphocytes—when present, tend to be near the odontoblastic
layer
d. Cells present in diseased pulp include monocytes,
polymorphonuclear leukocytes, eosinophils, and plasma cells
e. No fat cells are present
4. Structural arrangement
a. The outer periphery of the pulp gives rise to the odontoblastic
cell layer
b. The layer subjacent to the odontoblastic layer is called the cell-
free zone, or the zone of Weil
c. Next to the cell-free zone is a relatively cell-rich zone
d. The core of the pulp is centrally located
B. Functions
1. Nutritive functions—very rich blood supply that forms a capillary
plexus surrounding odontoblasts
2. Formative function—peripheral layer of pulp cells gives rise to
odontoblasts
3. Sensory function—naked nerve fibers travel as free nerve endings
and make contact with odontoblasts
4. Protective function—the pulp can respond to stimuli that occur
outside the tooth; response may trigger the formation of reactive
dentin
C. Blood supply and nerves
1. Blood vessels enter the pulp through the apical foramen; one or
more small arterioles form a rich capillary plexus under the
odontoblastic layer; exchange of nutrients occurs across the capillary
wall
2. Two types of nerve fibers enter the pulp:
a. Autonomic nerve fibers—only the sympathetic autonomic nerve
fibers are present; they regulate blood flow in the vessels
b. Afferent nerve fibers—come from the second and third
branches of the trigeminal nerve; they lose their myelin sheath
and terminate as free nerve endings in close association with
odontoblasts; it is thought that the presence of free nerve
endings is responsible for the perception of pain by the dental
pulp
D. Pulp changes

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 1. Changes resulting from aging
a. As the tooth ages, the amount of collagen fibers increases and
the number of reticulin fibers decreases; in addition, the ground
substance loses considerable water
b. The pulp becomes less cellular and more fibrous
c. The size of the pulp decreases because of the continued
deposition of dentin
2. Small calcified bodies, called denticles, may be present
a. The three types of denticles are:
(1) True denticles—form during tooth development in the
root; have dentinal tubules in their structure; odontoblasts
are present on the periphery
(2) False denticles—form when the components of the pulp
start to degenerate; calcify and grow into irregular calcified
bodies; dentinal tubules are not usually present
(3) Diffuse calcifications—occur in diseased pulp in many
locations; are likely to grow and cause problems
b. Both true and false denticles may be loose in the dental pulp,
attached to the dentin wall, or embedded in the dentin tissue
c. Calcified structures in the pulp appear radiopaque on
radiographs

Comparison of Pulp and Dentin

A. Dentin and the dental pulp are closely related functionally and
developmentally; both are products of the dental papilla (derived from
neural crest cells)
B. Two major differences exist between these tissues:
1. The pulp is a loose, noncalcified connective tissue; dentin is a highly
specialized, calcified connective tissue
2. The pulp is a very vascular tissue; dentin is avascular
C. Dentin and the pulp form the bulk of the fully developed tooth
D. During tooth development, the peripheral cells of the dental papilla
differentiate into odontoblasts and form dentin, while the core of the
dental papilla becomes the pulp

Enamel
A. Composition
1. Most highly calcified of all the dental tissues
2. Composed mainly of inorganic calcium salt and hydroxyapatite, with

138
 a small amount of protein material and water in the matrix
a. Inorganic component, 95%
b. Organic component, 1%
c. Water, 4%
B. Process of amelogenesis
1. Enamel formation, as with dentin formation, begins in the late bell
stage of tooth development
2. Shortly after the deposition of dentin, the inner enamel epithelial
cells of the enamel organ become secretory ameloblasts
a. Ameloblasts begin to deposit the enamel matrix, which is
mineralized almost immediately
b. Ameloblasts have tall columnar cell bodies that appear
hexagonal in cross section
c. The secretory process of the ameloblast is the shovel-shaped
Tomes’ process discussed earlier; the shape of the process is
closely related to the form of the structural units that make up
the fully developed enamel tissue
3. Ameloblasts pass through two main stages while depositing enamel:
a. Secretory stage—ameloblasts deposit the enamel matrix, which
contains both organic and inorganic components
b. Resorbing stage—ameloblasts remove most of the water and
organic components from the matrix
4. Enamel maturation begins before the completion of enamel
formation
a. First, very thin and needle-like hydroxyapatite crystals are
deposited in the matrix
b. During the process of enamel maturation, the crystals increase
in all dimensions, which is made possible by the continual
removal of water and organic components from the matrix
c. The hydroxyapatite crystals in enamel are four times larger than
those in bone, dentin, and cementum
C. Enamel rods—structural units of enamel
1. Enamel is composed of tightly packed masses of hydroxyapatite
crystals called enamel rods, or prisms
2. Rod formation is related to the shape of the Tomes’ process and the
orientation of crystals as they are deposited by ameloblasts
3. The prisms are rod-shaped structures that run from the DEJ to the
outer edge of the enamel surface
4. They are stacked in interlocking rows, one on top of the other; the
stacking arrangement causes the rods to appear as keyhole-shaped
prisms when viewed in cross section, with the top of the keyhole

139
 facing the occlusal or incisal edge of the tooth and the tail facing the
cervical portion; four ameloblasts contribute to form one keyhole
(Figure 2-22)

FIG 2-22 Enamel rod, the basic unit of enamel. A, Relationship of the rod
to enamel. B, Scanning electron micrograph of enamel showing head
(H) and tail (T). (B from Fehrenbach MJ, Popowics T: Illustrated dental emb ryology,
histology, and anatomy, ed 4, St Louis, 2016, Elsevier.)

5. The average width of an enamel rod is approximately 4 µm; the rods

are narrower near the DEJ and wider near the outer surface of the
enamel
6. The crystals in the head region of the rod are oriented with their
long axis parallel to the long axis of the rod; in the tail region,
crystals are perpendicular to the long axis of the rod
7. Adjacent rods are separated from each other by rod sheaths

140
 approximately 0.1 to 2.0 µm wide; they can be observed in the head
region of the rods but are not as clearly defined in the tail region;
and they are produced by an abrupt change in the angulation
(orientation) of the crystals as they are deposited by the moving
ameloblast (Figure 2-23)

FIG 2-23 Ameloblast depositing hydroxyapatite crystals from the Tomes’

process. Note the angular change in the orientation of crystals being
deposited, which accounts for the rod sheath around the head of the rod.
(Modified from Dr. Marlene Klyvert, Columbia University, School of Dental and Oral
Surgery, New York.)

8. Rodless enamel may be found near the DEJ and the outer surface of
the enamel
9. The rods are perpendicular to the outer surface of the enamel; near
the cervix of the tooth, they tend to be oriented apically; toward the
inner third of the enamel, groups of rods curve but then straighten
out to form right angles with the enamel surface
D. Microscopic structures
1. Bands of Hunter-Schreger—alternating light and dark bands;
perpendicular to the DEJ; manifest as a result of enamel rod
curvature
2. Stripes of Retzius—narrow brown lines that extend diagonally from
enamel rods; on the tooth surface, they end in shallow furrows
known as perikymata
3. Enamel lamellae—cracks that occur during enamel crystallization
4. Enamel tufts—hypomineralized inner ends of some enamel rods;

141
 located in the DEJ area
5. Enamel spindles—terminal portions of dentinal fibers that extend
across the DEJ into the enamel
E. Clinical importance
1. Dental procedures performed on enamel
a. Application of fluoride—because enamel is semi-permeable,
fluoride ions are attracted to the hydroxyapatite crystals;
fluoride also changes hydroxyapatite into fluorapatite; the tooth
becomes more resistant to acids produced by bacteria
b. Acid etching of enamel—the structure of enamel (rods and rod
sheaths) allows acid to penetrate it for a limited distance
(30 µm), and the acid attacks the mineral at the periphery of the
sheaths; the acid thus creates a rough enamel surface, which
helps bonding materials adhere more readily; the acid may
attack the rod core and produce the same effect
c. Cavity preparations—all rods are supported by dentin; margins
will fail if enamel is left unsupported
2. Tetracycline stains
a. Appear clinically as dark bands through enamel, especially near
the cervix of the tooth where enamel is thin
b. Caused by the administration of tetracycline (antibiotic) during
the formation of teeth
c. Tetracycline binds chemically to organic and inorganic
components of bone and dentin
d. The resulting darkened area shows through enamel, making the
fully developed tooth appear unattractive
e. Stains are difficult to bleach out; affected teeth may need
crowns or veneers, but only for aesthetic purposes
3. Pits and fissures in enamel
a. Are often present in less calcified areas
b. Form where ameloblasts become crowded between adjacent
areas (cusps), resulting in incomplete maturation of enamel
c. Place teeth at increased risk for dental caries
d. Require the application of dental sealants to prevent caries and
arrest incipient caries

Cementum
A. General properties and functions
1. Calcified connective tissue that covers the roots of teeth; in
conjunction with the alveolar bone proper and the periodontal

142
 ligament, forms the attachment apparatus of the teeth, allowing the
teeth to become suspended in the jaw
2. Derived from the dental sac (dental follicle)
3. Resembles bone in structure and composition; major differences are:
a. Bone is a vascularized tissue
b. Cementum is avascular
4. Least mineralized of the calcified tissues of the tooth
B. Mature cementum composition
1. Chemical composition
a. Organic components, 23%
b. Inorganic components, 65%
c. Water, 12%
2. Tissue composition
a. Cells—cementoblasts, cementocytes
b. Fibrous matrix—collagen fibers (type I); dominant component
of the tissue, 90%
c. Ground substance—proteoglycans
C. Process of cementogenesis (Figure 2-24)

143
 FIG 2-24 Relationship of the epithelial root sheath to the forming root and the
formation of cementum.

1. After crown formation is complete, the epithelial root sheath

(Hertwig’s root sheath) begins to grow down
a. Shapes the root of the tooth
b. Induces the formation of root dentin
2. After the first root dentin is deposited, the root sheath breaks down;
cells from the dental sac migrate onto the newly deposited dentin
and differentiate into cementoblasts
D. Mature cementum (fibrous matrix)
1. Very little cementum is deposited on the developing root until the
tooth reaches functional occlusion (only approximately two thirds of
the root has been formed when the tooth erupts)
2. Cores of fibers remain uncalcified in the calcified cementum;
referred to as Sharpey’s fibers

144
E. Cellular and acellular cementum (Figure 2-25)

FIG 2-25 Relationship of the primary acellular cementum to the secondary

(cellular) cementum, or root of tooth. Note the thickness of the cellular
cementum near the tooth apex.

1. Acellular cementum (primary cementum)

a. Cervical half of the tooth is covered with a thin layer of
cementum, approximately 10 µm thick
b. Does not contain any embedded cementocytes (cementoblasts)
in lacunae
c. Forms at a slower rate than does cellular cementum
d. Does not increase during the life of the tooth
e. Appears to be involved more in maintenance than in the
production of the tissue
f. Contains less inorganic matrix than does cellular cementum

145
 g. Better calcified than cellular cementum
2. Cellular cementum (secondary cementum)
a. Apical portion of the tooth is covered with cellular cementum,
reaching a thickness of 100 to 150 µm
b. Contains cementocytes trapped in the lacunae of the tissue
c. Deposited throughout the life of the tooth
d. Deposited at intervals (pauses), producing arrest lines—highly
calcified lines similar to those seen in bone tissue
F. Abnormalities
1. Reversal lines
a. May be present in cementum as in bone tissue
b. Reflect resorption of tissue (remodeling)
c. Resorption of cementum does not occur as frequently as in bone
tissue; when it does occur, it is usually associated with:
(1) Extreme orthodontic movement of the teeth
(2) Trauma to teeth
2. Cementicles
a. Small, abnormal calcified bodies occasionally found in the
periodontal ligament
b. Result of cellular debris (i.e., degenerating remnants of the
epithelial root sheath)
c. May be found:
(1) Attached to the cementum surface
(2) Free in the periodontal ligament
(3) Embedded in the cementum of the root
3. Hypercementosis
a. Local abnormal thickening of parts of the cementum
b. Usually found in the apical region, occurring on one or all of the
teeth
c. May be seen in cases of:
(1) Chronic inflammation of the tooth
(2) Loss of an antagonist tooth (no opposing tooth in the jaw)
(3) Additional eruption; compensatory cementosis takes place
(4) Tooth becoming fused with the surrounding alveolar bone
proper

Cemento-Enamel Junction
A. Three types of cemento-enamel relationships can occur during the
development of the tooth:
1. Cementum meets enamel edge to edge—occurs in approximately

146
 76% of all teeth
2. Cementum overlaps a small part of enamel—occurs in
approximately 14% of all teeth
3. Cementum is ditched with no exposed dentin—occurs in
approximately 10% of all teeth
B. Cemento-enamel relationships occur when root-cementum
development begins; this is related to the timing of the disruption
(breakdown) of the epithelial root sheath and allows the cells from the
dental sac to differentiate and begin depositing cementum
C. Differentiation of root dental papillae into odontoblasts is mediated
by a cell-to-matrix type of inductive interaction (between the basal
lamina of Hertwig’s root sheath and the undifferentiated root dental
papilla)
D. Differentiation of dental sac cells into cementoblasts is mediated by a
cell-substrate type of inductive interaction between sac cells and newly
deposited dentin
E. Practicing dental hygienists should use caution during
instrumentation in areas where cementum is thin or absent; conservation
of tooth structure is recommended
F. Recession of gingiva and loss of clinical attachment may also leave
exposed cementum or dentin, creating root sensitivity and increased risk
of root caries

Supporting Tissues
Alveolar Bone
A. The part of the bony maxilla and mandible, the alveolar process, in
which teeth are suspended in alveoli (bony sockets)
B. Existence or presence of alveolar bone is totally dependent on the
presence of dental roots; when teeth do not develop and erupt, alveolar
bone does not develop; when teeth are extracted, alveolar bone is
resorbed
C. Formed during the development and eruption of teeth; developing
teeth, primary or permanent, are located in bony crypts in the bone of
the maxilla or of the mandible
D. Has the same biophysical and chemical properties as other bone
tissue in the body; has the same basic components as other connective
tissue
1. Cells—osteoblasts, osteocytes, osteoclasts
2. Fibrous matrix—collagen fibers are the dominant component;

147
 calcified by deposition of the calcium salt hydroxyapatite into the
matrix
3. Ground substance—proteoglycans
E. Gross anatomy of a mature bone socket (Figure 2-26)

FIG 2-26 Components of alveolar bone. A, Mandibular arch of the skull with
teeth removed. B, Portion of the maxilla of a skull with teeth removed. C, Cross
section of mandible with teeth removed. (From Fehrenbach MJ, Popowics T: Illustrated
dental emb ryology, histology, and anatomy, ed 4, St Louis, 2016, Elsevier.)

1. Each tooth is suspended in its own alveolus (socket), with each

alveolus having the same structure and anatomy
a. Outer cortical (compact lamellar) plate of bone—faces the cheek
and lips (buccal)
b. Inner cortical (compact lamellar) plate of bone—faces the
tongue and palate (lingual)

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 c. Spongiosa—cancellous bone sandwiched between the cortical
plates of bone
2. Alveolar bone proper—the part of the alveolus directly facing the
root of the tooth; follows the general outline of the root; sometimes
referred to as the cribriform plate, or lamina dura
a. Cribriform plate
(1) Contains numerous small openings; allows blood vessels
and nerves in the periodontal ligament and bone to
communicate
(2) Consists of two layers of bone:
(a) Compact lamellar bone
(b) Layer of bundle bone into which the periodontal
fibers insert themselves; the cores of the fibers remain
uncalcified in the calcified tissues of bone or
cementum, called Sharpey’s fibers
b. Lamina dura is purely a radiographic term based on this area
appearing more radiopaque on radiographs; it is not more
calcified than the rest of the bone socket; rather, the opacity is
caused by the two-dimensional view of the compact bone in the
area
c. Alveolar bone proper that forms sockets around multiple-rooted
teeth consists of the cribriform plates of both the roots and
some spongy bone, called inter-radicular alveolar bone
d. The alveolar bone proper between teeth consists of the
cribriform plates of both the teeth and some spongy bone,
called interdental alveolar bone
e. Spongiosa is composed of small trabeculae of bone with large,
narrow spaces between the trabeculae
3. The alveolar bone proper (cribriform plate) is the only essential part
of the bone socket; spongiosa and outer and inner cortical plates of
bone are not always present; spongiosa may be absent, and outer
and inner cortical plates may be fused together
4. Trabeculae of the spongiosa reflect functional forces or loading
patterns imposed on teeth; the pattern changes when the forces are
altered; two principal directions of the trabeculae are parallel and
perpendicular to the direction of the imposed forces; trabecular
bone orientation can be observed on radiographs; the number of
trabeculae increases with increased function
5. Orthodontic movement of teeth always causes remodeling of the
alveolar bone proper to accommodate movement of teeth; it affects
the insertion of periodontal ligament fibers in the bundle bone but

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 is a localized type of resorption; when the bundle bone is
redeposited, fibers become firmly attached again; with pressure,
bone is resorbed; when tension is applied, bone formation occurs
6. Radiographs of teeth may be used to show the height or slope (or
both) of the interdental bone septum, which may reflect periodontal
disease or other disease; the crest of the alveolar bone is usually
between 0.75 and 1.49 mm from the cemento-enamel junction
7. The periosteum is a dense connective tissue layer on the outer
portion of bone and is active in bone formation
8. The endosteum lines the inner aspects (medullary cavity) of bone
F. Alveolar bone is constantly remodeled by means of resorption and
formation; this makes it the least stable of periodontal tissues
1. Alveolar bone is affected by function, age-related and disease-
related changes, hormones, and other systemic and host factors
2. Remodeling affects the height, contour, and density of alveolar bone

Periodontal Ligament
A. A specialized form of connective tissue derived from the dental sac
that contributes to the attachment of teeth
B. Consists of groups of fiber bundles called gingival fibers and principal
fiber bundles; areas of loose connective tissue, blood vessels, and nerves
are present between principal fiber bundles; areas of loose connective
tissue are called interstitial spaces
C. Tissue components
1. Fibroblasts of the periodontal ligament (PDL) are responsible for the
production of the fibrous matrix and the ground substance; they are
continually engaged in synthetic activities, rebuilding and producing
new fibers to be incorporated into existing fibers, which are
constantly being remodeled; PDL has a very fast turnover rate
2. Ground substance—proteoglycans
3. The fibrous matrix is the dominant component of the PDL
a. The fibers are collagen and oxytalan, with a few elastic fibers
associated with blood vessels
b. The fibers are arranged in dense bundles inserted into the
alveolar bone proper and cementum
c. The fibers are arranged into two groups:
(1) Gingival fiber groups (Figure 2-27, B)

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 FIG 2-27 Connective tissue fibers. A, Principal fiber groups
of the periodontal ligament. B, Gingival fiber groups. C,
Gingival ligament fibers in the col area. (Modified from Nanci A:
Ten Cate‘s oral histology: development, structure, and function, ed 8, St
Louis, 2013, Elsevier.)

(a) Dento-gingival fibers—extend from the cervical

cementum to the free gingiva and from the cervical
cementum to the lamina propria of the gingiva, over
the alveolar crest
(b) Dento-periosteal fibers—extend from cervical
cementum over the alveolar crest to the periosteum of
the cortical plates of bone
(c) Trans-septal fibers—extend from the cementum of the
tooth to the adjacent tooth, over the alveolar crest
(d) Circular fibers—extend horizontally around the most
cervical part of the root and insert into the cementum
and lamina propria of the gingiva and the alveolar crest
(2) Principal fiber groups (see Figure 2-27, A)
(a) Alveolar crest fibers—extend from cervical cementum

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 and insert themselves into the alveolar crest
(b) Horizontal fibers—extend at right angles to the long
axis of the root of the tooth in a horizontal plane from
alveolar bone to cementum; found in the cervical third
of the root
(c) Oblique fibers—slant occlusally from cementum to
alveolar bone; most abundant of the fiber bundles;
start at the apical two thirds of the root
(d) Apical fibers—radiate from apical cementum into
alveolar bone
(e) Inter-radicular fibers (seen only in multiple-rooted
teeth)—extend from the cementum in the furcation
area of the tooth to the inter-radicular alveolar bone
d. Sharpey’s fibers—the terminal portion of a PDL fiber that is
embedded in bone and cementum
e. Fiber groups are oriented to give the tooth optimal resistance to
all types of functional loading patterns
(1) Circular fibers resist rotational movements of the tooth
(see Figure 2-27, C)
(2) Alveolar crest and apical fibers resist pull of the tooth
from its socket
(3) Trans-septal fibers connect all teeth and maintain the
integrity of the dental arches
f. Elastic fibers in the PDL do not contribute to the support of the
tooth; the role of the oxytalan fibers is not clear
D. Blood vessels
1. The blood supply of the PDL is very rich and highly developed, more
than in any other connective tissue; blood vessels are found in the
interstitial spaces of the ligament
2. Each tooth, with its PDL and alveolar bone, has a common blood
supply; a small artery branches off the main artery that supplies the
jaw and enters the following:
a. Apical foramen of the tooth, which supplies the pulp of the
tooth
b. Periodontal ligament, which supplies the areas all around the
tooth
c. Alveolar bone of the tooth
3. Once blood vessels enter the pulp chambers, they are isolated from
surrounding tissues, but vessels supplying the PDL and alveolar
bone are richly interconnected through openings in the cribriform
plate

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E. Nerves
1. The PDL contains two types of nerves:
a. Autonomic—sympathetic fibers that travel with blood vessels;
these regulate blood flow to the tissues
b. Afferent sensory fibers—mostly myelinated nerves from the
branches of the second and third divisions of the trigeminal
nerve (fifth cranial nerve)
2. Two types of nerve endings are found in the PDL:
a. Free, unmyelinated nerve endings—responsible for pain
sensation
b. Encapsulated nerve endings—responsible for registering
pressure changes
F. The width of the PDL varies with the functional forces placed on the
tooth and at different levels of the root (apex and cervix)
1. The width is greater in young adults (0.21 mm) than in older adults
(0.15 mm)
2. The width is greater near the cervical and apical areas than in the
middle of the root
3. Minimal movement (rotations) of any tooth occurs around the axis in
the middle of the root; greatest movement occurs near the apex and
the cervix, accounting for the difference in the width of the PDL
along the root
4. The width is related to the amount of function and cellularity; an
actively functioning tooth has a slightly wider PDL and more
cellularity than does a nonfunctioning tooth
G. Abnormalities
1. Cementicles
2. Epithelial rests (cell rests of Malassez)
a. Remnants of the epithelium from the root sheath that did not
disintegrate; formed from a cluster of epithelial cells
surrounded by a basement membrane
b. In most cases, these rests are harmless, but they have the
potential to become cystic
3. Untreated periodontal disease can result in damage to the
supporting apparatus of the tooth and eventual loss of the tooth

Dento-Gingival Junction
A. The area on the tooth where enamel and the epithelium form a
junction; with aging, the junction is displaced more apically between
cementum and the epithelium

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B. First established as the tooth emerges into the oral cavity (Figure 2-28)

FIG 2-28 Tooth emerging into the oral cavity. Note that the reduced enamel
epithelium covering the tooth joins the oral epithelium. The reduced enamel
epithelium will form the initial junctional epithelium. A, Crown penetrating bone
and connective tissue. B, Contact of crown with oral epithelium. C, Fusion of
epithelia. D, Thinning of the epithelium. E, Rupture of the epithelium. F, Crown
emergence. G, Occlusal contact. (From Avery JK, Chiego DJ: Essentials of oral
histology and emb ryology: a clinical approach, ed 3, St Louis, 2006, Mosby.)

1. Developing tooth is covered with reduced enamel epithelium (REE),

consisting of:
a. A layer of outer enamel epithelial cells
b. Remnants of the stratum intermedium cell layers
c. Stellate reticulum
d. Postsecretory ameloblasts
2. Basal cells of oral epithelium covering the emerging tooth and outer
layer of cells of the REE begin to proliferate and soon grow together
to form one continuous unit; as the tooth emerges through the
combined epithelia, it forms the initial dento-gingival junction on
the enamel of the tooth
C. Dento-junctional epithelium
1. Gingival epithelium that faces the tooth
2. Composed of nonkeratinized stratified squamous epithelium
without rete pegs and divided into:
a. Sulcular epithelium
(1) Found occlusally at the same height as the free gingiva
(2) The sulcus forms a shallow pocket around the tooth, about
0.5 mm deep
(3) In the disease state, the sulcus deepens and exhibits rete
pegs and ulcerations

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 b. Junctional epithelium (see Figures 2-28 and 2-29)

FIG 2-29 The epithelial attachment is the part of the junctional

epithelium that attaches the junctional epithelium to the tooth
surface. Note that the outer external basal lamina is continuous
with the inner basal lamina, and between them are the cells of the
junctional epithelium. (From Fehrenbach MJ, Popowics T: Illustrated dental
emb ryology, histology, and anatomy, ed 4, St Louis, 2016, Elsevier.)

(1) Begins at the base of the sulcus

(2) Firmly attached to the tooth, enamel, cementum, or all by
hemidesmosomes
(3) Located between two basal laminae
(a) One basal lamina faces the enamel surface
(b) The second basal lamina faces the connective tissue of
the gingiva
(c) Basal laminae are continuous at the base of the
junctional epithelium (Figure 2-29)
3. A membrane called the primary cuticle intervenes between the basal
lamina of the junctional epithelium and the tooth surface
a. The primary cuticle is formed during the late stages of eruption
of the tooth
b. The composition of the cuticle is not known, but the cuticle
thickens with aging
4. The newly erupted tooth is covered with a thin, delicate membrane
(Nasmyth’s membrane)
a. Will float off the tooth surface if placed in a 10% solution of
hydrochloric acid
b. Contains some cells of the REE and the dental cuticle
5. In the area of the dento-gingival junction, the junctional epithelium
has the capacity to repair itself
6. The site of the dento-gingival junction is easily invaded by

155
 microorganisms and is the area where periodontal disease often
begins
For a review of the histology, see the listings in the Website
Information and Resources table.

Website Information and Resourc es

Source Website Address Description
University of http://www.dental.pitt.edu/informatics/periohistology/en/guin01m.htm Histology
Pennsylvania and slides of
Temple University, periodontal
1999 tissues and
quiz
questions
http://www.youtube.com/watch?v=zLiV-b1jS28 A video
describing
tooth
development
University of North http://www.med.unc.edu/embryo_images/ Images and
Carolina at Chapel text on
Hill normal and
abnormal
human
embryology

156
Suggested readings
Bath-Balogh M., Fehrenbach M.J. Dental embryology, histology and
anatomy. ed 3 St Louis: Saunders; 2011.
Chiego D. Essentials of oral histology and embryology, a clinical
approach. ed 4 St Louis: Elsevier; 2014.
Finkelstein M: Oral histology image index, The University of Iowa,
http://www.healthcare.uiowa.edu/anatomy/dental/oralhist/OHMAC/index
Accessed October 8, 2014.
Galil, KA: Anatomy and histology quizzes, University of Western
Ontario Department of Anatomy and Cell Biology:
http://www.drgalil.ca. Accessed October 8, 2014.
Ibsen O.A.C., Phelan J.A. Oral pathology for the dental hygienist. ed 6
St Louis: Saunders; 2014.

Chapter 2 review questions

Answers and rationales to chapter review questions are available on this
text’s accompanying Evolve site. See inside front cover for details.
Use Case A to answer questions 1 to 16.
Use Case B to answer questions 17 to 31.

Case A
Synopsis of Patient History
Age: 22
Sex: F
Height: 5′7″
Weight: 148 lbs

Vital Signs
Blood pressure: 110/55
Pulse rate: 68
Respiration: 14

Current Medications

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Medical History
Patient is a healthy 22-year-old girl with a history of a penicillin allergy.

Dental History
Patient reports for most recall appointments. She uses fluoride
toothpaste and a soft toothbrush. She flosses sporadically. Her chief
complaint is halitosis.

Social History
Patient lives with mother and younger brother.
She is a college student.

Chief Complaint
Gums bleed when she brushes. It also hurts to brush at times.

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Supplemental Oral Examination Findings
Extraoral and Intraoral Findings
The extraoral and intraoral exam reveals a tattoo on her neck and labial
mucosa and a white-coated tongue.

Gingival Examination
The gingiva is erythematous with localized areas appearing bright red.
The margins are rolled and in some areas irregular. The papillary shape
is bulbous. The texture is smooth and the consistency spongy.

Dentition
It is noted that she has pitting on all central incisors. Proximal caries are
recorded on the maxillary molars.

Radiographic Findings
There is no bone loss. There is an interproximal area of decay on the
mesial tooth #3 and the distal of #14.

Deposits
There is generalized heavy marginal and interproximal plaque. There is
generalized extrinsic yellow stain but no calculus.

Peridontal Charting
There is generalized bleeding on probing. The probing depths are within
normal limits, with the exception of 4-mm probing depths on the mesial
of teeth #4 and #13. There is no attachment loss.

Use Case A to answer questions 1 to 16, as needed.

1. What type of epithelial tissue is found in the area of the labial
mucosa?
a. Simple squamous epithelium
b. Simple cuboidal epithelium
c. Stratified squamous epithelium
d. Stratified cuboidal epithelium
e. Stratified columnar epithelium
2. The tissue of the labial mucosa is considered what type of mucosa?
a. Masticatory
b. Lining

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 c. Specialized
3. What type of epithelium is found on the neck?
a. Nonkeratinized stratified columnar
b. Nonkeratinized stratified squamous
c. Keratinized stratified columnar
d. Keratinized stratified squamous
e. Nonkeratinized simple squamous
4. Epithelial tissues are characterized by:
a. Much intercellular substance and few cells
b. No intercellular substance
c. Little intercellular substance and many cells
d. Intercellular substance in surface layer only
5. The last visible layer is nonkeratinized stratified epithelium is:
a. Basal cell layer
b. Prickle cell layer
c. Granular layer
d. Corneum layer
6. The cells of the outer layer of keratinized stratified squamous
epithelium:
a. Undergo constant mitosis
b. Contain large amounts of melanin
c. Are shaped like stars
d. Contain large amounts of keratin
e. Have several nuclei
7. Continuous replacement of cells is characteristic of which type of
epithelium?
a. Simple squamous
b. Stratified squamous
c. Pseudo-stratified columnar
d. Stratified transitional
e. Simple cuboidal
8. If the epithelium undergoes continuous cellular replacement, why
does the client’s tattoo remain?

160
 a. The tattoo ink keeps the surface cells from sloughing
b. The ink is placed in the spinosium layer
c. The ink is placed in the basal layer
d. The ink is placed in the papillary layer of the connective tissue
e. The ink is placed in the reticular layer of connective tissue
9. The client has a white coating on her tongue. The papillae that are
coated are:
a. Filiform
b. Fungiform
c. Foliate
d. Circumvallate
10. The tissue of the tongue labial mucosa is considered what type of
mucosa?
a. Masticatory
b. Lining
c. Specialized
11. In the oral cavity, one way in which lining mucosa differs from
masticatory mucosa is that:
a. Lining mucosa contains more muscle fibers
b. Masticatory mucosa contains glands
c. Lining mucosa has no submucosa
d. Lining mucosa is not keratinized
12. The anterior portion, or body, of the tongue develops from the:
a. Second branchial arch
b. Maxillary process
c. Mandibular process
d. Globular process
e. Rathke’s pouch
13. The client claims the pitting on all her central incisors has always
been present. She is told it is a condition called “enamel hypoplasia,” a
disturbance during the formation of enamel. It can occur as a result of:
a. Poor odontoblastic activity during matrix formation
b. Childhood diseases during the calcification stage
c. Too much fluoride during the calcification stage

161
 d. Poor deposition of the enamel matrix and not its actual calcification
14. Enamel is derived from the:
a. Outer enamel epithelium
b. Inner enamel epithelium
c. Stellate reticulum
d. Stratum intermedium
e. Reduced enamel epithelium
15. The client is told the caries on her maxillary molars has progressed
into the dentin. Caries in the dentin of the tooth progresses through the:
a. Interglobular dentin
b. Dentinal tubule
c. Secondary dentin
d. Predentin
e. Sclerotic dentin
16. Dentin is a product of the:
a. Dental lamina
b. Dental papilla
c. Dental organ
d. Dental cuticle
e. Dental sac

Case B
Synopsis of Patient History
Age: 55
Sex: F
Height: 5′3″
Weight: 160 lbs

Vital Signs
Blood pressure: 140/85
Pulse rate: 68
Respiration: 15

162
Current Medications

Medical History
Patient is a 55-year-old woman with a history of infective endocarditis.
She needs to be premedicated for dental treatment. She is currently
controlling her high blood pressure with Procardia. She has a history of
a cleft of the alveolar process and a cleft lip.

Dental History
Patient smokes two packs of cigarettes per day. She has tried to quit
twice. She complains of bleeding gums. Her chief complaint is

163
sensitivity in the area of her maxillary right premolars. She is a mouth
breather. She brushes twice a day and uses mouth rinse. She uses mints
at work for her breath.

Social History
Patient lives with husband and dog. She works as a bartender.

Chief Complaint
Appearance of teeth and gums

Supplemental Oral Examination Findings

Extraoral and Intraoral Findings
There is slightly visible scarring in the area of the lip repair and nicotine
stomatitis.

Dentition
It is noted that she has some missing maxillary teeth.
Pit and fissure caries on teeth #31 and #18.

Radiographic Findings
There is mild to moderate bone loss in the mandibular incisor area and
around all posterior teeth.

Deposits
Moderate generalized tobacco stain.
Generalized moderate supragingival and subgingival calculus and
plaque.

Periodontal Findings
Recession around the maxillary right premolars, but the gingiva in this
area is firm and stippled. She has a small zone of attached gingival tissue
in this area. All other areas reveal papillary and marginal inflammation.

Use Case B to answer questions 17 to 31, as needed.

17. When a cleft of the alveolar process is present, it occurs between the:
a. First and second premolars
b. Central incisors
c. Lateral incisor and canine
d. Canine and first premolar

164
 e. Central and lateral incisor
18. Which statement is correct?
a. Cleft lip occurs more frequently on the left
b. Cleft lip and palate always occur together
c. Cleft palate is more common in boys
d. Cleft lip and palate are hereditary
e. Cleft lip occurs equally in boys and girls
19. In the development of the oral cavity, the fusion of the embryonic
processes that form the palate is usually completed by the:
a. End of the fifth month in utero
b. End of the fifth week in utero
c. End of the second month in utero
d. End of the third month in utero
20. Which of the following structures does NOT fuse with the rest
during palate formation?
a. Nasal septum
b. Lateral nasal process
c. Right palatine process
d. Premaxillary process
e. Left palatine process
21. During palatal fusion, epithelial cells may become entrapped in the
line of fusion. These cells may later contribute to the formation of:
a. Teeth
b. A cleft palate
c. Cleft lips
d. Cysts
22. A cleft lip occurs when the maxillary process fails to fuse with the:
a. Palatine process
b. Lateral nasal process
c. Globular process
d. Mandibular process
e. Opposing maxillary process
23. With a cleft palate, the tooth that is most often missing or malformed

165
is the:
a. Central incisor
b. Lateral incisor
c. Canine
d. First premolar
e. Second premolar
24. The client has root sensitivity in the area of the maxillary right
premolars, where there is gingival recession. The client’s sensitivity in
this area is most likely related to:
a. Fluid entering the sulcular epithelium
b. Fluid entering the rodless enamel
c. Fluid entering the dentinal tubules
d. Fluid entering the lacuna of the cementum
25. The tooth sensitivity around the premolars is attributed to the nerve
sensation of the:
a. Cementum
b. Dentin
c. Pulp
d. Gingiva
26. The stippled texture of the gingiva may be attributed to:
a. Keratinization
b. Connective tissue projections
c. Presence of submucosa
d. Optimal blood supply
e. Pigmentation
27. The firm consistency of the gingiva is a result of the:
a. Collagenous nature of the lamina propria
b. Rete peg arrangement
c. Keratinization
d. Vascularity
e. Pigmentation
28. The color of the gingiva is affected by all the following EXCEPT:
a. Vascularity

166
 b. Rete peg arrangement
c. Keratinization
d. Thickness
e. Pigmentation
29. Attached gingiva extends from the mucogingival junction to the:
a. Free gingival margin.
b. Bottom of the pocket.
c. Cemento-enamel junction.
d. None of the above
30. Healthy attached gingiva contains:
a. Circular fibers
b. Rete pegs
c. Connective tissue papilla
d. Fibroblasts
e. All the above
31. Attached gingiva is composed of:
a. Keratinized stratified squamous epithelium
b. Nonkeratinized stratified squamous epithelium
c. Keratinized simple squamous epithelium
d. Pseudo-stratified columnar epithelium
e. Nonkeratinized simple squamous epithelium
32. The embryonic origin of all connective tissue is:
a. Mesenchyme
b. Fascia
c. Endoderm
d. Ectoderm
e. Epithelium
33. The site of muscle contraction is called the:
a. Sarcomere
b. I band
c. H zone
d. A band
e. Z line

167
34. The three types of muscle tissue are:
a. Skeletal, smooth, and striated voluntary
b. Cardiac, striated involuntary, and smooth
c. Nonstriated involuntary, cardiac, and skeletal
d. Striated involuntary, smooth, and cardiac
35. Bone formation that follows a cartilage pattern is called:
a. Endochondral
b. Intramembranous
c. Mesenchymal
d. Intercellular
e. Osteoblastic
36. The part of the neuron that conducts impulses toward the cell body
is called the:
a. Dendrite
b. Neurilemma
c. Axon
d. Myelin sheath
e. Neuroglia
37. An attachment plaque between a cell and a noncellular surface is
called a:
a. Desmosome
b. Tight junction
c. Hemidesmosome
d. Gap junction
38. The buccopharyngeal membrane is composed of:
a. Mesoderm and endoderm
b. Ectoderm and mesoderm
c. Ectoderm, mesoderm, and endoderm
d. Ectoderm and endoderm
39. Rathke’s pouch is the embryonic origin of the:
a. Thyroid gland
b. Palate
c. Globular process

168
 d. Pituitary gland
e. Nasal septum
40. In the area of the foramen cecum, epithelium invaginates deep into
the tissues and will eventually become the:
a. Pituitary gland
b. Lingual salivary gland
c. Submandibular salivary gland
d. Trachea
e. Thyroid gland
41. What separates the root and body of the tongue?
a. Lingual frenum
b. Median groove
c. Fungiform papillae
d. Third branchial arch
e. Circumvallate papillae
42. Tooth crown development begins during the:
a. Preeruptive stage
b. Eruptive stage
c. Prefunctional eruptive stage
d. Posteruptive stage
43. The cementum is derived from the:
a. Reduced enamel epithelium
b. Dental papilla
c. Outer enamel epithelium
d. Dental sac
e. Alveolar bone
44. Hertwig’s epithelial root sheath is derived from the:
a. Inner enamel epithelium
b. Reduced enamel epithelium
c. Primary enamel cuticle
d. Rests of Malassez
e. Periodontal ligament
45. The basement membrane of the developing tooth will become the:

169
 a. Cemento-enamel junction
b. Primary enamel cuticle
c. Dentino-cemental junction
d. Secondary enamel cuticle
e. Dentino-enamel junction
46. Which relationship between cementum and enamel at the CEJ cannot
occur?
a. Enamel overlaps cementum
b. Enamel and cementum just meet
c. Enamel and cementum do not meet
d. Cementum overlaps enamel
47. Remnants of Hertwig's epithelial root sheath found in the
periodontal ligament of a functioning tooth are called:
a. Enamel pearls
b. Rests of Malassez
c. Denticles
d. Cementicles
e. Intermediate plexuses
48. The mandible and maxilla are formed through what type of bone
formation?
a. Endochondral
b. Intramembranous
c. Circumferential
d. Lamellar
49. During cellular mitosis, what is the phase during which the
chromatids are held together by a centromere and the nuclear membrane
disappears?
a. Interphase
b. Prophase
c. Telophase
d. Metaphase
e. Anaphase
50. A decrease in the width of the periodontal ligament is most likely
caused by:

170
a. Hyperfunction
b. Hypofunction
c. Occlusal trauma
d. Inflammation

171
C HAPT E R 3

172
Anatomy and Physiology
Brenda Armstrong

Anatomy and physiology are subjects that focus on the structure,

organization, and function of the human body. Dental hygienists use
knowledge of anatomy and physiology most often during client
assessment, treatment, and evaluation; during oral radiographic and
pathologic examinations; and for the administration of local anesthetic
agents. This knowledge also allows a dental hygienist to determine
whether clients are functioning within normal limits, deviating from the
normal, or presenting with structures that are ectopic. Moreover, this
knowledge enables dental hygienists to link systemic and oral disease.
This chapter covers basic concepts: definitions of terms, cell structure
and function, and body systems, including the skeletal, muscular,
nervous, circulatory, lymphatic, digestive, endocrine, urinary, and
reproductive systems.

173
Basic concepts
Anatomy
A. Study of the structure of an organism and the relationships of its
parts; derived from the Greek word meaning “the act of cutting up”
B. Dissection is the principal technique used to isolate and study the
structural components of the body
C. Branches of anatomy
1. Gross anatomy—study of structures that can be identified with the
naked eye (see Chapter 4)
2. Microscopic anatomy—study of cells (cytology) and tissues
(histology) (see Chapter 2)
3. Developmental anatomy (embryology)—study of human growth and
development (see Chapter 2)

Physiology
Study of body functions—how the body parts work

Levels of Organization
See Figure 3-1.

174
 FIG 3-1 Levels of organization. (From Patton KT, Thibodeau GA, Douglas
MM: Essentials of anatomy and physiology, St Louis, 2012, Mosby)

The intricate human body is organized in a hierarchical order from

simple to complex. The levels of organization discussed below culminate
in the total organism, the human body.
A. Chemical level—organization of chemical structure separates living
and nonliving material; atoms, molecules, and macromolecules result in
living matter
B. Organelle level—organelles are structures made of molecules and
organized to perform specific functions; allow the cell to perform vital
functions; types include:
1. Endoplasmic reticulum
2. Golgi apparatus
3. Mitochondria
4. Peroxisomes

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 5. Proteasomes
C. Cellular level—cells comprise the basic structural and functional units
of an organism; the smallest living units in the human body
1. Nucleus surrounded by cytoplasm within a limiting membrane
2. Differentiate to perform unique functions
D. Tissue level—groups of cells and materials surrounding them that
work together to perform a particular function
1. Four major tissue types:
a. Epithelial tissue
b. Connective tissue
c. Muscle tissue
d. Nervous tissue
E. Organ level—different types of tissues joined together to form body
structures
1. Each organ has a unique size, shape, appearance, and placement in
the body (e.g., stomach, heart, liver, lungs, brain)
F. System level—related organs that have a common function (e.g.,
digestive system breaks down and absorbs molecules in food; organs
include the mouth, salivary glands, pharynx, esophagus, stomach, liver,
gallbladder, pancreas, small intestine, and large intestine)
G. Organism level—all the systems of the body combine to make up an
organism

Anatomic Nomenclature
Basic terms are needed to communicate regions and directions of the
body. The anatomic position provides a reference point for all other
terms (see the section on “Anatomic Nomenclature” in Chapter 4).
A. Anatomic position—erect body position with arms at the sides and
palms upward
B. Plane or section—imaginary flat surfaces that pass through the body
(Figure 3-2)

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 FIG 3-2 Directions and planes of the body. (Patton KT, Thibodeau GA, Douglas MM:
Essentials of anatomy and physiology, St Louis, 2012, Mosby.)

1. Sagittal plane—vertical plane dividing the body into right and left
sides; midsagittal plane bisects the body at the exact midline
2. Frontal plane—divides the body or organ into anterior and posterior
portions (may also be called the coronal plane)
3. Transverse plane—divides the body or organ into superior and
inferior portions (may also be called cross-sectional, or horizontal,
plane)

Body Cavities
The human body contains two major cavities, the dorsal cavity and the
ventral cavity. These two cavities are then sectioned into smaller cavities
that contain internal organs. The dorsal body cavities are in the back part
of the body. The ventral body cavities are on the front side of the trunk

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(Figure 3-3 and Table 3-1).

FIG 3-3 Major body cavities. (Patton KT, Thibodeau GA: Mosby’s handbook of
anatomy and physiology, ed 2, St Louis, 2014, Mosby.)

Table 3-1
Organs in the Ventral Body Cavities

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179
A. Dorsal cavity
1. Cranial cavity—formed by the cranial bones of the skull; contains
the brain
2. Vertebral cavity—formed by the vertebrae; contains the spinal cord
B. Ventral cavity
1. Thoracic (chest) cavity comprises the upper portion
a. Pericardial cavity—contains the heart
b. Pleural cavities—contain the lungs
c. Mediastinum—mass of tissue between pleural cavities; contains
all thoracic viscera except the lungs; includes the heart,
esophagus, trachea, and several large blood vessels
2. Abdominopelvic cavity
a. Upper (abdominal) cavity contains the stomach, spleen, liver,
gallbladder, small intestine, and most of the large intestine
b. Lower (pelvic) cavity contains the bladder, rectum, sigmoid, and
reproductive organs

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Cells
All living creatures or organisms are made up of one or more cells. Cells
in a multi-cellular organism have the ability to regenerate to sustain life.
As structural and functional units of the body, cells develop
characteristics and functionality, resulting in a large variety of cells in the
body (see the section on “General Histology” in Chapter 2).

Cellular Structure
See Figure 3-4.

FIG 3-4 Typical, or composite, cell. A, Artist’s interpretation of cell

structure. B, Color-enhanced electron micrograph of a cell. Both
show the many mitochondria, known as the “power plants of the cell.”
Note also the innumerable dots bordering the endoplasmic reticulum.
These are ribosomes, the cell’s “protein factories.” (From Patton KT,
Thibodeau GA: Anthony’s textbook of anatomy and physiology, ed 20, St Louis, 2013,
Elsevier.)

A. Plasma or cell membrane

1. Surrounds and contains the cytoplasm of a cell; composed of
proteins and lipids
2. Selective permeability characteristics
a. Protects cell from external environment
b. Permits the entrance and exit of selected substrates
c. Membrane proteins have several functions—channels and
transporters are integral proteins that help specific solutes
across the membrane; receptors serve as cellular recognition
sites; some membrane proteins are enzymes
3. Basic framework—lipid bilayer; two layers of phospholipids,
cholesterol, and glycolipids
B. Cytoplasm—all cellular contents between the plasma membrane and

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the nucleus; includes:
1. Cytosol—fluid portion of cytoplasm; site of many chemical reactions
for the cell’s existence
2. Cytoskeleton—network of several kinds of protein filaments that
extend throughout the cytoplasm; structural framework for the cell;
generates movement
3. Organelles—specialized cellular structures with characteristic
shapes and specific functions
C. Ribosomes
1. Free ribosomes—not attached to other organelles; synthesize
proteins used inside the cell
2. Bound ribosomes—attached to the endoplasmic reticulum (ER);
form rough ER; synthesize proteins destined for use in the plasma
membrane or for export from cell
D. Endoplasmic reticulum—network of membranes that form flattened
sacs called cisterns; arranged in parallel rows within the cytoplasm of a
cell; contains enzymes involved in a variety of metabolic activities
1. Rough ER (granular)
a. Contains ribosomes
b. Site of protein synthesis
2. Smooth ER (agranular)
a. No ribosomes present
b. Synthesizes certain lipids and carbohydrates
c. Contains enzymes that release glucose into the bloodstream and
inactivate or detoxify a variety of drugs and potentially harmful
substances, including alcohol, pesticides, and carcinogens
E. Golgi complex
1. Stack of 3 to 20 flattened membranous sacs (cisterns)
2. Within the cisterns, proteins are modified, sorted, and packaged into
vesicles for transport to different destinations
F. Lysosomes
1. Membrane-enclosed vesicles that form in the Golgi complex
2. Contain digestive enzymes
3. Function is the digestion of worn-out organelles (autophagy) and
self (autolysis)
G. Mitochondria
1. Ellipsoid bodies that consist of two membranes containing enzyme
complexes in a particular array (e.g., tricarboxylic acid cycle
enzymes)
2. Function as the “powerhouse of the cell” by transforming the
chemical energy bond of nutrients into the high-energy phosphate

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 bonds of adenosine triphosphate
3. A single cell may contain 50 to 2500 of these organelles, depending
on the cell’s energy needs
H. Nucleus
1. Consists of a double nuclear membrane, nuclear pores (control the
movement of substances into and out of nucleus), nucleoli (produce
ribosomes), and deoxyribonucleic acid (DNA)
I. Peroxisomes
1. Function to eliminate toxic substances from intercellular fluid
J. Proteasomes
1. Remove abnormal and misfolded proteins
2. Destroy specific normal proteins that are no longer needed

Movement of Substances through Cell Membranes

See Tables 3-2 and 3-3.

Table 3-2
Passive Transport Processes

Art from Patton KT, Thibodeau GA, Douglas MM: Essentials of anatomy and physiology,
St Louis, 2012, Mosby.

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Table 3-3
Active Transport Processes

Art from Patton KT, Thibodeau GA, Douglas MM: Essentials of anatomy and physiology,
St Louis, 2012, Mosby.
A. Passive transport processes—do not require energy expenditure of the
cell membrane
1. Diffusion—a passive process
a. Molecules spread through the membranes
b. Molecules move from an area of high concentration to an area of
low concentration (down a concentration gradient)
c. Eventually a state of equilibrium is reached
d. Membrane channels—pores in cell membranes through which
specific ions or small water-soluble molecules can pass
2. Simple diffusion—substances diffuse across a membrane in one of
two ways: lipid-soluble substances diffuse through the lipid bilayer,
ions diffuse through pores
3. Osmosis
a. Diffusion of water through a selectively permeable membrane
(limits diffusion of at least some solute particles); results in gain
of volume on one side of the membrane and loss of volume on
the other side of the membrane
b. A solution containing solute particles that cannot pass through
a membrane exerts osmotic pressure on the membrane
c. Potential osmotic pressure—maximum pressure that could

184
 develop in a solution when it is separated from pure water by a
selectively permeable membrane; knowledge of potential
osmotic pressure allows the prediction of the direction of
osmosis and resulting change of pressure
(1) Isotonic—when two fluids have the same potential
osmotic pressure
(2) Hypertonic (higher pressure)—cells placed in solutions
that are hypertonic to intracellular fluid shrivel as water
flows out of cells by osmosis faster than it enters
(3) Hypotonic (lower pressure)—a solution that has a lower
concentration of solutes than the cytosol inside the cell;
water molecules enter the cells by osmosis faster than they
leave
4. Facilitated diffusion (carrier-mediated passive transport)
a. Movement of molecules made more efficient by the action of
specific transport mechanisms in the plasma membrane;
facilitated by channel proteins or carrier proteins
b. Transports substances down a concentration gradient
c. Substances moved by facilitated diffusion include glucose,
fructose, galactose, urea, and some vitamins
5. Filtration
a. Passage of water and permeable solutes through a membrane by
the force of hydrostatic pressure; occurs most often in
capillaries
b. Small molecules travel down a hydrostatic pressure gradient
and through a sheet of cells; results in the separation of large
and small particles
B. Active transport processes—require the expenditure of metabolic
energy by the cell
1. Active transport
a. Process that moves substances against a concentration gradient
(from an area of low concentration to an area of high
concentration)
b. Opposite of diffusion
c. Substances moved by “pumps,” for example, calcium pumps
and sodium-potassium pumps
2. Endocytosis and exocytosis—allow substances to enter or leave the
interior of a cell without actually moving through its plasma
membrane
a. Endocytosis—process by which the plasma membrane “traps”
some extracellular material and brings it into the cell in a

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 vesicle; the two basic types are:
(1) Phagocytosis (cell eating)—large particles are engulfed by
the plasma membrane and enter the cell in vesicles; vesicles
fuse with lysosomes, where particles are digested
(2) Pinocytosis (cell drinking)—the plasma membrane folds
inward, forming a pinocytic vesicle containing a droplet of
extracellular fluid; the vesicle detaches from the plasma
membrane and enters the cytosol
b. Exocytosis—process by which large molecules, notably proteins,
can leave the cell, even though they are too large to move
through the plasma membrane; large molecules are enclosed in
membranous vesicles and then pulled to the plasma membrane
by the cytoskeleton, where the contents are released
(1) Provides a way for new material to be added to the plasma
membrane

Cell Metabolism
A. Metabolism—chemical reactions in a cell
1. Catabolism—breaking of large molecules into smaller ones; usually
releases energy
2. Anabolism—building of large molecules from smaller ones; usually
consumes energy
B. Role of enzymes
1. Enzymes—chemical catalysts, reducing activation energy needed for
a reaction
2. Regulate cell metabolism
3. Chemical structure of enzymes
a. Proteins of a complex shape
b. Active site—where the enzyme molecule fits the substrate
molecule; lock-and-key model
4. Enzyme nomenclature
a. Enzymes usually have an “-ase” suffix; the first part of the word
often signifies the substrate or the type of reaction catalyzed
b. Oxidation-reduction enzymes—known as oxidases, hydrogenases,
and dehydrogenases; energy release depends on these enzymes
c. Hydrolyzing enzymes—hydrolases, for example, digestive
enzymes
d. Phosphorylating enzymes—phosphorylases or phosphatases;
add or remove phosphate groups
e. Carboxylases and decarboxylases—add or remove carbon

186
 dioxide
f. Mutases or isomerases—rearrange atoms within a molecule
g. Hydrases—add water to a molecule without splitting it
5. Functions of enzymes
a. Regulate cell functions by regulating metabolic pathways;
specific in their actions
b. Chemical and physical agents called allosteric effectors alter
enzyme action by changing the shape of the enzyme molecule,
for example:
(1) Temperature
(2) Hydrogen ion (H+) concentration (pH)
(3) Ionizing radiation
(4) Cofactors
(5) End products of certain metabolic pathways
c. Most catalyze chemical reactions in both directions
d. Continually being destroyed and replaced
e. Many are first synthesized as inactive proenzymes
C. Catabolism—breakdown of larger molecules to smaller molecules.
1. Energy is needed to function and is obtained from the foods we eat;
the most efficient way for cells to harvest energy stored in food is
through cellular respiration, a catabolic pathway for the production of
adenosine triphosphate (ATP), a high-energy molecule expended by
working cells
2. Cellular respiration is what cells do to break up sugars into a form
that the cell can use as energy
3. There are three main stages of cellular respiration: glycolysis, the
citric acid cycle, and electron transport
a. Glycolysis
(1) The cellular degradation of the simple sugar glucose to
yield pyruvic acid, with ATP as an energy source
(2) Pathway in which glucose is broken apart into two pyruvic
acid molecules to yield a small amount of energy (which is
transferred to ATP and nicotinamide adenine dinucleotide
[NADH])
(3) Includes many chemical steps (reactions that follow one
another), each regulated by specific enzymes
(4) Can occur aerobically or anaerobically, depending on
whether oxygen is available
(5) Occurs within the cytosol (outside the mitochondria)
b. Citric acid cycle (Krebs cycle)
(1) Pyruvic acid (from glycolysis) is converted into acetyl

187
 coenzyme A (CoA) and enters the citric acid cycle after
losing carbon dioxide (CO2) and transferring some energy
to NADH
(2) A cyclic sequence of reactions that occurs inside the inner
chamber of a mitochondrion; the acetyl splits from the CoA
and is broken down, yielding CO2 and energy (in the form
of energized electrons), which is transferred to ATP, NADH,
and flavin adenine dinucleotide (FADH2)
c. The electron transport system (ETS)
(1) Energized electrons are carried by NADH and FADH2
from glycolysis and the citric acid cycle to electron
acceptors embedded in the cristae of the mitochondrion
(2) As electrons are shuttled along a chain of electron-
accepting molecules in the cristae, their energy is used to
pump accompanying protons (H+) into the space between
mitochondrial membranes
(3) Protons flow back into the inner chamber through carrier
molecules in the cristae; their energy of movement is
transferred to ATP
(4) Low-energy electrons coming off the ETS bind to oxygen
and rejoin their protons, forming water (H2O)
D. Anabolism—the opposite of catabolism; involves making larger
molecules out of smaller molecules
1. Anabolism allows the body to grow new cells and maintain all the
tissues
2. Protein synthesis is an example of a central anabolic pathway as
biologic cells generate new proteins (protein synthesis pathway is
outlined below)
3. DNA (see the section on “Genetics” in Chapter 7)
a. A double-helix polymer (composed of nucleotides); functions to
transfer the information encoded in genes, which directs protein
synthesis
b. Gene—a segment of a DNA molecule that consists of
approximately 1000 pairs of nucleotides; contains the code for
synthesizing one polypeptide
4. Transcription
a. Messenger ribonucleic acid (mRNA) forms along a segment of
one strand of DNA
b. Noncoding introns are removed, and the remaining exons are
spliced together to form the final edited version of the mRNA

188
 copy of the DNA segment
5. Translation
a. After leaving the nucleus and being processed, mRNA
associates with a ribosome in the cytoplasm
b. Transfer ribonucleic acid (tRNA) molecules bring specific
amino acids to the mRNA at the ribosome; the type of amino
acid is determined by the fit of a specific tRNA’s anticodon with
an mRNA’s codon
c. As amino acids are brought into place, peptide bonds join them,
eventually producing an entire polypeptide chain
6. Processing—enzymes in the ER and Golgi apparatus link
polypeptides into whole protein molecules or process them in other
ways

Cell Growth and Reproduction

A. Cell growth and reproduction of cells are the most fundamental of all
functions in a living being; together they constitute the life cycle of the
cell
1. Cell growth—depends on the use of the genetic information in DNA
to make structural and functional proteins for cell survival
2. Cell reproduction—ensures that genetic information is passed from
one generation to the next
B. Cell growth
1. Production of cytoplasm—more cell material is made, including
growth and replication of organelles and plasma membrane; a
largely anabolic process
2. DNA replication
a. Replication of the genome prepares the cell for reproduction;
mechanics similar to RNA synthesis
b. DNA replication
(1) DNA strand uncoils, and strands come apart
(2) Along each separate strand, a complementary strand
forms
(3) The two new strands are called chromatids (attached pairs);
their point of attachment is called a centromere
3. Growth phase of the cell’s life cycle—subdivided into the first phase
(G1), the DNA synthesis phase (S), and the second growth phase
(G2)
C. Cell reproduction
1. Mitosis—process of organizing and distributing nuclear DNA

189
 during cell division; cells reproduce by splitting themselves into two
smaller daughter cells (see the section on “Cell Replication” and
Figure 2-6 in Chapter 2)
2. Meiosis—germ cell division; produces gametes (sperm and oocytes),
the cells needed to form the next generation of sexually reproducing
organisms
D. Regulating the cell’s life cycle
1. Cyclin-dependent kinases (CDKs)—activating enzymes that drive
the cell through the phases of its life cycle
2. Cyclins—regulatory proteins that control the CDKs and “shift” them
to start the next phase; important in cancer pathways

190
Tissues
Cells that have a similar structure and function make up a tissue. Tissues
working together configure, connect, and hold together organs. The
study of tissues is referred to as histology (see the sections on “Concepts
Relating to Dental Tissues,” “Basic Tissues,” “Epithelial Tissue,”
“Connective Tissue,” “Blood and Lymph,” “Nerve Tissue,” and “Muscle
Tissue” in Chapter 2).

Body Membranes
A. Thin tissue layers that cover surfaces, line cavities, and divide spaces
or organs
B. Epithelial membranes are the most common
1. Cutaneous membranes (skin)
a. Primary organ of the integumentary system
b. One of the most important organs
c. Comprises approximately 16% of body weight
2. Serous membranes
a. Parietal membranes—line closed body cavities
b. Visceral membranes—cover visceral organs
c. Pleura—surround the lung and line the thoracic cavity
d. Peritoneum—covers the abdominal viscera and lines the
abdominal cavity
3. Mucous membranes (see the section on “Soft Tissue of the Oral
Cavity” and Figure 2-21 in Chapter 2)
a. Line and protect orifices that open to the exterior of the body,
for example, anus, vagina, and oral cavity
b. Line ducts and passageways of respiratory and digestive tracts
C. Connective tissue membranes
1. Have smooth and slick synovial membranes to reduce friction
between opposing surfaces in a movable joint; contain no epithelial
components
2. Synovial membranes—line bursae and the spaces between the bones
in joints; secrete synovial fluid

191
Systems of the body and their
components
The Integumentary System
The integumentary system is made up the skin, hair, nails, and glands
that provide a protective barrier for the internal environment of the body
from the external physical and biologic world.
A. Functions—regulation of body temperature, protection, sensation,
excretion, immunity, synthesis of vitamin D
B. Parts
1. Epidermis—thin outer portion composed of keratinized stratified
squamous epithelium
a. Components include keratin, melanin, Langerhans cells, Merkel
cells
b. Four layers:
(1) Stratum basale
(2) Stratum spinosum
(3) Stratum lucidum
(4) Stratum corneum
2. Dermis—deeper, thicker, connective tissue
a. Components include collagen and elastic fibers that give skin its
extensivity and elasticity; dermal papillae that produce
fingerprints and facilitate gripping objects; corpuscles of touch
(Meissner ’s corpuscles); and nerve endings that are sensitive to
touch
b. One layer
C. Skin color—from melanin, carotene, and hemoglobin pigments
D. Accessory structures—hair, skin glands, and nails
1. Hair—threads of fused, dead keratinized cells that have a protective
function
a. Consist of a shaft above the surface, a root that penetrates the
dermis and subcutaneous layer, and a hair follicle
2. Sebaceous glands—usually connected to hair follicles; absent in
palms and soles of feet; produce sebum, which moistens hair and
waterproofs skin
3. Sudoriferous glands—produce perspiration; carry waste to the skin’s
surface; assist in maintaining body temperature
4. Nails—hard keratinized epidermal cells covering terminal portions
of fingers and toes; the principal parts are body, free edge, root,
lunula, cuticle, and matrix

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Tissues and Membranes of the Body
A. Epithelial tissues
1. Form membranes that contain and protect the internal fluid
environment
2. Absorb nutrients
3. Secrete products that regulate functions involved in homeostasis
B. Connective tissues
1. Hold organs and systems together
2. Form structures that support the body and permit movement
C. Muscle tissues—work with connective tissues to permit movement
D. Nervous tissues—work with glandular epithelial tissue to regulate
body function

The Skeletal System

The skeletal system contributes about 20% of body weight. It comprises
the bones and cartilages, ligaments, and tendons related to the bones.
Bones are rigid living organisms that furnish the framework of the body
while protecting soft body parts. In addition to providing sites for muscle
attachment, the skeletal system enables bones and muscle to work
together for movement. It also contributes to blood cell formation and
storage of inorganic ions (calcium salts, sodium, magnesium, potassium,
and carbonate) (Figure 3-5; see the section on “Connective Tissue” in
Chapter 2.)

193
194
 FIG 3-5 Skeleton. A, Anterior view. B, Posterior view. (From Solomon
EP: Introduction to human anatomy and physiology, ed 2, St Louis, 2008, Saunders.)

A. Functions of the skeletal system

1. Provides rigid support system
2. Provides protection; for example, cranial bones protect the brain
3. Serves as a source and a sink for calcium; involved in the formation
of blood cells (hemopoiesis)
4. Basis of attachment of muscles; allows movement
B. Types of bones
1. Classified by shape
a. Long bones
b. Short bones
c. Flat bones
d. Irregular bones
2. Sutural bones—found between the sutures of certain cranial bones

195
C. Parts of a long bone
1. Diaphysis—shaft
2. Epiphyses—ends
3. Articular cartilage—layer of hyaline cartilage that covers the
articular surfaces of epiphyses; cushions jolts and blows to bone
4. Periosteum—white fibrous membrane that covers bone; contains
cells that form and destroy bone, blood vessels; point of attachment
for ligaments and tendons
5. Medullary (marrow) cavity
a. Tube-like hollow space in the diaphysis
b. Filled with narrow marrow in adult
6. Endosteum—epithelial membrane that lines the medullary cavity
D. Bone tissue
1. Most distinctive form of connective tissue
2. Extracellular components are hard and calcified
3. Rigidity allows its supportive and protective functions
4. Tensile strength nearly equal to cast iron at less than one-third the
weight
5. Bone matrix composition
a. Inorganic salts
(1) Hydroxyapatite—highly specialized chemical crystals of
calcium and phosphate contribute to the hardness of bone
(2) Slender needle-like crystals oriented to resist stress and
mechanical deformation
(3) Magnesium and sodium are also present
b. Organic matrix
(1) Ground substance—composite of collagenous fibers and
an amorphous mixture of protein and polysaccharides;
secreted by connective tissue cells
(2) Adds to the overall strength and resilience of bone

Microscopic Structure of Bone

See the section on “Bone” and Figure 2-9 in Chapter 2.
A. Compact bones’ microstructures
1. Osteons, or haversian systems—cylinder-shaped structural units
(living bone cells are located in these units); constitute the structural
framework of compact bone; surround canals that run lengthwise
through bone and are connected by transverse Volkmann’s canals;
permit the delivery of nutrients and removal of waste products
2. Four types of structures make up each osteon:

196
 a. Lamellae—concentric, cylinder-shaped layers of calcified matrix
b. Lacunae—small spaces containing tissue fluid; bone cells are
located between the hard layers of the lamellae
c. Canaliculi—ultra-small canals radiating in all directions from
the lacunae and connecting them to each other and to the
haversian canal
d. Haversian canal—extends lengthwise through the center of each
osteon; contains blood vessels and lymphatic vessels
B. Cancellous (spongy) bone
1. No osteons in cancellous bone; instead, it has trabeculae
2. Nutrients are delivered and waste products removed by diffusion
through tiny canaliculi
3. Bony spicules are arranged along the lines of stress, enhancing the
bone’s strength
C. Blood supply
1. Bone cells are metabolically active and need a blood supply, which
comes from the bone marrow in the internal medullary cavity of
cancellous bone
2. Blood vessels, lymphatic vessels, and nerves from the periosteum
penetrate bone by way of Volkmann’s canals; connect with vessels in
the haversian canals
D. Types of bone cells
1. Osteoblasts—bone-forming cells found in all bone surfaces;
synthesize and secrete osteoid, an important component of ground
substance; collagen fibrils line up in the osteoid and serve as a
framework for the deposition of calcium and phosphate
2. Osteoclasts—giant multi-nucleate cells that contain powerful
lysosomal enzymes that destroy bone matrix (resorption); contain
large numbers of mitochondria and lysosomes
3. Osteocytes—mature bone cells; maintain metabolism such as
exchange of nutrients and wastes with the blood

Bone Marrow
A. Myeloid tissue—specialized type of soft, diffuse connective tissue
found in the medullary cavities of long bones and in the spaces of spongy
bone; site for the production of blood cells
B. Two types of marrow occur during a person’s lifetime:
1. Red marrow
a. Found in virtually all bones in an infant or child’s body; in an
adult, red marrow found in ribs, bodies of the vertebrae,

197
 humerus, pelvis, and femur
b. Produces red blood cells
2. Yellow marrow
a. As an individual ages, red marrow is replaced by yellow marrow
b. Marrow cells become saturated with fat and are no longer active
in blood cell production
c. Yellow marrow can revert to red marrow during times of
decreased blood supply, for example, anemia, exposure to
radiation, and certain diseases

Regulation of Blood Calcium Levels

A. The skeletal system serves as a reservoir for approximately 98% of
body calcium reserves
1. Helps maintain the constancy of blood calcium
a. Calcium is mobilized in and out of blood during bone
remodeling
b. During bone formation, osteoblasts remove calcium from blood
and lower circulating levels
c. During breakdown of bone, osteoclasts release calcium into
blood and increase circulating levels
2. Homeostasis of calcium ion concentration essential for:
a. Bone formation, remodeling, and repair
b. Blood clotting
c. Transmission of nerve impulses
e. Maintenance of skeletal and cardiac muscle contraction

Divisions of the Skeleton

A. Axial skeleton—made up of 80 bones of the head, neck, and torso
B. Appendicular skeleton—made up of 126 bones that form the
appendages to the axial skeleton; the upper and lower extremities

Axial Skeleton
A. Skull (see Chapter 4)
B. Vertebral column (Figure 3-6)

198
 FIG 3-6 The vertebral column. (From Patton KT, Thibodeau GA: Anthony’s textb ook of
anatomy and physiology, ed 20, St Louis, 2013, Elsevier.)

1. Consists of 24 vertebrae plus the sacrum and the coccyx

2. Segments of the vertebral column
a. Cervical vertebrae (7)
b. Thoracic vertebrae (12), T1 to T12 are stronger than cervical
vertebrae; have facets for articulating with the ribs
c. Lumbar vertebrae (5), L1 to L5 are the largest and strongest
vertebrae; well adapted for the attachment of large back muscles
d. Sacrum (5 fused vertebrae)—provides strong foundation for
pelvic girdle
e. Coccyx (4 or 5 fused vertebrae)—articulates with the sacrum
3. Characteristics of vertebrae
a. All vertebrae, except the first, have a flat, rounded body
anteriorly and centrally, a spinous process posteriorly, and two

199
 transverse processes laterally
b. All vertebrae except the sacrum and the coccyx have a vertebral
foramen
c. The first cervical vertebra, the atlas, supports the head
d. The second cervical vertebra, the axis, has an upward projection
(dens) to allow the rotation of the head
4. The vertebral column as a whole articulates with the head, ribs, and
iliac bones
5. Individual vertebrae articulate with each other in joints between
their bodies and between their articular processes
C. Sternum
1. Dagger-shaped bone in the middle of the anterior chest wall made
up of three parts:
a. Manubrium—upper handle part
b. Body—middle blade part
c. Xiphoid process—blunt cartilaginous lower tip; ossifies during
adult life
2. The manubrium articulates with the clavicle and the first and second
ribs
3. Ribs join the body of the sternum, either directly or indirectly, by
means of costal cartilages
D. Ribs
1. Twelve pairs of ribs form the sides of the thoracic cavity
2. Each rib articulates with the body and the transverse process of its
corresponding thoracic vertebra
3. From its vertebral attachment, each rib curves outward and then
forward and downward
4. Rib attachment to the sternum:
a. Ribs 1 to 8 join a costal cartilage that attaches it to the sternum
b. The costal cartilage of ribs 8 to 10 indirectly joins the cartilage of
the rib above to the sternum (false ribs)
c. Ribs 11 and 12 are floating ribs, because they are not attached to
the sternum

Appendicular Skeleton
A. Upper extremity (Figure 3-7)

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 FIG 3-7 Right scapula and clavicle. (From Applegate E: The anatomy and physiology
learning system, ed 2, St Louis, 2011, Saunders.)

1. Consists of the bones of the shoulder girdle, upper arm, lower arm,
wrist, and hand
2. Shoulder girdle
a. Made up of the scapula and the clavicle
b. The clavicle forms the only bony joint with the trunk
(sternoclavicular joint)
c. At its distal end, the clavicle articulates with the acromion
process of the scapula
3. Humerus (Figure 3-8)

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 FIG 3-8 Humerus (upper arm). (Modified from Applegate E: The anatomy and
physiology learning system, ed 4, St Louis, 2011, Saunders.)

a. Longest bone of the upper arm

b. Articulates proximally with the glenoid fossa of the scapula and
distally with the radius and the ulna
4. Ulna (Figure 3-9)

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 FIG 3-9 Radius and ulna (lower arm). (Modified from Applegate E: The anatomy
and physiology learning system, ed 4, St Louis, 2011, Saunders.)

a. Long bone found on the little finger side of the forearm

b. Articulates proximally with the humerus and the radius and
distally with the fibrocartilaginous disc
5. Radius (Figure 3-9)
a. Long bone found on the thumb side of the forearm
b. Articulates proximally with the capitulum of the humerus and
the radial notch of the ulna; articulates distally with the
scaphoid and lunate carpals of the wrist
6. Carpal bones (Figure 3-10)

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 FIG 3-10 Bones of the hand and wrist. (From Patton KT, Thibodeau GA,
Douglas MM: Essentials of anatomy and physiology, St Louis, 2012, Mosby.)

a. Eight small bones that form the wrist; bound closely and firmly
by ligaments; arranged in two transverse rows:
(1) Top row made up of the pisiform, the triquetrum, the
lunate, and the scaphoid
(2) Bottom row made up of the hamate, the capitate, the
trapezoid, and the trapezium
b. Joints between the radius and carpals allow wrist and hand
movements
c. Carpal tunnel—concavity formed by the pisiform and the
hamate (on the ulnar side) and the scaphoid and the trapezium
(on the radial side), through which the median nerve passes;
narrowing of the carpal tunnel gives rise to carpal tunnel
syndrome
7. Metacarpal bones
a. Form the framework of the hand

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 b. The thumb metacarpal forms the most freely movable joint with
the carpals
c. The heads of the metacarpals (knuckles) articulate with the
phalanges
8. Phalanges—bones of the fingers
B. Lower extremity
1. Consists of the bones of the hip, thigh, lower leg, ankle, and foot
2. The pelvic girdle is made up of the sacrum and the two coxal (hip)
bones bound tightly by strong ligaments
a. A stable circular base that supports the trunk and attaches the
lower extremities to the axial skeleton
b. Each coxal bone is made up of three fused bones:
(1) Ilium—largest and uppermost part
(2) Ischium—strongest and lowermost part
(3) Pubis—anterior and inferior part
3. Femur—longest and heaviest bone in the body (Figure 3-11)

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 FIG 3-11 Bones of the thigh and leg. (Modified from Herlihy B: The human b ody
in health and illness, ed 5, St Louis, 2015, Elsevier.)

4. Patella—kneecap; small triangular bone in front of the joint between

the femur and the tibia
5. Tibia
a. Larger bone of the leg; bears the weight of the body
b. Articulates proximally with the femur to form the knee joint
c. Articulates distally with the fibula and the talus of the ankle
6. Fibula
a. Smaller, more laterally and deeply placed of the two shin bones
b. Articulates with the tibia
7. Foot (Figures 3-12 and 3-13)

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 FIG 3-12 The foot. A, Bones on the right foot viewed from above. Tarsal
bones consist of cuneiforms, navicular, talus, cuboid, and calcaneus. B,
Posterior aspect of the right ankle skeleton and inferior aspect of the
right foot skeleton. C, X-ray film of the left foot showing prominent
sesamoid bones near the distal end (head) of the first metatarsal bone of
the great toe. (From Patton KT, Thibodeau GA: Anthony’s textb ook of anatomy and
physiology, ed 20, St Louis, 2013, Elsevier.)

FIG 3-13 Arches of the foot. (From Solomon EP: Introduction to human anatomy
and physiology, ed 2, St Louis, 2008, Saunders.)

a. The structure is similar to that of the hand, with adaptations for

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 supporting weight
b. Foot bones are held together to form spring arches
(1) Tarsus (ankle)—contains seven bones: calcaneus (heel
bone), talus (ankle bone), cuneiforms, cuboid, and navicular

Joints
A. Classification of joints
1. Structural—based on the presence or absence of synovial cavity and
type of connecting tissue; classified as fibrous, cartilaginous, or
synovial
2. Functional—based on the degree of movement permitted; joints may
be synarthroses (immovable), amphiarthroses (slightly movable), or
diarthroses (freely movable)
B. Fibrous joints (Figure 3-14)

FIG 3-14 Fibrous joints. (From Patton KT, Thibodeau GA: Anthony’s textb ook of anatomy
and physiology, ed 20, St Louis, 2013, Elsevier.)

1. Bones held together closely by fibrous connective tissue

a. Syndesmoses—joints in which ligaments connect two bones
b. Sutures—found only in the skull; tooth-like projections from
adjacent bones interlock with each other
c. Gomphoses—found between the root of the tooth and the
alveolar process of the mandible or the maxilla
C. Cartilaginous joints (Figure 3-15)

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 FIG 3-15 Cartilaginous joints. (From Patton KT and Thibodeau GA: Anthony’s textb ook of
anatomy and physiology, ed 20, St Louis, 2013, Elsevier.)

1. Bones held together by hyaline cartilage or fibrocartilage; allow little

motion
a. Synchondroses—hyaline cartilage present between articulating
bones
b. Symphysis—joints in which a pad or disc of fibrocartilage
connects two bones
D. Synovial joints
1. Structures of synovial joints (Figure 3-16)

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 FIG 3-16 Structure of synovial joints. (From Herlihy B: The human b ody in
health and illness, ed 5, St Louis, 2015, Elsevier.)

a. Joint capsule—sleeve-like casing around the ends of bones,

which binds them together
b. Synovial membrane—membrane lining the joint capsule;
secretes synovial fluid
c. Articular cartilage—hyaline cartilage covering the articular
surfaces of the joint cavity
d. Menisci (articular discs)—pads of fibrocartilage located between
articulating bones
e. Bursae—sac-like body cavities; reduce friction in joints
f. Ligaments—strong cords of dense white fibrous tissue; hold the
bones of a synovial joint more firmly together
(temporomandibular joint [TMJ] has three ligaments)
2. Types of synovial joints

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 a. Uniaxial joints—permit movement around only one axis and in
only one plane
(1) Hinge joints—the articulating ends of bones form a hinge-
shaped unity that allows only flexion and extension
(2) Pivot joints—a projection of one bone articulates with a
ring or notch of another bone
b. Biaxial joints—permit movements around two perpendicular
axes in two perpendicular planes
c. Saddle joints—the articulating ends of bones that resemble
reciprocally shaped miniature saddles, for example, thumbs
d. Condyloid (ellipsoidal) joints—a bony projection that fits into
an elliptical socket
e. Multi-axial joints—permit movements around three or more
axes in three or more planes
(1) Ball-and-socket (spheroid) joints—most movable joints;
the ball-shaped head of one bone fits into a concave
depression, for example, shoulder
(2) Gliding joints—relatively flat articulating surfaces that
allow limited gliding movements along various axes, for
example, neck

Muscular System
The muscular system makes up about 40% of body weight and comprises
more than 600 muscles. The muscular system acts together with the
skeletal system to provide form, contours, and movement. The three
types of muscle are cardiac, smooth, and skeletal.

Anatomy of the Muscular System

See Figure 3-17.

211
212
 FIG 3-17 General overview of the body musculature. A, Anterior
view. B, Posterior view. (Modified from Applegate E: The anatomy and physiology
learning system, ed 4, St Louis, 2011, Saunders.)

A. Muscle tissue has five key functions:

1. Producing body movements
2. Stabilizing body positions
3. Regulating organ volume
4. Moving substances within the body
5. Producing heat
B. Characteristics
1. Excitability—ability of muscle fibers (and neurons) to respond to a
stimulus and convert it into an action potential
2. Contractibility—ability to contract (shorten and thicken)
3. Extensibility—ability to be stretched
4. Elasticity—ability to return to original shape after contraction or

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 extension
C. Types
1. Skeletal muscle—mostly attached to bones; striated and voluntary
2. Cardiac muscle—forms most of the walls of the heart; striated and
involuntary
3. Smooth muscle—located in viscera; participates in internal
processes

Skeletal Muscle Structure

See Figure 3-18.

FIG 3-18 Structure of a muscle organ. (From Patton KT, Thibodeau GA:
Anthony’s textbook of anatomy and physiology, ed 20, St Louis, 2013, Elsevier.)

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A. Connective tissue components (may become a tendon or an
aponeurosis)
1. Endomysium—delicate connective tissue membrane that covers
specialized skeletal muscle fibers
2. Perimysium—tough connective tissue binding fascicles together
3. Epimysium—coarse sheath covering the muscle as a whole
B. Size, shape, and fiber arrangement
1. Size—ranging from extremely small to large masses
2. Shape—variety of shapes, such as broad, narrow, long, tapering,
short, blunt, triangular, quadrilateral, or irregular, and as flat sheets
or bulky masses
3. Arrangement—variety of arrangements; the direction of fibers is
significant because of its relationship to function
C. Attachment of muscle
1. Origin—point of attachment that does not move when the muscle
contracts
2. Insertion—point of attachment that moves when the muscle
contracts
D. Muscle actions
1. Most movements produced by the coordinated actions of several
muscles; some muscles in the group contract while others relax
a. Prime mover (agonist)—muscles that directly perform a specific
movement
b. Antagonist—when contracting, directly oppose prime movers;
relax while the agonist is contracting to produce movement;
provide precision and control during contraction of prime
movers
c. Synergists—contract at the same time as prime movers do;
facilitate prime mover actions to produce a more efficient
movement
d. Fixator muscles—stabilize joints
E. Lever systems—bones serve as levers, and joints serve as fulcrums; the
muscle applies a pulling force on a bone lever at the point of the muscle’s
attachment to the bone, causing the insertion bone to move about its
joint fulcrum

Head and Neck Muscles

See the section on “The Muscular System” and Figure 4-4 in Chapter 4.
A. Muscles of facial expression—unique in that at least one point of
attachment is to the deep layers of the skin over the face or neck
B. Muscles of mastication—responsible for chewing movements

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C. Muscles that move the head—paired muscles on either side of the
neck that are responsible for head movements

Trunk Muscles
A. Muscles of the thorax—critical in respiration
B. Muscles of the abdominal wall—arranged in three layers, with fibers in
each layer running in different directions to increase strength
C. Muscles of the pelvic floor—support structures in the pelvic cavity

Upper Limb Muscles

A. Muscles acting on the shoulder girdle—muscles that attach the upper
extremity to the torso; located anteriorly (chest) or posteriorly (back and
neck); allow extensive movement
B. Muscles that move the upper arm—the shoulder is a synovial joint
allowing extensive movement in every plane of motion
C. Muscles that move the forearm—found proximal to the elbow and
attached to the ulna and radius
D. Muscles that move the wrist, hand, and fingers—located on the
anterior or posterior surfaces of the forearm

Lower Limb Muscles

A. The pelvic girdle and the lower extremity function in locomotion and
maintenance of stability
B. Muscles that move the thigh and the lower leg
C. Muscles that move the ankle and the foot
1. Extrinsic foot muscles—located in the leg; exert their actions by
pulling on tendons that insert on bones in the ankle and foot;
responsible for dorsiflexion, plantar flexion, inversion, and eversion
2. Intrinsic foot muscles—located within the foot; responsible for
flexion, extension, abduction, and adduction of the toes

Posture
A. Maintaining body posture is an important function of muscles
B. Good posture—body alignment that favors function and requires the
least muscular work to maintain, keeping the body’s center of gravity
over its base
C. How posture is maintained:
1. Muscles exert a continual pull on bones in the opposite direction
from gravity
2. Structures other than muscle and bone have a role in maintaining
posture

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 a. The nervous system—responsible for the existence of muscle
tone and for the regulation and coordination of the amount of
pull exerted by individual muscles
b. Respiratory, digestive, excretory, and endocrine systems all
contribute to maintain posture

Function of Skeletal Muscle

A. Overview of muscle cells
1. Muscle cells are called fibers because of their thread-like shape
2. Sarcolemma—plasma membrane of muscle fibers
3. Sarcoplasmic reticulum
a. A network of tubules and sacs found within muscle fibers
b. The membrane of the sarcoplasmic reticulum continually
pumps calcium ions from the sarcoplasm and stores the ions
within sacs
4. Muscle fibers contain many mitochondria and several nuclei
5. Myofibrils—numerous fine fibers packed close together in the
sarcoplasm
6. Sarcomere
a. The segment of myofibril between two successive Z lines
b. Each myofibril consists of many sarcomeres
c. The contractile unit of muscle fibers
7. Striated muscle
a. Dark stripes are called A bands; the light H zone runs across the
midsection of each dark A band
b. Light stripes are called I bands; the dark Z line extends across
the center of each light I band
8. T tubules
a. Transverse tubules that extend across the sarcoplasm at right
angles to the long axis of the muscle fiber
b. Formed by the inward extension of the sarcolemma
c. The membrane has ion pumps that continually transport
calcium ions inward from the sarcoplasm
d. Allow electrical impulses traveling along the sarcolemma to
move deeper into the cell
9. Triad
a. Triplet of tubules; a T tubule is sandwiched between two sacs of
the sarcoplasmic reticulum; allows an electrical impulse
traveling along a T tubule to stimulate the membranes of
adjacent sacs of the sarcoplasmic reticulum
B. Myofilaments

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 1. Each myofibril contains thousands of thick and thin myofilaments
2. Four different types of protein molecules make up myofilaments:
a. Myosin
(1) Makes up almost all the thick filament
(2) Myosin “heads” are chemically attracted to actin
molecules; known as cross-bridges when attached to actin
b. Actin—globular protein that forms two fibrous strands twisted
around each other to form the bulk of the thin filament
c. Tropomyosin—protein that blocks the active sites on actin
molecules
d. Troponin—protein that holds tropomyosin molecules in place
3. Thin filaments attached to both Z lines of a sarcomere and extend
partway toward the center
4. Thick myosin filaments are not attached to Z lines
C. Mechanism of contraction
1. Excitation and contraction
a. A skeletal muscle fiber remains at rest until stimulated by a
motor neuron
b. Neuromuscular junction—motor neurons connect to the
sarcolemma at the motor endplate
c. Neuromuscular junction—synapse where neurotransmitter
molecules transmit signals
d. Acetylcholine—neurotransmitter released into the synaptic
cleft, which diffuses across the gap, stimulates receptors, and
initiates an impulse in the sarcolemma
e. A nerve impulse travels over the sarcolemma and inward along
T tubules to trigger the release of calcium ions
f. Calcium binds to troponin, causing the tropomyosin to shift and
expose the active sites on actin
g. Sliding filament theory
(1) When active sites on actin are exposed, myosin heads bind
to them
(2) Myosin heads bend, pulling the thin filaments past them
(3) Each head releases itself, binds to the next active site, and
pulls again
(4) The entire myofibril becomes shortened
2. Relaxation
a. Immediately after calcium ions are released, the sarcoplasmic
reticulum begins actively pumping them back into sacs
b. Calcium ions are removed from troponin molecules, ending the
contraction

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 3. Energy sources for muscle contraction
a. Hydrolysis of ATP yields the energy required for muscular
contraction
b. ATP binds to the myosin head to perform the work of pulling
the thin filament during contraction
c. Muscle fibers continually synthesize ATP from the breakdown of
creatine phosphate
d. Catabolism by muscle fibers requires glucose and oxygen
e. At rest, excess oxygen (O2) in the sarcoplasm is stored by
myoglobin
(1) Red fibers—muscle fibers with high levels of myoglobin
(2) White fibers—muscle fibers with minimal myoglobin
f. Aerobic respiration occurs when adequate O2 is available
g. Anaerobic respiration occurs when low levels of O2 are available
and results in the formation of lactic acid
h. Skeletal muscle contraction produces excess heat that can be
used to maintain body temperature

Function of Skeletal Muscle Organs

A. Motor unit
1. Motor unit—comprises the motor neuron and the muscle fibers to
which it is attached
2. Some motor units can consist of only a few or numerous muscle
fibers
3. Generally, with a smaller number of fibers in a motor unit, more
precise movements are possible; the larger the number of fibers in a
motor unit, the more powerful is the contraction
B. Twitch contraction
1. A quick jerk of a muscle that is produced as a result of a single, brief
threshold stimulus (generally occurs only in experimental situations)
2. Three phases:
a. Latent phase—the nerve impulse travels to the sarcoplasmic
reticulum to trigger the release of calcium
b. Contraction phase—calcium binds to troponin, and the sliding
of filaments occurs
c. Relaxation phase—the sliding of filaments ceases
C. Treppe—the “staircase phenomenon”
1. Gradual, step-like increase in the strength of a contraction; observed
in a series of twitch contractions that occur 1 second apart
2. Eventually, the muscle responds with less forceful contractions, and

219
 the relaxation phase becomes shorter
3. If the relaxation phase disappears completely, a contracture
(abnormal shortening of muscle tissue that can cause disability)
occurs
D. Tetanus—smooth, sustained contractions
1. Multiple-wave summation—multiple twitch waves are added
together to sustain muscle tension for a longer time
2. Incomplete tetanus—very short periods of relaxation occur between
peaks of tension
3. Complete tetanus—twitch waves fuse into a single, sustained peak
E. Muscle tone
1. Tonic contraction—continual, partial contraction of a muscle
2. At any one time, a small number of muscle fibers within a muscle
contract, producing tightness of muscle tone
3. Muscles with less tone than normal are flaccid
4. Muscles with more tone than normal are spastic
5. Muscle tone is maintained by negative feedback mechanisms
F. Principle of graded strength
1. Skeletal muscles contract with varying degrees of strength at
different times
2. Factors that contribute to the phenomenon of graded strength:
a. Metabolic condition of individual fibers
b. Number of muscle fibers contracting simultaneously; the
greater the number of fibers contracting, the stronger the
contraction
c. Number of motor units recruited
d. Intensity and frequency of stimulation
3. Length-tension relationship
a. The maximal strength that a muscle can develop bears a direct
relationship to the initial length of its fibers
b. A shortened muscle’s sarcomeres are compressed; therefore the
muscle cannot develop much tension
c. An overstretched muscle cannot develop much tension because
the thick myofilaments are too far from the thin myofilaments
d. The strongest maximal contraction is possible only when the
skeletal muscle has been stretched to its optimal length
4. Stretch reflex
a. The load imposed on a muscle influences the strength of a
skeletal contraction
b. The body tries to maintain a consistency of muscle length in
response to increased load

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 c. Maintains a relatively constant length as the load is increased up
to a maximum sustainable level
G. Isotonic and isometric contractions
1. Isotonic contraction
a. Contraction in which the tone or tension within a muscle
remains the same as the length of the muscle changes
(1) Concentric—the muscle shortens as it contracts
(2) Eccentric—the muscle lengthens as it contracts
b. Isotonic means “same tension”
c. All the energy of contraction is used to pull on the thin
myofilaments and thereby change the length of a fiber ’s
sarcomeres
2. Isometric contraction
a. Contraction in which muscle length remains the same while
muscle tension increases
b. Isometric means “same length”
3. Body movements occur as a result of both types of contractions

Function of Cardiac and Smooth Muscle Tissue

A. Cardiac muscle (also known as striated involuntary muscle)
1. Found only in the heart; forms bulk of the walls of each chamber
2. Contracts rhythmically and continuously to maintain a constant
blood flow
3. Resembles skeletal muscle but has specialized features related to its
role in continuous pumping of blood
a. Each cardiac muscle contains parallel myofibrils
b. Cardiac muscle fibers form strong, electrically coupled
junctions (intercalated discs) with other fibers; individual cells
also exhibit branching
c. Syncytium—continuous, electrically coupled mass; important
for coordinating muscle contractions
d. Cardiac muscle fibers form a continuous, contractile band
around the heart chambers and conduct a single impulse across
a virtually continuous sarcolemma
e. T tubules are larger and form dyads with a rather sparse
sarcoplasmic reticulum
f. Cardiac muscle sustains each impulse longer than does skeletal
muscle; therefore, impulses cannot come rapidly enough to
produce tetanus
g. Cardiac muscle does not run low on ATP and does not
experience fatigue

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 h. Cardiac muscle is self-stimulating
B. Smooth muscle
1. Smooth muscle is composed of small, tapered cells with single
nuclei
2. T tubules are absent; only a loosely organized sarcoplasmic
reticulum is present
3. Calcium comes from outside the cell and binds to calmodulin
instead of troponin to trigger a contraction
4. No striations are present because both the thick and the thin
myofilaments have an arrangement different from that in skeletal or
cardiac muscle fibers; myofilaments are not organized into
sarcomeres
5. Two types of smooth muscle tissue:
a. Visceral muscle (single unit)
(1) Gap junctions join smooth muscle fibers into large,
continuous sheets
(2) Most common type; forms a muscular layer in the walls of
hollow structures such as the digestive, urinary, and
reproductive tracts
(3) Exhibits autorhythmicity, which produces peristalsis
b. Multi-unit
(1) Does not act as a single unit; is composed of many
independent cell units
(2) Each fiber responds only to input from nerves

The Nervous System

The nervous system is primarily composed of the brain, the spinal cord,
nerves, and ganglia. Along with the endocrine system, the nervous
system regulates and maintains homeostasis. It allows the human body
to communicate, integrate, and regulate body functions vital for living.
Subdivisions of the nervous system aid in the understanding of
structure, direction of information flow, and motor output or motor
function (see the section on “Nerve Tissue” in Chapter 2).
A. Two main subsystems (Figure 3-19):

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 FIG 3-19 The nervous system. (From Herlihy B: The human b ody in health and illness,
ed 5, St Louis, 2015, Elsevier.)

1. The central nervous system (CNS)—consists of the brain and the

spinal cord
2. The peripheral nervous system (PNS)—includes all nervous tissue
outside the CNS; contains the nerves to and from the body wall
B. Other divisions of the nervous system
1. Direction of information flow
2. Afferent consists of incoming sensory pathways
3. Efferent consists of outgoing motor pathways
4. Control of effectors
5. The somatic nervous system (SNS) carries information to the
somatic effectors (skeletal muscle)
6. The autonomic nervous system (ANS) carries information to the
autonomic effectors (e.g., cardiac and smooth muscle, glands,

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 adipose tissue)
C. Functions
1. Sensory—detection of different types of stimuli both inside and
outside the body
a. Afferent or sensory neurons—carry information from the PNS
to the CNS
2. Integrative—processing of sensory information by analyzing and
storing some of it and by making decisions regarding appropriate
responses; interneurons carry out this function
3. Motor—responses to integrative decisions
a. Efferent or motor neurons carry information from the CNS to
the PNS
D. The central nervous system
1. Brain—housed within the skull; contains about 100 billion neurons
2. Spinal cord—contains about 100 million neurons; is connected
directly to the brain and is protected by the vertebral column
3. Source of thoughts, emotions, memories; source of most nerve
impulses that stimulate muscles to contract and glands to secrete
4. Communication to and from CNS accomplished by:
a. Cranial nerves
b. Spinal nerves
c. Ganglia—small clusters of neuronal cell bodies that relay
signals traveling along cranial and spinal nerves
d. Enteric plexuses—in the walls of the organs of the
gastrointestinal (GI) tract; help regulate the digestive system
E. The peripheral nervous system
1. Subdivisions
a. The somatic nervous system
(1) Sensory neurons—convey information to the CNS from
the somatic receptors in the head, body wall, and limbs and
also from the receptors for the special senses of vision,
hearing, taste, and smell
(2) Motor neurons—conduct impulses from the CNS to
skeletal muscles only; motor responses are voluntary
b. The autonomic nervous system (ANS)
(1) Sympathetic division (thoracolumbar) involves motor
(afferent) nerves from the ANS
(2) Parasympathetic division (craniosacral)
c. The enteric nervous system
(1) “Brain of the GI system”
(2) Enteric motor neurons govern the contraction of GI tract

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 smooth muscle, secretions of the GI tract organs (e.g., acid
secretions by stomach), and activity of GI tract endocrine
cells

Cellular Organization
Nervous System Structure
See Figure 3-20 and the section on “Nerve Tissue” and Figures 2-13 and 2-
14 in Chapter 2.

FIG 3-20 Structure of a typical neuron. (From Applegate E: The anatomy

and physiology learning system, ed 4, St Louis, 2011, Saunders.)

A. Each neuron (nerve cell) consists of a cell body containing a nucleus

B. Dendrite—sends impulses toward the cell body or to a muscle or gland
C. Axon—conducts nerve impulses away from the cell body
D. Neuroglia—specialized tissue cells that support neurons, attach
neurons to blood vessels, produce the myelin sheath around the axons of
the CNS, carry out phagocytosis, and retain the ability to undergo
mitosis
E. Myelin—fatty substance around axons; provides insulation and
increases the speed of nerve conduction; deposited by Schwann cells in
layers in the PNS
1. Neurilemma—outermost layer of the Schwann cell
2. Nodes of Ranvier—located between myelin segments; unmyelinated
3. Oligodendrocytes myelinate CNS axons
F. White matter consists of aggregations of myelinated processes from
many neurons
G. Gray matter contains the neurons, dendrites, and axon terminals of

225
unmyelinated axons and neuroglia; forms an H-shaped inner core in the
spinal cord that is surrounded by white matter; a superficial shell of gray
matter covers the cerebrum and the cerebellum
H. The nervous system exhibits plasticity—the capability to change on
the basis of experiences; limited ability to regenerate
I. Axons and dendrites that are associated with a neurilemma in the PNS
may undergo repair if the cell body is intact, Schwann cells are
functional, and scar tissue does not form too rapidly

Action Potentials
See the section on “Characteristics and Physiology of Pain” in Chapter
18.
A. Neurons communicate by means of nerve action potentials (impulses)
B. Generation of action is dependent on:
1. The presence of special types of ion channels and the existence of a
resting membrane potential
2. Membrane potential—a difference in electrical charge across the
plasma membrane; a cell that has a membrane potential is said to be
polarized
3. A nerve impulse results from the concentration of two ions on the
inside and outside of the nerve
4. Resting membrane potential—the outside surface of plasma
membrane has a positive charge; the inside surface has a negative
charge; the resting membrane in neurons is ≈ 70 millivolts (mV)
5. During an action potential, voltage-gated sodium (Na+) and
potassium (K+) channels open in sequence; opening of voltage-gated
Na+ channels results in depolarization, followed by the loss and
reversal of membrane polarization (from − 70 mV to + 30 mV); then,
the opening of voltage-gated K+ channels allows repolarization, the
recovery of the resting membrane potential
6. According to the “all-or-none” principle, if a stimulus is strong
enough to generate an action potential, the impulse generated is of a
constant size; a stronger stimulus does not generate a larger impulse
7. During the absolute refractory period, another impulse cannot be
generated; during the relative refractory period, an impulse can be
triggered only by a supra-threshold stimulus
8. Nerve impulse conduction that occurs as a step-by-step process
along an unmyelinated axon is called continuous conduction; in
salutatory conduction, a nerve impulse “leaps” from one node of
Ranvier to the next along a myelinated axon
9. Axons with larger diameters conduct impulses faster than those with

226
 smaller diameters; myelinated axons conduct impulses faster than
unmyelinated axons

Synaptic Transmission
A. Neurons communicate with each other and with effectors at synapses
in a series of events known as synaptic transmission
B. Two types of synapses:
1. Electrical synapses—gap junctions allow ions to flow from one cell to
another
2. Chemical synapses—neurotransmitter is released from a presynaptic
neuron into the synaptic cleft and then binds to receptors on the
postsynaptic plasma membrane
C. Types of neurotransmitters
1. Excitatory neurotransmitter—depolarizes the membrane of the
postsynaptic neuron to bring the membrane potential closer to
threshold
2. Inhibitory neurotransmitter—hyperpolarizes the membrane of the
postsynaptic neuron
D. The postsynaptic neuron integrates excitatory and inhibitory signals
in a process called summation and then responds accordingly
E. The neurotransmitter is removed from the synaptic cleft in three ways:
diffusion, enzymatic degradation, and reuptake by neurons or neuroglial
cells
F. Important neurotransmitters include acetylcholine, gamma-
aminobutyric acid (GABA), glycine, norepinephrine, epinephrine,
dopamine, serotonin, neuropeptides, and nitric oxide

Spinal Cord
See Figure 3-21; see also Figure 2-11 in Chapter 2.

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 FIG 3-21 Coverings of the spinal cord. (From Patton KT, Thibodeau GA:
Anthony’s textbook of anatomy and physiology, ed 20, St Louis, 2013, Elsevier.)

A. Location—in the vertebral canal; extends from the foramen magnum

of the occipital bone of the skull to the superior border of the second
lumbar vertebrae in the vertebral column; approximately 40 to 45 cm (16
to 18 inches)
B. Meninges—three layers of connective tissue coverings that extend
around the spinal cord and the brain
1. Dura mater—outermost of three layers
2. Arachnoid—middle layer composed of collagen and elastic fibers
3. Pia mater—inner layer composed of collagen and elastic fibers that
adhere to the surface of the spinal cord and brain; contains
numerous blood vessels
C. Spinal cord does not run the entire length of the vertebral column;
nerves called cauda equina arise from the lowest portion of a cord and
angle down the vertebral canal
D. Functions
1. White matter tracts in the spinal cord are pathways for nerve
impulse conduction; sensory impulses flow from the periphery to
the brain, and motor impulses flow from the brain to the periphery
2. Gray matter receives and integrates incoming and outgoing
information
3. Spinal reflexes—fast automatic responses to sensory impulses that
enter the spinal cord via spinal nerves
4. Reflex arc—pathway followed by nerve impulses that produce a
reflex
a. Somatic reflex—reflex involving involuntary contraction of
skeletal muscles (e.g., knee-jerk reflex)
b. Withdrawal reflex—causes immediate withdrawal of a limb
from a source of injury before awareness of pain

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 c. Autonomic reflex—reflexes involving smooth muscle, cardiac
muscle, and glands (e.g., swallowing, urinating)
E. Spinal nerves
1. Thirty-one pairs of spinal nerves; each has a dorsal (afferent) root
and a ventral (efferent) root
2. Named and numbered according to the region and level of the
vertebral column from which they emerge
3. Emerge from the spinal cord to form plexuses along the cord, except
in the thoracic region
a. The cervical plexus (C1 to C4) innervates muscles, skin,
posterior head, neck, upper shoulders, and diaphragm
b. Brachial plexus (C5 to T1) nerves supply upper limbs, neck, and
muscles
(1) Radial—lateral side of the arm
(2) Medial—middle portion of the arm
(3) Ulnar—medial side of the arm
c. T2 to T12 comprise the intercostal nerves; do not form a plexus
d. Lumbosacral plexus—includes L1 to S4
(1) Lumbar portion—first four lumbar nerves contribute to
the femoral nerve; supplies abdominal wall, external
genitals, and part of lower limbs
(2) Sacral portion—sacral nerves, the last lumbar nerve, and
the coccygeal nerve supply the pelvis and legs; contribute to
the sciatic nerve (longest nerve in the body)

Brain
See Figure 3-22.

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 FIG 3-22 Divisions of the brain. (From Solomon EP: Introduction to human
anatomy and physiology, ed 2, St Louis, 2008, Saunders.)

A. Principal parts—brain stem (consists of the medulla oblongata, pons,

and midbrain), diencephalon (consists of the thalamus and
hypothalamus), cerebrum, and cerebellum
B. Supplied with oxygen and nutrients by the cerebral arterial circle, or
circle of Willis
1. Any interruption of the oxygen supply may permanently damage or
kill brain cells
2. Glucose deficiency may produce dizziness, convulsions, and
unconsciousness
C. The blood-brain barrier (BBB) limits the passage of certain materials
from the blood into the brain
D. The brain is protected by cranial bones, meninges, and the
cerebrospinal fluid
1. Cranial meninges are continuous with the spinal meninges (dura
mater, arachnoid, and pia mater)
2. Cerebrospinal fluid (CSF)—formed in the choroid plexuses;
circulates continually through the subarachnoid space, ventricles,
and central canal; protects the brain and spinal cord by serving as a
shock absorber; delivers nutritive substances from the blood and
removes wastes
E. Medulla oblongata (also called medulla)—is continuous with the upper

230
part of the spinal cord
1. Contains regions for regulating heart rate, diameter of blood vessels,
respiratory rate, swallowing, coughing, vomiting, sneezing, and
hiccupping
2. The vestibulocochlear, accessory, vagus, and hypoglossal nerves
originate at the medulla
F. Pons—connects the spinal cord to the brain; links parts of the brain to
one another; relays impulses related to voluntary skeletal movements
from the cerebral cortex to the cerebellum
1. Contains two regions that control respiration
2. The trigeminal, abducens, facial, and vestibular branches of the
vestibulocochlear nerves originate at the pons
G. Midbrain—conveys motor impulses from the cerebrum to the
cerebellum and the spinal cord, and transmits sensory impulses from the
spinal cord to the thalamus
H. Reticular formation—net-like arrangement of gray and white matter
extending throughout the brain stem; alerts the cerebral cortex to
incoming sensory signals; helps regulate muscle tone
I. Diencephalon—consists of the thalamus and the hypothalamus
1. Thalamus—contains nuclei that serve as relay stations for sensory
impulses to the cerebral cortex; provides crude recognition of pain,
temperature, touch, pressure, and vibration
2. Hypothalamus—located below the thalamus; controls and integrates
the ANS and pituitary gland; functions in rage and aggression;
controls body temperature; regulates food and fluid intake;
maintains consciousness and sleep patterns
J. The reticular activating system—functions in arousal (awakening from
deep sleep) and consciousness (wakefulness)
K. Cerebrum—largest part of the brain; the cortex contains convolutions,
fissures, and sulci
1. Cerebral lobes—frontal, parietal, temporal, and occipital
2. White matter under the cerebral cortex consists of myelinated axons
extending in three principal directions
3. Sensory areas receive and interpret sensory impulses; motor areas
govern muscular movement
4. Contains tissues associated with emotional and intellectual
processes
5. Generates brain waves measurable by electroencephalogram (EEG),
which may be used to diagnose epilepsy, infections, and tumors
L. Basal ganglia—paired masses of gray matter in the cerebral
hemispheres that control muscle movements

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M. The limbic system—found in cerebral hemispheres and the
diencephalon; functions in the emotional aspects of behavior and
memory
N. Hemispheres of the brain
1. Left hemisphere—receives sensory signals from and controls the
right side of the body; more important for language, numerical and
scientific skills, and reasoning
2. Right hemisphere—receives sensory signals from and controls the
left side of the body; more important for musical and other artistic
awareness, spatial and pattern perception, recognition of faces,
emotional content of language, and generating mental images of
sight, sound, touch, taste, and smell
O. Cerebellum—occupies the inferior and posterior aspects of the cranial
cavity; consists of two hemispheres with a cerebellar cortex of gray
matter and an interior of white matter tracts; attaches to the brain stem
by three pairs of cerebellar peduncles; coordinates skeletal muscles and
maintains normal muscle tone and body equilibrium

Cranial Nerves
See the section on “The Nervous System” in Chapter 4.
A. Twelve pairs of cranial nerves originate from the brain
B. As with spinal nerves, cranial nerves are part of the PNS

The Autonomic Nervous System

A. Regulates smooth muscle, cardiac muscle, and certain glands; usually
operates without conscious control by the centers in the brain, in
particular by the hypothalamus
B. Two principal divisions—sympathetic and parasympathetic; most
organs have dual innervation; in general, nerve impulses from one
division stimulate excitation, and impulses from the other division cause
inhibition
1. Sympathetic (thoracolumbar division)—sympathetic ganglia are
classified as sympathetic trunk ganglia (lateral to the vertebral
column) and prevertebral ganglia (anterior to the vertebral column)
2. Parasympathetic—parasympathetic ganglia are called terminal
ganglia; located near or within visceral effectors
3. Neurons of preganglionic autonomic neurons are myelinated; those
of postganglionic autonomic neurons are unmyelinated
C. Functions

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 1. Cholinergic neurons release acetylcholine (ACh); adrenergic
neurons release norepinephrine (NE)
2. Activation of the sympathetic division causes widespread responses;
the “fight-or-flight” response
3. Activation of the parasympathetic division produces more restricted
responses that typically are concerned with “rest-and-digest”
activities

Special Senses
A. Sensation—conscious or subconscious awareness of external and
internal conditions of the body; for a sensation to occur, three conditions
must be satisfied:
1. A stimulus, or change in environment, capable of activating certain
sensory neurons must occur
2. A sensory receptor must convert the stimulus to nerve impulses
3. The nerve impulses must be conducted along a neural pathway from
the sensory receptor to the brain
B. Components of the eye (Figure 3-23)

FIG 3-23 Horizontal cross section of the eye. (From Patton KT, Thibodeau GA,
Douglas MM: Essentials of anatomy and physiology, St Louis, 2012, Mosby.)

1. Conjunctiva—thin mucous membrane that covers the front of the

233
 eye and lines the eyelid
2. Lacrimal glands—located bilaterally on the outer borders of the
orbital cavity; secrete about 1 milliliter (mL) of fluid per day; contain
lysozyme to destroy bacteria
3. Nasolacrimal duct—carries fluid away from the gland
4. Iris—the colored part of the eye that is a circular diaphragm;
regulates the amount of light that enters the eye
5. Pupil—where light enters the eye; black in color
6. Lens—biconvex disc without blood
7. Sclera—white covering on the anterior aspect of the eye
8. Vitreous body—colloid inside of the eyeball; maintains the shape
9. Optic disc—located on the posterior surface of the eyeball; contains
no rods or cones, only optic nerves
10. Retina—contains cones in its center (fovea) and rods on the outer
periphery; process of forming an image on the retina is similar to a
camera producing a picture:
a. Light rays are bent as they enter the eye
b. The lens adjusts to the amount of light
c. Light rays are converged on the fovea
d. Rays cause changes in the chemistry of rods and cones
e. Optic nerve sends impulses to the occipital lobes of the brain
C. Hearing and equilibrium (Figure 3-24)

FIG 3-24 The ear. (From Patton KT, Thibodeau GA, Douglas MM: Essentials of anatomy
and physiology, St Louis, 2012, Mosby.)

1. The external ear consists of an ear flap

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 2. The middle ear is separated by the tympanic membrane (eardrum);
contains the ossicles (malleus, incus, and stapes) and the eustachian
tube (to equalize pressure)
3. The inner ear contains the vestibule, the cochlea, and semicircular
canals
a. Cranial nerve VIII innervates this structure
b. Small hairs detect various frequencies and pitches; impulses are
sent to the temporal lobes of the brain
c. Semi-circular canals maintain equilibrium
D. Tongue
1. Cranial nerve VII provides sensory fibers to the anterior two thirds
of the tongue, including fungiform and foliate papillae; sensations of
sweet, sour, and salty tastes are detected
2. Cranial nerve IX provides sensations of taste to the posterior one
third of the tongue’s circumvallate papillae; the bitter taste is
detected there
3. Food must be in solution in the mouth before taste buds can transfer
the information to the brain
4. Most taste sensations are made up of various combinations of the
four basic tastes
E. Olfactory sense
1. Stimulates hairs (cilia) that are sensitive to slight odors
2. On each side of the nose, bundles of slender, unmyelinated axons of
olfactory receptors extend through holes in the cribriform plate of
the ethmoid bone
3. These bundles of axons form cranial nerve I, the olfactory nerve; they
terminate in the brain in olfactory bulbs, which are located inferior
to the frontal lobes of the cerebrum
4. Within the olfactory bulbs, the axon terminals of olfactory receptors
synapse with the dendrites and cell bodies of the next neurons in the
olfactory pathway
5. The axons of the neurons extending from the olfactory bulb form the
olfactory tract
6. The olfactory tract projects into the primary olfactory area in the
temporal lobe, where the conscious awareness of smell begins
F. Tactile sensation (Table 3-4)

Table 3-4
Classification of Somatic Sensory Receptors

235
236
Modified from Patton KT, Thibodeau GA: Anthony’s textb ook of anatomy and physiology, ed 20, St Louis, 2013, Elsevier.

1. Meissner ’s corpuscles—receptors that control the sensation of touch

2. Pacinian corpuscles—receptors that control the sensation of
pressure
3. Ruffini’s corpuscles—receptors that control the sensation of heat
4. Krause’s end bulbs—receptors that control the sensation of cold
5. Nociceptors—sensory receptors for pain; during tissue irritation or
injury, release of chemicals such as prostaglandins stimulates
nociceptors
G. Proprioceptive sensations—inform consciously and subconsciously;
sense the degree of muscle contraction, amount of tension present in
tendons, position of joints, and orientation of head and equilibrium

The Endocrine System

A. The endocrine system is a collection of glands, each of which secretes
different types of hormones that regulate metabolism, growth and
development, tissue function, sexual function, reproduction, sleep,
mood, and other processes
B. Communication, integration, and control of body processes is
accomplished by secreting cells that send hormone molecules through
the blood to specific target cells contained in target tissues or target
organs
1. Works in conjunction with the nervous system to achieve and
maintain homeostasis
2. The neuroendocrine system—interaction of the endocrine and
nervous systems to perform similar functions
C. Endocrine glands—”ductless glands”; many are made of glandular
epithelium whose cells manufacture and secrete hormones; a few
endocrine glands are made of neurosecretory tissue; widely scattered
throughout the body

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Hormones
A. Function of hormones—regulate most cells to stimulate a physiologic
activity; work more slowly and last longer than neurotransmitters;
carried to almost every point in the body
B. Classification of hormones
1. Classification by general function
a. Tropic hormones—target other endocrine glands and stimulate
their growth and secretion
b. Sex hormones—target reproductive tissues
c. Anabolic hormones—stimulate anabolism in target cells
2. Classification by chemical structure
a. Steroid hormones
(1) Synthesized from cholesterol
(2) Lipid soluble; can easily pass through plasma membrane
of target cells
(3) Examples include cortisol, aldosterone, estrogen,
progesterone, and testosterone
b. Nonsteroid hormones—synthesized primarily from amino acids
c. Protein hormones—long, folded chains of amino acids (e.g.,
insulin, parathyroid hormone)
d. Glycoprotein hormones—protein hormones with carbohydrate
groups attached to the amino acid chain
e. Peptide hormones—smaller than protein hormones; short chain
of amino acids (e.g., oxytocin, antidiuretic hormone)
f. Amino acid derivative hormones—each is derived from a single
amino acid molecule
(1) Amine hormones—synthesized by modifying a single
molecule of tyrosine; produced by neurosecretory cells and
by neurons (e.g., epinephrine, norepinephrine)
(2) Amino acid derivatives produced by the thyroid gland;
synthesized by adding iodine to tyrosine
C. Mechanism of action
1. General principles
a. Hormones signal a cell by binding to the specific receptors of a
target cell in a “lock-and-key” arrangement
b. Different hormone-receptor interactions produce different
regulatory changes within the target cell through chemical
reactions
c. Combined hormone actions
(1) Synergism—combinations of hormones acting together

238
 have a greater effect on a target cell than the sum of the
effects that each would have if acting alone
(2) Permissiveness—when a small amount of one hormone
allows a second one to have its full effects on a target cell
(3) Antagonism—one hormone produces the opposite effects
of another hormone; used to fine-tune the activity of target
cells with great accuracy
d. Endocrine glands produce more hormone molecules than
needed; unused hormones are quickly excreted by the kidneys
or broken down by metabolic processes
2. Mechanism of steroid hormone action
a. Steroid hormones are lipid soluble, and their receptors are
normally found within the target cell
b. After a steroid hormone molecule has diffused into the target
cell, it binds to a receptor molecule to form a hormone-receptor
complex
c. Mobile receptor hypothesis—the hormone passes into the
nucleus, where it binds to a mobile receptor and activates a
certain gene sequence to begin transcription of mRNA; newly
formed mRNA molecules move into the cytosol, associate with
ribosomes, and begin synthesizing protein molecules that
produce the effects of the hormone
d. The amount of steroid hormone present determines the
magnitude of the target cell’s response
e. Because transcription and protein synthesis take time,
responses to steroid hormones are often slow
3. Mechanisms of nonsteroid hormone action
a. Second messenger mechanism—also known as the fixed-
membrane-receptor hypothesis
(1) A nonsteroid hormone molecule acts as a “first
messenger ” and delivers its chemical message to receptors
that are fixed in the plasma membrane of the target cell
(2) The message is then passed by way of a G-protein into the
cell where a “second messenger ” triggers the appropriate
cellular response
(3) The second messenger mechanism produces target cell
effects that differ from steroid hormone effects in several
important ways:
(a) The effects of the hormone are amplified by a cascade
of reactions
(b) The second messenger mechanisms include inositol

239
 trisphosphate (IP3), guanosine monophosphate (GMP),
and calcium calmodulin
(c) The second messenger mechanism operates much
more quickly than the steroid mechanism
b. Nuclear receptor mechanism—small iodinated amino acids (T4
and T3) enter the target cell and bind to receptors associated
with a DNA molecule in the nucleus; this binding triggers
transcription of mRNA and synthesis of new enzymes
D. Regulation of hormone secretion
1. Usually part of a negative feedback loop called an endocrine reflex; the
simplest regulatory mechanism is when an endocrine gland is
sensitive to the physiologic changes produced by its target cells
2. Regulated by a hormone produced by another gland
3. May be influenced by the input of the nervous system; this fact
emphasizes the close functional relationship between the two
systems

Prostaglandins
A. Function of prostaglandins
1. Unique group of lipid molecules (20-carbon fatty acid with 5-carbon
ring); serve important, widespread integrative functions, but do not
meet the usual definition of a hormone; tend to integrate activities of
neighboring cells
2. Called tissue hormones because the secretion is produced in a tissue
and diffuses only a short distance to other cells within the same
tissue
B. Structural classes of prostaglandins
1. Prostaglandin A (PGA)—intra-arterial infusion resulting in an
immediate drop in blood pressure accompanied by an increase in
regional blood flow to several areas
2. Prostaglandin E (PGE)—regulation of red blood cell deformability
and platelet aggregation; regulation of hydrochloric acid secretion in
the GI tract
3. Prostaglandin F (PGF)—causes uterine contractions; affects
intestinal motility; required for normal peristalsis

Pituitary Gland
A. The function of pituitary gland is divided by two separate glands:
1. The anterior pituitary gland: secretory cells produce growth

240
 hormone, prolactin, and a number of tropic hormones
2. The posterior pituitary gland: serves as a storage site for antidiuretic
hormone and oxytocin
B. Structure of the pituitary gland
1. Also known as hypophysis, the “master gland”
2. Size: 1.2 to 1.5 cm
3. Located on the ventral surface of the brain within the skull
4. Infundibulum—stem-like stalk that connects the pituitary to the
hypothalamus
5. Composed of two separate glands, the adenohypophysis (anterior
pituitary gland) and the neurohypophysis (posterior pituitary gland)
C. Adenohypophysis (anterior pituitary)
1. Divided into two parts:
a. Pars anterior—forms the major portion of the adenohypophysis
b. Pars intermedia
2. Tissue is composed of irregular clumps of secretory cells supported
by fine connective tissue fibers and surrounded by a rich vascular
network
3. Three types of cells can be identified by their stain affinity:
a. Chromophobes—do not stain
b. Acidophils—stain with acidic stains
c. Basophils—stain with basic stains
4. Five functional types of secretory cells:
a. Somatotrophs—secrete GH
b. Corticotrophs—secrete ACTH
c. Thyrotrophs—secrete TSH
d. Lactotrophs—secrete prolactin
e. Gonadotrophs—secrete LH and FSH
D. Hormones secreted by the adenohypophysis
1. Growth hormone (GH); also known as somatotropin (STH)
a. Promotes growth of bone, muscle, and other tissues by
accelerating amino acid transport into the cells
b. Stimulates fat metabolism by mobilizing lipids from storage in
adipose cells and speeding up the catabolism of lipids after they
have entered another cell
c. Shifts cell chemistry away from glucose catabolism and toward
lipid catabolism as an energy source; this leads to increased
blood glucose levels
d. Functions as an insulin antagonist; vital to maintaining the
homeostasis of blood glucose levels
2. Prolactin (PRL); also known as lactogenic hormone

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 a. Produced by acidophils in the pars anterior
b. Promotes breast development during pregnancy in anticipation
of milk secretion; stimulates lactation after delivery
3. Tropic hormones—have a stimulating effect on other endocrine
glands; four principal tropic hormones are produced and secreted by
the basophils of the pars anterior:
a. Thyroid-stimulating hormone (TSH), or thyrotropin—promotes
and maintains the growth and development of the thyroid;
causes the thyroid to secrete its hormones
b. Adrenocorticotropic hormone (ACTH), or adrenocorticotropin
—promotes and maintains normal growth and development of
the cortex of the adrenal gland; stimulates the adrenal cortex to
secrete some of its hormones
c. Follicle-stimulating hormone (FSH)—stimulates primary
graafian follicles to grow toward maturity in females; also
stimulates follicle cells to secrete estrogens; in males, stimulates
the development of the seminiferous tubules of the testes and
maintains spermatogenesis
d. Luteinizing hormone (LH)—stimulates the formation and
activity of the corpus luteum of the ovary in females; the corpus
luteum secretes progesterone and estrogens when stimulated by
LH; LH also supports FSH in stimulating the maturation of
follicles; in males, LH stimulates the interstitial cells in the
testes to develop and secrete testosterone
e. FSH and LH are called gonadotropins because they stimulate the
growth and maintenance of the gonads
4. Control of secretion in the adenohypophysis
a. The hypothalamus secretes releasing hormones into the blood,
which are then carried to the hypophyseal portal system;
through negative feedback, the hypothalamus adjusts the
secretions of the adenohypophysis, which then adjusts the
secretions of the target glands, which in turn adjust the activity
of their target tissues
b. The hypophyseal portal system carries blood from the
hypothalamus directly to the adenohypophysis, where the target
cells of the releasing hormones are located; releasing hormones
influence the secretion of hormones by acidophils and basophils
c. Under stress, hypothalamus translates nerve impulses into
hormone secretions by endocrine glands, creating a
neuroendocrine link
E. Neurohypophysis (posterior pituitary)

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 1. Serves as storage and release site for antidiuretic hormone (ADH,
vasopressin) and oxytocin (OT), which are synthesized in the
hypothalamus
2. ADH and OT are released into blood; controlled by nervous
stimulation
3. Antidiuretic hormone
a. Prevents the formation of a large volume of urine, thereby
helping the body conserve water
b. Causes the tubules in the kidney to resorb water from urine
c. Dehydration triggers the release of ADH
4. Oxytocin—has two actions:
a. Causes the release of milk from the lactating breast; regulated
by the positive feedback mechanism; PRL cooperates with OT
b. Stimulates the contractions of uterine muscles during
childbirth; regulated by positive feedback mechanism

Pineal Gland
A. Function of pineal glands
1. A member of the nervous system because it receives visual stimuli;
also a member of the endocrine system because it secretes hormones
2. Supports the body’s biologic clock
a. Principal pineal secretion is melatonin
B. Structure of pineal glands
1. Tiny, pinecone-shaped structure located on the dorsal aspect of the
brain’s diencephalon

Thyroid Gland
See the section on “Glands of the Head and Neck Region” and Figure 4-8
in Chapter 4.
A. Function of the thyroid gland
1. Increases metabolic rate and essential for growth and development;
crucial for brain development in children
2. Influences body temperature
B. Structure of the thyroid gland
1. Two large lateral lobes and a narrow connecting isthmus; located in
the neck, on the anterior and lateral surfaces of the trachea, just
below the larynx
2. A thin, worm-like projection of thyroid tissue, often extends upward
from the isthmus

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 3. The weight of the thyroid in an adult is approximately 30 grams (g)
4. Composed of follicles
a. Small hollow spheres
b. Filled with thyroid colloid that contains thyroglobulins
C. Thyroid hormone
1. Two different hormones:
a. Triiodothyronine (T3)—contains three iodine atoms; considered
to be the principal thyroid hormone; T3 binds efficiently to the
nuclear receptors in target cells
b. Tetraiodothyronine (T4), or thyroxine—contains four iodine
atoms; approximately 20 times more abundant than T3; its major
importance is its role as a precursor to T3
2. The thyroid gland stores considerable amounts of a preliminary
form of its hormones before secreting them
3. Before being stored in the colloid of follicles, T3 and T4 are attached
to globulin molecules to form thyroglobin complexes
4. On release, T3 and T4 detach from globulin and enter the
bloodstream
5. Once in the blood, T3 and T4 attach to plasma globulins and travel as
a hormone-globulin complex
6. T3 detaches from plasma globulin as it nears the target cells; T4 also
detaches, but to a lesser extent
7. Thyroid hormone—helps regulate the metabolic rate of all cells, cell
growth, and tissue differentiation; it is said to have a “general”
target
D. Calcitonin
1. Produced by the thyroid gland in the parafollicular cells
2. Influences the processing of calcium by bone cells by decreasing
blood calcium levels and promoting the conservation of the hard
bone matrix
3. Parathyroid hormone acts as antagonist to calcitonin to maintain
calcium homeostasis

Parathyroid Glands
A. Function of the parathyroid glands
1. Control calcium in the blood by stimulating bone breakdown,
increasing calcium absorption in the digestive tract, and decreasing
loss of calcium in the urine
B. Structure of the parathyroid glands

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 1. Four or five parathyroid glands are embedded in the posterior
surface of the thyroid’s lateral lobes
2. Tiny, rounded bodies within thyroid tissue formed by compact,
irregular rows of cells
C. Parathyroid hormone (PTH, parathormone)
1. An antagonist to calcitonin; acts to maintain calcium homeostasis
2. Acts on bone and the kidneys
a. Causes more bone to be dissolved, yielding calcium and
phosphate, which enter the bloodstream
b. Causes phosphate to be secreted by the kidney cells into urine
to be excreted
c. Increases the intestinal absorption of calcium by stimulating the
kidney to produce active vitamin D

Adrenal Glands
A. Function of the adrenal glands
1. Work with the hypothalamus and pituitary gland to stimulate and
produce hormones that influence metabolism, body characteristics,
ability to cope with physical and emotional stress, and aids in the
regulation of sodium and potassium levels
B. Structure of the adrenal glands
1. Located on top of the kidneys like caps
2. Made up of two portions:
a. Adrenal cortex—the outer part of the gland; produces hormones
that are vital to life, such as cortisol, which regulates
metabolism and the body’s response to stress, and aldosterone,
which helps regulate blood pressure
b. Adrenal medulla—produces nonessential hormones, such as
adrenaline, which helps the body react to stress
C. Adrenal cortex
1. All cortical hormones are steroids; known as corticosteroids
2. Composed of three distinct layers of secreting cells:
a. Zona glomerulosa—outermost layer, directly under the outer
connective tissue capsule of the adrenal gland; secretes
mineralocorticoids
b. Zona fasciculata—middle layer; secretes glucocorticoids
c. Zona reticularis—inner layer; secretes small amounts of
glucocorticoids and gonadocorticoids
3. Mineralocorticoids—important role in regulating sodium levels
a. Aldosterone

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 (1) The only physiologically important mineralocorticoid; its
primary function is to maintain sodium homeostasis in
blood by increasing sodium resorption in the kidneys
(2) Increases water retention; promotes the loss of potassium
and hydrogen ions
(3) Secretion is controlled by the renin-angiotensin
mechanism and by blood potassium concentration
b. Glucocorticoids
(1) Secreted by the zona fasciculata
(2) Examples include cortisol, cortisone, and corticosterone
(3) Affect every body cell
(4) Are protein mobilizing, gluconeogenic, and hyperglycemia
inducing
(5) Tend to cause a shift from carbohydrate catabolism to lipid
catabolism
(6) Essential for maintaining normal blood pressure by
helping norepinephrine and epinephrine to have their full
effect; cause vasoconstriction
(7) High blood concentration causes eosinopenia and marked
atrophy of lymphatic tissues
(8) Act with epinephrine to bring about normal recovery from
injury produced by inflammatory agents
(9) Secretion increases in response to stress
(10) Except during stress response, secretion is mainly
controlled by a negative feedback mechanism involving
ACTH from the adenohypophysis
4. Gonadocorticoids—sex hormones (androgens) released from the
adrenal cortex
D. Adrenal medulla
1. Neurosecretory tissue—composed of neurons specialized to secrete
their products into blood
2. Secretes epinephrine and norepinephrine, part of the class of
nonsteroid hormones called catecholamines; both hormones bind to
the receptors of sympathetic effectors to prolong and enhance the
effects of sympathetic stimulation by the ANS

Pancreatic Islets
A. Function of pancreatic islets
1. From the liver, increases breakdown of glycogen to increase blood
glucose levels

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 2. Decreases blood glucose by influencing uptake and use of the body’s
cells
B. Structure of the pancreatic islets
1. Elongated gland; its head lies in the duodenum; extends horizontally
behind the stomach and touches the spleen
2. Composed of endocrine and exocrine tissues
a. Islets of Langerhans—endocrine portion; each islet contains
four primary types of endocrine glands joined by gap junctions:
(1) Alpha cells (α-cells)—secrete glucagon
(2) Beta cells (β-cells)—secrete insulin; account for up to 75%
of all pancreatic islet cells
(3) Delta cells (δ-cells)—secrete somatostatin
(4) Pancreatic polypeptide cells (F- or PP-cells)—secrete
pancreatic polypeptides
b. Acini—exocrine portion; secretes a serous fluid containing
digestive enzymes into the ducts draining into the small
intestine
C. Pancreatic hormones—work as a team to maintain the homeostasis of
food molecules
1. Glucagon—produced by α-cells; tends to increase blood glucose
levels; stimulates gluconeogenesis in liver cells
2. Insulin—produced by β-cells; lowers the blood concentration of
glucose and fatty acids; promotes their metabolism by tissue cells
3. Somatostatin—produced by δ-cells; primary role is regulating the
other endocrine cells of pancreatic islets
4. Pancreatic polypeptide—produced by F-cells (PP-cells); influences
the digestion and distribution of food molecules to some degree

Gonads
A. Testes
1. Paired organs within the scrotum in a male
2. Composed of seminiferous tubules and a scattering of interstitial
cells
3. Testosterone—produced by interstitial cells; responsible for the
growth and maintenance of male sexual characteristics; secretion is
mainly regulated by gonadotropin levels in blood
B. Ovaries
1. Primary sex organs in a female
2. Set of paired glands in the pelvis that produce several types of sex
hormones

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 a. Estrogens—steroid hormones secreted by ovarian follicles;
promote development and maintenance of female sexual
characteristics
b. Progesterone—secreted by the corpus luteum; maintains the
lining of the uterus necessary for successful pregnancy
c. Ovarian hormone secretion depends on the changing levels of
FSH and LH from the adenohypophysis

Placenta
A. Tissues that form on the lining of the uterus as a connection between
the circulatory systems of the mother and the developing fetus
B. Serves as a temporary endocrine gland; produces human chorionic
gonadotropin, estrogens, and progesterone

Thymus Gland
A. Function of thymus gland
1. Important for immune system development and function
B. Structure of thymus gland
1. Located in the mediastinum just beneath the sternum
2. Large in children, begins to atrophy at puberty, and is a vestige of fat
and fibrous tissue by old age
3. Considered to be primarily a lymphatic organ
4. Thymosin—isolated from thymus tissue; stimulates development of
T cells

Gastric and Intestinal Mucosa

A. The mucous lining of the GI tract contains cells that produce both
endocrine and exocrine secretions
B. GI hormones such as gastrin, secretin, and cholecystokinin-
pancreozymin (CCK) play regulatory roles in coordinating the secretory
and motor activities involved in the digestive process
C. Ghrelin—a hormone secreted by endocrine cells in the gastric mucosa;
stimulates the hypothalamus to boost appetite; slows metabolism and fat
burning; may be a contributor to obesity

Heart
A. Has a secondary endocrine role; hormone-producing cells produce the
hormone atrial natriuretic peptide (ANP)

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B. ANP opposes increases in blood volume or blood pressure; also an
antagonist to ADH and aldosterone

The Cardiovascular System

The purpose of the cardiovascular system is to transport oxygen to all the
tissues in the body and remove, from these same tissues, metabolic waste
products. The cardiovascular system consists of three interrelated
components: blood, the heart, and blood vessels.
A. Blood—a vital liquid that has three general functions:
1. Transportation—transports oxygen from the lungs to the cells
throughout the body and carbon dioxide from the cells to the lungs;
carries nutrients from the GI tract to body cells, heat and waste
products away from cells, and hormones from endocrine glands to
other body cells
2. Regulation—helps regulate the pH of body fluids; helps adjust body
temperature; blood osmotic pressure also influences the water
content of cells
3. Protection—blood clots in response to injury to protect against
excessive blood loss; white blood cells protect against disease
through phagocytosis and by producing antibodies; blood contains
interferons, which also help protect against disease
B. Characteristics of blood
1. Viscosity greater than that of water; temperature of 38°C (100.4°F);
pH ranges between 7.35 and 7.45
2. Blood constitutes about 8% of body weight in an adult
C. Components of blood (Figure 3-25)

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 FIG 3-25 Composition of whole blood. (From Patton KT, Thibodeau GA: Anthony’s
textb ook of anatomy and physiology, ed 20, St Louis, 2013, Elsevier.)

1. Consists of 55% plasma; 45% formed elements that include red

blood cells (RBCs, erythrocytes), white blood cells (WBCs,
leukocytes), and platelets
2. Hematocrit—the percentage of RBCs in whole blood
3. Plasma contains 91% water, 7% proteins, and 2% solutes
4. Principal solutes include proteins (albumins, globulins, fibrinogen),
nutrients, hormones, respiratory gases, electrolytes, and waste
products
5. Hemopoiesis—the formation of blood cells from pluripotent stem
cells; occurs in red bone marrow
6. Red blood cells—biconcave discs without a nucleus that contain
hemoglobin
a. Hemoglobin transports oxygen
b. RBCs live for about 120 days; in terms of a normal blood count,
a healthy male has about 4.7 to 6.1 million/mm3 RBCs; a healthy
female has about 4.2 to 5.4 million/mm3 RBCs
c. After phagocytosis of aged RBCs by macrophages, hemoglobin
is recycled
d. Erythropoiesis—RBC formation occurring in adult red bone
marrow; stimulated by hypoxia, which stimulates the release of
erythropoietin by the kidneys
7. White blood cells—nucleated cells with two principal groups:
a. Granular leukocytes (neutrophils, eosinophils, basophils)
b. Agranular leukocytes (lymphocytes and monocytes)
c. Function—to combat inflammation and infection; neutrophils

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 and monocytes do so by phagocytosis
d. Eosinophils combat the effects of histamine in allergic reactions
and increase with allergies and parasites
e. Basophils develop into mast cells that liberate heparin,
histamine, and serotonin in allergic reactions that intensify the
inflammatory response
f. B cells (lymphocytes)—effective against bacteria and other
toxins
g. T cells (lymphocytes)—effective against viruses, fungi, and
cancer cells
h. WBCs usually live for only a few hours or a few days
i. Normal blood contains 5000 to 10,000 WBCs/mm3
8. Platelets—disc-shaped cell fragments without nuclei
a. Formed from megakaryocytes; take part in hemostasis by
forming a platelet plug
b. Normal blood contains 150,000 to 450,000 platelets/mm3
D. Hemostasis—stoppage of bleeding
1. Three mechanisms:
a. Vascular spasm—when a blood vessel is damaged, the smooth
muscle in its walls contracts immediately
b. Platelet plug—when platelets come into contact with parts of a
damaged blood vessel, their characteristics change drastically,
and they come together to form a plug that helps fill the gap in
the injured vessel
c. Blood clotting—a series of reactions
(1) Prothrombinase is formed
(2) Conversion of prothrombin into thrombin
(3) Conversion of soluble fibrinogen into insoluble fibrin
2. Clot—a network of insoluble protein fibers (fibrin), in which formed
elements of blood are trapped
3. Normal coagulation requires vitamin K and also involves clot
retraction and fibrinolysis
4. Anticoagulants prevent clotting
5. Thrombosis—clotting in an unbroken blood vessel; a thrombus that
moves from its site of origin is called an embolus
E. Blood groups
1. Surfaces of RBCs contain a genetically determined assortment of
glycolipids and glycoproteins called isoantigens
a. Based on the presence or absence of various isoantigens, blood
is categorized into different blood groups
b. Within a blood group, two or more different blood types may be

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 present
2. ABO blood group system—based on isoantigens A and B
a. Type A—red cells display only antigen A
b. Type B—red cells display only antigen B
c. Type AB—red cells display both antigens A and B
d. Type O—red cells display neither antigen A nor B
F. Heart
1. Located in the space between the lungs, behind the sternum, in the
thoracic cavity known as the mediastinum; size of a human fist; apex
of the heart points down and to the left
2. Consists of four chambers: two atria and two ventricles (Figure 3-26)

FIG 3-26 The heart and great vessels. (From Patton KT, Thibodeau GA,
Douglas MM: Essentials of anatomy and physiology, St Louis, 2012, Mosby.)

a. Blood from superior and inferior venae cavae fills the right
atrium and passes into the right ventricle through the tricuspid

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 valve (three flaps)
b. From the right ventricle, the unoxygenated blood is sent to the
lungs by passing through the semi-lunar valve and the
pulmonary artery
c. Oxygenated blood is sent from the lungs to the left atrium
through the pulmonary veins; the left semi-lunar valve separates
the left atrium from the pulmonary veins
d. From the left atrium, blood flows through the mitral valve (two
flaps) into the left ventricle
e. Blood enters the circulation by passing through the left semi-
lunar valve into the aorta
3. The heart walls consist of three layers:
a. Visceral pericardium or epicardium
b. Myocardium—heaviest covering
c. Endocardium—smooth continuous covering
d. All valves and chambers are lined by the endothelium
4. The valves of the heart are unique
a. Atrioventricular (AV) valves—tough, fibrous tissue; open except
when ventricles contract; hang into the ventricle like a leaf; held
in place by chordae tendineae at the edge of the valves
(1) Tricuspid AV valve—formed by three flaps
(2) Bicuspid AV valve (mitral valve)—formed by two parts
b. Semi-lunar (SL) valves—pressure opens them, and reverse
pressure closes them; remain closed until ventricles contract
(1) Pulmonary SL valve—located at the right
(2) Aortic SL valve—located at the left
5. Heart rate averages 70 to 72 beats per minute; the heart cannot
contract without nerve impulses; nerves regulate heart rate
a. Sinoatrial (SA) node—located in the walls of the right atrium
near the superior vena cava; the heart beat begins there
(1) From there, the action current spreads out and passes
down to the fibrous layer and stops
(2) The current goes through the AV node at the upper end of
the interventricular septum
(3) Modified cardiac muscle divides into right and left
branches
(4) Along the AV bundle, fibers pass out into the cardiac
muscle (Purkinje fibers)
b. The action current consists of an impulse starting at the SA
node, spreads to the atria, passes to the AV node, is picked up
and sent down through all the cardiac fibers from Purkinje

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 fibers, and ends by spreading over the ventricles; muscle
contracts after the impulse spreads over the heart
(1) Purkinje fibers provide for uniform contraction
(2) If the AV node is blocked, ventricles will set up their own
rhythm
6. Cardiac cycle—includes all the events associated with one heartbeat
(Figure 3-27)

FIG 3-27 The cardiac cycle. (From Patton KT, Thibodeau GA: Anthony’s textb ook
of anatomy and physiology, ed 20, St Louis, 2013, Elsevier.)

a. In a normal cardiac cycle, the two atria contract while the two
ventricles relax; then, while the two ventricles contract, the two
atria relax
(1) Systole—phase of contraction
(2) Diastole—phase of relaxation

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b. Three phases of cardiac cycle (each cycle lasts about 0.8 second):
(1) Relaxation period—begins at the end of a cardiac cycle;
ventricles start to relax, and all four chambers are in
diastole; repolarization of ventricular muscle fibers initiates
relaxation; as ventricles relax, pressure within them drops;
when ventricular pressure drops below atrial pressure, AV
valves open, and ventricular filling begins
(2) Contraction (atrial systole)—an action potential from the
SA node causes atrial depolarization; atria contract and
force the last 25% of blood into ventricles; AV valves are still
open, and SL valves are closed
(3) Contraction (ventricular systole)—ventricular contraction
pushes blood against AV valves, forcing them to shut;
pressure inside chambers rises when left ventricular
pressure surpasses aortic pressure; right ventricular
pressure rises above the pressure in the pulmonary trunk;
both SL valves open, and ejection of blood from the heart
begins; ejection continues until ventricles start to relax;
ventricular pressure drops, SL valves close, and another
relaxation period begins
c. Heart sounds
(1) First sound—AV valves close
(2) Second sound—SL valves close
d. Cardiac output—volume of blood ejected per minute from the
left ventricle into the aorta; determined by:
(1) Stroke volume (SV)—amount of blood ejected by the left
ventricle during each contraction or beat; in a resting adult,
stroke volume averages 70 mL, and heart rate is about 75
beats/min
(2) Number of heartbeats per minute
(3) Regulation of stroke volume depends on three factors:
(a) Starling’s law—the more the heart is stretched as it
fills during diastole, the greater the force of contraction
during systole
(b) The forcefulness of the contraction of individual
ventricular muscle fibers
(c) The pressure required to eject blood from the
ventricles
(4) Regulation of heart rate—adjustments of heart rate are
important in the short-term control of cardiac output and
blood pressure; for example, during exercise, cardiac output

255
 rises to supply working tissues with increased amounts of
oxygen and nutrients
(a) The most important factors are the autonomic nervous
system and the hormones epinephrine and
norepinephrine released by adrenal glands
(b) The regulation of the nervous system originates in the
cardiovascular center in the medulla oblongata
(c) Sympathetic impulses increase heart rate and force of
contraction; parasympathetic impulses decrease heart
rate
(d) Sensory receptors help adjust heart rate; for example,
baroreceptors (neurons sensitive to blood pressure) are
strategically located in the arch of the aorta and carotid
arteries; if an increase in blood pressure occurs,
baroreceptors send nerve impulses along the sensory
neurons that are part of the glossopharyngeal and
vagus nerves (X) to the cardiovascular center; the center
responds, and the result is a decrease in heart rate that
lowers cardiac output, thus lowering blood pressure
(5) Chemical regulation of heart rate
(a) Epinephrine and norepinephrine enhance the heart’s
pumping effectiveness by increasing both heart rate
and contraction force
(b) Thyroid hormones also increase heart rate; a sign of
hyperthyroidism is tachycardia
(c) Ions—elevated blood levels of K+ or Na+ decrease heart
rate and contraction force

The Circulatory System

The circulatory system contributes to the homeostasis of other body
systems by transporting and distributing blood throughout the body to
deliver oxygen, nutrients, and hormones and to carry away wastes.
A. Types of blood vessels
1. Arteries—carry blood away from the heart to body tissues; walls
have three layers of tissue surrounding a hollow space called the
lumen
a. Inner layer composed of endothelium
b. Middle layer composed of smooth muscle and elastic tissue
c. Outer layer composed mainly of elastic and collagen fibers
d. Vasoconstriction—increase in sympathetic stimulation

256
 stimulates smooth muscle to contract, squeezing the vessel wall
and narrowing the lumen
e. Vasodilation—sympathetic stimulation decreases; smooth
muscle fibers relax
2. Arteriole—very small artery that delivers blood to capillaries
3. Capillaries—microscopic vessels that connect arterioles to venules;
present near almost every body cell; permit the exchange of
nutrients and wastes between the body’s cells and blood; the number
of capillaries varies with the metabolic activity they serve
a. Because capillaries are so numerous, blood flows more slowly
through them than through larger blood vessels
b. Slow flow aids the prime mission of the entire cardiovascular
system—to keep blood flowing through capillaries so that
capillary exchange (movement of substances into and out of
capillaries) can occur
c. Methods of capillary exchange
(1) Diffusion
(2) Bulk flow (filtration and resorption)—capillary blood
pressure “pushes” fluid out of capillaries into interstitial
fluid (filtration); blood colloid osmotic pressure “pulls”
fluid into capillaries from interstitial fluid (resorption)
4. Venules—small vessels that emerge from capillaries and merge to
form veins; they receive blood from capillaries and empty blood into
veins, which return blood to the heart
5. Venous return—volume of blood flowing back to the heart occurs
because of the pumping action of the heart, aided by skeletal muscle
contractions (skeletal muscle pump) and breathing (respiratory
pump).
6. Hormonal regulation of blood pressure—several hormones regulate
blood pressure and blood flow by altering cardiac output, changing
vascular resistance, or adjusting the total blood volume
a. Renin-angiotensin-aldosterone (RAA) system—when blood
volume or blood flow to the kidneys decreases, certain cells in
the kidneys secrete renin into the bloodstream
(1) Renin and angiotensin together produce the hormone
angiotensin II, which raises blood pressure by causing
vasoconstriction
(2) Angiotensin II also stimulates the secretion of
aldosterone, which increases resorption of sodium ions
(Na+) and water by the kidneys; water resorption increases
the total blood volume, which in turn increases blood

257
 pressure
b. Epinephrine and norepinephrine—in response to sympathetic
stimulation, the adrenal medulla releases these hormones,
which in turn increase cardiac output by increasing the rate and
force of heart contractions; also cause vasoconstriction of
arterioles
B. Blood pressure—pressure exerted by blood on the walls of a blood
vessel; generated by the contraction of ventricles (see the sections on
“Health History Evaluation” in Chapter 15 and “Vital Signs” in Chapter
21)
1. Blood pressure is highest in the aorta and in the large systemic
arteries; it drops progressively as distance from the left ventricle
increases
2. An increase in blood volume increases blood pressure; a decrease in
blood volume decreases blood pressure
3. Vascular resistance—the opposition to blood flow because of friction
between blood and the walls of blood vessels; depends on the size of
the blood vessel lumen, blood viscosity, and total length of the blood
vessel
4. Neural regulation—the nervous system regulates blood pressure
through negative feedback loops that occur as two types of reflexes,
baroreceptor and chemoreceptor
a. Baroreceptors—neurons sensitive to pressure; send impulses to
the cardiovascular center to regulate blood pressure
b. Chemoreceptors—neurons sensitive to concentrations of O2,
CO2, and hydrogen ions (H+); chemoreceptors detect changes in
the blood levels of O2, CO2, and H+ and in the veins in skin and
abdominal organs
c. Antidiuretic hormone—produced by the hypothalamus and
released from the pituitary gland in response to dehydration or
decreased blood volume; also causes vasoconstriction
d. Atrial natriuretic peptide—released by cells in the atria of the
heart; lowers blood pressure by causing vasodilation and by
promoting loss of salt and water in urine, which reduces blood
volume
5. Autoregulation refers to local adjustments of blood flow in response
to physical and chemical changes in a tissue
C. Assessing circulation through pulse and blood pressure (see the
section on “Health History Evaluation” and Table 15-5 in Chapter 15, and
“Pulse, Blood Pressure, and Shock” and Figures 21-1 and 21-2 in Chapter

258
21)
1. Pulse—alternative expansion and elastic recoil of an artery with each
heartbeat
2. Blood pressure—pressure exerted by blood on the walls of an artery
when the left ventricle undergoes systole and then diastole
3. Shock—failure of the cardiovascular system to circulate blood
adequately or to deliver adequate amounts of O2 and nutrients to
meet the metabolic needs of cells
D. Circulatory route
1. Systemic circulation—takes oxygenated blood from the left ventricle
through the aorta to all parts of the body and returns deoxygenated
blood to the right atrium
a. Parts of the aorta include the ascending aorta, the arch of the
aorta, and the descending aorta; each part gives off arteries that
branch to supply the whole body
b. Blood leaving the aorta and traveling through systemic arteries
has a bright-red color; as it moves through the capillaries, it
loses some of its O2 and takes on CO2 so that the blood in
systemic veins has a dark-red color
2. Pulmonary circulation—takes deoxygenated blood from the right
ventricle to the air sacs of the lungs and returns oxygenated blood
from the air sacs to the left atrium; allows blood to be oxygenated for
systemic circulation; deoxygenated blood is returned to the heart
through systemic veins; all veins of systemic circulation flow into the
superior vena cava, inferior vena cava, or coronary sinus, which
empty into the right atrium
3. Hepatic portal circulation—collects deoxygenated blood from the
veins of the GI tract and spleen and directs it into the hepatic portal
vein of the liver; allows the liver to extract, modify, and detoxify
harmful substances in blood; the liver also receives oxygenated
blood from the hepatic artery

The Lymphatic and Immune System

The primary purpose of the lymphatic and immune system is to aid in
the body’s resistance against disease. Primary functions include
aborption of fats from the digestive system, transportation of fats and
surplus interstitial fluid, and a defense system against attacking
microorganisms and disease.
A. Components (Figure 3-28)

259
 FIG 3-28 Components of the lymphatic system. (From Patton KT, Thibodeau GA,
Douglas MM: Essentials of anatomy and physiology, St Louis, 2012, Mosby.)

1. Lymph
2. Lymphatic vessels
3. Structures and organs that contain lymphatic tissue (specialized
reticular tissue containing large numbers of lymphocytes)
4. Red bone marrow
B. Function
1. Drains tissue spaces of excess interstitial fluid
2. Transports dietary lipids (triglycerides, cholesterol, and lipid-soluble
vitamins A, D, E, K) from the GI tract to blood
3. With the help of macrophages, protects the body from foreign
invasion by microbes and cancer cells
4. The major difference between the interstitial fluid and lymph is
location; when fluid bathes tissue cells, it is called interstitial fluid, or
intercellular fluid; when it flows through lymphatic vessels, it is
called lymph
C. Lymphatic vessels and lymph circulation
1. Lymphatic vessels—begin as lymphatic capillaries in tissue spaces
between cells; have thinner walls and more valves than veins
2. Lymphatic capillaries—merge to form larger vessels, called lymphatic
vessels, which ultimately converge into the thoracic duct or the right
lymphatic duct
3. Lymph flows from the interstitial fluid, to lymphatic capillaries, to
lymphatic vessels, to lymph trunks, to the thoracic duct or right
lymphatic duct, and to the subclavian veins, as a result of skeletal

260
 muscle contractions, respiratory movements, and the valves in the
lymphatic vessels
a. The milking action of skeletal muscle contractions compresses
lymphatic vessels and forces lymph toward subclavian veins
(skeletal muscle pump)
b. Lymphatic vessels contain valves that ensure the one-way
movement of lymph; lymph flow is also maintained by pressure
changes that occur during inhalation (respiratory pump); lymph
flows from the abdominal region, where the pressure is higher,
toward the thoracic region, where it is lower; when the pressures
reverse during exhalation, valves prevent the backflow of lymph
c. Edema—accumulation of the interstitial fluid in tissue spaces
caused by an obstruction such as an infected lymph node,
blockage of lymphatic vessels, injury, or inflammation (see the
section on “Inflammation” in Chapter 7).
D. Lymphatic organs and tissues (see Table 9-9 and Figures 9-1 and 9-2 in
Chapter 9)
1. Primary lymphatic organs (red bone marrow)—sites where stem
cells divide and mature into B cells and T cells
2. Secondary lymphatic organs and tissues—lymph nodes, spleen, and
lymphatic nodules; sites where most immune responses occur
3. Thymus—a two-lobed organ located posterior to the sternum and
medial to the lungs
a. Site of T cell maturation
b. Produces hormones
c. Large in infants; after puberty, much of thymic tissue is replaced
by fat and connective tissue; the gland continues to function
throughout life
4. Lymph nodes—approximately 600 bean-shaped organs located along
lymphatic vessels; scattered throughout the body, both in superficial
and deep locations; usually occur in groups (see the section on
“Blood and Lymph” in Chapter 2; “The Lymphatic System” and
Figure 4-7 in Chapter 4; and “Extraoral and Intraoral Assessment”
and Figure 15-6 in Chapter 15)
a. Contain B cells that develop into plasma cells, which secrete
antibodies, T cells, and macrophages
b. Function as filters of lymphatic fluid

The Immune System

The immune system comprises a wide variety of body reactions or

261
responses to fight the invasion of pathogens. This is accomplished by
detecting pathogens and differentiating them from the body’s own
healthy tissue. The defense mechanisms are categorized as either
nonspecific or specific immunity, providing mechanical and chemical
barriers, inflammatory responses, phagocytosis, antibodies, and many
other means to protect the body (Figure 3-29; see the section on “Disease
Barriers,” Tables 9-8 and 9-9, and Figures 9-1 and 9-2 in Chapter 9).

FIG 3-29 Lines of defense. (From Patton KT, Thibodeau GA: Anthony’s
textbook of anatomy and physiology, ed 20, St Louis, 2013, Elsevier.)

A. Nonspecific (innate) immunity—mechanisms that provide general

defense by acting against anything recognized as “not self ” or foreign
B. Specific (adaptive) immunity—mechanisms that recognize specific
threatening agents

Nonspecific Immunity

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A. Species resistance—genetic characteristics of an organism or species
that defend against pathogens
B. First line of defense—mechanical and chemical barriers, for example,
skin, mucous membranes, sebum, mucus, enzymes, and hydrochloric
acid in the stomach
C. Second line of defense—inflammation (see Figure 3-29; see the
sections on “Inflammation,” “Acute Inflammation,” and “Chronic
Inflammation” in Chapter 7)
1. Inflammatory response—tissue damage elicits responses to
counteract injury and promote normalcy
2. Phagocytosis—ingestion and destruction of microorganisms or other
small particles by phagocytes, for example, neutrophils,
macrophages, histiocytes in connective tissue, microglia in the
nervous system, and Kupffer cells in the liver
D. Third line of defense—natural killer cells (lymphocytes that kill tumor
cells and cells infected by viruses); method of killing cells: lysing cells by
damaging plasma membranes
1. Interferon—protein synthesized and released into the circulation by
certain cells if invaded by viruses
2. Complement—group of enzymes lyse cells when activated by either
specific or nonspecific mechanisms

Specific Immunity
A. Specific immunity—part of the third line of defense consisting of
lymphocytes; lymphocytes are densest where they develop in bone
marrow, thymus gland, lymph nodes, and spleen; lymphocytes flow
through the bloodstream, become distributed in tissues, and return to
the bloodstream in a continuous recirculation; lymphocytes are named
by the CD protein surface markers that the cells carry, for example, CD4
and CD cells (called the CD system)
B. Two classes of lymphocytes—B lymphocytes (B cells) and T
lymphocytes (T cells)
1. B cells—produce antibodies that attack pathogens (antibody-
mediated immunity)
2. T cells—attack pathogens more directly (cell-mediated immunity)

B Cells and Antibody-Mediated Immunity

See the section on “Disease Barriers” and Figure 9-1 in Chapter 9.
A. B cells develop in two stages:
1. Pre-B cells develop by a few months of age
2. The second stage occurs in lymph nodes and the spleen—activation

263
 of B cell when it binds to a specific antigen
3. B cells serve as ancestors to antibody-secreting plasma cells
B. Antibodies—proteins (immunoglobulins) secreted by activated B cell;
resist disease first by recognizing foreign abnormal substances
C. Antibody molecule—consists of two heavy and two light polypeptide
chains; each molecule has two antigen-binding sites and two
complement-binding sites; produces antibody-mediated immunity
(humoral immunity) within plasma
D. Classes of immunoglobulin (Ig) (see Table 9-9 in Chapter 9)
1. IgM—inactive B cells synthesize and insert themselves into their
own plasma membranes; predominant class produced after initial
contact with an antigen
2. IgG—makes up 75% of antibodies in blood; predominant antibody
of the secondary antibody response
3. IgA—major class of antibody in external secretions of the mucous
membranes, saliva, and tears
4. IgE—role in immediate hypersensitivity reactions and parasitic
infections
5. IgD—small amount in blood; precise function unknown; thought to
activate B cells
E. Complement—component of blood plasma consisting of several
protein compounds; serves to kill foreign cells by cytolysis; causes
vasodilation and enhances phagocytosis and other functions;
complement protein 3 activated without antigen stimulation; produces
full complement effect by binding to bacteria or viruses in presence of
properdin
F. Clonal selection theory
1. The human body contains many diverse clones of cells, each
committed by its genes to synthesize a different antibody
2. When an antigen enters the body, it selects the clone whose cells are
synthesizing its antibody and stimulates them to proliferate and
create more antibodies
3. The clones selected by antigens consist of lymphocytes and are
selected by the shape of antigen receptors on the lymphocyte’s
plasma membrane

T Cells and Cell-Mediated Immunity

See the section on “Disease Barriers” and Figure 9-1 in Chapter 9.
A. T cells—lymphocytes that go through the thymus gland before
migrating to the lymph nodes and spleen; function to produce cell-
mediated immunity and regulate specific immunity in general

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 1. Pre-T cells develop into thymocytes while in the thymus
2. Thymocytes stream into blood and are carried to the T-dependent
zones in the spleen and lymph nodes
B. T cells display antigen receptors on their surface membranes; the T
cell is activated when an antigen (presented by a macrophage) binds to
its receptors, causing it to divide repeatedly to form a clone of identical
sensitized T cells
1. Sensitized T cells go to the site where the antigen entered, bind to
antigens, and release cytokines (lymphokines)
C. Killer T cells—release lymphotoxin to kill cells
D. Helper T cells—regulate the function of B cells
E. Suppressor T cells—suppress B cell differentiation into plasma cells

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The Respiratory System
In order to maintain life, the body needs oxygen for metabolic processes.
The respiratory system, working with the cardiovascular system, provides
oxygen and removal of waste products. Air is filtered and warmed by the
respiratory system while providing a mechanism for vocal
communication. It aids in homeostasis of circulation, metabolism,
electrolyte and water balance, and acidity of the blood.
A. The respiratory system functions as an air distributor and gas
exchanger that supplies O2 and removes CO2 from cells, and warms,
filters, and humidifies air (Figure 3-30)

FIG 3-30 Structural plan of the respiratory system. (From Herlihy B: The human
b ody in health and illness, ed 5, St Louis, 2015, Elsevier.)

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 1. Alveoli serve as gas exchangers; all other parts of the respiratory
system serve as air distributors
2. Respiratory organs influence speech, homeostasis of body pH, and
olfaction
B. Divided into two parts:
1. Upper respiratory tract—organs located outside of the thorax and
consist of the nose, nasopharynx, oropharynx, laryngopharynx, and
larynx
2. Lower respiratory tract—organs located within the thorax and
consist of the trachea, bronchial tree, and lungs
C. Accessory structures—oral cavity, rib cage, and diaphragm

Upper Respiratory Tract

See the section on “Osteology” in Chapter 4.
A. Nose—passageway for air traveling to and from the lungs; filters air,
aids speech, and makes the sense of smell possible
1. The external portion of the nose consists of a bony and cartilaginous
frame covered by skin containing sebaceous glands; two nasal bones
meet and are surrounded by frontal bone to form the roof; the floor
of the nose is bound by the maxilla
2. The internal nose (nasal cavity) lies over the roof of the mouth,
separated by the palatine bones
a. Cribriform plate—separates the roof of the nose from the
cranial cavity
b. Septum—separates the nasal cavity into right and left cavities;
consists of four structures: the perpendicular plate of the
ethmoid bone, the vomer bone, the vomeronasal cartilages, and
the septal nasal cartilage
3. Each nasal cavity is divided into three passageways: superior,
middle, and inferior meatus
4. Anterior nares—external openings to nasal cavities, open into the
vestibule
5. Nasal mucosa—a mucous membrane over which air passes; contains
a rich blood supply
a. Olfactory epithelium—specialized membrane containing many
olfactory nerve cells and a rich lymphatic plexus
6. Paranasal sinuses (see the section on “Paranasal Sinuses” in Chapter
4)
B. Pharynx (throat) (see the section on “Clinical Oral Structures” and
Figures 5-1 and Table 5-1 in Chapter 5)

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C. Larynx
1. Located between the root of the tongue and the upper end of the
trachea; functions as part of the airway to the lungs and produces the
voice
2. Consists of cartilages attached to each other by muscle; lined by a
ciliated mucous membrane that forms two pairs of folds:
a. Vestibular (false) vocal folds
b. True vocal cords
3. The framework of the larynx is formed by nine cartilages:
a. Single laryngeal cartilages—the three largest cartilages: the
thyroid cartilage, the epiglottis, and the cricoid cartilages
b. Paired laryngeal cartilages—three pairs of smaller cartilages: the
arytenoid, corniculate, and cuneiform cartilages
4. Muscles of the larynx
a. Intrinsic muscles both insert and originate within the larynx
b. Extrinsic muscles insert in the larynx but originate on another
structure

Lower Respiratory Tract

A. Trachea (windpipe)—extends from the larynx to the primary bronchi;
furnishes part of the open airway to the lungs; obstruction causes death
B. Bronchi and alveoli
1. The lower end of the trachea divides into two primary bronchi (one
at the right and one at the left), which continue into each lung and
then divide into secondary bronchi that branch into bronchioles,
which then divide into alveolar ducts
2. Alveoli—the primary gas exchange structures
a. Respiratory membrane—the barrier between which gases are
exchanged by alveolar air and blood; consists of the alveolar
epithelium, the capillary endothelium, and their joined
basement membranes
b. Surfactant—a component of the fluid coating the respiratory
membrane that reduces surface tension
3. Bronchi and alveoli distribute air to the lung’s interior
C. Lungs
1. Cone-shaped organs extending from the diaphragm to above the
clavicles; function in air distribution and gas exchange
a. Hilum—slit on lung’s medial surface, where primary bronchi
and pulmonary blood vessels enter
b. Base—the inferior surface of the lung; rests on the diaphragm

268
 c. Costal surface—lies against the ribs
d. Left lung—divided into two lobes (superior and inferior)
e. Right lung—divided into three lobes (superior, middle, and
inferior)
f. Lobes—further divided into functional units called
bronchopulmonary segments
(1) Ten segments in the right lung
(2) Eight segments in the left lung
D. Thorax
1. Part of the body between the neck and the abdomen; partially
encased by the ribs and containing the heart and lungs
2. Functions to bring about inspiration and expiration

Respiratory Physiology
The respiratory system includes pulmonary ventilation, gas exchange in
the lungs and tissues, transport of gases by blood, and regulation of
respiration.
A. Pulmonary ventilation (breathing)
1. Mechanism
a. Establishes two gas pressure gradients: in one gradient, the
pressure within the alveoli of the lungs is lower than
atmospheric pressure to produce inspiration; in the other, the
pressure in the alveoli of the lungs is higher than atmospheric
pressure to produce expiration
b. Pressure gradients—established by changes in the size of the
thoracic cavity through the contraction and relaxation of
muscles
c. Boyle’s law—the volume of gas varies inversely with pressure at
a constant temperature (expansion of the thorax results in
decreased intrapleural pressure, leading to a decreased alveolar
pressure and causing air to move into the lungs)
2. Two components of respiration:
a. Inspiration—contraction of the diaphragm produces
inspiration; as the diaphragm contracts, the thoracic cavity
enlarges; the ability of pulmonary tissues to stretch, which
makes inspiration possible, is termed compliance
b. Expiration—a passive process that begins when the inspiratory
muscles are relaxed, decreasing the size of the thorax and
increasing intrapleural pressure from about − 6 mm Hg to a
preinspiration level of − 4 mm Hg

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 (1) The pressure between the parietal and visceral pleurae is
always less than atmospheric pressure
(2) Elastic recoil—tendency of pulmonary tissues to return to
a smaller size after having been stretched passively during
expiration
3. Pulmonary volumes—amount of air moved in and out and air
remaining; important for normal exchange of O2 and CO2 to take
place
a. Spirometer—instrument used to measure the volume of air
b. Tidal volume (TV, VT)—amount of air exhaled after normal
inspiration
c. Expiratory reserve volume (ERV)—largest volume of additional
air that can be forcibly exhaled (normal ERV is 1.0 to 1.2 liters
[L])
d. Inspiratory reserve volume (IRV)—amount of air that can be
forcibly inhaled after normal inspiration (normal IRV is 3.3 L)
e. Residual volume—amount of air that cannot be forcibly exhaled
(1.2 L)
f. Pulmonary capacity—the sum of two or more pulmonary
volumes
g. Vital capacity—the sum of IRV + TV + ERV; depends on many
factors, including the size of the thoracic cavity and posture
h. Minimal volume—amount of air remaining after RV
i. Functional residual capacity—amount of air at the end of a
normal respiration
j. Total lung capacity—sum of all four lung volumes; the total
amount of air a lung can hold
k. Anatomic dead space—air in passageways that does not
participate in gas exchange
l. Physiologic dead space—anatomic dead space plus the volume
of any nonfunctioning alveoli (as in pulmonary disease)
m. Alveolar ventilation—volume of inspired air that reaches the
alveoli; alveoli must be properly ventilated for adequate gas
exchange
B. Pulmonary gas exchange
1. Once pulmonary ventilation (inhaled a breath of air) has occurred
and the lungs are filled with air, the second stage of respiration takes
place: pulmonary gas exchange occurs in the lungs between the
alveoli and the blood; also referred to as “external respiration”
because it involves the respiratory processes that have contact with

270
 the external environment
2. Gas exchange in the lungs takes place between alveolar air and blood
flowing through lung capillaries
a. Four factors determine the amount of O2 that diffuses into
blood:
(1) O2 pressure gradient between alveolar air and blood
(2) Total functional surface area of the respiratory membrane
(3) Respiratory minute volume
(4) Alveolar ventilation
b. Structural facts that facilitate O2 diffusion from alveolar air to
blood
(1) The walls of alveoli and capillaries form only a very thin
barrier for gases to cross
(2) Alveolar and capillary surfaces are large
(3) Blood is distributed through capillaries in a thin layer so
that each red blood cell comes close to alveolar air
C. How blood transports gases
1. O2 and CO2 are transported as solutes and as parts of the molecules
of certain chemical compounds
2. Transport of O2
a. Hemoglobin—made up of four polypeptide chains (two α-
chains, two β-chains), each with an iron-containing heme group;
CO2 can bind to amino acids in the chains, and O2 can bind to
iron in the heme groups
b. Oxygenated blood contains about 0.3 mL of dissolved O2 per
100 mL of blood
c. Hemoglobin increases the O2-carrying capacity of blood
d. O2 travels in two forms: as dissolved O2 in plasma (PO2) and
associated with hemoglobin (oxyhemoglobin)
(1) Increasing blood PO2 accelerates the association of
hemoglobin with O2
(2) Oxyhemoglobin carries the majority of the total O2
transported by blood
3. Transport of CO2
a. A small amount of CO2 dissolves in plasma and is transported
as a solute (10%)
b. Less than one fourth of blood CO2 combines with NH2 (amine)
groups of hemoglobin and other proteins to form
carbaminohemoglobin (20%)

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 c. The association of CO2 with hemoglobin is accelerated by an
increase in blood PO2
d. More than two thirds of the CO2 in plasma is bicarbonate ions (
, 70%)
D. Systemic gas exchange
1. Gas exchange in tissues takes place between arterial blood flowing
through tissue capillaries and cells
a. O2 diffuses out of arterial blood because the O2 pressure
gradient favors its outward diffusion
b. As dissolved O2 diffuses out of arterial blood, blood PO2
decreases, which accelerates oxyhemoglobin dissociation to
release more O2 to plasma for diffusion to cells
2. CO2 exchange between tissues and blood occurs in the opposite
direction from O2 exchange
a. Bohr effect—increased PO2 decreases the affinity between O2
and hemoglobin
b. Haldane effect—increased CO2 loading is caused by a decrease
in PO2
E. Regulation of respiration
1. Respiratory control centers—main integrators that are located in the
brain stem and control the nerves that affect inspiratory and
expiratory muscles
a. Medullary rhythmicity center—generates the basic rhythm of
the respiratory cycle
(1) Consists of two interconnected control centers:
(a) Inspiratory center, which stimulates inspiration
(b) Expiratory center, which stimulates expiration
b. The basic breathing rhythm can be altered by different inputs to
the medullary rhythmicity center
(1) Input from the apneustic center in the pons stimulates the
inspiratory center to increase the length and depth of
inspiration
(2) Pneumotaxic center in the pons—inhibits the apneustic
center and the inspiratory center to prevent overinflation of
the lungs
2. Factors that influence breathing—sensors from the nervous system
provide feedback to the medullary rhythmicity center
a. Changes in the partial pressure of oxygen (Po2) and carbon
dioxide (Pco2) and the pH of arterial blood influence the

272
 medullary rhythmicity area
(1) Pco2 acts on the chemoreceptors in the medulla; an
increase in Pco2 results in faster breathing; a decrease
results in slower breathing
(2) A decrease in blood pH stimulates the chemoreceptors in
the carotid and aortic bodies
(3) Arterial blood Po2 presumably has little influence if it stays
above a certain level
b. Arterial blood pressure controls breathing through the
respiratory pressor reflex mechanism
c. Hering-Breuer reflexes control respirations by regulating the
depth of respirations and the volume of tidal air
d. The cerebral cortex influences breathing by increasing or
decreasing the rate and strength of respirations

The Digestive System

The digestive system is vital in preparing nutrients to be absorbed and
utilized by body cells. The chemical and physical alteration of nutrients
to aid in absorption is called digestion. The digestive system includes the
digestive tract and other accessory organs (Figure 3-31).

273
 FIG 3-31 Location of digestive organs. (From Patton KT, Thibodeau GA,
Douglas MM: Essentials of anatomy and physiology, St Louis, 2012, Mosby.)

A. System of organs that breaks down food into molecules small enough
for cells to use; the two groups are:
1. Gastrointestinal tract—continuous tube that extends from the
mouth to the anus; organs include the mouth, pharynx, esophagus,
stomach, and small and large intestines
2. Accessory digestive organs—teeth, tongue, salivary glands, liver,
gallbladder, and pancreas; teeth and tongue only accessory organs
that come into direct contact with food
B. Functions
1. Ingestion—taking foods and liquids into mouth
2. Secretion—cells within the walls of the GI tract and accessory organs
secrete a total of about 7 L of water, acid, buffers, and enzymes into
the lumen of the tract
3. Mixing and propulsion—alternating contraction and relaxation of
smooth muscle in the walls of the GI tract mix food and secretions

274
 and propel them toward the anus; motility is the ability of the GI
tract to mix and move material along its length
4. Digestion—mechanical and chemical processes break down ingested
food into small molecules
5. Absorption—entrance of ingested and secreted fluids, ions, and
small molecules that are products of digestion into the epithelial
cells lining the lumen of the GI tract; absorbed substances pass into
blood or lymph and circulate to cells throughout the body
6. Defecation—wastes, indigestible substances, microorganisms, and
digested materials that were not absorbed leave the body through
the anus; the eliminated material is called feces
C. Organs
1. Mouth
a. Formed by cheeks, palates, lips, and tongue, which aid
mechanical digestion
b. Fauces—opening from the mouth to the throat
c. Tongue—composed of skeletal muscle covered with mucous
membrane and forms the floor of the oral cavity; superior and
lateral surfaces covered with papillae, some of which contain
taste buds
d. Salivary glands empty via ducts into the oral cavity; three pairs
of parotid, submandibular, and sublingual glands; secrete saliva
that lubricates food and starts the chemical digestion of
carbohydrates (salivary amylase begins the digestion of starches
in the mouth); salivation is entirely under the control of the
nervous system
e. Teeth—see the sections on “Dental Terminology” and “Dental
Anatomy” in Chapter 5.
f. Mastication—food is chewed, mixed with saliva, and shaped into
a bolus
2. Pharynx
a. Food that is swallowed passes from the mouth into the
oropharynx
b. From the oropharynx, food passes into the laryngopharynx
3. Esophagus
a. Muscular tube that connects the pharynx to the stomach
b. Swallowing—moves the bolus from the mouth to the
esophagus, which passes the food bolus into the stomach by
peristalsis; consists of a voluntary stage, a pharyngeal stage
(involuntary), and an esophageal stage (involuntary)
4. Stomach

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 a. Is attached to the esophagus and ends at the pyloric sphincter
b. Anatomic subdivisions: cardia, fundus, body, and pylorus
c. Adaptations for digestion include rugae; glands that produce
mucus, hydrochloric acid, a protein-digesting enzyme (pepsin),
intrinsic factor, and gastrin; and a three-layered muscularis for
efficient mechanical movement
d. Mechanical digestion consists of mixing waves; chemical
digestion consists of conversion of proteins into peptides by
pepsin; mixing waves and gastric secretions reduce food to
chyme
e. Gastric secretion and motility are regulated by neural and
hormonal mechanisms; parasympathetic impulses and gastrin
cause the secretion of gastric juices; food in the small intestine,
secretin, and cholecystokinin inhibit gastric secretion
f. Gastric emptying
(1) Stimulated in response to stretching; gastrin released in
response to the presence of certain foods
(2) Inhibited by reflex action and hormones (secretin and
cholecystokinin)
g. Impermeable to most substances; the stomach can absorb
water, certain ions, drugs, and alcohol
5. Pancreas
a. Connected to the duodenum by the pancreatic duct
b. Pancreatic islets (islets of Langerhans)—secrete hormones;
endocrine portion of the pancreas
c. Acinar cells—secrete pancreatic juice; exocrine portion of the
pancreas
d. Pancreatic juice—contains enzymes that digest starch, glycogen,
and dextrins (pancreatic amylase); proteins (trypsin,
chymotrypsin, and carboxypeptidase); triglycerides (pancreatic
lipase); and nucleic acids (nucleases)
6. Liver and gallbladder
a. Liver—has left and right lobes; produces bile
b. Gallbladder—a sac located in a depression under the liver;
stores and concentrates bile
D. Layers of the GI tract
1. Basic arrangement from deep to superficial: mucosa, submucosa,
muscularis, and serosa (visceral peritoneum)
2. The mucosa contains extensive patches of lymphatic tissue

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The Urinary System
The function of the urinary system is not only to produce urine, but also
to balance the composition of blood plasma. The primary organs of the
urinary system are the kidneys, which control the homeostasis of water,
electrolytes, and pH in body fluids. The accessory organs that aid in the
excretion of waste are the ureters, urinary bladder, and urethra.
A. Kidneys—principal organs of the urinary system; accessory organs are
ureters, urinary bladder, and urethra
B. Regulates content of blood plasma to maintain the “dynamic
constancy,” or homeostasis, of the internal fluid environment within
normal limits
C. Anatomy of the urinary system—structure
1. Kidneys (Figure 3-32)

FIG 3-32 Internal structure of the kidney. (From Solomon EP: Introduction to
human anatomy and physiology, ed 2, St Louis, 2008, Saunders.)

a. Shape, size, and location

(1) Roughly oval, with a medial indentation; each kidney
approximately 11 × 7 × 3 cm
(2) The left kidney is often larger than the right; the right
kidney is located slightly lower than the left

277
 (3) The kidneys are located in the retroperitoneal position; lie
on either side of the vertebral column between T12 and L3
(4) Superior poles of both kidneys extend above the level of
the twelfth rib and the lower edge of the thoracic parietal
pleura
(5) The renal fascia anchors the kidneys to surrounding
structures; heavy cushion of fat surrounds each kidney
b. Internal structures of the kidney
(1) Cortex and medulla
(2) Renal pyramids: constitute much of the medullary tissue
(3) Renal columns: where cortical tissue dips into the medulla
between the pyramids
(4) Calyx: cup-like structure at each renal papilla that collects
urine; the structures join together to form the renal pelvis
(5) Renal pelvis: narrows as it exits the kidney to become the
ureter
c. Kidneys are highly vascular
2. Renal artery: a large branch of the abdominal aorta; brings blood
into each kidney (Figure 3-33)

FIG 3-33 Circulation of blood through the kidney. (Modified from Applegate E:
The anatomy and physiology learning system, ed 4, St Louis, 2011, Saunders.)

3. Interlobular arteries—the renal artery branches between the

pyramids of the medulla; interlobular arteries extend toward the
cortex, arch over the bases of the pyramids, and form arcuate
arteries; from arcuate arteries, interlobular arteries penetrate the
cortex

278
4. Juxtaglomerular apparatus—located where the afferent arteriole
brushes past the distal tubule; important for the maintenance of
blood flow homeostasis by reflexively secreting renin when blood
pressure in the afferent arteriole drops
5. Ureter—tube running from each kidney to the urinary bladder;
composed of three layers: mucous lining, muscular middle layer, and
fibrous outer layer
6. Urinary bladder (Figure 3-34)

279
 FIG 3-34 Structure and location of the urinary bladder. A, Frontal view of
a dissected urinary bladder (male) in a fully distended position. B,
Sagittal view of the female urinary system (left) and male urinary system
(right), each showing a partially distended bladder. (From Patton KT,
Thibodeau GA: Anthony’s textb ook of anatomy and physiology, ed 20, St Louis, 2013,
Elsevier.)

a. Collapsible, bag-like structure located behind the symphysis

pubis; made mostly of smooth muscle tissue; lining forms
rugae; can distend considerably

280
 b. Functions
(1) Reservoir for urine before it is voided
(2) Expels urine from the body with the aid of the urethra
c. Mechanism for voiding
(1) Voluntary relaxation of external sphincter muscle
(2) Reflexive contraction of regions of the detrusor muscle
(3) Urine forced out of bladder through the urethra
7. Urethra
a. Small mucous membrane–lined tube; extends from the trigone
to the exterior of the body
b. In the female, lies posterior to the symphysis pubis and anterior
to the vagina; approximately 3 cm long
c. In the male, after leaving the bladder, passes through the
prostate gland, where it is joined by two ejaculatory ducts; from
the prostate, it extends to the base of the penis and then
through the center of the penis and ends as the urinary meatus;
approximately 20 cm long; the male urethra is part of the
urinary system as well as the reproductive system
D. Microscopic structure of the nephron
1. Nephrons—microscopic functional units; make up the bulk of the
kidney; those located in the renal cortex are called cortical nephrons;
those near the junction of the cortical and medullary layers are
called juxtamedullary nephrons; each nephron is made up of various
structures
a. Renal corpuscle
b. Bowman’s capsule—cup-shaped mouth of the nephron
(1) Formed by parietal and visceral walls, with a space
between them
(2) Pedicles in the visceral layer are packed closely together to
form filtration slits; slit diaphragm prevents filtration slits
from enlarging under pressure
(3) Glomerulus—network of fine capillaries in Bowman’s
capsule; together called renal corpuscle; located in the cortex
of the kidney
(4) The basement membrane lies between the glomerulus and
Bowman’s capsule
(5) Glomerular-capsular membrane—formed by the
glomerular endothelium, the basement membrane, and the
visceral layer of Bowman’s capsule; function is filtration
c. Proximal tubule—first part of the renal tubule nearest to
Bowman’s capsule; follows a winding, convoluted course; also

281
 known as proximal convoluted tubule
d. Loop of Henle
(1) Renal tubule segment just beyond proximal tubule
(2) Consists of a thin descending limb, a sharp turn, and a
thick ascending limb
(3) Juxtamedullary nephron—a nephron with a loop of Henle
that dips far into the medulla
(4) Cortical nephron—a nephron with a loop of Henle that
does not dip into the medulla but remains almost entirely
within the cortex; constitutes about 85% of the total number
of nephrons
e. Distal tubule—convoluted tubule beyond the loop of Henle;
also known as distal convoluted tubule
f. Collecting duct
(1) Straight tubule joined by the distal tubules of several
nephrons
(2) Joins larger ducts; larger collecting ducts of one renal
pyramid converge to form one tube that opens at a renal
papilla into a calyx
E. Physiology of the urinary system—the kidneys are important organs
with many functions in the body, including producing hormones,
absorbing minerals, and filtering blood and producing urine
1. Functions of the kidneys
a. Waste excretion—the kidneys filter out toxins, excess salts, and
urea, a nitrogen-based waste created by cell metabolism
(1) While filtering waste, kidneys measure out chemicals (e.g.,
sodium, phosphorus, potassium) and release these back to
the blood to return to the body; in this way, kidneys regulate
the body’s level of these substances
(2) Urea is synthesized in the liver and transported through
the blood to the kidneys for removal
b. Water level balance—kidneys are key in the production of urine
(1) The kidneys react to changes in the body’s water level
throughout the day
(2) As water intake decreases, the kidneys adjust accordingly
and leave water in the body instead of helping to excrete it
c. Blood pressure regulation—the kidneys need constant pressure
to filter the blood
(1) When it drops too low, the kidneys increase the blood
pressure
(2) One way is by producing a blood vessel–constricting

282
 protein (angiotensin) that also signals the body to retain
sodium and water
(3) Both constriction and retention help restore normal blood
pressure
d. Red blood cell regulation—when the kidneys do not receive
enough oxygen, they send out a “distress call” in the form of
erythropoietin, a hormone that stimulates the bone marrow to
produce more oxygen-carrying RBCs
e. Acid regulation—as cells metabolize, they produce acids
(1) Foods eaten can either increase the acid in the body or
neutralize it
(2) To function properly, the body needs to keep a healthy
balance of these chemicals, as is done by the kidneys
f. Nephron—basic functional unit; forms urine through:
(1) Filtration—movement of water and protein-free solutes
from the plasma in the glomerulus into the capsular space
of Bowman’s capsule
(2) Tubular resorption—movement of molecules out of the
tubule and into peritubular blood
(3) Tubular secretion—movement of molecules out of
peritubular blood and into the tubule for excretion
2. Filtration—first step in blood processing that occurs in the renal
corpuscles
a. From the blood in glomerular capillaries, about 180 L of water
and solutes filter into Bowman’s capsule each day; takes place
through the glomerular-capsular membrane
b. Occurs because of the existence of a pressure gradient
c. Occurs rapidly because of the increased number of fenestrations
d. Glomerular hydrostatic pressure and filtration are related to
systemic blood pressure
3. Tubular reabsorption—second step in urine formation; results from
passive and active transport mechanisms from all parts of the renal
tubules; major portion of resorption occurs in proximal tubules
a. Tubular reabsorption in the proximal tubule—most water and
solutes are recovered by blood, leaving only a small volume of
tubule fluid to move on to the loop of Henle
(1) Sodium—actively transported out of the tubule fluid and
into blood
(2) Glucose and amino acids—passively transported out of the
tubule fluid by means of the sodium co-transport
mechanism

283
 (3) Chloride, phosphate, and bicarbonate ions passively move
into blood because of an imbalance of electrical charge
(4) Water—movement of sodium and chloride into blood
causes an osmotic imbalance, moving water passively into
blood
(5) Urea—approximately one half of urea passively moves out
of the tubule; the remaining urea moves on to the loop of
Henle
b. Reabsorption in the loop of Henle
(1) Water is reabsorbed from the tubule fluid, and urea is
picked up from the interstitial fluid in the descending limb
(2) Sodium and chloride are resorbed from the filtrate in the
ascending limb, where the reabsorption of salt dilutes the
tubule fluid and creates and maintains a high osmotic
pressure of the medulla’s interstitial fluid
4. Reabsorption in the distal tubules and collecting ducts
a. The distal tubule resorbs sodium by active transport, but in
smaller amounts than in the proximal tubule
b. ADH—secreted by the posterior pituitary gland; targets the
cells of distal tubules and collecting ducts to make them more
permeable to water
c. With the reabsorption of water in the collecting duct, urea
concentration of the tubule fluid increases, causing urea to
diffuse out of the collecting duct into the medullary interstitial
fluid
d. Urea participates in a countercurrent multiplier mechanism
that, along with countercurrent mechanisms of the loop of
Henle and the vasa recta, maintains the high osmotic pressure
needed to form concentrated urine and avoid dehydration
5. Tubular secretion
a. Tubular secretion—movement of substances out of blood and
into the tubular fluid
b. The descending limb of the loop of Henle secretes urea by
diffusion
c. Distal and collecting tubules secrete potassium, hydrogen, and
ammonium ions
d. Aldosterone—hormone that targets the cells of distal and
collecting tubules; causes increased activity of sodium-
potassium pumps
e. Secretion of hydrogen ions increases with increased H+
concentration in blood

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 6. Regulation of urine volume
a. ADH influences water reabsorption; as water is resorbed, the
total volume of urine is reduced by the amount of water
removed by the tubules; ADH reduces water loss
b. Aldosterone—secreted by the adrenal cortex; increases the
absorption of sodium by the distal tubule, raising the sodium
concentration of blood and thus promoting the reabsorption of
water
c. Atrial natriuretic peptide—secreted by specialized atrial muscle
fibers; promotes the loss of sodium through urine; opposes
aldosterone, causing the kidneys to resorb less water and
thereby produce more urine
d. Tubuloglomerular feedback mechanism—maintains constant
glomerular filtration rate (GFR) by regulating resistance in
afferent arterioles; protects kidney GFR function from rapid
blood pressure variations; dependent on macula densa cells and
the juxtaglomerular apparatus; may influence the renin-
angiotensin mechanism
e. Myogenic mechanism—rapid and effective regulation of GFR
through changes in the contraction and relaxation of afferent
arteriole smooth muscle
f. Related to the total amount of solutes other than sodium
excreted in urine; generally, the more solutes present, the higher
the volume of urine
7. Urine composition—approximately 95% water with several
substances dissolved in it, for example:
a. Nitrogenous wastes—result of protein metabolism; for example,
urea, uric acid, ammonia, and creatinine
b. Electrolytes—mainly the ions sodium, potassium, ammonium,
chloride, bicarbonate, phosphate, and sulfate; amounts and
types of minerals vary with diet and other factors
c. Toxins—during disease, bacterial poisons leave the body in
urine
d. Pigments—especially urochromes
e. Hormones—high hormone levels may spill into the filtrate
f. Abnormal constituents such as blood, glucose, albumin, casts,
or calculi

The Reproductive System

The primary function of the reproductive system is to produce offspring.

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Other systems in the endocrine system function to maintain
homeostasis, whereas the reproductive system is vital for survival of the
species. The primary reproductive organs are the gonads (ovaries and
testes), producing gametes (egg or sperm) and hormones. All other
organs in the reproductive system are considered secondary and function
to nurture and transport the gametes and developing offspring.

Male
A. Testes
1. Two ovoid bodies that lie in the scrotum and are suspended in the
inguinal region by the spermatic cord
2. Sperm—formed and stored in the seminiferous tubules of the testes
3. Testosterone—produced in the testes
4. The epididymis is adjacent to the testes in the scrotum
a. Acts as a storage reservoir for sperm along with the
seminiferous tubules
b. Sperm may live for as long as 1 month in both the epididymis
and the seminiferous tubules
5. If the testes fail to descend during infancy, the condition is referred
to as cryptorchidism
B. Vas deferens
1. Conducts sperm from the epididymis to the urethra
2. Acts as a storage site for sperm
C. Urethra
1. Passageway for semen from the vas deferens through the penis
2. Passage for urine from the bladder through the penis
3. Ends at the urinary meatus, which is the opening in the glans penis
through which urine and semen are excreted
D. Seminal vesicles
1. Membranous pouches located posterior to the bladder
2. Produce a secretion that contains fructose, amino acids, and mucus
3. Secrete mucoid material into the upper end of the vas deferens
E. Prostate gland
1. Located inferior to the bladder
2. Secretes an alkaline fluid to activate sperm
3. Secretes its milky fluid into the vas deferens
F. Bulbourethral glands (Cowper ’s glands)
1. Located inferior to the prostate gland
2. Secrete a mucous secretion into the urethra before ejaculation to aid
in lubrication

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G. Penis
1. Organ of copulation; divided into the shaft and the glans penis
a. Glans penis—most sensitive portion of the penis
b. The foreskin covers the glans penis (removed by circumcision)
2. Erectile tissue (corpus cavernosum) surrounds the penile urethra;
causes erection when engorged with blood
H. Sperm
1. Spermatozoa formed in the testes
2. Contains head, neck, body, and tail
a. The head contains the genetic material of the male
b. The tail provides motility through flagellar movement
c. Sperm move through the female genital tract to seek the ovum
at a velocity of approximately 1 to 4 mm per minute
3. Spermatogenesis
a. After a spermatogonium has been divided by mitosis for the
last time, it increases in size and forms a primary spermatocyte
b. The primary spermatocyte is divided by meiosis to form the
secondary spermatocyte, with a haploid number of
chromosomes
c. Division of the secondary spermatocytes results in the
formation of spermatoids
d. Spermatoids are transformed into motile cells called
spermatozoa
I. Physiology of ejaculation
1. Erection—stiffening of a flaccid penis
2. Rhythmic peristalsis in the genital ducts during orgasm causes
semen to be propelled through the epididymis, vas deferens,
seminal ducts, and urethra
3. Semen—a thick, whitish fluid of high viscosity
a. Between 2.5 and 5 mL are secreted at ejaculation
b. Each milliliter contains 10 million to 150 million sperm
c. Sperm usually move at about 3 mm per minute
J. Hormonal influences
1. Hormones are essential to the mechanism of reproduction and to the
development and maintenance of secondary sex characteristics
2. The anterior pituitary gland secretes FSH and LH, which cause the
growth and function of testes at puberty
3. Secondary sex characteristics in the male (appear during
adolescence)
a. Deepening of voice; widening of the musculature of the chest
and shoulders

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 b. Growth of facial and body hair

Female
A. Pelvis
1. Wider and shallower than the male’s pelvis
2. Shaped like a funnel with a wide mouth
3. Divided into true and false pelvis by the inlet, or brim; the sacral
promontory and ileopectineal lines are dividing points between true
and false pelvis
4. Forms part of the birth canal
5. The perineum, vagina, muscles, and ligaments form the soft
structures of the pelvis
a. Retain pelvic organs in place
b. During labor, the direct presenting part of the infant is forward
B. Ovaries
1. Flat, oval-shaped bodies about 2.5 cm long
2. Supported in the pelvis by the broad ligament and suspensory
ligament
3. Three types of follicles in the ovaries:
a. Primordial follicles contain a primary oocyte
(1) Present at birth
(2) Follicles complete their first maturation under the
influence of FSH
b. Growing follicles—contain a mature ovum and spaces that
contain fluid
c. Mature follicles—bulge from the surface of the ovary
C. Fallopian tubes (oviducts)
1. Lie in the folds of the broad ligaments
2. Fimbriae (finger-like projections) located at the ovarian ends; the
isthmus portion is connected to the uterus
3. Important events occurring in the fallopian tube are fertilization of
the ovum by a spermatozoon, segmentation, and formation of the
blastocyst
D. Uterus
1. Hollow, pear-shaped organ with thick muscular walls; located behind
the bladder and in front of the rectum
2. Divided into three parts:
a. Fundus—rounded upper part
b. Body—narrows from the fundus
c. Cervix—tapering projection

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 3. Muscular layers
a. Endometrium—one layer of ciliated columnar cells except for
the lower one third of the cervical canal where it changes to
stratified squamous epithelium; contains glands and a good
blood supply
b. Myometrium—contains smooth muscle and large blood vessels
c. Exometrium—contains the pelvic peritoneum
4. Serves as the womb for a developing fetus
E. External genitalia
1. Vagina—female organ of copulation
a. Passageway for menstrual flow
b. Connects the uterus to the external surface (vaginal orifice)
c. Serves as the birth canal
2. Mons pubis—rounded eminence in front of the pubic symphysis
3. Labia majora—two longitudinal folds; protect the inner vulva
4. Labia minora—two smaller inner folds; protect the clitoris
5. Clitoris
a. Homologue of the penis in the male
b. Increases in size with sexual stimulation
F. The perineum contains the structures found between the pubic
symphysis and the coccyx
G. Mammary glands
1. Composed of compound alveolar glands
2. Secrete milk to the nipples under the influence of lactogenic
hormone from the pituitary gland
3. Pigmented circular region (areolae surround the nipple)
4. Active glandular growth occurs during pregnancy to prepare
mammary glands to produce milk (lactation)
H. Hormonal cycle
1. Begins at puberty and ends at menopause
2. FSH—secreted by the anterior pituitary gland; activates the primary
graafian follicle; maturing follicle produces estrogen; causes the
endometrium to become engorged with blood and prepares it to
receive the fertilized ovum
3. Both hormones (FSH and estrogen) allow the ovum to mature
4. The mature ovum is released into the fallopian tube by a ruptured
graafian follicle; LH assists ovulation; the follicle forms the corpus
luteum and secretes progesterone
5. Increased progestogen levels reduce FSH and increase LH; cause the
corpus luteum to secrete progesterone
a. Stimulate the uterus to store glycogen and increase the uterine

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 blood supply
b. The corpus luteum begins to involute as a result of lowered FSH
levels
6. Menstrual cycle lasts 21 to 35 days
a. Menstruation begins if the ovum is not fertilized
b. If fertilization occurs, the placenta will secrete chorionic
gonadotropin to maintain the corpus luteum; estrogens and
progesterone continue to be secreted to maintain the rich
vascular supply in the endometrium for the developing embryo

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Suggested readings
Applegate E.J. The anatomy and physiology learning system. ed 4 St
Louis: Saunders; 2011.
Herlihy B. The human body in health and illness. ed 5 St Louis:
Saunders; 2014.
Patton K.T., Thibodeau G.A. Mosby’s handbook of anatomy and
physiology. ed 2 St Louis: Mosby; 2014.
Patton K.T., Thibodeau G.A., Douglas M.M. Essentials of anatomy and
physiology. St Louis: Mosby; 2012.

Chapter 3 review questions

Answers and rationales to chapter review questions are available on
this text’s accompanying Evolve site. See inside front cover for details.

1. Which passive transport process enables the transfer of molecules into

cells by a carrier molecule?
a. Channel mediated
b. Facilitated diffusion
c. Osmosis
d. Simple diffusion
2. Which active transport process requires metabolic cell energy to move
substances against a concentration gradient?
a. Active transport pump
b. Endocytosis
c. Exocytosis
d. Phagocytosis
3. The dental hygienist created a client treatment plan by dividing the
oral cavity at the midsagittal plane, or two dentition quadrants per client
appointment (UR, upper right; UL, upper left; LR, lower right; LL, lower
left). Which quadrants will be treated at each scheduled appointment?
a. Appointment one: UR and LR; Appointment two: UL and LL
b. Appointment one: LR and LL; Appointment two: UR and UL
c. Appointment one: UR and LL; Appointment two: UL and LR
d. Appointment one: all anterior teeth; Appointment two: all posterior

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 teeth
4. Which epithelial membrane covers body cavities that open to the
exterior of the body and are adapted for absorption and secretion?
a. Cutaneous
b. Mucous
c. Periosteal
d. Synovial
5. Which of the following BEST describes the functions of the
hypodermis, or subcutaneous layer of the skin?
a. Forms ridges that make up fingerprints and footprints
b. Serves as an attachment for skeletal muscle fibers
c. Serves as a protection against microorganisms and dehydration
d. Forms as a connection between the skin and underlying structures
6. Which one of the following statements is NOT true about cancellous
bone?
a. Arranged in crisscrossing branches or plates called trabeculae
b. Provides structure for blood production
c. Makes up 80% of the body’s bone mass
d. Located in the ends of long bones
7. Which statement describes the importance and function of
osteoblasts?
a. Creates bone resorption, allowing the movement of calcium from
bone to blood
b. Widens the bone through internal “sculpting”
c. Helps in the regulation of blood calcium by increasing calcium levels
d. Located on the undersurface of periosteum, and deposits bone
8. Suzy, an RDH, has not maintained good ergonomics during her 20-
year professional career as a dental hygienist and is experiencing
paresthesias in her right-hand phalanges. This is most likely caused by:
a. Constriction of nerves in the carpal tunnel
b. Constriction of nerves at the acromion process
c. Constriction of blood supply at the radial tuberosity
d. Constriction of blood supply at the coronoid process of the ulna
9. What do the ulna, radius, and humerus have in common?

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 a. Articulate at the glenoid cavity
b. Are part of the appendicular skeleton
c. Are bony impressions that form joints
d. Are distal to the tarsals
10. Which classification of joints is between the radius and carpal bones?
a. Cartilaginous
b. Fibrous
c. Syndesmoses
d. Synovial
11. The muscle action group that serves to stabilize joints is referred to
as:
a. Agonist
b. Antagonist
c. Fixator
d. Synergist
12. Which type of muscle contraction is an example of concentric
(isotonic) contraction?
a. Biceps curl
b. Setting an object down
c. Sitting in a chair
d. Walking down the stairs
13. Which muscle is found in the respiratory tract?
a. Striated and voluntary
b. Smooth
c. Skeletal
d. Striated and involuntary
14. Which muscle has an origin on the cheek bone and inserts on the
corner of the mouth?
a. Buccinator
b. Frontalis
c. Orbicularis oris
d. Zygomaticus
15. Which muscle group moves the phalanges for the dental hygienist?

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 a. Adductor
b. Flexor and extensor carpi
c. Flexor and extensor digitorum
d. Supinator
16. Which nervous system structure has the ability to undergo mitosis,
thus making its cells also vulnerable to cancer?
a. Axon
b. Dendrite
c. Neuroglia
d. Neuron
17. Which of the following is a function of myelin?
a. Increases the speed of nerve conduction
b. Transmit impulses away from the spinal cord or brain
c. Transmit impulses to the spinal cord or brain
d. Provides impulses toward the cell body
18. The period of time that the neuron is “recovering” from
depolarization is referred to as:
a. Absolute refractory period
b. Refractory period
c. Reverse polarization
d. Salutatory conduction
19. All the following are descriptive of neurotransmitters EXCEPT:
a. Classified by their function or chemical structure
b. Facilitate synaptic transmission across the synaptic cleft
c. Are inactivated by enzymes to prevent prolonged reactions
d. Allow ions to flow from one cell to another as they are joined
together
20. Spinal meningitis is an infection or inflammation of the connective
tissue covering that includes all the following layers EXCEPT:
a. Arachnoid
b. Cauda equina
c. Dura mater
d. Pia mater

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21. The area of the cerebrum most responsible for personality and
emotional expression is the:
a. Frontal lobe
b. Occipital lobe
c. Parietal lobe
d. Temporal lobe
22. Which of the following would NOT be a response by the
sympathetic nervous system?
a. Constrict blood vessels
b. Constrict iris of eye
c. Dilate bronchial tubes
d. Increase heart rate
23. The auditory area that extends from the middle ear down to the
nasopharynx is called the:
a. Auricle
b. Basilar membrane
c. Eustachian tube
d. Tympanic membrane
24. All the following describe a steroid hormone EXCEPT:
a. A mobile receptor in nucleus
b. Chemical structure is made up of lipids
c. Response time is 1 hour to several days
d. Stored in secretory vesicles before release
25. Which one of the following is a function of the anterior pituitary
gland?
a. Produces growth hormone
b. Secretes melatonin
c. Stores and releases antidiuretic hormone
d. Stores and releases oxytocin

Case A
A 32-year-old woman has been diagnosed with hyperthyroidism. Her
symptoms include nervousness, weakness, and heart palpitations
whenever she tries to exert herself. Recently, she noticed that she even

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sweats at night.

Use Case A to answer questions 26 to 29.

26. Which of the following is one of the main actions of the thyroid
gland?
a. Increases breakdown of glycogen
b. Increases heart rate and blood pressure
c. Increases metabolic rate
d. Increases sodium resorption and potassium secretion
27. Which of the following is a symptom manifested from high levels of
thyroid hormone?
a. Dry skin
b. Increased heart rate
c. Fatigue
d. Unexplained weight gain
28. Which trophic hormone does the anterior pituitary gland secrete that
is essential for the thyroid gland to secrete its hormones?
a. ACTH
b. FSH
c. LH
d. TSH
29. Which is the function of parathyroid hormone?
a. Important for the promotion of breast development
b. Increase the release of calcium into the blood by influencing bone
and kidneys
c. Inhibits the production of large amounts of urine
d. Stimulates contraction of uterine muscles during labor
30. A dental hygiene client states on his medical history that he is
experiencing polyuria and polydipsia. Which of the following hormones
could be at decreased levels for this client?
a. ADH
b. Gonadotropin
c. Prolactin
d. TSH

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31. Which blood protein account for 38% of plasma, functioning to
transport lipids and antibodies for immunity?
a. Albumin
b. Fibrinogen
c. Globulin
d. Prothrombin
32. Which chamber of the heart pumps oxygen depleted blood into the
lungs?
a. Left atrium
b. Left ventricle
c. Right atrium
d. Right ventricle
33. Which is the innermost layer of the heart and also lines the valves?
a. Endocardium
b. Epicardium
c. Myocardium
d. Pericardium
34. During a health history review, the client tells the RDH that she has
stenosis of the aortic valve. This means that:
a. Deoxygenated blood is not reaching the lungs
b. The left ventricle could have hypertrophy
c. The client has a diagnosis of mitral valve prolapse
d. The right atrium is not working effectively
35. The four major factors that affect blood pressure include all the
following EXCEPT:
a. Blood volume
b. Cardiac output
c. Peripheral resistance
d. Pulse points
e. Viscosity
36. The acquired immunity response that results from a person
contracting a disease and then recovering is called:
a. Active artificial immunity
b. Active natural immunity

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 c. Passive artificial immunity
d. Passive natural immunity

Case B
A 23-year-old patient presents for an initial exam and prophylaxis. Her
medical history is negative, but during the review, you learn that she is
extremely nervous at dental visits and has avoided preventive care since
she lived at home as a teenager. She appears anxious, and her vitals are
slightly elevated from previous appointments (pulse 90; respiration 20;
blood pressure 130/85). Following the assessment, a care plan is
discussed, and you begin treatment for moderate gingivitis. During
treatment, the patient then complains of not being able to “catch my
breath.” You recognize that this might be hyperventilation and a
potential emergency.

Use Case B to answer questions 37 to 39.

37. During hyperventilation, a patient is breathing faster and deeper,
eliminating more carbon dioxide than is produced. This results in
respiratory alkalosis, or a decrease in the pH of the circulating blood.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
38. What other physiologic effect(s) can result from the decrease of
carbon dioxide?
a. Reduction of calcium levels in the bloodstream
b. Vasoconstriction of blood vessels and veins
c. Reduced cardiac output and coronary blood flow
d. All the above
39. What is the effect of the diaphragm relaxing during the breathing
cycle?
a. Air is let out of the lungs.
b. The diaphragm contracts and drops.
c. The volume of the thoracic cavity increases.
d. Surfactants cause the alveoli to collapse.
40. A client presents for a dental hygiene appointment. On review of the

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medical history, the client reports that he frequently experiences
dyspnea. This means that he is experiencing:
a. Frequent urination
b. Muscle fatigue
c. Peripheral edema
d. Shortness of breath
41. What is the function of the blood cell called a basophil?
a. Phagocytosis
b. Secretes antibodies
c. Secretes heparin
d. Transportation of respiratory gases
42. Which of the following is one of the openings found in the pharynx?
a. Epiglottis
b. Eustachian tube
c. Glottis
d. Paranasal sinus
43. Aldosterone is a mineralocorticoid that functions to:
a. Support sodium homeostasis of the blood
b. Break down proteins into amino acids
c. Give male characteristics
d. Increase the release of calcium in the blood
44. Which portion of the small intestine makes up the uppermost
division?
a. Ascending colon
b. Duodenum
c. Fundus
d. Ileum
45. Which of the following is NOT a function of the liver?
a. Detoxify substances
b. Secrete bile
c. Secrete insulin
d. Store iron
46. Which organ(s) of the digestive system include the mechanical

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process of deglutition?
a. Colon
b. Pharynx
c. Rectum
d. Small intestine
47. The structures of a kidney nephron include the following:
a. Bowman’s capsule, loop of Henle, renal corpuscle
b. Cortex, medulla, calyx
c. Juxtaglomerular apparatus, renal artery, urinary bladder
d. Urethra, Ureter, Interlobular arteries
48. The three main functions of the kidneys include all the following
EXCEPT:
a. Digestion
b. Filtration
c. Tubular reabsorption
d. Tubular secretion
49. Which hormone is secreted by the anterior pituitary gland and
influences both male and female reproductive systems?
a. Adrenocorticotropin
b. Follicle-stimulating hormone
c. Prolactin
d. Thyroid-stimulating hormone

Case C
A 62-year-old man presents at an end-of-day appointment for an initial
dental exam and prophylaxis. On review of his health history, you learn
he is hypertensive with type 2 diabetes. In addition, he suffers from
clinical depression. You record his vitals as blood pressure 150/95; pulse
72 beats per minute; and respiration 16 breaths per minute. Further
questioning reveals that the patient did not eat lunch today and that he
frequently experiences xerostomia.

Use Case C to answer questions 50 to 55.

50. Which of the following medications taken by the client controls his
hypertension?

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 a. Glipizide
b. Hydrochlorothiazide
c. Metformin
d. Sertraline (Zoloft)
51. Which of the following BEST describes this client’s blood pressure?
a. Blood pressure rate is considered prehypertensive, and he should be
encouraged to see a physician.
b. Blood pressure rate is considered high, and he should be
encouraged to see a physician.
c. Blood pressure rate is considered too high, and he should not receive
dental treatment until seen by a physician.
d. Blood pressure is within normal limits.
52. Which statement is TRUE regarding insulin secretion by pancreatic
islets?
a. If blood glucose level is low, there is a decrease of glucagon secreted.
b. If blood glucose level is low, there is an increase of insulin secreted.
c. If blood glucose level is high, there is a decrease of insulin secreted.
d. If blood glucose level is high, there is a decrease of glucagon
secreted.
53. During the initial exam, the client begins to exhibit unusual
nervousness, complaining of blurry vision and a headache. On taking his
vitals, you note that his heart rate has increased to 100 beats per minute.
You use the glucometer, and his blood glucose is 68 mg/dL. Which
statement BEST describes the situation?
a. The client’s blood glucose is too high; defer elective treatment and
refer to physician.
b. The client’s blood glucose is within normal limits; proceed with
treatment plan.
c. The client’s blood glucose is too low; defer treatment and give
carbohydrates.
d. The client’s blood glucose is within normal limits, but his heart rate
needs to be addressed.
54. Which statement BEST describes oral manifestations of xerostomia?
a. An operculum on tooth #17
b. Raised lesion with a rough surface

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 c. The floor of the mouth does not have a “pool” of saliva
d. White, soft, elevated plaque on the mucosa that can be wiped away
55. Rapid changes in chair position for this client should be avoided
because:
a. Antihypertensive medications can produce orthostatic hypotension
b. It might be disruptive to the patient, causing low blood sugar
reactions
c. The client’s blood pressure could be elevated
d. It may cause the patient to experience hypothyroid conditions

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C HAPT E R 4

303
Head and Neck Anatomy and
Physiology
Kim T. Isringhausen

For the dental hygienist, knowledge of the skeletal, muscular, circulatory,

endocrine, and nervous systems within the head and neck is essential for
client assessment and evaluation; radiologic examination and
interpretation; identification of sources of infection and pathways of
spread; and client referral for abnormal findings. An understanding of
the nervous system will facilitate treatment planning and safe and
effective delivery of local anesthesia by the dental hygienist.

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Anatomic nomenclature
A. All references to body structures are made assuming the body is in
anatomic position; anatomic position is the erect position of the body, arms
at the sides, with head, eyes, and palms facing forward (Figure 4-1)

FIG 4-1 Anatomic directions and planes of section. A, Sagittal. B, Frontal. C,

Transverse. (From Herlihy B: The human b ody in health and illness, ed 5, St Louis, 2015,
Elsevier.)

B. Planes—sections of the body divided by imaginary lines; the body may

be sectioned in one of three planes:
1. Sagittal plane—a vertical plane that passes through the body from
front to back; divides the body into right and left regions
a. Midsagittal or median plane—a sagittal plane passing through
the midline of the body from front to back; divides the body into
equal right and left sides
2. Coronal or frontal plane—a vertical plane passing through the body
from side to side; divides the body into front (anterior) and back
(posterior)
3. Transverse or horizontal plane—a horizontal plane dividing the body
into upper (superior) and lower (inferior) parts
C. Directional terms—used to describe the location of one body structure
in relation to another
1. Anterior or ventral—structures toward or at the front of the body; in
front
2. Posterior or dorsal—structures toward or at the back of the body;
behind

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3. Tongue surfaces—the ventral surface of the tongue is the bottom
surface, toward the belly; and the dorsal surface of the tongue is the
top surface, toward the back when the tongue is upright in the
mouth with the tip of the tongue touching the palate
4. Medial—structures toward or at midline of the body; inner side (e.g.,
eyes)
5. Lateral—structures away from the midline of the body; outer side
(e.g., ears)
6. Contralateral—structures on opposite sides of the body
7. Superficial—structures located toward the body surface
8. Deep—structures located away from the body surface
9. Proximal—closer to the point of attachment of a limb to the body
trunk; closer to the shoulder or hip (e.g., the elbow is proximal to the
wrist)
10. Distal—farther from the point of attachment of a limb to the body
trunk; farther from the shoulder or hip (e.g., the ankle is distal to the
knee)
11. Superior or cranial—structures toward the head; upper
12. Inferior or caudal—structures away from the head; lower
13. Apex—the narrow end or tip of a conical structure

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Osteology
A. Definition—the study of bones
B. Classification—bones are classified on the basis of shape (each shape
has a distinct function), pattern of development (membranous,
cartilaginous, or mixed), region (axial or appendicular), and structure
(arrangement of material, compact or spongy)
C. Function—bone supports organs and structures; protects the soft
tissues and organs of the body; enables movement by providing
attachments for muscles and ligaments; and is involved in mineral
storage and blood cell formation
D. Histology of bone (see the section on “Connective Tissue” in Chapter
2)
1. Intramembranous ossification—one of two processes resulting in
bone formation, no cartilage is present; begins as a fibrous
membrane of collagen and blood vessels; osteoblasts form a sponge-
like network of bony processes; (e.g., flat bones of the skull)
a. Osteoblasts—bone-forming cells, form bone tissue; model bone
b. Osteoclasts—bone-destroying cells, break down bone tissue;
resorb bone
c. Osteocytes—mature bone cell embedded in bone matrix;
maintain bone; most abundant cells
2. Endochondral ossification— one of two processes resulting in bone
formation; cartilage is present as a precursor; cartilage is gradually
replaced by bone produced by osteoblasts; (e.g., long bones)
3. Cartilage—noncalcified, avascular, pliable connective tissue; three
types of cartilage:
a. Hyaline cartilage—most abundant, precursor to bone, facilitates
smooth movement at joints
b. Fibrocartilage—strongest, contains collagen fibers in its matrix,
provides rigidity (e.g., intervertebral discs)
c. Elastic cartilage—contains elastic fibers in its matrix; provides
support and defines shape (e.g., external ear)
E. Descriptive terminology
1. Bony prominences—an area where bone is immediately below the
skin surface; usually landmarks for the attachment of muscles,
ligaments, and tendons; process is a general term used to describe
any prominence on the bony surface
a. Condyle—a rounded articular process; forms joints
b. Tuberosity—a large, rough, rounded process on the surface of
bone for the attachment of connective tissue

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 c. Tubercle or eminence—a small, rough, rounded process on the
surface of bone for the attachment of connective tissue
d. Arch—a bridge-like bony structure
e. Cornu (plural, cornua)—a horn-like prominence
f. Crest—a raised, prominent border or ridge; attachment for
connective tissue, usually muscle
g. Spine—a sharp, slender projection; higher than a crest; often a
site for muscle attachment
2. Bony depressions—on the surface of bones; provide for the passage
of blood vessels and other soft tissue
a. Notch—an indentation at the edge of the bone; an articulatory
surface
b. Sulcus (plural, sulci)—a channel-like, shallow depression or
groove that usually accommodates a blood vessel, nerve, or
tendon (plural, sulci)
c. Fossa (plural, fossae)—a deeper depression on a bone surface,
basin-like; can be an area for muscle attachment or articulating
bone
d. Sinus—a cavity within a bone
3. Bony openings—occur primarily where blood vessels and nerves
pass into or through the bone
a. Foramen (plural, foramina)—a short, window-like opening in a
bone; round hole (e.g., incisive foramen)
b. Canal—a longer, tube-like opening in a bone (e.g., mandibular
canal)
c. Meatus—a type of canal or channel within the bone (e.g.,
internal acoustic meatus)
d. Fissure—a narrow, slit-like opening between adjacent parts of
bones forming a passageway for blood vessels and nerves (e.g.,
superior orbital fissure)
4. Skeletal articulations—connections between bones that be movable
or immovable
a. Joints—articulation classified by the amount of movement
allowed (e.g., immovable, slightly movable, free); the
temporomandibular joint (TMJ) is the only movable joint in the
skull
b. Sutures—fibrous joints found on the skull where bones are held
together, immovable

Axial Skeleton: Skull

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Bones of the head are grouped into two categories—cranial bones and
facial bones.
A. Cranial bones, or neurocranium (eight bones)—bones that surround
the brain; four singular bones, two paired bones
1. Frontal bone (single bone) (Figure 4-2)

FIG 4-2 Superior view of the internal surface of the skull. (From Abrahams
PH, Marks SC Jr, Hutchings RT: McMinn’s color atlas of human anatomy, ed 6, St Louis,
2008, Mosby.)

a. Forms the forehead and the top portion of the orbits

b. Contains the frontal sinuses
c. Supraorbital ridges form the roof of the orbits
d. Articulates with many of the cranial and facial bones;
articulation with the parietal bones forms the coronal suture
e. Landmarks include the supraorbital notch, the zygomatic
process of the frontal bone, and the lacrimal fossa, which
contains the tear-producing lacrimal gland
2. Parietal bones (paired bones) (see Figure 4-2)
a. Constitute a large part of the vault and sides of the cranium
b. Articulate with each other at the sagittal suture and with
various bones to form the coronal, lambdoidal, and squamosal
sutures of the skull
3. Temporal bones (paired bones)
a. Form the lateral walls of the skull
b. Articulate on each side of the skull with the zygomatic and
parietal bones, the sphenoid and occipital bones, and the

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 mandible
c. Divided into three portions:
(1) Squamous portion—largest portion; forms the zygomatic
process of the temporal bone, which is a portion of the
zygomatic arch; the zygomatic process contains the
articular (mandibular) fossa and articular eminence, which
articulate with the mandible; this area also forms the
cranial portion of the TMJ
(2) Tympanic portion—forms most of the external acoustic
meatus; it is separated from the petrous portion by the
petrotympanic fissure, through which the chorda tympani
nerve emerges
(3) Petrous portion—located inferiorly; contains the mastoid
process that serves as an attachment for the
sternocleidomastoid muscle; other landmarks include the
styloid process, stylomastoid foramen, jugular notch, and
internal acoustic meatus
4. Occipital bone (single bone) (see Figure 4-2)
a. Forms the posterior portion of the skull
b. Articulates with the parietal bones to form the lambdoidal
suture and temporal and sphenoid bones
c. Foramen magnum is formed completely by occipital bone
d. Jugular notches on both the occipital and the temporal bones
form the jugular foramen
e. Occipital condyles on each side form a movable articulation with
the first cervical vertebrae (atlas)
f. Occipital bone has paired hypoglossal canals that are openings
for cranial nerve (CN) XII
5. Sphenoid bone (single bone)
a. Articulates with the frontal, patietal, ethmoid, temporal,
zygomatic, maxillary, palatine, vomer, and occipital bones
b. Body of the sphenoid bone contains the sphenoid sinuses and
the sella turcica, the seat of the pituitary gland, which supplies
numerous hormones to the body
c. Three paired processes: lesser wing of the sphenoid bone,
greater wing of the sphenoid bone, and the pterygoid processes
d. Lesser sphenoid wings—anterior process
(1) Forms the top of the superior orbital fissure
(2) Optic foramen—entrance point of CN II
e. Greater sphenoid wings—lateral projections in the temporal
area

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 (1) Forms the inferior border of the superior orbital fissure
(2) Infratemporal crest—union of the temporal and
infratemporal surfaces
(3) Foramen rotundum—maxillary division of CN V
(4) Foramen ovale—mandibular division of CN V
(5) Foramen spinosum—opening that gives passage to the
middle meningeal artery
(6) Superior orbital fissure—a cleft between the lesser and
greater wings; transmits cranial nerves III, IV, and VI and
the ophthalmic division of CN V
f. Pterygoid process—long process projecting downward from the
junction of the body and greater wing of the sphenoid bone;
formed by two plates
(1) Medial and lateral pterygoid plates—attachment points for
pterygoid muscles
(2) Pterygoid fossa—formed by divergence of the medial and
lateral pterygoid plates
(3) Hamulus—inferior termination of the medial pterygoid
plate; also provides attachment for a tendon of the soft
palate
6. Ethmoid bone (single bone) (see Figure 4-2)
a. Single midline bone of the skull, anterior to the sphenoid
b. Articulates with the sphenoid, frontal, lacrimal, and maxillary
bones; joins the vomer inferoposteriorly
c. Contains ethmoid sinuses
d. Cribriform plate—horizontal plate with numerous openings for
passage of olfactory nerves
e. Crista galli—midline process of the ethmoid bone that serves as
an attachment for the dura mater (meninges) of the brain
f. Perpendicular plate—projects downward from the crista galli,
assists in forming the nasal septum
g. Superior and middle nasal conchae—located laterally in the
nasal cavity; part of ethmoidal labyrinth; protect olfactory bulb
and buffer sinuses
B. Facial bones, or viscerocranium (14 bones)— surround the face; two
singular bones, six paired bones (Figure 4-3)

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 FIG 4-3 Anterior view of facial bones. (From Abrahams PH, Marks SC Jr, Hutchings RT:
McMinn’s color atlas of human anatomy, ed 6, St Louis, 2008, Mosby.)

1. Inferior nasal conchae (paired bones)

a. Arise from the maxilla horizontally into the nasal cavity
b. Responsible for airflow direction, humidification, and heating
and filtering of inhaled air
2. Nasal bones (paired bones) (see Figure 4-3)
a. Form the bridge of the nose, articulating with each other
b. Articulate with the maxillae, and the frontal and ethmoid bones
3. Lacrimal bones (paired bones) (see Figure 4-3)
a. Thin bones that form part of the medial wall of the orbit of the
eye
b. The nasolacrimal duct is located at the junction of the lacrimal
and maxillary bones
c. Fluid (tears) from the lacrimal gland is drained through this
duct into the inferior nasal meatus
4. Zygomatic bones (paired bones) (see Figure 4-3)
a. Zygomatic arch (cheekbone)—composed of the temporal
process of the zygomatic bone and the zygomatic process of the
temporal bone
b. Three processes are named for the bones with which the
zygomatic bones articulate: frontal process, maxillary process,
and temporal process
5. Maxillae (paired bones)—fused; each has a body and four processes

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 (see Figure 4-3)
a. The body contains the maxillary sinus and forms the lower and
medial rims of the orbits and the borders of the nasal cavity;
other landmarks are:
(1) Infraorbital foramen—originates as the inferior orbital
fissure and becomes the infraorbital canal that carries the
infraorbital nerve, the inferior ophthalmic vein, and the
infraorbital artery; it is a landmark for the administration of
local anesthesia (infraorbital nerve block) to achieve
facial/pulpal anesthesia to the maxillary premolars, canines,
and incisors
(2) Canine fossa—inferior to the infraorbital foramen and
distal to the roots of the maxillary canines
b. The frontal process articulates with the frontal bone, forming
the medial orbital rim with the lacrimal bone
c. The alveolar process (see the section on “Supporting Tissues” in
Chapter 2)
(1) Less dense bone containing the roots of the maxillary
teeth; thinner facially; less dense than mandibular alveolar
process, making infiltration of local anesthesia more
successful; may resorb completely in edentulous arch
(2) Sockets (alveoli) for maxillary teeth
(3) Canine eminence—a protuberance over the root of the
maxillary canine
(4) Maxillary tuberosity— a soft tissue depression distal to the
last maxillary molar; contains foramina for the passage of
the posterior superior alveolar nerve; it is a landmark for
the administration of local anesthesia (posterior superior
alveolar nerve block) to achieve buccal/pulpal anesthesia for
the maxillary molar teeth
d. Zygomatic process
(1) Articulates with the zygomatic bone
(2) Completes the infraorbital rim
e. Palatine processes
(1) Articulate with each other to form the anterior, major
portion of the hard palate and the median palatine suture
(2) Contains the incisive foramen, a landmark for the
administration of local anesthesia (nasopalatine nerve
block) to the lingual of maxillary canines and incisors
6. Palatine bones (paired bones)
a. The horizontal plates of the palatine bones articulate with each

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 other to form the posterior portion of the hard palate
b. Articulate with the maxillary and sphenoid bones
c. The vertical plates form part of the lateral walls of the nasal
cavity and a small part of the orbital apex
d. Contain the greater palatine foramen, located at the apex of the
maxillary second or third molar, a landmark for the
administration of local anesthetic agent (greater palatine nerve
block) to palatal soft tissues distal to the canine
7. Vomer (single bone)
a. Located in the midsagittal line; forms the posterior portion of
the nasal septum
8. Mandible (single bone) (see Figure 4-3)
a. Largest, strongest, and only movable facial bone; articulates
with the temporal bones on both sides
b. Body—curved, horizontal portion with two surfaces and two
borders; landmarks include:
(1) Mental protuberance—the chin
(2) Symphysis—midline, faint ridge formed by fusion
(3) Alveolar process of the mandible—contains roots of
mandibular teeth; less dense around mandibular incisors
than posterior molars, allowing for improved infiltration of
local anesthetic to anterior teeth; may resorb completely in
edentulous arch
(4) Sockets (alveoli)—for mandibular teeth
(5) Mental foramen—located bilaterally on the external
surface, below and between the first and second premolars;
the landmark for the administration of local anesthesia
(mental nerve block) to facial periodontium of mandibular
premolars and incisors; also important landmark on
radiographs, not to be confused with periapical or other
lesions
(6) Genial tubercles—near the midline on the internal surface,
provide points of muscle attachment
(7) Retromolar triangle—distal to the last mandibular molar
(8) Sublingual and submandibular fossae—shallow
depressions on the internal surface, these fossae contain
their corresponding salivary glands
c. Ramus—extends vertically and backward from the body of the
mandible
(1) External oblique line—a crest on the external surface
where the ramus joins the body of the mandible

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 (2) Mandibular foramen—located bilaterally on the internal
surface; forms the opening of the mandibular canal and the
exit for blood vessels and the inferior alveolar nerve; the
landmark for the administration of local anesthesia
(inferior alveolar nerve block) to the lingual periodontium
and pulp of mandibular teeth, and the facial periodontium
of mandibular anterior and premolar teeth
(3) Condyle—articulates with temporal bone, forming the
movable part of the TMJ
(4) Lingula—a sharp bony spine overlapping the mandibular
foramen, giving attachment to the sphenomandibular
ligament
(5) Coronoid process—the superior margin, which forms the
anterior border of the ramus and provides points of muscle
attachment
(6) Coronoid notch—greatest concavity on the anterior border
of the ramus; landmark for determining height of injection
for the inferior alveolar nerve block
(7) Mandibular notch—concave area between the condyle and
the coronoid process
C. Neck bones
1. Hyoid bone—U-shaped bone suspended in the neck; located superior
and anterior to the thyroid cartilage; paired projections are the
greater and lesser cornua for the attachment for many muscles and
ligaments of the tongue and throat
2. Atlas—first cervical vertebra; its lateral masses articulate superiorly
with the occipital condyles of the skull and inferiorly with the axis
3. Axis—second cervical vertebra; along with the atlas, the axis
provides attachment points for many muscles responsible for the
movement of the head

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Paranasal sinuses
A. Air-filled, mucus-lined cavities in the bones of the skull that function
to lighten the weight of the skull and act as sound resonators; the four
paired sinuses are:
1. Frontal sinuses—frontal bone above the nasal cavity; drain into the
middle nasal meatus
2. Sphenoid sinuses—body of sphenoid bone; drain into the superior
nasal meatus
3. Ethmoid sinuses—small compartments in ethmoid bone: anterior
and middle compartments drain into the middle meatus; posterior
compartment drains into the superior meatus of the nasal cavity
4. Maxillary sinuses—largest, pyramid shaped, drain into the middle
meatus; infection and diseases of these sinuses can cause
complications of the maxillary posterior teeth

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The muscular system
A. Descriptive terminology
1. Muscle tissue, one of the four classifications of body tissue, consists
of specialized fibers for contraction; three types of muscle tissue are
skeletal (voluntary), cardiac (involuntary), and smooth (involuntary);
muscles in the head and neck region are skeletal muscles
2. Movement—muscles are under neural control to shorten or contract;
contraction is the action of the muscle fibers
3. Origin—origin of a muscle is bone; less movable structure (e.g.,
sternocleidomastoid muscle originates on the clavicle and sternum)
4. Insertion—the structure muscle attaches to and tends to be moved
by the contraction of the muscle (e.g., tendon); more movable
structure; during muscle contraction the insertion moves toward the
origin (e.g., sternocleidomastoid muscle inserts on the mastoid
process of the temporal bone; when contracted, the head bends to
the side)
B. Muscles of facial expression—most facial muscles are superficial,
paired muscles originating in bone and inserting into skin; responsible
for functions related to speech, emotional expression, and mastication;
innervated by the seventh cranial, or facial, nerve; damage to this nerve
results in facial paralysis
1. Epicranial muscle—scalp region; composed of two bellies, the
frontal and occipital, which are connected by the epicranial
aponeurosis; raise the eyebrows and scalp when a person shows
surprise
2. Orbicularis oculi muscle—surrounds the eye; closes the eyelid
3. Corrugator supercilii muscle—superior to the orbicularis; wrinkles
the forehead when a person frowns
4. Orbicularis oris muscle—encircles the mouth; closes lips
5. Buccinator muscle—anterior part of the cheek; functions to pull the
mouth laterally, thereby shortening the cheek, and as an aid in
keeping food on the chewing surfaces of the teeth
6. Risorius muscle—mouth region; widens mouth when a person
smiles broadly
7. Levator labii superioris muscle—upper lip; raises the upper lip
8. Levator labii superioris alaeque nasi muscle—upper lip; raises the
upper lip and dilates the nose, as in sneering
9. Zygomaticus minor muscle—upper lip; raises the upper lip
10. Zygomaticus major muscle—angle of the upper lip; pulls the angle
of the upper lip laterally, creating the appearance of a smile

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 11. Levator anguli oris muscle—angle of the mouth; elevates the angle
of the mouth, as in smiling
12. Depressor anguli oris muscle—angle of the mouth; depresses the
angle of the mouth, as when frowning
13. Depressor labii inferioris muscle—lower lip; lowers the lower lip to
expose lower mandibular incisors
14. Mentalis muscle—chin area; raises the chin, narrows the vestibule
near mandibular incisors
15. Platysma muscle—neck region; originates in the clavicle fascia and
inserts in the region of the mandible and facial muscles of the
mouth; pulls down the corners of the mouth, raises the skin of the
neck
C. Muscles of mastication—four paired muscles, all inserting on the
mandible; innervated by the mandibular division of the fifth cranial, or
trigeminal, nerve; they are responsible for movement of the jaw:
depression, elevation, protrusion, retraction, and lateral deviation
1. Masseter muscle—most superficial, largest, and strongest of the four
muscles
a. Originates on the zygomatic arch; originates from two heads,
one superficial and one deep, and inserts on the lateral surface
of the angle of the mandible
b. Action—elevates the mandible, raising the lower jaw during
closing
2. Temporalis muscle
a. Originates from a fan-like attachment on the temporal fossa;
inserts on the coronoid process of the mandible
b. Action—when the entire muscle contracts, it elevates the
mandible, raising the jaw; contraction of only the posterior
portion causes retraction of the mandible
3. Medial (internal) pterygoid muscle (Figure 4-4)

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 FIG 4-4 Medial pterygoid muscle and lateral pterygoid muscle with both
heads of each muscle highlighted (inferior part of temporalis muscle,
zygomatic arch, and most of the mandibular ramis have been removed).
(From Fehrenbach MJ, Herring SW: Illustrated anatomy of the head and neck, ed 5, St
Louis, 2017, Elsevier.)

a. Originates from the pterygoid fossa; inserts on the medial

surface of the angle of the mandible
b. Action—elevates the mandible, raising the lower jaw
4. Lateral (external) pterygoid muscle; lies within the infratemporal
fossa (see Figure 4-4)
a. Originates from two heads: the superior head originates from
the greater wing of the sphenoid bone; the inferior head
originates from the lateral pterygoid plate of the sphenoid bone;
both heads unite, passing posteriorly to insert on the anterior
neck of the mandibular condyle at the pterygoid fovea
b. Action—both heads working together protrude the mandible,
which occurs during opening; when only one side is contracted,
the jaw shifts to the opposite side, causing lateral deviation of
the mandible; lateral pterygoid is the only muscle of mastication
that depresses the mandible
D. Cervical muscles—superficial, paired, large, easily palpated muscles,
both innervated by CN XI (accessory nerve)
1. Sternocleidomastoid muscle—large, well-defined muscle; important
landmark for palpating lymph nodes
a. Originates from the clavicle and sternum; inserts on the mastoid
processes of the temporal bone

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 b. Action—contraction of one side makes the head bend to the
same side, turning the face to the opposite side; contraction of
both muscles causes the head to flex forward
c. Innervated by CN XI (accessory nerve)
2. Trapezius muscle—broad, superficial muscles covering lateral and
posterior surfaces of the neck
a. Originates from the occipital bone and the cervical and thoracic
vertebrae; inserts on the clavicle and the scapula
b. Action—lifts the clavicle and scapula, as when shrugging
shoulders
c. Innervated by CN XI (accessory nerve) and third and fourth
cervical nerves
E. Hyoid muscles—all are attached to the hyoid bone; usually grouped as
suprahyoid or infrahyoid muscles, depending on their relationship to the
hyoid; aid in mastication and swallowing
1. Suprahyoid muscle group—located superior to the hyoid; act to raise
the hyoid and the larynx during swallowing and depress the
mandible during mastication
a. Digastric muscle
(1) Two separate bellies—anterior belly originates from the
intermediate tendon on the hyoid bone and inserts near the
symphysis of the mandible; posterior belly originates from
the mastoid notch and inserts on the intermediate tendon
of the hyoid; form the submandibular triangles and
submental triangle
(2) Action—pulls the jaw back; anteriorly innervated by the
mylohyoid nerve and posteriorly by the posterior digastric
nerve
b. Mylohyoid muscle
(1) Originates from the inner surface of the mandible; unites
with counterpart to form the floor of the mouth, and inserts
on the body of the hyoid
(2) Action—depresses mandible, helps elevate the tongue;
innervated by the mylohyoid nerve, a division of CN V
(trigeminal nerve)
c. Stylohyoid muscle
(1) Originates from the styloid process; inserts on the body of
the hyoid; innervated by the stylohyoid branch of the
seventh cranial, or facial, nerve
d. Geniohyoid muscle
(1) Originates from the genial tubercles on the mandible;

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 inserts into the body of the hyoid
(2) Innervated by CN XII (hypoglossal nerve)
2. Infrahyoid muscle group—act to depress the hyoid bone; all muscles
in the group innervated by the second and third cervical nerves
a. Sternothyroid muscle
(1) Originates on the sternum; inserts on the thyroid cartilage
(2) Depresses the thyroid cartilage and the larynx (but not the
hyoid)
b. Sternohyoid muscle
(1) Originates on the sternum; inserts on the body of the
hyoid
c. Omohyoid muscle
(1) Two separate bellies—inferior belly originates from the
scapula and attaches to the tendon of the superior belly,
which is the origin of the superior belly that inserts on the
body of the hyoid
d. Thyrohyoid muscle
(1) Originates on the thyroid cartilage; inserts on the body
and greater cornu of the hyoid
(2) Raises the thyroid cartilage and larynx in addition to
depressing the hyoid
F. Muscles of the tongue—all are innervated by CN XII (hypoglossal
nerve); aid in speech, mastication, and swallowing; grouped into intrinsic
and extrinsic muscles
1. Intrinsic tongue muscles
a. Located entirely within the tongue; include the superior
longitudinal, transverse, vertical, and inferior longitudinal
muscles; considered by some to be one muscle; act together to
change the shape of the tongue
2. Extrinsic tongue muscles
a. All insert inside the tongue but originate elsewhere; their
names indicate their origin; these muscles move the tongue
(1) Genioglossus muscle—acts in the protrusion of the
tongue, helps prevent airway obstruction; originates from
the genial tubercles
(2) Styloglossus muscle—acts in the retraction of the tongue;
originates from the styloid process of the temporal bone
(3) Hyoglossus muscle—depresses the tongue; originates on
areas of the hyoid bone

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Temporomandibular joint
A. Description—a bilateral articulation between the articular fossa of the
temporal bones (immovable) and condylar process of the mandible
(movable); innervated by the mandibular division of the fifth cranial, or
trigeminal, nerve; blood supply comes from the external carotid artery
B. Type of joint—a synovial joint by structure
C. Type of movement—gliding in the upper synovial cavities, rotating in
the lower synovial cavities; the action allows for functions of speech and
mastication
D. Structure of joint (Figure 4-5)

FIG 4-5 View of the temporomandibular joint depicting upper and lower synovial
cavities and the joint disk. (From Avery JK, Chiego DJ: Essentials of oral histology and
emb ryology: a clinical approach, ed 3, St Louis, 2006, Mosby.)

1. Articular (joint) capsule—completely surrounds the TMJ

2. Articular (joint) disc—a fibrous disc that divides the synovial cavity

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 of the TMJ into superior and inferior synovial cavities; both cavities
are filled with synovial fluid secreted by the articular capsule;
perforation or displacement can cause TMJ problems
3. Temporomandibular joint ligament—located laterally on each joint,
extending from the zygomatic arch to the posterior neck of the
condyle; prevents posterior and inferior displacement of the
mandible
4. Sphenomandibular ligament—located medially; extends from the
spine of the sphenoid to the lingula of the mandible; the inferior
alveolar nerve is located in the space between the mandibular ramus
and the sphenomandibular ligament, making it an important
landmark for the administration the inferior alveolar nerve block
5. Stylomandibular ligament—located medially; runs from the styloid
process of the temporal bone to the angle of the mandible; also
assists in stabilizing the jaw; separates the submandibular salivary
and parotid glands

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The circulatory system
A. Classification and function
1. Blood is classified as connective tissue and consists of two main
components, plasma and formed elements (blood cells and platelets)
2. Three main functions of blood:
a. Transportation—transports gases (oxygen and carbon dioxide),
nutrients, waste products of metabolism, hormones, and heat to
the skin for maintenance of body temperature
b. Regulation—sustains the pH of the body; maintains fluid
balance
c. Protection—defends the body against infections and blood loss
B. Four components of blood (see the section on “Blood and Lymph” in
Chapter 2)
1. Plasma—liquid portion of blood; consists of 90% water, the
remaining mixture comprises proteins, glucose, hormones, and
electrolytes; makes up more than half the total volume of blood
2. Erythrocytes—red blood cells (RBCs) lack nuclei and have a
biconcave shape; produce hemoglobin, which functions to transport
oxygen (O2) from the lungs to body tissues in exchange for carbon
dioxide (CO2); then delivered to the lungs
3. Leukocytes—white blood cells (WBCs); much less numerous than
RBCs; protect the body against infections
a. Granulocytes—contain granules in their cytoplasm
(1) Neutrophils are the first to respond to bacterial invasion;
fight infection by the digesting bacteria (phagocytosis) and
releasing enzymes that destroy bacteria; make up the
majority of leukocytes
(2) Eosinophils function in the destruction of allergens and
release enzymes that destroy parasites
(3) Basophils secrete histamine and heparin in allergic
reactions, intensifying inflammatory reactions
b. Agranulocytes—lack granules in their cytoplasm
(1) Lymphocytes produce antibodies and provide immune
response; second most abundant leukocyte
(2) Monocytes reach sites of infection after neutrophils and
can phagocytize more microbes than neutrophils; clean up
cellular debris after an infection
4. Platelets—thrombocytes; cell fragments that participate in blood
clotting
C. Vascular system

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 1. Arteries carry blood, typically oxygenated, away from the heart to
arterioles and capillaries, which supply blood directly to the tissue
2. Venules (smaller veins that drain capillaries) and veins carry blood,
typically deoxygenated, to the heart
3. Arteries supply blood to all structures in their surrounding vicinity,
and veins drain blood from all their regional structures
D. Descriptive terminology
1. Anastomosis—connection between vessels by channels
2. Arteriole—smaller artery that connects with a capillary
3. Capillary—smaller blood vessel branching off an arteriole to supply
blood directly to tissue
4. Plexus—a congregation of multiple veins
5. Venous sinus—blood-filled space between two layers of tissue
E. Arterial blood supply to the head and neck
1. Common carotid and subclavian arteries supply the head and neck;
pathways from the aorta to the head and neck differ on the right and
left sides:
a. Right side of the body—the right common carotid and right
subclavian arteries arise from the brachiocephalic artery
b. Left side of the body—the left common carotid and left
subclavian arteries ascend directly from the aorta
c. The subclavian artery terminates in the upper arm extremity
2. Each common carotid artery ends by dividing into the internal
carotid and external carotid arteries
a. Internal carotid artery—enters the skull to the brain area
b. External carotid artery—supplies the principal areas of the oral
cavity and face
c. Carotid sinus—just before the common carotid artery
bifurcates; a swelling; most reliable arterial pulse in the body
3. Anterior branches of the external carotid artery (Figure 4-6)

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 FIG 4-6 Carotid vasculature. Note the arteries branching from the
external carotid artery. (From Reynolds PA, Abrahams PH: McMinn’s interactive
clinical anatomy: head and neck, ed 2, London, 2001, Mosby Ltd.)

a. Lingual artery—runs above the hyoid bone; supplies the floor of

the mouth, the tongue, and the suprahyoid muscles; gives rise
to the sublingual artery, which supplies the mylohyoid muscle,
sublingual salivary gland, and mucous membranes of the floor
of the mouth
b. Facial artery—complicated path that runs over the
submandibular gland, crossing the lower border of the
mandible laterally, anterosuperioly near the angle of the mouth
and alongside the nose terminating near the eye; supplies the
muscles of the face in the oral, buccal, nasal, infraorbital, and
orbital regions; branches from the facial artery are:
(1) Ascending palatine artery—supplies the soft palate,
palatine muscles, and palatine tonsils

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 (2) Submental artery—supplies the submandibular lymph
nodes, the submandibular salivary gland, and mylohyoid
and digastric muscles
(3) Inferior labial artery—supplies lower lip muscles of facial
expression
(4) Superior labial artery—supplies the upper lip tissues
4. Medial branch of the external carotid artery
a. Ascending pharyngeal artery—supplies the pharyngeal walls,
where they form an anastomosis with the ascending palatine
artery; supplies the soft palate and meninges of the brain
5. Posterior branch of the external carotid artery
a. Occipital artery—supplies the suprahyoid and
sternocleidomastoid muscles as well as the scalp and meningeal
tissue of this region
b. Posterior auricular artery—supplies the inner ear and mastoid
air cells
6. Terminal branches of the external carotid artery
a. Superficial temporal artery—gives rise to smaller arteries
supplying the temporalis muscle, the parotid salivary gland
duct, and the scalp in the frontal and parietal regions
b. Maxillary artery—three parts:
(1) The first diverges from the external carotid artery near the
neck of the condyle in the parotid gland; the second runs
between the mandible and the sphenomandibular ligament
anteriorly and through the infratemporal fossa superiorly;
within the infratemporal fossa, this part of the maxillary
artery gives off many branches:
(a) Inferior alveolar artery—enters the mandibular canal
by way of the mandibular foramen, along with the
inferior alveolar nerve; supplies the mandibular teeth
and the floor of the mouth and diverges into three
branches
(b) Mylohyoid artery—travels in mylohyoid groove;
supplies the mylohyoid muscle and the floor of the
mouth
(c) Mental artery—exits the mandibular canal by the
mental foramen; supplies the chin region; forms an
anastomosis with the inferior labial artery
(d) Incisive artery—remains in the mandibular canal,
dividing into branches that supply the teeth,
periodontium, and gingiva of the anterior mandibular

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 region
(2) The second part of the maxillary artery also has muscle
branches:
(a) Deep temporal artery—supplies the temporalis
muscle
(b) Pterygoid artery—supplies the lateral and medial
pterygoid muscles
(c) Masseteric artery—supplies the masseter muscle
(d) Buccal artery—supplies the buccinator muscle and
buccal region
(3) After traversing the infratemporal fossa, the maxillary
artery enters the pterygopalatine fossa as the third part:
(a) Posterior superior alveolar artery—exits the
infratemporal fossa and descends into the maxillary
tuberosity; supplies the maxillary posterior teeth and
periodontium and maxillary sinus
(b) Infraorbital artery—branches off the maxillary artery
in the pterygopalatine fossa; travels through the
inferior orbital fissure, enters the infraorbital canal,
giving off branches to the orbit, and then branches off
as the anterior superior alveolar artery; it travels
through the infraorbital foramen, exiting on the face
(c) Anterior superior alveolar artery—travels down the
maxillary sinus to supply the anterior maxillary teeth
and the periodontium; forms an anastomosis with the
posterior superior alveolar artery
(d) Greater palatine and lesser palatine arteries—travel to
the palate through the pterygopalatine canal and the
greater and lesser foramina, supplying the hard and
soft palates
F. Venous drainage of the head and neck
1. Generalizations—the venous system originates as small venules,
which become larger veins in the neck region that carry blood back
to the heart; veins anastomose freely with one another; veins lack
one-way valves, which would prevent backflow, they are easily
involved in the spread of infections
2. Internal and external jugular veins
a. Internal jugular vein—drains the brain and most tissue of the
head and neck
b. External jugular vein—drains a small portion of extracranial
tissue

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3. Facial vein—drains into the internal jugular vein
a. Drains the veins from the tissues of the frontal region and orbit
of the eye; communicates with the cavernous venous sinus,
which may become fatally infected through spread of dental
infection
b. Drains the veins of the lower lip, chin, and submandibular
region
c. Variations of the facial vein drain the tongue and floor of the
mouth; sometimes drain indirectly into the facial vein or directly
into the internal jugular vein
4. Retromandibular vein—formed by the superficial temporal and
maxillary veins
a. Posterior division—drains the temporal, maxillary, and posterior
auricular areas and joins the external jugular vein
b. Anterior division—joins the facial vein
5. Maxillary vein—originates in the infratemporal fossa; drains the
pterygoid plexus, which drains the veins from the area served by the
maxillary artery, such as the middle meninges, oral cavity, nose, and
palate
6. Pterygoid plexus of veins—collection of vessels that form
anastomoses with the facial and retromandibular veins located in
the infratemporal fossa
a. Drains portions of the face into the maxillary vein
b. Drains the meninges of the brain
c. Surrounds and protects the maxillary artery
d. Can be pierced during the administration of a local anesthetic
agent
e. Can be involved in the spread of dental infections during
improper administration of local anesthetic agent
7. External and internal jugular veins on both sides of the neck merge
with the subclavian veins to form the brachiocephalic veins, which
then drain into the superior vena cava, directly to the heart

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The lymphatic system
A. Function—part of the circulatory system; primary function is to help
fight disease through ridding the body of toxins (Figure 4-7).

FIG 4-7 The lymphatic drainage system of the head and neck. If the group of
nodes is often referred to by another name, the second name appears in
parentheses. (From Ball JW, et al: Seidel’s guide to physical examination, ed 8, St Louis,
2015, Elsevier.)

B. Descriptive terminology (see the section on “Blood and Lymph” in

Chapter 2)
1. Lymph—tissue fluid that drains into lymphatic vessels from
surrounding regions
2. Lymphatic vessels—a system of structures paralleling blood vessels
that transport fluid (lymph) away from tissues; only carries fluid one
direction, away
3. Lymph nodes—oval shaped organs of lymphatic system clustered
along connecting lymphatic vessels; contain lymphocytes that filter
toxins from lymph; not visible or palpable during extraoral
examination in a healthy patient
4. Lymphadenopathy—an increase in size or consistency of lymphoid
tissue; allows lymph node to be visualized and palpated; can indicate
infection or disease
5. Tonsils—masses of lymphoid tissue located in the oral cavity and

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 pharynx, remove toxins
C. Superficial cervical lymph nodes
1. Submental nodes
a. Located beneath the chin near the midline
b. Drain the chin, lower lip, floor of the mouth, mandibular
incisors, and the apex of the tongue
c. Empty into the submandibular nodes or superior deep cervical
nodes
2. Submandibular nodes
a. Located along the inferior border of the mandible superficial to
the submandibular gland
b. Drain the cheek, upper, lip, anterior portion of the hard palate,
the body of the tongue, and all teeth except maxillary third
molars and mandibular incisors
c. Empty into the superior deep cervical nodes
D. Deep cervical lymph nodes
1. Superior deep cervical nodes
a. Located deep beneath the sternocleidomastoid muscle, 2 inches
(5 cm) below the ear
b. Primary nodes for the drainage of the posterior nasal cavity,
posterior hard palate, base of tongue, and maxillary third molars
c. The jugulodigastric lymph node in this area is easily palpable in
clients with tonsillar lymphadenopathy
d. Empty into the inferior deep cervical nodes or directly into the
jugular trunk
2. Inferior deep cervical nodes
a. Continuation of the superior deep cervical nodes, two inches
above the clavicle
b. Primary nodes for the drainage of the posterior part of the scalp
and neck as well as part of the arm
c. The inferior deep cervical node also communicate with the
axillary lymph nodes, which can become involved in breast
cancer
d. Empty into the jugular trunk
E. Superficial lymph nodes of the head
1. Occipital nodes
a. Located in the occipital region on the posterior head; drain the
occipital portion of the scalp
b. Empty into the deep cervical nodes
2. Three groups of nodes drain the external ear and lacrimal gland; all
empty into the deep cervical nodes:

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 a. Retroauricular nodes—located posterior to the ear; also drain
adjacent region
b. Anterior auricular nodes—located anterior to the ear; also drain
adjacent region
c. Superficial parotid nodes—located on the surface of the parotid
gland; also drain adjacent region
3. Facial nodes
a. Located along the facial vein; subgroups include buccal and
mandibular; all drain the skin where they are located
b. Infections from teeth may cause lymphadenopathy, described as
being “firm like a pea”
c. Drain into submandibular nodes, which empty into deep
cervical nodes
F. Deep lymph nodes of the head—all located too deep for palpation;
include deep parotid and retropharyngeal nodes
G. Tonsils—not located along lymphatic vessels; drain into the superior
deep cervical nodes
1. Palatine tonsils—located between the anterior and posterior pillars,
commonly referred to as “tonsils”
2. Lingual tonsils—located on the dorsal surface of the base of the
tongue
3. Pharyngeal tonsils—located on the midline of the posterior wall of
the nasopharynx, commonly referred to as “adenoids,” enlarged in
children
4. Tubal tonsils—located in the nasopharynx, posterior to the openings
of the auditory tube

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Glands of the head and neck region
A. General definition—a gland is an organ that secretes chemical
substances for use in normal body functioning; two main types of glands:
1. Exocrine glands—have ducts; empty directly to a body location
where secretions will be used (e.g., salivary glands)
2. Endocrine glands—have no ducts; empty directly into the circulatory
system, which transports secretions to the region to be used (e.g.,
thyroid gland)
B. Exocrine glands of the head
1. Major salivary glands—paired glands, have named ducts
a. Parotid salivary gland—located on the surface of the masseter
muscle behind the ramus of the mandible, anterior and inferior
to the ear; has a superficial and deep lobe and is the largest
salivary gland, but produces only 25% of the total salivary
volume, mainly serous; the associated duct is the parotid, or
Stensen duct; the duct pierces the buccinator muscle and opens
opposite the second maxillary molar; the parotid papilla marks
the opening of the duct
b. Submandibular salivary gland—located medially underneath
the angle of the mandible; the second largest salivary gland,
providing 60% to 65% of the total salivary volume, mixed serous
and mucous; the associated duct is the submandibular, or
Wharton duct; the duct opens at the sublingual caruncle on the
floor of the mouth; the submandibular gland is the most
common salivary gland involved in salivary stone formation
c. Sublingual salivary gland—located in the sublingual fossa,
anterior to the submandibular gland; the smallest, most diffuse
salivary gland, providing 10% of the total salivary volume, mixed
serous and mucous; associated ducts are located along the
sublingual fold, combine to form the sublingual or Bartholin
duct
2. Minor salivary glands—smaller and more numerous than major
salivary glands
a. Numerous small glands—located in oral cavity tissues such as
the soft palate; buccal, labial, and lingual mucosa; and the floor
of the mouth; most secrete mainly mucous fluid
b. Von Ebner glands—located in the circumvallate lingual papillae
of the dorsal surface of the tongue; only minor salivary gland
that secretes serous fluid only
3. Lacrimal glands—located in the lacrimal fossa of the frontal bone;

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 secrete lacrimal fluid, or tears; the associated duct is the
nasolacrimal duct, at the junction of the lacrimal and maxillary
bones
C. Endocrine glands of the neck region
1. Thyroid gland—located below the hyoid bone; consists of two lobes
connected by an isthmus; largest of the endocrine glands; secretes
the hormone thyroxine, which regulates body metabolism; in a
healthy patient, the thyroid gland moves with the thyroid cartilage
when swallowing (Figure 4-8)

FIG 4-8 Anatomic position of the thyroid gland. (From Potter PA, et al:
Fundamentals of nursing, ed 9, St Louis, 2017, Elsevier.)

2. Parathyroid glands—located behind or within the thyroid gland;

secrete parathyroid hormone, which regulates calcium metabolism
and phosphorus uptake; not visible or palpable during examination
3. Thymus gland—located inferior to the thyroid in the upper part of
the chest; secretes thymosin, which assists in the maturation of T cell
lymphocytes, which play a role in the immune system of the body;
shrinks after puberty

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The nervous system
A. Classification and function—a complex network of nerves and cells
that coordinates voluntary and involuntary actions through transmission
of information from one location to another; the nervous system controls
all body functions essential to life
B. Descriptive terminology (see the section on “Nerve Tissue” in Chapter
2)
1. Neuron—a nerve cell that is the basic building block of the nervous
system, specialized to transmit information; contains a nucleus,
which holds genetic information; dendrites, which conduct impulses
to the cell body; and axons, which conduct impulses away from the
cell body
2. Nerve—a collection of neurons in the peripheral nervous system
(PNS)
3. Synapse— connection that allows the transmission of nerve
impulses between two neurons or between a neuron and an effector
organ
4. Ganglion—a group of nerve cell bodies in the PNS
5. Afferent, or sensory, neurons carry nerve impulses toward the
central nervous system (CNS) away from a body structure (e.g.,
information sent to the brain for analysis or action)
6. Efferent, or motor, neurons transmit carry nerve impulses away from
the CNS toward a body structure (e.g., information sent to a muscle
for activation)
C. The nervous system—two major divisions:
1. Central nervous system—comprises the brain and spinal cord
2. Peripheral nervous system—composed of nerves outside the CNS,
such as sensory neurons carrying impulses to the CNS and motor
neurons carrying messages from the CNS
a. Autonomic nervous system (ANS)—responsible for control of
body functions not consciously directed, such as respiratory
rate, heart rate, and salivation; functions performed
involuntarily and reflexively; two subdivisions of the ANS:
(1) Sympathetic nervous system—prepares the body for
stressful situations (e.g., increases heart rate, dilates
airways); known as the “fight-or-flight” response; also slows
body processes that are less important in emergencies, such
as digestion (salivation) and urination
(2) Parasympathetic nervous system—controls the body in
ordinary situations (e.g., slows heart rate, decreases blood

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 pressure); known as the “rest and digest” system; it
generally conserves and restores body functions
D. Cranial nerves (12 pairs)—part of the PNS; designated with Roman
numerals, for example, cranial nerves V, VI, and VII; provide afferent,
efferent, or mixed impulses
1. Cranial nerve I (olfactory nerve)—afferent type; carries smell from
the nasal mucosa to the brain; enters the skull through the
cribriform plate of the ethmoid bone
2. Cranial nerve II (optic nerve)—afferent type; carries visual impulses
from retina to the brain; enters the skull through the optic canal of
the sphenoid bone
3. Cranial nerve III (oculomotor nerve)—efferent type; innervates
muscles of the eye; exits the skull through the superior orbital
fissure of the sphenoid bone
4. Cranial nerve IV (trochlear nerve)—efferent type; supplies one eye
muscle; also exits the skull through the superior orbital fissure of the
sphenoid bone
5. Cranial nerve V (trigeminal nerve)— largest cranial nerve, both
efferent and afferent types; efferent component for the muscles of
mastication and some cranial muscles; afferent component for the
teeth, tongue, oral cavity, and most of the skin of the face and head;
knowledge of CN V is critical for the successful administration of a
local anesthetic agent (Tables 4-1 and 4-2; see Chapter 18,
Management of Pain and Anxiety)

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 Table 4-1
Summary of Maxillary Injection Sites for Local Anesthetic Agent Administration

Landmark and Nerve Injection Teeth or Tissue Anesthetized

Maxillary tuberosity/posterosuperior Posterosuperior Maxillary first,* second, and
alveolar nerve of the maxillary branch of alveolar (PSA) third molars and related buccal
trigeminal nerve (second division, V2) tissues
Apex of second premolar/middle superior Middle Maxillary first and second
alveolar nerve of V2 (not present in all superior premolars; mesiobuccal root of
people) alveolar (MSA) maxillary first molar and
buccal tissues
Apex of maxillary canine/anterosuperior Anterosuperior Maxillary premolars, canines,
alveolar nerve of V2 alveolar (ASA) and incisors and associated
buccal tissues
Greater palatine foramen/greater palatine Greater Palatal roots of maxillary
nerve of V2 palatine (GP) molars and premolars and
related lingual tissues
Incisive foramen/nasopalatine nerve of V2 Nasopalatine Anterior portion of palate or

(NP) lingual aspects of anterior

maxillary teeth
Infraorbital foramen/infraorbital nerve of Infraorbital Facial aspects of anterior
V2 (IO) maxillary teeth and buccal
aspects of the premolars
* In some cases, the mesiobuccal root is not innervated by the PSA nerve, but by the MSA nerve.

Table 4-2
Summary of Mandibular Injection Sites for Local Anesthetic Agent Administration

Landmark and nerve Injection Teeth or Tissue Anesthetized

Mandibular foramen/inferior Inferior Mandibular teeth to midline; buccal
alveolar nerve of the alveolar mucoperiosteum; mucous membrane anterior to
mandibular branch of the (IA) mandibular fist molar; anterior two thirds of
trigeminal nerve (third tongue and floor of oral cavity; lingual soft
division, V3) tissues
Mental foramen/inferior Mental IB: mandibular premolars, canines, and incisors;
alveolar nerve; mental and block lower lip and skin of chin; buccal mucous
incisive nerve branches of V3 (MB) or membrane anterior to the mental foramen
incisive MB: buccal mucous membranes anterior to
block (IB) mental foramen to midline; skin of lower lip and
chin
Buccal tissue distal and buccal Buccal Buccal periodontium and gingiva of mandibular
to the most distal block molars
molar/buccal nerve of V3 (LB)

6. Three divisions or branches of the trigeminal nerve:

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a. Ophthalmic nerve, first division, or V1—afferent nerve; carries
information to the brain via the superior orbital fissure of the
sphenoid bone for the conjunctiva, cornea, eyeball, orbit,
forehead, and ethmoid and frontal sinuses; arises from three
major nerves:
(1) Frontal nerve—a merger of the supraorbital nerve
(forehead and anterior scalp) and the supratrochlear nerve
(bridge of the nose and medial part of the upper eyelid and
forehead)
(2) Lacrimal nerve—controls the upper eyelid, conjunctiva,
and lacrimal gland; regulates the production of lacrimal
fluid (tears)
(3) Nasociliary nerve—several branches from the eyelids,
sides of the nose, eyeball, nasal cavity, and paranasal
sinuses
b. Maxillary nerve, second division, or V2—afferent nerves enter
the skull through the foramen rotundum of the sphenoid bone
to supply the maxillae and related skin, maxillary sinuses, nasal
cavity, palate, and nasopharynx (Figure 4-9)

FIG 4-9 Lateral view of the skull (part of lateral wall of orbit has
been removed) with branches of the maxillary nerve (V2)
highlighted. (From Fehrenbach MJ, Herring SW: Illustrated anatomy of the
head and neck, ed 5, St Louis, 2017, Elsevier.)

(1) Zygomatic nerve—merger of two smaller nerves emerging

from the lateral wall of the orbit that serve the skin of the
cheek and the temple
(2) Infraorbital (IO) nerve—formed from the merger of nerve
branches from the upper lip, medial portion of the cheek,

338
 lower eyelid, and side of the nose; passes into the
infraorbital foramen of the maxilla, which is the landmark
for anesthetic injection of the infraorbital nerve block
(3) Anterior superior alveolar (ASA) nerve—carries
sensations from the dental branches in the pulp tissue of
maxillary central incisors, lateral incisors, and canines and
their associated tissues; forms a nerve network with
interdental branches, which is the landmark for anesthetic
injection of the anterior superior alveolar nerve block
(4) Middle superior alveolar (MSA) nerve—carries sensations
from the dental branches in the pulp tissue of the maxillary
premolar teeth and mesial buccal root of the maxillary first
molar, the associated periodontium, and buccal gingiva;
forms a nerve network that is the landmark for anesthetic
injection of the middle superior alveolar nerve block; the
MSA is not present in all clients. In this case, the area is
innervated by the ASA primarily and posterior superior
alveolar nerves
(5) Posterior superior alveolar (PSA) nerve—carries sensations
from the dental branches in the pulp tissue of the maxillary
molars, periodontium, buccal gingiva, and the maxillary
sinus; internal branches of the PSA nerve exit from several
PSA foramina on the maxillary tuberosity, these foramina
are landmarks for anesthetic injection of the posterior
superior alveolar nerve block
(6) Greater palatine (GP) nerve, anterior nerve—carries
sensations from the hard palate and posterior lingual
gingiva; enters the greater palatine foramen near the
maxillary second or third molar, which is the landmark for
anesthetic injection of the greater palatine block
(7) Lesser palatine nerve, posterior nerve—carries sensations
from the soft palate and palatine tonsil; enters the lesser
palatine foramen where it joins the greater palatine nerve
within the pterygopalatine canal
(8) Nasopalatine (NP) nerve—carries sensations from the
anterior hard palate and lingual gingiva of maxillary
anterior teeth; enters the incisive canal through the incisive
foramen, which is the landmark for anesthetic injection of
the nasopalatine block; the NP nerve travels along the nasal
septum and communicates with the greater palatine nerve
c. Mandibular nerve, third division, or V3—the only division

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containing both afferent and efferent types; largest of the
trigeminal branches; enters the skull through the foramen ovale
on the sphenoid bone (Figure 4-10)

FIG 4-10 Pathway of the mandibular nerve (branch), or third

division (V3), of the trigeminal nerve is highlighted. Inset shows
innervation coverage. (From Fehrenbach MJ, Herring SW: Illustrated
anatomy of the head and neck, ed 5, St Louis, 2017, Elsevier.)

(1) Buccal nerve, long buccal nerve—carries sensations from

the cheek, buccal mucosa, and buccal gingiva of mandibular
posterior teeth; the nerve crosses in front of the anterior
border of the ramus between the two heads of the lateral
pterygoid muscle, which is the landmark for anesthetic
injection of the buccal nerve block
(2) Muscular branches—efferent (motor) nerves supplying the
four muscles of mastication, deep temporal nerves,
masseteric nerve, and lateral pterygoid nerve
(3) Auriculotemporal nerve—carries sensations from the ear
and scalp; branches of this nerve innervate the parotid
salivary gland through postganglionic parasympathetic
fibers from the ninth cranial nerve (CN IX)
(4) Lingual nerve—carries sensations from the floor of the
mouth, the lingual mandibular gingiva, and the body of the
tongue; it communicates with CN VII (facial nerve)
supplying parasympathetic fibers to the submandibular

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 and sublingual salivary glands; because of its location in the
floor of the mouth, it is often anesthetized when an inferior
alveolar nerve block is administered
(5) Inferior alveolar (IA) nerve—carries sensations from
mandibular teeth; it travels through the mandibular canal,
along with the inferior alveolar artery and vein; exits the
mandible through the mandibular foramen, which is the
landmark for anesthetic injection of the inferior alveolar
nerve block; it is a merger of the mental and incisive nerves
(a) Mental nerve—carries sensations from the chin, lower
lip, and the labial mucosa of anterior teeth and
premolars; enters the mental foramen between the
premolars, which is the landmark for anesthetic
injection of the mental nerve block
(b) Incisive nerve—carries sensations from the dental
branches of the pulp tissue of the mandibular anterior
teeth and premolars; merges with the mental nerve to
form the inferior alveolar nerve and travels through the
mandibular canal
(6) Mylohyoid nerve—a small efferent (motor) nerve branch
that supplies the mylohyoid muscle and the anterior belly
of the digastric muscle; it joins the inferior nerve entering
the foramen ovale
7. Cranial nerve VI (abducens)—efferent nerve; supplies one eye
muscle; exits the skull through the superior orbital fissure of the
sphenoid bone
8. Cranial nerve VII (facial)—efferent and afferent components, leaves
the brain through the internal acoustic meatus and gives off two
branches, the greater petrosal and chorda typmpani (Figure 4-11)

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 FIG 4-11 Pathway of the trunk of the facial nerve: greater petrosal nerve
and chorda tympani nerve. Note relationship with the lingual nerve. (From
Fehrenbach MJ, Herring SW: Illustrated anatomy of the head and neck, ed 5, St Louis,
2017, Elsevier.)

a. Greater petrosal nerve—efferent nerve; fibers are carried

through the pterygopalatine ganglion to the lacrimal gland,
nasal cavity, and minor salivary glands of the hard and soft
palate; the afferent nerve fibers also carry taste sensations from
the palate
b. Chorda tympani nerve—parasympathetic efferent nerve
supplying submandibular and sublingual salivary glands; has an
afferent component carrying taste sensations for the body of the
tongue
c. Facial nerve continues anteriorly, passing through the parotid
gland, and separates into efferent branches supplying the
muscles of facial expression in their respective areas; temporal,
zygomatic, buccal, mandibular, and cervical branches (Figure 4-
12)

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 FIG 4-12 Pathway of the branches of the facial nerve to the
muscles of facial expression. (Fehrenbach MJ, Herring SW: Illustrated
anatomy of the head and neck, ed 5, St Louis, 2017, Elsevier.)

d. Although the facial nerve passes into the parotid salivary gland,
it does not innervate the gland; disease process in the parotid
gland may be painful due to the proximity of the facial nerve
e. Knowledge of the facial nerve is important for avoidance of
complications in the administration of local anesthesia
9. Cranial nerve VIII (vestibulocochlear nerve)—afferent nerve for
hearing, supplied to the cochlea, and balance, supplied to the
semicircular canals; enters the brain through the internal acoustic
meatus of the temporal bone
10. Cranial nerve IX (glossopharyngeal nerve)—afferent and efferent
nerve; carries sensory fibers from the back of the oropharynx,
providing taste and sensation from the base of the tongue; also
controls gag reflex; the efferent innervation controls swallowing
11. Cranial nerve X (vagus nerve)—mixture of afferent and efferent
nerves; the larger efferent component supplies the muscles of the

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 soft palate, pharynx, larynx, and parasympathetic fibers to the
organs in the thoracic and abdominal cavities; the smaller afferent
component conveys to skin around the ear and taste sensation of the
epiglottis
12. Cranial nerve XI (accessory nerve)—efferent nerve; impulses to the
trapezius and sternocleidomastoid muscles, soft palate, and pharynx
13. Cranial nerve XII (hypoglossal nerve)—efferent nerve; innervates
all muscles of the tongue; exits the skull through the hypoglossal
canal of the occipital bone
Note: Cranial nerves IX, X, and XI are part of the pharyngeal plexus; all
pass through the skull by way of the jugular foramen.

Website Information And Resourc es

Source Web Address Description
Laboratory Dissections http://ect.downstate.edu/courseware/haonline/labs/headneck.htm Laboratory
of the Head and Neck/ dissections of
Osteology of the Skull the head and
Laboratories neck, along
with quiz
questions
Digital library of http://www.anatomyatlases.org/atlasofanatomy/index.shtml Atlas of
anatomy information anatomy
providing
illustrations as
representations
of the human
body, including
bones, muscles,
nerves, blood,
and lymph
vessels of the
head and neck
Loyola University http://www.meddean.luc.edu/lumen/meded/grossanatomy/ Cross-sectional
Medical Center, Chicago, magnetic
Medical Education resonance
Network (images from imaging (MRI),
the Visible Human computed
Project) tomography
(CT), and
cinematic
images of
human
anatomy

Chapter 4 review questions

Answers and rationales to chapter review questions are available on
this text’s accompanying Evolve site. See inside front cover for details.

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1. All references to body structures are made assuming the body is in
anatomic position; anatomic position is the erect position of the body,
arms at the sides, with head, eyes and palms facing forward.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
2. The anatomic term that BEST describes the top surface of the tongue
is:
a. Superior
b. Inferior
c. Ventral
d. Dorsal
3. Which of the following results in the formation of the flat bones of the
skull?
a. Osteoclasts
b. Osteocytes
c. Intramembranous ossification
d. Endochondral ossification
4. Each of the following bones of the skull is considered a facial bone
EXCEPT the:
a. Maxilla
b. Occipital bone
c. Zygomatic bone
d. Lacrimal bone
5. The articulation between the frontal bone and the parietal bone is the:
a. Coronal suture
b. Sagittal suture
c. Frontonasal suture
d. Lambdoidal suture
6. The petrous portion of the temporal bone contains the mastoid
process. This process serves as an attachment for the trapezius muscle.

345
 a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
7. All three branches of which one of the following nerves passes
through foramina on the sphenoid bone?
a. Facial nerve
b. Glossopharyngeal nerve
c. Hypoglossal nerve
d. Trigeminal nerve
8. Which of the following bones has paired canals that transmit cranial
nerve XII, hypoglossal?
a. Sphenoid bone
b. Occipital bone
c. Maxilla
d. Mandible
9. Which part of the temporal bone forms the cranial portion of the
temporomandibular joint?
a. Squamous part
b. Tympanic part
c. Zygomatic process
d. Petrous part
10. In which of the following pairs is a movable articulation formed?
a. Frontal bone with parietal bones
b. Coronoid process with mandibular fossa
c. Occipital condyles with first cervical vertebrae (atlas)
d. Coronoid notch with mandibular fossa
11. Which of the following is a landmark on the sphenoid bone for the
attachment of many of the muscles of mastication?
a. Body of the sphenoid
b. Lesser wing
c. Greater wing
d. Pterygoid process

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12. Which of the following structures is perforated by foramina for the
passage of olfactory nerves for the sense of smell?
a. Sphenoid bone
b. Maxillary tuberosity
c. Cribriform plate
d. Ethmoidal sinuses
13. All the following are paired facial bones EXCEPT the:
a. Nasal bone
b. Maxilla bone
c. Zygomatic bone
d. Vomer
14. An important landmark for local anesthesia lies posterior to the most
distal maxillary molar. Identify the landmark and the nerve that passes
through its foramina.
a. Infraorbital foramen, infraorbital nerve
b. Greater palatine foramen, greater palatine nerve
c. Maxillary tuberosity, posterior superior alveolar nerve
d. Incisive foramen, nasopalatine nerves
15. Infiltration of local anesthetic is more successful in mandibular
anterior teeth than mandibular posterior teeth because:
a. The alveolar process of the mandibular incisors is less dense
b. The alveolar process of the mandibular incisors is denser
c. The alveolar process of the mandibular incisors is absent
d. The body of the mandible is less dense than the alveolar process
16. Which of the following landmarks on the ramus of the mandible
serves as a landmark for determining the height of injection for the
inferior alveolar nerve block?
a. Coronoid process
b. Mandibular notch
c. Coronoid notch
d. Lingula
17. Which of the following is an important landmark to note
radiographically to avoid misinterpretation as an oral radiolucent lesion?
a. Mental foramen

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 b. Genial tubercles
c. Mandibular foramen
d. Mental protuberance
18. Infection of which of the following sinuses can cause discomfort and
complications with the maxillary posterior teeth?
a. Maxillary
b. Ethmoid
c. Sphenoid
d. Frontal
19. When a skeletal muscle contracts to cause a given movement, the
more movable end of attachment of the muscle is termed its:
a. Origin
b. Insertion
c. Antagonist
d. Synergist
20. All the following are muscles of facial expression EXCEPT the:
a. Orbicularis oculi
b. Buccinator
c. Temporalis
d. Mentalis
21. When contracted, which of the following muscles tightens and
narrows the vestibule, making access to the facial aspect of the
mandibular incisors difficult?
a. Buccinator
b. Mentalis
c. Levator labii superioris
d. Depressor labii inferioris
22. Which one of the following muscles of facial expression encircles the
mouth and is responsible for closure of the lips?
a. Orbicularis oris
b. Buccinator
c. Levator anguli oris
d. Depressor anguli oris
23. The muscles of mastication consist of four paired muscles inserting

348
on the mandible. The muscles of mastication are innervated by the
mandibular division of cranial nerve V.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
24. The muscle of facial expression that aids in mastication is the:
a. Risorius
b. Buccinator
c. Mentalis
d. Masseter
25. Lateral deviation of the mandible occurs when:
a. The medial pterygoid muscle is contracted
b. The digastric muscle is contracted
c. One head of the lateral pterygoid muscle is contracted
d. Both heads of the lateral pterygoid muscle are contracted
26. Which of the following occurs when one side of the
sternocleidomastoid muscle is contracted?
a. The head and neck bend to the same side.
b. The head and neck bend to the opposite side.
c. The head flexes and extends the neck.
d. The head flexes and remains stable.
27. Which of the following muscle groups elevate the hyoid bone?
a. Intrinsic tongue muscles
b. Extrinsic tongue muscles
c. Suprahyoid muscles
d. Infrahyoid muscles
28. All the following muscles of mastication elevate the mandible
EXCEPT the:
a. Masseter
b. Medial pterygoid
c. Temporalis
d. Lateral pterygoid

349
29. During an oral examination, you ask the client to protrude the
tongue. What muscle is necessary for this action?
a. Hypoglossus
b. Genioglossus
c. Palatoglossus
d. Styloglossus
30. Intrinsic tongue muscles are located entirely inside the tongue. These
muscles act to change the shape of the tongue.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
31. The muscle that unites with its counterpart to form the floor of the
mouth is the:
a. Stylohyoid
b. Digastric
c. Mylohyoid
d. Geniohyoid
32. Taste sensations for the body of the tongue are provided by which of
the following nerves?
a. Maxillary division of the trigeminal
b. Mandibular division of the trigeminal
c. Chorda tympani branch of the facial
d. Greater petrosal branch of the facial
33. Which of the following describes the type of movement achieved by
the temporomandibular joint?
a. Gliding only
b. Gliding and rotation
c. Rotation only
c. Gliding, rotation, and extension
34. The articular fossa of the temporal bone articulates with the
mandible at the temporomandibular joint at which landmark?
a. Articular eminence
b. Articular fossa

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 c. Zygomatic process of the temporal bone
d. Condyle
35. The temporomandibular joint is innervated by the:
a. Hypoglossal nerve
b. Trigeminal nerve
c. Facial nerve
d. Accessory nerve
36. All the following major salivary glands secrete mixed secretions
EXCEPT the:
a. Parotid gland
b. Submandibular salivary gland
c. Sublingual salivary gland
d. Von Ebner gland
37. The parotid gland produces the least volume of saliva because it is
the smallest salivary gland.
a. Both the statement and the reason are correct and related.
b. Both the statement and the reason are correct but are NOT related.
c. The statement is correct, but the reason is NOT correct.
d. NEITHER the statement NOR the reason is correct.
38. The sublingual caruncle:
a. Receives the parotid duct
b. Receives the sublingual duct
c. Receives the submandibular duct
d. Receives the Bartholin duct
39. A ligament associated with the temporomandibular joint is an
important landmark for local anesthesia. Name the landmark and the
nerve block.
a. Sphenomandibular ligament, inferior alveolar
b. Sphenomandibular ligament, long buccal
c. Stylomandibular ligament, long buccal
d. Temporomandibular joint ligament, inferior alveolar
40. Salivary glands in the soft palate (buccal, labial, and lingual mucosa)
secrete mostly mucous fluid. Von Ebner glands located in the
circumvallate lingual papillae secrete only serous fluid.

351
 a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
41. Which of the following glands secrete hormones to regulate calcium
metabolism and phosphorus uptake?
a. Thymus
b. Thyroid
c. Parathyroid
d. Adrenal
42. Which of the following is NOT an exocrine gland of the head?
a. Parotid gland
b. Lacrimal gland
c. Von Ebner gland
d. Thyroid gland
43. The thymus gland is an endocrine gland because it has an associated
duct.
a. Both the statement and the reason are correct and related.
b. Both the statement and the reason are correct but are NOT related.
c. The statement is correct, but the reason is NOT correct.
d. NEITHER the statement NOR the reason is correct.
44. The salivary gland most often associated with salivary stone
formation is the:
a. Parotid
b. Submandibular
c. Sublingual
d. Lacrimal
45. Which of the following glands is the largest salivary gland?
a. Parotid
b. Submandibular
c. Sublingual
d. Lacrimal
46. When examining a healthy client, this exocrine gland moves with its

352
associated cartilage.
a. Parotid gland
b. Thymus gland
c. Thyroid gland
d. Parathyroid gland
47. The palatine tonsil is commonly enlarged in children. This tonsil is
also referred to as the adenoids.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
48. Which of the following lymph nodes is easily palpable in clients with
tonsillar lymphadenopathy?
a. Submental node
b. Jugulodigastric node
c. Jugulo-omohyoid node
d. Accessory node
49. Pea-like firmness of the facial lymph nodes might indicate:
a. Infection from adjacent teeth
b. Infection from the upper lip
c. Infection from tonsils
d. Normal health
50. Which of the following lymph nodes drain the cheek, hard palate,
tongue, and anterior nasal cavity?
a. Submental nodes
b. Submandibular nodes
c. Facial nodes
d. Occipital nodes
51. Which of the following lymph nodes empty into the jugular trunk?
a. Deep cervical nodes
b. Superficial nodes
c. Submandibular nodes
d. Facial nodes

353
52. Leukocytes are white blood cells that protect the body against
infection. All the following are leukocytes EXCEPT:
a. Neutrophils
b. Eosinophils
c. Basophils
d. Erythrocytes
53. The most reliable arterial pulse in the body is located in the:
a. Internal carotid artery
b. External carotid artery
c. Carotid sinus
d. Lingual artery
54. Which of the following arteries supplies the muscles of mastication?
a. Occipital artery
b. Maxillary artery
c. Facial artery
d. Lingual artery
55. The facial vein communicates with the cavernous venous sinus; this
sinus can become fatally infected through the spread of dental infection.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
56. Which of the following facial arteries supplies the submandibular
salivary gland?
a. Ascending palatine artery
b. Submental artery
c. Inferior labial artery
d. Superior labial artery
57. Which one of the following statements is NOT true about the
pterygoid plexus?
a. Drains portions of the face into the maxillary vein
b. Can be involved in the spread of dental infections by improper
administration of local anesthesia
c. Protects the maxillary artery

354
 d. Has valves that prevent backflow of blood
58. Dental infections can lead to serious complications, since veins in the
head and neck generally lack valves that prevent the backflow of blood.
a. Both the statement and the reason are correct and related.
b. Both the statement and the reason are correct but are NOT related.
c. The statement is correct, but the reason is NOT correct.
d. NEITHER the statement NOR the reason is correct.
59. The central nervous system consists of the following:
a. Sympathetic nervous system
b. Parasympathetic nervous system
c. Brain and spinal cord
d. Nerves, receptors, muscles, and glands of the body
60. Nerves that carry impulses away from the brain or spinal cord to a
body structure are known as:
a. Synapse
b. Ganglion
c. Afferent
d. Efferent
61. The sympathetic nervous system prepares the body for stressful
situations, “fight or flight.” Which of the following symptoms might a
client with severe dental anxiety exhibit during the dental appointment?
a. Decrease in blood pressure
b. Increase in salivary flow
c. Dental caries
d. Increase in heart rate
62. Which of the following nerves is paired correctly with the tissue it
innervates?
a. Glossopharyngeal nerve, base of tongue
b. Buccal nerve, buccinator muscle
c. Hypoglossal nerve, extrinsic tongue muscles
d. Facial nerve, parotid gland
63. All the following are branches of the maxillary division of the
trigeminal nerve EXCEPT the:
a. Infraorbital nerve

355
 b. Anterior superior alveolar nerve
c. Auriculotemporal nerve
d. Nasopalatine nerve
64. The only trigeminal nerve division carrying both afferent and
efferent nerves is the:
a. Ophthalmic
b. Mandibular
c. Maxillary
d. Facial
65. Which of the following nerves is NOT always present in the oral
cavity?
a. Greater palatine
b. Mental
c. Middle superior alveolar
d. Anterior superior alveolar
66. Damage to this nerve can result in facial paralysis or Bell palsy.
a. Trigeminal
b. Facial
c. Buccal
d. Hypoglossal
67. The facial nerve travels through the parotid gland; innervation of the
parotid gland is provided by the facial nerve.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
68. Which of the following nerves enters the skull through the foramen
ovale?
a. Ophthalmic
b. Maxillary
c. Mandibular
d. Zygomatic
69. Knowledge of the trigeminal nerve is critical for the successful
administration of a local anesthetic agent. Which of the following cranial

356
nerves is the trigeminal nerve?
a. I
b. III
c. IV
d. V
70. Which of the following nerves is NOT part of the mandibular
division of the trigeminal nerve?
a. Buccal
b. Mental
c. Lacrimal
d. Incisive
71. Which of the following nerves innervates the four muscles of
mastication?
a. Mandibular
b. Maxillary
c. Ophthalmic
d. Trigeminal
72. Which of the following nerves is the largest of the trigeminal
branches?
a. Maxillary
b. Facial
c. Ophthalmic
d. Mandibular
73. What is the purpose of synovial fluid in the synovial joint?
a. Lubricates the joint
b. Transports nutrients to the joint
c. Prevents displacement of the joint
d. Stabilizes the joint
74. The four muscles of mastication are the masseter, temporalis, medial
pterygoid, and lateral pterygoid; these muscles of mastication are
innervated by the cranial nerve VI.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.

357
 d. The first statement is FALSE; the second statement is TRUE.
75. All the following cranial nerves are part of the pharyngeal plexus and
pass through the skull by way of the jugular foramen EXCEPT:
a. Cranial nerve VI (abducens nerve)
b. Cranial nerve IX (glossopharyngeal nerve)
c. Cranial nerve X (vagus nerve)
d. Cranial nerve XI (accessory nerve)

Case A
Ms. Thomas, 49 years old, is a new patient at the dental office. Her health
history and pharmacologic history reveal that she takes medications for
hypertension and depression. She complains of thermal hypersensitivity
on tooth #5. She reports brushing twice per day, using a soft toothbrush,
and occasionally flossing. Ms. Thomas has a history of orthodontic
appliances as a teenager. Her periodontal history reveals generalized
severe chronic periodontitis with moderate subgingival calculus. She has
generalized, moderate levels of plaque biofilm. The dental hygienist has
planned for four quadrants of scaling and root planing and a
reevaluation appointment 6 weeks after the initial treatment. She is
missing teeth #1, #5, #12, #16, #17 #21, #28, and #32.

Use Case A to answer questions 76 to 82.

76. Which of the following is mostly likely the swollen lymph node
identified by the dental hygienist during an extraoral exam?
a. Occipital
b. Posterior auricular
c. Preauricular
d. Submental
77. Which of the following American Academy of Periodontology
classifications would Ms. Thomas’s periodontal condition be
documented as?
a. AAP type I
b. AAP type II
c. AAP type III
d. AAP type IV
78. Which of the following premolars are often extracted before

358
orthodontic treatment?
a. Teeth #1 and #16
b. Teeth #5 and #12
c. Teeth #6 and #11
d. Teeth #20 and #29
79. Which of the following local anesthetic agents would be a better
choice for Ms. Thomas because of her hypertension?
a. Lidocaine hydrochloride with epinephrine
b. Mepivacaine hydrochloride
c. Benzocaine topical anesthetic
d. Lidocaine without epinephrine
80. To make sure that tooth #5 is anesthetized, which of the following
nerves would be infiltrated during anesthesia?
a. Posterior superior alveolar
b. Middle superior alveolar
c. Anterior superior alveolar
d. Nasopalatine
81. Infiltration of all the following nerves would help anesthetize
quadrant 1 EXCEPT the:
a. Greater palatine
b. Mental
c. Posterior superior alveolar
d. Nasopalatine
82. Which of the following would the dental hygienist NOT do during
the reevaluation appointment?
a. Assess bleeding on probing
b. Assess the gingival health
c. Remove residual calculus
d. Take four horizontal bitewings

359
C HAPT E R 5

360
Clinical Oral Structures, Dental
Anatomy, and Root Morphology
Jeanne M. Anderson

The practice of dental hygiene is based on oral anatomy, a fundamental

dental science. A thorough knowledge of oral anatomy provides the basis
for assessing, diagnosing, planning, implementing, and evaluating
clients during the dental hygiene process of care. Oral structures reflect
oral and systemic health. Oral anatomy provides the basis for
nonsurgical periodontal therapy, fluoride regimens, pit-and-fissure
sealant placement, and patient education; all requiring imagery and
tactile perception. The dental hygienist also uses oral anatomy to assess
the relationship of teeth, both within and between the arches. These
factors influence evidence-based decision making, care plans,
professional recommendations, and referral to other health care
practitioners.

361
Clinical oral structures
Oral tissues are indicators of a client’s oral and general health. Abnormal
conditions can be recognized if the appearance of normal oral structures
is known (Figures 5-1 to 5-8 and Table 5-1). Oral structures are identified
according to their specific locations and functions. Generally, oral
structures appear in shades of pink and may be pigmented in dark-
complexioned individuals. In the oral cavity, the presence of melanin
pigmentation is random, scattered, and unpredictable. Most importantly,
the dental hygienist must be proficient in performing a clinical
examination of the head and neck both extraorally and intraorally to
detect variations of normal and abnormal conditions that may be
indicators of overall health.

362
FIG 5-1 Labial and oral mucosa. A, Maxillary. B, Mandibular.

363
 FIG 5-2 Buccal mucosa.

FIG 5-3 Dorsum of the tongue.

364
FIG 5-4 Lateral surface of the tongue.

FIG 5-5 Ventral surface of the tongue.

365
FIG 5-6 Ventral surface of the tongue and the floor of the mouth.

FIG 5-7 Hard palate.

366
 FIG 5-8 Soft palate and oropharynx.

Table 5-1
Oral Structures

367
368
369
Dental terminology
A. Parts of a tooth (Figure 5-9; see the section on “Tissues of the Tooth”
in Chapter 2)

FIG 5-9 Parts of a molar. (From Fehrenbach MJ, Popowics T: Illustrated dental
emb ryology, histology, and anatomy, ed 4, St Louis, 2016, Elsevier.)

1. Crown
a. Anatomic crown—part of the tooth covered by enamel
b. Clinical crown—portion of the tooth that is unattached and
visible in the oral cavity; determined by the location of the
gingival margin
c. Anatomic crown and clinical crown are the same when the
marginal gingiva is at the junction of the cementum and enamel
(CEJ)
2. Root—part of the tooth covered by cementum; single root or multi-
rooted
a. Apex (plural, apices)—rounded end of the root
b. Periapex (periapical)—area around the apex of a tooth
c. Foramen (plural, foramina)—opening at the apex through which
blood vessels and nerves enter
d. Furcation—area of a two-rooted or three-rooted tooth where the
root divides
(1) Furcation entrance—area of opening into the furcation
(2) Roof of the furcation—most coronal area of the furcation;
the “ceiling” of a mandibular furcation; the base of a
maxillary furcation
(3) Interfurcal area/furcal area—area between the roots of a

370
 two-rooted or three-rooted tooth
e. Root trunk—area from the cemento-enamel junction (CEJ) to
the furcation
f. Root concavity/depression—concave, vertical depression on the
root; named by location: mesial, distal, and lingual; can be
narrow or broad, shallow or deep; a concavity located within the
furcation is called a furcal concavity
3. Enamel—hardest calcified tissue covering the dentin in the crown of
the tooth; 96% mineralized (inorganic); thinnest at the CEJ of
permanent teeth
4. Dentin—hard calcified tissue surrounding the pulp and underlying
enamel and cementum; makes up the bulk of the tooth; 70%
mineralized (inorganic)
5. Cementum—bone-like calcified tissue covering the dentin in the
root of the tooth; 50% mineralized (inorganic)
6. Pulp—innermost, noncalcified tissue containing blood vessels,
lymph, and nerves
a. Pulp cavity—space containing the pulp; within the crown and
root
b. Pulp canal—portion of the pulp cavity in the root of the tooth
c. Pulp chamber—portion of the pulp cavity in the crown of the
tooth
d. Pulp horns—pointed, crown-ward extensions of the pulp
chamber tooth; generally, one horn per cusp on posterior teeth
and one to three horns per cusp on anterior teeth
B. Junction of tooth tissues
1. Cemento-enamel junction/cervical line—junction of cementum and
enamel
2. Dento-enamel junction (DEJ)—junction of dentin and enamel
3. Cemento-dentin junction (CDJ)—junction of cementum and dentin
C. Tooth surfaces—axial surfaces are those parallel to the tooth long axis;
facial, lingual, mesial, and distal
1. Facial—surface toward the face
a. Labial (toward the lips)—facial surfaces of anterior teeth
b. Buccal (toward the cheeks)—facial surfaces of posterior teeth
2. Lingual—surface toward the tongue; may also be called palatal for
maxillary teeth
3. Proximal—surface toward the adjacent tooth
a. Mesial—proximal surface toward the midline
b. Distal—proximal surface farthest from the midline
4. Contact area—area that touches the adjacent tooth in the same arch;

371
 at the crest of curvature/height of contour in normal occlusion
5. Incisal—surface of an incisor that is toward the opposite arch; the
biting surface
6. Occlusal—surface of a posterior tooth that is toward the opposite
arch; the chewing surface; has elevations and depressions, complex
anatomy of ridges, pits, and grooves (Figure 5-10)

FIG 5-10 Occlusal anatomy.

7. Features of biting or chewing surfaces

a. Cusp—large, rounded, elevated area of enamel found on
posterior teeth, usually named for its location
b. Ridge—rounded, linear elevation of enamel
(1). Marginal ridge—forms the mesial and distal borders of the
lingual surface of anterior teeth and the occlusal proximal
surfaces of posterior teeth (see Figure 5-10)
(2) Triangular ridge—ridges on posterior teeth from the tip of
the cusp to the central developmental groove; formed by
the junction of two cuspal inclines
(3) Oblique ridge—two triangular ridges meeting in an
oblique line; a characteristic of maxillary molars
(4) Transverse ridge—two triangular ridges meeting in a

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 faciolingual line (often on two-cusped premolars, molars)
(see Figure 5-10)
(5) Cingulum (plural, cingula)—large, rounded elevation of
enamel on the linguocervical third of anterior teeth (the
lingual developmental lobe) (Figure 5-11)

FIG 5-11 Lingual developmental lobe and cingulum. (From

Fehrenbach MJ, Popowics T: Illustrated dental emb ryology, histology,
and anatomy, ed 4, St Louis, 2016, Elsevier.)

c. Cuspal inclines—two surfaces of a cusp that slant or slope down

and away from the crests of the triangular ridge toward
developmental grooves
d. Groove—narrow linear depression (see Figure 5-10)
(1) Fissure—narrow crevice within a groove where fusion is
incomplete; potential site for caries
(2) Developmental groove/depression—groove or line that
indicates the primary anatomic divisions (cusps,
developmental lobes) of a crown
(3) Supplemental groove—a less distinct groove that branches
from a developmental groove
e. Fossa (plural, fossae)—a depression on anterior teeth between
marginal ridges on the lingual surfaces, and on occlusal surfaces
of posterior teeth
f. Pit—a sharp, pointed depression generally located at the
junction of developmental grooves (fissures) or at their

373
 termination; narrow or wide; pits in primary teeth are not as
deep as those in permanent teeth (see Figure 5-10)
D. Angles/junction of surfaces—a tooth has curved surfaces; therefore,
no “corner ” where one surface begins and another ends
1. Line angle—the junction of two tooth surfaces; a transition area
named for the surfaces that are involved (e.g., mesiobuccal,
distolingual); each tooth has eight line angles
2. Point angles—the junction of three tooth surfaces (e.g., mesiodisto-
occlusal); each tooth has four point angles
E. Embrasure—the interproximal space between teeth that begins at the
contact area and widens in facial, lingual, occlusal or incisal, and
cervical/gingival directions; functions in deflecting food and reducing the
forces placed on the periodontium during chewing; provides a self-
cleaning area; the interproximal gingiva fills the cervical embrasure

374
Dental anatomy
A. Permanent dentition (Table 5-2)

Table 5-2
Characteristics of the Crowns and Roots of Permanent Teeth

375
376
 1. Humans are diphyodonts, with two sets of teeth in a lifetime—a
primary dentition and a permanent dentition; span three dentition
periods: primary, mixed/transitional, and permanent
2. The permanent dentition consists of 32 teeth if all are present;
arranged in four quadrants: maxillary right, maxillary left,
mandibular left, and mandibular right (quadrants 1 to 4)
3. Naming teeth—use this order: set, arch, side, type, class (e.g.,
permanent mandibular right second molar)
B. Classes of teeth: incisors, canines, premolars, and molars; each
quadrant (from the midline) has two incisors (central and lateral), one
canine, two premolars (first and second), and three molars (first, second,
and third); incisors and canines are anterior teeth; premolars and molars
are posterior teeth
1. Anatomic features of anterior teeth
a. Incisors
(1) Developmental lobes—developmental centers; anterior
teeth are formed from four developmental lobes; posterior
teeth have four or five lobes

377
 (2) Incisal ridge—found on incisors; function is cutting; newly
erupted incisors have mamelons: three rounded elevations
on the incisal ridge, delineating the three facial
developmental lobes, which are usually worn away with
normal function after eruption
(3) Incisal angles—formed by the proximal surfaces and the
incisal ridge; central incisor angles are sharper and more
acute than lateral incisor angles, and mesioincisal angles
are sharper than distoincisal angles
(4) Maxillary lateral incisors vary the most in size and shape
and may be congenitally missing or anomalous, as in the
case of a peg lateral (smaller and more pointed)
b. Canines—one in each quadrant; only teeth with one cusp;
function in grasping and tearing
(1) Considered the cornerstone of the dentition because of the
long, large root, which is externally manifested by the
canine eminence of maxillary alveolar bone
(2) Have a prominent lingual ridge between two fossae;
lingual anatomy is more prominent on maxillary canines
2. Anatomic features of posterior teeth
a. Premolars—two in each quadrant; first and second premolars;
function in grinding
(1) Generally have two cusps; the mandibular second
premolar also typically has a three-cusped type
(2) Have one root, except maxillary first premolars, which have
two roots 60% of the time
(3) Replace (succeed) primary molars when exfoliated
(4) First premolars are frequently extracted for orthodontic
reasons
b. Molars—three in each quadrant; named first, second, and third
molars
(1) Largest crown in the dentition both mesiodistally and
faciolingually; shorter cervico-occlusally
(2) Only teeth that do not replace primary teeth
(nonsuccedaneous); erupt posterior to primary molars
(3) The mandibular first molar is the first permanent tooth to
erupt
(4) Multi-cusped, with each having a distinct cusp-and-groove
pattern
(5) Maxillary molars have three roots; mandibular molars have
two roots

378
 (6) The presence, size, and shape of third molars vary greatly,
roots commonly fused
C. Tooth-numbering systems
1. Universal Numbering System—Arabic numerals 1 to 32 to specify
permanent teeth, beginning with the maxillary right third molar and
ending with the mandibular right third molar.
2. International Numbering System—a two-digit code: the first digit—
1 to 4—designates the quadrant location; the second digit—1 to 8—
designates the tooth, starting from the midline, from the central
incisor to the third molar (e.g., 1-1 is the maxillary right central
incisor)
D. General characteristics of tooth form
1. Crest of curvature (crest of convexity) or height of contour (HOC)—
the greatest curvature on each axial surface; four on each tooth
2. All proximal surfaces narrow mesiodistally from the crest of
curvature (HOC) to the CEJ (Figure 5-12)

FIG 5-12 Apical convergence (arrows) of proximal surfaces.

3. The proximal crest (HOC) convergence provides spacing for the

interproximal gingiva and bone
4. Contact area—ideally formed by the proximal HOC area, which
functions to stabilize adjacent teeth and protect the interproximal
gingiva
5. Proximal crests (HOC) gradually move from the incisal third on
incisors to the middle third on molars; as a general rule, the mesial

379
 crest is more incisal-occlusal than the distal crest
6. Facial and lingual crests (HOC) are generally in the cervical third on
anterior teeth, with the lingual HOC more in the middle third on
premolars and molars; mandibular posteriors, especially molars,
have their lingual HOC more toward the occlusal third
7. Mesial cusp ridges are shorter than distal cusp ridges (except the
maxillary first premolar); mesial outlines are straighter than distal
outlines (Figure 5-13)

FIG 5-13 Comparison of mesial (M) and distal (D) outlines.

8. All facial and lingual surfaces converge toward the apex and toward
the incisal-occlusal surface from the crests of curvature
a. This convergence facilitates mastication (Figure 5-14)

380
 FIG 5-14 Apical and incisal occlusal convergence (arrows) of facial
and lingual surfaces.

b. These contours deflect food away from the gingiva and facilitate
the function of teeth (Figure 5-15)

381
 FIG 5-15 Facial and lingual contours (arrows) and the proximal
curvature of the cemento-enamel junctions. L, Lingual aspect.

9. Cemento-enamel junctions
a. The CEJ on the proximal surface curves toward the incisal-
occlusal; more prominent on anterior teeth than on posterior
teeth; curves more on the mesial surface than on the distal
surface (see Figure 5-15)
b. Maxillary CEJs curve more than mandibular
10. Crown and root inclination—from a proximal view, the long axes of
the crown and the root are in line, except for the mandibular
posterior teeth crowns, which tilt lingually to the long axes of the
root; this lingual inclination enables the intercuspal relationship of
posterior teeth and the distribution of forces along their long axes
(Figure 5-16)

382
 FIG 5-16 Lingual inclination of mandibular posterior crowns.

11. Proximal surfaces converge toward the lingual; this is most

prominent on maxillary incisors and canines
a. Lingual embrasures then are larger than facial embrasures
b. The two exceptions are the mandibular second premolar, three-
cusp type, and the maxillary first molar, because of its large
distolingual cusp (Figure 5-17; see Table 5-2)

383
 FIG 5-17 Lingual convergence (arrows) of proximal surfaces. L,
Lingual aspect.

D. General characteristics of roots

1. Root anatomy varies in size, shape, and number
2. Teeth have one, two, or three roots; some roots may divide in the
apical third
a. One root—incisors, canines, maxillary second premolars,
mandibular premolars
b. Two roots—maxillary first premolars (buccal and lingual) and
mandibular molars (mesial and distal)
c. Three roots—maxillary molars (mesiobuccal, distobuccal, and
lingual)
3. Root trunk—area from the CEJ to the division of the roots
4. Teeth with two or three roots have a root trunk with depressions that
deepen until the trunk divides at the furcation
a. Furcation—area where the root divides; complex anatomy
within the furcation
b. The more cervical the furcation, the more stable the tooth
because of the divergence of roots with inter-radicular bone;
first molars have the shortest root trunk

384
c. Furcation involvement—loss of attachment of tissue and bone
exists
d. Furcations closer to the CEJ are more likely to become involved
in periodontal disease, but are more accessible
e. Individual roots are basically cone shaped, widest at the CEJ
and converge (taper) to the apex; more root surface area is
present in the cervical than apical third
f. A cervical cross section of a tooth with one root shows three
basic shapes (Figure 5-18; see Table 5-2), which may be slightly
altered by the presence of root concavities

FIG 5-18 Root shapes as seen in cervical cross section: elliptical,

ovoid, and triangular.

(1) Triangular—maxillary incisors; have narrower mesiodistal

dimension on the lingual surface
(2) Ovoid (egg shaped)—canines and some mandibular
premolars
(3) Elliptical (oblong)—maxillary premolars, mandibular
incisors, and some mandibular premolars
g. A cervical cross section of molars follows the form of the crown,
with depressions on most axial surfaces
h. From a facial or lingual view, roots often have distal flexion;
more reliably on posterior teeth
i. Second-molar and third-molar roots are more likely to be closer

385
 together or fused, and distally inclined
j. Variations in root form
(1) Fused roots—no division or furcations
(2) Supernumerary roots—extra roots
(3) Dilaceration—unusual bending or root curvature
(4) Hypercementosis—deposition of extra cementum
(5) Enamel pearls—spherical enamel formed on cementum,
usually near a furcation
(6) Cervical enamel projections—CEJ curves more apically
near a furcation
(7) Bifurcational ridge—ridge of cementum between mesial
and distal roots on mandibular molars
E. Clinical considerations of permanent tooth form—as a general rule,
proximal surfaces of most teeth are more accessible from the lingual
approach because of the convergence (tapering) of lingual teeth surfaces
producing larger lingual embrasures
1. Incisors
a. Maxillary lingual anatomy is more prominent than mandibular
lingual anatomy; however, plaque, calculus, and stain readily
collect on mandibular lingual surfaces
b. Repeated instrumentation on the narrow roots of mandibular
incisors makes them subject to loss of structure, resulting in
unsupported cervical enamel
c. Deep fossae and narrow dimensions of roots are difficult for
instrumentation
d. Pits on maxillary lateral incisors more subject to caries
2. Canines
a. Crown length, bulk, and long roots make these teeth very stable
b. Prominent distal crown and root depression
3. Premolars
a. Distinctive pit-and-groove patterns facilitate the identification
of premolars
b. Proximal root concavities, especially the mesial of the maxillary
first premolar, make subgingival instrumentation difficult on
the proximal surfaces
c. Lingual inclination of mandibular premolar crowns makes
instrumentation difficult
d. Self-care more difficult with root depressions and lingual
inclination
4. Molars
a. Complex pit-and-groove patterns make molars susceptible to

386
 dental caries; sealants should be placed shortly after eruption
b. Lingual inclination of mandibular molar crowns makes self-care
and instrumentation difficult
c. Maxillary molar furcations better accessed from the lingual
approach because of locations
d. Furcation involvement challenging for access; requires more
time and possible surgical intervention
F. Primary/deciduous dentition
1. The primary (deciduous) dentition consists of 20 teeth (5 per
quadrant): 8 incisors, 4 canines, and 8 molars
2. Numbering systems
a. The Universal Numbering System uses capital letters (Figure 5-
19): A through T for primary teeth, beginning with the maxillary
right second primary molar and ending with the mandibular
right second primary molar

387
 FIG 5-19 Primary teeth, designated according to the Universal
Numbering System; F, facial; O, occlusal.

b. The International System uses a two-digit code: the first digit—

5 to 8—designates the quadrant in the dentition, clockwise from
the upper-right quadrant; the second digit—1 to 5—designates
the tooth, from the central incisor to the second primary molar
3. Set traits—the anatomy of primary teeth is similar to that of
permanent teeth, except (Figure 5-20):

388
 FIG 5-20 Comparison of dentitions. A, Comparison of primary and
permanent anterior teeth. B, Comparison of primary second molars and
permanent first molars.

a. Primary teeth are smaller in size than their permanent

counterparts; primary molars are wider than the premolars
(leeway space)
b. Primary teeth are whiter than permanent teeth
c. The crowns of primary teeth are shorter cervico-
incisally/occlusally, with pronounced labial and lingual cervical
ridges
d. Occlusal tables of primary teeth narrower faciolingually
(smaller intercuspal width), and the cuspal anatomy is not as
pronounced as in permanent teeth (smaller intercuspal depth)
e. Enamel thickness is more consistent and thinner: 0.5 to 1 mm
thick, compared with that of permanent teeth, 2.5 mm

389
 f. Pulp chambers (relative to the size of the tooth) are larger, and
pulp horns extend more occlusally than in permanent teeth; the
amount of dentin is proportionately less
g. Roots are slender and longer than in permanent teeth,
approximately twice the length of the crown (larger root-crown
ratio)
h. Molar root trunks are shorter (furcations closer to the CEJ);
roots are more divergent to accommodate the developing
premolar crown
i. Primary teeth have fewer anomalies and variations in tooth form
5. Class traits—anatomy of primary teeth (see Figure 5-19)
a. Incisors—resemble the outline of their permanent counterparts,
except no mamelons on the incisal ridge and no pits on the
lingual surface
b. Canines—resemble the outlines of their permanent
counterparts; maxillary canine has a sharp cusp, wide and short;
mesial cusp ridge is longer than the distal cusp ridge
c. Molars
(1) First primary molars—do not resemble any other teeth
(2) Have the same number and position of roots as that of
permanent molars
(3) The CEJ on the mesial half of the buccal surface curves
apically around a very prominent cervical ridge
(4) The maxillary first primary molar has an H-shaped groove
pattern and usually has three to four cusps; somewhat
resemble a maxillary premolar; the mesial cusps are the
largest; a prominent cervical ridge is present
(5) The mandibular first primary molar has four cusps; the
mesial cusps are larger, and the mesiolingual cusp is long,
pointed, and angled toward the occlusal surface
(6) Second primary molars are larger than the first primary
molars and resemble the form of the first permanent molar
(isomorphic)

390
Eruption
A. General comments
1. Eruption frequently is defined as “the emergence of the tooth
through the gingiva”
2. Also defined as the movements a tooth makes to attain and maintain
a relationship with the teeth in the same and opposing arches;
follows distinct stages:
a. Beginning of hard tissue formation
b. Enamel (crown) completion, after which actual tooth movement
begins
c. Eruption; approximately 50% of the root is formed when
eruption begins
d. Root completion
3. Ages at which eruption occurs are given in classic eruption tables
4. Sequential pattern (order) is more predictable than age of eruption
5. As a generalization, the mandibular tooth of a class (e.g., incisor,
canine) emerges before the maxillary tooth of the same type, and the
first before the second (e.g., the central incisor emerges before the
lateral incisor)
B. Primary dentition development and eruption
1. A guide for the emergence of teeth into the oral cavity is provided in
the following table:

Mandibular Maxillary
Central incisor 6 months 7 months
Lateral incisor 7 months 9 months
Canine 16 months 18 months
First molar 12 months 14 months
Second molar 20 months 24 months

2. The order of eruption for primary tooth development is: central

incisor, lateral incisor, first molar, canine, and second molar
3. Hard tissue formation begins in utero between 4 and 6 months
4. Crowns are completed between 1 and 10 months of age
5. Roots are completed between 1 and 3 years of age, 6 to 18 months
after eruption
6. By 3 years of age, all primary teeth are erupted, and permanent teeth
(except the third molars) are in some stage of development
7. Root resorption of a primary tooth is triggered by the pressure
exerted by the developing permanent tooth; followed by primary

391
 tooth exfoliation in sequential patterns
C. Mixed/transitional dentition—period with both deciduous and
permanent teeth present; begins with the eruption of the first permanent
tooth (often the mandibular first molar) and ends with the exfoliation of
the last primary tooth
1. Mixed/transitional dentition occurs between 6 and 12 years of age
2. Characteristics
a. Edentulous areas
b. Perception of disproportionately sized teeth
c. Varying clinical crown heights
d. Crowding
e. Enlarged and edematous gingiva
f. Enamel color variations between dentitions
D. Permanent dentition development and eruption
1. Succedaneous teeth replace primary teeth: incisors, canines, and
premolars; nonsuccedaneous teeth are the permanent molars
2. Permanent tooth formation begins between birth and 3 years of age
(except for the third molars)
3. The crowns of permanent teeth are completed between 4 and 8 years
of age, at approximately one-half the age of eruption
4. The order of eruption in permanent tooth development follows:

Mandibular Maxillary
First molar First molar
Central incisor Central incisor
Lateral incisor Lateral incisor
Canine First premolar
First premolar Second premolar
Second premolar Canine
Second molar Second molar
Third molar Third molar

5. A guide for the emergence of permanent teeth into the oral cavity
follows:

392
 Mandibular Maxillary
First molar* 6-7 years 6-7 years
Central incisor 6-7 years 7-8 years
Lateral incisor 7-8 years 8-9 years
Canine 9-10 years 11-12 years
First premolar 10-12 years 10-11 years
Second premolar 11-12 years 10-12 years
Second molar 11-13 years 12-13 years
Third molar 17-21 years 17-21 years
* First permanent tooth to erupt.

6. Roots of permanent teeth are completed between 10 and 16 years of

age, 2 to 3 years after eruption

393
Intra-arch and interarch relationships
Each tooth has a relationship with adjacent teeth in the same and
opposing arches. These relationships are influenced by size and shape of
the maxilla, the mandible, the teeth themselves, spacing, and a variety of
external factors, such as oral habits and dental disease.
A. Intra-arch relationship—the alignment of the teeth within an arch
1. Position of teeth in the jaw
a. Interproximal contacts—in an ideal alignment, teeth contact at
their proximal crests of curvature (HOC); a continuous arch
form is observed from an occlusal view
(1) Anterior teeth contacts are in the middle of the
faciolingual dimension
(2) Posterior teeth contacts are facial of center in a faciolingual
dimension
(3) Some permanent dentitions have normal alignment with
no contact
(4) Primary dentitions often have developmental spacing in
the anterior area; some have primate spaces between the
primary maxillary lateral incisor and the canine and
between the primary mandibular canine and the first molar
(Figure 5-21)

FIG 5-21Primary teeth showing primate spaces. A,

Mandibular primate space between the canine and the first
molar. B, Maxillary primate space between the lateral incisor
and the canine. (Modified from Wilkins E: Clinical practice of the
dental hygienist, ed 10, Philadelphia, 2008, Lippincott, Williams &
Wilkins.)

b. Axial positioning—relationship of the long axis of individual

394
 teeth to an imaginary horizontal or median plane (mesiodistally
and faciolingually); ideally, each tooth “sits” at an angle that
best withstands the forces placed on it (Figure 5-22)

FIG 5-22 Tooth positioning in relation to the horizontal plane. (From

Dempster WT, Adams WJ, Duddles RA: Arrangement in the jaws of the roots of
the teeth, J Am Dent Assoc 67:779, 1963.)

(1) Most teeth are inclined facially, with the incisors having
the greatest inclination
(2) The mandibular posterior teeth tip lingually toward the
median plane
c. Curves of the occlusal plane (a line connecting the cusp tips of
canines, premolars, and molars)
(1) Curve of Spee—from the buccal aspect in centric
occlusion, the cusp tips of posterior teeth curve
anteroposteriorly; for mandibular teeth, the curve is
concave, and for maxillary teeth, it is convex (Figure 5-23, A)

395
 FIG 5-23 The curves of occlusion. A, Curve of Spee. B,
Curve of Wilson. (From Berkovitz BKB, Holland GR, Moxham BJ:
Color atlas and textb ook of oral anatomy, histology and emb ryology, ed
2, London, 1992, Mosby–Year Book, Inc.)

(2) Curve of Wilson—mediolateral curve connecting cusp tips

of posterior mandibular teeth on opposite sides of the
mouth (side to side); for mandibular teeth, the curve is
concave because of their lingual tilt, and for maxillary
molars, it is convex (Figure 5-23, B).
(3) The matching curve is termed the compensating curve
2. Disturbances in intra-arch alignment
a. Open contacts—sites where an interproximal space exists
because proximal crests (HOC) do not meet; from
developmental disturbances, missing teeth, oral habits, dental
disease, or overdeveloped frena
b. Positional variations, or versions—misplaced positioning of
teeth from developmental disturbances, crowding, oral habits,
dental caries, or periodontal disease; named for their positions:
facioversion (facial of normal alignment), linguoversion,
mesioversion, distoversion, supraversion (supraerupted),
infraversion (undererupted), and torsiversion (rotated);
interproximal contacts are often not normal
B. Interarch relationships—alignment between arches; can be viewed
from a stationary (fixed) perspective and a dynamic (movable)
perspective
1. Stationary relationships

396
a. Centric relationship—the most retruded position of the
mandible, as in swallowing; muscles contract fully, not usually
resulting in maximum tooth contact
b. Centric occlusion—habitual occlusion where maximum tooth
contact between arches (intercuspation) occurs (note: a normal
physiologic rest position of the mandible during nonfunction)
(1) Overjet (horizontal overlap)—the characteristic of
maxillary teeth to overlap mandibular teeth in a horizontal
direction; the maxillary arch is slightly larger; it functions to
protect the narrow edge of incisors and to provide for an
intercusping relationship of posterior teeth (Figure 5-24)

FIG 5-24 Overjet, the term used to describe the horizontal

overlap of the anterior maxillary teeth on the anterior
mandibular teeth.

397
(2) Overbite (vertical overlap)—the characteristic of the
anterior maxillary teeth to overlap the anterior mandibular
teeth in a vertical direction normally; facilitating the
scissors-like cutting function of incisors (Figure 5-25)

FIG 5-25 Overbite, the term used to describe the vertical

overlap of the anterior maxillary teeth on the anterior
mandibular teeth.

(3) Intercuspation—the characteristic of posterior teeth to

intermesh in a faciolingual direction; mandibular facial
cusps and maxillary lingual cusps are centric cusps
(supporting cusps) that contact interocclusally in the
opposing arch (Figure 5-26)

398
 FIG 5-26 Intercuspation of posterior teeth. Centric cusps
have interocclusal contact with opposing teeth.

(a) Guiding cusps (maxillary facial and mandibular

lingual) protect the teeth and tissues
(4) Interdigitation—the characteristic of each tooth to
articulate with two opposing teeth (except for mandibular
central incisors and maxillary last molars); a mandibular
tooth occludes with its counterpart in the upper arch and
the one mesial to it; a maxillary tooth occludes with its
counterpart in the mandibular arch and the one distal to it
(Figure 5-27)

399
 FIG 5-27 Interdigitation of teeth.

c. Angle’s classification of occlusion—using the first permanent

molars, Edward H. Angle classified these relationships as
follows (Figure 5-28):

400
 FIG 5-28 Malocclusion classified using Angle’s system. A, Angle’s
class I occlusion. B, Angle’s class II malocclusion (division 1). C,
Angle’s class II malocclusion (division 2). D, Angle’s class III
malocclusion. (Modified from Berkovitz BKB: Oral anatomy, histology and
emb ryology, ed 4, London, 2009, Elsevier Ltd.)

(1) Normal (ideal)—mesiobuccal groove of the mandibular

first permanent molar aligns with the mesiobuccal cusp of
the maxillary first permanent molar with no deviations in
tooth positioning
(2) Class I occlusion (orthognathic)—normal molar
relationships with alterations in other characteristics of the
occlusion, such as versions, crossbites, excessive overjets, or
overbites
(3) Class II malocclusion (retrognathic)—distal relationship of
the mesiobuccal groove of the mandibular first permanent
molar to the mesiobuccal cusp of the maxillary first

401
 permanent molar
(a) Division 1—protruded anterior maxillary teeth
(b) Division 2—one or more retruded anterior maxillary
anterior teeth
(4) Class III malocclusion (prognathic)—a mesial relationship
of the mesiobuccal groove of the mandibular first
permanent molar to the mesiobuccal cusp of the maxillary
first permanent molar
d. Canines may also be used to classify occlusion when a molar is
missing; class I canine relationship: cusp tip of the maxillary
canine is facial to and between the mandibular canine and the
first premolar
e. Occlusion in a primary dentition is assessed by the relationship
of the distal terminus (surface) of second primary molars in
centric occlusion; three relationships are possible: a flush
terminal plane, a distal step, or a mesial step (Figure 5-29)

402
 FIG 5-29 Terminus of second primary molars in centric occlusion.
A, Flush terminal plane. B, Distal step. C, Mesial step.

f. Mixed dentition represents a transitional stage of occlusal

development; the initial contact of permanent first molars
usually begins at age 7, and by 12 years of age, the final
occlusion of the first molars is established
(1) Distal-step primary dentitions always lead to a class II
permanent molar occlusion
(2) Exaggerated mesial-step primary dentitions lead to a class
III permanent molar occlusion
(3) Development of occlusion from a flush terminus or a mild
mesial-step primary dentition is variable but frequently
leads to a class I first permanent molar relationship
2. Disturbances in interarch alignment
a. Excessive overbite—the incisal edges of maxillary incisors

403
 extend to the cervical third of mandibular incisors
b. Excessive overjet—horizontal overlap of maxillary teeth to
mandibular teeth by more than 3 mm
c. End-to-end relationships—edge-to-edge bite; anterior teeth
meet at their incisal edges with no overjet or overbite; cusp-to-
cusp bite in which posterior teeth meet cusp to cusp with no
intercuspation
d. Open bite—no incisal or occlusal contact between maxillary and
mandibular teeth; teeth cannot be brought together, a space is
created, may be caused by tongue thrust or thumb sucking
e. Crossbites—altered normal faciolingual relationship between
maxillary teeth and mandibular teeth; for anterior teeth,
mandibular teeth are facial rather than lingual to maxillary
teeth; for posterior teeth, normal intercuspation is not observed;
numerous alterations are possible and result in maxillary or
mandibular, buccal or lingual, or partial or total crossbites
3. Dynamic interarch relationships are a result of functional
mandibular movements that start and end with centric occlusion
during mastication
a. Mandibular movements involve complex neuromuscular
functions
(1) Depression (opening)
(2) Elevation (closing)
(3) Protrusion (thrusting forward)
(4) Retrusion (bringing back)
(5) Lateral movements right and left; one side is always the
working, or chewing, side; the opposite side is the
nonworking, or balancing, side; ideally, these alternate
during chewing
b. Mandibular movements from centric occlusion are guided by
maxillary teeth
(1) Protrusion is guided by incisors; called incisal guidance
(2) Lateral movements are guided by the canines on the
working side in young, unworn dentitions (canine-protected
occlusion); lateral movements may be guided by incisors
and posterior teeth in worn dentitions
c. As mandibular movements commence from a centric occlusion,
posterior teeth should disengage in protrusion; on the balancing
side, posterior teeth should disengage in lateral movement
d. If tooth contact occurs where teeth should be disengaged,
occlusal interferences or premature contacts exist

404
Summary of tooth dimensions
A. Crowns
1. From 7 to 11 mm cervico-incisally
2. Anterior teeth are longer cervico-incisally (2 to 3 mm longer) than
posterior teeth in both arches
3. Smallest crown mesiodistally is the mandibular central incisor
4. Maxillary first molar is the widest tooth faciolingually; mandibular
first molar is the widest tooth mesiodistally
B. Roots
1. From 12 to 17 mm in length
2. Incisor roots are shortest
3. Longest root is the maxillary canine
C. Ratio of root length to crown length is smaller in anterior teeth (root-
to-crown ratio)
1. Smallest ratio is the maxillary central incisor, where the root is only
slightly longer
2. Molars have a greater root-crown ratio because of short crowns
cervico-occlusally
3. Largest ratio is the mandibular first molar, where the root is 1.83
times longer

Website Information and Resourc es

Source Website Address Description
National Institute of http://www.nidcr.nih.gov Information and links related to awareness of
Dental and craniofacial development and disorders;
Craniofacial publications aimed at client/patient education
Research are available.
Dental Hygiene http://www.dhed.net/Site_Map.html Links to both professional dental and dental
Education Net hygiene organizations as well as numerous
health care resource centers
Dental anatomy information for professionals
and clients/patients is available, as well as
resources such as journals and research sites
for and by dental hygienists.
Medscape from http://emedicine.medscape.com Numerous topics concerning oral health,
WebMD including the oral examination, diseases of the
oral cavity, and links to the Centers for Disease
Control and Prevention (CDC) and other
resources
Medline Plus https://www.nlm.nih.gov/medlineplus/ Current health information, including a
medical encyclopedia; a service of the U.S.
National Library of Medicine and the National
Institutes of Health

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Suggested readings
Bath-Balogh M., Fehrenbach M.F. Illustrated dental embryology,
histology, and anatomy. ed 4 St Louis: Saunders; 2015.
Beck M., Bryan L. Root morphology and instrumentation
implications. In: Darby M.L., Walsh M.M., eds. Dental hygiene:
theory and practice. ed 3 Philadelphia: Saunders; 2010.
Nelson S. Wheeler’s dental anatomy, physiology, and occlusion. ed 10
Philadelphia: Saunders; 2014.
Norton N. Netter’s head and neck anatomy for dentistry. Philadelphia:
Saunders; 2012.
Wilkins E. Clinical practice of the dental hygienist. ed 11 Philadelphia:
Lippincott, Williams & Wilkins; 2012.
Woelfel J.B., Scheid R.C. Dental anatomy: its relevance to dentistry. ed
8 Baltimore: Lippincott, Williams & Wilkins; 2011.
Zwemer T., Thomas J., eds. Mosby’s dental dictionary. ed 3 St Louis:
Mosby; 2014.

Chapter 5 review questions

Answers and rationales to review questions are available on this text’s
accompanying Evolve site. See inside front cover for details.

Case A
Permanent Dentition
A 19-year-old woman presents for an initial dental hygiene appointment.
Although she has had restorative procedures completed due to caries,
she has not had prophylaxis for a few years. After a complete
assessment, she is diagnosed with gingivitis and given oral self-care
instructions. She has several questions about her bite and intraoral
tissues, and she is concerned about her front teeth.

Use Case A and Figures 5-30 and 5-31 to answer questions 1 to 10.
1. Several of this patient’s maxillary anterior teeth show irregular incisal
edges. What term is used to describe this wear?
a. Abfraction

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b. Abrasion
c. Attrition
d. Erosion

FIG 5-30 Lateral view, permanent dentition.

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 FIG 5-31 Occlusal view, permanent dentition.

2. From the lateral view of the maxillary left quadrant, there is a fracture
of what feature of tooth #10?
a. Cervical area
b. Mesioincisal angle
c. Distoincisal angle
d. Distal height of contour
3. What term is used to describe the space between #10 and #11?
a. Diastema
b. Leeway space
c. Primate space
d. Missing tooth
4. Using the canine relationship, determine Angle’s classification for this
patient.
a. Class I occlusion
b. Class II, division 1

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 c. Class II, division 2
d. Class III
5. From the lateral view, which teeth do NOT have an ideal vertical
overlap?
a. #4 and #5
b. #11 and #12
c. #13 and #14
d. #21 and #22
6. What term is used to describe this malocclusion?
a. Overjet
b. Overbite
c. End-to-end
d. Crossbite
7. During the clinical examination, you notice small round areas of
pigmentation on the:
a. Commissure
b. Vermillion zone
c. Mucosal tissue
d. Gingival margins
8. From the occlusal view of the maxillary right quadrant (Figure 5-31),
which tooth is malpositioned?
a. Canine
b. First premolar
c. Second premolar
d. First molar
9. The malpositioning of that tooth is called:
a. Supraversion
b. Torsiversion
c. Infraversion
d. Linguoversion
10. During the assessment, you note slight erythema at the anterior
entrance to the tonsillar recess. Name this structure.
a. Palatine raphe

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 b. Fauces
c. Pharyngopalatine arch
d. Glossopalatine arch

Case B
Mixed dentition
An 8½-year-old boy presents to your clinic for radiographs, examination,
and prophylaxis. His mother is concerned about the appearance of his
teeth and whether his permanent teeth are erupting on schedule.

Use Case B and Figure 5-32 to answer questions 11 to 17.

FIG 5-32 Facial view, mixed dentition.

11. This patient’s history of thumb sucking has caused malocclusion in

the anterior of his mouth. This malocclusion is referred to as:
a. Crossbite
b. Open bite
c. Overjet
d. Edge-to-edge
12. Of the following, which of his permanent teeth are unerupted?
a. #8, #9, and #10
b. #23, #24, and #25
c. #7, #10, and #26
d. #23, #25, and #26

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13. By what age would all permanent maxillary incisors normally be
erupted?
a. 4 to 5 years
b. 5 to 6 years
c. 6 to 7 years
d. 8 years
14. Which tooth is malpositioned in linguoversion?
a. #7
b. #9
c. #23
d. #25
15. Which primary/deciduous mandibular incisor is still present?
a. N
b. O
c. P
d. Q
16. What explains the intraoral lesion present on the marginal gingiva of
the maxillary arch?
a. Apthous ulcer
b. Abscess of the permanent tooth
c. Eruption lesion
d. Pericoronitis
17. Approximately how many millimeters of anterior overbite exist with
this boy’s occlusion?
a. 0 mm
b. 2 to 3 mm
c. 4 to 5 mm
d. More than 5 mm
18. Which of the following teeth would NOT be observed clinically in an
11-year-old child?
a. Permanent lateral incisors
b. Mandibular permanent canines
c. Permanent central incisors
d. Permanent second molars

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19. Which succedaneous teeth are usually present in a 7-year-old child?
a. Mandibular first molars
b. Mandibular central incisors
c. Maxillary canines
d. Mandibular canines
20. When comparing maxillary premolars, the maxillary first premolar
has two cusps that are more equal in size than the second premolar, but
the second premolar has a greater mesial depression on the crown and
root.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
21. Which of the following is TRUE of furcations on molars?
a. A long root trunk places the furcation nearer to the cemento-enamel
junction.
b. Second molars have furcations more cervical than first molars.
c. Third molars often have furcations in the cervical third of the root.
d. Furcations increase the amount of attachment of bone and tissues.
22. When tooth J exfoliates, it will be replaced by:
a. #5
b. #12
c. #13
d. #21
23. Which of the following permanent teeth develops from five lobes?
a. Maxillary premolar
b. Mandibular canine
c. Maxillary second molar
d. Mandibular first molar
24. Performing root canal therapy would be most complex on this tooth
because it usually has the most pulp canals.
a. #12
b. #14
c. #20

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 d. #28
25. In class I occlusion, normal wear can occur on all these structures
EXCEPT:
a. Incisal edges of mandibular incisors
b. Mandibular canine cusp tips
c. Maxillary lingual fossae
d. Cervical areas
26. All the following are common sites for caries on a mandibular first
molar EXCEPT:
a. Occlusal pits and grooves
b. Lingual developmental groove
c. Interproximal contact areas
d. Mesiofacial developmental groove
27. Radiographically, the density of this tooth tissue resembles that of
caries.
a. Pulp
b. Dentin
c. Cementum
d. D. Enamel
28. For both arches, the interproximal heights of contour/crests of
convexities follow this pattern.
a. For incisors, heights of contour are in the middle third.
b. For molars, heights of contour are in the occlusal third.
c. The mesial height of contours are less incisal/occlusal than the distal
height of contours.
d. The mesial height of contours are more incisal/occlusal than the
distal height of contours.
29. Which permanent tooth has the smallest root-to-crown ratio?
a. Maxillary canine
b. Mandibular first molar
c. Maxillary central incisor
d. Maxillary lateral incisor
30. What term is used to describe the extra spacing that exists to allow
the permanent premolars adequate room to erupt?

413
 a. Primate spaces
b. Leeway space
c. Diastemas
d. Interproximal space
31. Choose a trait that describes teeth in the maxillary arch.
a. Fossae of incisors and canines have more distinct features.
b. Crowns are wider mesiodistally than faciolingually.
c. Premolars and molar crowns are inclined to the median.
d. Interproximal curvatures of the CEJ are less than for mandibular
teeth.
32. Comparing the maxillary canine with the mandibular canine, the
maxillary canine has more prominent root depressions, whereas the
mandibular canine has interproximal heights of contour more in the
middle third of the cervico-incisal dimension.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE, the second statement is FALSE.
d. The first statement is FALSE, the second statement is TRUE.
33. Of the permanent teeth, which usually erupts out of sequence and
may cause problems with spacing?
a. Maxillary canine
b. Mandibular canine
c. Maxillary second premolar
d. Mandibular second premolar
34. Of the following, during mastication of hard or hot food, all these
structures of the palate may be injured EXCEPT:
a. Rugae
b. Median sulcus
c. Alveolar process
d. Incisive papilla
35. When giving a supraperiosteal (infiltration) injection, into which area
is the penetration site?
a. Pterygomandibular raphe
b. Sublingual fold

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 c. Mucobuccal fold
d. Palatine fovea
36. During a clinical examination, the patient presents with geographic
tongue. This indicates the involvement of which papillae?
a. Fungiform
b. Circumvallate
c. Foliate
d. Filiform
37. Which of these structures provides openings into the mouth for two
major salivary glands?
a. Parotid papilla
b. Sublingual caruncle
c. Palatal salivary duct
d. Stensen duct
38. Each cusp on a posterior tooth has one cusp ridge, but each posterior
tooth has two marginal ridges.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
39. For molars, which ridges extend from the cusp tip of each cusp to the
grooves of the occlusal surface?
a. Triangular
b. Marginal
c. Facial
d. Lingual
40. For a buccal injection, choose the correct penetration site.
a. In the mucobuccal fold near the mental foramen
b. Lateral to the retromolar pad near the most posterior molar
c. In the mucobuccal fold posterior to the maxillary second molar
d. Medial to the deep tendon of the temporalis muscle
41. Which statement is TRUE of the mandibular first molar?
a. It usually has four cusps.

415
 b. It usually has two root canals.
c. Its roots are close together.
d. The mesial root is wider faciolingually than mesiodistally.
42. Which of the following is NOT an anomaly of the maxillary incisors?
a. Peg lateral
b. Shovel shape
c. Supernumerary tooth
d. Bifid/bifurcated root
43. The curve of Spee is determined by the mediolateral curvature of the
posterior occlusal surfaces, whereas the curve of Wilson is determined
by the anteroposterior curvature of the occlusal surfaces.
a. BOTH statements are TRUE.
b. BOTH statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
44. Correct vertical overlap of teeth exists with which of the following
relationships?
a. Mandibular anterior teeth overlap the maxillary anterior teeth
facially.
b. Mandibular lingual cusps fall within the occlusal table of maxillary
teeth.
c. Maxillary buccal cusps fall within the occlusal table of mandibular
teeth.
d. Maxillary buccal cusps overlap mandibular buccal cusps facially.
45. Which of the following intraoral structures is NOT observed when
lifting the tongue palatally?
a. Plica fimbriata
b. Lingual frenum
c. Philtrum
d. Lingual veins
46. Choose the CORRECT statement regarding axial positioning of teeth
in the dental arches.
a. The mandibular posterior teeth crowns tip facially to the median
plane.

416
 b. The incisors of both arches have the greatest inclination
faciolingually.
c. The premolars are at approximately 60 degrees to the horizontal
plane.
d. Maxillary teeth are more prone to axial deviation than mandibular
teeth.
47. What tooth surface is used to assess the occlusion in the primary
occlusion?
a. Distal surface of the primary maxillary first molar
b. Mesial surface of the primary maxillary first molar
c. Distal surface of the primary mandibular second molar
d. Mesial surface of the primary mandibular second molar
48. All the following anatomic variations can occur within furcations and
can complicate instrumentation EXCEPT:
a. Tubercles
b. Cervical enamel projections
c. Enamel pearls
d. Bifurcational ridges
49. Which permanent premolar can present with three different pit-and-
groove patterns?
a. Maxillary first premolar
b. Maxillary second premolar
c. Mandibular first premolar
d. Mandibular second premolar
50. When comparing crown lengths to root lengths, the canines have the
longest roots, whereas the third molars have the shortest crowns.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.

417
C HAPT E R 6

418
Oral and Maxillofacial Radiology
Laura Jansen Howerton

Diagnostic dental radiographs are an important and necessary

component of total patient care. Radiographic images enable the
practitioner to see conditions that may otherwise go undetected. The goal
of dental radiography is to obtain the highest-quality radiographic image
while maintaining the lowest possible radiation exposure dose to the
patient. The dental hygienist must be not only capable of producing
diagnostic radiographs but also competent in interpretation skills.
Knowledge and skill in applying this information are critical for the
safe use of ionizing radiation in the oral health care setting. This chapter
emphasizes basic information on radiation, film processing, digital
imaging, intraoral and extraoral techniques and errors, and radiographic
interpretation.

419
General considerations
Discovery of X-Radiation
A. Radiation—a form of energy carried through space in the form of
waves or a stream of particles
B. Radiation characteristics
1. Bundles of energy that have neither mass nor charge
2. Travels at the speed of light (186,000 miles per second)
3. Electromagnetic energies exist over a wide range of magnitudes,
termed the electromagnetic spectrum (Figure 6-1)

FIG 6-1 Electromagnetic energy spectrum. (From Iannucci JM, Howerton LJ:
Dental radiography: principles and techniques, ed 4, St Louis, 2012, Elsevier
Saunders.)

4. Interaction of radiation with biologic tissues causes change in the

tissue due to ionization
5. Electromagnetic spectrum is measured according to frequency,
velocity, and wavelength
C. X-ray—a beam of energy that has the power to penetrate substances
and record image shadows on receptors
D. Wilhelm Roentgen discovered the x-ray in 1895
1. He was experimenting with vacuum tubes, photographic plates, and
electrical currents
2. Dr. Roentgen was awarded a Nobel Prize in physics

420
Radiation Physics
A. Ion—an atom that gains or loses an electron and becomes
electronically unbalanced
B. Ionization— the process by which radiant energy removes an orbital
electron from an atom to yield an ion pair
C. Ionizing radiation—radiation capable of producing ions; two types:
1. Particulate radiation
a. Tiny particles have both mass and energy, travel in straight lines
at high speeds
b. Examples: neutrons, protons, alpha and beta particles
2. Electromagnetic radiation
a. Electromagnetic radiation
b. The propagation of wave-like energy without mass through
space
c. Arranged in an electromagnetic spectrum and measured
according to frequency, velocity, and wavelength (see Figure 6-1)
(1) Wavelength—distance from one crest of a wave to the next;
the shorter the wavelength, the greater are the energy and
penetrating ability of the radiation
(2) Velocity—the speed of a wave
(3) Frequency—number of wavelength crests passing a
particular point per unit of time; the shorter the
wavelength, the higher the frequency
(4) Photon and quantum—a single unit or bundle of energy
(5) Energy—ability to do work; electromagnetic radiation is
measured in electron volts (eV)
D. X-ray machine
1. Control panel—contains on/off switch exposure button and the
controls to regulate the exposure factors (mA, kVp, time); modern x-
ray machines may have preset exposure factors for various anatomic
areas of the maxilla and mandible
2. Extension arm—suspends the x-ray tubehead and houses electrical
wires
3. X-ray tubehead—lead-lined metal casing for the x-ray tube designed
to prevent excessive radiation exposure and electrical shock
a. Protects the x-ray tube
b. Insulating oil surrounds x-ray tube and absorbs excess heat
produced during x-ray production
c. Transformers alter voltage of incoming electricity
d. Aluminum discs filter the longer-wavelength x-rays

421
 e. Lead collimator restricts the size and shape of the x-ray beam
f. Position-indicating device (PID) aims and shapes the x-ray beam;
the longer PID produces an x-ray beam less divergent, decreases
radiation exposure to client, and provides less image
magnification
g. X-ray tube is the heart of the x-ray–generating system
(1) Cathode
(a) Negative electrode
(b) Consists of a tungsten wire filament and
molybdenum (focusing) cup
(c) Supplies the electrons necessary to generate x-rays;
milliamperage control (mA) regulates the step-down
transformer, the quantity of x-rays produced, and
heating of the filament
(d) Because like charges repel, the electron beam is
directed to a small area on the anode
(2) Anode
(a) Positive electrode
(b) Consists of a tungsten plate fixed to a copper arm
(c) The tungsten target serves as a focal spot and converts
bombarding electrons into x-ray photons
(d) Kilovoltage control (kVp) regulates the step-up
transformer, voltage between cathode and anode, and
speed of electrons
(3) Aluminum filters are placed in the path of the x-ray beam
to filter and selectively remove the low-energy,
nonpenetrating x-rays from the beam
(4) A lead collimator is positioned next to the aluminum filter
to restrict the size and shape of the x-ray beam
E. Production of x-radiation (Figure 6-2)

422
 FIG 6-2 Diagram of x-ray tube. (From Iannucci JM, Howerton LJ: Dental radiography:
principles and techniques, ed 5, St Louis, 2017, Elsevier.)

1. Control panel is activated by the on/off switch; appropriate mA, kVp,

and time selections are chosen
a. Milliamperage (mA)—allows for warming of the cathode
filament and determines the number of electrons available for x-
ray production; the higher the mA setting, the hotter the
filament becomes, resulting in a greater number of available
electrons
b. Kilovoltage peak (kVp)—controls the current passing from
cathode to anode; the higher the kVp setting, the greater the
penetrating power and speed of acceleration of electrons from
the cathode to the anode
c. Exposure time establishes the time during which electrons are
available for the bombardment of target material; the higher the
time setting, the more electrons available for x-ray production
2. Exposure button is pressed
a. The heated filament provides electrons for x-ray production by
thermionic emission, referred to as a “boiling off ” of electrons; an
electron cloud surrounding the filament is formed
b. An electrical potential difference is created whereby electrons
are attracted from the negative cathode to the positive anode
c. The directional flow of electrons is influenced by the focusing
cup of the cathode; electrons are repelled away from the
negatively charged focusing cup; this mechanism controls the
size and shape of the electron stream
d. Less than 1% of the kinetic energy leaving the cathode is

423
 converted into x-ray energy; more than 99% of the energy
leaving the cathode is converted into heat and absorbed by the
insulating oil
F. Types of x-rays produced
1. General (braking or “bremsstrahlung”) radiation
a. Produces 70% of x-ray photons by dental x-ray machines
b. The accelerating electron passes near the nucleus of the target
atom and is slowed down by the attraction of the nucleus
c. The slowing-down process results in the transference of the
kinetic energy of the electron into x-ray energy
2. Characteristic radiation
a. Can only occur at levels of 70 kVp or higher with a tungsten
target; accounts for a small portion of x-rays produced by dental
x-ray machines
b. Occurs when an electron removes an orbital electron from the
target atom
c. During restabilization of the ionized atom, the movement of the
outer-shell electron results in the transference of electron-
binding energy into x-ray energy
G. Interactions of x-rays with matter
1. Definitions
a. Primary radiation—penetrating beam that is produced at the
target anode; also termed primary or useful beam
b. Secondary radiation—results from the interaction of primary
radiation and matter
c. Scatter radiation—one form of secondary radiation in which the
direction of travel of the x-ray has been altered
2. Interactions of x-ray photons and matter
a. No interaction
(1) The passing of x-ray photons through a material without
any alteration of the photon or the material
(2) Photons proceed to strike the image receptor
b. Photoelectric effect
(1) Results from an incident photon colliding with a tightly
bound inner-shell electron
(2) Incident photon ceases to exist; the electron is ejected as a
recoil electron; ionization of the atom occurs
(3) Accounts for approximately 30% of interactions
c. Compton scatter
(1) Results from an incident photon colliding with a loosely
bound outer-shell electron

424
 (2) Incident photon gives up part of its energy in the ejection
of the orbiting electron; ionization of the atom occurs
(3) Accounts for approximately 62% of interactions
d. Coherent scatter
(1) The interaction of an incident photon passing near an
outer-shell electron and being scattered without energy loss
(2) Incident photon ceases to exist, and a new photon of
identical energy is released from the electron; no ionization
of the atom occurs
(3) Accounts for approximately 8% of interactions

Characteristics of X-Radiation
A. Beam quality—the mean energy or penetrating ability of the x-ray
beam
1. Controlled by kVp; increasing the kVp will result in a higher-energy
x-ray beam with increased penetrating ability
2. Increasing the kVp will create a beam with shorter wavelength and
higher frequency
3. Density—the overall darkness of an image
a. Increase kVp = increase density (darker)
b. Decrease kVp = decrease density (lighter)
4. Contrast—the differences between the dark and light areas on an
image
a. Increase kVp = low contrast (many shades of gray)
b. Decrease kVp = high contrast (few shades of gray, mostly dark
and light)
B. Beam quantity—the number of x-rays produced in the dental x-ray
machine
1. Controlled by mA; determines the amount of electrons passing
through the cathode filament
2. Increasing the mA will increase the number of x-rays produced and
will also increase the temperature of the cathode filament
a. Increase mA = increased density (darker)
b. Decrease mA = decreased density (lighter)
c. Milliamperage does not have an affect on image contrast
3. Exposure time also has an effect on the beam quantity; an increase in
exposure time results in an increase in the number of x-rays
produced
C. Beam intensity—the product of the quality and quantity of x-radiation;
beam intensity is affected by kVp, mA, exposure time, and distance

425
1. Increase kVp = increase beam intensity
2. Increase mA = increase beam intensity
3. Increase exposure time = increase beam intensity
4. Increase distance = decrease beam intensity
a. The distance between the source of radiation and the receptor
has an influence on the intensity of the x-ray beam.
b. The inverse square law is defined as “the intensity of radiation
is inversely proportional to the square of the distance from the
source of radiation”

(1) As the distance between the source of radiation and

an object increases, the intensity of the x-ray beam
decreases
(2) As the distance between the source of radiation and
an object decreases, the intensity of the x-ray beam
increases
(3) For example, if the intensity of an x-ray beam is
400 mSv at 36 inches, at 72 inches the intensity is
only one-fourth as great, or 100 mSv

426
Radiation biology and protection
A. Radiation exposure
1. Harmful to all living tissues; should be used cautiously
2. Injury to cells, tissues, and organs occurs at the time of exposure but
may take hours, days, or generations to manifest
3. Two mechanisms of radiation injury are possible
a. Radiation injury is caused by ionization
(1) May cause a breakage in the molecule or a relocation of the
atom in the molecule
(2) Such changes may have a profound effect of structures of
great importance, such as DNA
b. Radiolysis of water
(1) Yields free radicals that combine to form hydrogen
peroxide (H2O2)
(2) H2O2 is toxic to living tissues; its formation is an indirect,
damaging effect of ionizing radiation
B. Characteristics of dose-response relationships
1. Linear—the response is directly proportional to the dose
2. Nonthreshold—any dose, regardless of its size, is expected to
produce a response
3. Threshold—from zero to a particular point, no response would be
expected; above the threshold point, any dose will produce a
response
C. Interactions of ionizing radiation with cells, tissues, and organs
1. Stochastic effects—occur as a direct function of dose
2. Nonstochastic effects—increase in severity with an increase in dose
3. Genetic effects— not seen in the irradiated person but are passed to
future generations
4. Somatic effects—seen in the irradiated person but are not passed to
future generations
5. Short-term effects—associated with large amounts of radiation
absorbed in a short time
6. Long-term effects—associated with small amounts of radiation
absorbed repeatedly over a long period of time
D. Sequence of radiation injury
1. Latent period—the time between exposure to radiation and the
appearance of the first observable clinical signs
2. Period of injury—a variety of cellular injuries may occur
3. Recovery period—not all cellular radiation injuries are permanent
4. Cumulative effects—repeated radiation exposures can lead to

427
 problems with the health of the patient
E. Radiation effects on cells
1. Not all cells respond to radiation in the same manner
2. Several factors determine tissue sensitivity
a. Mitotic activity—cells that divide frequently or undergo many
divisions are more sensitive to radiation
b. Cell differentiation—cells that are immature are more sensitive
to radiation
c. Cell metabolism—cells that have a higher metabolism are more
sensitive to radiation
3. Tissue and organ sensitivity
a. Radiosensitive—a cell that is sensitive to radiation effects
(1) Lymphatic (most sensitive)
(2) Erythrocytes
(3) Reproductive cells
b. Radioresistant—a cell that is resistant to radiation effects
(1) Nerve (most resistant)
(2) Liver
(3) Muscle
c. Organ tissues considered critical for dental radiography are
skin, thyroid gland, lens of the eyes, and bone marrow
d. Continued low-dose exposure negatively affects the repair
mechanism; overloading of the repair system by time or amount
of exposure can result in somatic or genetic damage

Radiation Measurements and Sources

A. Two systems are used to define the radiation measurements: the older
system, or traditional system (may be found in literature dated before
1985), and the newer or metric equivalent system known as International
System of Units (SI)
B. The International Commission on Radiation Units and Measurements
(ICRU) has established units for the measurement of radiation1
1. Radiation exposure—the measurement of ionization in air produced
by x-rays
a. Traditional unit of exposure is the roentgen (R)
b. SI unit of exposure – defined as electrical charge per unit mass
of air or coulomb per kilograms (C/kg)
c. 1 R = 2.58 × 10− 4 C/kg
1 C/kg = 3.88 × 103 R
2. Radiation absorbed dose—the amount of radiation absorbed by a

428
 tissue
a. Traditional unit is the radiation absorbed dose (rad)
b. SI unit is the gray (Gy)
c. 1 Gy = 100 rad
3. Dose equivalent—the measure of biologic effects produced by
different types of radiation
a. Traditional unit is the roentgen-equivalent man (rem)
b. SI unit is the sievert (Sv)
c. 1 Sv = 100 rem
C. Radiation risks and sources of radiation
1. Naturally occurring (or background) radiation constitutes 50% of the
overall exposure to the United States population2
a. Radon gas, the result of naturally occurring radionuclides found
in soil (a radionuclide is an unstable atom that decays by
emitting particles and energy from the nucleus to become
electrically stable) accounts for 37% of the natural background
radiation (Figure 6-3)

429
 FIG 6-3 Annual effective dose equivalent of ionizing radiations.
This chart illustrates the approximate percentage of exposure of
the U.S. population to background and artificial radiations. (From
www.NCRPonline.org.)

b. Other terrestrial sources, cosmic radiation from outer space,

and internal sources constitute another 13% of natural exposure
2. Medical applications account for 48% the overall exposure to the U.S.
population2
a. Computed tomography (CT) and nuclear medicine lead medical
exposures by 24% and 12%, respectively
b. Other conventional radiographs, including oral and
maxillofacial radiography, constitute 5% of medical exposures
c. Consumer products and industrial and occupational exposures
account for the remaining 2% of total exposure to the U.S.
population
3. Exposure is defined as the average annual effective dose equivalent of
ionizing radiation
a. Average annual effective dose equivalent of ionizing radiation to
a member of the U.S. population is 6.2 millisieverts (mSv), up

430
 from 3.6 mSv in the early 1980s2 (Figure 6-4)

FIG 6-4 Comparison of effective dose equivalents. These charts

illustrate the difference in approximate percentage of exposure of
the U.S. population to background and artificial radiations in the
early 1980s and 2006. (From www.NCRPonline.org.)

b. Significant increase largely arising from the increased use of

large-dose medical imaging technologies

Radiation Protection
A. Before exposure
1. Proper prescribing of radiographs (Table 6-1)

Table 6-1
Guidelines for Prescribing Dental Radiographs

431
 * Clinical situations for which radiographs may be indicated include, but are not limited to the following. Positive
historical finding: Previous periodontal or endodontic treatment, history of pain or trauma, familial history of dental
anomalies, postoperative evaluation of healing, remineralization monitoring, presence of implants or evaluation
for implant placement. Positive clinical signs and symptoms: Clinical evidence of periodontal disease; large or
deep restorations; deep carious lesions; malposed or clinically impacted teeth; swelling; evidence of dental or
facial trauma; mobility of teeth; fistula involving sinus tract; clinically suspected sinus pathology; growth
abnormalities; oral involvement in known or suspected systemic disease; positive neurologic findings in the head
and neck; evidence of foreign objects; pain, dysfunction, or both, of the temporomandibular joint; facial asymmetry;
abutment teeth for fixed or removable partial prosthesis; unexplained bleeding; unexplained sensitivity of teeth;
unusual eruption, spacing, or migration of teeth; unusual tooth morphology, calcification, or color; unexplained
absence of teeth; clinical erosion.
† Factors increasing the risk for caries may include, but are not limited to the following: High level of caries
experience or demineralization, history of recurrent caries, high titers of cariogenic bacteria, existing restoration(s)
of poor quality, poor oral hygiene, inadequate fluoride exposure, prolonged nursing (bottle or breast), high-
sucrose diet, poor familial oral health, developmental or acquired enamel defects, developmental or acquired
disability, xerostomia, genetic abnormality of teeth, many multi-surface restorations, chemotherapy or radiation
therapy, eating disorders, drug or alcohol abuse, irregular dental care.

a. To limit the amount of radiation received by the patient,

radiographs must be ordered on an individual basis, based on
the patient need
b. Evidence-based selection criteria is recommended3
2. Proper equipment must be used
a. Filtration removes long-wavelength, less penetrating x-rays from

432
 the beam; dental x-ray machines operating at or below 70 kVp
require 1.5-mm aluminum filtration; machines operating above
70 kVp require 2.5-mm aluminum filtration (Figure 6-5)

FIG 6-5 Aluminum discs are placed in the path of the beam to filter
out the low-energy, longer-wavelength x-rays that are harmful to
the patient. (From Iannucci JM, Howerton LJ: Dental radiography: principles
and techniques, ed 5, St Louis, 2017, Elsevier.)

b. Collimation restricts the size and shape of the x-ray beam;

federal regulations require that the x-ray beam be collimated to
a diameter of no more than 2.75 inches as it reaches the skin of
the patient (Figure 6-6)

433
 FIG 6-6 Federal regulations require that the diameter of a
collimated x-ray beam be restricted to 2.75 inches at the patient’s
skin. (From Iannucci JM, Howerton LJ: Dental radiography: principles and
techniques, ed 5, St Louis, 2017, Elsevier.)

c. The PID must be an open-ended, lead-lined cylinder; the longer

the focal spot to object distance, the less divergent beam is
created
B. During exposure
1. Use of the fastest image receptor
a. Currently, “F” speed is the fastest speed intraoral film available
b. Digital imaging further reduces patient exposure
2. Use of the lead apron and thyroid collar limits the amount of
radiation received by the patient
3. Beam alignment devices and proper technique also reduce the
chances of retakes, thereby reducing unnecessary exposure to the
patient
C. After exposure
1. Correct film or sensor handling is necessary to produce diagnostic
images
2. Proper film processing and retrieval of digital images is necessary to
produce diagnostic results
D. Operator protection
1. The dental radiographer should remain behind a barrier during
patient exposure
2. If a structural wall or shield is not available, the radiographer should
stand at least 6 feet away from the source of radiation and should be
in a position at an angle of 90 to 135 degrees to the primary beam
(Figure 6-7)

434
 FIG 6-7 Operator protection guidelines suggest that the dental
radiographer stand at an angle of 90 to 135 degrees to the primary
beam. (From Iannucci JM, Howerton LJ: Dental radiography: principles and
techniques, ed 5, St Louis, 2017, Elsevier.)

E. Maximum permissible dose (MPD)—defined by the National Council

on Radiation Protection and Measurements (NCRP) as the maximum
dose equivalent that a body is permitted to received within a specific
period2
1. The current MPD for occupationally exposed persons is 50 mSv/year
2. The current MPD for nonoccupationally exposed persons is
5 mSv/year (one-tenth [1/10] the dose of the occupational radiation
worker)
F. ALARA concept—individuals working with radiation should attempt
to keep all radiation exposures “as low as reasonably achievable”

435
Dental x-ray film
A. Film composition
1. The base material (polyester) must possess the dimensional stability
to withstand processing procedures and support the emulsion
2. An adhesive is applied evenly to the base to provide for uniform
attachment of emulsion to the base
3. The emulsion consists of gelatin and silver halide crystals; gelatin
suspends the silver halide crystals, which are sensitive to radiation
and light
4. A protective layer is applied to protect the emulsion from being
scratched
B. Classifications of dental x-ray film
1. Intraoral and extraoral film refer to the designated use of the film
a. Intraoral film is placed inside the oral cavity (e.g., bitewing,
periapical, or occlusal)
b. Extraoral film is placed outside the mouth for exposure of larger
areas of the head or skull (e.g., panoramic, cephalometric, skull)
2. Film speed—the amount of radiation needed to produce an image
with standard density
a. Film speed is determined by the size of silver halide crystals in
the emulsion, the thickness of the emulsion, and the presence of
radiosensitive dyes
b. Speed ranges used in dental radiography are designated from
“D” (slowest) to “F” (fastest)
c. E-speed intraoral film requires only 50% of the exposure of D-
speed intraoral film; F-speed film requires only 77% of the
exposure of E-speed film4
3. Film size—various sizes are available for both intraoral and extraoral
films
a. Intraoral film
(1) No. 0 size film—22 × 35 mm
(2) No. 1 size film—24 × 40 mm
(3) No. 2 size film—31 × 41 mm (standard film size)
(4) No. 3 size film—27 × 54 mm
(5) No. 4 size film—57 × 76 mm
C. Components of intraoral film packets
1. Light-tight, leakproof wrapping protects film from light and
moisture
2. Black protective paper is used for additional protection of the film
from light

436
 3. Lead foil is inserted between the black paper and the outer wrapping
on the back side of the film packet; the purpose of the lead foil is to
prevent backscattered radiation from fogging the film
4. Single or double films are enclosed in the packet
D. Intensifying screens used with extraoral film
1. Housed inside a light-tight cassette
2. Used as a component of the indirect imaging system to reduce client
exposure to x-radiation for study of large anatomic areas
3. Screen construction
a. Base material composed of polyester plastic
b. Reflective layer is coated onto the base material; redirects light
toward the film to increase film efficiency
c. Phosphor layer composed of phosphorescent crystals; calcium
tungstate emits blue light to expose the film; rare-earth crystals
emit green light and respond more efficiently to reduce
radiation exposure needed to produce the image
d. Protective coating is applied to phosphor layer
E. Film storage and protection
1. Unexposed film must be stored away from heat, moisture, chemical
vapors, and radiation; film should be stored in a cool, dry place
2. Film has a limited shelf life and must be used before the expiration
date

Dental X-Ray Image Characteristics

Table 6-2 summarizes the characteristics and respective influencing
factors.

437
Table 6-2
Radiation Characteristics and Influencing Factors

A. Radiolucent—refers to a portion of an image that is dark or black

B. Radiopaque—refers to a portion of an image that is light or white
C. Density—the overall darkness or blackness of an image
1. Increase kVp, increase density
2. Increase mA, increase density
3. Increase time, increase density
D. Contrast—the difference in the degrees of darkness between adjacent
areas on an image
1. Increase kVp, low contrast (many shades of gray)
2. Decrease kVp, high contrast (many areas of black and white)
E. Sharpness—the capability of the image receptor to reproduce the
distinct outlines of an object
1. The smaller the focal spot size, the sharper the image
2. The smaller the silver halide crystals in the film emulsion, the
sharper the image
3. The less movement of the patient, tubehead, or film, the sharper the
image
F. Magnification—a radiographic image that is larger than its actual size
1. The longer the target-to-receptor distance, the less image
magnification produced
2. The shorter the tooth-to-receptor distance, the less image
magnification produced
G. Distortion—a variation in the true size and shape of an object
1. Align the tooth and receptor parallel to each other to avoid
distortion
2. Position the x-ray beam perpendicular to the tooth and receptor to
avoid distortion

438
Dental X-Ray Film Processing
A. Manual film processing consists of five steps: development, rinse,
fixation, rinse, and dry
1. Developer solution reduces the exposed silver halide crystals into
black metallic silver and softens the emulsion
a. Reducing agent (hydroquinone and elon) reduces the exposed
silver halide crystals to black metallic silver
b. Alkalizer (sodium carbonate) softens and swells the gelatin of
the emulsion to allow the reducing agent to reach the silver
halide crystals
c. Preservative (sodium sulfite) slows the oxidation of the solution
to prolong its life span
d. Restrainer (potassium bromide) slows down the action of
chemicals
2. A water bath is used to wash or rinse the film and stop the
development process
3. Fixer solution removes the unexposed silver halide crystals from the
emulsion and hardens the emulsion
a. Clearing or fixing agent (sodium or ammonium thiosulfate)
removes the unexposed or undeveloped crystals from the
emulsion
b. Acidifier (acetic acid) provides the required acidity so that the
fixing solutions can work; stops the action of the developer
c. Preservative (sodium sulfite) slows the solution’s oxidation to
prolong its life span
d. Hardener (potassium aluminum) shrinks and hardens the
emulsion
4. A water bath is used to wash the films and remove all chemicals
5. Films must be completely dried before handling for mounting or
viewing
6. Total time involved for manual film processing: approximately 45 to
60 minutes
B. Equipment needed for manual film processing
1. Darkroom: to provide a completely darkened environment for film
handling
2. Processing tanks: two insert tanks hold the developer and fixer
solutions, while a master tank holds circulating water
3. A thermometer is needed to determine the temperature of the
developer solution
a. The optimum time/temperature for manual processing is 68°F

439
 (20°C) for 5 minutes
b. Higher temperatures require shorter development time; cooler
temperatures require longer development time
4. A timer, film hangers, and stirring paddles are also recommended
for manual film processing
C. Automatic film processing consists of four steps: development,
fixation, rinse, and dry
1. Films are carried from solutions to the dryer by a roller assembly
2. Processing solutions are highly concentrated to work quickly
3. Total time involved for automatic film processing: approximately 4 to
5 minutes
D. Equipment needed for automatic film processing
1. Darkroom: to provide a completely darkened environment for film
handling
a. Some processors are equipped with daylight loaders
b. Daylight loaders are light-shielded compartments that allow
processing to be completed in a room with white light
2. Automatic processor is built with a housing; film feed slot; roller
film transporter; compartments for developer, fixer, and water; a
drying chamber; and replenisher pumps
E. Darkroom design and requirements
1. Light-tight room with a revolving light-sealed door, or door with an
inside lock
2. Safelight to allow sufficient illumination without exposing or
damaging the film
a. Low-wattage bulb of 7.5 or 15 watts
b. Must be placed at least 4 feet from the work surface
c. The GBX-2 filter is recommended because it is safe to use with
both intraoral and extraoral films
3. Overhead white light provides illumination for cleaning and
stocking materials
4. Adequate work space
F. Film duplication
1. Copies of original radiographs may be needed for third-party
payment, a change to another oral health care practitioner, referrals
to specialists, or use in litigation
2. The duplication of film requires the use of a film duplicator machine
and specialized duplicating film

440
Film-processing errors
A. Fogged radiographs; appear gray and lack contrast (Figure 6-8)

FIG 6-8 A fogged film appears gray and lacks detail and contrast. (From Iannucci
JM, Howerton LJ: Dental radiography: principles and techniques, ed 5, St Louis, 2017,
Elsevier.)

1. Improper safelighting in the darkroom

2. Exposure to scatter radiation, heat, humidity, or chemical vapors
3. Contaminated processing chemicals
4. Old, expired, or damaged film
B. Dark radiographs (Figure 6-9)

441
 FIG 6-9 An overdeveloped film appears dark. (From Iannucci JM, Howerton LJ: Dental
radiography: principles and techniques, ed 5, St Louis, 2017, Elsevier.)

1. Temperature of developer solution too high; developer solution too

concentrated
2. Excessive developing time used
3. Inaccurate timer or thermometer
C. Light radiographs (Figure 6-10)

442
 FIG 6-10 An underdeveloped film appears light. (From Iannucci JM, Howerton LJ:
Dental radiography: principles and techniques, ed 5, St Louis, 2017, Elsevier.)

1. Temperature of developer solution too cool; developer solution too

weak
2. Insufficient developing time
3. Inaccurate timer or thermometer
D. Clear (blank) radiographs
1. Film was not exposed to radiation; most common reason for a clear
radiograph
2. Film placed in fixer solution prior to developer solution
3. Excessive washing, which causes the removal of film emulsion
E. Completely black radiographs are caused by the film being exposed to
white light before processing
F. Radiographs with spots (Figure 6-11)

443
 FIG 6-11 Fixer spots appear light or white. (From Iannucci JM, Howerton LJ: Dental
radiography: principles and techniques, ed 5, St Louis, 2017, Elsevier.)

1. Developer splashing on film before processing causes dark or black

spots
2. Fixer splashing on film before processing causes white or light spots
3. Water splashing on film before processing causes light spots
G. Yellow-brown stained radiographs
1. Insufficient fixing or washing times
2. Processing solutions are exhausted and must be replaced or
replenished
H. Dark roller lines or marks
1. Dirty or contaminated processing chemicals cause dark lines to
appear on automatically processed films
2. Dirty or contaminated automatic processor rollers may also cause
roller marks
I. Static electricity artifacts (Figure 6-12)

444
 FIG 6-12 Static electricity appears as black branching lines. (From Iannucci JM,
Howerton LJ: Dental radiography: principles and techniques, ed 5, St Louis, 2017, Elsevier.)

1. Caused by the rapid removal of the film from the packet or the
cassette when the humidity level is very low, such as during winter
months
2. Yields black artifacts in tree-shaped streaks, smudges, or dots

445
Quality assurance
A. A quality control plan in dental radiography ensures the production of
diagnostic-quality radiographs while minimizing radiation exposure
through a plan of action; in addition, the means of testing and regulating
x-ray equipment and procedures used to expose, process, and store
radiographs are reviewed
B. Components of a quality control plan
1. Competence of radiographer
a. Evaluation of radiographs for self-analysis of technique
b. Peer review of radiographs for technique analysis
c. Continuing education courses to maintain state-of-the-art
practice
2. Equipment inspections by state and local radiation regulatory
agencies
a. Milliamperage, kilovoltage, timer accuracy
b. Collimation and alignment of the x-ray beam
c. Measures to avoid leakage radiation
d. Mechanical support of the unit; may include tube drifting
e. Penetrating quality of the beam tested by using the half-value
layer (HVL); uses a material (usually aluminum) that reduces
exposure by one-half when placed within path of radiation beam
3. Quality assurance procedures for film processing
a. Periodic evaluation of the darkroom
(1) Checks for light leaks
(2) Coin test for safelight evaluation involves the placement of
a coin on an unwrapped, unexposed film under a safelight
for 2 to 3 minutes; if the outline of the coin is present on the
processed film, corrective action is necessary
4. Creation of a reference or step-wedge radiograph to compare
strengths of processing solutions; evaluates films for consistency in
density and contrast
5. Periodic cleaning, maintenance, and daily monitoring of processing
equipment
a. Clean the automatic roller assembly and manual racks to
prevent debris buildup and artifacts; schedule cleaning
maintenance on the basis of usage
b. Schedule preventive maintenance for optimal equipment
operation
c. Monitor solution temperatures daily
d. Replenish solutions in accordance with the volume of films

446
processed

447
Digital imaging
A. Digital imaging is a filmless system in which a radiographic image is
captured using a sensor, the image is broken down into electronic pieces
and viewed and stored on a computer
1. Source of radiation—a conventional dental x-ray unit
2. Intraoral sensor—replaces the traditional dental x-ray film
3. Computer—converts the electronic signal received by the sensor;
processes and stores the information
B. Methods of obtaining digital images
1. Direct digital imaging
a. Uses an x-ray machine, intraoral sensor, and computer
b. The sensor contains a fiberoptic cable linked to the computer as
it is placed into the mouth of the patient; the sensor is rigid, and
patients may complain of the bulkiness
c. Within seconds of exposure, the image appears on the computer
monitor
2. Indirect digital imaging
a. Uses an x-ray machine, intraoral sensor, and computer
b. The sensor is a reusable imaging plate coated with phosphors
(often termed PSP plate); this sensor is thin and flexible, much
like an intraoral film packet
c. After exposure, the plate is scanned to convert the information
into electronic files
d. Because of the laser scanning step, this type of digital imaging
is less rapid than direct digital imaging
C. Advantages of digital imaging5
1. Superior resolution produces images with increased diagnostic
capabilities
2. Because of the sensitivity of the sensors, patients are exposed to less
radiation than with traditional film
3. Increased speed of image viewing leads to increased time efficiency
in the dental office
4. Because the image may be viewed on a computer monitor, patient
education is enhanced
D. Disadvantages of digital imaging
1. Initial expense of purchasing and setting up equipment may be
costly
2. Depending on the system used, sensor size and bulkiness may be an
issue
3. Infection control procedures may be difficult, especially with corded

448
 sensors
4. Learning a new computer language may be problematic for the staff

449
Radiology techniques: intraoral and
extraoral
A. Adhering to shadow-casting principles produces diagnostic
radiographic images
1. Smallest focal spot possible
2. Longest source-to-object distance possible (focal spot to tooth)
3. Shortest object-to-receptor distance possible (tooth to receptor)
4. Tooth and receptor should be in a parallel relationship
5. X-ray beam should be perpendicular to the tooth and the image
receptor
B. Angulation of the x-ray beam
1. Vertical angulation refers to the position of the PID in the vertical
plane
a. Positive vertical angulation indicates the PID is pointing
downward
b. Negative vertical angulation indicates the PID is pointing
upward
2. Horizontal angulation refers to the position of the PID in the
horizontal plane

Intraoral Radiographic Techniques

A. Paralleling
1. Yields radiographs with a minimum of image distortion
2. Minimizes the superimposition of adjacent oral structures
3. Application of the paralleling technique
a. The receptor is placed parallel to the long axis of the tooth
b. The x-ray beam is directed perpendicular to the long axis of the
tooth and the receptor
c. The x-ray beam is directed perpendicular through interproximal
spaces
d. The x-ray beam is centered over the anatomic structures and the
receptor
B. Bisecting the angle
1. Applies the rule of isometry: the accurate length of the tooth is
obtained if the x-ray beam is perpendicular to the imaginary bisector
of the angle formed by the plane of the receptor and the long axis of
the tooth (Figure 6-13)

450
 FIG 6-13 The image on the receptor is equal to the length of the tooth
when the central ray is directed at 90 degrees to the imaginary bisector.
A tooth and its image will be equal in length when two equal triangles are
formed that share a common side (imaginary bisector). (From Iannucci JM,
Howerton LJ: Dental radiography: principles and techniques, ed 5, St Louis, 2017,
Elsevier.)

2. Allows for ease of receptor placement for certain patients with a

small mouth, shallow palate, large tori, or gag reflex
3. Application of the bisecting angle technique
a. The receptor is placed against the teeth
b. The x-ray beam is directed perpendicular to the imaginary
bisector of the angle formed by the plane of the receptor and the
long axis of the tooth
c. The x-ray beam is directed perpendicular through the
interproximal spaces
d. The x-ray beam is centered over the anatomic structures and the
receptor

Types of Intraoral Radiographic Examinations

A. Periapical
1. Periapical examination demonstrates the entire tooth and
surrounding bone (Figure 6-14)

451
 FIG 6-14 Periapical radiograph.

2. Indications for periapical radiographs3

a. Suspected periapical conditions
b. Evidence of periodontal disease
c. Injury or trauma to teeth
d. Endodontic therapy
e. Deep or large carious lesions
f. Suspected impacted teeth
g. Unusual eruption, malposition, or unexplained missing teeth
h. Unexplained sensitivity or tooth mobility
i. Unusual tooth morphology or color
j. Dental implant evaluation
B. Bitewing
1. Bitewing radiographs demonstrate the anatomic crowns of maxillary
and mandibular teeth as well as the height of alveolar bone (Figure
6-15)

452
 FIG 6-15 Bitewing radiographs. A, Long horizontal bitewing. B, Traditional
horizontal bitewing. C, Vertical bitewing.

2. Indications for bitewing radiographs3

a. Suspected interproximal caries
b. Defective restorations
c. Early periodontal disease
3. Horizontal bitewing radiographs are considered the traditional
placement; the long dimension of the receptor positioned
horizontally
4. Bitewing radiographs may also be exposed by placing the receptor
with the long dimension vertically; vertical bitewing radiographs are
typically used with patients with periodontal disease because the
vertical image increases the viewing area of alveolar bone
C. Occlusal
1. An occlusal radiograph demonstrates a large anatomic region or the
entire arch; it is usually exposed in conjunction with other intraoral
radiographs (Figure 6-16)

453
 FIG 6-16 Occlusal radiographs. A, Topographic maxillary occlusal
radiograph. B, Topographic mandibular occlusal radiograph. C, Cross-
sectional mandibular occlusal radiograph.

2. Indications for the exposure of occlusal radiographs6

a. Image margins of large pathologic conditions
b. Localization of objects (foreign or impactions)
c. Injury or trauma to surrounding bone structure
d. Suspected supernumerary teeth
e. Unexplained swelling or growth abnormality
f. Salivary stone detection
3. Occlusal radiographs may be prescribed for children, patients with
limited jaw opening or those who cannot tolerate periapical receptor
placement
D. Full-mouth survey (Figure 6-17)

454
 FIG 6-17 Full-mouth radiographic survey. (From Bird DL, Robinson DS: Modern dental
assisting, ed 11, St Louis, 2015, Elsevier.)

1. A series of intraoral radiographs that reveal all the tooth-bearing

areas of the maxilla and mandible
2. Usually a combination of periapical and bitewing radiographs
3. May include dentulous and edentulous areas

Types of Extraoral Radiographic Examinations

A. The panoramic radiograph is the most common extraoral exposure
(Figure 6-18)

FIG 6-18 Panoramic radiograph.

B. Provides an overall view of the maxilla, mandible, and surrounding

structures; used to supplement intraoral images
C. Indications for the exposure of panoramic radiographs6
1. Impacted teeth
2. Eruption patterns; growth and development
3. Assessment of trauma
4. Examination of the extent of large lesions or pathologic conditions

455
D. Image production is created while the receptor and tubehead rotate
around the patient
1. The image is produced through a process termed tomography
2. Tomography is a radiographic technique that permits visualization
of structures in a chosen plane or layer while intentionally blurring
the images above and below the selected plane
3. The zone in which structures are most clearly demonstrated is
termed the focal trough
a. The size and shape of each focal trough varies, determined by
the manufacturer of the panoramic machine
b. The focal trough is designed to accommodate the average-size
maxilla and mandible
E. Patient positioning is important in preparation of exposure of
panoramic radiographs
1. Follow the directions from the manufacturer for specific positioning
guidelines for determining the location of the focal trough
2. Insert the receptor into the cassette and panoramic unit
3. Position the patient with the midsagittal plane perpendicular to the
floor and the Frankfort plane parallel to the floor
4. Instruct the patient to occlude on the bite stick or similar device and
to hold still throughout the exposure
5. Consult the manufacturer ’s instructions to select appropriate
exposure settings
6. Maintain pressure on the exposure button until the procedure is
completed

456
Radiographic errors: intraoral and
extraoral
Intraoral Technique Errors7
A. Receptor placement
1. Correct receptor placement is important for the production of
diagnostic images
2. Improper receptor placement includes not centering the receptor
over the area of interest, inadequate coverage of the apical areas, and
tipped occlusal/incisal edges (Figure 6-19)

FIG 6-19 Improper placement; no apices are seen on this periapical

image. (From Iannucci JM, Howerton LJ: Dental radiography: principles and
techniques, ed 5, St Louis, 2017, Elsevier.)

B. Vertical angulation
1. Too much or excessive vertical angulation causes foreshortened
images (Figure 6-20)

457
 FIG 6-20 If the vertical angulation is too steep, the image of the tooth on
the receptor is shorter than the actual tooth; the images are
foreshortened. (From Iannucci JM, Howerton LJ: Dental radiography: principles and
techniques, ed 5, St Louis, 2017, Elsevier.)

2. Too little or insufficient vertical angulation causes elongated images

(Figure 6-21)

458
 FIG 6-21 If the vertical angulation is too flat, the image of the tooth on the
receptor is longer than the actual tooth; the images are elongated. (From
Iannucci JM, Howerton LJ: Dental radiography: principles and techniques, ed 5, St
Louis, 2017, Elsevier.)

C. Horizontal angulation
1. Correct horizontal angulation directs the central ray of the beam
through the interproximal regions
2. Incorrect horizontal angulation causes overlapping of the contact
areas; the adjacent teeth appear overlapped onto each other (Figure
6-22)

459
 FIG 6-22 Nondiagnostic bitewing image with overlapped interproximal
contacts. (From Iannucci JM, Howerton LJ: Dental radiography: principles and
techniques, ed 5, St Louis, 2017, Elsevier.)

D. Position-indicating device alignment problems

1. If the PID is not aligned correctly and the x-ray beam is not centered
over the receptor, a partial image is seen on the resultant image
2. A clear, unexposed area is seen on the image known as a cone-cut
(Figure 6-23)

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 FIG 6-23 A cone-cut is seen as a curved unexposed (clear) area on the
radiograph. (From Iannucci JM, Howerton LJ: Dental radiography: principles and
techniques, ed 5, St Louis, 2017, Elsevier.)

E. Blurred images
1. If the patient or tubehead is not still during exposure, blurred
images will appear on the image (Figure 6-24)

FIG 6-24 Movement results in a blurred image. (From Iannucci JM, Howerton
LJ: Dental radiography: principles and techniques, ed 5, St Louis, 2017, Elsevier.)

2. Instruct patients to keep all movement to a minimum during x-ray

461
 exposure
F. Reversed film
1. If the film is placed backward in the mouth and then exposed, a light
image with a herringbone (or “tire track”) pattern will appear
(Figure 6-25)

FIG 6-25A reversed film causes an image that appears light with a
herringbone (or tire track) pattern. (From Iannucci JM, Howerton LJ: Dental
radiography: principles and techniques, ed 5, St Louis, 2017, Elsevier.)

2. Since the primary beam penetrated the lead foil inside the packet
before reaching the film, the image demonstrates a lighter
appearance and the herringbone pattern

Extraoral Technique Errors7

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A. Frankfort plane positioning errors
1. If the chin is too low or tipped down, the mandibular incisor region
will appear blurred, the condyles may not be visible, and an
exaggerated smile line is seen on the image (Figure 6-26, A)

A, Chin positioned too far down; the Frankfort plane is angled

FIG 6-26
downward. B, Chin positioned too far up; the Frankfort plane is angled
upward.

2. If the chin is too high or tipped upward, the hard palate will be
superimposed over the maxillary roots, the maxillary incisors will be
blurred and magnified, and a reverse smile line is seen on the image
(Figure 6-26, B)
B. Focal trough positioning errors
1. Anterior teeth appear blurred and magnified in size if the dental
arches are positioned too far back (posterior) in the focal trough
(Figure 6-27, A)

463
 FIG 6-27 A, Dental arches positioned too far posterior to the focal trough.
B, Dental arches positioned too far anterior to the focal trough.

2. Anterior teeth will appear narrowed and diminished in size if the

dental arches are positioned too far forward (anterior) in the focal
trough (Figure 6-27, B)
C. Midsagittal plane errors
1. If the head of the patient is not centered in the panoramic machine,
the ramus and posterior teeth will be unequally magnified
2. The side closest to the receptor will appear smaller, whereas the side
farther away from the receptor will appear magnified
D. Cervical spine errors—if the patient is not standing or sitting up, the
cervical spine will appear as a vertical radiopacity in the middle of the
image
E. Lead apron errors—if the lead apron is placed too high on the neck of
the patient, the apron will block the x-ray beam from reaching the
receptor, and a radiopaque, cone-shaped artifact will obscure the
mandible
F. Ghost images
1. Any metallic object that remains in the head and neck region during
panoramic radiography may cause a ghost image to appear

464
2. Earrings, hearing aids, napkin chains, removable dental appliances,
and hair clips are some examples of items that may cause a ghost
image
3. Ghost images are seen on the panoramic image on the opposite side
of the original item, located higher than the original item, and
indistinct or distorted

465
Film mounting
A. Purpose—film mounting provides a systematic approach for viewing
and evaluating radiographs, with placement of radiographs in a holding
device according to anatomic considerations
B. Mount construction—made of cardboard or plastic; available with
windows for placement of radiographs in various number and size
combinations
C. Mounting procedures
1. Intraoral radiographs—labial mounting; recommended by the
American Dental Association (ADA)
a. Raised portion of the embossed dot is toward the radiographer
b. The patient’s left side is the radiographer ’s right side
c. The orientation is that of the radiographer facing the patient
2. Intraoral radiographs—lingual mounting
a. Raised portion of the embossed dot is away from the
radiographer
b. The patient’s left side is the radiographer ’s left side
c. The orientation is that of the radiographer behind the patient
3. Extraoral radiographs
a. During exposure, side(s) under examination should be
identified with a metal letter (R or L) placed on the cassette
b. A commercial film identification imprinter can be used to label
after exposure but before processing

466
Radiographic interpretation
A. Radiographic tooth anatomy (Figure 6-28)

FIG 6-28 Tooth anatomy. 1, Enamel. 2, Dentin. 3, Cementum. 4, Pulp. 5,

Periodontal ligament space. 6, Lamina dura. 7, Alveolar crest. 8, Trabeculae.

1. Enamel—outermost layer of the crown; radiopaque

2. Dentin—found beneath the enamel and surrounds the pulp cavity;
less radiopaque than enamel
3. Pulp cavity—relatively radiolucent
4. Alveolar bone—composed of cancellous and cortical bone;
radiopaque
5. Lamina dura—dense radiopaque line that surrounds the root of a
tooth
6. Periodontal ligament space—the space between the root of a tooth
and the lamina dura; appears as a thin radiolucent line
B. Radiographic anatomic landmarks of the maxilla (Figure 6-29)

467
 FIG 6-29 Radiographic anatomy of the maxillary arch. A, Maxillary anterior
region. 1, Incisive foramen. 2, Median palatal suture. 3, Nasal cavity (fossae).
4, Nasal septum. 5, Anterior nasal spine. 6, Lateral (canine) fossa. 7, Soft
tissue outline of the nose (dashed line). 8, Inferior nasal conchae. B, Maxillary
posterior region. 9, Maxillary sinus. 10, Zygomatic process. 11, Hanulus. 12,
Maxillary tuberosity. 13, Floor of the maxillary sinus. 14, Septa dividing the
sinus. 15, Coronoid process.

1. Incisive foramen—a hole in bone found at the midline of the

anterior portion of the hard palate; oval radiolucency located
between the maxillary central incisors
2. Lateral fossa (canine fossa) —diffuse radiolucency located between
the maxillary lateral incisor and the canine
3. Median palatine suture—radiolucent line extending vertically
between maxillary central incisors
4. Nasal fossae (nasal cavity)—two paired radiolucent compartments
seen superior to the maxillary central incisors; outlined by the floor

468
 of the nasal cavity
5. Nasal septum—vertical bony radiopaque wall that divides the nasal
cavity
6. Inferior nasal conchae—curved plates of bone that extend from the
lateral walls of the nasal cavity; appear as a diffuse radiopacity
within the nasal cavity
7. Anterior nasal spine—V-shaped radiopacity seen at the intersection
of the floor of the nasal cavity and the nasal septum
8. Inverted Y—Y-shaped radiopacity seen at the intersection of the
lateral wall of the nasal cavity and the anterior portion of the
maxillary sinus
9. Maxillary sinus—paired cavities of bone seen as bilateral
radiolucencies that originate at the maxillary canine region and
extend posteriorly; outlined by a radiopaque wall or floor
10. Nutrient canals—tiny, tube-like passageways through bone that
appear as thin radiolucent lines with radiopaque borders; may be
seen within the maxillary sinus
11. Zygomatic process of the maxilla—J- or U-shaped radiopacity seen
superior to the maxillary posterior teeth
12. Maxillary tuberosity—rounded prominence bone seen as a
radiopaque bulge in the most posterior region of the maxilla
13. Hamulus—radiopaque spine located on the medial pterygoid plate
seen posterior to the maxillary tuberosity
14. Lateral pterygoid plate—radiopaque extension of sphenoid bone;
distinguished as separate from the maxillary tuberosity
C. Radiographic anatomic landmarks of the mandible (Figure 6-30)

469
 FIG 6-30 Radiographic anatomy of the mandibular arch. A, Mandibular anterior
region. 1, Genial tubercles. 2, Lingual foramen. 3, Mental ridge. 4, Inferior
border of the mandible. B, Mandibular posterior region. 5, Mylohyoid ridge. 6,
External oblique ridge. 7, Submandibular fossa. 8, Mental foramen. 9,
Mandibular canal.

1. Genial tubercles—circular radiopaque spines located inferior to

mandibular central incisors
2. Lingual foramen—tiny opening in bone found on the internal
surface of the mandible; small radiolucent dot seen in the center of
the genial tubercles
3. Nutrient canals—tiny, tube-like passageways through bone that
appear as thin radiolucent lines with radiopaque borders; may be
seen in the mandibular anterior region
4. Mental ridge—radiopaque ridge of bone that extends from the
mandibular premolar region to the midline, extending upward
5. Mylohyoid ridge—radiopaque ridge of bone that extends downward
and forward from the mandibular molar region; may be
superimposed over the roots of the mandibular posterior teeth
6. Internal oblique ridge—radiopaque ridge of bone that extends
downward and forward from the ramus; may continue as the
mylohyoid ridge
7. External oblique ridge—radiopaque ridge of bone that ends at the

470
 anterior border of the ramus
8. Submandibular fossa—large radiolucent area in the posterior body
of the mandible; represents the lingual depression corresponding to
the location of the submandibular salivary gland
9. Mental foramen—a hole in bone found on the external surface of the
mandible; seen as a round radiolucency in the area of the apical
portion of the mandibular premolars
10. Mandibular canal—a tube-like passageway through bone; seen as a
radiolucent horizontal canal with radiopaque borders that runs in
the mandible below the apices of mandibular posterior teeth
11. Coronoid process of the mandible—a marked prominence of bone
seen on the anterior portion of the mandible; this radiopacity is the
only mandibular landmark to be viewed on maxillary posterior
periapical images
D. Radiographic appearance of restorative materials (Figure 6-31)

FIG 6-31 Common restorative materials. 1, Composite. 2, Post-and-core

restoration with a porcelain-fused-to-metal crown. 3, Porcelain-fused-to-metal
crown. 4, Occlusal composite or temporary restoration. 5, Amalgam. 6,
Porcelain-fused-to-metal crowns with endodontic material, silver points.

1. Amalgam—completely radiopaque, irregular borders

2. Gold—completely radiopaque, smooth borders
3. Stainless steel crown (temporary crown)—slightly radiopaque with a
“see-through” component
4. Porcelain crown—slightly radiopaque; thin radiopaque line
represents cement
5. Porcelain-fused-to-metal crown—metal component is completely
radiopaque; porcelain component is slightly radiopaque
6. Composite—radiolucent to radiopaque
7. Endodontic materials—guttapercha is slightly radiopaque; silver
points are radiopaque
8. Orthodontic appliances—radiopaque bands, brackets, and wires

471
 representing the materials
E. Radiographic appearance of dental caries7 (Figure 6-32)

FIG 6-32 Dental caries are evident on this bitewing image. (From Iannucci JM,
Howerton LJ: Dental radiography: principles and techniques, ed 5, St Louis, 2017, Elsevier.)

1. Interproximal caries—seen as a radiolucent area at or just below the

contact area
2. Occlusal caries—seen as a radiolucent area in the chewing surfaces
of posterior teeth
3. Buccal or lingual caries—seen as a circular radiolucency in the buccal
or lingual surface of a tooth
4. Root surface caries—seen as a radiolucent area that involves only the
roots of teeth; usually preceded by bone loss or gingival recession
5. Recurrent caries—a radiolucent area seen below or adjacent to an
existing restoration
6. Rampant caries—radiolucent areas seen in numerous teeth
F. Radiographic appearance of periodontal disease7 (Figure 6-33)

472
 FIG 6-33 Dental caries and bone loss. 1, Interproximal caries. 2, Interproximal
calculus deposits. 3, Heavy calculus deposits. 4, Severe bone loss.

1. Bone loss
a. Pattern—horizontal or vertical bone loss
b. Distribution—localized or generalized bone loss
c. Severity—slight, moderate, or severe bone loss
2. Classification of periodontal disease: ADA case types I, II, III, and
IV

Website Information and Resourc es

Source Website Address Description
American Academy of http://www.aaomr.org Promotes and advances the art and science of
Oral and Maxillofacial radiology in dentistry and provides a forum for
Radiology communication among its members and to the health
care community and the public
International http://www.icrp.org Provides recommendations and guidance on all
Commission on aspects of protection against ionizing radiation
Radiological Protection
(ICRP)
National Council on http://www.ncrponline.org Dissemination of information and recommendations
Radiation Protection and on protection against radiation
Measurements (NCRP)
International http://www.icru.org Develops and promulgates internationally accepted
Commission on recommendations on radiation-related quantities and
Radiological Units and measurement procedures and references data for the
Measurements (ICRU) safe and efficient application of ionizing radiation

473
References
1 International Commission on Radiation Units and Measurements,
www.icru.org.
2 National Council on Radiation Protection and Measurements.
Ionizing radiation exposure of the population of the united states.
Report No 160 Bethesda, Md: NCRP; 2009.
3 American Dental Association, US Food and Drug Administration:
The selection of patients for dental radiographic examinations,
www.ada.org.
4 Radiation Safety in Dentistry, www.carestreamdental.com.
5 Van der Stelt P.F. Better imaging: the advantages of digital
radiography. J Am Dent Assoc. 2008;139:7S–13S.
6 Thomson E.M., Johnson O.N. Essentials of dental radiography for
dental assistants and hygienists. ed 9 Upper Saddle River, NJ:
Pearson Education, Prentice Hall; 2012.
7 Iannucci J.M., Howerton L.J. Dental radiography: principles and
techniques. ed 4 St Louis: Elsevier Saunders; 2012.

Chapter 6 review questions

Answers and rationales to review questions are available on this text’s
accompanying Evolve site. See inside front cover for details.

Case A
An adult male patient presents to the dental office with a chief
complaint of heat/cold sensitivity in his teeth, along with discontent of
the appearance of the anterior crown. It has been 5 years since his last
dental visit. Tooth #30 was recently avulsed due to advanced periodontal
disease and trauma.

Use Case A and the panoramic radiograph in Figure 6-34 to answer

questions 1 to 5.

474
 FIG 6-34 Panoramic and occlusal view.

1. Which type of caries is visible on teeth #3 and #14?

a. Interproximal
b. Occlusal
c. Buccal/lingual
d. Root
2. Which type of caries is visible on tooth #29?
a. No caries are visible
b. Interproximal
c. Occlusal
d. Root
3. Which restorative material is seen on tooth #9?
a. Guttapercha and metal crown
b. Silver points and all-porcelain crown
c. Guttapercha and composite
d. Post-and-core restoration
4. The arrow is pointing to which radiopaque structure?
a. Internal oblique ridge
b. Mandibular canal
c. Condensing bone
d. Descending ramus
5. In addition to the panoramic image, which intraoral radiographs
would be most beneficial for the total care of this patient?

475
 a. Maxillary and mandibular occlusal radiographs
b. Four horizontal bitewing radiographs
c. Four vertical bitewing radiographs
d. A full-mouth series
Use Figure 6-35 to answer questions 6 and 7.

FIG 6-35

6. All the anatomic landmarks may be viewed on this radiograph

EXCEPT:
a. Incisive foramen
b. Median palatal suture
c. Maxillary torus
d. Inferior nasal conchae
7. The yellow arrow is pointing to a V-shaped radiopacity. What is this

476
radiographic finding?
a. Anterior nasal spine
b. Nasal septum
c. Nutrient canal
d. Root fracture
Use Figure 6-36 to answer questions 8 to 10.

FIG 6-36

8. Which tooth has been extracted and is not visible on this periapical
image?
a. #4
b. #5
c. #12
d. #13
9. Which tooth demonstrates interproximal caries?
a. Distal of maxillary premolar
b. Mesial of maxillary first molar
c. Distal of maxillary first molar
d. Mesial of maxillary second molar

477
10. Which restorative material is present on the maxillary first molar?
a. Amalgam
b. Amalgam with base material
c. Gold
d. Composite
Use Figure 6-37 to answer questions 11 to 13.

FIG 6-37

11. Along with bone loss and calculus deposits, what other radiographic
sign indicative of periodontal disease is present?
a. Furcation involvement
b. Cantilevered bridge
c. Root caries
d. Attachment loss
12. The cantilevered bridge is fabricated from what dental material?
a. Gold
b. Porcelain
c. Stainless steel
d. Porcelain-fused-to-metal
13. The arrow is pointing to which radiographic finding?
a. Zygomatic arch

478
 b. Zygoma
c. Maxillary tuberosity
d. Scratched emulsion
Use Figure 6-38 to answer questions 14 and 15.

FIG 6-38

14. The overlapped contact area between teeth #18 and #19 was the
result of:
a. Too much vertical angulation
b. Too little vertical angulation
c. Incorrect horizontal angulation
d. Improper receptor placement
15. The yellow arrow is pointing to which radiographic finding?
a. The identification dot
b. Submandibular fossa
c. Mental foramen

479
 d. Periapical pathology
16. Which is an appropriate condition to expose a periapical radiograph?
a. Pulpitis
b. Slight bone loss
c. Amalgam overhang
d. Interproximal caries
17. Which would be an appropriate reason to expose an occlusal
radiograph?
a. Mucocele
b. Salivary stones
c. Advanced bone loss
d. Temporomandibular joint (TMJ) disorder
18. Which is a suitable use of a panoramic radiograph?
a. Diagnosis of occlusal caries
b. Assessment of eruption patterns
c. Evaluation of periapical pathology
d. Measurement of periodontal bone loss
19. Which type of caries does NOT involve the enamel surface?
a. Root
b. Rampant
c. Recurrent
d. Interproximal
20. A male patient has been diagnosed with slight to moderate
periodontitis. He declines the prescription of a full-mouth series due to
concern with x-radiation. Which exposures would be appropriate to
replace the intraoral periapical series?
a. Maxillary and mandibular occlusal radiographs
b. Panoramic
c. Four vertical bitewings
d. Four horizontal bitewings
21. Which exposure factor controls the penetrating power of the x-ray
beam?
a. Time
b. Voltage

480
 c. Milliamperage
d. Kilovoltage peak
22. Which speed of film is currently recommended by the American
Dental Association (ADA) and the American Academy of Oral and
Maxillofacial Radiology (AAOMR)?
a. C
b. D
c. E
d. F
23. Which error will produce a lighter radiographic image?
a. Timer set too long
b. Film exposed to light
c. Fixer solution too weak
d. Developer solution too warm
24. Your film exits the automatic processor completely clear. What is the
most common reason for this appearance?
a. Expired film
b. Exposed to white light
c. Not exposed to radiation
d. Exposed backward in the mouth
25. The patient states that movement occurred during x-ray exposure.
Which error will result on the image?
a. Decreased distortion
b. Increased sharpness
c. Decreased sharpness
d. Increased magnification
26. Where should the thermometer be kept for manual processing
procedures?
a. Water bath
b. Fixer solution
c. Developer solution
d. Light-tight drawer inside the darkroom
27. Which agent is responsible for converting the exposed silver halide
crystals to black metallic silver?

481
 a. Acetic acid
b. Hydroquinone
c. Sodium thiosulfate
d. Ammonium thiosulfate
28. Which error produces a darker radiographic image?
a. Fixer solution too cold
b. Film left in the water rinse too long
c. Film exposed backward in the mouth
d. Film placed in fixer before developer solution
29. Which of the following is a quality control test used to monitor the
strength of the developer solution?
a. Coin test
b. Light-leak check
c. Step-wedge radiograph
d. Half-value layer (HVL)
30. Which anatomic landmark will appear on an image of the
mandibular anterior teeth?
a. Mental ridge
b. Mental foramen
c. Mylohyoid ridge
d. Mandibular canal
31. Which structure appears radiopaque on a dental radiograph?
a. Dentin
b. Air spaces
c. Dental pulp
d. Periodontal ligament space
32. Which periapical radiograph reveals the anatomic landmark referred
to as the “inverted Y”?
a. Maxillary canine
b. Maxillary incisor
c. Mandibular molar
d. Mandibular incisor
33. Which cell is most sensitive to radiation exposure?

482
 a. Muscle
b. Nerve
c. Oral mucosa
d. Bone marrow
34. A dental hygienist is working in a mobile dental unit and is asked to
expose radiographs. No wall is present in the small x-ray room. What is
the minimum distance in feet that the hygienist should stand from the
source of x-radiation?
a. 4
b. 6
c. 8
d. 10
35. Which statement is correct for the production of the most diagnostic
image?
a. The receptor is placed as close as possible to the tooth.
b. The shortest PID length is used.
c. The receptor is placed as far away from the tooth as possible.
d. The x-ray beam is positioned parallel to the long axis of the tooth.
36. Which of the following is MOST likely to cause a ghost image to
appear on a panoramic radiograph?
a. Cervical spine
b. Hearing aid
c. Dental implant
d. Tongue
37. Which item remains stationary during panoramic exposure?
a. Patient
b. Film
c. Tubehead
d. Cassette
38. All the following landmarks may be viewed on a maxillary incisor
periapical image EXCEPT:
a. Nasal cavity
b. Anterior nasal spine
c. Inferior conchae

483
 d. Lingual foramen
39. What is the first stage of radiation injury?
a. Period of injury
b. Cumulative effects
c. Latent period
d. Period of recovery
40. Which restorative materials have the same radiographic appearance?
a. Gold and amalgam
b. Porcelain and stainless steel crown
c. Guttapercha and silver points
d. Composite and porcelain-fused-to-metal crown
41. Why is a filter placed inside the dental x-ray tubehead?
a. To eliminate scatter radiation
b. To reduce high-energy electrons
c. To narrow the size and shape of the x-ray beam
d. To remove long-wavelength photons
42. All the following situations may cause film fogging EXCEPT:
a. Films stored for several years
b. Films stored near a heat source
c. Films left in an area exposed to x-radiation
d. Films left in the fixing solution too long
43. Which ingredient is the clearing agent found in the fixer solution?
a. Potassium alum
b. Ammonium thiosulfate
c. Acetic acid
d. Hydroquinone
44. In the bisecting-angle technique, the central ray of the x-ray beam is
directed perpendicular to what plane?
a. Long axis of the tooth
b. Long axis of the receptor
c. Angle formed by the intersection of the long axis of the tooth and
receptor
d. Angle formed by the intersection of the occlusal plane and the tooth

484
45. Which is the standard film size?
a. 0
b. 1
c. 2
d. 4
46. A person standing 2 feet from a source of radiation receives a dose of
2 rad. What would be the dose for a person standing 4 feet from the
source of radiation?
a. 0.5 rad
b. 1.0 rad
c. 2.0 rad
d. 4.0 rad
47. What is the primary factor in the determination of the contrast of an
image?
a. kVp
b. Exposure time
c. Source-to-receptor distance
d. mA
48. The size of the focal spot inside the x-ray tubehead determines which
radiographic characteristic?
a. Sharpness
b. Distortion
c. Density
d. Magnification
49. In what part of the x-ray tube does thermionic emission occur?
a. Positive anode
b. Positive cathode
c. Negative anode
d. Negative cathode
50. X-rays belong to which category of radiation?
a. Particulate
b. Alpha
c. Beta
d. Electromagnetic

485
C HAPT E R 7

486
General Pathology
JoAnn R. Gurenlian

Concepts of general pathology relate to multiple facets of dental hygiene

care. Inflammatory diseases significantly affect the oral cavity, and
research continues to focus on the linkages among inflammatory
processes, systemic diseases, and oral diseases. Advances in genomics
contribute to our understanding of the genetic basis of oral health
conditions and their treatment. Individuals vary in their genetic makeup
and thus their response to microbial challenges, injury, risk factors, and
treatments. Dental hygienists use genomic information to assess clients
for periodontal and other disease risks and will use genetics in planning
effective care and evaluating therapeutic outcomes in the near future.
This chapter reviews major concepts related to inflammation, wound
healing, and repair; genetics; and the differential diagnostic process that
enables dental hygienists to integrate the biologic basis of health and
disease into client care and acquire skills in diagnostic decision making.

487
Inflammation1–3
A. A host response to cellular injury that consists of vascular responses,
migration and activation of leukocytes, and systemic reactions
B. Cellular injury may occur because of trauma, genetic defects, physical
and chemical agents, tissue necrosis, foreign bodies, immune reactions,
and infections
C. A protective response designed to rid the body of the initial cause of
cell injury and the consequences of that injury, paving the way for a
return to normal structure and function
D. Inflammatory response consists of a vascular reaction and a cellular
reaction
1. Reactions are mediated by chemical factors derived from plasma
proteins or cells
2. Reactions are produced in response to or activated by the
inflammatory stimulus
E. Cardinal signs of inflammation
1. Rubor (redness)—caused by increased vascularity
2. Tumor (swelling)—caused by exudation of fluid; synonymous with
edema or increased fluid in the interstitial space
3. Calor (heat)—caused by a combination of increased blood flow and
the release of inflammatory mediators
4. Dolor (pain)—caused by the stretching of pain receptors and nerves
by inflammatory exudates and by the release of chemical mediators
5. Functio laesa (loss of function)—caused by a combination of the
previous signs
F. Types of inflammation
1. Acute
a. Characterized by rapid onset and short duration
b. Manifests with exudation of fluid and plasma proteins and
emigration of leukocytes, mainly neutrophils
2. Chronic
a. Sustained inflammatory reaction characterized by longer
duration
b. Histologic manifestation identified by the presence of
lymphocytes and macrophages, blood vessels, fibrosis, and
tissue necrosis
G. Cells involved in inflammation (Figure 7-1)

488
 FIG 7-1 Components of acute and chronic inflammatory responses: circulating
cells and proteins, cells of blood vessels, and cells and proteins of the
extracellular matrix. (From Kumar V, Abbas AK, Fausto N, Aster JC: Rob b ins and Cotran
pathologic b asis of disease, ed 8, Philadelphia, 2010, Saunders.)

1. Neutrophil or polymorphonuclear leukocyte (PMN)

a. First cell to emigrate to the site of injury
b. Primary cell involved in acute inflammation
c. Capable of phagocytosis
2. Monocyte or macrophage
a. Second white blood cell (WBC) to emigrate to injured tissue,
where it becomes a macrophage
b. Capable of phagocytosis; helper during the immune response
c. Produces potent vasoconstrictive mediators (prostaglandins,
leukotrienes, platelet-activating factor, and inflammatory
cytokines), which maintain chronic inflammation
3. Lymphocytes and plasma cells—involved in both chronic
inflammation and immune response
4. Eosinophils—involved in immune reactions and parasitic infections
5. Mast cells
a. Involved in both acute and chronic inflammatory reactions
(releasing chemical mediators) and in immune responses
b. Important in regulating vascular permeability and bronchial
smooth muscle tone, especially in allergic hypersensitivity
reactions

Acute Inflammation
A. Vascular changes (Figure 7-2)

489
 FIG 7-2 Major local manifestations of acute inflammation, compared with
normal. 1, Vascular dilation and increased blood flow (causing erythema and
warmth). 2, Extravasation and deposition of plasma fluid and proteins (edema).
3, Leukocyte emigration and accumulation at the site of injury. (From Kumar V,
Abbas AK, Fausto N, Aster JC: Rob b ins and Cotran pathologic b asis of disease, ed 8,
Philadelphia, 2010, Saunders.)

1. Transient vasoconstriction of arterioles caused by neurogenic reflex

lasting several seconds to minutes
2. Vasodilation
a. First involves arterioles, then results in the opening of new
capillary beds
b. Results in increased blood flow, which causes heat and redness,
known as hyperemia
c. Induced by chemical mediators such as histamine and nitric
oxide on vascular smooth muscle
3. Increased permeability of microvasculature
a. An exudate of protein-rich fluid escapes into extravascular

490
 tissue, resulting in edema
b. Proposed mechanisms to explain the leakage of endothelium in
inflammation to allow this response:
(1) Formation of endothelial gaps in venules elicited by
chemical mediators
(a) Usually reversible
(b) Lasts 15 to 30 minutes
(2) Direct endothelial injury resulting in endothelial cell
necrosis and detachment
(a) Occurs in severe burns or lytic bacterial infections
(b) Sustained for several hours
(c) Venules, capillaries, and arterioles affected
(3) Delayed prolonged leakage
(a) Begins after a delay of 2 to 12 hours
(b) Lasts for several hours or days
(c) Involves venules and capillaries
(d) Caused by thermal injury, radiation, and certain
bacterial toxins
(4) Leukocyte-mediated endothelial injury
(5) Increased transcytosis across the endothelial cytoplasm
(6) Leakage from new blood vessels until new endothelial
cells mature and form intercellular junctions
4. Concentration of red blood cells (RBCs) in small vessels and
increased viscosity of blood, known as stasis
5. Leukocytes, mainly neutrophils, accumulate along the vascular
endothelium (margination); the endothelium becomes lined by
leukocytes (“pavementing”); leukocytes adhere to the endothelium
and, soon after, migrate through the vascular wall into interstitial
tissue (diapedesis or emigration)
a. Neutrophils predominate in the inflammatory infiltrate during
the first 6 to 24 hours
b. Neutrophils are replaced by monocytes in 24 to 48 hours
B. Chemotaxis
1. Chemical attraction of leukocytes to emigrate in tissues
2. Exogenous agents are bacterial products
3. Endogenous chemoattractants
a. Components of the complement system, particularly C5a
b. Products of the lipoxygenase pathway, such as leukotriene B4
(LTB4)
c. Cytokines, such as interleukin-8 (IL-8)

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C. Phagocytosis
1. Recognition and attachment
a. Mannose receptors and scavenger receptors bind and ingest
microbes
b. Phagocytosis is greatly enhanced by opsonins, specific proteins
such as immunoglobulin G (IgG) antibodies, fragments of the
complement protein C3, and plasma lectins, which are
recognized by specific receptors on leukocytes
2. Engulfment
a. Extensions of the cytoplasm flow around the particle to be
engulfed, resulting in the complete enclosure of the particle
within a phagosome created by cell’s plasma membrane
b. Neutrophils and monocytes become degranulated during this
process
3. Killing and degradation
a. Eliminate infectious agents and necrotic cells
b. After the killing, acid hydrolases degrade the microbes within
phagolysosomes
c. pH drops to between 4 and 5
4. Release of leukocyte products
a. Include lysosomal enzymes, reactive oxygen intermediates, and
products of arachidonic acids such as prostaglandins and
leukotrienes
b. These products may cause endothelial injury and tissue damage
c. If unchecked, this leukocyte infiltrate becomes harmful and is
associated with many chronic systemic diseases
d. Also produce growth factors that aid in repair after tissue injury
5. Apoptosis—defined as programmed cell death, used by the body to
eliminate old cells
a. After phagocytosis, neutrophils undergo apoptotic cell death
and are then ingested by macrophages
D. Chemical mediators (Table 7-1)

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Table 7-1
Actions of the Principal Mediators of Inflammation

From Kumar V, Abbas AK, Fausto N Aster JC: Rob b ins and Cotran pathologic b asis of disease, ed 8, Philadelphia, 2010,
Saunders.

1. General principles
a. Originate from plasma proteins or from cells
(1) Plasma-derived mediators such as complement proteins
and kinin are in precursor form and must be activated
(2) Cell-derived mediators such as histamine, prostaglandins,
and cytokines come from mast cells, platelets, neutrophils,
and monocytes/macrophages
b. Production of active mediators is triggered by microbial
products or by host proteins
c. Mediators perform their activities by binding to specific
receptors on target cells, performing direct enzymatic activity, or
mediating oxidative damage
d. Once activated, most mediators are short-lived, but cause
harmful effects
2. Vasoactive amines
a. Histamine
(1) Found in mast cells, blood basophils, and platelets

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 (2) Causes dilation of the arterioles and increases the
permeability of venules; constricts large arteries
b. Serotonin
(1) Present in platelets and certain neuroendocrine cells
(2) Causes increased permeability during immunologic
reactions
3. Plasma proteins
a. Complement system
(1) Consists of 20 component proteins found in greatest
concentration in plasma; primary function is defense
against microbes
(2) Causes increased vascular permeability, chemotaxis, and
opsonization (the process by which certain cells are made
more susceptible to phagocytosis)
(3) C3 and C5 are the most important inflammatory mediators
of the complement components
(a) Vascular phenomenon created by C3a, C5a, and to a
lesser extent, C4a; stimulate histamine release from
mast cells; called anaphylatoxins because they have
similar effects in the reaction of anaphylaxis
(b) Leukocyte adhesion, chemotaxis, and activation occur
through C5a as a chemotactic agent for neutrophils,
monocytes, eosinophils, and basophils
(c) Phagocytosis enhanced by C3b, which acts as opsonin
to facilitate foreign bodies being more efficiently
engulfed by phagocytosis
(d) Acquired or congenital deficiencies of specific
complement components or regulatory proteins result
in increased susceptibility to infectious agents and a
propensity for autoimmune diseases associated with
circulating immune complexes (e.g., systemic lupus
erythematosus, pyogenic infections, hereditary
angioedema)
b. Kinin system
(1) Generates vasoactive peptides from plasma proteins called
kininogens by the action of proteases known as kallikreins
(2) Bradykinin increases vascular permeability; causes the
contraction of smooth muscle, dilation of blood vessels,
plasma extravasation, cell migration, inflammatory cell
activation and inflammatory-mediated pain responses
(3) Is triggered by the activation of Hageman factor (factor XII

494
 of the intrinsic clotting pathway)
(4) Is short-lived; quickly inactivated by the enzyme kininase
c. Clotting system
(1) Induces the formation of thrombin, fibrinopeptides, and
factor XII, which have inflammatory properties
(2) Activated by substances released during tissue
destruction, such as collagen, proteinases, kallikrein, and
bacterial endotoxins
(3) Prevents the spread of infection and inflammation;
localizes microorganisms at the site of phagocytosis; helps
clot formation to stop bleeding and for repair, chemotaxis
of neutrophils, and increased permeability of vessels
4. Other mediators
a. Arachidonic acid
(1) A lipid mediator that is a short-range hormone; is formed
rapidly and acts locally
(2) Produces prostaglandins, leukotrienes, and lipoxins
(a) Prostaglandins (e.g., PGE2, PGD2, PGF2a , PGI 2) and
thromboxane A2 (TXA2), are most important in
inflammation, causing increased permeability, the
chemotactic effects of other mediators, and
vasodilation resulting in edema as well as pain and
fever in inflammation
(b) Pathway initiating these prostaglandins occurs by two
different enzymes, COX-1 and COX-2
[1] Cyclooxygenase-1 (COX-1) produces
prostaglandins that are involved in inflammation
and also maintains homeostasis, protecting the
gastrointestinal mucosal lining, regulating
water/electrolyte balance, stimulating platelet
aggregation, and maintaining resistance to
thrombosis on vascular endothelial cell surfaces
[2] Cyclooxygenase-2 (COX-2) stimulates the
production of prostaglandins involved in the
inflammatory reactions previously noted and may
play a role in normal homeostasis
(c) Leukotrienes cause intense vasoconstriction,
bronchospasm, and increased vascular permeability;
important in the pathogenesis of bronchial asthma
(d) Lipoxins are synthesized by platelets and neutrophils;

495
 inhibit leukocyte recruitment, neutrophil chemotaxis,
and adhesion to the endothelium; may play a role in
resolving inflammation
(e) Resolvins inhibit leukocyte recruitment and activation
by inhibiting the production of cytokines; aspirin may
work by stimulating the production of resolvins
(f) Platelet-activating factor (PAF) causes platelet
stimulation, vasoconstriction, bronchoconstriction,
vasodilation, and increased venular permeability; far
more potent than histamine; increased leukocyte
adhesion to endothelium; chemotaxis, degranulation,
and oxidative burst; also boosts synthesis of other
mediators, such as serotonin, causing changes in
vascular permeability
(g) Tumor necrosis factor (TNF) and interleukin-1 (IL-1)
[1] Two major cytokines that mediate inflammation
and are produced primarily by macrophages
[2] Responsible for endothelial activation, which
induces the synthesis of endothelial adhesion
molecules and chemical mediators, producing
enzymes associated with matrix remodeling and
increasing the surface thrombogenicity of
endothelium
[3] Induces the systemic acute-phase responses of
infection and injury, including fever, loss of
appetite, release of neutrophils, corticotropin, and
corticosteroids
[4] TNF—responsible for the hemodynamic effects of
septic shock; regulates body mass and contributes
to cachexia (wasting away), which is part of some
infections and diseases
(h) Chemokines—small proteins that act as
chemoattractants for leukocytes and control the normal
migration of cells through various tissues
(i) Nitric oxide (NO)—released from endothelial cells;
causes vasodilation by relaxing vascular smooth
muscle; microbicidal; a mediator of host defense
against infection
(j) Lysosomal components of leukocytes
[1] Neutrophils and monocytes, contain lysosomal
granules; granules contain a variety of enzymes

496
 used for phagocytosis (e.g., lysozyme, collagenase,
alkaline phosphatase, elastase)
[2] These enzymes are destructive and, if unchecked,
can potentiate further inflammation and tissue
damage
(k) Oxygen-derived free radicals may be released from
leukocytes following a phagocytic event and are potent
mediators
[1] Can be damaging to the host, causing endothelial
cell damage and increased vascular permeability,
inactivation of antiproteases, and injury to other
cell types, such as parenchymal cells and RBCs
b. Neuropeptides
(1) Include substance P and neurokinin A
(2) Play a role in the initiation and propagation of
inflammatory response
E. Outcomes of inflammation
1. Complete resolution
2. Healing by connective tissue replacement
3. Abscess
4. Lymphadenitis
5. Progression of tissue response to chronic inflammation

Chronic Inflammation
A. Causes
1. Persistent infections
2. Prolonged exposure to potentially toxic agents
3. Autoimmunity
B. Characteristics
1. Infiltration with macrophages, lymphocytes, and plasma cells
2. Tissue destruction, a hallmark of chronic inflammation
3. Attempts at healing by connective tissue replacement and fibrosis
C. Cells involved
1. Macrophages, lymphocytes, plasma cells, eosinophils, mast cells,
and fibroblasts
2. Produce granulomatous inflammation, characterized by focal
accumulation of activated macrophages that develops an epithelioid
appearance, and fibrosis
3. Products of these cells eliminate injurious agents and help initiate
repair, but are also responsible for much of the tissue injury in

497
 chronic inflammation
D. Role of lymphatics
1. Secondary line of defense that monitors the extravascular fluids
2. Help drain edema from the extravascular space
E. Systemic effects of inflammation—acute-phase response or the
systemic inflammatory response syndrome (SIRS)
1. Fever—produced in response to pyrogens that act by stimulating
prostaglandin synthesis
2. Acute-phase proteins, including C-reactive protein (CRP),
fibrinogen, and serum amyloid A protein (SAA) increase during the
inflammatory process
a. Bind to microbial cell walls; act as opsonin and fix complement
b. Prolonged activation causes secondary amyloidosis in chronic
inflammation
c. Elevated CRP used as a marker for increased risk of myocardial
infarction in persons with coronary artery disease
3. Leukocytosis
a. Common feature in bacterial infections resulting in elevated to
extremely high levels of different types of leukocytes, depending
on the type of infection
b. Normal count of WBCs is 4000 to 10,000/mm3 in blood
c. In an inflammatory reaction, particularly with an infection, WBC
count can increase to 15,000 or 20,000 and sometimes to
extremely high levels exceeding 40,000/mm3
4. Sepsis
a. In severe bacterial infections, large quantities of cytokines,
particularly TNF and IL-1, cause thrombosis and coagulation
b. Eventually, hypoglycemia and cardiovascular failure occur,
resulting in septic shock
c. Multiple organs can be affected by inflammation and
intravascular thrombosis, resulting in organ failure
F. Systemic disease affected by chronic inflammation
1. Cardiovascular disease
2. Cancer
3. Diabetes mellitus
4. Asthma
5. Chronic obstructive pulmonary disease (COPD)
6. Alzheimer ’s disease
7. Periodontal diseases

498
Regeneration and wound healing1–3
A. Definitions
1. Regeneration—growth of cells and tissues to replace lost structures;
favored when the matrix composition and architecture are unaltered
2. Healing—a tissue response to a wound, inflammatory process, or
cell necrosis in organs that cannot regenerate; involves either
regeneration or scar formation (Figure 7-3)

FIG 7-3 Repair responses after injury and inflammation. Repair after
acute injury has several outcomes, including normal tissue restitution
and healing with scar formation. Healing in chronic injury involves scar
formation and fibrosis. (From Kumar V, Abbas AK, Fausto N, Aster JC: Rob b ins
and Cotran pathologic b asis of disease, ed 8, Philadelphia, 2010, Saunders.)

B. General concepts
1. Involves a complex process that includes a number of steps
a. A thrombus (clot) is formed at the site of injury; scab results
from the drying of the exposed surfaces of the clot; forms a
barrier to invading microorganisms.
b. An inflammatory response caused by the initial injury
c. Proliferation of parenchymal and connective tissue cells
d. Formation of new blood vessels (angiogenesis) and granulation
tissue (transient, specialized tissue of repair)
e. Synthesis of extracellular matrix (ECM) proteins and collagen
deposition
f. Tissue remodeling
g. Wound contraction

499
 h. Acquisition of wound strength
2. Repair process—a combination of regeneration and scar formation
influenced by local and systemic factors that may inhibit or prolong
the wound-healing process
a. Local factors
(1) Size, location, and type of wound
(2) Persistent infection
(3) Early movement
(4) Foreign material
(5) Ionizing radiation
b. Systemic factors
(1) Blood supply
(2) Metabolic factors (e.g., diabetes)
(3) Corticosteroids
(4) Cytotoxic drugs
(5) Nutritional deficiencies
3. Generally, repair begins early in inflammation—formation of
granulation tissue, which is a hallmark of healing
a. Pink, soft, granular appearance on the surface of wounds
b. Formation of new small blood vessels and proliferation of
fibroblasts
c. New vessels tend to leak; edematous
d. Amount of granulation tissue that forms depends on the size of
the wound and the intensity of the inflammation
C. Angiogenesis (new blood vessels formed through preexisting vessels)
1. Occurs from the branching and extension of adjacent blood vessels
and the recruitment of endothelial progenitor cells (EPCs) from
bone marrow
2. Angiogenesis from adjacent blood vessels occurs through the
vasodilation and increased permeability of existing vessels,
degradation of ECM, migration of endothelial cells, maturation of
endothelial cells and remodeling into capillary tubes, and
recruitment of periendothelial cells to support endothelial tubes and
to form the mature vessel
3. Growth factors such as vascular endothelial growth factor (VEGF)
support adult tissues undergoing angiogenesis
4. Directed migration of endothelial cells—controlled by ECM proteins,
including integrins, matricellular proteins, and proteinases
D. Scar formation—three processes occur: emigration and proliferation
of fibroblasts in the site of injury, deposition of ECM, and tissue
remodeling

500
 1. Fibroblast emigration and proliferation
a. Migration of fibroblasts to the site of injury and their
proliferation triggered by growth factors that come from
platelets, inflammatory cells, and activated endothelium
2. ECM deposition
a. Fibroblasts deposit increased amounts of ECM
b. Fibrillar collagens form a major portion of connective tissue in
repair sites; help develop the strength of the healing wound
c. Fibroblasts begin forming 3 to 5 days after injury and continue
for several weeks
d. Growth factors that stimulate fibroblasts also stimulate ECM
synthesis
e. Granulation tissue is converted into a scar composed of
fibroblasts, dense collagen, fragments of elastic tissue, and
other ECM components; richly vascularized granulation tissue
transforms into a pale, avascular scar
3. Tissue remodeling
a. Degradation of ECM components causes tissue remodeling;
achieved through matrix metalloproteinases (MMPs)
b. MMPs are produced by fibroblasts, macrophages, neutrophils,
synovial cells, and some epithelial cells
(1) MMP secretion is induced by certain growth factors,
physical stress, and phagocytosis; inhibited by steroids and
other growth factors
(2) MMPs degrade matrix proteins at the site of injury,
allowing reorganization of the tissue capable of influencing
cell growth and apoptosis
E. Cutaneous wound healing (Figure 7-4)

501
 FIG 7-4 Steps in wound healing by primary intention (left) and secondary
intention (right). Note large amounts of granulation tissue and wound
contraction in healing by secondary intention. (From Kumar V, Abbas AK, Aster JC:
Rob b ins and Cotran pathologic b asis of disease, ed 9, Philadelphia, 2015, Elsevier.)

1. Healing by primary intention—primary union (e.g., surgical incision

and placement of sutures)
a. Narrow incisional space fills with clotted blood, a clot forms,
and a scab covers the surface of the wound; the clot stops the
bleeding and acts as a scaffold for migrating cells
b. Within 24 hours, neutrophils appear at the margins of the
incision and move toward the clot
c. In 24 to 48 hours, epithelial cells move from the wound edges
and fuse in the midline beneath the scab to close the wound; a
basement membrane is formed
d. Within 3 days, neutrophils are replaced by macrophages, and
granulation tissue forms
(1) Collagen fibers begin to form in the margins of the
incision
(2) Epithelial cells proliferate and thicken the epidermal layer
e. By day 5, the incisional space is filled with granulation tissue
(1) Collagen fibers become more abundant and start to bridge

502
 the incision
(2) A mature epidermal architecture with surface
keratinization appears
f. During week 2, proliferation of collagen and fibroblasts
continues
(1) The inflammatory process has largely dissipated
(2) Blanching begins as the incisional scar forms
g. By week 4, the scar is composed of connective tissue and an
intact epidermis; the tensile strength of the wound increases
2. Healing by secondary intention—secondary union (e.g., wounds with
separated edges)
a. Abundant granulation tissue grows in from the margin to
complete the repair
b. The inflammatory reaction is more intense because of the
presence of a larger clot and more necrotic debris and exudates
that must be removed from the defect
c. Wound contraction occurs in larger surface wounds because of
myofibroblasts that have the characteristics of smooth muscle
cells
d. Substantial scar formation and thinning of the epidermis occurs
3. Healing by tertiary intention (delayed primary closure)
a. Reserved for highly contaminated wounds
b. Contaminated wound is initially treated with repeated
debridement and either topical or systemic antibiotics to control
infection
c. Once wound is ready for closure, surgery is performed
(suturing, skin graft replacement, flap)
F. Wound strength
1. Tissues recover approximately 70% to 80% of tensile strength over a
3-month period compared with intact skin
2. Recovery of wound strength comes from an excess of collagen
synthesis over collagen degradation during the first 2 months of
healing and from structural modifications of collagen fibers after
collagen synthesis is complete
G. Complications of cutaneous wound healing
1. Deficient scar formation leading to wound dehiscence or ulceration
—often seen after abdominal surgery and in lower extremity wounds
in patients with peripheral vascular disease, diabetes, or severe
atherosclerosis
2. Excessive scar formation
a. Raised scar (hypertrophic scar, keloid)

503
 b. Scar grows beyond the boundaries of the original wound and
does not regress (keloid)
3. Contracture
a. Exaggeration of the normal contraction process of wound
healing, resulting in the deformity of the wound and
surrounding tissues
b. Common after serious burn injuries; can affect joint mobility
H. Fibrosis
1. Processes that occur in cutaneous scar formation because of
extensive deposition of collagen; similar to the fibrosis associated
with chronic inflammatory diseases (e.g., rheumatoid arthritis,
cirrhosis); a major component of diseases that involve ongoing
injury
2. Characterized by the persistence of initial stimuli for fibrosis or the
development of immune and autoimmune reactions that sustain the
synthesis and secretion of growth factors and other biologically
active molecules
3. May cause permanent dysfunction

504
Regenerative medicine4
A. Stem cells
1. Characterized by self-renewal abilities and the capacity to generate
differentiated cells; stem cells from bone marrow and basal layer of
epidermis provide a renewal source of epidermal and dermal cells
that can form new blood vessels and epithelium and regenerate skin
structures
a. Autogenous stem cells—derived from the individual being
treated
b. Allogenous stem cells—derived from other individuals
c. May be totipotent, multipotent, or unipotent
d. Process of differentiation is known as plasticity or
transdifferentiation
2. Types (Table 7-2)

505
Table 7-2
Types of Stem Cells

Type of Stem Cell May Differentiate to:

Embryonic Any type of cell
Amniotic fluid derived Cartilage cells
Fat cells
Bone cells
Muscle cells
Endothelial cells
Neuron-like cells
Liver cells
Umbilical cord Liver cells
Skeletal muscle cells
Neural tissue
Immune cells
Bone marrow–derived mesenchymal Bone cells
Cartilage cells
Muscle cells
Fat cells
Neuron-like cells
Pancreatic islet beta-cells
Tooth derived Neural cell lineages
Bone cells
Cartilage cells
Muscle cells
Fat cells
Pancreatic islet beta-cells
Adipose derived Fat cells

Cartilage cells
Muscle cells
Neuronal cells
Bone cells
Induced pluripotent stem cells Any type of cell, potentially
From Mao JJ: Stem cells and the future of dental care, NY State Dent J 74(2):20-24, 2008.

a. Embryonic stem cells

(1) Pluripotent and can generate all tissue of the body
(2) Isolated from inner cell mass of blastocytes
(3) May be used in the future for the treatment of organs
affected by diabetes, neurologic defects, myocardial
infarction, and liver damage
b. Adult stem cells or somatic stem cells
(1) More restricted capacity to generate different cell types
(2) Potential for adult stem cells to be reprogrammed into
pluripotent cells similar to embryonic stem cells

506
 (3) Found in skin, lining of intestine, cornea, brain, and
hematopoietic tissue (e.g., bone marrow, umbilical cord)
3. Types of adult stem cells
a. Induced pluripotent stem cells (iPs)—adult cells that behave
similar to embryonic cells
b. Amniotic fluid–derived stem cells (AFSCs)
(1) Isolated from the aspirates of amniocentesis during
genetic screening
(2) Capacity to differentiate into multiple lineages, such as
chondrocytes, adipocytes, osteoblasts, myocytes,
endothelial cells, neuron-like cells, and live cells
c. Umbilical cord blood stem cells (UCBSCs)
(1) Derived from the blood of the umbilical cord
(2) Differentiate into cells that resemble liver cells, skeletal
muscle, neural tissue, pancreatic cells, immune cells, and
mesenchymal stem cells
d. Bone marrow–derived stem cells (BMSCs)
(1) Consists of both hematopoietic stem cells and stromal
cells (mesenchymal stem cells) that generate bone,
cartilage, other connective tissues, and fat
(2) Most common commercially available stem cells
e. Adipose-derived stem cells (ASCs)
(1) Derived from lipectomy or liposuction aspirates
(2) Differentiate into adipocytes, chondrocytes, myocytes, and
neuronal and osteoblastic lineages; may provide
hematopoietic support
f. Dental stem cells
(1) Develop from material created during the development of
the nervous system and can differentiate into neural cell
lines
(2) Sources include primary teeth, permanent third molars, or
extracted healthy permanent teeth and periodontal
ligament
(3) Have been transdifferentiated in the laboratory to form
bone, nervous tissue, and pancreatic islet beta-cells that
produce insulin
(4) Current animal studies are exploring applications to
regenerate bone, cartilage, skin, nerve and brain tissues,
adipose, and heart and muscle tissues
(5) Dental application may include tooth, root, jaw, and
salivary gland regeneration and cranial bone repair

507
Genetics2,5
A. General concepts
1. Almost all health-related conditions (except trauma) have a genetic
component; common diseases such as cardiovascular disease,
dyslipidemia, diabetes, and cancer, as well as dental caries,
periodontitis, oral cancer, cleft lip, and craniofacial abnormalities,
are associated with genetic factors
2. Draft sequencing of the human genome has been completed;
provides information about biologic inheritance and health
consequences
3. Genome—all the deoxyribonucleic acid (DNA) of a given organism
4. Genomics—the study of all the genes in the genome, their extensive
DNA sequences, and their interactions
5. Gene—a segment of DNA that contains instructions for making a
specific protein or proteins required by the human body; found in
succession along the length of chromosomes; humans have 20,000 to
25,000 genes
6. About 99.5% of DNA sequences are shared among humans; the
diversity of humans is encoded in approximately 0.5% of human
DNA; this 0.5% represents 15 million base pairs
7. Chromosomes—thread-like structures in the nucleus of a cell; made
of DNA and structural proteins; human cells other than egg and
sperm have 46 chromosomes (23 pairs); egg and sperm cells have 23
chromosomes
8. Molecular biology has resulted in the development of recombinant
DNA technology that has allowed the isolation and characterization
of genes through cloning, production of human biologically active
agents, study of gene therapy, and development of molecular probes
to aid in disease diagnosis
B. Mutations
1. Mutations represent permanent changes in the DNA code; they can
be beneficial, neutral, or harmful
a. Four letters of the DNA code: A = adenine, T = thymine,
C = cytosine, and G = guanine; one letter can be changed,
deleted, or added; entire pieces of code can be spelled backward,
cut and pasted, or cut short, which can change the form and
function or the end protein product in the body
b. The impact of a mutation depends on the environment in which
it is expressed
c. Classification of mutations

508
 (1) Genome mutations—involve the loss or gain of whole
chromosomes, resulting in monosomy or trisomy
(2) Chromosome mutations—rearrangement of genetic
material that gives rise to structural changes in the
chromosome; most are incompatible with survival
(3) Submicroscopic gene mutations—represent the vast
majority of mutations associated with hereditary diseases;
may result in a partial or complete deletion of a gene or
may affect a single base
C. Single-gene disorders
1. Autosomal dominant inheritance
a. An affected person usually has an affected parent
b. An affected person has a 50% chance of passing the trait to an
offspring
c. Both genders are equally likely to be affected, and both can
transmit the condition
d. Dominant traits are usually seen in multiple, successive
generations
2. Additional characteristics of autosomal dominant disorders
a. Some affected persons do not have affected parents; the
disorder is caused by new mutations involving either the egg or
the sperm and seems to occur in the germ cells of older fathers
b. Some inherit the mutant gene but are phenotypically normal
(called reduced or incomplete penetrance)
c. If the trait is seen in all individuals but is expressed differently
among them, the phenomenon is called variable expressivity;
combinations of these traits can be less or more severe among
individuals even within the same family
d. In many conditions, onset is delayed, and symptoms do not
appear until adulthood
e. Biochemical mechanism is either loss-of-function mutations or
gain-of-function mutations; the effects of these mutations
depend on the nature of the enzyme protein affected
f. Examples of autosomal dominant disorders
(1) Huntington’s disease
(2) Neurofibromatosis
(3) Polycystic kidney disease
(4) Von Willebrand disease
(5) Marfan syndrome
(6) Ehlers-Danlos syndrome
(7) Osteogenesis imperfecta

509
 (8) Familial hypercholesterolemia
3. Autosomal recessive inheritance
a. Both genders equally likely to be affected
b. Disease often found in siblings; affected individuals often have
unaffected parents
c. Offspring of the affected person are carriers of the gene
mutation
d. If a child is born to two carrier parents and is not affected, a
two-thirds chance of the child being a carrier is present
e. Carriers are usually not clinically affected
f. Two carrier parents have a 25% chance with each conception to
have an affected child
g. Onset is frequently early in life
h. In many cases, enzyme proteins are affected by a loss of
function
i. Examples of autosomal recessive disorders
(1) Cystic fibrosis
(2) Phenylketonuria
(3) Sickle cell anemia
(4) Thalassemias
(5) Congenital adrenal hyperplasia
(6) Neurogenic muscular atrophies
(7) Spinal muscular atrophy
4. X-linked recessive inheritance
a. Primarily affects males
b. Sons of carrier females have a 50% chance of receiving the gene
and expressing that trait or condition
c. Carrier females may show no disease trait or mild symptoms
only
d. No male-to-male transmission
e. Affected males transmit the genes to all daughters but not to
their sons; all daughters are carriers
f. Uncles and cousins may also be affected
g. Examples of X-linked recessive disorders
(1) Duchenne muscular dystrophy
(2) Hemophilia A and B
(3) Chronic granulomatous disease
(4) Glucose-6-phosphate dehydrogenase (G6PD) deficiency
(5) Agammaglobulinemia
(6) Diabetes insipidus
(7) Fragile X syndrome

510
5. Biochemical and molecular basis of single-gene disorders
a. The genetic defect may lead to the formation of an abnormal
protein as reduction in the output of gene product
b. The pattern of inheritance is related to the type of protein
affected by the mutation
c. The mechanisms are classified into four categories:
(1) Enzyme defects and their consequences
(2) Defects in membrane receptors and transport systems
(3) Alterations in structure, function, or quality of nonenzyme
proteins
(4) Mutations resulting in unusual reactions to drugs—
pharmacogenetics
6. Disorders with multifactorial inheritance
a. Result from the combined actions of environmental influences
and two or more mutant genes having additive effects
b. The greater the number of inherited deleterious genes, the
more severe the expression of the disease
c. Risk is greater in siblings of persons having severe expressions
of the disorder
d. Frequency of concordance for identical twins is 20% to 40%
e. Examples of disorders with multifactorial inheritance
(1) Cleft lip, cleft palate, or both
(2) Congenital heart disease
(3) Coronary heart disease
(4) Hypertension
(5) Gout
(6) Diabetes mellitus
(7) Pyloric stenosis
7. Diagnosis of genetic diseases—requires examination of genetic
material through cytogenetic analysis or molecular analysis
a. Cytogenetic analysis involves karyotyping, an organized graphic
representation of the chromosomes in a single cell
(1) Normal human karyotypes show 23 pairs of chromosomes,
numbered from larger to smaller
(2) The twenty-third pair comprises the sex chromosomes
(XX = female, XY = male)
(3) Karyotypes are described using a shorthand notation, with
the total number of chromosomes listed first, followed by
the sex chromosome complement, and then a description of
the abnormalities in ascending numerical order
b. Prenatal chromosome analysis should be offered to individuals

511
 at risk; can be performed on cells obtained by amniocentesis, on
chorionic villus biopsy, or on umbilical cord blood
c. Postnatal chromosome analysis can be performed on peripheral
blood lymphocytes in cases of multiple congenital anomalies,
unexplained mental retardation or developmental delay,
suspected genetic disorders such as Turner syndrome or fragile
X syndrome, infertility, or multiple spontaneous abortions
d. Recombinant DNA technology is also used for the diagnosis of
inherited diseases because it is highly sensitive; tests are not
dependent on a gene product produced only in certain
specialized cells
(1) Testing performed through either direct gene diagnosis
using polymerase chain reaction (PCR) analysis or indirect
DNA diagnosis through linkage analysis, which involves
studying several relevant family members
(2) 0.1 µL of blood or cells scraped from the buccal mucosa is
sufficient for PCR analysis
(3) Salivary DNA-PCR used to evaluate periodontal status
(a) MyPerioPathSM identifies the type and quantity of 13
periodontopathic bacteria
(b) MyPerioIDSM PST determines if the patient is
genetically predisposed to periodontal disease by
evaluating IL-1 polymorphism
(c) Perio Predict Genetic Risk Test identifies genetic
predisposition to periodontal disease
(www.PerioPredict.com)
e. Identifying molecular genetic signatures for acquired diseases
(1) Diagnosis and management of cancer
(a) Detection of tumor-specific acquired mutations and
cytogenic alterations that are hallmarks of specific
tumors
(b) Determination of clonality as an indicator of
neoplastic condition
(c) Identification of specific gene alterations that can
direct therapeutic choices
(d) Determination of treatment efficacy
(e) Determination of Gleeve-resistant forms of chronic
myeloid leukemia or gastrointestinal stromal tumors
(2) Diagnosis and management of infectious diseases
(a) Detection of microorganisms and specific genetic
material for definitive diagnosis (i.e., human

512
 immunodeficiency virus [HIV], human papillomavirus
[HPV], herpes simplex virus [HSV])
(b) Identification of specific genetic alterations in the
genomes of microbes that are associated with drug
resistance
(c) Determination of treatment efficacy (e.g., assessing
viral loads in HIV and hepatitis C virus [HCV])
f. Ribonucleic acid (RNA) analysis
(1) Not as stable as DNA-based diagnosis, but useful for the
detection and quantification of RNA viruses such as HIV
and HCV
(2) Becoming an important tool for the molecular
stratification of tumors
8. Referral for genetic counseling
a. Clients who present with evidence of suspected or diagnosed
genetic disorder should be referred to a genetics center for
evaluation and counseling; any genetic health condition or risk
that affects one individual can affect that person’s biologic and
extended family
b. Genetics professionals can be consulted through the National
Society for Genetics Counselors (NSGC) website at
http://www.nsgc.org
c. Document referrals are made to a physician, a genetics
professional, or both by recording:
(1) Causes for concern
(2) Possible diagnosis (if known)
(3) Family history information obtained
(4) Relevant oral examination findings, radiographs, and
records
d. Genetics consultation involves:
(1) Confirming, diagnosing, or ruling out the genetic
condition
(2) Identifying medical management issues
(3) Determining genetic risks
(4) Providing psychosocial support

513
Differential diagnosis6
A. Diagnostic approaches
1. Appearance recognition—clinical manifestations of routine oral
diseases can be recognized by their characteristic appearances
because no other diseases produce these lesions (e.g., dental caries,
gingivitis, periodontitis)
2. Differential diagnosis—determination of which of two or more
diseases with similar signs and symptoms is the one manifested in
the client
a. Requires a comparison of signs and symptoms and other
pertinent details against the known features of all diseases that
can produce the observed primary manifestation
b. Reflects a conceptual process and a listing of pathologic
conditions in the order of most likely to least likely
c. Pathoses are ruled out on the basis of examinations, tests such
as blood assays (see reference 5 for specific examples),
urinalysis, biopsy, and so on
B. Conceptual stages of the differential diagnosis process
1. Stage 1: classification of the abnormality by primary manifestation—
describe the general nature of the lesion that makes it different from
normal tissue
a. A white mucosal discoloration without loss of mucosal integrity
or enlargement
b. A dark discoloration without loss of mucosal integrity or
enlargement
c. Loss of mucosal integrity or ulceration without enlargement
d. Enlargement of soft tissues
e. Radiographic manifestations of a lesion originating in bone
f. Concurrence of several dissimilar abnormalities suggestive of a
syndrome
2. Stage 2: listing of secondary features and contributing factors—
objectively describe the secondary features of the lesion; reserve
making judgments about the diagnosis based on information
obtained
a. Visual examination
(1) Specific location of the lesion
(2) Shape of the lesion and contours of tissue
(3) Size of the lesion
(4) Occurrence of the lesion as isolated, multifocal, or diffuse
(5) Delineation of the borders of the abnormality from

514
 adjacent tissue
(6) Consistency of appearance as homogeneous or
heterogeneous
(7) Surface color and texture
(8) Alteration of adjacent structures, such as displacement of
teeth
b. Palpation
(1) Degree of compressibility
(2) Tenderness during compression
(3) Alteration in color during compression
c. Auscultation
(1) Wheezing
(2) Popping and clicking of the temporomandibular joint
(3) Clicking of poorly fitting dentures
d. Probing
(1) Tissue defects
(2) Exudates
e. Aspiration
(1) Pus
(2) Cysts and nodules
f. Evaluation of function
(1) Tear production
(2) Salivary glands
(3) Tongue
(4) Muscles of mastication
(5) Neurologic function
g. Client awareness
(1) Pain, discomfort, or altered function
(2) Duration
(3) Course as constant, healing with recurrence, or steady
progression
(4) Response to factors such as stress and certain foods
h. Demographics
(1) Age
(2) Gender
(3) Race and ethnicity
i. Habits
(1) Alcohol use
(2) Tobacco use
(3) Oral
(4) Other (ask client)

515
 j. Recent history
(1) Injury
(2) Infection
(3) Surgery
k. Medical conditions
(1) Chronic diseases
(2) Recent acute illnesses
l. Current medical treatment
(1) Medications
(2) Other treatment
3. Stage 3: listing of conditions capable of causing primary
manifestations
a. Consider the variety of abnormalities that cause the condition,
and compare them with the client’s abnormality
b. Create a list of plausible diagnoses
4. Stage 4: elimination of unlikely causes
a. Identify contradictions between the features of the lesion and
the known characteristics of the diagnostic possibilities
b. The category of the lesion determines the secondary features
that are most reliable; then eliminate those conditions that
appear least likely
c. Elimination of malignant neoplasia as a possible cause is often
more important than achieving a definitive diagnosis
5. Stage 5: ranking of possible causes by probability
a. Rank the diseases that could explain the abnormality on the
basis of the number of secondary features exhibited that
correspond with the typical features of each possible diagnosis
6. Stage 6: Determination of a working diagnosis
a. The condition considered the most likely cause of the lesion is
referred to as the working, tentative, or preliminary diagnosis or
the clinical impression
b. Provides the basis for additional diagnostic testing and for the
initial clinical management of the condition
c. When all the diseases except one have been eliminated from the
differential diagnosis, then that provides the definitive
diagnosis
d. Reevaluate to verify the correct diagnosis and that the client has
responded to treatment without recurrence

Website Information and Resourc es

516
Source Website Address Description
National Human Genome www.genome.gov/glossary.cfm Talking glossary of
Research Institute/Talking genetic terms; text-
Genetics Glossary only version
available
Centers for Disease Control and www.cdc.gov/genomics Information about
Prevention/Office of Genomics human genomic
and Disease Prevention discoveries and
how they can be
used to improve
health and prevent
disease
Timely and credible
information for the
effective and
responsible
translation of
genomics research
into population
health benefits
National Library of http://ghr.nlm.nih.gov/ Allows users to
Medicine/Genetics Home search for
Reference information on
diseases, tutorials
about basic
concepts in genetics,
and educational
resources
National Institutes of Health http://stemcells.nih.gov/info/basics/pages/basics7.aspx Reviews stem cells;
unique properties,
types, and potential
uses of human stem
cells
International Society for Stem http://www.isscr.org Provides overview
Cell Research of research related
to stem cells;
promotes
professional and
public education in
all areas of stem cell
research and
application
Medline Plus http://www.nlm.nih.gov/medlineplus/stemcells.html Consumer health
database that
includes news,
health resources,
and clinical trials
related to stem cells

517
References
1 Goljan E.F. Rapid review: pathology. ed 4 Philadelphia: Elsevier;
2014.
2 Kumar V., Abbas A.K., Fausto N., Aster J.C. Robbins and cotran
pathologic basis of disease. ed 8 Philadelphia: Saunders; 2010.
3 Rubin E., Reisner H.M. Essentials of Rubin’s pathology. ed 6
Philadelphia: Wolters Kluwer/Lippincott, Williams & Wilkins;
2014.
4 Mao J.J., Giannobile W.V., Helms J.A., et al. Craniofacial tissue
engineering by stem cells. J Dent Res. 2006;85(11):966–979.
5 National Coalition for Health Professional Education in Genetics.
Genetics primer. 2014. Available at http://www.nchpeg.org
Accessed September 5, 2014.
6 Coleman G.C., Nelson J.F. Principles of oral diagnosis. St Louis:
Mosby; 1993.

518
Suggested readings
Lee H.N., Surh Y.J. Therapeutic potential of resolvins in prevention
and treatment of inflammatory disorders. Biochem Pharmacol.
2012;84(10):1340–1350.
Mao J.J., Collins F.M. Stem cells: sources, therapies and the dental
professions. RDH. 2009;49–57.
Mariotti A. A primer on inflammation. Compend Cont Educ Dent.
2004;25(7 Suppl 1):7–15.
Nadig R.R. Stem cell therapy—hype or hope? A review. J Conserv
Dent. 2009;12(4):131–138.
National Coalition for Health Professional Education in Genetics:
Core competencies for all health professionals, 2007,
http://www.nchpeg.org. Accessed September 5, 2014.
Pagana K.D., Pagana T.S. Mosby’s manual of diagnostic and laboratory
tests. ed 4 Philadelphia: Mosby; 2010.

Chapter 7 review questions

Answers and rationales to review questions are available on this text’s
accompanying Evolve site. See inside front cover for details

1. Cellular injury may be caused by all the following EXCEPT one. Which
one is the exception?
a. Infections
b. Chemical agents
c. Mitosis
d. Tissue necrosis
2. A protective response of the body designed to rid the initial cause and
consequences of cell injury explains:
a. Inflammation
b. Regeneration
c. Angiogenesis
d. Autoimmune response
3. Inflammation consists of vascular responses, migration and activation
of white blood cells, and systemic reactions. It is present during cellular

519
injury and wound repair.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
4. Mr. Smith presents with generalized gingivitis with swelling, bleeding,
and redness. The redness (rubor) is caused by:
a. Vasoconstriction of blood vessels
b. Increased vascularity
c. Stretching of pain receptors
d. Exudation of fluid
5. Mr. Smith’s gingival swelling is caused by:
a. Vasoconstriction of blood vessels
b. Increased vascularity
c. Stretching of pain receptors
d. Exudation of fluid
6. Increased blood flow and the release of inflammatory mediators cause
which cardinal sign of inflammation?
a. Rubor
b. Calor
c. Dolor
d. Functio laesa
7. Acute inflammation is characterized by a sustained inflammatory
response. It is manifested by the exudation of fluid and plasma proteins
and the emigration of leukocytes, most notably neutrophils.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
8. What is the first white blood cell to emigrate to the site of injury?
a. Monocyte
b. Neutrophil
c. Eosinophil
d. Macrophage

520
9. Macrophages, lymphocytes, and eosinophils are all involved in the
immune response. Neutrophils are involved in acute inflammation and
not the immune response.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
10. Which white blood cell produces potent vasoconstrictive mediators?
a. Neutrophil
b. Macrophage
c. Lymphocyte
d. Eosinophil
11. Which white blood cells regulate bronchial smooth muscle tone,
especially in allergic hypersensitivity reactions?
a. Neutrophils
b. Monocytes
c. Mast cells
d. Lymphocytes
12. What is the term for the concentration of red blood cells in small
vessels and increased viscosity of blood?
a. Margination
b. Pavementing
c. Diapedesis
d. Stasis
13. The first step in the vascular changes associated with acute
inflammation is:
a. Vasodilation
b. Vasoconstriction
c. Increased permeability
d. Concentration of red cells in small vessels
14. Vasodilation results in decreased blood flow. This causes heat and
redness, also known as hyperemia.
a. Both statements are TRUE.
b. Both statements are FALSE.

521
 c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
15. Endogenous chemoattractants involved in chemotaxis include all the
following EXCEPT:
a. C5a
b. LTB4
c. SIRS
d. IL-8
16. Which phase of phagocytosis involves the complete enclosure of a
particle within a phagosome?
a. Recognition and attachment
b. Engulfment
c. Killing and degradation
d. Apoptosis
17. During which phase of phagocytosis does the pH drop to between 4
and 5?
a. Recognition and attachment
b. Engulfment
c. Killing and degradation
d. Apoptosis
18. The release of leukocyte products during phagocytosis may cause
endothelial injury and tissue damage because neutrophils and
monocytes become degranulated during this process.
a. Both the statement and the reason are correct and are related.
b. Both the statement and the reason are correct but are NOT related.
c. The statement is correct, but the reason is NOT correct.
d. The statement is NOT correct, but the reason is correct.
e. NEITHER the statement NOR the reason is correct.
19. Examples of vasoactive amines are:
a. Histamine and serotonin
b. Histamine and bradykinin
c. Serotonin and complement
d. Serotonin and bradykinin

522
20. Chemical mediators perform their activities by binding to specific
receptors on target cells, performing direct enzymatic activity, or
mediating oxidative damage. Most mediators can last for extended
periods, causing harmful effects.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
21. Which chemical mediator is triggered by the activation of Hageman
factor?
a. Arachidonic acid
b. Bradykinin
c. Complement C3a
d. Serotonin
22. Which mediators induce the systemic acute-phase response of
infection and injury?
a. Leukotrienes and lipoxins
b. Tumor necrosis factor and lipoxins
c. Tumor necrosis factor and interleukin-1
d. Leukotrienes and interleukin-1
23. Oxygen-derived free radicals may be released from nitric oxide
following a phagocytic event. These are potent mediators that can cause
endothelial cell damage and increased vascular permeability.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
24. Examples of acute-phase proteins seen in chronic inflammation
include all the following EXCEPT:
a. Leukocyte K
b. C-reactive protein
c. Fibrinogen
d. Serum amyloid A
25. The lymphatics are a secondary line of defense in inflammation,

523
because they help drain edema from the extravascular space.
a. Both the statement and the reason are correct and are related.
b. Both the statement and the reason are correct but are NOT related.
c. The statement is correct, but the reason is NOT correct.
d. The statement is NOT correct, but the reason is correct.
e. NEITHER the statement NOR the reason is correct.
26. Which of the following systemic diseases is/are affected by chronic
inflammation?
a. Diabetes mellitus
b. Cancer
c. Gingivitis
d. All the above
27. The first step in wound healing is:
a. An inflammatory response
b. Proliferation of parenchymal and connective tissue cells
c. Formation of a thrombus
d. Formation of new blood vessels
28. Systemic factors that influence wound healing include all the
following EXCEPT:
a. Blood supply
b. Ionizing radiation
c. Corticosteroids
d. Nutritional deficiencies
29. A hallmark of healing is:
a. Angiogenesis
b. Granulation tissue
c. Fibroblast proliferation
d. Matrix metalloproteinases
30. All the following are processes of scar formation EXCEPT:
a. Proliferation of fibroblasts in the site of injury
b. Deposition of extracellular matrix
c. Tissue remodeling
d. Angiogenesis

524
31. During primary intention healing, granulation tissue forms within:
a. 2 days
b. 3 days
c. 4 days
d. 5 days
32. During primary intention healing, a basement membrane is formed
within:
a. 2 days
b. 3 days
c. 4 days
d. 5 days
33. During primary intention healing, the inflammatory process
dissipates during:
a. Week 1
b. Week 2
c. Week 3
d. Week 4
34. Delayed primary closure represents which type of healing?
a. Primary intention
b. Secondary intention
c. Tertiary intention
d. None of the above
35. What is the term for excessive scar formation?
a. Keloid
b. Contracture
c. Dehiscence
d. Ulcer
36. Autogenous stem cells are derived from the individual being treated.
They may be totipotent, multipotent, or unipotent.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.

525
37. Adult stem cells are pluripotent and can generate cell tissue of the
body. Embryonic stem cells have a more restricted capacity to generate
different cell types.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
38. All the following are types of adult stem cells EXCEPT:
a. Amniotic fluid–derived stem cells
b. Umbilical cord blood stem cells
c. Adipose-derived stem cells
d. Blastocyte-derived stem cells
39. What type of stem cell consists of both hematopoietic stem cells and
mesenchymal stem cells?
a. Amniotic fluid–derived stem cells
b. Umbilical cord blood stem cells
c. Bone marrow–derived stem cells
d. Adipose-derived stem cells
40. The most common commercially available stem cells are:
a. Embryonic stem cells
b. Bone marrow–derived stem cells
c. Adipose-derived stem cells
d. Dental stem cells
41. Humans have approximately 20,000 to 25,000 chromosomes. The
study of genes in the genome, their extensive DNA sequences, and their
interactions define genomics.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
42. Permanent changes in the DNA code is called a mutation. All
mutations are harmful to the body.
a. Both statements are TRUE.
b. Both statements are FALSE.

526
 c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
43. The loss or gain of whole chromosomes resulting in monosomy or
trisomy represents:
a. Chromosome mutations
b. Genome mutations
c. Submicroscopic gene mutations
d. All the above
44. The majority of mutations associated with hereditary disease are:
a. Genome mutations
b. Chromosome mutations
c. Submicroscopic gene mutations
d. Adenine gene mutations
45. Which pair of chromosomes constitutes the sex chromosomes?
a. Twenty-first
b. Twenty-third
c. Thirty-eighth
d. Forty-sixth
46. Huntington’s disease exemplifies:
a. Autosomal dominant disorder
b. Autosomal recessive disorder
c. X-linked recessive disorder
d. Disorder with multifactorial inheritance
47. Cleft lip and cleft palate exemplify:
a. Autosomal dominant disorder
b. Autosomal recessive disorder
c. X-linked recessive disorder
d. Disorder with multifactorial inheritance
48. An organized graphic representation of the chromosomes of a single
cell defines:
a. Cytogenic typing
b. Polymerase chain typing
c. Karyotyping

527
 d. All the above
49. All the following are salivary DNA-PCR tests used to evaluate
periodontal status EXCEPT:
a. MyPerioPredict
b. MyPerioPathSM
c. MyPerioIDSM PST
d. Perio Predict Genetic Risk Test
50. Palpating a submental node during a clinical examination represents
which stage of the differential diagnosis process?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4

528
C HAPT E R 8

529
Oral Pathology
Olga A.C. Ibsen

Dental hygienists perform comprehensive extraoral and intraoral

examinations, identify pathologic conditions, and communicate these
findings to the dentist for diagnosis, treatment, or referral. Knowledge of
oral pathology is essential for the preliminary evaluation of oral lesions.
The dental hygienist differentiates between normal and abnormal
findings and relates significant medical, dental, and cultural histories to
clinical, radiographic, and histologic findings. Although the dental
hygienist is not responsible for the dental diagnosis, skill in the use of
the diagnostic process is essential for the dental hygiene diagnosis and
collaborative practice.

530
Benign lesions of soft tissue origin
General Characteristics
A. Etiology—unknown
B. Age and gender vary with the type of lesion
C. Clinical features
1. Sharp line of demarcation outlines the lesion
2. Sessile or pedunculated base
3. Lesion is easily palpable
D. Histologic characteristics depend on the lesion (e.g., a lipoma is
composed of fat cells)
E. Lesion grows slowly, or it may be encapsulated, which contributes to
an evaluation of a benign state
F. Lesion is removed surgically and usually does not recur

Irritative Fibroma (or Traumatic Fibroma)

See Fig. 8-1.

FIG 8-1 Fibroma with a sessile base. (From Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

A. Etiology—chronic mild irritant; chronic trauma

531
B. Age and gender related—40 to 60 years; more common in females (2:1)
C. Location—most common on the buccal mucosa along the area of the
occlusal plane and gingiva; also found on the tongue, lips, and palate
D. Clinical features
1. Light pink
2. Round or semi-circular shape
3. Less than 1 cm in size
4. Sessile or pedunculated base
5. Exophytic lesion
E. Histologic characteristics
1. Stratified squamous epithelium; surface may be keratinized or
ulcerated (resulting from secondary trauma)
2. Contains dense connective tissue and few blood vessels
F. Treatment—complete excision

Papilloma
A. Etiology—benign lesion of squamous epithelium; long duration; slow
development
B. Age and gender related—may arise at any age, but there is a 50%
incidence between ages 20 and 50 years; no gender predilection
C. Location—soft palate or tongue
D. Clinical features (Fig. 8-2, A)

532
 FIG 8-2 A, Clinical appearance of a papilloma on the palate showing a
cauliflower-like appearance and rough surface resulting from finger-like
projections. B, Microscopic appearance of a papilloma showing finger-like
projections covered by a squamous epithelial layer and supported by thin cores
of fibrous tissue. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed
6, St Louis, 2014, Elsevier.)

1. Cauliflower-like appearance
2. Usually grayish or white color; can also be pink; color depends on
amount of keratin
3. Well-delineated, exophytic nodule with a pedunculated or sessile
base
4. Under 0.5 cm in size
E. Histologic characteristics (Fig. 8-2, B)
1. Composed primarily of long, finger-like projections of stratified
squamous epithelium with a core of fibrous connective tissue;
surface keratin
2. Normal stratified squamous epithelium with a thick surface layer of
keratin

533
F. Treatment and prognosis
1. Surgical excision, including the base of the lesion to prevent
recurrence
2. Does not usually recur

Verruca Vulgaris (Wart)

A. Etiology—benign viral-induced lesion of stratified squamous
epithelium; caused by human papillomavirus (HPV) (low-risk HPV)
B. Age and gender related—more common in children; but lesions have
also been identified in adults; no gender predilection
C. Location—common skin lesion; lips are the most common oral site;
can also be found on the tongue or mucosa
D. Clinical features (Fig. 8-3)

FIG 8-3 A and B, Verruca vulgaris on the tongue of a child, with a similar lesion
on the thumb. (Courtesy of Dr. Edward V. Zegarelli; from Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. White, papillary exophytic lesion

2. Can spread to other areas of a person’s skin
3. Self-inoculated (finger to mouth)
4. Often has a sessile base

534
 5. Differs from a papilloma in that warts grow faster, are smaller, and
develop in a shorter time
E. Histologic characteristics
1. Hyperkeratotic stratified squamous epithelium with a prominent
granular cell layer in the upper spinous layer of epithelium
2. Numerous koilocytes (cells with clear cytoplasm) are located in the
upper spinous layer of epithelium
3. Central cores of fibrous connective tissue
F. Treatment and prognosis
1. Conservative surgical excision
2. Lesions may recur because of reinoculation

Hemangioma
A. Etiology—congenital or developmental origin; when found in adults,
these lesions develop as a response to trauma during the healing stages;
a benign proliferation of blood capillaries
B. Age and gender related—lesions present at birth or develop shortly
thereafter; more common in females (3:1); occur in adults as a response
to trauma
C. Location—most common on the tongue; also found on the buccal
mucosa, labial mucosa, and the vermilion border of lips
D. Clinical features (Fig. 8-4, A)

535
 FIG 8-4 A, Clinical appearance of a hemangioma of the lower lip. B,
Photomicrograph of a hemangioma. (From Ibsen OAC, Phelan JA: Oral pathology for
the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Flat or raised, well-circumscribed lesion on tongue or mucosa

2. Deep red or bluish purple
3. Lesions blanch when pressure applied
4. Two types of hemangioma:
a. Capillary—small to moderate size; soft texture
b. Cavernous—larger in size, more than 2 cm in diameter; exhibits
a significant protrusion of tissue; deep purple; soft or semi-firm
texture
E. Histologic characteristics (Fig. 8-4, B)
1. Capillary—many small capillaries lined by a single layer of
endothelial cells supported by a connective tissue stroma of varying
density; endothelial cell proliferation
2. Cavernous—large, dilated blood sinuses with thin walls, each having

536
 an endothelial lining; sinusoidal spaces filled with blood and
lymphatic vessels
F. Treatment and prognosis
1. Treatment is variable
a. Nonintervention for patients in whom spontaneous remission
has occurred or can occur
b. Surgical excision
c. Sclerosing agents injected into the lesion result in its resolution
d. Laser procedures
G. Prognosis is good

Lipoma
A. Etiology—unknown; rare; benign tumor of mature fat cells
B. Age and gender—over 40 years; no gender predilection
C. Location—most common on the buccal mucosa or in the mucobuccal
fold
D. Clinical features (Fig. 8-5, A)

FIG 8-5 A, Clinical appearance of a lipoma. B, Photomicrograph of a lipoma

showing mature fat cells. (A courtesy of Dr. Edward V. Zegarelli; from Ibsen OAC, Phelan
JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders; B from Regezi
JA, Sciubba JJ: Oral pathology: clinical-pathologic correlations, ed 5, Philadelphia, 2008,
Saunders.)

1. Single or lobulated, well-defined, painless mass less than 3 cm in

size
2. Sessile or pedunculated base
3. Soft to palpation
4. Yellowish color (if aspirated, a brown-yellow fluid is withdrawn)
E. Histologic characteristics (Fig. 8-5, B)
1. Circumscribed mass of mature fat cells with collagen strands and a
few blood vessels
2. Thin epithelium covers lesion
3. If fibrous connective tissue forms a more significant part of the

537
 lesion, it is called a fibrolipoma
F. Treatment and prognosis
1. Conservative surgical excision
2. Recurrence is rare

538
Inflammatory tumors (Granulomas)
General Characteristics
A. Growth or enlargement of tissue composed mainly of inflammatory
cells
B. Account for the major portion of all oral tumors
C. Benign tumors

Pyogenic Granuloma
A. Etiology—an exuberant tissue response to chronic irritants or trauma
(i.e., plaque biofilm, calculus, poor restorative margins, hormonal levels)
B. Age and gender related—teenagers and young adults; more common
in females (3:1), perhaps related to an increase in hormonal levels
C. Location—much more common on the maxillary labial gingiva than
mandibular gingiva; can occur on the lips, tongue, and buccal mucosa
D. Clinical features (Fig. 8-6)

FIG 8-6 Pyogenic granuloma. (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Protrusive mass; pedunculated, sessile, or lobulated base

2. Deep-red to purple surface
3. Soft and spongy; freely movable; ulcerated, bleeds easily

539
 4. Lesions are a few millimeters to several centimeters in size
5. In pregnancy, these lesions were formerly called “pregnancy tumors”
E. Histologic characteristics
1. The epithelium, if present, is thin
2. Rich in capillaries with proliferation of connective tissue;
inflammatory cells
3. The lesion contains polymorphonuclear neutrophil leukocytes
(PMNs), acute and chronic inflammatory cells, plasma cells, and
lymphocytes
F. Treatment and prognosis
1. Removal of the irritant
2. Surgical excision of the lesion
3. These lesions can recur if the irritant remains (e.g., calculus)
4. The lesions that occur during pregnancy may resolve spontaneously,
and hormonal levels return to normal

Papillary Hyperplasia of the Palate (Palatal

Papillomatosis)
A. Etiology—type of denture stomatitis
1. Chronic irritation to the vault of the hard palate related to poorly
fitting denture (full or partial); excessive pressure of an ill-fitting
maxillary denture; and poor denture hygiene (secondary)
2. Can also be associated with poorly fitting orthodontic appliance or
wearing the prosthetic device 24 hours a day
B. Age and gender related—especially individuals who wear maxillary
dentures; no gender predilection
C. Location—especially in vault of the hard palate in maxillary denture
wearers (suction chamber area)
D. Clinical features (Fig. 8-7)

540
 FIG 8-7 Papillary hyperplasia of the palate. (Courtesy of Dr. Edward V. Zegarelli; from
Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Closely clustered erythematous papillary projections, 1 to 4 mm in

diameter
2. Round, smooth, glistening red surface; granular appearance
3. Varying degrees of inflammation present
E. Histologic characteristics
1. Small vertical projections, each composed of stratified squamous
epithelium and a central core of connective tissue
2. Epithelial proliferation
3. Infiltrated with inflammatory cells
F. Treatment
1. Surgical excision of the hyperplastic tissue before construction of a
new denture or a reline
2. After surgery, emphasize denture care and removing the denture at
night to rest the tissues
G. Prognosis—good

Denture-Induced Fibrous Hyperplasia (Epulis

Fissuratum, Inflammatory Hyperplasia)
A. Etiology—irritation caused by poorly fitting denture, which produces
a proliferation of tissue in the vestibule along the denture flange
B. Age and gender related—denture wearers; no gender predilection

541
C. Location—vestibule along denture border; alveolar ridge in regions
along the denture border (maxillary or mandibular)
D. Clinical features (Fig. 8-8)

FIG 8-8A, Denture-induced fibrous hyperplasia (epulis fissuratum) (arrows),

shown with denture in place, and B, denture removed. (From Ibsen OAC, Phelan
JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Exophytic folds of hyperplastic tissue in the vestibule under or

around the denture flange
2. Pink to red color (can have ulcerated areas)
3. Firm to palpation
E. Histologic characteristics
1. Dense fibrous connective tissue covered by stratified squamous
epithelium (same tissue seen in an irritation fibroma)
2. Connective tissue composed of coarse bundles of collagen fibers

542
 3. Same type of tissue as seen in irritation fibroma
F. Treatment and prognosis
1. Surgical removal of the excess tissue
2. Reline or reconstruct the denture
3. Prognosis is excellent

Peripheral Giant Cell Granuloma

A. Etiology—a reactive lesion caused by local irritants arising from the
periodontal ligament
B. Age and gender related—40 to 60 years; more common in females (2:1)
C. Location—gingiva or alveolar mucosa, anterior to molars
D. Clinical features (Fig. 8-9, A)

543
 FIG 8-9 A, Peripheral giant cell granuloma. B, Microscopic appearance of a
peripheral giant cell granuloma showing multi-nucleated giant cells (M),
capillaries, and fibroblasts. (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Exophytic lesion 0.5 to 2.0 cm in diameter

2. Deep red
3. Pedunculated or sessile base
4. Arises from a deeper area in tissue than does pyogenic granuloma or
fibroma
E. Radiographic appearance—peripheral giant cell granuloma
1. May cause a superficial destruction of alveolar bone
2. Radiolucent “cuffing” or erosion of bone may appear in the area
F. Histologic characteristics (Fig. 8-9, B)
1. Composed of a delicate reticular and fibrillar connective tissue
stroma containing a large number of young, ovoid or spindle-
shaped, connective tissue cells

544
 2. Multi-nucleated giant cells
3. Proliferation of blood vessels
4. Appears to originate from the periodontal ligament or
mucoperiosteum
G. Treatment and prognosis
1. Surgical removal of the entire base to eliminate recurrence

Central Giant Cell Granuloma

A. Etiology—occurs within bone; trauma caused by a fall, blow, or tooth
extraction
B. Age and gender related—children and young adults; more common in
females (2:1) age 10 to 30 years
C. Location—75% in the anterior segment of the mandible; also found in
the maxilla
D. Clinical features
1. Appears as a swelling or bulge resulting from the expansion of
cortical plates
2. No symptoms, so may be discovered on routine radiographs
3. A similar lesion, often called “brown tumor,” occurs in persons with
hyperparathyroidism; resolves without treatment
E. Radiographic appearance (Fig. 8-10, A and B)

545
 FIG 8-10 Radiographs of central giant cell granulomas showing multi-locular
radiolucencies. A, The mandible. B, The maxilla. (From Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Usually a large radiolucent area with diffuse margins that are poorly
defined with faint trabeculae
2. Displacement of teeth; divergence of the roots of teeth adjacent to
the lesion is a common feature
3. Root resorption
F. Histologic characteristics
1. Loose, fibrillar connective tissue with many fibroblasts
2. Rich vascularity
3. Foreign body, multi-nucleated giant cells
G. Treatment and prognosis
1. Curettage (perhaps more than one treatment)
2. Surgical removal
3. Radiotherapy is contraindicated

546
 4. Occasionally recurs
5. In hyperparathyroid patients, the lesion is not removed because it
resolves when hyperparathyroidism is treated

Chronic Hyperplastic Pulpitis (Pulpal Granuloma,

Pulp Polyp)
A. Etiology—excessive proliferation of chronically inflamed pulp tissue
found in teeth with large open carious lesions; rapid caries; lesion
projects from the pulp chamber
B. Age and gender related—children and young adults; no gender
predilection
C. Location
1. Usually in primary molars or permanent molars
2. Can occur in any tooth with a large, open, carious lesion
D. Clinical features (Fig. 8-11)

FIG 8-11 Chronic hyperplastic pulpitis (pulp polyp) (arrow). (From Ibsen OAC,
Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Red to pink outgrowth of pulp tissue protruding from the occlusal

547
 surface of the crown of a tooth that has a large, open, carious lesion
2. Lesion is not painful because hyperplastic tissue contains few nerves
E. Histologic characteristics
1. Originates from pulpal tissue
2. Contains acute and chronic inflammatory cells, plasma cells, and
lymphocytes
3. Granulation tissue
F. Treatment and prognosis
1. Extraction of the involved tooth
2. Endodontic therapy
3. Root canal therapy for the involved tooth plus full restorative
coverage (if possible)
4. Prognosis is good

Internal Resorption
A. Etiology—not clear; theories include:
1. Inflammatory response in the pulp
2. Trauma
3. Caries-related pulpitis
B. Age and gender related—any age; no gender predilection
C. Location—usually found within a tooth in the permanent dentition
D. Clinical features
1. Dentin immediately surrounding the pulp in the area of resorption
is destroyed
2. The crown may appear pink (“pink tooth”) because of the vascularity
of the lesion within (this is not easily observable on posterior teeth)
E. Radiographic appearance well defined, but radiolucent lesion in close
proximity to the pulp canal (Fig. 8-12)

548
 FIG 8-12 Radiograph showing an area of internal resorption on the maxillary
first molar (arrow). (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed
6, St Louis, 2014, Elsevier.)

F. Histologic characteristics—highly vascularized, chronic inflammatory

tissue; few nerves
G. Treatment—endodontic therapy if perforation of the root has not
occurred; otherwise, extraction of the tooth is essential

Periapical Granuloma
A. Etiology—dental caries or deep restorations; a response to injury
B. Age and gender related—any age; no gender predilection
C. Location—apex of a nonvital tooth
D. Clinical features
1. Nonvital tooth
2. Fistula or parulis may be present if the condition has been chronic
3. The affected tooth can be sensitive to percussion
4. Many times can be asymptomatic
E. Radiographic appearance—varies from a well-defined, circular,
radiolucent lesion at the apex of the involved tooth to a diffuse
radiolucency or thickening of the periodontal ligament space (Fig. 8-13,
A)

549
 FIG 8-13A, Radiograph of a periapical granuloma. B, Low-power microscopic
appearance of a periapical granuloma. (From Ibsen OAC, Phelan JA: Oral pathology
for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

F. Histologic characteristics (Fig. 8-13, B)

1. Lymphocytes, plasma cells, macrophages
2. Dense, fibrous connective tissue
3. Epithelial (Malassez) rests (remnants of tooth-forming tissues)
G. Treatment—endodontic therapy or extraction of the affected tooth

550
Benign intraosseous neoplasms
General Characteristics
A. Etiology—generally unknown
B. Onset—gradual, with slow development or enlargement
C. Early stages—asymptomatic
D. With expansion of the lesion, malocclusion may occur; bone
tenderness on palpation; cortical bone may become thin

Osteoma
A. Etiology—asymptomatic benign tumor of compact bone; etiology
generally unknown, but the cause may be irritation or inflammation;
associated with a genetic condition called Gardner syndrome
B. Age and gender related—more common in young adults but can be
found at any age; no gender predilection
C. Location—most common posterior mandible; mandibular condyle;
craniofacial skeleton only; exophytic or periosteal, endosteal, or central
osteoma
D. Clinical features—the affected individual may be unaware of the
lesion because it grows slowly; considerable growth must occur before
cortical plates expand
E. Radiographic appearance
1. Well-circumscribed radiopaque mass that is indistinguishable from
scar bone
2. Panoramic or lateral plate radiograph may be needed to view the
lesion in its entirety (Fig. 8-14)

551
 FIG 8-14 Radiograph of an osteoma showing a radiopacity (arrow) of the
posterior mandible. (Courtesy of Dr. Sidney Eisig; from Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

F. Histologic characteristics—extremely dense, compact bone or coarse,

cancellous bone
1. Compact osteomas—have minimal marrow tissue
2. Cancellous osteomas—have fibrofatty marrow
G. Treatment and prognosis
1. Surgical excision for large lesions
2. Does not recur

Chondroma
A. Etiology—benign tumors of hyaline cartilage; cause unknown
B. Age and gender related—ages 30 to 40 years; no gender predilection
C. Location
1. Maxilla—anterior area
2. Mandible—posterior to canines
3. May involve the body of the mandible or the coronoid or condylar
process
D. Clinical features
1. Painless
2. Slow, progressive swelling of the jaw may loosen or malposition
teeth
3. Tendency to become malignant—potential chondrosarcoma
E. Radiographic appearance—irregular radiolucent or mottled area in

552
bone; may displace surrounding teeth or cause root resorption
F. Histologic characteristics
1. Mass of hyaline cartilage with areas of calcification or necrosis
2. Cartilage cells are small, and each has one nucleus
3. Large biopsy sample must be obtained because the lesion is similar
to a malignant chondrosarcoma (more common in men)
G. Treatment and prognosis
1. Nonconservative surgical removal; tumor may be resistant to
radiation therapy
2. Periodic follow-up evaluation is necessary to detect recurrence or
possibility of a chondrosarcoma

Odontogenic Myxoma
A. Etiology—unknown; benign; originates from mesenchymal tissue of
the tooth germ; odontogenic origin
B. Age and gender related—most often in young adults, ages 10 to 30
years; no gender predilection
C. Location—mandible more often than maxilla
D. Clinical features—deeply situated lesion; small lesions asymptomatic
E. Radiographic appearance (Fig. 8-15)

553
 FIG 8-15 Radiograph of a myxoma showing multi-locular, honeycombed
radiolucency. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St
Louis, 2014, Elsevier.)

1. May be unilocular or multi-locular

2. Several small radiolucencies occurring in groups, giving a
“honeycomb” appearance
3. May show displaced teeth, mandibular canal, and antrum (may also
invade the antrum)
4. Peripheral borders are irregular, diffuse, and not well defined
5. Large lesions may have a “soap bubble” radiolucent pattern similar
to the ameloblastoma
F. Histologic characteristics
1. Loosely textured tissue containing delicate reticulin fibers and
mucoid material
2. Contains stellate, spindle-shaped cells
3. The tumor is not encapsulated and may invade surrounding tissues
4. Does not metastasize
G. Treatment and prognosis
1. Complete surgical excision
2. Recurrence is common (25%)

554
Exostosis
Torus Palatinus
A. Etiology—inherited, autosomal dominant; some believe the cause to
be genetic or environmental factors
B. Age and gender related—usually seen by the age of puberty; rarely
observed in children, but peak incidence occurs before 30 years; more
common in females (2:1)
C. Location—midline of the hard palate
D. Clinical features (Fig. 8-16, A)

FIG 8-16 A, Clinical appearance of a lobulated torus palatinus. B, Clinical

appearance of bilateral mandibular tori. (From Ibsen OAC, Phelan JA: Oral pathology
for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Bony, hard protuberance in the midline in a variety of shapes—

nodular; lobulated; smooth; spindle
2. Occurs in 20% to 35% of the U.S. population
3. Torus may appear ulcerated because of trauma to the thin overlying

555
 mucosa
E. Radiographic appearance—dense radiopaque area
F. Histologic characteristics—dense cortical bone
G. Treatment—usually none, but surgical removal if the lesion interferes
with a prosthodontic appliance

Torus Mandibularis
A. Etiology—inherited, autosomal dominant; possibly genetic or
environmental
B. Age and gender related—first observed in early teen years; slightly
more common in males
C. Location—lingual surface of the mandible above the mylohyoid line in
the area of premolars; often bilateral
D. Clinical features (Fig. 8-16, B)
1. Bony protuberance varying in size and shape; common exostosis—
modular, lobulated, or smooth
2. Slow growing
3. Bilateral incidence more common (90%)
E. Radiographic appearance—dense radiopaque area
F. Histologic characteristics—dense cortical bone
G. Treatment—surgical excision if the lesion interferes with a
prosthodontic appliance

Odontoma
A. Etiology—most common odontogenic tumor; composed of all tooth
structure and pulp but not considered a neoplasm
B. Age and gender related—usually seen in adolescents and young
adults, mean age 14 years; no gender predilection
C. Location—more frequently seen in the maxilla (especially anterior
maxilla for the compound type) than in the mandible; usually between
the roots of teeth or near apices; complex odontomas seen more often in
posterior mandible
D. Clinical features
1. Failure of a permanent tooth to erupt
2. Asymptomatic
E. Radiographic appearance—irregular mass of radiopacities (“tooth-like
structures”) surrounded by a narrow radiolucent halo
1. Two types
a. Compound—tooth structures are identified radiographically

556
 (Fig. 8-17)

FIG 8-17 Radiograph of a compound odontoma, showing a

collection of numerous, small, tooth-like radiopacities (arrows)
surrounded by a radiolucent halo. (From Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

b. Complex—appears as a radiopaque mass (can be confused with

other lesions in bone) (Fig. 8-18)

557
 FIG 8-18 Radiograph of a complex odontoma showing a
radiopaque mass surrounded by a radiolucent halo (arrow). (From
Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis,
2014, Elsevier.)

2. Cyst involvement may occur with an odontoma

F. Histologic characteristics—tumor in which epithelial and
mesenchymal cells show differentiation, resulting in abnormal enamel
and dentin formation
G. Treatment and prognosis
1. Complete surgical removal (both forms are well encapsulated)
2. Prognosis is good

558
Gingival fibromatosis
General Characteristics
A. Enlargement of gingival tissue, sometimes covering teeth
B. Contains a proliferation of dense fibrous connective tissue
C. Classification includes:
1. Irritative fibromatosis—localized areas associated with extraneous
irritants
2. Hereditary fibromatosis—generalized enlargement of gingival tissue
3. Chemical fibromatosis—caused by certain medications (drug-
influenced gingival enlargement)

Irritative Fibromatosis
A. Etiology—irritant such as mouth breathing, orthodontic appliances,
bacterial plaque biofilm, dental calculus, debris, overhanging
restorations, or poorly fitting dental appliances
B. Age and gender related—any age; no gender predilection
C. Location—localized areas on interproximal papillae; in mouth
breathers, on maxillary and mandibular anterior labial gingiva
D. Clinical features—solitary round, smooth-surfaced, pink enlargement
of papillae; well attached to surrounding structures
E. Histologic characteristics—proliferation of dense fibrous connective
tissue with increase in number of fibroblasts
F. Treatment and prognosis
1. Removal of the irritant
2. Improved oral hygiene
3. Gingivectomy in severe cases
4. Prognosis is excellent once the cause is removed

Hereditary Gingival Fibromatosis (Gingival Lesions

of Genetic Origin)
A. Etiology (see the section on “Genetics” in Chapter 7)
1. Hereditary; believed to have genetic or developmental involvement
or to be related to hormonal imbalances; a component of several
syndromes (e.g., Zimmerman-Laband, Cross, Rutherfurd, Murray-
Puretic-Drescher, Cowden)
2. Contributing factors include poor oral hygiene, food impaction,
calculus, and malocclusion
3. Other conditions associated with gingival fibromatosis may include

559
 growth hormone deficiency, hypothyroidism, epilepsy, and
intellectual and developmental disabilities (IDDs)
B. Age and gender related—appears during the eruption of primary or
permanent teeth; slightly more common in females
C. Location—excessive enlargement of interproximal gingival tissues; can
be localized
D. Clinical features
1. Gingival enlargement may be generalized or localized
2. Diffuse, smooth-surfaced, pink, firm tissue involving the
interproximal papillae
3. Multiple protruding pink, stippled, firm masses; labial and buccal
areas are most affected; teeth may be displaced; delays eruption of
teeth
E. Histologic characteristics—bundles of fibrous connective tissue with
fibroblasts and fibrocytes (depending on the formative stage)
F. Treatment and prognosis
1. Gingivectomy
2. Rigid adherence to home care
3. Recurrence is common

Chemical Fibromatosis (Drug-influenced Gingival

Enlargement)
A. Etiology—reaction to drugs, specifically phenytoin (Dilantin); calcium
channel blockers including nifedipine (Procardia), amlodipine (Norvasc),
diltiazem (Cardizem), and verapamil (Calan); cyclosporin, an
immunosuppressant drug given in association with organ transplants
B. Age and gender—no gender predilection
C. Location—papillae and gingivae
D. Clinical features—smooth, pink, firm enlargement of the papillae (Fig.
8-19)

560
 FIG 8-19 Drug-influenced gingival enlargement. A, Gingival enlargement
caused by phenytoin (Dilantin). B and C, Gingival hyperplasia caused by
nifedipine (Procardia). (A courtesy of Dr. Edward V. Zegarelli; B and C courtesy of Dr. Victor
M. Sternberg; A to C from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6,
St Louis, 2014, Elsevier.)

E. Histologic characteristics—extensive proliferation of connective tissue

F. Treatment
1. Change in the prescribed medication, if possible
2. Gingivectomy
3. Improved oral self-care; control of the biofilm

561
Ulcerative diseases
General Characteristics
A. Ulcer—formed by the destruction of the epithelium and some
underlying tissue
B. Factors aiding in the diagnosis of ulcers occurring in the oral cavity
1. Number and size
2. Location
3. Depth
4. Borders
5. Patient history (personal, health, cultural, pharmacologic)
C. Etiology—not always known
D. Can be classified as an acute or chronic condition
1. Acute ulcerative conditions include traumatic ulcers, aphthous
ulcers, allergic reactions, and viral ulcerations
2. Chronic ulcerative conditions include those caused by or associated
with systemic diseases such as leukemia, colitis, malnutrition,
tuberculosis, syphilis, sickle cell anemia, and drug toxicity

Traumatic Ulcer
A. Etiology—various types of trauma; history of lesion plays a significant
role in the diagnosis
1. Physical—biting the mucosa, denture irritation, toothbrush injury,
sharp tooth, fractured filling (Fig. 8-20)

562
 FIG 8-20 A, Traumatic ulceration caused by irritation of gingiva by
fingernails. B, Traumatic ulcer caused by a denture. (From Ibsen OAC,
Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

2. Chemical—oral rinse, phenol, misuse of medication used to treat a

toothache (e.g., misuse of aspirin causes an aspirin burn) (Fig. 8-21)

563
 FIG 8-21Mucosal burns. A, Burns caused by aspirin. B, Chemical burn
caused by contact with caustic material during endodontic treatment.
(From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis,
2014, Elsevier.)

3. Thermal—hot foods (e.g., soup) (Fig. 8-22, A); crack cocaine (Fig. 8-
22, B)

564
 FIG 8-22 Mucosal burns. A, Thermal burn of palate caused by contact
with hot soup. B, Ulcer of midline of palate caused by heat generated
during the use of crack cocaine. (A from Ibsen OAC, Phelan JA: Oral pathology
for the dental hygienist, ed 6, St Louis, 2014, Elsevier; B from Mitchell-Lewis DA,
Phelan JA, Kelly RB, Bradley JJ, Lamster IB: Identifying oral lesions associated with
crack-cocaine use, J Am Dent Assoc 125:1104, 1994.)

4. Electrical
B. Age and gender related—any age; no gender predilection
C. Location—lateral border of the tongue, buccal mucosa, lips, palate
(especially tori)
D. Clinical features
1. Small, single, oval, round, or irregular shape
2. Flat or slightly depressed
3. Covered by necrotic membrane and surrounded by an erythematous
halo
4. Painful for 2 to 5 days
5. Heals within 7 to 14 days

565
E. Histologic characteristics
1. Loss of continuity of surface epithelium
2. Fibrinous exudate covering exposed connective tissue
3. Infiltration of PMNs in connective tissue
4. Fibroblastic activity can be prominent
F. Treatment and prognosis
1. Removal of the irritant or cause
2. Application of benzocaine (Orabase with benzocaine) to relieve
symptoms
3. Corticosteroids (recommended by some, whereas others suggest
corticosteroid medications can delay healing)
4. Topical dyclonine hydrochloride for temporary relief
5. In severe cases, systemic antibiotics are given to prevent secondary
infection (these patients may also require surgical debridement
depending on the extent of tissue damage)
6. In patients with electrical burns, tetanus immunization is necessary
7. Prognosis is good

Necrotizing Ulcerative Gingivitis (NUG; Vincent’s

Infection, Trench Mouth)
A. Etiology
1. Anaerobic bacteria—fusiform bacilli (Bacillus fusiformis)
2. Borrelia vincentii, a spirochete
3. Sophisticated technology has identified the involvement of other
species as well
4. Contributory factors
a. Systemic—stress, fatigue, poor hygiene, malnutrition,
suppressed immune system, recent illness
b. Local—poor restorations, trauma, gingivitis, poor oral hygiene,
heavy smoking
B. Age and gender related—any age, usually 17 to 35 years; no gender
predilection
C. Location—free gingival margin, crest of gingiva, interdental papillae
D. Clinical features (Fig. 8-23)

566
 FIG 8-23 Necrotizing ulcerative gingivitis. (From Ibsen OAC, Phelan JA: Oral pathology
for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Acute gingivitis with extensive necrosis

2. Blunted, “punched-out,” crater-like necrosis of interdental papillae
3. Fetid mouth odor, pain, bleeding, bad taste
4. Headaches, low-grade fever
5. Regional lymphadenopathy
E. Histologic characteristics
1. Ulcerated stratified squamous epithelium
2. Thick fibrinous exudate containing PMNs
3. Significant bacterial colonization
4. Connective tissue infiltrated by dense numbers of PMNs
F. Treatment and prognosis
1. Scaling and debridement (patient may need several visits)
2. Use of ultrasonic instruments (except when contraindicated)
3. Topical anesthetic or even local anesthetic may be necessary for the
procedure
4. Use of an oxygenating rinse four or more times daily for 1 to 2 weeks
5. 0.12% chlorhexidine rinses
6. Use of systemic antibiotics such as penicillin, tetracycline, or
erythromycin, if patient has systemic symptoms such as a fever,
lymphadenopathy, or both

567
7. Home care to improve oral hygiene status (e.g., power toothbrush,
interdental cleaning)
8. Once treatment is completed, a 1-month follow-up appointment
should be scheduled to evaluate therapy and reinforce oral self-care;
the patient should be encouraged to have recare visits every 4
months
9. Condition can recur if the individual lacks optimal oral self-care or
has associated risk factors

568
Minor aphthous ulcers
Recurrent Ulcerative Stomatitis (RUS); Recurrent
Aphthous Stomatitis
A. Etiology
1. Autoimmune response of oral epithelium
2. T cell–mediated immunologic response
3. Decrease of mucosal tissue barrier
4. Inherited predisposition
5. Risk factors
a. Hormonal imbalance—premenstrual (incidence increases),
pregnancy (incidence decreases)
b. Psychological—anxiety, depression, acute emotional problems,
stress
c. Allergy—asthma, hay fever, food, drug, gluten
d. Blood abnormalities
e. Trauma
f. Bacterial or viral agents (e.g., herpes simplex virus;
cytomegalovirus)
6. Systemic conditions associated with aphthous stomatitis:
a. Behçet syndrome
b. Crohn disease
c. Ulcerative colitis
d. Cyclic neutropenia
e. Sprue
f. Intestinal lymphoma
B. Age and gender related—childhood to adolescence and young adults;
more common in females
C. Location—buccal and labial mucosa, soft palate, pharynx, tongue;
more common in the anterior regions
D. Clinical features (Fig. 8-24)

569
 FIG 8-24 Example of a minor aphthous ulcer. (From Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Ulcerations—oval or round in shape with distinct borders; the center

of the ulcer has a yellowish white fibrous surface surrounded by an
erythematous halo
2. Range from 1 to 12 in number (3 to 10 most common)
3. Size—3 to 10 mm
4. Pain, tenderness, discomfort
5. Interference with functions—speech, eating
6. Prodromal period of 1 to 2 days; characterized by a tingling or
burning sensation in the area where the ulcer will appear
7. Associated systemic factors can include low-grade fever and
localized lymphadenopathy
E. Histologic characteristics
1. Superficial erosion of mucosal tissue covered by a membrane
2. Connective tissue shows increased vascularity
3. Increase in PMNs, lymphocytes, and histiocytes
F. Treatment and prognosis
1. Self-limiting, healing in 10 to 12 days; recurrent episodes are
common
2. Topical corticosteroids; 0.12% chlorhexidine rinse; topical
tetracyclines
3. Betamethasone syrup (rinse and expectorate)

570
Major aphthous ulcers
Recurrent Scarifying Ulcerative Stomatitis
(RSUS); Periadenitis Mucosa Necrotica
Recurrens; Mikulicz Aphthae; Sutton Disease
A. Etiology
1. Autoimmune response of oral epithelium
2. T cell–mediated immunologic response
3. Decrease of mucosal tissue barrier
4. Inherited predisposition
B. Age and gender related—usually young adults, onset after puberty;
more common in females
C. Location—labial mucosa, buccal mucosa, soft palate, posterior fauces
D. Clinical features (Fig. 8-25)

FIG 8-25 Example of major aphthous ulcers located on the labial mucosa.
(From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014,
Elsevier.)

1. Multiple large ulcers, 1 to 10 in number and 1 to 3 cm in diameter

2. Crater-like formations with irregular shapes
3. Lesions heal in 3 to 6 weeks, producing scarring
4. Very painful

571
 5. Occur at frequent intervals; patient is rarely without an ulcer
E. Histologic characteristics
1. Fibrinopurulent membrane covering the ulcerated area
2. Necrotic epithelium
3. Intense inflammatory cell infiltration in connective tissue
4. Neutrophils and lymphocytes present
5. Granulation tissue at the base of the lesion
6. Microscopic picture is nonspecific; a conclusive diagnosis cannot be
made without thorough clinical and historical data
F. Treatment and prognosis
1. Corticosteroids
a. Systemic
b. Topical
2. Inject the lesion with triamcinolone acetonide
3. 0.05% Halobetasol propionate ointment
4. Recurrence is common

Mucous Membrane Pemphigoid, Cicatricial

Pemphigoid, Benign Mucous Membrane Pemphigoid
A. Etiology—chronic benign autoimmune disease
B. Age and gender related—ages 50 to 65 years; more common in females
(2:1)
C. Location
1. Gingiva
2. Oral mucous membranes
3. Eyes, nasal, esophageal, and vaginal mucosa
4. Skin
D. Clinical features
1. Vesicles or bullous lesions; surface is “thick” and does not rupture
easily
2. After rupture, the surface is eroded and raw (desquamated)
3. Desquamative appearance (not descriptive of this condition alone)
E. Histologic characteristics (Fig. 8-26)

572
 FIG 8-26 Histologic appearance of pemphigoid. (Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Vesicles and bullae are subepithelial

2. The epithelium appears to be detached from connective tissue
3. No evidence of acantholysis—degeneration of cohesive elements of
epithelial cells (as seen in pemphigus)
4. Inflammatory infiltrate in connective tissue
5. Direct immunofluorescence shows a linear pattern at the basement
membrane in over 90% of cases
F. Treatment and prognosis
1. Mild forms—topical corticosteroids
2. With bullous eruptions or conjunctival involvement, high doses of
systemic corticosteroids are needed
3. Certain systemic antibiotics
4. Once the diagnosis of cicatricial pemphigoid is made, the patient
should be referred for an eye examination, since eye involvement can
be severe but may not show any symptoms in the early stages
5. Patients go through periods of remission; long-term disease or
condition

Herpes
Primary Herpetic Gingivostomatitis
A. Etiology
1. Virus—initial infection with herpes simplex virus (HSV)
2. Member of the human herpesvirus (HHV) group
3. Transmission—droplet infection; direct contact; highly contagious

573
 (the amount of virus is highest in the vesicle stage); patients can self-
inoculate (especially the eyes)
B. Age and gender related—ages 6 months to 6 years; no gender
predilection
C. Location—lips, gingiva, tongue, pharynx, floor of the mouth, buccal
mucosa
D. Clinical features (Fig. 8-27)

FIG 8-27 A, Example of primary herpetic gingivostomatitis in a child. B and C,

Primary herpetic gingivostomatitis in an adolescent. (A courtesy of Dr. Edward V.
Zegarelli; A to C from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St
Louis, 2014, Elsevier.)

1. Systemic symptoms
a. Abrupt onset of fever
b. Headache, irritability

574
 c. Pain on swallowing
d. Regional lymphadenopathy
2. Oral symptoms
a. Hypertrophic gingivitis
b. Initially, tiny vesicles (pinhead size) that develop into
ulcerations
c. Painful ulcers 1 to 3 mm in size; covered by a yellowish fibrinous
surface
d. Shallow craters covered by white or yellow plaque; bright
erythematous margins (“halo”)
e. Most acute on days 3 to 7
E. Laboratory tests and findings
1. Cytologic smear (noninvasive and inexpensive test)
2. Blood test for HSV
3. Viral isolation from tissue culture of intact vesicles (best diagnostic
procedure but can take up to 2 weeks to obtain results)
F. Histologic characteristics
1. Vesicle is an intraepithelial blister filled with fluid
2. Degenerating cells show “ballooning”
3. Displacement of chromatin around the nucleus
4. Acantholysis of epithelium (Tzanck cells)
G. Treatment and prognosis
1. Symptomatic therapy—bed rest, fluids
2. Antiviral medications such as acyclovir (“swish and swallow”)
started within the first few days
3. Ibuprofen to reduce pain and discomfort
4. Self-limiting; healing in 7 to 14 days
5. Recurrence most common in the form of herpes labialis

Herpes Labialis (Cold Sore, Fever Blister)

A. Etiology
1. Residual form of HSV type 1
2. Recurrence of HSV from its latent stage
3. Stimuli that can trigger the onset
a. Exposure to sunlight
b. Trauma
c. Menstruation
d. Emotional stress, anxiety, fatigue
e. Allergic reactions
f. Systemic diseases

575
B. Age and gender related—adults; no gender predilection
C. Location
1. Lips—most common (herpes labialis)
2. Intraorally—hard palate, attached gingiva (keratinized mucosa fixed
to bone)
D. Clinical features (Fig. 8-28)

FIG 8-28 Herpes labialis. A, Twelve hours after onset. B, Forty-eight hours after
onset. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis,
2014, Elsevier.)

1. Prodromal period (any time up to 24 hours before the lesion erupts)

—burning sensation, feeling of tightness, tingling, or soreness where
the vesicle eventually appears
2. Several fluid-filled papules may appear in clusters (most contagious
state)

576
 3. Vesicles rupture, and crust forms on lips
4. Intraoral lesions can appear on keratinized mucosa
5. Do not confuse with angular cheilitis, a fungal infection
E. Histologic characteristics
1. Ballooning degeneration
2. Chromatin margination around the nucleus
3. Isolation of HSV
F. Treatment and prognosis
1. Antiviral drugs (e.g., acyclovir, valacyclovir) especially effective if
given during the prodromal period
2. Prophylactic treatment with antivirals before encountering a risk
factor, if possible
3. Topical application of 10% n-docosanol cream has been effective
4. Self-limiting; healing in 7 to 10 days
5. Sunscreen to prevent the development of herpes labialis
6. Chlorhexidine (0.12%) rinses, acyclovir suspension, or both can be
helpful to treat intraoral recurrent HSV
7. The condition does recur

Herpes Zoster (Shingles)

A. Etiology
1. Reactivation of varicella-zoster virus (VZV, HHV-3) from its latent
stage
2. VZV also causes chickenpox, which is considered the primary
infection with VZV
3. Risk factors for reactivation of VZV
a. Systemic disease (malignancies, Hodgkin’s disease, leukemia)
b. Drug toxicity, radiation, alcohol abuse
c. Advanced age
d. Extreme fatigue
e. Immunosupression
4. Depression of cell-mediated immunity
B. Age and gender related—adults, usually over 50 years; no gender
predilection
C. Location—skin or mucosa, supplied by the affected sensory nerve; any
of the three branches of the trigeminal nerve (Fig. 8-29); unilateral
distribution

577
 FIG 8-29 The divisions of the trigeminal nerve. (From Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

D. Clinical features (Fig. 8-30)

578
 FIG 8-30 Herpes zoster. A, Unilateral distribution of vesicles along the
distribution of a sensory nerve. B, Many vesicles coalesce to form large
lesions. C, Unilateral facial lesions occurring along the distribution of the
maxillary branch of the trigeminal nerve. (From Ibsen OAC, Phelan JA: Oral pathology
for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Three phases—prodromal, acute, chronic

2. Prodromal period of extreme pain 1 to 3 days before eruption of the
unilateral rash, which can be accompanied by systemic features such
as fever, severe headaches, lymphadenopathy, and overall weakness
3. The erythematous rash develops into vesicles; the pain becomes
more intense with a burning, tingling, or stabbing sensation
4. Clusters of these vesicles develop along the pathway of a sensory
nerve
5. Intraoral lesions can appear as multiple vesicles with a white center,
which eventually form shallow ulcerations; these lesions are also
unilateral and can be on movable or attached mucosa

579
 6. After the skin vesicles heal, a postherpetic neuralgia occurs
E. Treatment and prognosis
1. Antiviral medications (acyclovir, valacyclovir, famciclovir)
2. Postherpetic neuralgia is most difficult to control; several therapies,
including analgesics, narcotics, corticosteroids, anticonvulsants;
biofeedback, and nerve block
3. Cutaneous lesions should be kept clean and dry to prevent
secondary infection (antibiotics may have to be prescribed if the
infection does occur)
4. Antibacterial oral rinses for intraoral lesions
5. A varicella vaccine is available; Zostavax, for people 60 years and
older; is 14 times more effective than Varivax, the vaccine for
chickenpox
6. Prognosis is good if trigeminal nerve involvement is present (healing
in 2 to 3 weeks)
7. Postherpetic neuralgia can last for extended periods

Herpangina (Aphthous Pharyngitis)

A. Etiology—coxsackievirus
B. Age and gender related—children age 6 months to 5 years; no gender
predilection
C. Location—posterior hard or soft palate, fauces (pillars), uvula, tonsils;
most likely seen in the summer
D. Clinical features
1. Systemic symptoms
a. Comparatively mild and of short duration
b. Sore throat; dysphagia; headaches
c. Fever
d. Headache; vomiting; diarrhea
e. No lymphadenopathy—differs from primary herpes, which has
lymphadenopathy
f. Transmission through fecal-oral route or droplets
2. Oral symptoms (Fig. 8-31)

580
 FIG 8-31 Herpangina. (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

a. From erythematous macules to vesicles, to ulcers; ulcerations 2

to 4 mm in size
b. Vesicles are often overlooked
c. Two to six small ulcers; ulcers appear with a gray base and
inflamed periphery, usually on the soft palate or tonsillar areas
d. Slightly painful; the affected person has difficulty swallowing
(dysphagia)
e. Sudden onset—mild or subclinical
f. Erythematous pharynx
E. Laboratory tests
1. Viral isolation (throat culture during early stage)
2. Stool specimens
F. Treatment and prognosis
1. Self-limiting, with few complications
2. Nonaspirin pain relievers
3. Usually resolves within 7 days without treatment

Infectious Mononucleosis (Glandular Fever)

A. Etiology
1. Epstein-Barr virus (EBV)

581
 2. Transmission—intimate oral exchange of saliva; “kissing disease”
B. Age and gender related—children (transmission through saliva on
toys) and mostly young adults; no gender predilection
C. Clinical features
1. Systemic symptoms (depending on age)
a. Fever, chills, prodromal fatigue, malaise
b. Sore throat, pharyngitis
c. Headache
d. Nausea, vomiting
e. Prominent lymphadenopathy—large tender nodes (however, in
adults over 40, less than 30% exhibit lymphadenopathy)
f. Enlarged spleen (rupture)
g. Neurologic disorders, including seizures
2. Oral symptoms
a. Palatal petechiae
b. Necrotizing ulcerative gingivitis
c. Inflamed attached gingiva
d. Ulcerations similar to those of herpes or herpangina
e. Purpuric spots beneath the epithelium (thrombocytopenia—a
decrease in the number of platelets)
f. Edema of the soft palate and uvula
D. Laboratory tests and findings
1. Increased white blood cells (WBCs) with atypical activated
lymphocytes; presence of these atypical lymphocytes in peripheral
blood is very characteristic
2. Increased heterophil antibody titer; positive Paul-Bunnell test in
young adults but not in children under 4 years old
3. Indirect immunofluorescence test for EBV
E. Treatment and prognosis
1. Bed rest
2. Nonaspirin antipyretics and nonsteroidal anti-inflammatory drugs
(NSAIDs)
3. Benign and self-limiting; fatigue may last longer
4. Mononucleosis resolves in 4 to 6 weeks
5. Complications can include splenic, hepatic, and neurologic
involvement

582
Skin diseases
General Characteristics
A. Characterized by various forms and sizes of ulcerative eruptions
B. Lesions may appear first or during the course of the disease
C. Reaction simulates an allergic-type reaction

Erythema Multiforme
A. Etiology
1. Etiopathogenesis, acute onset, self-limiting condition thought to be a
hypersensitivity reaction
2. May be triggered by HSV infection, tuberculosis, or histoplasmosis;
drugs (e.g., barbiturates, sulfonamides); Mycoplasma pneumoniae
3. Immunologic response
B. Age and gender related—young adults ages 20 to 30 years; more
common in males
C. Location
1. Extremities—hands, feet, arms, legs
2. Skin—macular, papular, or bullous eruptions; characteristic “target”
or “bull’s-eye” lesions in 50% of cases.
3. Oral findings—lips, labial and buccal mucosa, tongue, floor of the
mouth, soft palate
D. Clinical features (Fig. 8-32)

583
 FIG 8-32 Skin lesions of erythema multiforme. A, Target lesion (arrow). B,
Bullae. C, Crusted lip lesions with edema, ulceration, and erythema. D,
Erythematous and ulcerated lesions of the lips and buccal mucosa. (A courtesy
of Dr. Edward V. Zegarelli; A to D from Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Systemic symptoms
a. Abrupt onset
b. Prodomal symptoms (e.g., fatigue, malaise, fever)
c. Previous occurrences
d. Has been associated with systemic conditions
e. The characteristic skin lesion is referred to as bull’s-eye, target,
or iris
2. Oral symptoms
a. Generally lips, tongue, and buccal mucosa
b. Red patches develop into multiple, painful ulcerations; onset is
explosive
c. Macules, papules, or vesicles ulcerate and bleed easily
d. A raw tissue base with a grayish, necrotic slough
e. Irregular shape; surrounded by a band of inflammation;
encrustations
f. Edema and hemorrhagic crusting of the vermilion border of lips

584
E. Laboratory tests—biopsy for differential diagnosis
F. Histologic characteristics
1. Mixed inflammatory infiltrate
2. Intraepithelial vesicle formation and thinning
3. Absence of a basement membrane
4. Dilation of capillaries and lymphatic vessels in the surface layer of
connective tissue
G. Treatment and prognosis
1. Removal of the cause, if identified or even suspected
2. Topical or systemic applications of corticosteroids
3. Mild antibacterial oral rinses; antibiotics if secondary infection
develops
4. If patient has significant oral pain, intravenous rehydration may be
necessary
5. Condition resolves in 2 to 4 weeks
6. Recurrence is possible

Stevens-Johnson Syndrome (Erythema Multiforme

Major)
A. Severe bullous form of erythema multiforme (EM)
B. Etiology—unknown; usually triggered by a drug; the most severe form
of EM
C. Age and gender related—children and young adults under 25 years;
more common in males; history of previous similar illness
D. Location—oral cavity, skin; lesions involving the eyes or genitalia must
be present for the diagnosis to be made
E. Clinical features (Fig. 8-33)

585
 FIG 8-33 Stevens-Johnson syndrome. (Courtesy of Dr. Sidney Eisig; from Ibsen OAC,
Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Oral symptoms—bullae rupture, leaving ulcerations with a raw base;

eating becomes impossible; lips are severely encrusted and bleed
easily
2. Skin lesions—severe, numerous; cover wide areas of the body (face,
chest, abdomen)
3. Eye involvement—severe conjunctivitis, photophobia, corneal
ulceration, scarring, and blindness
F. Treatment and prognosis
1. Antibiotics and corticosteroids to control severity
2. Sometimes antiviral medications to reduce recurrent episodes if
HSV recurs
3. Duration of 1 to 4 weeks
4. Some patients require hospitalization
5. Prognosis is usually good
6. Mortality rate is 2% to 10% with this form of EM

586
Behçet Syndrome
A. Etiology—chronic recurrent autoimmune disease
B. Age and gender related—young adults, no gender predilection
C. Location—although now considered a multi-system disorder, Behçet
syndrome is characterized by a triad of locations: oral, occular, and
genital areas are involved; two of the three areas must be involved for the
diagnosis
1. Oral cavity—in most cases, the first manifestation
2. Eyes are involved in up to 85% of cases, with greater severity in men
3. Genital lesions occur in 75% of cases, with more involvement in men
D. Clinical features (Fig. 8-34)

FIG 8-34 Oral lesion seen in Behçet syndrome. Aphthous-like oral mucosal
ulcer. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis,
2014, Elsevier.)

1. Oral lesions
a. Painful ulcerations similar to minor aphthous or major
aphthous ulcers, occurring in about 40% of Behçet patients, and
in 3% with the herpetiform variety

587
 b. Large ulcers with gray or yellow center surrounded by a red
border
c. Oral ulcerations involve the soft palate and oropharynx
2. Eye lesions
a. Begin with photophobia and irritation
b. Purulent conjunctivitis and uveitis
c. Healing may be followed by scarification and, consequently,
blindness
d. Hypopyon (pus in anterior chamber of eye between iris and
cornea) in severe cases; rare
3. Genital lesions
a. In females—painful ulcerations in the vagina, vulval folds, and
labia majora
b. In males—painful ulcerations on the scrotum and base of the
penis
4. Systemic symptoms
a. Occasionally fever; pallor
b. Complications can involve the central nervous system (CNS)
and cardiac, vascular, and pulmonary systems
c. Arthritis involving knees, wrists, elbows, and ankles
E. Laboratory tests and findings
1. Cutaneous pathergy test is positive in many patients with Behçet
syndrome
2. Specific changes involving the neutrophils
F. Histologic characteristics
1. Histopathologic features are nonspecific
2. Endothelial proliferation in lesions
3. Other characteristics similar to those of aphthous stomatitis
G. Treatment and prognosis
1. Early aggressive therapy for patients with severe clinical
manifestations
2. Systemic and topical corticosteroids
3. Other immunosuppressive drugs are given for systemic and ocular
involvement
4. Lesions last 2 to 4 weeks
5. Disease is long lasting with remission periods
6. Mortality is low and most often associated with CNS or pulmonary
hemorrhage or bowel perforation

Pemphigus Vulgaris

588
A. Etiology—severe, progressive autoimmune disease that affects skin
and mucous membranes
B. Age and gender related—adults, usually between ages 40 and 55 years;
no gender predilection
1. More common in Ashkenazic Jews, South Asians, or persons of
Mediterranean heritage
C. Location—anywhere on the oral mucosa; eyes, or skin
D. Clinical features (Fig. 8-35)

FIG 8-35 A and B, Examples of oral lesions in pemphigus vulgaris. (B courtesy of

Dr. Fariba Younai; A and B from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist,
ed 6, St Louis, 2014, Elsevier.)

1. In over 50% of cases, the oral lesions appear first; skin lesions can
erupt many months or even a year later
2. Blisters (caused by an abnormal production of autoantibodies),

589
 vesicles, or bullae collapse as soon as they are formed
a. Vary in shape and size (from several millimeters to several
centimeters)
b. Ragged peripheral borders; flat or shallow; base intensely red
and raw; may extend into the lips with crusting
3. Filmy, necrotic slough of tissue can be detached from underlying
tissue
4. Neighboring soft tissue appears normal
5. Nikolsky sign present—an intraoral bulla can form under light
pressure from air syringe or tongue blade; same reaction can occur if
pressure is applied to skin
6. Pain may be severe, and the person is unable to eat
7. Salivation is profuse; mouth odor
8. Gingival desquamation
E. Laboratory tests and findings
1. Biopsy and most conclusive microscopic analysis
2. Direct immunofluorescence used to identify antibodies
(intercellular)
3. Indirect immunofluorescence is positive for 80% to 90% of patients
with pemphigus vulgaris, showing circulating autoantibodies in the
serum; also used to monitor patient’s therapy
F. Histologic characteristics
1. The vesicle or bulla is entirely intraepithelial above the basal cell
layer, producing a distinctive “split”; the basement layer stays
attached to underlying connective tissue
2. Intercellular bridges between epithelial cells disappear, with loss of
cohesiveness; epithelial cells separate (acantholysis)
3. Clumps of rounded epithelial cells, called Tzanck cells, are present
4. Some inflammatory cell infiltration in connective tissue
G. Treatment and prognosis
1. Systemic corticosteroids (prednisone)
2. Other immunosuppressive drugs such as azathioprine and
methotrexate are used in addition to corticosteroids
3. Measure the titers of circulating autoantibodies using indirect
immunofluorescence
4. Patient may experience periods of remission; never a “cure”
5. Mortality is under 10% and associated with complications from long-
term corticosteroid therapy
6. Potential side effects associated with long-term systemic
corticosteroids include diabetes mellitus, adrenal suppression, and
infections

590
White lesions
General Characteristics
A. Often associated with hyperkeratosis; clinical term for leukoplakia
B. Vary from simple lesions to diffuse coverage; smooth to rough
surfaces; elevated to flat
C. Attached to mucous membranes
D. Color—white, grayish white, yellowish white
E. Painless
F. Associated with a variety of conditions (including variants of normal,
systemic disease, and premalignant lesions)

Nicotine Stomatitis
A. Etiology—heavy tobacco smoking using cigarettes, cigars, water pipe
(hookah), or pipe; often associated with pipes (“pipe smoker ’s palate”)
B. Age and gender related—most common in male smokers over 40 years
C. Location—posterior hard and soft palates
D. Clinical features (Fig. 8-36)

FIG 8-36 Nicotine stomatitis. (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Begins with erythema and inflammation of the palate; response to an

591
 irritant (heat)
2. Over time, the palate becomes more keratinized and grayish white;
thickened nodules surround the inflamed orifices of the minor
salivary ducts
3. Fissures or cracks around the nodules create an overall wrinkled
appearance
E. Histologic characteristics
1. Hyperkeratosis and acanthosis
2. Thickening of the epithelium adjacent to the orifice
F. Treatment and prognosis
1. If the cause is removed—smoking—the condition may be reversible
2. The prognosis is good if the person permanently stops smoking and
the tissues return to normal
3. If tissues do not return to normal after smoking irritants are
removed, biopsy may be necessary

Linea Alba
A. Etiology—pattern of occlusion; pressure of teeth on buccal mucosa
B. Age and gender related—any age; no gender predilection
C. Location—buccal mucosa along the occlusal plane; usually bilateral
D. Clinical features (Fig. 8-37)

592
 FIG 8-37 Linea alba. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist,
ed 6, St Louis, 2014, Elsevier.)

1. “White line” on the buccal mucosa, anterior to posterior along the

line of occlusion
2. Localized, single line in thickness; usually bilateral
E. Histologic characteristics—hyperorthokeratosis; some localized
intracellular edema
F. Treatment and prognosis—no treatment required

Leukoedema
A. Etiology—unknown; a variant of normal
B. Age and gender related—average age 45 years; no gender predilection;
African Americans are more affected (85% of incidence) than other racial
groups
C. Location—bilateral buccal and labial mucosa
D. Clinical features
1. Soft, diffuse, velvety, filmy opalescence of buccal mucosa
2. Later becomes grayish white with a coarsely wrinkled surface
3. When the tissue is stretched, the white opalescence disappears (this
clinical characteristic can help in the differential diagnosis)
4. Some research shows it is more prominent in smokers

593
E. Histologic characteristics
1. Intracellular edema of prickle cells (spinous layer)
2. Increased thickness of epithelium with a superficial parakeratotic
layer several cells thick
3. Broad rete pegs that appear irregularly elongated
4. Parakeratin on epithelial surface
F. Treatment and prognosis—no treatment required; considered a variant
of normal

Systemic Lupus Erythematosus (SLE)

A. Etiology—acute and chronic inflammatory autoimmune disease
involving several systems
1. Cellular and humoral immunity are impaired
2. B lymphocytes increase function; T lymphocytes do not function
properly
B. Age and gender related—much more common in females (8:1) during
childbearing years; African American females more affected than white
females (3:1); average age 31 years
C. Location
1. Buccal mucosa, palate, gingiva (25% to 30% of persons with SLE)
2. Skin—lesions occur in 85% of persons with SLE; a characteristic
erythematous butterfly-shaped rash on the face (malar areas) and
nose; chest, back, extremities; exposure to sunlight makes the rash
worse
D. Systemic characteristics
1. Fever, weight loss, arthritis, muscle pain
2. Raynaud phenomenon is seen in up to 15% of persons with SLE
3. CNS involvement, depression, and seizures
4. Ocular involvement; retinal nerve damage
5. Kidney involvement (complications can be fatal)
6. Cardiac involvement (pericarditis)
7. Warty vegetations affecting heart valves (Libman-Sacks endocarditis)
E. Clinical features (Fig. 8-38)

594
 FIG 8-38 A and B, Oral lesions in lupus erythematosus. (Courtesy of Dr. Edward V.
Zegarelli; from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis,
2014, Elsevier.)

1. Skin lesions—erythematous rash; scales form, scarring in the center;

butterfly configuration on the malar areas of the face and nose
2. Among those with SLE, 25% to 30% have oral manifestations
3. Erythematous plaques with white striae; can resemble lichen planus
but is less defined
4. Burning mouth; xerostomia; candidiasis
F. Laboratory tests and findings
1. Direct immunofluorescence of skin lesion (95% effective for SLE)
2. Direct immunofluorescence of normal skin showing a positive lupus
band in 25% to 60% of persons with SLE
3. Anemia; leukopenia; thrombocytopenia
4. Positive identification of antinuclear antibodies (ANAs); not very
specific

595
 5. Anti–double-stranded DNA antibodies, a specific finding in up to
80% of patients with SLE
6. A combination of these test findings, multi-organ involvement, skin
lesions, and possible oral lesions can all play a role in the definitive
diagnosis of this very complex disease
G. Histologic characteristics
1. Hyperkeratosis; alternating changes within the spinous layer of the
epithelium
2. Necrosis of the basal cell layer
3. Inflammatory infiltrate around blood vessels in the connective tissue
not in a subepithelial band as seen in lichen planus
4. Deposits of a periodic acid–Schiff (PAS) stain material in the
basement membrane
5. Subepithelial edema
H. Treatment and prognosis
1. Aspirin and NSAIDs
2. Antimalarial and corticosteroids combined with other
immunosuppressive medications
3. Periods of remission; in mild cases, the prognosis is good; with
significant organ involvement, the disease can be fatal; prognosis is
worse for men
4. Consult with patient’s physician before dental treatment;
prophylactic antibiotic premedication may be necessary
5. Patients should avoid exposure to sunlight because ultraviolet light
can precipitate disease activity

White Sponge Nevus (Cannon Disease, Familial

White Folded Dysplasia)
A. Etiology—hereditary; autosomal dominant trait; mutation in the
mucosal keratin pair K4 or K13; complete penetrance with varying
degrees of expressivity
B. Age and gender related—progressive from childhood to adulthood; no
gender predilection
C. Location—bilateral buccal mucosa is always affected (sometimes soft
palate or ventral tongue)
D. Clinical features
1. White, velvety, thickened, and folded tissue of the buccal mucosa
2. Diffuse, generalized, and bilateral
3. Early years—the white mucosa is smooth and flat; becomes
corrugated over time

596
 4. Adolescence—tissues become increasingly folded or corrugated;
appear opalescent-white when the condition peaks
E. Histologic characteristics
1. Thickened epithelium with hyperparakeratosis and acanthosis
2. Perinuclear condensation of keratin tonofilaments in the superficial
cells of the epithelium
3. Cells of the spinous layer toward the surface exhibit vacuolation
(space filled with fluid or air)
F. Treatment and prognosis
1. No treatment required
2. Prognosis is excellent

Lichen Planus
A. Etiology—benign, chronic disease; immunologically mediated
mucocutaneous disorder
B. Age and gender related—middle-aged adults; slight predilection for
females
C. Location—skin; oral mucosa; especially buccal mucosa, dorsal tongue,
gingiva, and palate
D. Clinical features—two forms: reticular and erosive
1. Reticular lichen planus (most common) (Fig. 8-39, B)

597
 FIG 8-39 Lichen planus. A, Erosion of the mucosa appears as erythema
adjacent to white striae. B and C, Two additional examples of the oral
lesions of lichen planus. (A courtesy of Dr. Edward V. Zegarelli; A to C from Ibsen
OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

a. White, narrow, interconnecting, slightly elevated lines forming a

mesh, net, or lace-like pattern (Wickham’s striae); these lesions
can also look like white papules; cannot be wiped off
b. Mucous membrane between the white lines appears normal
c. When the dorsal tongue is involved, the lesion may appear as a
solid gray to white, plaque-like area
d. Usually asymptomatic
2. Erosive or ulcerative form
a. Lesions are symptomatic, patient experiences pain
b. The condition begins as an erosive, flat lesion
c. This erythematous area is ulcerated, painful, and surrounded by
fine white borders

598
 d. Slightly increased risk for squamous cell carcinoma in persons
with erosive lichen planus; a 3-month recare appointment with
thorough extraoral and intraoral examination should be
scheduled
e. Atrophy of the gingiva is described as desquamative (Fig. 8-40);
this feature can appear with other oral conditions

FIG 8-40 Lichen planus. The gingival lesions of lichen planus are
described clinically as desquamative tissue. (Courtesy of Dr. Edward V.
Zegarelli; from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist,
ed 6, St Louis, 2014, Elsevier.)

E. Histologic characteristics (Fig. 8-41)

599
 FIG 8-41 Lichen planus seen by low-power microscopy. Note the degeneration
of the basal cell layer of the epithelium (B) and the band-like infiltrate of
lymphocytes (L). (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed
6, St Louis, 2014, Elsevier.)

1. Hyperparakeratosis or hyperorthokeratosis on the surface

epithelium
2. Thickened spinous layer (acanthosis)
3. Intracellular edema of cells in the spinous layer
4. Necrosis or degeneration of the basal cell layer
5. Band-like infiltrate of lymphocytes
F. Treatment and prognosis
1. Treatment for symptomatic cases; no treatment for reticular lichen
planus
2. Corticosteroids to decrease ulcerations and inflammation (systemic
only when absolutely necessary)
3. Topical corticosteroids (e.g., fluocinonide) applied several times a
day
4. Meticulous oral hygiene
5. Lesions are self-limiting; heal in a few weeks with topical
corticosteroid therapy
6. The condition does recur, and corticosteroids need to be reapplied
7. Patients with erosive lichen planus should be reevaluated every 3 to
4 months

Hyperkeratosis
A. Etiology—local factors; constant, low-grade irritation (frictional
keratosis; chronic tongue chewing, cheek biting, repetitive irritation);

600
vitamin A deficiency can cause excessive keratinization of skin and
mucous membranes
B. Age and gender related—usually over age 40 years; more common in
males
C. Location—anywhere in the oral cavity; alveolar ridge, buccal mucosa,
lateral tongue
D. Clinical features (Fig. 8-42, A and B)

FIG 8-42A, Frictional keratosis (arrow) caused by an opposing third molar. B,

Caused by chronic tongue chewing. C, Low-power microscopic appearance of
hyperkeratosis showing an increase in the amount of surface keratin (K). (From
Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. White, flat lesion with a diffuse boundary

2. Three layers of epithelium affected: granular, prickle, and basal cell
layers

601
 3. Fissures or ulcerations rare
E. Laboratory tests—incisional biopsy
F. Histologic characteristics (Fig. 8-42, C)
1. Abnormal layer of keratin or parakeratosis where not normally
found
2. Increased thickness of keratin in areas where normally found (e.g.,
attached gingiva, palate)
3. Normal underlying epithelial cells
4. Scalpel biopsy necessary for microscopic evaluation
G. Treatment and prognosis
1. Removal of the cause (irritant)
2. Tissue should return to normal

602
Neoplasia
Squamous Cell Carcinoma (SCC)
A. Etiology—chemicals such as phenoxyacetic acids, viruses, and
radiation; secondary to genetic mutation; immunosuppression
1. Risk factors include use of all forms of tobacco, alcohol abuse, and
increasing age
2. A combination of these risks can be lethal
3. Iron deficiency anemia, especially the severe form, Plummer-Vinson
syndrome, also elevates the risk for SCC in the posterior mouth and
esophagus
4. SCC accounts for 90% to 95% of oral cancers
B. Age and gender related—young adults to adults in their 60s, 70s, and
beyond
1. Incidence increases with increasing age
2. Sixth most common cancer in males and twelfth in females
3. Ratio of incidence in males and females is 2:1
4. Highest overall incidence in white males after 65 years; highest
incidence in middle age found in African American males
C. Locations
1. Tongue—37% to 50% of all oral carcinomas, excluding cancer of the
pharynx
a. Posterior third, including the lateral borders and ventral
surfaces, account for most of these
b. The tongue is by far the primary location for SCC in the oral
cavity
2. Floor of the mouth—30% to 35%, mostly in men
3. Lips—22%; most of these occur on lower lip; pipe, cigar smokers,
patients with fair skin, and persons with an outdoor occupation who
are exposed to sunlight have a definite predilection for SCC of the
lower lip (Fig. 8-43)

603
 FIG 8-43 A and B, Clinical appearance of squamous cell carcinoma of
the lower lip. (Courtesy of Dr. Edward V. Zegarelli; from Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

4. Buccal mucosa—6%
5. Gingiva—6%
6. Soft palate—4%; metastasis has already occurred by the time a
diagnosis is made
7. The mandible is a more common location than the maxilla and is
usually the result of metastasis from other areas
D. Clinical features (Fig. 8-44, A to C)

604
 FIG 8-44 A, Clinical appearance of squamous cell carcinoma (SCC) of the
posterolateral tongue showing an exophytic, ulcerated mass. B, Clinical
appearance of SCC of the left side of the soft palate and fauces. C, Clinical
appearance of SCC on the floor of the mouth. D, Left side of a panoramic
radiograph showing destruction of the mandible by SCC. (C courtesy of Dr. Edward
V. Zegarelli; A to D from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St
Louis, 2014, Elsevier.)

1. Exophytic, indurated, ulcerated, firm lesion in soft tissue; feels

anchored to underlying tissue
2. On lower lip, smaller crusted ulceration, indurated border;
asymptomatic
3. Sores or ulcerations that do not heal
4. Stages—tumor-node-metastasis (TNM) staging system helps predict
the patient’s prognosis (Box 8-1)

Box 8-1
TNM Staging System for Oral Squamous Cell
Carc inoma
T—Tumor
T1—Tumor < 2 cm in diameter
T2—Tumor 2-4 cm in diameter
T3—Tumor > 4 cm in diameter
T4—Tumor invades adjacent structures
N—Node

605
N0—No palpable nodes
N1—lpsilateral (same side as primary tumor) palpable nodes (same side
as tumor)
N2—Contralateral (opposite side from primary tumor) or bilateral nodes
N3—Fixed palpable nodes
M—Metastasis
M0—No distant metastasis
M1—Clinical radiographic evidence of metastasis
From Regezi JA, Sciubba JJ: Oral pathology: clinical pathologic correlations, ed 5, Philadelphia, 2008,
Saunders.TNM, Tumor-node-metastasis.

a. Stage I—early; asymptomatic; tumor less than 2 cm

in diameter
b. Stage II—intermediate; tumor 2 to 4 cm in diameter
c. Stage III—advanced; tumor greater than 4 cm
d. Stage IV—tumor metastasizes to other, adjacent areas
E. Radiographic appearance (Fig. 8-44, D)
1. Diffuse radiolucency with irregular borders after significant bone
has been destroyed; penetration into the cortex
2. Resorption of tooth roots; expansion in between roots
F. Laboratory tests and findings
1. Biopsy—scalpel biopsy is the “gold standard”
a. Incisional—removal of a segment or piece of the lesion for
microscopic analysis
b. Excisional—removal of the entire lesion in question for
microscopic analysis
2. Screening tools (see the section on “Diagnostic Tools for Oral Cancer
Detection” in Chapter 16)
a. Brush test—a small circular brush is rotated about 10 times on
the surface cells of the lesion to obtain a transepithelial
specimen from all layers of the epithelium to the basement
membrane; positive and atypical results require a scalpel biopsy
for complete microscopic analysis and a definitive diagnosis;
research needed to establish efficacy
b. ViziLite—tissues are illuminated with a special light after
patient rinses with acetic acid; areas that turn white are
evaluated and, for those in question, a scalpel biopsy is
performed; subtle lesions that may appear “within normal
limits” during the intraoral examination can clearly be

606
 identified with ViziLite, although some variants of normal may
also become more obvious; research needed to establish efficacy
c. VelScope Vx—enhanced oral assessment screening tool that
uses a handheld scope and natural tissue fluorescence to
discover abnormalities; used with the recommended intraoral
examination; handheld device emits a fluorescent blue light into
the oral cavity; normal tissue reflects green; abnormal tissue
reflects brown to black; “abnormal” tissue may be linea alba;
clinician needs to be experienced with variants of normal before
using VelScope; research needed to establish efficacy
G. Histologic characteristics
1. Invasion of sheets of tumor cells into underlying connective tissue
(neoplastic squamous cells)
2. Presence of keratin pearls (cluster of concentrically layered
keratinized cells)
3. Neoplastic cells that contain large, hyperchromatic nuclei and
mitotic figures
H. Treatment and prognosis
1. Surgical excision alone or excision with a combination of radiation
and chemotherapy; sometimes radiation therapy alone
2. Tumor size and location both influence the treatment protocol
3. Adjunctive chemotherapeutic agents
4. When metastasis has occurred (lymph node involvement), more
radical procedures are performed
5. Prognosis depends on the tumor stage

607
Pleomorphic adenoma (benign mixed
tumor)
A. Etiology—benign salivary gland tumor that accounts for 90% of all
benign salivary gland tumors
B. Age and gender related—most common in adults ages 35 to 55 years;
female predilection; can occur in children
C. Location
1. Parotid gland
2. Posterior hard or soft palate (most common intraoral site); unilateral
D. Clinical features (Fig. 8-45)

FIG 8-45 Benign salivary gland tumor of the palate (pleomorphic adenoma).
(From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014,
Elsevier.)

1. Located on either side of the midline of the posterior palate

2. Painless, slow growing
3. Smooth, dome-shaped mass, not ulcerated (unless traumatized)
4. Size from a few millimeters to a few centimeters
E. Histologic characteristics
1. An encapsulated tumor composed of epithelium and connective
tissue
2. Most benign; malignant transformation in less than 5% of cases
F. Treatment and prognosis
1. Surgical excision
2. Sometimes partial or complete removal of the parotid gland in the

608
 area
3. Research reports about 5% risk of malignant transformation
4. Conservative enucleation is not recommended because it leads to
high recurrence rates
5. Prognosis is excellent if proper surgical techniques are used

609
Cysts
A. True cyst
1. Cavity lined by epithelium and enclosed within a capsule of
connective tissue
2. Space often filled with fluid or fragments of tissues
B. Cysts are classified according to:
1. Etiology, histologic components; location
2. Odontogenic; nonodontogenic; inflammatory response

Radicular Cyst (Root-End Cyst, Periapical Cyst)

A. Etiology
1. A true cyst; develops as an inflammatory response; associated with a
nonvital tooth
2. Factors could include dental caries, trauma, deep restorations
causing pulpitis
B. Age and gender related—any age, but common ages 30 to 60 years;
slight predilection for males
C. Location—apex of a tooth or lateral to the tooth root
D. Clinical features
1. Nonvital tooth
2. Usually asymptomatic
E. Radiographic appearance
1. Round or ovoid, well-defined radiolucent area attached to the apex
or lateral to the root (Fig. 8-46, A)

610
 FIG 8-46 Radicular cyst. A, Radiograph showing a well-circumscribed
radiolucency around the root of a tooth (arrow). B, Microscopic features
of a radicular cyst. (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

2. Loss of lamina dura in the area; root resorption is possible

3. Same radiographic appearance as periapical granuloma
F. Histologic characteristics
1. Lined by stratified squamous epithelium; developing from epithelial
rest of Malassez
2. The wall is composed of well-vascularized dense fibrous connective
tissue (Fig. 8-46, B)
3. Lumen is filled with cellular debris
G. Treatment
1. Root canal therapy
2. Extraction of the tooth and curettage of the socket and apical area to
remove the cystic sac

611
 3. If radiolucency fails to resolve the condition, retreatment
endodontically; apicoectomy may be required
4. Follow-up in 1 to 2 years

Residual Cyst
A. Etiology
1. Radicular cyst that has not been removed after extraction of the
involved tooth
2. Open socket with debris acting as a stimulus
B. Age and gender related—usually adults who were treated for a
radicular cyst
C. Location
1. Apical area where a tooth had previously been extracted
2. Within the socket area or on the alveolar ridge
3. At the alveolar ridge where a tooth had previously been extracted
D. Clinical features—small and asymptomatic
E. Radiographic appearance
1. Well-defined radiolucent area (Fig. 8-47)

612
 FIG 8-47 A, Schematic of a residual cyst. B, Radiograph of a residual
cyst showing a radiolucency at the site of a previously extracted tooth.
(Courtesy of Drs. Paul Freedman and Stanley Kerpel; from Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

2. Round or oval in shape

3. In time, this radiolucency can become somewhat radiopaque
because of histologic changes within the lumen
F. Histologic characteristics
1. Stratified squamous epithelium lining the lumen
2. Dense fibrous connective tissue wall
G. Treatment—surgical removal of the cyst

613
Developmental cysts
Nonodontogenic Cysts
A. Etiology
1. Median mandibular cyst—cyst in midline of the mandible; develops
from an odontogenic origin, possibly a primordial cyst; rare
2. Globulomaxillary cyst—arises from the odontogenic epithelium
between the maxillary lateral incisor and canine (not a fissural cyst)
3. Nasolabial cyst—soft tissue cyst; develops from the inferior and
anterior segments of the nasolacrimal duct; strong female
predilection (4:1)
4. Median palatine cyst—fissural cyst; posterior form of a nasopalatine
canal cyst; young adults
5. Nasopalatine canal cyst (incisive canal cyst)—develops from the
epithelial remnants of embryonal nasopalatine ducts; strong male
predilection
B. Age and gender related—adults; no gender predilection, unless
specified
C. Location—names are based on location
1. Median mandibular cyst—occurs at the midline of the anterior
mandible; surrounding teeth are vital
2. Globulomaxillary cyst—appears as a pear-shaped radiolucency
between the roots of the maxillary lateral incisor and canine
3. Nasolabial cyst—upper lip, lateral to midline; in the mucolabial fold
in the area of the maxillary canine and the floor of the nose
4. Median palatine cyst—arises at the midline of the hard palate
5. Nasopalatine canal cyst—appears within the nasopalatine canal or
the incisive papilla
D. Clinical features
1. Cysts vary in size from no evidence of a lesion to a bulge or
expansion of bone
2. All teeth are vital when associated with nonodontogenic cysts
E. Radiographic appearance—well-defined radiolucent area; some have
particular shapes because of the anatomical location where they develop
1. Globulomaxillary cyst—located between the maxillary lateral incisor
and canine; often pear shaped (Fig. 8-48)

614
 FIG 8-48 Radiograph of a globulomaxillary cyst showing a characteristic
pear-shaped radiolucency between the maxillary lateral incisor and
canine. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St
Louis, 2014, Elsevier.)

2. The nasopalatine canal (incisal canal) cyst is heart shaped

F. Histologic characteristics
1. Median mandibular cyst—most often lined by stratified squamous
epithelium; few cases of pseudostratified ciliated columnar
epithelium
2. Globulomaxillary cyst—lined by inflamed stratified squamous
epithelium; can histologically resemble the components of several
other cystic lesions
3. Nasolabial cyst—lined by pseudostratified columnar epithelium;
some cuboidal epithelium
4. Median palatal cyst—lined by stratified squamous epithelium;
chronic inflammation in cell wall

615
 5. Nasopalatine canal cyst—several types of epithelium are found in
this cyst; most often, stratified squamous epithelium
G. Treatment and prognosis
1. Enucleation of the cystic sac and curettage of surrounding bone
2. Prognosis is excellent

Thyroglossal Tract Cyst (Thyroglossal Duct Cyst)

A. Etiology—developmental; in the thyroglossal tract, which extends
from the foramen cecum to the permanent position of the thyroid gland
in the neck region; the embryonic thyroglossal tract; inflammation is the
stimulus possibly associated with adjacent lymph tissue that reacts from
a draining infection from the head and neck area
B. Age and gender related—usually young adults under 20 years; no
gender predilection
C. Location—posterior tongue, anywhere from the foramen cecum to the
suprasternal notch; 75% of these lesions are below the hyoid bone
D. Clinical features (Fig. 8-49)

616
 FIG 8-49 A, Thyroglossal tract extends from the area of the foramen cecum,
lingual to the lower part of the neck. B, Thyroglossal tract cyst is the cause of
enlargement at the midline of the neck. (From Ibsen OAC, Phelan JA: Oral pathology
for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Asymptomatic; painless; movable swelling; midline of the neck

2. Bulge is round or oval shaped; usually less than 3 cm in diameter
3. Fistulous tracts to the skin or mucosa can develop
4. Swallowing becomes difficult (dysphagia)
5. Inability to extend the tongue
E. Histologic characteristics
1. Cysts below the hyoid bone are lined with ciliated columnar
epithelium; squamous epithelium or other types of epithelial tissue
above the hyoid bone
2. Connective tissue wall may contain thyroid tissue
F. Treatment and prognosis
1. Complete surgical excision of the cyst (after a thyroid scan)

617
 2. Surgical procedure will include removal of part of the hyoid bone
and muscle tissue in the tract
3. Prognosis is good
4. Malignant transformation is rare

Lymphoepithelial Cyst (Branchial Cleft Cyst)

A. Etiology
1. Epithelial remnants of the embryonic brachial arches
2. About 95% develop from the second branchial arch
3. Epithelium entrapped in lymph nodes (another theory of
development)
B. Age and gender related—young adults; no gender predilection
C. Location
1. Intraoral lymphoepithelial cyst—posterior floor of the mouth and
lateral borders of the tongue
2. Cervical lymphoepithelial cyst—located on the lateral neck near the
anterior border of the sternocleidomastoid muscle
3. Area from the clavicle to the parotid gland
D. Clinical features
1. Slow-growing, movable mass 1 to 10 cm in diameter; asymptomatic
2. Can have a pink to yellowish color when found intraorally
3. If trauma or infection is associated, pain may be present
E. Histologic characteristics (Fig. 8-50)

618
 FIG 8-50 Low-power microscopic appearance of a lymphoepithelial cyst
showing lumen (Lu), epithelial lining (E), surrounding lymphocytes (L), and
connective tissue (CT). (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Lined by stratified squamous epithelium that may or may not be

keratinized
2. Lymphoid tissue in the wall
F. Treatment and prognosis
1. Surgical removal
2. Prognosis is good

Dermoid Cyst
A. Etiology—developmental from all three germ layers: ectoderm,
endoderm, mesoderm; benign cystic form of teratoma
B. Age and gender related—present at birth or in young children; no
gender predilection
C. Location
1. In the oral cavity, anterior floor of the mouth; can displace tongue
2. Ovarian teratomas, or “dermoids,” contain actual tooth structures
D. Clinical features
1. Semi-firm, dough-like consistency
2. Size—a few millimeters to several centimeters
3. Midline of the floor of the mouth
E. Histologic characteristics
1. Lined with orthokeratinized stratified squamous epithelium
2. Keratin within the lumen

619
 3. A fibrous connective tissue wall
4. May contain sebaceous glands, hair follicles, sweat glands, and
occasionally teeth
F. Treatment and prognosis
1. Surgical removal; approach depends on the location relative to the
geniohyoid muscle
2. Prognosis is good

620
Odontogenic cysts
Lateral Periodontal Cyst (LPC)
A. Etiology—developmental; odontogenic cyst; develops from the rests of
the dental lamina
B. Age and gender related—adults over 30 years; common ages 50 to 70
years; male predilection
C. Location—most often lateral root surface of mandibular canine or
premolar teeth (occasionally seen in the maxilla in the same areas)
D. Clinical features
1. Tooth or teeth involved are vital
2. Asymptomatic, no bulge
E. Radiographic appearance
1. Small; less than 1 cm
2. Well-defined ovoid or elliptically shaped radiolucent area found
lateral to a tooth root (Fig. 8-51, A)

621
 FIG 8-51 A, Radiograph of a lateral periodontal cyst. This biloculated,
well-defined radiolucency is located lateral to the tooth root. B,
Microscopic appearance of a lateral periodontal cyst showing a thin
epithelial lining with focal epithelial thickenings. (From Ibsen OAC, Phelan JA:
Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

3. The botryoid odontogenic cyst (BOC) is closely related to the LPC, and
the diagnosis is used for multi-cystic or multi-locular variants; BOC
is most common in the mandibular cuspid and premolar area
4. The odontogenic keratocyst and other inflammatory cysts can have
the same radiographic features
F. Histologic characteristics (Fig. 8-51, B)
1. Stratified squamous epithelial lining only a few cells thick; focal
epithelial thickening
2. Thin connective tissue wall
G. Treatment and prognosis
1. Surgical enucleation of the cyst without damage to surrounding

622
 teeth
2. Few cases of recurrence have been reported
3. BOC has greater recurrence potential than LPC

Odontogenic Keratocyst
A. Etiology—odontogenic developmental cyst with unique histologic
appearance and frequent recurrence
B. Age and gender related—60% between 10 and 40 years of age; slight
male predilection
C. Location—most often in posterior mandible
D. Clinical features—may be asymptomatic; does not expand bone
E. Radiographic appearance—well-defined, multi-locular radiolucent
lesion; can be similar to that of an odontogenic tumor; lesion can move
teeth and resorb tooth structure
F. Histologic characteristics
1. Lumen lined by epithelium 8 to 10 cell layers thick
2. Surfaced by parakeratin
3. Basal cell layer is palisaded
G. Treatment and prognosis
1. Aggressive surgical excision and osseous curettage
2. High recurrence rate
3. Close follow-up

Primordial Cyst
A. Etiology—neoplastic; arises from epithelium of the enamel organ or
from primordial epithelium; history that a tooth was never present; the
cyst develops in place of the tooth; sometimes histologically considered
the same as an odontogenic keratocyst
B. Age and gender related—child to young adult; ages 10 to 40 years;
slight male predilection
C. Location—posterior mandible; third molar area or posterior to an
erupted third molar and up the ramus
D. Clinical features—no obvious clinical features; the affected person
may be asymptomatic
E. Radiographic appearance—well-defined radiolucent oval lesion; can be
multi-locular
1. Tooth never present in the space occupied by the cyst (this history is
essential to the diagnosis)
2. An unerupted tooth can be involved in this cyst

623
 3. Size varies from a few millimeters to a centimeter
4. Radiographic features not diagnostic
F. Histologic characteristics
1. Four to eight cells of stratified squamous epithelium
2. No rete pegs
3. Cuboidal columnar epithelial cells are hyperchromatic and appear in
the basal epithelial level
G. Treatment and prognosis
1. Surgical removal of the cyst, biopsy, and histologic examination
2. Recurrence depends on the histologic findings; odontogenic
keratocysts recur in 30% of cases

Dentigerous Cyst (Follicular Cyst)

A. Etiology—from reduced enamel epithelium after the crown of the
tooth is completely formed (unerupted or impacted tooth); accumulation
of fluid between the crown and reduced enamel epithelium; cyst must be
associated with a tooth; developmental or inflammatory origin
B. Age and gender related—young adults 20 to 30 years; second most
common odotongenic cyst; higher predilection for white males
C. Location
1. Mandibular third molar area—around the crown of an unerupted
third molar; often extending to the ramus
2. Maxillary canine region—compromising the maxillary sinus
D. Clinical features
1. Always associated with the crown of an unerupted tooth;
asymptomatic
2. Can be an aggressive lesion, causing expansion of bone and extreme
displacement of teeth; fracture of the mandible; or both, in which
case it would be painful
E. Radiographic appearance (Fig. 8-52)

624
 FIG 8-52A, Radiographs of dentigerous cysts surrounding the crown of an
unerupted premolar. B, Impacted third molar. (From Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Smooth, unilocular radiolucency associated with the crown of an

unerupted tooth
2. At least 4 mm of radiolucency extending from the crown to the
epithelium of the reduced enamel
F. Histologic characteristics
1. Stratified squamous epithelium lining the lumen; not keratinized
2. Surrounded by a thin fibrous connective tissue wall
3. In the inflamed variety, the fibrous wall has an inflammatory
infiltrate
G. Treatment and prognosis
1. Enucleation of the cystic sac, and sometimes the associated tooth
2. The tooth may be left in place, with orthodontic intervention to
assist eruption

625
 3. Rare transformation to the ameloblastoma
4. Prognosis is very good

Injuries to Oral Soft Tissue

Ranula
A. Etiology
1. Blockage or obstruction by a salivary “stone” (sialolith) in the duct of
a major salivary gland (sublingual or submandibular); unilateral
2. Trauma to same area
3. Term used for a mucocele that occurs in the floor of the mouth
B. Age and gender related—any age, but usually adults; no gender
predilection
C. Location—unilaterally on the floor of the mouth
D. Clinical features (Fig. 8-53)

FIG 8-53 Ranula. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed
6, St Louis, 2014, Elsevier.)

1. Translucent, bluish, round, smooth-surfaced bulge 1 to 3 cm in

diameter
2. Semi-firm, unilateral, fluctuant mass

626
 3. Increases in size between meals; decreases immediately after a meal
4. Located lateral to the midline (helpful to the differential diagnosis)
5. Small lesions can develop along the sublingual plica from the
superficial ducts of Rivini
E. Radiographic appearance—radiopaque sialolith in the duct area if it is
present
F. Histologic characteristics
1. Epithelial lining is present; mucous fluid surrounded by granulation
tissue
2. Inflammatory cells
G. Treatment and prognosis
1. Surgical excision
2. Removal of the obstruction, if present
3. May recur

Mucocele (Mucus Extravasation)

A. Etiology
1. Trauma to a minor salivary gland duct; mucous secretion spills into
connective tissue
2. Mechanical trauma to the salivary duct by lip biting or pinching
B. Age and gender related—all ages but most common in children and
young adults; no gender predilection
C. Location—the most common site is the lower lip mucosa
D. Clinical features
1. Blister-like, raised, circumscribed vesicle; 1 to 4 mm in size; painless
2. Bluish hue if the mucocele is near the surface
3. Firm, movable on palpation
4. Vesicle ruptures and can leave fragments of epithelial tissue
E. Histologic characteristics
1. The lesion is not a true cyst because it is not lined with epithelium
2. An inflammatory response occurs and granulation tissue forms
F. Treatment and prognosis
1. Excision of the lesion and associated gland
2. Sometimes the vesicle breaks, and the lesion resolves by itself
3. Recurrence is possible (and may recur in the same place)

Necrotizing Sialometaplasia
A. Etiology
1. Benign condition of salivary gland

627
 2. Lack of blood supply to the area of the lesion
3. Trauma to the area that causes a blockage of blood supply
B. Age and gender related—adults
C. Location—most often found on the palate; however, it may be found in
any site containing salivary glands
D. Clinical features (Fig. 8-54)

FIG 8-54 Necrotizing sialometaplasia. (From Ibsen OAC, Phelan JA: Oral pathology for
the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Initial finding of tenderness and swelling in the area

2. Well-demarcated ulcer
3. Localized pain; can be very painful
E. Histologic characteristics
1. Necrosis of the salivary gland tissue involved
2. Squamous metaplasia of ductal epithelium
3. Islands of epithelium deep in connective tissue
F. Treatment and prognosis
1. Incisional biopsy may be performed to rule out other conditions; the
ulcer may then heal by secondary intention
2. May be self-limiting
3. Prognosis is good

Pseudocysts
Aneurysmal Bone Cyst

628
A. Etiology—reactive cyst; etiologic theories include:
1. Arteriovenous shunt—a benign fibro-osseous lesion in the area
alters blood vessels
2. Trauma—trauma ruptures a blood vessel, and blood accumulates
outside the wall
B. Age and gender related—under 30 years; no gender predilection
C. Location
1. Long bones or vertebral column
2. When the occurrence is in the jaws, the mandible is the more
common site (2:1)
D. Clinical features
1. May be asymptomatic or may appear as a slightly to moderately well-
defined bulge
2. Tenderness, pain on motion; may limit movement
3. Mobility or migration of teeth
E. Radiographic appearance—hazy, gray, radiolucent area; appears cystic,
with a “soap bubble” or honeycomb effect; multi-locular pattern can be
present
F. Histologic characteristics
1. No epithelial lining—a “pseudocyst”
2. Walls of fibrous connective tissue
3. Blood-filled spaces surrounded by multi-nucleated giant cells
G. Treatment and prognosis
1. Surgical enucleation and thorough curettage (sometimes with
cryosurgery—a freezing technique to help control bleeding)
2. Follow-up treatment, if necessary
3. May sometimes recur

Simple Bone Cyst (Traumatic Bone Cyst,

Hemorrhagic Bone Cyst)
A. Etiology—theories include:
1. Intramedullary hemorrhage following trauma; altered bone prevents
fibroblasts and endothelial cells from entering the hemorrhage;
clotting does not occur; blood never organizes, leaving a void within
the bone
2. Ischemic marrow necrosis
3. Degeneration of a benign tumor
4. Bone did not develop in the area
B. Age and gender related—ages 10 to 20 years; male predilection
C. Location

629
 1. More common in the mandible than in the maxilla
2. Most common in long bones
D. Clinical features—asymptomatic (discovered through radiographic
examination)
E. Radiographic appearance (Fig. 8-55)—well-defined radiolucent area 1
to 7 cm in diameter; round, oval; may be multi-locular; the radiolucent
projections extend between roots of teeth, defined as “scalloping around
the roots”; borders are sometimes sharp or diffuse

FIG 8-55 Extraoral radiograph showing a simple (traumatic) bone cyst (arrow)
in the mandible, with its unique radiolucent characteristic scalloping around the
roots. (Courtesy of Dr. Edward V. Zegarelli; from Ibsen OAC, Phelan JA: Oral pathology for the
dental hygienist, ed 6, St Louis, 2014, Elsevier.)

F. Histologic characteristics
1. Thin vascular fibrous connective tissue lining; no epithelium so it is
not a true cyst
2. The center is a void
G. Treatment and prognosis
1. Surgical intervention to establish bleeding and clotting is often
sufficient
2. Lesion heals 6 months to 1 year after surgical intervention
3. Prognosis is excellent

630
Static Bone Cyst (Lingual Mandibular Bone
Concavity, Stafne Bone Cyst)
A. Etiology—developmental; salivary gland extends laterally into the
mandible
B. Age and gender related—young persons; slightly more common in
males
C. Location—posterior of the mandible, anterior to the angle of the
ramus, inferior to the mandibular canal
D. Clinical features—asymptomatic; occasionally bilateral
E. Radiographic appearance (Fig. 8-56)—sharp, well-defined ovoid
radiolucency 1 to 3 cm in diameter, anterior to angle of the ramus,
inferior to the mandibular canal; filled with salivary gland tissue

FIG 8-56 Part of a panoramic radiograph showing a lingual mandibular bone

concavity (Stafne bone cyst). Note the well-circumscribed radiolucency inferior
to the mandibular canal (arrow). (From Ibsen OAC, Phelan JA: Oral pathology for the
dental hygienist, ed 6, St Louis, 2014, Elsevier.)

F. Histologic characteristics—lymphoid, fat, submaxillary salivary gland

tissues; striated muscle (not a true cyst)
G. Treatment and prognosis
1. Surgical intervention to determine contents; once diagnosed, no
treatment necessary
2. Prognosis is excellent; no complications

631
632
Blood disorders
General Characteristics
A. Disease with numerous variations
B. Important to know normal blood levels and chemistries in order to
make differential diagnosis
C. Anemias are categorized according to etiology
1. Blood loss
2. Excessive destruction of red blood cells (RBCs) because of a
congenital or hemolytic condition
3. Decrease in production of RBCs

Sickle Cell Anemia

A. Etiology—hereditary; severe genetic disorder involving hemoglobin;
abnormal hemoglobin in RBCs; decreased oxygen in RBCs
B. Age and gender related—under 30 years; female predilection; 1 in 400
African Americans in the United States are affected; also persons of
Mediterranean or Asian origin
C. Clinical features
1. Systemic symptoms
a. Weakness, easily fatigued; pallor of tissues
b. Shortness of breath; nausea, vomiting
c. Pain in joints
d. Sickle cell crisis involves severe systemic complications
e. Infections—patients are prone to infection because of early
destruction of the spleen
f. Delayed growth and development in children
g. Cardiac, kidney, CNS, eyes, and pulmonary involvement
2. Oral symptoms
a. Some radiographic findings
b. Osteomyelitis of the mandible
c. Prolonged paresthesia of the mandibular nerve
D. Radiographic appearance (Fig. 8-57)

633
 FIG 8-57 Sickle cell anemia. The radiograph shows abnormal trabeculation.
(Courtesy of Dr. Edward V. Zegarelli; from Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Perpendicular trabeculations radiating outward, giving a “hair-on-

end” appearance in the skull
2. Decrease in number of trabeculae in the jaws, with large marrow
spaces
3. Lamina dura not affected
E. Laboratory tests and findings (Fig. 8-58)

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 FIG 8-58 Normal red blood cells compared with sickled red blood cells. (From
Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. RBC count reduced to 1 million/mm3 (normal is 4 to 6 million/mm3)

2. Decrease in the hemoglobin level in red blood cells (normal in
males, 13.5 to 18 g/dL; in females, 12 to 16 g/dL)
3. Blood smear showing sickle-shaped RBCs
F. Histologic characteristics
1. Crescent-shaped erythrocytes caused by hemoglobin S
2. Atypical chromatin distribution
G. Treatment and prognosis
1. Symptomatic management; oxygen and intravenous fluids
2. Bone marrow transplantation has numerous complications and is a
cure for a very low percentage of patients
3. Hydroxyurea—drug treatment for adults, but has several side effects
4. Prognosis is unpredictable and depends on various aspects of
disease activity

Pernicious Anemia (Primary Anemia, Addison

Anemia, Biermer Anemia)
A. Etiology
1. Autoimmune destruction of the parietal cells of the stomach
2. Deficiency of intrinsic factor (produced by the parietal cells of the
stomach lining) necessary to absorb vitamin B12 (cobalamin)
3. Deficiency of vitamin B12 (extrinsic factor) necessary for
deoxyribonucleic acid (DNA) synthesis
B. Age and gender related—older adults; rarely before age 30; no gender
predilection

635
C. Clinical features
1. Systemic symptoms
a. General weakness, dizziness, pallor, anemia (caused by low
oxygen in the blood)
b. Numbness or tingling of extremities
c. Gastrointestinal manifestations—nausea, vomiting, diarrhea,
abdominal pain
d. Loss of appetite and weight loss
e. Shortness of breath
f. Neurologic changes—severe paresthesias
2. Oral symptoms
a. Sore, painful, burning tongue; angular cheilitis
b. Shallow ulcers on the mucosa
c. Atrophy of papillae; distorted perception of taste
d. Pallor of the oral mucosa with focal patches of erythema
D. Laboratory tests and findings
1. Diagnosis of pernicious anemia is made by laboratory testing; the
Schilling test is also used to determine the body’s inability to absorb
an oral dose of vitamin B12 (cyanocobalamin)
2. Achlorhydria—lack of gastric hydrochloric acid secretion
3. Megaloblastic anemia—immature, large RBCs
E. Histologic characteristics
1. Epithelial atrophy; no rete ridges
2. Pale-staining nuclei
F. Treatment and prognosis
1. Injections of vitamin B12
2. Increased dietary intake of folic acid (leafy green vegetables, organ
meats, wheat cereals)
3. From 1% to 2% of persons with pernicious anemia develop gastric
carcinoma

Iron Deficiency Anemia (Plummer-Vinson Syndrome)

A. Etiology—iron deficiency caused by:
1. Chronic blood loss
2. Inadequate dietary intake of iron
3. Decreased iron absorption
4. Increased iron requirements (e.g., infancy, pregnancy)
5. Longstanding iron deficiency anemia (Plummer-Vinson syndrome);
symptoms include dysphagia and an increased predilection for
esophageal and oral cancer

636
B. Age and gender related—ages 40 to 50 years; more common in females
(5% to 30% female incidence in the United States)
C. Clinical features
1. Systemic symptoms
a. Pallor of skin, weakness; fatigue
b. Difficulty swallowing (dysphagia)
c. Shortness of breath
d. Enlarged spleen (splenomegaly) (20% to 30% of cases)
e. Absence of free hydrochloric acid in the stomach
f. Predisposition to development of oral cancer
2. Oral symptoms (Fig. 8-59)

FIG 8-59 Iron deficiency anemia. The tongue is devoid of filiform papillae.
Angular cheilitis is also present. (From Ibsen OAC, Phelan JA: Oral pathology for
the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

a. Angular cheilitis; pallor and atrophy of oral tissues

b. Depapillated, smooth, burning, painful tongue
c. Risk for oral candidiasis
D. Histologic characteristics
1. Altered exfoliated squamous epithelial cells of the tongue and soft
tissues
2. Deficiency of keratinized cells
3. Abnormal cell maturation; enlarged nuclei

637
E. Laboratory findings
1. Complete blood count (CBC) with RBC indices
2. Hypochromatic microcytic RBCs
3. Low number of erythrocytes (RBCs)
4. Low hemoglobin and hematocrit
5. In Plummer-Vinson syndrome the esophagus is evaluated for
mucosal tissue growths that may inhibit swallowing
F. Treatment
1. Increased iron intake
2. Dietary supplement
3. Parenteral iron occasionally

Aplastic Anemia
Primary Aplastic Anemia
A. Etiology—unknown; severe depression in bone marrow activity; rare,
life-threatening disease
B. Age and gender related—young adults; no gender predilection
C. Clinical features
1. Oral symptoms
a. Spontaneous bleeding
b. Petechiae
c. Purpuric spots
d. Gingival infection
e. Pallor of oral tissues
2. Systemic symptoms
a. Fatigue, weakness
b. Tachycardia, dizziness
c. Retinal and cerebral hemorrhages in most severe cases
d. Significant bruising
e. Predisposition to infection
D. Laboratory tests and findings establish the diagnosis
1. Reduction in the number of all blood cells (pancytopenia)
2. Reduction in the number of RBCs (anemia)
3. Reduction in the number of WBCs (leukopenia)
4. Reduction in the number of platelets (thrombocytopenia)
5. Bone marrow changes
E. Treatment and prognosis
1. Blood transfusions
2. Antibiotic drugs to try to control infection

638
 3. Bone marrow transplantation
4. Guarded prognosis, depending on the severity of the condition
5. Rapid decrease in various blood cells usually fatal

Secondary Aplastic Anemia

A. Etiology
1. Result of a drug or chemical substance; chemotherapy
2. Exposure to radiant energy—x-rays, radium, or radioactive isotopes
B. Age and gender related—any age; no gender predilection
C. Clinical features—same as in primary aplastic anemia
D. Treatment and prognosis
1. Remove the cause
2. Supportive therapy
3. Prognosis is good

Thalassemia (Cooley Anemia, Mediterranean

Anemia)
A. Etiology—inherited; autosomal dominant
1. Disorder of hemoglobin synthesis
2. Ethnic predilection—high incidence in Mediterranean and African
countries and India
B. Age and gender related
1. Thalassemia major
a. Affects individuals within the first year of life (homozygous
type)
b. Both X and Y chromosomes are involved
c. Is a more severe type of anemia
2. Thalassemia minor
a. The milder form appears in later childhood (heterozygous type)
b. Only one gene at the locus is involved
c. No gender predilection
C. Clinical features
1. Systemic symptoms for thalassemia major
a. Yellow pallor of the skin
b. Enlarged spleen (splenomegaly); enlarged liver (hepatomegaly)
c. Mongoloid facial features
d. Sunken nose bridge
e. Protruding zygoma
f. Slanting eyes

639
 2. Oral symptoms for thalassemia major
a. Malocclusion; protrusion of the anterior maxillary teeth
b. Pallor of the mucosa
3. No significant clinical manifestations in thalassemia minor
D. Radiographic appearance
1. Peculiar trabecular pattern of the maxilla and the mandible—”salt
and pepper ” or “hair on end” of the cranial bones
2. Mild osteoporosis of the jaws
3. Thinning of lamina dura
E. Laboratory tests and findings
1. Elevated white blood cell (WBC) count—10,000 to 25,000/mm3
2. Elevated serum bilirubin level
3. Decreased hemoglobin level
F. Histologic characteristics—bone marrow shows cellular hyperplasia
G. Treatment and prognosis
1. Blood transfusions (frequently administered every 2 weeks)
2. Frequent transfusions cause a significant buildup of iron in tissues
throughout the body (hemochromatosis); these toxic accumulations
of iron may be fatal; treated with deferoxamine
3. Bone marrow transplantation
4. Prognosis is guarded; periods of remission can extend the life span
to age 20

Polycythemia
General Characteristics
A. Abnormal increase in the number of circulating RBCs
B. Increased hemoglobin level
C. Three forms:
1. Relative polycythemia—temporary increase in the number of RBCs;
caused by shock, a severe burn, or excessive loss of body fluids
2. Primary polycythemia (polycythemia vera)
3. Secondary polycythemia

Primary Polycythemia (Polycythemia Vera)

A. Etiology—unknown; possibly familial; neoplastic proliferation of bone
marrow stem cells
B. Age and gender related—ages 40 to 60 years; slightly more common in
males
C. Clinical features

640
 1. Systemic symptoms
a. Headache, dizziness, weakness
b. Enlarged, painful spleen
c. Gastric complaints; peptic ulcers
d. Tips of fingers cyanotic
e. Nose bleeds easily (epistaxis)
f. Itching of skin (pruritus) without the presence of rash
2. Oral symptoms
a. Oral mucosa deep red to purple because of decreased
hemoglobin level
b. Gingivae edematous and spongy; bleed easily
c. Submucosal petechiae; ecchymosis
D. Laboratory tests and findings
1. RBC count elevated to 10 to 12 million cells/mm3 (significant
increase)
2. Increase in:
a. Hemoglobin content
b. Blood viscosity
c. WBC counts
d. Hematocrit value
3. Decrease in platelets
E. Treatment and prognosis
1. Medications and procedures to control platelets
2. Intermittent phlebotomy
3. Chemotherapeutic drugs

Secondary Polycythemia
A. Etiology—increased number of erythrocytes caused by a physiologic
response to decreased oxygen
1. Bone marrow anoxia (lack of oxygen) caused by:
a. Pulmonary dysfunction
b. Heart disease
c. High altitudes
d. Carbon monoxide poisoning
2. Stimulatory factors such as drugs or chemicals
B. Other characteristics and features similar to those of primary
polycythemia

Relative Polycythemia

641
A. Etiology—decreased plasma volume (not an increase in RBCs) that
may be caused by:
1. Use of diuretics
2. Vomiting, diarrhea
3. Excessive sweating
B. Age and gender related—the chronic form of relative polycythemia
(also called stress polycythemia) is more common in white, middle-aged
men, who are stressed, overweight, and hypertensive and who smoke
C. Treatment—related to the type of polycythemia and risk factors;
attempt to remove risk factors

Agranulocytosis
A. Etiology—significant reduction in or absence of circulating
neutrophils (neutropenia)
1. Primary form—unknown; immunologic disorder
2. Secondary form—drug ingestion; chemotherapy; toxic effect of drugs
or chemicals
B. Age and gender related—any age; more common in adults; female
predilection in secondary agnanulocytosis
C. Clinical features
1. Systemic symptoms
a. Sudden onset
b. High fever, chills, sore throat
c. Malaise, weakness
d. Skin is jaundiced
e. Regional lymphadenopathy
2. Oral symptoms
a. Infection (clinical signs affecting the gingiva can be similar to
NUG)
b. Ulcerations of the pharynx, palate, buccal mucosa, and tongue
D. Laboratory tests and findings—confirm the diagnosis
1. Severe decrease in or absence of granulocytes or polymorphonuclear
cells
2. Accelerated destruction of neutrophils; bone marrow has few or no
granulocytes
3. WBC count is reduced to less than 1000 cells/mm3
E. Histologic characteristics
1. Necrosis of involved tissues
2. Many bacterial microorganisms
F. Treatment

642
 1. Removal of the causative drug or agent, if possible
2. Administration of antibiotics to control infection

Cyclic Neutropenia
A. Etiology—inherited; autosomal dominant; regular periodic episodes
lasting 3 to 4 days with a significant decrease in circulating neutrophils;
mutation of the neutrophil elastase (ELA2) gene.
B. Age and gender related—infants and young children; no gender
predilection
C. Clinical features
1. Systemic symptoms
a. General weakness, malaise
b. Fever, sore throat, headache
c. Cervical lymphadenopathy
d. Gastrointestinal mucosal ulcerations
2. Oral symptoms (Fig. 8-60)

FIG 8-60 Marked gingivitis, with areas of gingival recession in a patient

with cyclic neutropenia. (From Ibsen OAC, Phelan JA: Oral pathology for the
dental hygienist, ed 6, St Louis, 2014, Elsevier.)

a. Severe gingivitis, recession, and periodontitis (gingiva severely

affected)

643
 b. Painful ulcerations on any oral mucosal tissue, especially lips,
tongue, buccal mucosa, and oropharynx
c. Mild to severe loss of alveolar bone
d. Dental treatment should be performed when circulating
neutrophils are normal to reduce complications and secondary
infections
D. Laboratory tests and findings
1. Neutrophils may completely disappear in the acute stage
2. Cycles occur at intervals of 21 to 27 days
3. Sequential blood counts several times a week for several weeks are
used to determine neutrophil cycling
E. Treatment and prognosis
1. Optimal oral hygiene practices by the patient
2. Treatment with granulocyte colony-stimulating factor (G-CSF)
several times a week
3. Antibiotics to control significant infections
4. Premedication with antibiotics before dental hygiene or surgical
procedures (which should be scheduled when neutrophils are at
their highest peak)

Leukemia
General Characteristics
A. Malignant neoplastic disorder involving blood-forming cells;
originates in the bone marrow
B. Excessive proliferation of WBCs in the immature state
C. Etiology—combination of genetic and environmental factors;
oncogenic viruses
1. Chronic exposure to chemicals or ionizing radiation
2. Higher incidence among persons with genetic disorders, including
Down syndrome and other chromosomal abnormalities,
neurofibromatosis, and Klinefelter syndrome (see the section on
“Genetics” in Chapter 7)
D. A number of types and subtypes of this condition exist

Acute Leukemia
A. Two types:
1. Acute myeloblastic leukemia (AML)
2. Acute lymphoblastic leukemia (ALL)
B. Age and gender related—according to cell type

644
 1. AML generally affects adolescents and young adults but can affect
children
2. ALL almost always affects children
3. Slight male predilection
C. Clinical features—onset is sudden
1. Systemic symptoms
a. Infection in lungs, urinary tract
b. Weakness, fever, headache
c. Swelling of lymph nodes
d. Bruising of the skin and mucous membranes—caused by a
decrease in the number of platelets (thrombocytopenia)
e. Enlargement of organs—spleen, liver
f. Bone and joint pain
2. Oral symptoms (Fig. 8-61)

FIG 8-61 Generalized gingival hyperplasia in a patient with leukemia.

(Courtesy of Dr. Edward V. Zegarelli; from Ibsen OAC, Phelan JA: Oral pathology for the
dental hygienist, ed 6, St Louis, 2014, Elsevier.)

a. Purpuric spots; gingival hemorrhage

b. Severe gingival enlargement—red, soft, spongy; spontaneous
bleeding
c. Gingiva sometimes similar to necrotizing ulcerative gingivitis
(NUG; see earlier)—characterized by ulcerations, blunted
papillae, necrosis, odor

645
 d. Pallor of tissues; nonulcerated edema
e. Candidiasis, herpetic infection, or both
f. Toothache caused by invasion and necrosis of the pulp
g. Mobility of teeth caused by a breakdown of the periodontal
membrane and supporting structures
D. Laboratory tests and findings
1. Both anemia and thrombocytopenia present
2. Prolonged bleeding and coagulation times
3. WBC count elevated to 100,000/mm3 (many immature cells)
4. Leukemic cells in bone marrow and peripheral blood
5. Tests to identify certain enzymes can help classify the type
E. Treatment and prognosis
1. Chemotherapy depending on the type and form of leukemia
2. Antibiotics to control infection
3. Drug and radiation therapy to the CNS
4. Transfusions with platelets or packed RBCs
5. Optimal oral hygiene care
6. Prognosis depends on multiple factors (e.g., type of leukemia, age)

Chronic Leukemia
A. Common forms
1. Chronic myeloid leukemia (CML)—associated with the Philadelphia
chromosome (first chromosomal abnormality)
2. Chronic lymphocytic leukemia (CLL)—the most common form;
asymptomatic for a long time
B. Age and gender related—adults; no gender predilection; chronic
leukemia affects older adults
C. Clinical features
1. Systemic symptoms
a. Very slow onset—disease may be present for weeks or months
before symptoms lead to diagnosis
b. Weight loss, fatigue
c. Lymph node enlargement and enlarged spleen in the CLL type,
not in the CML type
d. Petechiae on the skin with nodules of leukemic cells
e. Destructive bone lesions—result in bone fracture
2. Oral symptoms
a. Gingival tissues are severely affected; become tender, enlarged,
and bleed easily
b. Pallor of the gingiva and lips

646
 c. Purpuric spots; ecchymosis
d. Cervical lymphadenopathy may be an early sign (underlines the
importance of the extraoral clinical examination)
e. Oral candidiasis
D. Laboratory tests and findings
1. Anemia and thrombocytopenia sometimes present
2. WBC count can increase to 500,000/mm3 (95% of the total number of
blood cells)
3. Shift to the left in the maturity of cells
4. Differential count elevated in the cell type involved
E. Treatment and prognosis
1. Chemotherapy
2. Bone marrow transplantation (especially for patients with CML—
better survival rates)
3. Prognosis depends on the stage of the disease; chronic leukemia—2-
to 10-year survival depending on stage)

Purpura
General Characteristics
A. Purplish discoloration of the skin and mucous membranes caused by
the spontaneous escape of blood into tissues
B. Caused by:
1. Defect or deficiency in blood platelets (thrombocytopenic purpura)
2. Unexplained increase in capillary fragility (vascular or
nonthrombocytopenic purpura)

Thrombocytopenic Purpura
A. Etiology
1. Primary—idiopathic thrombocytopenic purpura; cause is unknown
2. Secondary—caused by a variety of conditions
a. Drug toxicity
b. Chemotherapy
c. Infectious diseases
B. Age and gender related—primary form occurs in childhood before age
10 years; secondary form may appear at any age; no gender predilection
C. Clinical features
1. Systemic symptoms
a. Spontaneous hemorrhagic skin lesions that vary in size
(petechiae, ecchymosis, hematomas)

647
 b. Patient bruises easily
c. Bleeding through the urinary tract (hematuria)
d. Bleeding from the nose (epistaxis)
e. Spleen not palpable
2. Oral symptoms
a. Profuse gingival hemorrhage
b. Clustered petechiae
D. Laboratory tests and findings
1. Severe reduction in the platelet count—below 50,000/mm3 (normal,
150,000 to 400,000/mm3)
2. Bleeding time prolonged to 1 hour or more
3. Positive capillary fragility test
E. Treatment
1. Discontinue causative drug, if known
2. Corticosteroid therapy
3. Blood transfusions (platelets, in particular)
4. Guarded prognosis
5. Consult patient’s physician of record prior to any dental hygiene or
surgical procedure

Nonthrombocytopenic Purpura
A. Etiology—results from a variety of conditions that produce capillary
fragility
1. Defect in capillary walls (vitamin C deficiency, infections)
2. Disorder of platelet function (drugs, allergies, autoimmune diseases)
B. Clinical features
1. Platelet count normal
2. Other symptoms similar to those of thrombocytopenic purpura
3. Oral manifestations—spontaneous bleeding, petechial ecchymosis
C. Laboratory tests
1. Platelet count normal
2. Bleeding time prolonged
D. Treatment
1. Systemic corticosteroids
2. Splenectomy
3. Remove cause

Hemophilia
A. Etiology—a genetic deficiency of a clotting factor in the blood;

648
prolonged clotting time; usually factor VIII or factor IX; bleeding
disorder of blood coagulation
1. Inherited; X-linked disease; occurs mostly in males; occurs in
females in extremely rare cases.
2. Defect carried by the X chromosome; females are carriers of the trait
3. Transmitted genetically from asymptomatic carrier mothers to sons
B. Age and gender related—usually present at birth; symptoms may not
appear until later; males are most susceptible, whereas females are
carriers of the trait
C. Clinical features
1. Systemic symptoms
a. Clotting deficiency produces persistent bleeding
b. Massive hematomas; hemorrhage
c. Three forms—differ in the deficiency of a blood clotting factor
(1) Type A—most common type; factor VIII; X-linked
recessive
(2) Type B—or Christmas disease; factor IX; X-linked recessive
(3) Von Willebrand’s disease—abnormal von Willebrand’s
factor; disorder of platelet function; autosomal dominant;
both men and women
2. Oral symptoms
a. Gingival hemorrhage
b. Prolonged hemorrhage following tooth eruption, exfoliation,
scaling, extraction, or surgery
D. Laboratory tests and findings—prolonged coagulation time (classic
feature)
E. Treatment
1. Injections with clotting factor
2. Identify missing factors and replace them (complications can occur)
3. Genetic counseling
4. Optimal dental and dental hygiene care to prevent problems

649
Human immunodeficiency virus (HIV)
A. Etiology—infectious disease; immune deficiency resulting from HIV
infection (Box 8-2)

Box 8-2
Definition and Diagnosis of Ac quired
Immunodefic ienc y Syndrome (AIDS)
AIDS is an illness characterized by one or more of the following diseases
or conditions:

HIV Laboratory Tests Not Performed or Results

Inconclusive and the Patient Has No Other Cause of
Immunodeficiency
1. Candidiasis of the esophagus, trachea, bronchi, or lungs
2. Cryptococcosis, extrapulmonary
3. Cryptosporidiosis with diarrhea persisting longer than 1 month
4. Cytomegalovirus disease of an organ other than liver, spleen, or lymph
nodes in a patient older than 1 month of age
5. Herpes simplex virus infection causing a mucocutaneous ulcer that
persists longer than 1 month, or bronchitis, pneumonitis, or
esophagitis for any duration affecting a patient older than 1 month of
age
6. Kaposi’s sarcoma affecting a patient < 60 years of age
7. Lymphoid interstitial pneumonia or pulmonary hyperplasia, or both;
affecting a child < 13 years of age
8. Mycobacterium avium or Mycobacterium kansasii disease, disseminated
9. Pneumocystis jiroveci (formerly P. carinii) pneumonia
10. Progressive multifocal leukoencephalopathy
11. Toxoplasmosis of the brain affecting a patient older than 1 month

With Laboratory Evidence for Human

Immunodeficiency Virus (HIV) Infection
Less than 200 CD4 + T lymphocytes/mL, or a CD4 + T lymphocyte
percentage of total lymphocytes of < 14
Any of the diseases previously listed or those that follow:
1. Multiple bacterial infections of certain types affecting a child < 13 years
of age
2. Coccidioidomycosis, disseminated

650
3. HIV encephalopathy (HIV dementia)
4. Histoplasmosis, disseminated
5. Isosporiasis with diarrhea persisting longer than 1 month
6. Lymphoma of the brain at any age
7. Kaposi’s sarcoma at any age
8. Certain types of lymphoma
9. Mycobacterial disease, other than tuberculosis, disseminated
10. Extrapulmonary tuberculosis
11. Salmonella septicemia, recurrent
12. HIV wasting syndrome
13. Pulmonary tuberculosis
14. Recurrent pneumonia
15. Invasive cervical cancer
Even if HIV laboratory test results are negative, if other causes of
immunodeficiency are not ruled out, a diagnosis of AIDS can be made if
certain of these diseases are diagnosed.
Modifed from Centers for Disease Control and Prevention: 1993 Revised classifications system for
HIV infection and expanded surveillance case definition for AIDS among adolescents and adults,
MMWR 41(RR-17), 1992.

B. Syndrome includes HIV infection, cell lymphopenia, and reduced CD4

helper T lymphocyte function
C. Age—usually adults age 20 to 40 years; infants of infected mothers;
anyone to whom the virus is transmitted
D. Gender and ethnic characteristics
1. Male predilection; however, women are fastest-growing group of
infected persons
2. Homosexual or bisexual men
3. Overall increased incidence among intravenous (IV) drug users
4. Others at risk include sex workers, prison inmates, and children of
infected mothers
E. Transmission
1. Sexual contact
2. Infected blood serum; in infected patients, the virus has been found
in blood and bodily fluids, including saliva and tears
3. Infected mothers to newborn (breast milk); artificial insemination
4. IV drug users
5. Cofactors (e.g., other infections) may influence transmission
F. Clinical features—oral (Box 8-3)

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Box 8-3
Oral Lesions Assoc iated with Human
Immunodefic ienc y Virus (HIV) Infec tion
Candidiasis
Herpes simplex infection
Herpes zoster
Hairy leukoplakia
Human papillomavirus (HPV) lesions
Atypical gingivitis and periodontitis
Other opportunistic infections reported
Mycobacterium avium
Cytomegalovirus
Cryptococcus neoformans
Klebsiella pneumoniae
Enterobacter cloacae
Histoplasma capsulatum
Kaposi’s sarcoma
Non-Hodgkin’s lymphoma
Aphthous ulcers
Mucosal pigmentation
Bilateral salivary gland enlargement and xerostomia
Spontaneous gingival bleeding resulting from thrombocytopenia
From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.

1. At the earliest stage of the disease, the oral findings

can be subtle or totally asymptomatic
2. Oral candidiasis occurs in more than 85% of cases
(pseudomembranous, erythematous, hyperplastic,
angular cheilitis)
3. History of herpes simplex; herpes zoster; aphthous
ulcers, HPV
4. NUG; linear gingival erythema; necrotizing
ulcerative periodontitis (NUP)
5. Petechiae on attached gingiva
6. Sudden onset of inflammation

652
 7. A creamy white patch covering a raw, red base, as
seen in pemphigus
8. Distinct odor
9. Hairy leukoplakia
10. Kaposi’s sarcoma
G. Clinical features—general
1. Opportunistic infections—candidiasis; infection by cytomegalovirus
(CMV), HSV types 1 and 2; pneumocystic pneumonia; herpes zoster
2. Susceptible to forms of cancer—squamous cell carcinoma, Kaposi’s
sarcoma, and non-Hodgkin’s lymphoma
3. Constitutional signs include sudden, unexplained weight loss,
lymphadenopathy involving cervical and submandibular nodes
4. Health history—past and present history of long-term illness, slow
healing, vital signs (fever is especially significant), and patient
profile
5. Other characteristics—lymphadenopathy, fatigue, diarrhea, fever,
gastrointestinal involvement, weight loss; oral lesions usually
manifest last
6. Epstein-Barr virus (EBV; hairy leukoplakia involving corrugated
white areas, especially on the lateral tongue)
H. Laboratory
1. Serologic testing for HIV infection using the enzyme-linked
immunosorbent assay (ELISA) test twice
2. Western blot test is performed after two positive ELISA tests
3. The polymerase chain reaction (PCR) identifies the virus and the
viral load rather than antibodies
I. Histologic findings—can be extremely variable, depending on the
pathologic conditions involved and the opportunistic disease
J. Treatment—symptomatic
1. Antiretroviral drugs; nucleoside analogs, nonnucleoside reverse
transcriptase inhibitors, protease inhibitors, and fusion inhibitors
2. Drugs that prevent or treat opportunistic diseases (e.g., protease
inhibitor)
3. Prognosis—depends on early diagnosis and current therapy

653
Fibrous dysplasia
General Characteristics
A. Etiology—unknown; abnormal mesenchymal cell function; rare
diseases affecting bones; replacement of bone with fibrous connective
tissue
B. Swelling of bones with deformities in some forms of disease
C. Benign fibro-osseous lesion

Monostotic Fibrous Dysplasia

A. Etiology—unknown; theories include:
1. Local infection
2. Trauma
B. Age and gender related—children and young adults; no gender
predilection
C. Location
1. Ribs—most common site
2. Maxilla more often involved than mandible
3. Can affect any bone; most common form
D. Clinical features
1. Painless swelling; enlargement of the jaw or expansion of the buccal
plate of maxilla or mandible
2. Can cause malocclusion, tipping, or displacement of teeth
3. In the maxilla, lesions are not clearly outlined because they extend
into the sinus or the floor of the orbit
E. Radiographic features
1. The lesion blends into surrounding bone
2. Diffuse radiopacity; “ground glass” appearance
3. Sometimes a radiolucency with areas of radiopacity (depending on
the degree of calcification)
F. Histologic characteristics
1. Proliferating fibroblasts in the stroma of woven collagen fibers
2. Irregularly shaped trabeculae; some are C shaped
G. Treatment and prognosis
1. Surgical correction of the deformed bone
2. Radiation therapy contraindicated because of possible malignant
transformation

Polyostotic Fibrous Dysplasia

654
A. Etiology—unknown; involves more than one bone
B. Age and gender related—children; female predilection
C. Location
1. Long bones (bowing); often unilateral
2. Bones of the face and skull
3. Clavicles
4. Pelvic bones
D. Clinical features (depend on the type of polyostotic fibrous dysplasia)
1. Systemic symptoms
a. Café au lait spots: irregular, light-brown macules on the skin
b. Painless enlargement of affected bone(s)
c. Bowing of long bones (pathologic fracture)
d. Females may reach premature puberty at age 2 or 3 years
e. Dysfunction of the endocrine system—pituitary, thyroid, and
parathyroid glands
2. Oral symptoms
a. Expansion and deformity of the jaws; unilateral enlargement of
maxilla or mandible
b. Disturbed eruption pattern caused by endocrine dysfunction
3. Types
a. Craniofacial fibrous dysplasia—the maxilla is involved, and the
lesion extends into the sinus and surrounding bones
b. Jaffe-Lichtenstein type—lesions arise in multiple bones; café au
lait skin lesions appear over the involved bone
c. McCune-Albright syndrome—most severe form of polyostotic
fibrous dysplasia
(1) Severe endocrine abnormalities
(a) Premature puberty in females before age 2 years
(b) Stunted growth caused by early epiphyseal closure in
both genders
(c) Café au lait skin lesions
(2) Other systemic complications (diabetes; hyperthyroidism)
E. Radiographic appearance—irregular bone trabeculae; expansion of
cortical bone; sometimes a multi-locular cystic appearance with several
radiopacities; diffuse radiopacity resembling ground glass
F. Laboratory tests and findings
1. Serum alkaline phosphatase level sometimes elevated
2. Moderately elevated basal metabolic rate
G. Histologic characteristics
1. Fibrillar connective tissue
2. Many trabeculae

655
 3. Irregularly shaped, coarse woven fibers
4. Osteocytes
H. Treatment and prognosis
1. Surgical correction; postpone surgery as long as possible
2. No treatment for minor involvement
3. Radiation treatment is contraindicated because it has been
associated with malignant transformation

Cherubism
A. Etiology—inherited; autosomal dominant gene; marked penetrance;
gene 4p16
B. Age and gender related—onset at birth or early childhood (ages 2 to 5
years), females less severely affected
C. Location—only in the maxilla and the mandible (more common in the
mandible)
D. Clinical features
1. Painless bilateral facial swelling or enlargement of the posterior
mandible; firm and hard when palpated
2. Taut facial skin; downward pull of the eyelids; “cherubic”
appearance; eyes are displaced when maxilla is affected
3. Regional lymphadenopathy
4. Has been mistaken for an ameloblastoma or multi-locular cyst
5. Primary dentition may be prematurely shed at age 3 years
6. Permanent dentition often defective; absence of teeth (hypodontia);
lack of eruption of the teeth or delayed eruption
7. Speech problems; distortion of alveolar ridge
E. Radiographic appearance
1. Multi-locular radiolucencies; or typical soap bubble radiolucencies in
jaw
2. Bilateral thinning of cortical plates
3. Numerous unerupted or displaced teeth in cyst-like radiolucent
spaces
F. Laboratory tests and findings—all blood levels normal
G. Histologic characteristics
1. Similar to central giant cell granuloma; fibrous tissue proliferation
2. Numerous large, multi-nucleated giant cells in a loose, delicate,
fibrous connective tissue stroma
3. Eosinophilic cuff-like deposits surround small blood vessels
H. Treatment and prognosis
1. Self-limiting; remission at puberty

656
 2. Sometimes surgical intervention
3. Radiation contraindicated because of risk of sarcoma
4. Prognosis is good

Periapical Cemento-osseous Dysplasia (Cementoma)

A. Etiology—unknown; a common disease that affects periapical bone
B. Age and gender related—mid-30s; more common in females (15:1) and
African Americans (70%); these characteristics are critical to the
diagnosis
C. Location
1. Anterior mandible; rare in the maxilla
2. Apex of teeth near the periodontal ligament
D. Clinical features
1. Asymptomatic and localized; teeth in the affected area are vital (this
feature is critical to the diagnosis and is seen radiographically)
2. Pulp testing must be part of the diagnostic process to determine
teeth are vital
E. Radiographic appearance—depends on the stage of development
1. Early radiolucent lesion cannot be differentiated from several other
principal pathologic lesions
2. Mature stage showing radiopacities surrounded by radiolucency
3. Periodontal ligament remains intact
F. Histologic characteristics
1. Increase in connective tissue cells of the periodontal ligament
2. Normal bone replaced with a fibrous mass; varying amounts of
calcified material within
G. Treatment and prognosis
1. Self-limiting; no treatment necessary at any time
2. Prognosis is good

Paget Disease (Osteitis Deformans)

A. Etiology—unknown; nonneoplastic disease of bone; chronic metabolic
disease of bone; resorption, osteoblastic repair, and remineralization of
involved bone; theories include:
1. Viral cause
2. Inflammatory response
3. Endocrine imbalance
B. Age and gender related—age over 50 years; male predilection
C. Location—especially in the pelvis and spine; more common in the

657
maxilla than the mandible
D. Clinical features
1. Systemic symptoms
a. Symptoms develop slowly
b. Enlargement of bones (bowing in long bones)—spine, femur,
tibia; skull (change in hat size); pain in the involved bone
c. Affected bones are warm to the touch as a result of increased
vascularity
d. Severe headaches, deafness, dizziness, bone neuralgia
e. Joint pain with limited mobility
2. Oral symptoms
a. Enlarged maxilla; spread of the dentition
b. No change in enamel or dentin; hypercementosis of the roots of
teeth makes extractions more difficult
E. Radiographic appearance
1. Initial decreased radiodensity
2. Irregular radiolucent and radiopaque patches, giving a classic
“cotton wool” appearance
3. Root resorption; hypercementosis; lamina dura may be missing
completely
F. Laboratory tests and findings
1. Serum alkaline phosphatase level is significantly elevated (this is
significant to the diagnosis)
2. Serum calcium and phosphorus levels are normal
G. Histologic characteristics—characterized by both bone resorption and
bone deposition
1. Areas of resorption—osteoclast activity
2. Areas of deposition—osteoblast activity
3. Areas of both resorption and deposition—osteoclasts and
osteoblasts present
4. Vascular fibrous connective tissue replaces bone marrow
5. Reversed bone lines—”mosaic bone”
H. Treatment and prognosis
1. No treatment, if asymptomatic
2. Bone pain—analgesics
3. Neurologic complications (eyes, ears)
4. Systemic bisphosphonate medications

658
Endocrine disorders
General Characteristics
A. Associated with metabolic disturbances, deficiencies, or excesses
B. Excess or deficiency in hormone

Hyperparathyroidism
A. Etiology—excess secretion of parathyroid hormone (PTH,
parathormone)
1. Primary hyperparathyroidism—parathyroid gland produces
excessive PTH; results from parathyroid adenoma
2. Secondary hyperparathyroidism—accompanies other systemic
diseases, such as renal disturbances, in which calcium is excreted by
the kidneys in abnormal amounts; rickets; vitamin D deficiency
B. Age and gender related—age over 60 years; female predilection (3:1)
C. Clinical features
1. Systemic symptoms
a. Joint and bone pain, joint stiffness, and resorption of bone with
spontaneous fractures
b. Urinary tract stones caused by increased calcium in urine
(kidney stones)
c. Weakness, fatigue, dementia
d. Duodenal ulcers
2. Oral symptoms
a. Resembles a giant cell tumor or cyst
b. Diffuse bone loss causing malocclusion and shifting or mobility
of teeth
D. Radiographic appearance (Fig. 8-62, A)

659
 FIG 8-62 A, Radiograph of a mandibular lesion in a patient with
hyperparathyroidism. B, Microscopic appearance of a jaw lesion occurring in a
patient with hyperparathyroidism. The histologic appearance is identical to that
of a central giant cell granuloma. (A courtesy of Drs. Paul Freedman and Stanley
Kerpel; A and B from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St
Louis, 2014, Elsevier.)

1. Cyst-like radiolucencies found in posterior jaws; ground-glass

appearance
2. Lamina dura lost or sketchy
3. Mottled appearance
E. Laboratory tests and findings
1. Loss of calcium replaced by fibrous tissue
2. Serum calcium level elevated (hypercalcemia)
3. Low levels of blood phosphorus (hypophosphatemia)
F. Histologic characteristics (Fig. 8-62, B)
1. Osteoclastic resorption of trabeculae of spongiosa bone
2. Fibrosis of marrow spaces

660
 3. Fibroblasts replace resorbed bone
4. Indistinguishable from central giant cell granuloma
5. Highly vascular granulation tissue
G. Treatment
1. Correct the cause of increased PTH production (tumors, renal
disease, vitamin D deficiency)
2. Surgical removal of the hyperplastic functional parathyroid gland
3. Parathyroidectomy
4. Renal transplants

Osteomalacia
A. Etiology—deficiency of calcium over a long time
1. Deficiency or impaired absorption of vitamin D (produces
osteomalacia in adults and rickets in children)
2. Urinary loss of calcium and phosphorus
3. Fanconi syndrome—group of diseases related to renal tubular
function
B. Age and gender related—adults; female predilection
C. Clinical features
1. Loss of calcification in bone; soft bone
a. Generalized weakness
b. Bone pain and tenderness; fractures
c. Affects gait
2. Polyuria—urine output greatly increased
3. Polydipsia—severe thirst
4. No oral symptoms
D. Radiographic appearance
1. Generalized demineralization of bone; milkman’s syndrome
2. Lamina dura of teeth may be absent
3. Radiopaque renal calculi in the kidney
E. Laboratory tests and findings
1. Low serum calcium and phosphorus levels
2. Serum alkaline phosphatase level elevated
F. Treatment and prognosis
1. Increased dosage of vitamin D; if malabsorption, water-soluble,
synthetic vitamin D can be given
2. Calcium supplements
3. Pathologic fractures may occur in persons with osteomalacia

Rickets

661
A. Etiology
1. Deficiency of vitamin D, phosphorus, and calcium
2. Form of osteomalacia; failure of calcification of cartilage and bone
B. Age related—young children
C. Clinical features
1. Systemic symptoms
a. Pliable bones; bow leg, knock-knee
b. Muscle pain
c. Enlarged skull, spinal curvature
d. Enlarged liver and spleen
2. Oral symptoms
a. Retardation of tooth eruption
b. Malposition of teeth
c. Retardation of mandibular growth; class II malocclusion
D. Treatment—increase dietary intake of vitamin D, calcium, and
phosphorus; supplements

Langerhans Cell Disease

General Characteristics
A. Etiology—unknown; a reactive process
B. Cells accumulate in granulomatous masses
C. Includes a group of three diseases characterized by proliferation of
Langerhans cells; a combination of histiocytic cells and eosinophils
D. Three forms:
1. Letterer-Siwe disease (acute disseminated form)
a. Age and gender related—first 2 years of life; infants; male
predilection
b. Clinical features
(1) Skin rash on the trunk, scalp, and extremities
(2) Persistent low-grade fever; malaise, irritability
(3) Splenomegaly, hepatomegaly
(4) Anemia
(5) Oral lesions—not common because the disease is very
rapid
(6) Most severe form of Langerhans cell disease
c. Prognosis—invariably fatal; sometimes responds to
chemotherapy
2. Hand-Schüller-Christian disease (chronic disseminated form)
a. Age and gender related—early life; more common in males

662
 b. Clinical features
(1) Systemic symptoms—classic triad of symptoms in 25% of
patients:
(a) Skull and jaws affected—punched-out radiolucencies
(b) Diabetes insipidus—result of pituitary dysfunction
(c) Exophthalmos—bulging eyes caused by massive
infiltration of reticulocytes
(2) Oral symptoms
(a) Sore mouth, ulcerations, erythema
(b) Halitosis, unpleasant taste, gingivitis
(c) Loose, sensitive teeth
(d) Failure to heal after extractions
c. Radiographic appearance—radiolucencies in the skull and jaws;
punched-out radiolucencies
d. Treatment and prognosis
(1) Curettage of the lesion
(2) Radiation therapy
(3) Cytotoxic drugs and adrenocortical hormones
(4) Prognosis is poor; high fatality rate
3. Eosinophilic granuloma (localized)
a. Age and gender related—older children and young adults
approximately age 20 years; male predilection (2:1)
b. Clinical features
(1) Most benign variety of Langerhans cell disease
(2) May be asymptomatic; local pain, swelling, tenderness
(3) Sore mouth, fetid breath, loosening of teeth, swollen
gingiva
(4) Mandible more involved than maxilla
c. Radiographic appearance—irregular radiolucencies, single or
multiple; well defined, resembling a cyst (Fig. 8-63)

663
 FIG 8-63 Radiograph of eosinophilic granuloma. (Courtesy of Drs.
Paul Freedman and Stanley Kerpel; from Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

d. Treatment and prognosis

(1) Curettage and conservative surgical excision
(2) Radiation therapy
(3) Prognosis is good; recurrence is rare

664
Abnormalities of teeth
Loss of Tooth Structure
Attrition
A. Etiology—wearing away of tooth surfaces by active, physiologic forces
1. Mastication
2. Bruxism and chewing of tobacco accelerate attrition of teeth
3. Occlusion—heavy biting forces
4. Diet—chewing of coarse foods influences attrition
B. Age and gender related—occurs in primary and permanent dentition;
the rate of attrition is higher in males
C. Clinical features (Fig. 8-64)

665
 FIG 8-64 A, Attrition. B, Incisal view of attrition of the adult dentition. (From Ibsen
OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Polished facets
2. Flat incisal edge
3. Discolored surface
4. Exposed dentin
5. Muscle tenderness (more associated with bruxism)

Abrasion
A. Etiology—wearing away of tooth structure through abnormal
mechanical processes
1. Improper toothbrushing technique
2. Abrasive dentifrices
3. Repetitive oral habits
B. Clinical features (Fig. 8-65)

666
 FIG 8-65Abrasion of the cervical area of mandibular premolars caused by
aggressive toothbrushing. (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

1. U-shaped loss of tooth structure at the cervical margin; common in

the canine and premolar areas
2. Recession of gingiva creates sensitivity
3. Pipe smoking abrades teeth where the pipe rests
4. Notching associated with carpenters and tailors who hold tacks,
nails, and pins between their teeth

Abfraction
A. Etiology—related to microfracture of tooth structure in areas of
concentration of stress; biomechanical forces on teeth
B. Age—adults
C. Location
1. Cervical area of teeth
2. Predisposes the patient to abrasion
D. Clinical features—a wedge-shaped or V-shaped loss of tooth structure
at the cemento-enamel junction (CEJ); the tooth is more susceptible to
toothbrushing abrasion
E. Treatment
1. Composite

667
 2. Glass ionomers

Erosion
A. Etiology—loss of tooth structure resulting from chemical action; when
caused by gastric acids, it is known as perimylolysis
1. Acid or low-pH fluid intake
2. Acidic foods habitually used over long periods
3. Eating disorders (bulimia)
B. Clinical features (Fig. 8-66)

FIG 8-66 Erosion caused by bulimia. A, Decreased tooth size. B, Erosion of

maxillary lingual surfaces. (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Usually found on the labial or buccal surfaces; loss of enamel on the

668
 anterior maxillary lingual surfaces and mesial and distal surfaces
may be indicative of bulimia
2. “Wear ” depressions or etchings on cervical or occlusal surfaces
3. Hypersensitivity of affected teeth

Drugs Affecting Teeth

Methamphetamine Abuse and Addiction
A. Street names: meth, speed, crystal, ice, glass, fire
B. Etiology—a man-made psychostimulant that can be injected, snorted,
inhaled, taken orally, or smoked
1. Mood alterations depend on how it is taken
2. Smoking produces a high that can last 10 to 24 hours
C. Gender related
1. Majority are males age 18 to 34
2. Increased incidence in females
D. Clinical symptoms of use
1. Inability to sleep
2. Irritability
3. Extreme anorexia (causes a decrease in appetite)
4. Tremors
5. Sensitivity to noise
6. Increased craving for sweets
7. Possession of drug paraphernalia
E. Clinical signs—oral
1. “Meth mouth”; snorting or inhaling has the most severe effect on
teeth
2. Xerostomia; candidiasis
3. “Rampant caries” caused by the acidic nature of the drug; smooth
buccal or labial surfaces of teeth and interproximal surfaces of
anterior teeth are especially affected
4. Bruxism and clenching, leading to cracked teeth
5. Advanced gingival problems and periodontal disease
6. One report described the oral condition as “teeth rotted to the
gumline”
7. Dangerous interactions with common local anesthetics, nitrous
oxide, and pain medications
F. Clinical signs—systemic
1. Cardiovascular problems, including increased heart rate and blood
pressure

669
 2. Toxic effects on the CNS
3. Hyperthermia
4. Irreversible stroke producing damage to the blood vessels in the
brain
5. Acute lead poisoning in IV drug abusers
6. During pregnancy, congenital deformities, prenatal complications,
and premature birth
7. Rapid aging

Tetracycline Stain
A. Etiology—ingested medication during tooth development
B. Clinical—tooth staining that can be yellow-green or gray-brown;
endogenous stain

Developmental Defects Affecting Enamel and Dentin

Amelogenesis Imperfecta
A. Etiology—inherited condition affecting the enamel of teeth resulting
from a malfunction of the tooth germ
B. Produces four types
1. Type 1: enamel hypoplasia—defect in the formation of the matrix
a. Etiology—hereditary; environmental factors, nutritional
deficiency, congenital syphilis, high fever, and birth injuries also
can cause a hypoplastic response
b. Clinically (Fig. 8-67), the enamel of primary and permanent
teeth appears pitted; vertical grooves, deficiency in thickness,
yellow to dark-brown color, open contacts, and occlusal wear are
noted; seven varieties of type 1 hypoplastic amelogenesis
imperfecta; the pitted, autosomal variety is most common

670
 FIG 8-67 Pitted autosomal dominant amelogenesis imperfecta.
Note the multiple pits on the labial surface of teeth. Some of the
pits have been filled with composite. (From Young WG, Sedano HO:
Atlas of oral pathology, Minneapolis, 1981, University of Minnesota Press.)

c. Radiographic appearance—enamel absent or very thin layer over

tips of cusps and interproximal areas
d. Histologic characteristics—thin, defective enamel; few enamel
prisms; no lamellae
e. Treatment—restorations; crowns; bonding; laminates
2. Type 2: enamel hypocalcification—defect in mineralization of the
formed matrix; normal enamel thickness, but the enamel is poorly
calcified
a. Etiology—two varieties include autosomal dominant and
autosomal recessive
b. Clinically (Fig. 8-68), the enamel appears yellow to dark brown
and chalky; easily breaks down

671
 FIG 8-68 Note the loss of enamel in the teeth of a patient with
hypocalcified amelogenesis imperfecta. (From Ibsen OAC, Phelan JA:
Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

c. Radiographic appearance—the tooth shape is normal; enamel

and dentin have the same radiodensity, which makes them
difficult to differentiate; enamel appears “moth eaten” and is
less radiopaque than dentin
d. Histologic characteristics—broadening of interprismatic
substance; distinct enamel prisms; enamel low in mineral
content
e. Treatment—restorations; crowns; bonding; laminates
3. Type 3: enamel hypomaturation
a. Etiology—X-linked recessive (“snowcapped”) or autosomal
dominant
b. Clinical appearance (Fig. 8-69)

672
 FIG 8-69 Note the uniform whitening of incisal edges and occlusal
cusps in a case of “snowcapped” amelogenesis imperfecta. (From
Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis,
2014, Elsevier.)

(1) Enamel is of normal thickness but appears mottled with

large amounts of enamel matrix and is therefore softer
(2) Occlusal third of teeth appear “white” with normal
hardness
(3) Enamel easily chips from crowns of teeth
(4) Four varieties of this type (snowcapped type shown in Fig.
8-69)
4. Type 4: hypoplastic—hypomaturation of enamel
a. Etiology—characterized by association with taurodontic teeth
b. Clinically, the enamel is thin, pitted, and appears yellow to
brown in color

Dentinogenesis Imperfecta (Hereditary Opalescent

Dentin)
A. Etiology
1. Hereditary
2. Disturbance of dentin formation
a. Affects the mesodermal component
b. Enamel remains normal
B. Clinical features (Fig. 8-70, A)

673
 FIG 8-70 A, Clinical view of dentinogenesis imperfecta. B, Radiographic view.
(Courtesy of Dr. Edward V. Zegarelli; from Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Teeth appear “opalescent,” a translucent hue

2. Gray to bluish brown color
3. Distinct constriction at the CEJ
C. Radiographic appearance (Fig. 8-70, B)
1. Partial or total obliteration of pulp chambers and root canals
2. Roots are short, blunted, and sometimes fractured
3. Cementum, periodontal membrane, and alveolar bone appear
normal
D. Histologic characteristics
1. Disturbance of the mesoderm
2. Dentin composed of irregular tubules; uncalcified matrix
3. Tubules large in width; few in number
4. Odontoblasts degenerate easily within the matrix

674
 5. Decrease in inorganic content
E. Treatment—cast-metal crowns; caution needed with partial appliances
because of root fractures

Developmental Defects Affecting Tooth Shape

Dilaceration
A. Sharp bend or curve in the root of a formed tooth (Fig. 8-71, A).

FIG 8-71 A, Dilaceration on the distal root of an extracted tooth. B, Mesial root
dilaceration on a mandibular second molar. (A courtesy of Dr. Rudy Melfi; A and B from
Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

B. Etiology—trauma during tooth development

1. Calcified area displaced
2. Amount of tooth formed at the time of trauma will affect the angle

675
 or curve of the root; usually affects the apical third of the root
C. Radiographic appearance—sharp bend or curve in the root (Fig. 8-71,
B)
D. Treatment—none

Fusion
A. Union of two normally separated tooth germs
B. Etiology—physical force or external pressure; hereditary tendency
C. Clinical features (Fig. 8-72)

FIG 8-72 A, Clinical view of fusion involving a permanent mandibular lateral

incisor. B, Fusion of mandibular molars. (A courtesy of Dr. George Blozis; B courtesy of
Dr. Rudy Melfi; from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St
Louis, 2014, Elsevier.)

1. If the defect occurs early in development, one large tooth results

676
 2. If the defect occurs later, fusion of roots only
3. Dentin always confluent (if true fusion)
4. Can occur in both primary and permanent dentitions
5. Can occur between two normal teeth or between one normal tooth
and one supernumerary tooth
D. Location—anterior region; incisors are most often affected
E. Radiographic appearance—can have separate or fused root canals
F. Treatment—usually none; hemisection for a crown or bridge, if
necessary

Gemination
A. Division of a single tooth germ by invagination; results in incomplete
formation of two teeth (gemination means paired or occurring in twos)
B. Etiology—unknown; possibly trauma; hereditary tendency
C. Location—can affect the primary or permanent dentition, although it
is slightly more common in the primary dentition (e.g., in mandibular
incisors or in permanent maxillary incisors)
D. Clinically teeth usually have two completely or incompletely separate
crowns with one root, or with one root canal (Fig. 8-73)

677
 FIG 8-73 Clinical (A) and radiographic (B) views of gemination seen in the right
maxillary central incisor. (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

Concrescence
A. Fusion that occurs after root formation is complete; roots united by
cementum only
B. Etiology—traumatic injury; crowding of teeth with resorption of
interdental bone
C. Location—most often seen in adjacent maxillary molars
D. Radiographic appearance—establishes diagnosis because teeth are
joined at the root surfaces and cannot be observed clinically (Fig. 8-74)

678
 FIG 8-74A and B, Example of concrescence seen in extracted teeth and in a
corresponding radiograph. (Courtesy of Dr. George Blozis; from Ibsen OAC, Phelan JA:
Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

E. Treatment and prognosis—usually no treatment; if extraction is

necessary, all teeth joined by cementum are compromised

Dens in Dente (Dens Invaginatus)

A. Tooth within a tooth
B. Etiology—increased localized external pressure; growth retardation
C. Location—maxillary lateral incisor (Fig. 8-75)

679
 FIG 8-75 Clinical view of dens in dente in maxillary lateral incisor. (Courtesy of Dr.
George Blozis; from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St
Louis, 2014, Elsevier.)

D. Often bilateral
E. Radiographic appearance—small tooth within the pulp chamber (Fig.
8-76)

680
 FIG 8-76 Radiograph of dens in dente in maxillary lateral incisor. (From Ibsen
OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

F. Treatment—none, unless the pulp becomes inflamed or necrotic

Dens Evaginatus
A. An accessory cusp found on the occlusal surface
B. Etiology—rare developmental anomaly caused by proliferation of
enamel epithelium
C. Location—most often mandibular premolars (tuberculated premolars)
D. Clinical appearance—small, round nodule of enamel found on the
occlusal surface (Fig. 8-77)

681
 FIG 8-77 Dens evaginatus of maxillary premolar. (Courtesy of Dr. Margot Van Dis;
from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014,
Elsevier.)

E. Treatment—usually none, unless the condition poses occlusal

problems

Natal Teeth
A. Teeth present at birth
B. Etiology
1. Develop from part of dental lamina before the deciduous bud or
from bud of accessory dental lamina
2. Neonatal teeth are those that erupt 30 days after birth
C. Location—usually found in the mandibular incisor area
D. Histologic characteristics—keratinized epithelial structures without
roots (therefore not true teeth)
E. Treatment and prognosis
1. Removal (after determining they are not prematurely erupted
primary teeth)
2. Prognosis is excellent; no complications

Developmental Defects Affecting the Number of

Teeth
Anodontia
A. Missing teeth
B. Etiology—congenital lack of teeth; tooth germ did not develop
C. Two forms
1. Total anodontia
a. Rare condition—all teeth missing

682
 b. May involve both primary and permanent dentitions
c. Usually associated with ectodermal dysplasia, a hereditary
disturbance
2. Hypodontia (partial anodontia) (Fig. 8-78)

FIG 8-78 A and B, Hypodontia. The missing teeth were not extracted;
they never developed. (A courtesy of Dr. George Blozis; B courtesy of Dr. Margot
Van Dis; from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St
Louis, 2014, Elsevier.)

a. Rather common
b. Teeth usually affected include third molars and maxillary lateral
incisors
c. Familial or hereditary tendency
d. Odontodysplasia, “ghost teeth” (Fig. 8-79); teeth in this
condition are malformed and unerupted

683
 FIG 8-79 Regional odontodysplasia. (From Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

D. Treatment
1. Space maintainers during childhood
2. Crown and bridge work
3. Prosthetic appliances
4. Dental implants

Supernumerary Teeth
A. More than the normal number of teeth
B. Etiology—additional tooth buds arise from dental lamina; hereditary
C. Classification
1. Mesiodent (mesiodens)—most common; cone-shaped crown; short
root; located between maxillary centrals (Fig. 8-80)

684
 FIG 8-80 A, Mesiodens seen between maxillary central incisors. B,
Radiograph of a mesiodens. C, Radiograph showing a pair of inverted,
impacted mesiodens. (A and B courtesy of Dr. George Blozis; A to C, from Ibsen
OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

2. Maxillary fourth molar—distal to the third molar; a mandibular

fourth molar occasionally is found
3. Maxillary paramolar—usually a small molar; located buccally or
lingually in the area of the maxillary molars
D. Treatment—none; observe for cystic transition; remove when
interference occurs with normal dentition

Developmental Defects Affecting Tooth Size

Macrodontia
Abnormally large tooth; rare; possibly a result of fusion

685
Microdontia
Abnormally small tooth; maxillary lateral incisor and third molar most
frequently affected (Fig. 8-81)

FIG 8-81 Peg-shaped lateral incisor. (Courtesy of Dr. George Blozis; from
Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014,
Elsevier.)

686
Conditions of oral soft tissues
Abnormalities Affecting Mucous Membranes or
Skin
Amalgam Tattoo
A. Etiology—dust or particle of an amalgam restoration embedded in the
mucosa or gingiva
B. Clinical features—blue to purplish area near an amalgam restoration
(Fig. 8-82, A)

FIG 8-82 A, This blue-gray pigmentation on the gingiva is an amalgam tattoo.

B, Periapical radiograph showing amalgam particles in the gingival tissue.
(From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014,
Elsevier.)

C. Radiographic appearance—radiopaque if amalgam particles are

present (Fig. 8-82, B)
D. Treatment

Melanin Pigmentation
A. Dark pigmentation of the gingiva or mucosa (Fig. 8-83 and 8-84)

687
 FIG 8-83 Melanin pigmentation of the gingiva. (From Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

FIG 8-84 Posttraumatic melanin pigmentation. This area of melanin

pigmentation on the gingiva occurred after the healing of an injury caused by
trauma. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis,
2014, Elsevier.)

B. Etiology—hereditary; those with dark complexions are most often

affected; can occur after inflammation from injury
C. Treatment—none, because tissue is healthy

688
Angular Cheilitis
A. Etiology (considered a form of candidiasis)
1. Infection caused by Candida albicans
2. Nutritional deficiency
3. Denture-associated cheilitis
B. Clinical features—inflammation and cracking at the corners of the lips;
extend into facial skin (Fig. 8-85)

FIG 8-85 Angular cheilitis. (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

C. Histologic characteristics—inflammatory cells

D. Treatment—depends on the etiology: improved diet; correction of the
vertical dimension of the denture; applying antifungal ointment or cream
three to four times per day for 5 to 7 days

Fordyce Granules
A. Etiology—developmental; aberrant sebaceous glands
B. Clinical features (Fig. 8-86)

689
 FIG 8-86 Fordyce granules on the buccal mucosa. (From Ibsen OAC, Phelan JA:
Oral pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Affects the vermilion border of the lips and the buccal mucosa
2. Yellow, slightly raised spots a few millimeters in size
C. Location—buccal mucosa; lips
D. Histologic characteristics—glandular tissue; not pathologic
E. Treatment—none

Abnormalities Affecting the Tongue

See Table 12-4 in Chapter 12.

Geographic Tongue (Benign Migratory Glossitis,

Erythema Migrans)
A. Etiology—unknown; theories include:
1. Nutritional deficiency
2. Heredity
3. Stress
4. Psoriasis
B. Age and gender related—any age, but more common in children and

690
young adults; no gender predilection
C. Clinical features (Fig. 8-87)

FIG 8-87 A, Geographic tongue. B, Ectopic geographic tongue observed in the

anterior mandibular mucosa. (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

1. Fungiform papillae appear as red, mushroom-like projections

2. Diffuse desquamation of filiform papillae
3. Condition assumes variations in shape, giving a map-like
appearance; remission in depapillated areas
4. Discomfort occurs when the patient eats certain foods
D. Histologic characteristics—characteristic inflammatory cells; keratotic
cells around the borders of the lesion
E. Treatment—none; variant of normal

691
Black Hairy Tongue
A. Etiology—irritation to filiform papillae caused by:
1. Smoking
2. Alcohol
3. Hydrogen peroxide
4. Antacid liquids
5. Systemic antibiotic therapy
B. Clinical features—brownish to black appearance on the dorsal surface
of the tongue (Fig. 8-88)

FIG 8-88 Black hairy tongue. (From Ibsen OAC, Phelan JA: Oral pathology for the dental
hygienist, ed 6, St Louis, 2014, Elsevier.)

692
 FIG 8-89 Leukoedema. (From Regezi JA, Sciubba JA, Jordan CK: Oral pathology: clinical
pathologic correlations, ed 7, St Louis, 2017, Elsevier.)

FIG 8-90 Radiographs.

C. Histologic characteristics—elongation of filiform papillae;

characteristic inflammatory cells
D. Treatment and prognosis
1. Gentle brushing or scraping of the tongue; toothpaste should not be
used

693
 2. Removal of the cause
3. Prognosis is good; the condition is totally reversible, but may recur

Website Information and Resourc es

Source Website Address Description
Doctor ’s Guide http://www.pslgroup.com Articles on medical industry and medical news
National Institute of http://www.nidcr.nih.gov/ News and information related to dentistry and
Dental and information about the Institute’s research
Craniofacial Research
Mayo Clinic Medicine http://www.mayohealth.org
Information and links to health conditions and
Center diseases
Clinical trials listing
http://www.centerwatch.com International listing of clinical research trials and
service medical centers that perform clinical research and
drug therapies newly approved by the U.S. Food and
Drug Administration (FDA)
National Cancer http://www.nci.nih.gov Information about types of cancer, treatments, risk
Institute factors, screening, tests, and statistics
American Cancer http://cancer.org Information about cancers and leukemias from both
Society professional and patient points of view
American Society of http://www.aspho.org Information for both professionals and patients about
Pediatric Hematology pediatric hematology and oncology
and Oncology
Support for People http://www.spohnc.org Information and support for those suffering from oral
with Oral and Head and head and neck cancers
and Neck Cancers
Leukemia and http://www.leukemia.org Information about blood-related cancers
Lymphoma Society of
America

694
Suggested readings
Ibsen O.A.C., Phelan J.A. Oral pathology for the dental hygienist. ed 6
St Louis: Elsevier Saunders; 2014.
Neville B.W., Damm D.D., Allen C.M., Bouquot J.E. Oral and
maxillofacial pathology. ed 3 St Louis: Elsevier Saunders; 2009.
Regezi J., Sciubba J., Jordan R.C.K. Oral pathology: clinical pathologic
correlations. ed 5 St Louis: Elsevier Saunders; 2008.

Chapter 8 review questions

Answers and rationales to review questions are available on this text’s

accompanying Evolve site. See inside front cover for details.

Case A
Synopsis of Patient History
Age: 30
Sex: M
Height: 6′3″
Weight: 200 lbs

Vital Signs
Blood pressure: 120/80
Pulse rate: 60
Respiration: 16

695
Medical History
Patient is African American and in good health.

Dental History
Patient is meticulous with his oral hygiene, but has a tendency to brush
vigorously.

Social History
Patient lives with his wife and 3-year-old son.

Chief Complaint
“I don’t like the appearance of my gums pulling away from my teeth,
and my teeth are sensitive around my upper canines.”

Supplemental Oral Examination Findings

Patient has a generalized opalescent appearance of the buccal mucosa.
Patient has generalized melanin pigmentation of the gingiva. A
mucocele is noted.
The gingiva is firm and stippled with no bleeding evident on probing.
There is gingival recession on teeth #6 and #11 and mandibular anterior
facials, with a 1-mm zone of attached gingiva.

Use Case A and Fig. 8-89 to answer questions 1 to 11.

1. The generalized opalescence of the buccal mucosa is most likely:
a. Linea alba
b. Leukoedema
c. Lichen planus
d. Leukoplakia
2. In which layer of the stratified epithelium is the generalized
opalescent condition in question 1 caused by significant intercellular
edema?
a. Corneum
b. Basal
c. Prickle
d. Granular

696
3. What treatment does this condition require?
a. Nonsteroidal anti-inflammatory drugs
b. Excision
c. Antifungal drugs
d. No treatment
4. The patient has a 2-mm probing depth on the facial aspect of tooth #6,
and he has 3 mm of recession. What is the attachment loss in this area?
a. 5 mm
b. 2 mm
c. 3 mm
d. 1 mm
5. The patient’s sensitivity in this area is most likely related to fluid
entering the:
a. Sulcular epithelium
b. Rodless enamel
c. Dentinal tubules
d. Lacuna of cementum
6. The tooth itself is capable of experiencing painful nerve sensation
from all the following EXCEPT:
a. Pressure
b. Heat
c. Cold
d. Olfaction

The patient wants the areas of gingival recession treated to resolve issues
of sensitivity and esthetic problems. The dental care plan includes
covering the areas around the canines with soft tissue grafts. The
periodontist states that she will perform connective tissue grafts. She
explains that the connective tissue taken from an area (donor site) will
produce the same type of epithelium at the canine area (recipient site) as
the tissue that exists at that donor site.

7. The type of tissue normally present around the canine area is:
a. Keratinized, stratified squamous epithelium
b. Nonkeratinized, stratified squamous epithelium

697
 c. Keratinized, simple squamous epithelium
d. Pseudo-stratified columnar epithelium
8. The most appropriate connective tissue donor site would be the:
a. Buccal mucosa
b. Soft palate
c. Hard palate
d. Sublingual area
9. With this procedure, the ideal outcome would be for some of this
tissue to form a fibrous attachment to the tooth cementum. From which
type of tissue would the cells come to remodel the cementum in this area
in which root surfaces previously were exposed?
a. Cellular cementum
b. Bone
c. Sulcular epithelium
d. Periodontal ligament
10. This patient also has a mucocele that is the result of trauma to a
minor salivary duct. A mucocele is usually found on the:
a. Gingiva
b. Lower lip mucosa
c. Hard palate
d. Dorsum of the tongue
11. To prevent further recession, what changes should this patient make
in his oral self-care regimen?
a. More frequent recare appointments
b. Modifying flossing technique
c. More frequent toothbrushing
d. Modifying toothbrushing technique
12. The radiographs in Fig. 8-90 indicate congenital absence of the:
a. Maxillary right first premolar and the maxillary left first premolars
b. Mandibular right first premolar and the mandibular left first
premolar
c. Mandibular left first premolar and the mandibular right second
premolar
d. Mandibular right second premolar and the mandibular left second

698
 premolar
13. A bony, developmental, benign asymptomatic area found on the
midline of the hard palate that appears radiopaque on a radiograph is
most likely a:
a. Odontogenic myxoma
b. Median palatal cyst
c. Compound odontoma
d. Torus palatinus
Use Fig. 8-91 to answer questions 14 to 16.

FIG 8-91 Panoramic radiograph.

14. On the panoramic radiograph in Fig. 8-91, the bilateral radiolucent

areas apical to the mandibular molars and identified by A are:
a. Stafne bone cysts
b. Periapical abscesses
c. Submandibular fossae
d. Traumatic bone cysts
15. The horizontal radiopaque structure identified by B in Fig. 8-91 is
the:
a. Anterior coronoid process
b. Maxillary tuberosity
c. Mandibular condyle
d. Zygomatic arch

699
16. The bilateral radiolucent areas identified by C in Fig. 8-91 are:
a. Nasal fossae
b. Orbits
c. Frontal sinuses
d. Maxillary sinuses
17. The Pleomorphic adenoma is most often found in the:
a. Palate
b. Mandible
c. Buccal mucosa
d. Lymph nodes
18. Which of the following cysts would create difficulty swallowing?
a. Branchial cleft
b. Thyroglossal
c. Nasopalatine
d. Stafne bone
19. Which disease may have oral characteristics similar to those found in
necrotizing ulcerative gingivitis (NUG)?
a. Primary herpes
b. Mononucleosis
c. Leukemia
d. Nonthrombocytopenic purpura
20. A ranula usually is found on the:
a. Palate
b. Lower lip mucosa
c. Buccal mucosa
d. Floor of the mouth
21. A definitive dental diagnosis of soft tissue oral cancer is made by:
a. A complete radiographic survey
b. Exfoliative cytology
c. Scalpel biopsy
d. Brush test
22. Fig. 8-92 shows a periapical radiograph of the mandibular right
quadrant, which was taken as part of a full-mouth radiographic series.

700
The patient was 14 years of age and asymptomatic. The periapical
radiolucency indicated by the arrow on tooth #31 is most likely:

FIG 8-92 Periapical radiograph.

a. Resorption caused by a traumatic injury

b. Periapical abscesses
c. Incomplete root formation
d. Hypercementosis
23. Primordial cysts are most often found radiographically:
a. In the anterior maxillary regions
b. Around a supernumerary tooth
c. Posterior to erupted third molars or in place of a tooth that was never
present
d. In the mandibular canine and first premolar areas
24. The usual location of periapical cemento-osseous dysplasia
(cementoma) is:
a. Mandibular anteriors
b. Maxillary anteriors
c. The mandibular ramus
d. Maxillary premolars

701
25. Which of the following is a rickettsial infection?
a. Malaria
b. Psittacosis
c. Rocky Mountain spotted fever
d. Tularemia
26. A slightly raised, noncoated, red rectangular area in the midline of
the tongue has been present as long as the patient can remember. Once
thought to be developmental, it is associated with Candida albicans. This
condition is most likely:
a. Geographic tongue
b. Pathologic tongue
c. Median rhomboid glossitis
d. Fissured tongue
27. Which of the following provides the most conclusive diagnostic
evidence in distinguishing pemphigus from pemphigoid?
a. Clinical picture
b. History of the disease
c. Biopsy and histology report
d. Nikolsky's sign
28. An isolated radiopaque area in the periodontal ligament space is
observed on a patient’s radiographs. This radiopaque structure may be
a(n):
a. Epithelial rest
b. Cementum spur
c. Exostosis of alveolar bone
d. Cementicle
29. A 30-year-old patient calls and complains of sudden swelling in both
sides of his neck, which seems to be enlarging. His record indicates that
he recently has canceled two appointments. He needs to have restorative
care completed on the mandibular second molars, which have extensive
decay. The patient may have:
a. Actinomycosis
b. Mumps
c. Syphilis
d. Ludwig angina

702
30. Which of the following two diseases represent different forms of
infection resulting from the same virus?
a. Measles and German measles
b. Chickenpox and smallpox
c. Bacterial pneumonia and croup
d. Shingles and chickenpox
31. A lesion is noted on the lips of a 40-year-old female patient. The
lesion appears as several discrete vesicles; some have ulcerated. When
questioned, the patient says she “always gets a sore like that” before she
develops a cold. The patient most likely has:
a. A chancre
b. Perlèche
c. An aphthous ulcer
d. Herpes labialis
32. Which of the following statements most accurately describes the
most common effect of pregnancy on the health of the mother’s oral
tissues?
a. Pregnancy-associated gingivitis is caused by hormonal changes, and
nothing can be done about it.
b. Pregnant women can often experience the growth of tumors in the
mouth that relate to hormonal changes.
c. Hormonal changes during pregnancy result in increased bacteria
and increased gingival response to plaque biofilm.
d. Pregnancy results in hormonal changes, but these changes do not
affect the mother ’s oral tissues.
33. The gingival enlargement shown in Fig. 8-93 was caused by a calcium
channel blocker drug. The condition was most likely caused by:

703
 FIG 8-93 Gingival enlargement. (Courtesy of Dr. Victor M. Sternberg; from
Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, St Louis, 2014,
Elsevier.)

a. Phenytoin (Dilantin)
b. Enalapril (Vasotec)
c. Fluoxetine (Prozac)
d. Nifedipine (Procardia)
34. In Fig. 8-94, the soft tissue lesion on the mandibular mucosa erupted
suddenly, was filled with a clear fluid, and broke easily. The condition
most likely described here is:

704
 FIG 8-94 Soft tissue lesion.

a. Ranula
b. Mucocele
c. Fibroma
d. Fistula
35. Which of the following produce(s) no radiographic image?
a. Dental caries
b. Supernumerary teeth
c. Odontoma
d. Fibroma
36. Which of the following diagnostic methods is most reliable and
ensures the highest degree of accuracy when evaluating squamous cell
carcinoma?
a. Surgical
b. Microscopic
c. Therapeutic
d. Clinical
37. Which of the following does NOT define the term pathogenesis?

705
 a. How the lesion begins
b. Behavior of the lesion
c. Clinical picture of the lesion
d. Development of the lesion
38. A pyogenic granuloma is known to scar down to a(n):
a. Pregnancy tumor
b. Fibrogranuloma
c. Lipoma
d. Osteoma
39. The patient is a 28-year-old woman who is pregnant. A gingival
lesion involving the interproximal papillae between teeth #7 and #8 on
the labial surface is bright red, soft, and spongy; it bleeds easily. The
histology report shows proliferation of inflammatory cells and thin
epithelium. The lesion described is most likely:
a. Fibroma
b. Pyogenic granuloma
c. Redundant tissue
d. Papilloma
40. Which one of the following cysts has the potential for developing
into an ameloblastoma?
a. Lateral periodontal cyst
b. Primordial cyst
c. Stafne bone cyst
d. Residual cyst
41. The clinical oral examination of the patient reveals a possible
leukoplakia. The first course of action should be to:
a. Perform a scalpel biopsy
b. Perform a cytologic smear
c. Give the patient vitamin A therapy
d. Have the patient return in 2 months to evaluate the growth
42. Which one of the following tests is NOT used for pemphigus?
a. Pels-Macht
b. Tzanck
c. Enzyme-linked immunosorbent assay (ELISA)

706
 d. Nikolsky sign
43. A palatal condition of an elderly patient that is primarily caused by
chronic irritation from the suction chamber of a denture is clinically
observed as:
a. Fibroma
b. Papilloma
c. Papillary hyperplasia
d. Median palatal cyst
44. A lesion found on the buccal mucosa of a 30-year-old white woman is
pink, well defined, and soft to palpation. It has been slow growing and
histologically consists of collagenous fibers, fibroblasts, and fibrocytes,
but with no fat cells or bone. It has a pedunculated base. The lesion is
most likely a:
a. Sarcoma
b. Fibroma
c. Fibrolipoma
d. Fibro-osteoma
45. A radiolucent lesion in the posterior part of the mandible anterior to
the angle has the radiographic features of a cyst. After surgical
intervention, the histology report shows submaxillary salivary gland
tissue; also, the lesion is not lined with epithelium. One may conclude
that the lesion is most likely a(n):
a. Residual cyst
b. Traumatic bone cyst
c. Lingual mandibular bone concavity
d. Ameloblastoma
46. A cyst typically found unilaterally in the floor of the mouth changes
size between meals. Clinically, it has a bluish hue. It may be caused by:
a. Decayed tooth
b. Blockage or trauma to a major salivary duct
c. Failure of developmental fusion of the branchial arches
d. Medications
47. The onset of this chronic, recurring autoimmune disease is at 30
years, with no gender predilection. A triad of symptomatic locations
(oral, eye, and genital) is involved, and two of the three areas must be

707
present to make the diagnosis of:
a. Erythema multiforme
b. Stevens-Johnson syndrome
c. Behçet syndrome
d. Minor aphthous ulcers
48. For which one of the following is the etiology definitely known to be
an irritant?
a. Papilloma
b. Torus
c. Granuloma
d. Lipoma
49. An intraoral examination of the gingiva reveals a clinical picture of
punched-out papillae. The patient complains of pain and a bad taste.
The history indicates that the patient’s diet is poor, that he has been
under stress, and that he has had little rest. What is the best course of
action for the condition you suspect?
a. Perform culture and laboratory studies
b. Apply a therapeutic course, debride the mouth, and recommend
hydrogen peroxide oral rinse and possibly systemic antibiotics
c. Immediately refer the patient to a periodontist
d. Perform periodontal therapy, including extensive root planing and
stain removal
50. Which one of the following is MOST important to the pathologist
when a chondroma is suspected?
a. Complete personal history of the patient
b. Remove a very small part of the tumor in question
c. Submission of a “large enough” sample of tissue for histologic study
because a chondroma resembles a malignant chondrosarcoma
d. Radiographs of all large bones
51. The clinical assessment of a patient’s lesion is best described as a
well-defined, yellowish, blister-like eruption. Straw fluid may be
aspirated. It is a rare, benign neoplasm. The histology report shows a
predominance of fat cells. The lesion is a(n):
a. Papilloma
b. Osteoma

708
 c. Lipoma
d. Fibroma
52. A tooth involved in a cyst is discovered to be nonvital on pulp
testing. The cyst is probably a:
a. Residual cyst
b. Lateral periodontal cyst
c. Radicular cyst
d. Dentigerous cyst
53. Which one of the following can be a characteristic of pemphigus
vulgaris?
a. Nikolsky sign
b. Occurs predominantly in African American females
c. Is caused by a drug reaction
d. Occurs predominantly in white males
54. The clinical assessment reveals an inflamed, palpable benign tumor
in the anterior of the palate, lingual to the maxillary incisors. The tumor
arises from deeper tissue and appears to originate from the periodontal
ligament. The radiograph shows the lesion infiltrating bone but no
metastasis. The patient is a 35-year-old woman. A possible diagnosis is:
a. Peripheral giant cell granuloma
b. Lipoma
c. Torus palatinus
d. Pleomorphic adenoma
55. Clinical assessment of a lesion reveals a severe hypersensitivity
reaction, with the lips and tongue especially affected. Additionally,
“bull’s-eye” or “target” skin lesions are present, and the onset of all
lesions was abrupt or “explosive.” The condition is most likely:
a. Lichen planus
b. Herpes
c. Erythema multiforme
d. Mononucleosis
56. Which one of the following cysts is the result of extracting a tooth
without the cystic sac?
a. Radicular cyst
b. Residual cyst

709
 c. Lateral periodontal cyst
d. Primordial cyst
57. The dental hygienist observes an adult patient with the following
clinical feature and medical history; gingival enlargement resulting from
a history of Zimmerman-Laband syndrome and phenytoin (Dilantin)
therapy. Which one of the following statements is CORRECT?
a. The patient should stop taking the drug.
b. An overgrowth of the connective tissue is present.
c. The epithelium remains the same.
d. A gingivectomy would “cure” the condition.
58. Which one of the following diagnostic processes should be applied to
establish the diagnosis of nicotine stomatitis?
a. Surgical and microscopic
b. Radiographic
c. Laboratory
d. Clinical and historical
59. Clinically, this benign white, cauliflower-like lesion usually on the
palate is similar to a wart. The histology report indicates long, finger-
like projections of stratified squamous epithelium. The etiology is
human papillomavirus (HPV) types 6 and 11. What is the most likely
condition?
a. Verruca vulgaris
b. Papilloma
c. Aspirin burn
d. Linea alba
60. In which of the following locations is a lateral periodontal cyst
usually found?
a. Between the roots of mandibular canines and premolars
b. Between the roots of maxillary central incisors
c. On the maxillary canine
d. In the mandibular third molar area
61. A platelet count of 150,000 to 400,000 cells/mm3 of blood and a normal
bleeding time are NOT indicative of:
a. Thrombocytopenia
b. Anemia

710
 c. Leukemia
d. Nonthrombocytopenic purpura
62. All the following are characteristic of necrotizing ulcerative gingivitis
EXCEPT:
a. Punched-out papillae and craters
b. Hyperkeratinization
c. Odor
d. Pain and bleeding
63. Which of the following makes Behçet’s syndrome different from
recurrent ulcerative stomatitis?
a. Bull’s-eye skin lesions
b. Triad of locations of lesions (oral, eye, and genital)
c. Exudate from lesions
d. Mesenchymal proliferations
64. What is the causative agent of herpangina?
a. Chickenpox virus
b. Coxsackievirus
c. Epstein-Barr virus
d. Varicella-zoster virus
65. In treating fibrous dysplasia, which one of the following would NOT
be advised, because it can trigger a malignancy?
a. Radiation
b. Surgery
c. Chemotherapy
d. Bone marrow depressants
66. Precocious puberty is most characteristic of:
a. Jaffe syndrome
b. Monostotic fibrous dysplasia
c. Cherubism
d. McCune-Albright syndrome
67. Achlorhydria, inability to absorb vitamin B12, and burning, painful
tongue are characteristics of:
a. Thrombocytopenia

711
 b. Hypervitaminosis
c. Pernicious anemia
d. Hyperkeratosis
68. Bone marrow anoxia occurs in:
a. Secondary polycythemia
b. Pernicious anemia
c. Thalassemia
d. Aplastic anemia
69. Which one of the following is referred to as “Cooley anemia”?
a. Acute anemia
b. Thalassemia
c. Primary aplastic anemia
d. Thrombocytopenia
70. In which of the following cysts are nonvital teeth involved?
a. Nasoalveolar cyst
b. Lateral periodontal cyst
c. Radicular cyst
d. Cyst of the incisive papilla
71. Which of the following cysts could develop into an ameloblastoma?
a. Residual cyst
b. Primordial cyst
c. Median mandibular cyst
d. Lateral periodontal cyst
72. A radicular cyst is most often caused by:
a. Deep restorations
b. Trauma
c. Primary occlusal traumatism
d. Dental caries
73. Epulis fissuratum is caused by:
a. Denture flange
b. Suction chamber of a denture
c. Allergic reaction to acrylic material
d. Denture cleaners

712
74. Sickle cell anemia is of hereditary origin and occurs primarily in:
a. Whites
b. Native Americans
c. Eskimo population
d. African Americans
75. Which one of the following is found in a person with achlorhydria?
a. Low blood glucose level
b. Lack of hydrochloric acid
c. Too much hydrochloric acid
d. Xerostomia
76. Which one of the following is found in a person with leukopenia?
a. Decrease in the number of white blood cells
b. Increase in the number of white blood cells
c. Decrease in the number of red blood cells
d. Decrease in the number of platelets
77. Which clinical feature is most associated with bulimia?
a. Abrasion
b. Abfraction
c. Erosion
d. Attrition
78. Aspirin burn is caused by the misuse of aspirin. It will appear on the
buccal mucosa as:
a. A white lesion with sudden onset
b. An erythematous lesion with chronic history
c. A lesion requiring microscopic analysis
d. An allergic reaction
79. On which location do you normally see thermal burns?
a. Hard palate
b. Soft palate
c. Buccal mucosa
d. Floor of the mouth
80. Necrotizing sialometaplasia is observed clinically on the:
a. Palate

713
 b. Buccal mucosa
c. Lower lip
d. Floor of the mouth
81. Which one of the following does not cause gingival enlargement?
a. Dilantin
b. Cyclosporine
c. Acyclovir
d. Norvasc
82. Pulp polyps are seen clinically:
a. Within the open crown of a carious tooth
b. At the apex of a tooth
c. Between the roots of teeth
d. On the buccal aspect of alveolar bone
83. Which one of the recurrent aphthous ulcers occurs most often?
a. Minor aphthous ulcers
b. Major aphthous ulcers
c. Sutton Disease
d. Herpetiform
84. Wickham Striae and desquamative gingivitis are characteristic
features of which one of the following:
a. Erythema multiforme
b. Cannon disease
c. Pemphigus
d. Lichen Planus
85. Which one of the following is not part of the triad of symptoms
associated with Reactive Arthritis?
a. Arthritis
b. Urethritis
c. Conjunctivitis
d. Appendicitis
86. The varicella zoster virus causes which one of the following:
a. Measles
b. Mononucleosis

714
c. Verruca Vulgaris
d. Shingles

715
C HAPT E R 9

716
Microbiology and Immunology
Jessica Peek Scott*

Basic concepts of microbiology and immunology relate to transmissible

diseases encountered in client care. Using standard precautions in the
dental setting greatly reduces the transmission of pathogens. Dental
hygienists must prevent and manage potential occupational exposures
from infectious diseases.

717
General microbiology
Microorganisms
General Considerations
A. Ubiquitous—found virtually everywhere
B. Only 3% are pathogenic (disease causing); 97% are nonpathogenic
C. Exhibit characteristics common to all biologic systems: reproduction,
metabolism, growth, response to stimuli, adaptability, mutation, and
organization
D. Medically important microorganisms
1. Eukaryotes
a. Protozoa—unicellular, nonphotosynthetic, heterotrophic
b. Fungi—molds (multi-cellular) or yeast (unicellular)
(1) Nonphotosynthetic, heterotrophic
(2) Classified by type of spores produced, presence or absence
of mycelia (singular, mycelium), and mechanisms of sexual
and asexual spore formation
(3) Part of the fungi kingdom
(4) Identification of infection is accomplished clinically and
microbiologically
c. Helminths
(1) Multi-cellular, nonphotosynthetic, heterotrophic
(2) Generally, macroparasites of the human alimentary tract or
hemolymphatic system
(3) Part of the animal kingdom
(4) Identification of infection is accomplished on
microbiologic and clinical grounds
2. Prokaryotes (aerobic or anaerobic unicellular bacteria)
a. Classified by shape
(1) Cocci (round)
(2) Bacilli (rod shaped)
(3) Vibrio (comma shaped)
(4) Spirochete (corkscrew shaped)
b. Classified by Gram staining
(1) Gram-positive (violet on Gram stain)
(2) Gram-negative (pink on Gram stain)
c. Classified into two taxa (singular, taxon):
(1) Eubacteria—“true” bacteria; most important bacteria in
medicine
(2) Archeobacteria—primitive bacteria; can occupy and

718
 inhabit extreme environments
3. Viruses; classification based on:
a. Type and properties of nucleic acid
b. Morphology of nucleoproteins
c. Presence and properties of envelopes—the envelope is the
protein coat that protects the capsid and nucleic acid of the
virus
4. Prion
a. Type of protein found in brain neurons; contains no genetic
material
b. Not bacterial, viral, or fungal
c. Improper folding and inability to be degraded allows for
accumulation and damage to the nervous system
d. Transmissible (spongiform encephalopathies)
(1) Creutzfeldt-Jakob disease
(2) Mad cow disease
e. Highly resistant to traditional sterilization methods because of
the extreme stability of prion proteins
E. Nomenclature—the binomial system
1. Two-word designation
a. Genus and species
b. First word capitalized and both words italicized (e.g., Escherichia
coli)
2. Devised by Carolus Linnaeus

Methods of Measurement and Observation

A. Types
1. Macroscopic—measurable and observable by the naked eye
2. Microsocopic—too small to be measured or observed by the naked
eye; requires a microscope or lens to see
B. Most commonly used units of measurement
1. Centimeter (cm = 10− 2 m)
2. Millimeter (mm = 10− 3 m)
3. Micrometer or micron (µm = 10− 6 m)
4. Nanometer (nm = 10− 9 m)
5. Angstrom unit (Å = 10− 10 m)
C. Light microscopes illuminate objects by visible light
1. Bright-field microscopy
a. Used to observe the morphology of microorganisms
b. Used with stained smears

719
 c. Cannot be used to observe microorganisms less than 0.2 µm,
such as viruses and spirochetes
d. Compound microscopes have at least two lens systems:
(1) Objective
(a) Magnifies the specimen and is close to it
(b) Four powers— × 4, × 10, × 40, and oil immersion
(× 100)
(2) Ocular
(a) Eyepiece
(b) Magnifies the image produced by the objective lens
2. Darkfield microscopy
a. Specimens seen as bright objects against a dark background
b. Used for the examination of unstained microorganisms and
spirochetes and hanging-drop preparations
c. Advantage—allows a view of living bacteria not visible by Gram
stain; undisturbed in size or shape by fixing and staining
techniques
3. Phase-contrast microscopy
a. Useful in examining transparent, living cells, including their
internal structure, and in determining motility in a fluid
medium; can show dense structures
b. Variations in density between the microbes and the
surrounding medium are capitalized on to increase the contrast
between the two
4. Fluorescence microscopy
a. Used to visualize objects that fluoresce or emit light when
exposed to light of different wavelengths
b. Ultraviolet light, fluorescent chemicals, and special filter
systems required
c. Typically used in the medical field to track antigen-antibody
reactions and as a diagnostic technique (immunofluorescence)
5. Confocal-scanning laser microscopy
a. A conventional light microscope uses a laser light source to
illuminate planes of a fluorochrome-stained specimen
b. Confocal images combine fluorescent and reflected images
c. Successive planes are scanned until the entire specimen is
scanned
d. Useful in creating three-dimensional pictures of biofilms
6. Specimen preparation
a. Viewing living organisms
(1) Methods

720
 (a) Hanging drop
(b) Temporary wet mount
(2) Advantages
(a) Maintains the shape of organisms
(b) Is useful to determine organisms’ size, shape, motility,
and reactions to chemicals or immune sera
b. Staining
(1) Procedure
(a) Thin films of microorganisms are spread on a glass
slide and allowed to dry (smear)
(b) Films are fixed, either by a chemical fixative or by
passing through a flame; this denatures the proteins
and kills the cell
(c) Dyes or stains are applied to the smear to allow for
greater visualization; allows for some differentiation of
species
(d) Fixation process tends to reduce the sizes of cells; dye
addition tends to increase the sizes of cells
(2) Types of dyes
(a) Acidic, or negative, dye is used to stain basic
components of the cell (e.g., glycoproteins, matrix)
(b) Basic, or positive, dye is used to stain acidic
components of the cell (e.g., nucleic acid and
polysaccharides)
(3) Simple staining procedures
(a) Use a single dye (e.g., carbolfuchsin, crystal violet,
methylene blue, or safranin)
(b) Are used to show shapes, sizes, and arrangements of
bacterial cells
(4) Differential staining procedures (Table 9-1)

721
 Table 9-1
Comparison of Gram-Positive and Gram-Negative Bacteria

Gram-Positive Gram-Negative
Bacteria Bacteria
Color after Gram stain Blue to purple Pink to red
procedure
Peptidoglycan layer in cell Thick Thin
walls
Teichoic acid in cell walls Present Absent
Lipopolysaccharide in cell Absent Present

walls

(a) More than one dye preparation used

(b) Used for initial bacterial grouping
(c) Most common methods
[1] Gram stain—differentiates microorganisms based
on color as gram-positive (blue to purple) or gram-
negative (pink to red); certain characteristics of
microorganisms appear correlated with their
staining reactions: cell wall thickness, chemical
composition, and sensitivity to penicillin; useful in
the diagnosis of infectious diseases
[2] Acid-fast stain—differentiates between acid-fast
and non–acid-fast bacteria; differentiates
mycobacteria (e.g., Mycobacterium leprae, M.
tuberculosis) from other bacteria by indicating the
presence or absence of special lipids in the cell
wall; organisms resist decolorization with an acidic
solution of alcohol after being stained with a basic
dye
(5) Special staining procedures—used to color and isolate
specific parts of microorganisms
(a) Negative staining for capsules—determines if
organism is encapsulated
(b) Schaeffer-Fulton spore stain (e.g., Bacillus,
Clostridium)—determines if organism is a spore former
(c) Flagellar staining—determines if organism has
flagella
(d) Toluidine blue-O staining—determines prions,
proteoglycans, and glycosaminoglycans in tissues
D. Electron microscopy

722
 1. Electrons used as a source of illumination
2. Higher magnification and better resolving power available than with
a light microscope, but because specimens must be dead, dynamic
processes cannot be examined
3. Types
a. Transmission electron microscope—used to visualize the
ultrastructures of cells and viruses
b. Scanning electron microscope—used to visualize three-
dimensional images of surface features of cells and viruses

Prokaryotic (Bacterial) Cell Structure and Function

A. Bacterial morphology
1. Cocci (singular, coccus)
a. Spherical or ovoid shape
b. Occur in pairs (diplococci), chains (streptococci), four-in-a-
square arrangement (tetrad), eight cells in a cubic arrangement
(sarcinae), and irregular clusters (staphylococci)
2. Bacilli (singular, bacillus)
a. Cylindrical or rod-like
b. Occur in pairs (diplobacilli); chains (streptobacilli); small,
rounded rods (coccobacilli); and with tapered ends (fusiform
bacilli)
3. Spirilla (singular, spirillum)
a. Spiral or curved
b. Vary in number and fullness of turns
c. Vibrios are portions of a spiral
4. Palisade arrangement (bacterial cells form weird angles to one
another)
a. “Fence post” appearance
b. Cornynebacterium diphtheriae
5. Pleomorphic (no defined cell shape)
a. Variable in shape
b. Mycoplasma pneumoniae
B. External cell structures
1. Appendages
a. Provide motility
(1) Flagella (singular, flagellum)
(a) Threads of protein that extend from the cell surface
and move in a whip-like motion
(b) Vectored motility must be distinguished from

723
 brownian movement, which is caused by bacteria
randomly hitting molecules in the surrounding
medium; flagella enable bacteria to move toward
favorable environments and away from adverse ones
(chemotaxis)
(2) Axial filaments
b. Allow for movement—spirochetes (e.g., Treponema pallidum,
Borrelia burgdorferi) move by this method
c. Provide attachments
(1) Pili (singular, pilus)
(a) Hair-like structures often found on gram-negative
bacteria; not associated with motility
(b) Longer and fewer in number
(c) Sex pili join bacterial cells in preparation for
deoxyribonucleic acid (DNA) transfer (conjugation)
(2) Fimbriae (singular, fimbria)
(a) Shorter and numerous
(b) Enable a cell to adhere to surfaces (e.g., Neisseria
gonorrhoeae, E. coli)
2. Surface coating (glycocalyx)
a. Capsules
(1) Condensed and well-defined masses of polysaccharides or
polypeptides firmly attached to the cell wall
(2) Encapsulation protects pathogenic organisms from drugs,
phagocytosis, and bactericidal factors
(3) Some bacteria need capsules to maintain virulence (e.g.,
Streptococcus pneumoniae, Streptococcus mutans)
b. Slime layer (glycocalyx)
(1) Unorganized, soluble mass of polysaccharides or
polypeptides loosely attached to the cell wall; polymeric
material (glycoprotein)
(2) Protects microorganisms; aids in adherence and gliding
motility of organism
3. Cell wall
a. Functions
(1) Determines and maintains the shape of the microorganism
(2) Provides support for flagella
(3) Prevents rupture of the cell resulting from osmotic
pressure differences on either side of the cell wall
b. Composed of the macromolecule peptidoglycan
c. Comparison of gram-negative and gram-positive cell walls

724
 (1) Gram-positive cell walls consist of many layers of
peptidoglycan and contain teichoic acids
(2) Gram-negative bacteria have a lipoprotein-
lipopolysaccharide-phospholipid outer membrane
surrounding a thin, peptidoglycan layer
(3) Outer membrane protects gram-negative cells from
phagocytosis, penicillin, lysozymes, and other chemicals
(4) Gram-negative cell walls are more easily broken by
mechanical forces; susceptible to lysis by antibody,
complement, and streptomycin
4. Cytoplasmic (plasma) membrane
a. Structure—consists of a phospholipid bilayer interspersed with
proteins in a mosaic pattern (fluid mosaic)
b. Functions
(1) Barrier that regulates movement of materials in and out of
the cell
(2) Active transport
(3) Excretion of hydrolytic exoenzymes
(4) Bears enzymes and carrier molecules
(5) Bears receptors and other proteins of the chemotactic and
other sensory transduction systems
c. Lies adjacent to and beneath the cell wall and encloses the
cytoplasm of the cell
5. Cell envelope
a. Includes all external structures and appendages, including the
capsule, pili, flagella, cell wall, and cytoplasmic membrane
b. May play a role in protection from degradation, maintenance of
cell shape, and cell adhesion
c. Properties confer staining characteristics
d. Organization and structure different in gram-positive and gram-
negative bacteria
C. Internal cell structure
1. Cytoplasm (protoplasm)
a. Fluid compartment inside the cytoplasmic membrane
b. Prominent site for many of the cell’s biochemical and synthetic
activities
c. Contains chromatin body, ribosomes, and granules
2. Mesosomes—irregular folds of the cytoplasmic membrane resulting
from dehydration of cells in preparation for electron microscopy;
considered artifacts
3. Genetic material or genome (nucleoid)

725
 a. Prokaryotes lack the distinct nucleus of eukaryotes
b. Single chromosome is composed of a single molecule of DNA,
existing as a closed loop not enclosed by the nuclear membrane;
located in the nucleoplasm of the cell
c. Additional genetic material is found in plasmids, which are
extrachromosomal DNA molecules; they often carry information
that determines drug resistance or sensitivity
4. Ribosomes
a. Function in protein synthesis
b. Composed of ribosomal protein and ribosomal ribonucleic acid
(RNA)
c. Distributed throughout the cytoplasm
5. Photosynthetic apparatus
6. Inclusions
a. Accumulations of reserve storage materials
b. Include polysaccharide granules, metachromatic granules,
sulfur granules, lipid inclusions, carboxysomes, and gas
vacuoles
D. Endospores (spores)
1. Dormant structures formed within gram-positive bacterial cells as a
means of survival
2. Formed during a process called sporulation—disintegration of parent
cell releases endospore; then called exposure or free spore
3. Can remain in a spore state for years; exhibit unusual resistance to
heat, drying, chemical disinfection, and radiation
4. Can transform back into a vegetative cell through a process called
germination
5. Ability of bacteria to produce endospores restricted mainly to the
genera Bacillus and Clostridium

Eukaryotic Cell Structure and Function

See Tables 9-2 and 9-3.

Table 9-2
Eukaryotic Organelles and Their Functions

726
727
Table 9-3
Major Characteristics of Eukaryotes and Prokaryotes

A. More complex than a prokaryotic cell; has a distinct nucleus bounded

by a nuclear membrane, a nucleolus, and membrane-bound organelles
B. Animal cells
1. Cell membrane
a. Surrounds the cell and interconnects with the cell’s internal
membrane systems
b. Functions
(1) Regulates the passage of substances in and out of the cell
through active and passive transport
(2) Involved in phagocytosis, tumor formation, drug
sensitivity, and immune response
2. Nucleus
a. Controls the cell’s physiologic and reproductive processes
b. Composition
(1) Nuclear membrane
(2) Nucleoli (involved in RNA synthesis)
(3) Chromosomes (composed of DNA)
(4) Nucleoprotein (chromatin)
3. Internal structures
a. Mitochondria are sites of adenosine triphosphate (ATP), or
energy, production

728
 b. Endoplasmic reticulum
(1) Network of membranes involved in chemical reactions,
storage, and transportation
(2) Rough endoplasmic reticulum has ribosomes attached
c. Golgi complex—storage and packaging structure for cellular
components
d. Lysosomes—contain digestive enzymes
e. Microtubules
f. Vacuoles

Microbial Growth and Cultivation

See Fig. 9-1.

FIG 9-1 Bacterial production.

A. Definitions
1. Culture media—nutrient preparations used to cultivate
microorganisms
2. In vitro techniques—procedures using nonliving materials in a
culture vessel
3. In vivo techniques—procedures using living cells or entire animals
or plants
4. Colony—accumulation of bacteria on a medium
B. Conditions that affect growth
1. Physical

729
 a. Thermal conditions
(1) Most bacteria grow best over a range of temperatures
(a) Psychrophiles—0°C to 15°C
(b) Mesophiles—20°C to 40°C
(c) Thermophiles—45°C to 60°C
(2) 30°C is the optimal temperature for many free-living
organisms
b. Acidity or alkalinity (pH)—most bacteria prefer a neutral pH,
between 7.0 and 7.4
(1) Acidophiles—pH 0 to 4
(2) Neutrophiles—pH 5 to 9
(3) Alkalinophiles—pH greater than 9
c. Osmotic pressure
(1) Most microorganisms must be grown in an aquatic
medium
(2) Halophilic organisms require high salt concentration
(3) Osmophilic organisms require high osmotic pressure
2. Chemical
a. Gaseous requirements
(1) Aerobes require oxygen
(2) Micro-aerophilic organisms require low concentrations of
oxygen
(3) Anaerobes do not require oxygen
(4) Obligate (strict) anaerobes cannot tolerate any free oxygen
(5) Facultative anaerobes can metabolize aerobically if oxygen
is present or anaerobically if it is absent
(6) Aerotolerant anaerobes metabolize substances
anaerobically but are not harmed by oxygen
b. Nutrition available
(1) Heterotrophic organisms
(a) Require organic compounds for growth; obtain carbon
from glucose
(b) Most often cultured on a medium of glucose
(2) Autotrophic organisms
(a) Do not require organic nutrients for growth
(b) Use inorganic compounds such as carbon dioxide
(c) Thrive in soils and bodies of water
(3) Hypotrophic organisms
(a) Obligate intracellular parasites; grow only within a
living host cell
(b) Include viruses and rickettsiae

730
 (4) Phototrophic organisms
(a) Use light for energy
(5) Chemotrophic organisms
(a) Oxidize chemical compounds for energy
(6) Nutrients needed include sulfur and phosphorus
(7) Nitrogen is derived from proteins and their products
(8) Certain vitamins and growth factors required
C. Types of culture media
1. Synthetic defined media—exact chemical composition is known
2. Rich complex media—exact chemical composition varies slightly
from batch to batch (e.g., addition of blood or beef extract); contain
digested extracts from animal organs, meats, fish, yeasts, and plants
3. Differential media
a. Contain combinations of nutrients and pH indicators to produce
visual differentiation between several microorganisms
b. Examples
(1) Blood agar is an enriched medium that allows streptococci
to leave different signs on the medium; green discoloration
around colonies indicates α-hemolytic streptococci, clear
zone signifies β-hemolysis, and no effect denotes γ-
hemolysis
(2) Chocolate agar is even more enriched than blood agar
4. Selective media
a. Allow interference with or prevention of the growth of certain
microorganisms while permitting others to grow
b. Dyes and antibiotics make the media selective
c. Examples
(1) Sabouraud dextrose agar is selective for fungi
(2) Thayer-Martin agar is selective for Neisseria gonorrhoeae
5. Selective and differential media
a. Combine properties of the preceding two types of media
b. Examples—mannitol, salt agar, and MacConkey agar
6. Enriched media—similar to selective media but designed to increase
the numbers of particular microbes to detectable levels
7. Reducing media
a. Contain ingredients that chemically combine with and deplete
oxygen in the culture medium
b. Used for anaerobes
D. Pure culture techniques
1. Used to isolate and identify a bacterial species
2. Methods

731
 a. Pour-plate technique
(1) Cool the melted agar-containing medium
(2) Inoculate the medium
(a) Use the loop or needle to transfer the organism
(b) Pass the loop through the flame and heat to redness
(c) Flame the edges of tubes from which cultures are
taken before and after removal of the organism
(3) Pour the inoculated medium into a sterile Petri dish
(4) Allow the medium to solidify
(5) Incubate at the desired temperature
b. Streak-plate technique
(1) Spread a loopful of material containing organisms over the
surface of the solidified agar
(2) Various streaking directions or patterns are possible
E. Bacterial growth
1. Most bacteria reproduce through binary fission (i.e., two new cells
are produced by one parent cell)
2. Growth on the culture medium
a. Typical growth curve results
b. Phases
(1) Lag phase—period of intense metabolic activity but no
increase in cell number
(2) Log phase or exponential growth phase—cell number
increases in an exponential manner; generation time is the
average time for the cell to divide; phase when cells are
most metabolically active
(3) Stationary phase—total number of viable cells is constant;
metabolic activity slows
(4) Phase of decline (death phase)—number of viable cells
decreases
3. Measurement of growth
a. Population growth curve—made by observing an increase in
mass or numbers over time
b. Cell mass can be measured by dry weight, chemical analysis,
and turbidity
c. Population counts—cell numbers can be measured by viable
platelet counts; estimates are expressed as colony-forming units
(CFU) for bacteria or plaque-forming units (PFU) for viruses

Microbial Metabolism and Cell Regulation

732
A. Metabolism
1. Definition—set of chemical reactions by which cells maintain life
2. Phases
a. Anabolism—biosynthetic reactions that use energy (ATP)
(1) Energy-consuming phase in which macromolecules such
as nucleic acids, proteins, lipids, and polysaccharides are
synthesized
b. Catabolism—degradative reactions that release energy (ATP)
(1) Energy-releasing phase in which complex compounds are
broken down, creating energy in the form of ATP
3. Energy storage and transfer
a. Chemical energy is stored as ATP
b. May be generated through the transport of electrons (electron
transport system)
c. Energy produced through oxidation-reduction reactions
(1) Aerobic oxidation (respiration)
(2) Anaerobic oxidation (fermentation)
4. Metabolic pathways
a. Series of steps to complete biochemical process
b. Glycolytic pathway (glycolysis)
(1) Most important way carbohydrates are metabolized
(2) Converts glucose to pyruvic acid
(3) Anaerobic fermentation process
(4) Tricarboxylic acid (Krebs) cycle
c. Occurs inside mitochondria
(1) Follows the glycolytic pathway
(2) Responsible for further oxidation of glucose and the
production of other biochemically important intermediates
(3) Important to aerobic bacteria
5. Protein synthesis
a. DNA directs the formation of proteins aided by various types of
RNA
b. Transcription—synthesis of messenger RNA (mRNA) from a
DNA template
c. Translation—synthesis of protein from an mRNA template
d. Three stages of protein synthesis occurring at the ribosome:
(1) Initiation
(2) Elongation
(3) Termination
B. Metabolic control
1. Largely by enzymatic control

733
 2. Types of regulation
a. Feedback inhibition
(1) Allosteric enzymes—end product binds to the enzyme and
lowers its affinity for its substrate, thus preventing further
product formation
(2) When more end product is needed, the enzyme is released
b. Genetic regulation—regulated by a specific unit of DNA called
an operon
(1) Enzyme repression—when the level of end product is
sufficient, the genetic synthesis of the enzyme is
suppressed
(2) Enzyme induction—enzymes are genetically synthesized
only when substrates are present

Microbial Genetics
A. Eukaryotic genome
1. Almost all the eukaryotic genome is diploid
2. Gene expression can be recessive or dominant
3. Mitochondria and chloroplasts have a single, circular DNA; function
of DNA is related to that organelle
B. Prokaryotic genome
1. Most prokaryotes have a single, circular chromosome
2. Additional genes are present on plasmids (small circles of DNA)
C. Some viruses (phage) multiply in bacteria
D. Genetic recombination (see the section on “Genetics” in Chapter 7)
1. Conjugation
a. Transfer of genetic material between two living bacteria that are
in physical contact
b. Plasmids are most frequently transferred
2. Transduction—a bacterial virus (bacteriophage) transfers genetic
material
3. Transformation—the direct uptake of donor DNA by a recipient cell
E. Genetic rearrangement—transposons are small segments of DNA that
can move from one region of a chromosome to another region of the
genome
F. Mutations
1. Result in changes in DNA sequence
2. Can be caused by agents such as ultraviolet light, radiation, nitrous
acid, and carcinogens

734
Microbial Relationships
A. Syntrophism
1. Organisms are not intimately associated with each other but benefit
from each other
2. Examples—yogurt production, organisms feeding in soil where
decaying plant material is found
B. Competition
1. Interaction between organisms resulting from a demand for a finite
supply of nutrients and other resources
2. Example—molds such as Penicillium compete by secreting
substances toxic to other organisms
C. Predation—interaction that controls the population by predators
feeding on another species, the prey
D. Symbiosis—interaction in which two different species live in a
mutually beneficial coexistence
E. Commensalism—interaction in which only one organism benefits and
the other neither benefits nor is harmed
F. Parasitism—interaction in which one organism benefits at the expense
of the other

Bacteria
A. Firmicutes—gram-positive eubacteria
B. Gracilicutes
1. Gram-negative eubacteria
2. Largest group of bacteria
3. Contain many medically significant microorganisms
C. Tenericutes (mycoplasmas)
1. Eubacteria lacking cell walls—because they lack cell walls, they are
highly pleomorphic
2. Enclosed by the plasma membrane—plasma membranes have lipids
called sterols that aid in resisting lysis
3. Mycoplasmas are the smallest self-replicating microorganisms
D. Mendosicutes (archaeobacteria)
1. Conventional peptidoglycan in the cell wall is replaced with
pseudomurein
2. Often live in extreme environments
3. Carry out atypical metabolic processes
4. No known medically significant species

735
Fungi
A. Description
1. Eukaryotic
2. Nonphotosynthetic
3. Heterotrophic saprophytes—use preexisting organic products, either
living or dead
4. Grow well in dark, moist environments
5. Few species are pathogenic to humans
B. Forms
1. Molds (mycelial forms)
a. Long filaments are structural units called hyphae; multi-cellular
hyphae result in a cobweb-like growth called a mycelium
b. Reproduce by sexual or asexual spores
2. Yeasts
a. Oval or spherical single cells
b. Produce moist, shiny colonies
c. Reproduce asexually by producing new buds or daughter cells
3. Dimorphic fungi—some fungi exhibit characteristics of both molds
and yeasts, depending on growth conditions
C. Classification of medically important fungi
1. Zygomycota (the phycomyces)—include the common bread molds
Rhizopus and Mucor
2. Ascomycota (sac fungi)—include Histoplasma, Microsporum,
Aspergillus, Trichophyton, Penicillium (a source of antibiotics), and
Saccharomyces (leavened bread and fermented beer and wine)
3. Basidiomycota—include Cryptococcus neoformans
4. Deuteromycota (the imperfect fungi)—include Candida,
Pneumocystis, Coccidioides, Sporothrix, and Epidermophyton; do not
produce sexual spores
D. Fungal diseases (mycoses)
1. Generally long-lasting infections
2. Classification
a. Systemic—involving a number of tissues and organs
b. Subcutaneous—beneath the skin
c. Cutaneous (superficial)—involving only the epidermis, hair, and
nails
(1) Tinea infections caused by Microsporum, Trichophyton, and
Epidermophyton
d. Opportunistic—generally harmless; can become pathogenic in a
debilitated host

736
Protozoa
A. Description
1. Unicellular
2. Eukaryotic
3. Heterotrophic
4. Most have a motile feeding stage called trophozoite
5. Many can form cysts
a. Protective resting stage
b. Can serve as a site for division or spreading of pathogenic
protozoans (e.g., Entamoeba histolytica, which causes amoebic
dysentery)
6. Reproduce asexually by fission, budding, or schizogony (multiple
fission); reproduce sexually by conjugation
B. Four phyla (Sarcomastigophora, Mastigophora, Ciliophora,
Microspora)

Viruses
A. Properties of a mature virus particle, or virion
1. Has a single type of nucleic acid, RNA or DNA, that contains genetic
material, or a genome
2. Nucleic acid is surrounded by an outer protein coat, the capsid;
nucleic acid and capsid compose the nucleocapsid
3. Capsids may or may not be covered by an envelope
4. Viral nucleic acid contains the necessary information for
programming an infected host cell
5. Absence of cellular structures
6. Lack components for energy production and protein synthesis
7. Obligate intracellular parasites
B. Bacteriophages (bacterial viruses)
1. Contain either RNA or DNA
2. Life cycles: lytic and lysogenic
a. Lytic cycle—virus enters a host cell, takes over cell replication
mechanism, makes viral DNA and protein, then lyses (breaks
open) the cell; this allows newly produced viruses to leave host
cell and infect other cells (destroys host cell)
b. Lysogenic cycle—virus attaches to host cell’s DNA and
replicates when host cell divides; once integrated, the virus is
referred to as a prophage, and a stable association is established
between the host cell and the virus (no harm done to host cell)
C. Plant viruses (most contain RNA)—viroids

737
 1. Small, single-stranded, circular RNA molecules
2. Found mainly in plants
D. Human viruses (Table 9-4)

Table 9-4
Selected Important Groups of Viruses and Viral Diseases

From Burton GRW, Engelkirk PG: Microb iology for the health sciences, ed 7, Philadelphia, 2004, Lippincott, Williams &
Wilkins.

1. Classified by structure and type of nucleic acid, mode of replication,

and morphology
2. Destructive effects on cells are termed cytopathic
3. Prions
a. Proteinaceous infectious particles believed to cause kuru and
Creutzfeldt-Jakob disease (CJD)
b. Organization, replication, and how they cause disease are
unknown
E. Viral replication
1. Uses biosynthetic mechanisms of the host cell
2. Phases

738
 a. Attachment, penetration, and uncoating
b. Synthesis of viral components
c. Morphogenesis and release
F. Modes of viral transmission
1. Direct transmission from person to person
2. Transmission from animal to animal
3. Transmission by an arthropod vector
G. Role of virus in cancer
1. Oncogenous viruses can induce various types of cancers (RNA-type
or DNA-type viruses)
2. Proto-oncogenes are highly conserved, “friendly” transforming
genes
3. Mechanisms of oncogene activation
a. Transduction by a virus
b. Insertional mutagenesis
c. Translocation
d. Gene amplification
e. Mutation
4. Role oncogenes play in the development of cancer is unclear

Microbial virulence and disease transfer

A. Bacteria that produce disease or pathologic changes in humans (Table
9-5)

Table 9-5
Bacteria of Human Importance

739
B. Definitions
1. Pathogen—agent producing disease or pathologic changes
2. Opportunist—commensal bacterium that invades the host under
favorable conditions
3. Virulence—the degree of pathogenicity; properties that determine
pathogenicity of an organism include invasiveness (transmissibility),
ability to multiply in the host, and toxin production
4. Infection—invasion of the tissue by a pathogenic microorganism and
multiplication of the organism
a. Localized—organism remains in a particular area of the body
b. Generalized or systemic—microorganism invades the

740
 bloodstream and the lymphatic system
c. Acute—runs a rapid course; terminates abruptly (less than 6
months)
d. Chronic—slow onset; infection of long duration
e. Primary—original infection
f. Secondary—infection that follows a primary infection and is
often caused by an opportunistic organism
g. Toxemia—presence of toxin in the blood
h. Subclinical—lacking recognizable symptoms
i. Focal—localized in one area and spreading elsewhere in the
body from that point
j. Bacteremia—presence of bacteria in the bloodstream
k. Latent—causative agent remains inactive for a time but then
becomes active to produce symptoms of the disease
l. Sequelae—long-term or permanent damage to diseased tissues
or organs
m. Nosocomial—acquired during a hospital stay
n. Sign—objective changes that a health care provider can observe
and measure
o. Symptom—subjective changes in body experienced by the
patient or client
5. Infectious disease—interference with the normal functioning of the
host; proof by Koch’s postulates:
a. Microorganisms are present in every case of disease
b. Microorganisms grow in pure culture from the diseased host
c. Same disease is reproduced when pure culture is inoculated into
a healthy host
d. Microorganism is recovered from the inoculated host
C. Transmission of disease
1. Reservoir of infection—contains potential sources of the disease-
causing agent
a. Human
(1) Active cases of infectious disease
(2) Carriers—persons (asymptomatic) harboring infectious
agents potentially pathogenic for other members of the
population
(3) Endogenous infection—the causative organism is derived
from the host’s own microflora
b. Animal—zoonosis; disease transmitted from animal to human
c. Insects and arthropods—flies, mosquitoes, fleas, lice, ticks, and
mites

741
 d. Nonliving—water, food, soil, and dust
2. Portals of exit are sources of infectious body fluids
a. Gastrointestinal (GI) tract
b. Genitourinary system
c. Oral region
d. Respiratory tract
e. Blood and blood derivatives
f. Skin lesions
g. Conjunctiva
3. Routes of transmission
a. Contact
(1) Direct
(2) Indirect—involves nonliving reservoir (fomite)
(3) Droplet transmission (short distance)
b. Vehicles
(1) Waterborne transmission
(2) Foodborne transmission
(3) Airborne transmission
c. Vectors—insects and arthropods
4. Basic path of an infectious disease
a. Exposure to the pathogen
b. Incubation period
c. Prodromal period
d. Appearance of the signs and symptoms of the disease
e. Outcome of the disease (e.g., convalescence, disability, or death)

Microbial Virulence Factors

A. Capsules (Streptococcus pneumoniae)—resist the host’s defenses by
impairing phagocytosis
B. Enzyme production—includes coagulases, kinases, hyaluronidases,
collagenases, mucinases, lecithinases, leukocidins, and hemolysins
C. Toxin production
1. Exotoxins
a. Soluble substances secreted by gram-positive bacteria
b. Clinically significant exotoxins are associated with botulism,
tetanus, diphtheria, gas gangrene, scarlet fever, staphylococcal
food poisoning, toxic shock syndrome, and traveler ’s diarrhea
2. Endotoxins
a. Heat-stable lipopolysaccharides—toxic component associated
with cell wall

742
 b. From gram-negative bacteria
c. Pathologic effects
(1) Fever
(2) Interference with hemostatic mechanisms of blood
(3) Activation of the complement system
(4) Leukopenia
(5) Hypotension and shock
(6) Organ dysfunction
(7) Activation of complement system
(8) Death

Disease Barriers
A. Normal or indigenous flora
1. Most highly specialized bacteria; highly adapted to commensal life;
cause minimal damage under normal conditions
2. Includes beneficial microorganisms and pathogens
3. When ecologic balance is disturbed, infection can occur (e.g.,
antibiotic therapy may result in Candida albicans infection)
B. Nonspecific immunity
1. Physical and chemical barriers
a. Intact skin
b. Mucous membranes and their secretions
c. Gastric acid barrier
2. Blood and lymphatics
a. Leukocytes—proportionate number changes in response to
infection
(1) Granulocytes (basophils, eosinophils, and neutrophils
[polymorphonuclear leukocytes])
(2) Agranulocytes (lymphocytes and monocytes)
b. Lymphatic system transports white blood cells and removes
foreign cells and tissue debris
(1) Consists of lymphatic vessels, lymph fluid, nodes, and
lymphocytes
(2) Mononuclear phagocyte system—mononuclear phagocytic
cells that remove particulate matter from bloodstream and
lymph (e.g., Kupffer cells in the liver)
3. Phagocytosis
a. Digestion of the invading matter
b. Accomplished by neutrophils and mature monocytes, or
macrophages

743
 4. Inflammation
a. Produced by disease agents or irritants such as chemicals, heat,
or mechanical injury
b. Cardinal signs include heat, pain, redness, swelling, and loss of
function
c. Pus formation possible
5. Fever
a. Bacterial endotoxins and interleukin-1 (IL-1) can induce fever
b. Intensifies the effect of interferon (IFN)
c. Inhibits the growth of some microorganisms
6. Antimicrobial substances
a. Complement system—a defense system consisting of serum
proteins that participate in lysis of foreign cells, inflammation,
and phagocytosis
b. Interferons (IFN-α, -β, and -γ)—interfere with viral replication
C. Specific immunity—the immune system (Fig. 9-2 and Box 9-1)

FIG 9-2 The duality of the immune system. Left, Humoral immunity mediated
by soluble antibody proteins produced by B lymphocytes. Right, Cellular
immunity mediated by T lymphocytes. (Modified from Kumar V, Cotran R, Robbins S:
Basic pathology, ed 7, Philadelphia, 2005, Saunders.)

Box 9-1

744
Immunology Terms
Anaphylatoxin: a substance produced by complement activation
(especially C3a, C5a) that results in increased vascular permeability
through release of pharmacologically active mediators from mast cells
Antibody (Ab): a protein that is produced as a result of the introduction
of an antigen and has the ability to combine with the antigen that
stimulated its production
Antigen (Ag): a substance that can induce a detectable immune response
when introduced into an animal
B cell (B lymphocyte): strictly, a bursa-derived cell in avian species and,
by analogy, a cell derived from the equivalent of the bursa in nonavian
species; B cells are the precursors of plasma cells that produce
antibody
Chemotaxis: a process whereby phagocytic cells are attracted to the
vicinity of invading pathogens
Complement: a system of serum proteins that is the primary mediator of
antigen-antibody reactions
Cytokine: a factor such as a lymphokine or monokine produced by cells
that affect other cells (e.g., lymphocytes and macrophages) and have
multiple immunomodulating functions; cytokines include interleukins
and interferons
Cytolysis: the lysis of bacteria or of cells such as tumor cells or red blood
cells by the insertion of the membrane attack complex derived from
complement activation
Hapten: a molecule that is not immunogenic by itself but can react with a
specific antibody
Histocompatible: sharing transplantation antigens
Hypersensitivity reactions: these occur in four types:
Antibody-mediated hypersensitivity
Type I. Anaphylactic (“immediate”): immunoglobulin E (IgE) antibody
is induced by allergen and binds via its Fc receptor to mast cells and
basophils; after encountering the antigen again, the fixed IgE
becomes cross-linked, inducing degranulation and release of
mediators, especially histamine (e.g., in asthma, hay fever, hives,
anaphylactic shock)
Type II. Cytotoxic: antigens on a cell surface combine with antibody,
which leads to complement-mediated lysis (e.g., transfusion or Rh
reactions) or other cytotoxic membrane damage (e.g., in
autoimmune hemolytic anemia)
Type III. Immune complex: antigen-antibody immune complexes are

745
 deposited in tissues, complement is activated, and
polymorphonuclear cells are attracted to the site, causing tissue
damage (e.g., in serum sickness, Arthus reactions)
Cell-mediated hypersensitivity
Type IV. Delayed: T lymphocytes, sensitized by an antigen, release
lymphokines on second contact with the same antigen; the
lymphokines induce inflammation and activate macrophages (e.g., in
contact dermatitis, poison ivy, graft rejection, tuberculin skin
reaction)
Immune response: development of resistance (immunity) to a foreign
substance (e.g., infectious agent); it can be antibody mediated
(humoral), cell mediated (cellular), or both
Immunoglobulin: a glycoprotein composed of H and L chains that
functions as an antibody; all antibodies are immunoglobulins, but not
all immunoglobulins have an antibody function
Immunoglobulin class: a subdivision of immunoglobulin molecules
based on unique antigenic determinants in the Fc region of the H
chains; five immunoglobulin classes in humans
1. IgG: principal immunoglobulin of the secondary immune response;
the only immunoglobulin capable of crossing placental barriers
2. IgM: first immunoglobulin to appear in a given immune response
3. IgA: principal immunoglobulin in external secretions of mucosal
surfaces, tears, saliva, bile, urine, and colostrum
4. IgD: thought to activate the B cell
5. IgE: plays important role in immediate hypersensitivity reactions
and parasitic infections
Interferon: one of a heterogeneous group of low-molecular-weight
proteins elaborated by infected host cells that protect noninfected cells
from viral infection; interferons, which are cytokines, also have
immunomodulating functions
Interleukin (IL): a cytokine that stimulates or otherwise affects the
function of lymphocytes and some other cells
IL-1: induces T helper cell synthesis of IL-2; activates T cells; induces
chemotaxis for neutrophils
IL-2: stimulates antibody synthesis, T cytotoxic cells, and natural killer
cells
IL-3: stimulates hematopoiesis
IL-4: induces isotype switching
IL-5: promotes the growth and differentiation of B cells
IL-6: stimulates B cell differentiation; activates T cells
IL-7: promotes pre–B cell growth and pre–T cell growth

746
 IL-8: stimulates chemotaxis of neutrophils
IL-9: promotes T cell growth; enhances mast cell
IL-10: inhibits T helper cell 1 (TH1) and cytokine release; stimulates
mast cell growth
IL-11: stimulates development of B cells; stimulates hematopoiesis
IL-12: activates T cells; stimulates TH1 cell development
IL-13: anti-inflammatory activity; B cell growth and differentiation
IL-14: induces proliferation of activated B cells
IL-15: stimulates growth of intestinal epithelium, T cells, and natural
killer cells
IL-16: lymphocyte chemoattractant factor
Lymphocyte: a mononuclear cell 7 to 12 µm in diameter containing a
nucleus with densely packed chromatin and a small rim of cytoplasm;
lymphocytes include T cells and B cells, which have primary roles in
immunity
Lymphokine: a cytokine that is a soluble product of a lymphocyte;
lymphokines are responsible for multiple effects in a cellular immune
reaction
Macrophage: a phagocytic mononuclear cell derived from bone marrow
monocytes and found in tissues and at the site of inflammation;
macrophages serve accessory roles in cellular immunity
Major histocompatibility complex (MHC): a cluster of genes located
close to each other; this determines the histocompatibility antigens of
the members of a species
Membrane attack complex (MAC): the end product of activation of the
complement cascade, which contains C5, C6, C7, and C8 (and C9); the
MAC makes holes in the membranes of gram-negative bacteria, killing
them and, in red blood cells or other cells, resulting in lysis
Monocyte: a circulating phagocytic blood cell that develops into tissue
macrophages
Opsonin: a substance capable of enhancing phagocytosis; antibodies and
complement are the two main opsonins
Opsonization: the coating of an antigen or particle (e.g., infectious agent)
by substances such as antibodies, complement components,
fibronectin, and so on, that facilitate uptake of the foreign particle into
a phagocytic cell
Polymorphonuclear cell (leukocyte, PMN): also known as a neutrophil or
granulocyte; a PMN is derived from a hematopoietic cell of bone
marrow and is characterized by a multi-lobed nucleus; PMNs migrate
from the circulation to a site of inflammation by chemotaxis and are
phagocytic for bacteria and other particles

747
T cell (T lymphocyte): a thymus-derived cell that participates in a variety
of cell-mediated immune reactions
TH1 (helper) or CD4 cell: activates macrophages and cytotoxic and
other T cells
TH2 (helper) or CD4 cell: activates B cells to secrete immunoglobulin
TC (cytotoxic) or CD8 cell: destroys target cells
TD (delayed hypersensitivity) cell: causes inflammation associated
with allergic reactions and tissue transplant rejection
TS (suppressor) or CD8 cell: regulates the immune response
Modified from Stites DP, Stobo JD, Wells JV, editors: Basic and clinical immunology, ed 8, East
Norwalk, Conn, 1994, Appleton & Lange.

1. Humoral immunity—B lymphocyte production and release of specific

antibodies into the circulating blood or body fluids; antibodies then
interact with foreign antigens; defends primarily against bacteria, toxins,
and viruses; antibodies protect the host as follows:
a. Recognize an organism or its toxin by binding to it
b. Opsonize or coat bacteria, which enhances ingestion by macrophages
or natural killer (NK) cells
c. Cause antigens to clump or agglutinate, which enhances phagocytosis
d. Activate complement system, resulting in cell lysis
2. Cell-mediated (cellular) immunity—stimulation of T lymphocytes to
activate a variety of effector T cells in response to foreign organisms or
tissues (antigens); defends primarily against bacteria, viruses, fungi,
protozoa, helminths, foreign tissue, and cancerous cells
3. Acquired immunity
a. Natural
(1) Active—person is exposed to an antigen and the body produces
antibodies
(2) Passive—antibodies of a mother are passed to her infant
b. Artificial
(1) Active—vaccination with killed, inactivated, or attenuated
microorganisms or toxoid
(2) Passive—injection of immune serum or γ-globulin
D. Hypersensitivity or allergy is an exaggerated response to specific
substances; the inciting agent is the allergen (Fig. 9-3; see Box 9-1)

748
749
750
751
 FIG 9-3 Hypersensitivity reactions are secondary responses to antigens that
occur in an exaggerated or inappropriate form. These reactions have been
classified into four major types. A, Type I reaction (antibody mediated). B, Type
II reaction (antibody mediated). C, Type III reaction (antibody mediated). D,
Type IV reaction (cell mediated). (Modified from Huether SE, McCance KL:
Understanding pathophysiology, ed 6, St Louis, 2017, Elsevier.)

Immunodeficiency
See the section on “Human Immunodeficiency Virus” in Chapter 8.
A. Inability of the immune system to perform normally; properly
functioning system recognizes and destroys all that is foreign or “non-
self ”
B. Results in increased susceptibility to infection
C. Autoimmune disease (autoallergic)
1. “Self ” antigens stimulate the production of antibodies or sensitized
lymphocytes; antigen-antibody complex
2. Mechanisms

752
 a. May be caused by the release of sequestered antigens; escape of
tolerance to the “self ” antigen at the T cell level; diminished
suppressor T cell function
b. Intolerance of self antigen because of cross-reactions
c. Decreased function of suppressor T cells
3. Includes systemic lupus erythematosus, rheumatoid arthritis,
myasthenia gravis, and Graves disease
D. Immunodeficiencies in B cells or T cells
1. Hypergammaglobulinemias—overabundance of immunoglobulin
2. Hypogammaglobulinemias—decreased catabolism, or loss of
immunoglobulins
3. Thymic aplasia (DiGeorge syndrome)—congenital absence of
thymus gland
E. Drug-induced immunosuppression
1. Used as an adjunct to organ transplantation and other organ grafts;
also used for the treatment of immunologically mediated disease
2. Examples of drugs used include corticosteroids, rapamycin (now
sirolimus), 15-deoxy- spergualin trihydrochloride (now gusperimus
trihydrochloride), and cyclosporine; common complication is
infection
F. Acquired immunodeficiency syndrome (AIDS)
1. Definition
a. Disease that occurs because of a defect in cell-mediated
immunity
b. Cellular immunity is profoundly suppressed, allowing
development of opportunistic infections and cancers
c. U.S. Centers for Disease Control and Prevention (CDC)
surveillance case definition includes all human
immunodeficiency virus (HIV)–infected persons with a CD4 + T
lymphocyte count of less than 200 cells/mm3 of blood
d. AIDS diagnosis can also be established by the development of
one or more opportunistic infections regardless of CD4 + count1
2. Irreversible acquired defect
3. Etiology
a. Lentivirus subfamily of human retroviruses
b. Infects lymphocytes, macrophages, promyelocytes, and
epidermal Langerhans cells
4. High fatality rate
5. Virus isolated from blood, semen, vaginal secretions, saliva, tears,
breast milk, cerebrospinal fluid, amniotic fluid, and urine
6. Transmission

753
 a. Susceptible exposure to infected blood (e.g., intravenous [IV]
drug use, blood transfusion)
b. Sexual contact
c. Mother to newborn (perinatal)
d. Cofactors (e.g., genital herpes) may influence transmission
7. CDC classification system for HIV-infected adolescents and adults
categorizes persons based on CD4 + T lymphocyte counts and
clinical conditions associated with HIV infection
a. CD4 + T lymphocyte categories
(1) Three CD4 + T lymphocyte categories:
(a) Category 1—500 or more cells/µL
(b) Category 2—200 to 499 cells/µL
(c) Category 3—less than 200 cells/µL
(2) These categories correspond to CD4 + T lymphocyte counts
per microliter of blood and guide clinical and therapeutic
actions in the management of HIV-infected adolescents and
adults; the revised HIV classification system also allows for
the use of the percentage of CD4 + T cells
(3) Classification of HIV-infected persons should be based on
existing guidelines for the medical management of HIV-
infected persons; thus, the lowest accurate but not
necessarily the most recent CD4 + T-lymphocyte count
should be used for classification purposes
b. Clinical categories of HIV infection
(1) Category A—consists of one or more of the conditions
listed below in an adolescent or adult (at least 13 years old)
with documented HIV infection; conditions listed in
categories B and C must not have occurred
(a) Asymptomatic HIV infection
(b) Persistent generalized lymphadenopathy
(c) Acute (primary) HIV infection with accompanying
illness or history of acute HIV infection
(2) Category B—consists of symptomatic conditions in an
HIV-infected adolescent or adult that are not included
among conditions listed in clinical category C and that meet
at least one of two criteria: the conditions are attributed to
HIV infection or are indicative of a defect in cell-mediated
immunity, or the conditions are considered by physicians to
have a clinical course or to require management that is
complicated by HIV infection; examples of conditions in
clinical category B include, but are not limited to:

754
 (a) Bacillary angiomatosis
(b) Candidiasis, oropharyngeal (thrush)
(c) Candidiasis, vulvovaginal; persistent, frequent, or
poorly responsive to therapy
(d) Cervical dysplasia (moderate or severe) or cervical
carcinoma in situ
(e) Constitutional symptoms such as fever (38.5°C) or
diarrhea lasting longer than 1 month
(f) Hairy leukoplakia, oral (Fig. 9-4)

FIG 9-4 Hairy leukoplakia.

(g) Herpes zoster (shingles), involving at least two

distinct episodes or more than one dermatome
(h) Idiopathic thrombocytopenic purpura
(i) Listeriosis
(j) Pelvic inflammatory disease, particularly if
complicated by tubo-ovarian abscess
(k) Peripheral neuropathy
(3) For classification purposes, category B conditions take
precedence over those in category A; for example, someone
previously treated for oral or persistent vaginal candidiasis
(and in whom a category C disease has not developed) but
who is now asymptomatic should be classified in category B
(4) Category C—includes the clinical conditions listed in the
AIDS surveillance case definition; for classification
purposes, once a category C condition has occurred, the
person will remain in category C
8. Secondary neoplasms

755
 a. Kaposi’s sarcoma—skin lesions; may be oral; multiple small,
reddish blue, purple, or hyperpigmented brown papules,
plaques, or nodules; associated with human herpesvirus 8
(HHV-8) (Fig. 9-5)

FIG 9-5Kaposi’s sarcoma of the neck (top); presenting as a dark

macule in the right posterior palate (bottom). (From Regezi JA,
Sciubba JA, Jordan CK: Oral pathology: clinical pathologic correlations, ed 7, St
Louis, 2017, Elsevier.)

b. B cell lymphomas
9. Opportunistic infections
a. Cytomegalovirus—frequently involves the eye, causing retinal

756
 lesions
b. Tuberculosis
c. Pneumocystis jiroveci (P. carinii)
d. Oral and esophageal infection from Candida albicans
e. Herpes simplex viruses 1 and 2
10. Incidence and prevalence
a. Approximately 1.1 million people live with AIDS in the United
States
b. Leading cause of death among men (25 to 44 years) and the fifth
leading cause of death among women (15 to 44 years) in the
United States
c. Risk factors
(1) Unsafe sexual practices
(2) Exposure to blood or blood products
(3) IV drug use
(4) Infant of infected individual
d. Transmission to health care personnel providing care to infected
individuals is rare
11. Treatment (see the section on “Antiviral Agents” in Chapter 11)
a. No known cure or vaccine yet available
b. Vaccine will have to be targeted both to free virus in
bloodstream and to virus present in infected host cells
c. Food and Drug Administration (FDA)–approved antiretroviral
drugs used for the treatment of HIV:
(1) Multi-class combination products (e.g., Atripila)
(2) Nucleoside reverse transcriptase inhibitors (NRTIs) (e.g.,
zidovudine [AZT], didanosine [ddI], stavudine [d4T],
lamivudine [3TC])
(3) Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
(e.g., nevirapine [NVP], efavirenz [EFV])
(4) Protease inhibitors (PIs) (e.g., amprenavir [AP], indinavir
[IDV], darunavir, atazanavir sufate [ATV])
(5) Fusion inhibitors (e.g., enfuvirtide [T-20])
(6) Entry inhibitors (e.g., maraviroc [Selzentry, Celsentri])
(7) HIV integrase strand transfer inhibitor (e.g., raltegravir)
12. Oral manifestations
a. Hairy leukoplakia
b. Herpetic lesions
c. Oral and esophageal candidiasis
d. Kaposi’s sarcoma
e. Linear gingival erythema and necrotizing ulcerative

757
 periodontitis
f. Human papillomavirus
g. Lymphoma
h. Recurrent aphthous ulcers

Infections of the Skin, Nails, and Hair

A. Bacterial infections
1. Tetanus
a. Etiology—Clostridium tetani
b. Pathogenesis and transmission—by spores that germinated in
the wound and produce tetanus-causing toxin
c. Clinical findings and symptoms
(1) Trismus (stiff jaw); eventually, locked jaw
(2) Spasms of facial muscles
(3) Dysphagia
(4) Difficulty breathing
2. Leprosy
a. Etiology—Mycobacterium leprae
b. Pathogenesis and transmission—transmitted via prolonged
direct contact or inhalation of organisms
c. Clinical findings and symptoms
(1) Skin lesions
(2) Oral lesions are tumor-like masses of tissue that involve
the oral lining, tongue, lips, or palate
3. Pseudomonas aeruginosa infections
a. Pathogenesis
(1) Low pathogenicity for humans, except in debilitated
persons (e.g., burn victims or those taking antibiotics or
immunosuppressive drugs)
(2) Ubiquitous in nature
b. Clinical findings and symptoms
(1) Pseudomonas dermatitis—self-limiting rash associated with
swimming pools, hot tubs, and saunas
(2) Otitis externa—infection of the external ear canal
4. Staphylococcal infections
a. Etiology—Staphylococcus aureus and Staphylococcus epidermidis
b. Pathogenesis—determined by extracellular factors and invasive
properties of the strain
c. Clinical findings and symptoms
(1) Most S. aureus strains are resistant to penicillin

758
 (2) Causes furuncles (boils), carbuncles, impetigo, and
cellulitis
5. Streptococcal infections
a. Etiology—Streptococcus pyogenes (group A β-hemolytic)
b. Pathogenesis
(1) Determined by portal of entry
(2) Diffuse and rapidly spreading infection
c. Clinical findings and symptoms
(1) Scarlet fever
(a) Acute inflammation of the upper respiratory tract
(b) Generalized rash caused by erythrogenic exotoxin
(c) Oral mucosa is red; “strawberry tongue”
(d) Sequelae from group A streptococcal infection include
rheumatic fever and hemorrhagic glomerulonephritis
(2) Erysipelas
6. Lyme disease
a. Etiology—Borrelia burgdorferi (spirochetes)
b. Pathogenesis
(1) Transmitted by ticks (zoonotic)
(2) Antigen-antibody complexes may be responsible for
arthritic or neurologic difficulties
c. Clinical findings and symptoms
(1) Initial phase—rash, headache, fever, and myalgia
(2) Secondary phase—possible cardiac involvement
(3) Recurring neurologic symptoms, arthritis, or both
B. Fungal infections
1. Ringworm infections (tinea)
a. Etiology—dermatophytes most important; Microsporum,
Trichophyton, Epidermophyton
b. Pathogenesis—grow only within dead keratinized tissue
c. Clinical findings and symptoms—inflammatory response,
especially at the border of lesions; patching; scaling
2. Candidiasis
a. Etiology—Candida albicans
b. Pathogenesis
(1) Dissemination and sepsis in compromised patients
(opportunistic infection)
(2) Normal inhabitant of the skin and mucosal surfaces
(3) Predisposing factors include diabetes mellitus, pregnancy,
obesity, vitamin deficiency, use of broad-spectrum
antibiotics, and immunologic defects

759
 c. Clinical findings and symptoms—vary with site
C. Viral infections
1. Herpes simplex
a. Etiology—herpes simplex virus (HSV)
b. Pathogenesis
(1) Transmission through oral and ocular secretions
(2) Virus is present in saliva, even in apparent good health
(3) Indirect contact (e.g., fomites)
(4) Infects epithelial cells
(5) Establishes a latent infection from retroviruses
c. Clinical findings and symptoms
(1) Types
(a) HSV-1—generally above the waist; usually found in
and around the mouth
(b) HSV-2—herpes genitalis
(2) Frequently asymptomatic
(3) Most often, acute gingivostomatitis; usually in children—
fever, malaise, irritability, local lymphadenopathy, and
anorexia; red, edematous gingiva and adjacent mucosa;
lesions are vesicles with yellowish contents that rupture
and ulcerate; bright margin of erythema; sharply defined;
pain may be severe; duration of about 7 days; self-limiting
(4) Herpetic whitlow infection of fingers; can be caused by
HSV-1 or HSV-2; abrupt onset; local irritation; tenderness,
edema, erythema, and vesicles; difficult to differentiate
from bacterial pyoderma caused by staphylococci
(5) Recurrent secondary infections by HSV-1
(a) Virus now latent but permanently established in nerve
ganglia (carrier)
(b) Infections may be induced by stress, sun, or colds
(6) Herpes labialis is the most common clinical manifestation
of recurrent infection
(a) Cold sores, fever blisters
(b) Vesicles on an erythematous base
(c) Prodromal burning and hyperesthesia
(d) Swollen lymph nodes
(7) Intraoral lesions
(a) Usually found on the mucosa or hard palate overlying
bone
(b) Small, discrete lesions; vesicles of clear fluid; ulcerate
with a red base

760
2. Chickenpox
a. Etiology—varicella-zoster virus (VZV)
b. Pathogenesis
(1) Route of infection through the mucosa of the upper
respiratory tract
(2) Highly infectious
(3) Virus probably circulates in the blood and localizes on the
skin
(4) Incubation period 2 weeks
(5) Vaccine available
c. Clinical findings and symptoms
(1) Earliest symptoms are malaise and fever, followed by a
rash and formation of vesicles
(2) Oral lesions may occur throughout the mouth and appear
as small canker sores or aphthae; vesicles rupture quickly
(Fig. 9-6)

FIG 9-6 Herpes labialis.

3. Shingles
a. Etiology—VZV
b. Pathogenesis
(1) Reactivation of latent virus in dorsal root ganglion
(2) Closely follows area of innervation
(3) Chickenpox and shingles represent different forms of
infection by the same agent
(4) Virus resides in ganglia; usually affects sensory nerves
(thoracic area most often involved; ophthalmic division of
trigeminal nerve next most involved)
(5) Vaccine available
c. Clinical findings and symptoms
(1) Mostly found in adults

761
 (2) Malaise, fever, followed by severe pain in area
(3) Rash and vesicles along the nerve trunk
4. Warts
a. Etiology—papillomaviruses
b. Pathogenesis—affects epithelial cells of skin and mucous
membranes
c. Clinical findings and symptoms
(1) Skin warts, plantar warts, flat warts, genital condylomas,
laryngeal papillomas
(2) Oral warts are papular or nodular lesions covered with
papilliferous projections; also may look like common warts
5. Measles
a. Etiology—rubeola virus
b. Pathogenesis
(1) Transmission through the respiratory tract
(2) Spreads to regional lymphoid tissue
(3) Primary viremia disseminates the virus
(4) Secondary viremia seeds the epithelial surfaces of the body
c. Clinical findings and symptoms
(1) Koplik’s spots
(a) Small, bluish white spots with a red surrounding
zone; cannot be wiped off
(b) Occur on the buccal mucosa opposite the molars
(2) Followed by a diffuse skin rash and fever
(3) Bacterial secondary infections occur, such as middle ear
infections or pneumonia
6. German measles
a. Etiology—rubella virus
b. Pathogenesis
(1) Occurs through the upper respiratory tract
(2) Incubation period 2 to 3 weeks
c. Clinical findings and symptoms
(1) Malaise, low-grade fever, rash, and lymphadenopathy
(2) Rash starts on face; extends to trunk and extremities
7. Erythema infectiosum (also called fifth disease)
a. Etiology—human parvovirus B19
b. Pathogenesis
(1) Children most affected by the virus
(2) Virus transmitted through the upper respiratory tract
c. Clinical findings and symptoms
(1) Low-grade fever, malaise, and bright-red rash on cheeks

762
 spreading to the rest of the body
(2) Sequelae include arthritis in adulthood

Infections of the Respiratory Tract

Upper Respiratory System Infections
A. Bacterial infections
1. Diphtheria
a. Etiology—Corynebacterium diphtheriae
b. Pathogenesis
(1) Droplets or by contact with susceptible individuals
(2) Bacilli grow on mucous membranes or in skin abrasions
(3) Damage caused by the systemic distribution of toxin
c. Clinical findings and symptoms
(1) Enlarged lymphadenopathy of the neck; possibly edema
(2) Pseudomembrane forms on tonsils
2. Streptococcal pharyngitis (“strep throat”)
a. Etiology—Streptococcus pyogenes (group A)
b. Pathogenesis—transmitted by the respiratory route and
contaminated food, water, and milk
c. Clinical findings and symptoms: severe inflammation of the
throat and tonsils; fever
B. Viral infections—common cold (Table 9-6)

763
Table 9-6
Viral Infections of the Respiratory Tract

From Brooks GF, Butel JS, Morse SA: Jawetz, Melnick & Adelb erg’s medical microb iology, ed 23, Columbus, Ohio, 2004,
McGraw-Hill.

Lower Respiratory System Infections

A. Bacterial infections
1. Pneumococcal pneumonia
a. Etiology—most common agent is Streptococcus pneumoniae
b. Pathogenesis
(1) Spread by droplets from nasal or pharyngeal secretion

764
 (2) Person may contract the disease or become an
asymptomatic carrier
(3) Predisposing factors include age, impaired resistance, and
bacteremia
c. Clinical findings and symptoms: symptoms include sudden
onset of high fever, chills, chest pain, dry cough, and rust-
colored sputum
2. Bacterial pneumonia
a. Etiology—several species—Streptococcus pyogenes, Staphylococcus
aureus, Klebsiella pneumoniae, Haemophilus influenzae
b. Pathogenesis is similar to that caused by S. pneumoniae
c. Inflammation of the lungs
3. Legionnaires disease
a. Etiology—Legionella pneumophila
b. Pathogenesis
(1) Inhalation of bacteria from aerosols
(2) Bacteria multiply in lungs and produce pneumonia
c. Clinical findings and symptoms
(1) Influenza-like illness with pneumonia
(2) Complications include renal failure, GI hemorrhage, and
respiratory failure
4. Tuberculosis
a. Etiology—Mycobacterium tuberculosis
b. Pathogenesis
(1) Transmitted by inhalation of droplets, ingestion, or direct
inoculation; disseminated by coughing, sneezing, or
contaminated dust
(2) Predisposing factors include advanced age, chronic
alcoholism, poor nutrition, diabetes mellitus, and
prolonged stress
(3) Incubation period is generally 28 to 47 days; can be as long
as 6 months
c. Clinical findings and symptoms
(1) Symptoms vary but include fever, general discomfort,
weight loss, tubercle formation (nodule in lung tissue),
night sweats, and persistent cough
(2) Oral lesions may appear as an ulcerated lesion on the
tongue or mucosa (rare)
(3) Diagnosis by a skin test and a radiograph
5. Whooping cough (pertussis)
a. Etiology—Bordetella pertussis

765
 b. Pathogenesis—transmitted by inhalation of droplets; produce
toxins
c. Clinical findings and symptoms—spasmodic coughing and
gasping noise with inhalation
6. Mycoplasmal pneumonia
a. Etiology—Mycoplasma pneumoniae
b. Pathogenesis—transmitted in airborne droplets; binds
respiratory epithelium and inhibits ciliary action
c. Clinical findings and symptoms—mild symptoms of low fever,
cough, and headache that persist for 3 weeks or longer
B. Fungal infections
1. Histoplasmosis
a. Etiology—Histoplasma capsulatum
b. Pathogenesis—transmitted by inhalation of spores, especially in
excreta of wild birds, poultry, and bats
c. Clinical findings and symptoms
(1) Skin lesions are common
(2) Meningitis
2. Pneumocystis pneumonia
a. Etiology—Pneumocystis jiroveci
b. Pathogenesis—inhalation of spores; disease more common
among immunosuppressed persons, especially those with AIDS
c. Clinical findings and symptoms—nonspecific; fever; dry,
nonproductive cough
3. Coccidioidomycosis
a. Etiology—Coccidioides immitis
b. Spores in desert soils are inhaled along with dust (common in
the southwestern United States)
c. Clinical findings and symptoms—chest pain, fever, cough,
weight loss
C. Viral infections
1. Influenza virus infection
a. Etiology—orthomyxoviruses
b. Pathogenesis
(1) The genome can undergo sudden genetic reassortment
(2) Spread by airborne droplets or contact with contaminated
objects
(3) Virus attaches to the respiratory epithelium
c. Clinical findings and symptoms
(1) Chills, headache, dry cough, fever, malaise, muscular ache,
and inflammation of the soft palate

766
 (2) Secondary infection by S. aureus, H. influenzae, S. pyogenes,
and S. pneumoniae; may result in bronchitis and pneumonia
(3) Reye syndrome may be a complication
2. Hantavirus pulmonary syndrome
a. Etiology—hantavirus
b. Pathogenesis—inhalation of excreta of deer mice
c. Clinical findings and symptoms—severe cold followed by an
internal hemorrhage of blood plasma in the lungs

Infections of the Gastrointestinal Tract

A. Bacterial infections
1. Cholera
a. Etiology—Vibrio cholerae
b. Pathogenesis
(1) Transmitted as a result of unsanitary living conditions and
through ingestion of the organisms
(2) Organisms attach to microvilli of epithelial cells; produce
toxin
c. Clinical findings and symptoms—dehydration, nausea,
vomiting, profuse diarrhea, and abdominal and leg cramps
2. Salmonellosis
a. Etiology—several species of Salmonella
b. Pathogenesis—organisms enter by the oral route usually
through contaminated food or drink
c. Clinical findings and symptoms—organisms cause enteric
fevers, bacteremia, followed by focal lesions or endocarditis
3. Shigellosis (bacillary dysentery)
a. Etiology—Shigella dysenteriae, S. flexneri, S. boydii, and S. sonnei
b. Pathogenesis
(1) Transmitted through contaminated food or water
(2) The organism invades the mucosal epithelium
c. Clinical findings and symptoms—abdominal pain, fever, and
watery or bloody diarrhea
4. Enteric infections caused by Escherichia coli
a. Etiology
(1) Enterotoxigenic E. coli (ETEC)—traveler ’s diarrhea
(2) Enteroinvasive E. coli (EIEC)
(3) Enteropathogenic E. coli (EPEC)
(4) Enterohemorrhagic E. coli (EHEC)—serotype O157: H7
(5) Enteroaggregative E. coli (EaggEC)

767
 b. Pathogenesis
(1) Acquired by ingestion of contaminated food or water or
through contact with contaminated persons
(2) Factors responsible for the different ways in which E. coli
produces disease vary with strain
c. Clinical findings and symptoms—abdominal pain, malaise, loss
of appetite, diarrhea, and dehydration; diarrhea may be watery
or bloody, depending on the strain of E. coli
5. Typhoid fever
a. Etiology—Salmonella typhi
b. Pathogenesis—transmitted through contaminated food or water
c. Clinical findings and symptoms
(1) Fever, severe headache, abdominal pain, and abdominal
rash
(2) Complications include carrier state, relapses,
inflammation of the gallbladder, and intestinal bleeding
6. Helicobacter peptic disease syndrome
a. Etiology—Helicobacter pylori
b. Pathogenesis—H. pylori produces ammonia, which neutralizes
stomach acid, allowing the bacteria to colonize the stomach
mucosa
c. Clinical findings and symptoms—peptic ulcers
7. Food poisoning
a. Botulism
(1) Etiology—Clostridium botulinum
(2) Pathogenesis
(a) Regularly contaminates human, plant, and animal
food products
(b) Produces a deadly toxin that acts on nerves
(c) Transmitted through improperly preserved foods and
uncooked fish and meats; foods do not appear
contaminated
(3) Clinical findings and symptoms
(a) Difficulty speaking, blurred vision, inability to
swallow, heart failure, and respiratory paralysis
(b) Infant botulism may be one of the causes of sudden
infant death syndrome
b. Staphylococcal food poisoning
(1) Etiology—toxin produced by staphylococci (usually S.
aureus) in unrefrigerated foods such as dairy products,
custard, cream-filled products, fish, or processed meats

768
 (2) Pathogenesis
(a) Caused by ingestion of preformed enterotoxin
(b) Incubation period is from 1 to 8 hours
(c) Symptoms include nausea, violent vomiting, diarrhea;
no fever
(d) Rapid convalescence; self-limiting
c. Perfringens poisoning
(1) Etiology—Clostridium perfringens
(2) Pathogenesis
(a) Precise mechanism is unknown
(b) Organism produces an enterotoxin
(c) Incubation period is 8 to 16 hours
(3) Clinical findings and symptoms
(a) Symptoms are similar to those of staphylococcal food
poisoning
(b) Usually self-limiting
B. Viral infections
1. Hepatitis A (Tables 9-7 and 9-8)

769
Table 9-7
Characteristics of the Various Types of Viral Hepatitis

From Tortora GJ, Funke BR. Case DL: Microb iology: an introduction, ed. 8, Menlo Park, Calif, 2003,
Benjamin/Cummings.

* Information on hepatitis G, from the Centers for Disease Control and Prevention: Guidelines for viral hepatitis
surveillance and case management, Atlanta, 2005. Available at
http://www.cdc.gov/ncidod/diseases/hepatitis/resource/PDFs/revised_GUIDELINES_formatted5.pdf.

Table 9-8
Viral Hepatitis: Significance of Key Terms

770
From Wilkins EM: Clinical practice of the dental hygienist, ed 10, Philadelphia, 2009, Lippincott, Williams &
Wilkins.

a. Etiology—hepatitis A virus (HAV)

b. Pathogenesis
(1) Oral-fecal route in unsanitary conditions; contaminated

771
 food and water; close, intimate contact with infected person
(2) Rarely through the blood
(3) The incubation period is 15 to 50 days
(4) Usually occurs in children and young adults
c. Clinical findings and symptoms
(1) Preicteric (before jaundice appears)—similar to influenza;
fever, headache, nausea, vomiting, fatigue, abdominal pain,
loss of appetite, dark urine
(2) Icteric—jaundice (rare in children); other symptoms
continue
(3) Anicteric—without jaundice; two or three times more
prevalent than the icteric state; symptoms resemble those
of influenza
(4) Recovery and immunity
(a) Antibody to HAV (anti-HAV) is usually in the blood 2
weeks after onset
(b) Most individuals recover completely in 4 to 6 weeks
(c) Immunity develops after recovery
(d) No carrier state develops
(e) Usually self-limiting
d. Active immunization
(1) Hepatitis A vaccine (Havrix) at least 2 weeks before
expected exposure; booster dose recommended 6 to 12
months later for adults
(2) The vaccine may be administered concomitantly with
immunoglobulin in persons exposed to HAV
2. Hepatitis B (see Tables 9-7 and 9-8)
a. Etiology—hepatitis B virus (HBV)
b. Pathogenesis
(1) Infected blood or serum through parenteral inoculation
(e.g., blood transfusions, contaminated dental or medical
instruments, needles and syringes used by IV drug abusers,
accidental self-inoculation by health care professionals)
(2) Other body fluids, including saliva, semen, tears, urine,
sweat, and nasopharyngeal secretions
(3) Oral or sexual contact or other close, personal contact
(4) Coughing, sneezing, and aerosols
(5) Salivary transmission by way of hands, instruments, and
other equipment is an important consideration in the
practice of dental hygiene
c. Incubation

772
 (1) Between 45 and 160 days
(2) Presence of hepatitis B surface antigen (HBsAg) indicates
potential to be infective
d. Symptoms
(1) Similar to hepatitis A
(2) Slower onset; longer duration
(3) Asymptomatic to severe and debilitating
(4) Patient may have subclinical disease and remain
undiagnosed
(5) May result in chronic liver disease; strong evidence for link
between chronic HBV infection and hepatocellular
carcinoma (liver cancer)
e. Recovery
(1) Development of antibody to HBsAg (anti-HBs) indicates
immunity
(2) Approximately 5% to 10% of those infected develop a
chronic carrier state; HBsAg still present after 6 months;
carriers are usually asymptomatic and often remain
undetected
f. Risk factors
(1) Exposure to virus at birth (e.g., infants born to mothers
infected with HBV)
(2) Exchange of blood or blood products (e.g., during
hemodialysis, blood transfusions, or IV drug use)
(3) Exposure to blood or blood products (e.g., in the case of
health care workers)
(4) Close, intimate contact with infected person
(5) Unsafe sexual practices
(6) Institutionalization (e.g., in the case of some individuals
with Down syndrome and prisoners)
(7) Immunosuppressive therapy
g. Immunization
(1) Two types of HBsAg vaccines
(a) Obtained from HBsAg-positive carriers (Heptavax)
(b) Obtained from recombinant DNA in yeast cells
(Recombivax)
(2) Passive immunization results from hepatitis B immune
globulin (HBIg); used for postexposure prophylaxis;
preferably within 24 to 48 hours; partially effective
(3) Given as a series of 3 or 4 shots
3. Hepatitis type C (see Tables 9-7 and 9-8)

773
 a. Etiology—hepatitis C virus
b. Pathogenesis
(1) Originally named “non-A, non-B” hepatitis virus
(2) Risk factors include blood transfusion, IV drug use, and
heterosexual transmission
c. Clinical findings and symptoms
(1) Mild symptoms; most asymptomatic
(2) Development of chronic hepatitis in 50%; may develop into
cirrhosis and hepatocellular carcinoma
4. Hepatitis D (formerly delta hepatitis) (see Tables 9-7 and 9-8)
a. Etiology—hepatitis D virus
b. Pathogenesis
(1) Similar to HBV
(2) Infection dependent on HBV replication
c. Clinical findings—may produce acute exacerbations of chronic
HBV and fulminant hepatitis
5. Hepatitis type E (see Tables 9-7 and 9-8)
a. Etiology—hepatitis E virus
b. Pathogenesis
(1) Originally named “non-A, non-B” hepatitis virus
(2) Enteric transmission
(3) Epidemic outbreaks occurring in developing countries
6. Hepatitis G (see Table 9-7)
a. Etiology—hepatitis G virus
b. Pathogenesis
(1) Bloodborne transmission and co-infection with HCV
(2) Acute disease spectrum unknown
7. Rotavirus
a. Pathogenesis—disease spread via the fecal-oral route; the virus
replicates in the epithelial cells on the tips of villi in the small
intestine
b. Clinical findings and symptoms—acute onset of vomiting,
watery diarrhea, fever, and abdominal pain in children younger
than 2 years
8. Norwalk virus and Norwalk-like virus
a. Pathogenesis—disease spread via the fecal-oral route
b. Clinical findings and symptoms—nausea, vomiting, abdominal
cramps, lethargy, and diarrhea in older children and adults

Infections of the Circulatory System

774
Diseases of the Heart
A. Rheumatic fever
1. Etiology—β-hemolytic group A streptococcal infection
2. Pathogenesis
a. Rheumatic fever—hypersensitivity state developing after
streptococcal infection; associated with β-hemolytic group A
streptococci
b. Heart valves become inflamed; subsequent abnormal growths of
connective tissue; scarring of valves occurs, resulting in
rheumatic heart disease
3. Clinical findings and symptoms
a. Fever, malaise, polyarthritis, inflammation of the heart
b. Defective heart valves are a result of carditis
c. Heart valve damage
(1) Stenosis—narrowing of the valve opening
(2) Valvular insufficiency—failure of the valve to close
completely
4. Prophylactic antibiotic premedication is necessary before dental and
dental hygiene treatments
B. Infective endocarditis
1. Etiology—most often associated with the normal flora of the
respiratory or intestinal tract
2. Pathogenesis
a. Inflammatory condition of the heart; microbial colonization of
the endothelial membrane that covers the inner surface of the
heart and the heart valves
b. Predisposing factors
(1) Artificial heart valves
(2) Congenital heart defects
(3) History of endocarditis
(4) Damaged heart valves
(5) History of IV drug use
c. Dental and dental hygiene procedures may allow bacteria to
enter the bloodstream (bacteremia) and lodge in the heart
valves
3. Clinical findings and symptoms
a. Fever, anemia, weakness, and heart murmur
b. Inflammation of the heart
c. May result in death

Other Microbial Diseases of the Circulatory System

775
A. Bacterial infections
1. Rickettsial infections
a. Etiology—obligate intracellular parasites
b. Pathogenesis
(1) Transmitted by arthropods such as fleas, lice, mites, and
ticks
(2) Rocky Mountain spotted fever (tick vector)
(3) Typhus (flea-borne, common in rats)
(4) Rickettsialpox (mouse-mite vector)—usually involves fever,
rash, and vasculitis
B. Protozoan infections
1. Malaria—Plasmodium species (spp.)
a. Spread by mosquitoes
b. Symptoms—shaking, chills, fever, headache, and nausea, which
appear at 2- to 3-day intervals
C. Viral infections
1. Infectious mononucleosis
a. Etiology—Epstein-Barr virus (EBV)
b. Pathogenesis
(1) Transmitted by kissing or sharing drinking glasses with an
infected person
(2) Involves lymph nodes and the spleen; increase in
lymphocytes
c. Clinical findings and symptoms
(1) Acute leukemia-like infection
(2) Primarily found in young adults
(3) Symptoms include mild jaundice, fever, enlarged and
tender lymph nodes, sore throat, bleeding gingiva, and
general weakness
2. Cytomegalovirus (CMV) infections
a. Etiology—cytomegalovirus
b. Pathogenesis
(1) Cytomegalic inclusion disease is caused by intrauterine or
perinatal infection
(2) Virus may persist in organs in a latent state or as a chronic
infection
(3) CMV mononucleosis occurs spontaneously or through
blood transfusions
(4) The route of infection in older infants, children, and adults
is unknown
c. Clinical findings and symptoms

776
 (1) May result in death in infants
(2) Prematurity, jaundice, pneumonitis, central nervous
system (CNS) damage, and mental or motor retardation can
occur in infants
(3) Acquired infection in children results in hepatitis,
pneumonitis, and anemia
(4) CMV mononucleosis produces a mononucleosis-like
disease

Infections of the Reproductive and Urinary Systems

Reproductive System Infections
A. Bacterial infections
1. Gonorrhea
a. Etiology—Neisseria gonorrhoeae, a gram-negative aerobic
bacterium; often co-infection with Chlamydia trachomatis
b. Pathogenesis
(1) Risk of infection is 20% to 30% from a single exposure for
men; higher percentage for women
(2) Grows primarily in the genitourinary tract; possesses pili
that allow attachment to mucosal cells and resist
phagocytosis; can infect the eye, rectum, and throat
c. Clinical findings and symptoms
(1) Sometimes found in the pharynx; localized yellow or gray-
white raised patches or generalized lesions with a gray
membrane; the membrane sloughs, leaving a bright area;
seen on the gingiva, tongue, and soft palate; may have
itching or burning
(2) Gonococcal glossitis (Fig. 9-7)

777
 FIG 9-7 Gonococcal glossitis. (Courtesy of Beverly Entwistle
Isman, formerly with the Department of Applied Dentistry, University of
Colorado School of Dentistry, Denver.)

(3) The newborn’s eyes may be infected while the baby is

passing through the birth canal (ophthalmia neonatorum);
use of silver nitrate or antibiotic after birth alleviates the
condition
(4) Men experience painful and frequent urination and
discharge containing mucus and pus
(5) Women often do not have symptoms; may have urethral or
vaginal discharge, backache, or abdominal pain (pelvic
inflammatory disease)
(6) Oral infection results in pharyngitis, glossitis, or
stomatitis, including some areas of ulceration
(7) Complications include sterility, disseminated infection,
and meningitis
2. Syphilis (Fig. 9-8)

778
 FIG 9-8 Primary, secondary, and tertiary stages of syphilis.

a. Etiology—Treponema pallidum; spirochete, anaerobic

b. Pathogenesis
(1) Usually transmitted by sexual contact with skin or mucous
membrane lesions of an infected person
(2) Infection limited to the human host
(3) Congenital syphilis occurs when the organism crosses the
placenta
(4) T. pallidum can pass through abraded skin and can
probably pass through intact mucous membranes
(5) If the organisms gain access to the circulatory system, they
can affect all organs and spread rapidly to the lymphatic
system and bloodstream
c. Clinical findings and symptoms (Fig. 9-9)

779
 FIG 9-9 Chancre lesion of primary syphilis. (From Sapp JP, Eversole
LR, Wysocki GP: Contemporary oral and maxillofacial pathology, ed 2, St
Louis, 2004, Mosby.)

(1) Primary stage—chancre, a single granulomatous lesion;

often asymptomatic; common on the lips; may involve the
tongue and oral mucosa; highly contagious; occurs 2 to 3
weeks after exposure and lasts 3 to 5 weeks; red, small,
elevated nodule; heals spontaneously; no scarring
(2) Secondary stage
(a) Appears 6 to 8 weeks after exposure; patient can be
asymptomatic for 2 to 6 months, and then secondary
lesions appear
(b) Flu-like symptoms
(c) Skin rashes—maculopapular rash on the face, hands,
and feet
(d) Mucous patches on the lips, soft palate, and tongue—
painless shallow ulcers; grayish white areas may be
removed, leaving red areas of erosion; highly
contagious
(e) Swollen lymph nodes
(3) Tertiary stage
(a) Gumma—inflammatory granulomatous lesion with a
central zone of necrosis; may be on the tongue, palate
(perforation), or facial bones; soft, swollen areas or
tumors; not contagious and usually asymptomatic
(b) Often takes 5 to 20 years to develop
(c) Involvement of the CNS and spinal cord leads to
paresis, loss of fine muscle coordination, and
personality changes
(d) Involvement of the cardiovascular system—major
cause of death
(4) Congenital syphilis

780
(a) Hutchinson’s incisors—notched, bell shaped (Fig. 9-
10)

FIG 9-10 Congenital syphilis. The patient exhibits

anomalously shaped teeth, consisting of incisors with
screwdriver-shaped crowns and notched incisal
edges and molars with constricted crowns and a lack
of cuspal development (mulberry molars). (From Sapp
JP, Eversole LR, Wysocki GP: Contemporary oral and
maxillofacial pathology, ed 2, St Louis, 2004, Mosby.)

(b) “Mulberry molars”—first molars are irregular with

poorly developed cusps (Fig. 9-11)

781
 FIG 9-11 “Mulberry molars” of congenital syphilis.
(Courtesy of Beverly Entwistle Isman, formerly with the
Department of Applied Dentistry, University of Colorado School
of Dentistry, Denver.)

(c) Skin, mucous membrane lesions

(d) High mortality
3. Toxic shock syndrome (TSS)
a. Etiology—Staphylococcus aureus
b. Pathogenesis
(1) Short incubation period of 1 to 8 hours
(2) The toxin is produced by the microorganism
c. Clinical findings and symptoms
(1) Rash, nausea, violent vomiting, and diarrhea, but no fever
(2) Rapid convalescence
(3) Often occurs within 5 days of the onset of menses
(4) Can recur
B. Viral infections (Fig. 9-12)

782
 FIG 9-12 Primary herpetic gingivostomatitis.

1. Genital herpes
a. Etiology
(1) Herpesvirus
(2) HSV-2—herpes genitalis (genital herpes)
b. Pathogenesis—transmitted by sexual contact
c. Clinical findings and symptoms
(1) Lesions appear 2 to 7 days after exposure
(2) Lesions appear in or on the genitalia and skin
(3) Lesions may ulcerate early and be painful or crust over
(4) Fever, lymphadenopathy, malaise, anorexia
(5) Initial lesions subside and heal in 2 to 3 weeks
(6) Recurrent lesions have a milder course
(7) Highly infectious
(8) Primary and recurrent infections

783
 (a) Most (90%) primary infections are subclinical
(b) Recurrent infections in women often serve as a source
of neonatal herpes

Urinary Tract Infections

A. Etiology—primarily caused by E. coli
B. Pathogenesis—predisposing conditions
1. Diabetes mellitus
2. Neurologic diseases (e.g., polio and spinal cord injury)
3. Lesions (e.g., kidney stones) interfering with urine flow
4. Eclampsia of pregnancy
C. Clinical findings and symptoms
1. Blood in urine
2. Accumulation of fluid in tissue
3. Pain

Infections of the Central Nervous System

A. Bacterial infections
1. Meningitis
a. Etiology
(1) Aseptic meningitis—caused by a variety of agents,
including viruses, spirochetes, bacteria, mycoplasmas, and
chlamydiae
(2) Meningococcal meningitis—caused by Neisseria
meningitidis
b. Pathogenesis—meningococcal meningitis is transmitted by
droplet inhalation
c. Clinical findings and symptoms
(1) Aseptic meningitis produces an acute onset, fever,
headache, and stiff neck
(2) Meningococcal meningitis produces headache, vomiting,
stiff neck, and coma within a few hours
B. Viral infections
1. Poliomyelitis
a. Etiology—poliomyelitis virus
b. Pathogenesis—virus transmitted through the mouth and
intestines
c. Clinical findings and symptoms
(1) Flaccid paralysis; destruction of motor neurons in the
spinal cord

784
 (2) Acute inflammation of the meninges
(3) May range from mild illness to paralysis
2. Rabies
a. Etiology—rabies virus
b. Pathogenesis
(1) Transmitted to humans through the bite of a rabid animal
(2) Incubation period is 4 to 6 weeks or longer
c. Clinical findings and symptoms—include visual difficulties,
painful throat spasms, convulsions, and respiratory paralysis
3. Viral encephalitis
a. Etiology—usually caused by arboviruses
b. Pathogenesis—virus replicates in, and is spread by, arthropods,
usually mosquitoes or ticks
c. Clinical findings and symptoms
(1) Causes extensive nervous tissue damage and encephalitis
(2) Symptoms—include fever, chills, nausea, fatigue,
drowsiness, pain, stiff neck, general disorientation,
blindness, deafness, and paralysis
C. Protozoan infection—toxoplasmosis
1. Etiology
a. Toxoplasma gondii
b. Sources include infected cat feces, contaminated raw meat and
soil, and rodents (cats may eat infected mice)
2. Pathogenesis
a. Inhaling or ingesting cysts when handling cat litter or
sandboxes frequented by the infected cat
b. Eating raw meat
c. Through the placenta (pregnant women must not eat raw or
undercooked meat and handle litter boxes)
3. Clinical findings and symptoms
a. Resembles infectious mononucleosis in adults
b. Congenital infection can lead to stillbirth, psychomotor
dysfunction, blindness, and other congenital defects
D. Fungal infection—cryptococcosis
1. Etiology—Cryptococcus neoformans
2. Pathogenesis
a. The organism tends to reside in pigeon droppings
b. Transmitted by inhalation of dehydrated yeasts
3. Clinical findings and symptoms
a. Meningitis most common; often associated with
immunocompromised patients

785
 b. Disseminated disease can affect skin, lungs, or other organs

Infections of the Eye

A. Bacterial infections
1. Conjunctivitis
a. Etiology—Haemophilus aegyptius
b. Clinical findings
(1) Purulent conjunctivitis
(2) Epidemic in warmer climates
2. Trachoma-inclusion conjunctivitis
a. Etiology—Chlamydia trachomatis
b. Pathogenesis—transmitted through person-to-person contact;
associated with poor sanitation and poor personal hygiene
c. Clinical findings and symptoms
(1) Inflammation of conjunctiva; scarring of eyelids or cornea;
can lead to secondary infection; can lead to partial or
complete blindness
(2) “Swimming pool conjunctivitis,” which results in
conjunctival inflammation; is usually self-limiting
B. Viral infections
1. Adenovirus infection
a. Etiology—adenoviruses
b. Pathogenesis
(1) Hand-to-eye contact is the most significant factor
(2) Swimming pool conjunctivitis most likely transmitted by
the waterborne route
c. Clinical findings and symptoms—inflammation of the
conjunctiva, excessive lacrimation, periorbital edema
2. Enterovirus type 70 is one of the causes of acute hemorrhagic
conjunctivitis
3. Herpetic keratitis
a. Etiology—primarily caused by HSV-1; occasionally by HSV-2
b. Pathogenesis—cytolytic, herpetic infection of the cornea
c. Clinical findings and symptoms
(1) Severe keratoconjunctivitis; corneal ulcers or vesicles on
the eyelids
(2) May recur
(3) May cause blindness

Chemotherapeutic Agents

786
See Tables 9-9 and 9-10.

Table 9-9
Choice of Antibacterial Agents for Therapy

787
788
Modified from Morello JA, Mizer HE, Granato PA: Microbiology in patient care, ed 6,
Boston, 1998, WCB/McGraw-Hill.
* Penicillin-allergic patients are often treated with erythromycin or clarithromycin. Resistant
strains are treated with vancomycin ± rifampin.

Table 9-10
Antimicrobial Agents for Fungi, Parasites, and Viruses

789
790
Modified from Morello JA, Mizer HE, Granato PA: Microbiology in patient care, ed 6,
Boston, 1998, WCB/McGraw-Hill.
*A number of antifungal imidazole drugs that are similar to ketoconazole in mechanisms of
action and spectra of antifungal activity are available as topical preparations. These
agents, which include clotrimazole, econazole, and terconazole, are not used to treat
serious systemic disease.
† Rimantadine, a similar agent for prophylaxis of influenza A, may produce fewer side
effects than does amantadine.

791
792
Microbiology of the oral cavity
Normal oral flora
A. Composition and distribution—different types of surfaces create
distinct habitats within the mouth, so the distribution of microflora is
not uniform throughout the mouth (Table 9-11)

Table 9-11
Bacterial Genera Found in the Oral Cavity

793
794
1. Lips—predominantly facultatively anaerobic streptococci;
Streptococcus vestibularis found in the vestibule
2. Palate—predominantly Actinomyces spp. and Streptococcus spp.
3. Cheek—predominantly Streptococcus spp. and Haemophilus spp.; 5 to
25 bacteria per epithelial cell
a. Majority of streptococci are Streptococcus oralis and S. mitis, and
fewer are S. sanguis
b. Simonsiella spp. isolated primarily from human cheek cells
4. Tongue (100 bacteria per tongue epithelial cell)—papillae allow for a
large surface area for colonization, resulting in higher bacterial
density and diverse microflora
a. Predominantly S. oralis, S. mitis, and Streptococcus salivarius
b. Stomatococcus mucilagenosus is found exclusively on the tongue
c. Veillonella spp., Actinomyces naeslundii, Actinomyces odontolyticus,
and Haemophilus spp. also isolated
d. Increased numbers of Porphyromonas, Prevotella, Fusobacterium,
and Treponema spp. lead to halitosis resulting from an increase
in volatile sulfur compound production
5. Saliva—108 to 109 bacteria/mL of saliva; normal salivary flow ensures
that bacteria do not multiply in saliva; so saliva does not contain
resident flora but rather bacteria from other surfaces—primarily
from the dorsum of the tongue and dental plaque
6. Tooth surfaces (plaque)
a. Pits and fissures
(1) Morphologic condition allows for proliferation
(2) Predominantly Streptococcus mutans and A. naeslundii
(3) Common sites for caries
b. Interproximal surfaces
(1) Inaccessible to routine oral hygiene care
(2) Bacteria in biofilm can proliferate in microcolonies
undisturbed
(3) Predominantly A. naeslundii, Actinomyces israelii, and
Streptococcus, Veillonella, and Prevotella spp.
(4) Majority of streptococci are S. sanguis
(5) Common site for caries
c. Smooth coronal surfaces
(1) Can be covered with plaque if oral hygiene is not practiced
(2) Plaque formation limited by the cleaning action of saliva,
the movement of soft tissue, and the action of food particles
(3) Oral bacteria colonize in a predictable succession

795
B. Factors that influence microbial composition
1. Temperature 35°C to 36°C (95°F to 96.8°F)
a. Temperature may influence proportions of bacterial species
b. Periodontal pockets with active disease have higher
temperatures—up to 39°C (102.2°F)
2. Nutrient sources
a. Exogenous sources include the host’s diet, especially dietary
sugar, which is needed for acid and polysaccharide production
b. Endogenous sources
(1) Saliva
(2) Gingival exudate
(3) Epithelial cells and leukocytes
(4) Continuing existence of flora even when humans and
animals are fed by a stomach tube
(5) Certain bacteria use metabolic byproducts from other
bacteria
3. pH requirements
a. The pH of most surfaces regulated by saliva (pH 6.75 to 7.25)
b. Dietary sugars provide a selective force favoring predominance
of certain organisms that tolerate an acidic medium (pH 5)
c. Strains of S. mutans, related streptococci, and lactobacilli are
both acidogenic (produce acid) and aciduric (tolerate low pH
values)
d. Dairy products can elevate pH
e. The pH of the gingival sulcus becomes alkaline during the host
inflammatory response in periodontal disease (pH 7.2 to 7.8)
f. Alkaline pockets favor the growth of the pathogen
Porphyromonas gingivalis
4. Oxygen concentration
a. Distribution of microorganisms in the mouth is related to the
redox potential at a particular site
b. The majority of organisms are micro-aerophilic, facultative, or
obligate anaerobes
5. Microbial interactions
a. Microbial aggregation
(1) Certain species undergo reactions between host cell
surfaces (adhesion receptor)
(2) Bacterial cells can attach to each other (co-aggregation)
(3) Some bacteria produce extracellular polysaccharides
(glucans, fructans, heteropolysaccharides) that provide
structural and energy sources for plaque

796
 b. Interspecies antagonisms
(1) Competition for host receptors
(2) Competition for endogenous nutrients
(3) Production of inhibitory substances (e.g., hydrogen
peroxide by S. mitis and S. sanguis; bacteriocin by
streptococci; formation of acid by S. mutans, S. salivarius,
and lactobacilli)
6. Saliva
a. Nonspecific factors
(1) Flow of saliva removes planktonic bacteria from oral
surfaces
(2) Flow rate bears some relationship to caries susceptibility
(3) Rate of secretion is correlated to buffering capacity
(4) Proteins and glycoproteins form acquired pellicles on
teeth; bacteria can attach to the pellicle
(5) Proteins and glycoproteins act as nutrient source for
microflora
(6) Proteins and glycoproteins can aid in co-aggregation of
bacteria, thus facilitating their clearance
(7) Antibacterial components include lysozymes,
lactoperoxidase, lactoferrin, salivary thiocyanate, and
peptides
b. Specific factors—secretory immunoglobulin A inhibits
microbial attachment
7. Host factors that affect microflora
a. Oral hygiene—antimicrobial agents in toothpaste and mouth
rinses; mechanical force of toothbrush and interdental care
b. Gender and race
c. Age
d. Alterations in the food web
e. Long-term use of antibiotics and development of antimicrobial
resistance
f. Scratches and grooves on tooth surfaces or restorations, or
margins between dental restorations and tooth surface that
enhance biofilm formation
g. Genetics

Development of Oral Microflora

A. The oral cavity is usually sterile at birth
B. Initial colonization of the infant’s mouth by the microflora of the

797
mother, milk, water, and saliva of those in close contact
1. Oral microflora consist of aerobic and facultatively anaerobic gram-
positive species
2. S. salivarius, S. oralis, and S. mitis predominate by the first month of
the infant’s life
C. The microflora diversify in the next few months with several gram-
negative anaerobes—Prevotella melaninogenica, Fusobacterium nucleatum,
and Veillonella spp.
D. At 12 months, most children have the following organisms:
1. Streptococci
a. S. salivarius, S. oralis, and S. mitis predominate
b. S. mutans and S. sanguis are not established until tooth eruption
c. S. mutans disappears when full-mouth extractions occur;
reappears with dentures
2. Staphylococci
3. Veillonella spp.
4. Neisseria spp.
5. Actinomyces spp.
6. Lactobacilli
7. Nocardia spp.
8. Fusobacterium spp.
E. Preschool-age child
1. Adult-like microflora
2. P. melaninogenica and spirochetes not common at age 5 years, but
increase in numbers by age 13 years
F. Relatively stable oral microflora in healthy adults
G. Age-related changes in oral microflora
1. Increase in numbers of yeast (C. albicans) may be associated with
increased denture wear, changes in the oral mucosa, blood glucose
level, and malnutrition
2. Increased use of medications common with aging; may decrease
salivary flow

Bacterial plaque
See the section on “Bacterial Dental Biofilm” in Chapter 14.
A. Definition
1. Deposit formed by the colonization of teeth by members of the
normal oral flora
2. Complex of bacteria in the matrix mainly of bacterial
polysaccharides; biofilm

798
 3. Bacteria embedded in an exopolymeric matrix that provides a
protective environment for bacteria
B. Stages of formation
1. Cell-free pellicle
a. High-molecular-weight salivary glycoproteins
b. Quickly colonized by bacteria
2. Supragingival plaque formation
a. Phase I—initiation
(1) Begins in 1 to 2 days of plaque accumulation
(2) Gram-positive cocci and short rods show early dominance
(3) Streptococci (aerobe)
b. Phase II
(1) From 2 to 4 days of plaque accumulation
(2) Cocci still dominate, but gram-positive rods and gram-
negative cocci begin to appear
(3) Streptococcus sanguis, S. oralis, or S. mitis usually first
colonizer, but Haemophilus and Neisseria spp. may also be
early colonizers
c. Phase III
(1) From 4 to 7 days of plaque accumulation
(2) After 7 days, streptococci remain the dominant organism,
but by day 8, their numbers decrease
(3) Filamentous bacteria (Veillonella and Actinomyces spp.)
appear in 7 to 14 days
(4) Respiration becomes increasingly anaerobic; rods and
filaments predominate (increase in Tannerella, Actinomyces,
Capnocytophaga, Treponema, P. melaninogenica, and
Fusobacterium)
(5) Composition of mature plaque biofilm varies with site,
oxygen and nutrient sources, and level of protection
3. Subgingival plaque formation
a. Microbiota
(1) Vibrios and spirochetes prevalent
(2) Anaerobic, gram-negative, motile, asaccharolytic
b. Types
(1) Tooth associated (attached)
(2) Tissue associated
(3) Unattached subgingival
C. Factors that affect adherence and retention
1. Salivary glycoprotein
a. Affinity for hydroxyapatite

799
 b. Causes bacteria to aggregate
2. Specific bacterial attachment mechanisms
a. Electrostatic forces
b. Bacterial surface components (adhesions) bind specific sites of
the pellicle (receptors)
c. Hydrophobic interactions
3. Bacterial competition
a. Relative numbers of a species may affect colonization patterns
b. Streptococcus sanguis has a stronger affinity for enamel than does
S. mutans; fewer numbers of S. mutans are in saliva to compete
for tooth sites
4. Bacterial interactions—some evidence that S. mutans and S. sanguis
are antagonistic
5. Natural local cleansing activity and retentive areas
6. Diet
D. Plaque polysaccharides
1. Extracellular glucans—structural component of plaque
a. Synthesized from sucrose
b. Properties
(1) Insoluble
(2) May mediate attachment of bacteria to dental tissues
(3) May entrap bacterial enzymes or metabolic products
(4) Ability of S. mutans to produce glucans appears essential
for cariogenicity
2. Levans (fructans and heteropolysaccharides)—produced by S.
mutans, S. sanguis, S. salivarius, Lactobacillus spp., Rothia spp.,
Eubacterium spp., and A. naeslundii
a. Soluble
b. Reserve nutrients
c. Can be used as sources of energy in bacterial metabolism
E. Microbial composition of plaque
1. Bacterial composition of supragingival (supramarginal) plaque
a. Thin layer; 1 to 20 cells thick
b. Mostly gram-positive facultative anaerobic organisms
c. Most predominant organisms are S. sanguis and A. naeslundii
d. Other species found include A. israelii, S. mutans, Veillonella and
Fusobacterium spp., Treponema spp., and Capnocytophaga spp.
2. Bacterial composition of normal gingival crevicular plaque
a. Gingival crevice—an area of stagnation and bacterial
proliferation—environmental influences include an increase in
crevicular fluid, desquamation of epithelial cells, and bacterial

800
 acid products
b. Quantity of species relatively constant; proportions of species
vary among people and even within the same mouth
c. Predominant organisms are S. mitis, S. sanguis, A. naeslundii, A.
odontolyticus, A. meyeri, A. georgiae, Rothia dentocariosus, and
Eubacterium, Fusobacterium, and Treponema spp.
3. Calculus
a. Inorganic salts, 70% to 90%
b. Microbes similar to those of the gingival crevicular area
c. Main role in periodontal disease is to serve as a collection site
for more bacteria

Dental caries
See Fig. 9-13.

801
 FIG 9-13 Formation of dental caries.

A. Prerequisites for caries development

1. Cariogenic bacteria
2. Supply of substrate for acid production
3. Susceptible host
B. Cariogenic bacteria
1. Essential properties
a. Acidogenic and aciduric; acid must be produced and a low pH
maintained for a long period
b. Ability to attach to tooth surfaces
c. Formation of a protective matrix
2. Streptococci
a. Streptococcus mutans
(1) Most strongly cariogenic bacteria in animals
(2) Hard surfaces are a prerequisite for its presence; the
organisms disappear if teeth are extracted and reappear
with dentures

802
 (3) Homofermentive lactic acid former
(4) Produces insoluble and soluble glucans
(5) A high-sucrose diet is generally associated with an increase
in the S. mutans population
(6) Usually found in the early stages of plaque formation
b. Streptococcus sobrinus
(1) A mutans streptococcus
(2) Possible roles in caries are still evolving
c. Streptococcus sanguis
(1) Produces glucans
(2) Some strains cariogenic in animals
(3) Colonizes tooth enamel
(4) Is present in plaque and sometimes cheek
d. Streptococcus mitis
(1) Cariogenic in animals
(2) Found on oral soft tissues
e. Streptococcus salivarius
(1) Produces fructans
(2) Usually has a strong affinity for oral soft tissues, especially
the tongue
(3) Some strains cariogenic in animals
3. Lactobacilli
a. Present in small numbers in plaque
b. Increase in number in the mouth when the sugar content in the
diet is high
(1) Present in the mouth where sugar is retained
(2) Carious lesions act as retention sites
d. Strongly acidogenic and aciduric
e. May have important role in the progression of caries
2. Actinomyces
a. Actinomyces naeslundii primary cause of root-surface caries
b. Plaque-forming organisms
c. Ferment glucose to produce mostly lactic acid
d. A. naeslundii present on tongue, tooth surfaces, and plaque
C. Acid production in plaque
1. Decalcification of teeth caused by acids produced through bacterial
fermentation
2. Cariogenic plaque, when exposed to sugar, shows a decrease in pH
that is low enough to decalcify enamel within minutes; pH returns to
resting levels after approximately 40 minutes; even though sugar is
washed away by saliva, pH can remain at a low level for 20 minutes

803
 3. Important features of the acid production process
a. Amount of plaque
b. Predominant microflora
c. Rate of salivary flow
d. Substrate characteristics
e. Location of plaque
4. More lactic acid present than any other acid
D. Bacterial substrates and diet
1. Sucrose
a. Main substrate for cariogenic bacteria
b. Important in the formation of smooth-surface caries
c. Metabolized to form acids and glucans
d. Essential for caries production in animals
e. Epidemiologic evidence has established its role in human caries
f. Increase in the frequency of sucrose consumption is associated
with an increase in caries
g. High cariogenic effect when retained on teeth for a long period
2. Starches
a. Low cariogenicity
b. Probably influences plaque microflora
E. Host factors
1. Tooth surface
a. Caries formation influenced by tooth morphology and arch form
b. Enamel surfaces are probably more caries resistant than the
subsurface
2. Saliva
a. Functions that affect the carious process
(1) Clearance of food
(2) Buffer activity
(3) Bacterial aggregation
(4) Antibacterial function (e.g., immunoglobulin A,
lysozymes, salivary peroxidase)
b. Amount of ambient calcium, phosphate, and fluoride ions in
the saliva for remineralization of tooth structure
c. Rate of flow and buffering abilities
(1) As flow rate increases, pH rises
(2) High salivary flow rates and buffering are associated with
low caries activity

Periodontal diseases

804
See the section on “Diseases of the Periodontium” in Chapter 14.
A. Classification of periodontal diseases
1. Gingival diseases
a. Dental plaque–induced gingival diseases
(1) Early gingivitis
(a) Plaque is thicker (100 to 300 cells thick) and more
complex than in healthy tissue
(b) Proliferation of Fusobacterium nucleatum and
Actinomyces organisms
(c) Mostly gram-positive organisms
(2) Chronic gingivitis (Box 9-2)

Box 9-2
Predominant Bac teria of Experimental
Gingivitis in Young Adults
Gram-Positive Bacteria Gram-Negative Bacteria
Actinomyces israelii Prevotella oris
Actinomyces naeslundii Prevotella intermedia
Actinomyces odontolyticus Campylobacter spp.
Propionibacterium acnes Veillonella parvula
Lactobacillus spp. Fusobacterium nucleatum
Streptococcus anginosus Treponema spp.
Streptococcus mitis Wolinella spp.
Peptostreptococcus micros
Eubacterium spp.

From Marsh P, Martin MV: Oral microbiology, ed 4, Boston, 1999, Wright.

(a) Anaerobic, gram-negative organisms increase; rods form 75% of the

subgingival flora
(b) Presence of Actinomyces naeslundii, Fusobacterium nucleatum, Prevotella
intermedia, and Veillonella parvula
(c) Spirochetes are elevated at affected sites
b. Plaque-induced gingival disease is modified by systemic factors
(1) Endogenous sex-steroid–hormone gingival disease (pubertal-
associated gingivitis, pregnancy-associated gingivitis, menstrual
gingivitis)
(2) Diabetes mellitus–associated gingivitis
(3) Hematologic (leukemic) gingival disease
(4) Drug-influenced gingival enlargement
(5) Gingival disease associated with nutrition
c. Non–plaque-induced gingival disease

805
(1) Gingival disease of specific bacterial, viral, fungal, or genetic origin
(2) Gingival manifestations of systemic conditions
(3) Traumatic lesions, foreign-body reactions, and nonspecific gingival
lesions
2. Periodontal diseases
a. Necrotizing periodontal diseases
(1) Necrotizing ulcerative gingivitis (NUG)
(a) Anaerobic infection of gingival margins causes ulceration; if allowed
to progress, destruction of gingivae and underlying bone occurs; onset is
sudden and acute
(b) The interproximal areas are affected first
(c) Appears to be an opportunistic infection based on predisposing
factors (e.g., plaque formation, depression of polymorphonuclear
leukocyte [PMN] function, stress, poor diet, immunocompromise)
(d) Predominant microflora include P. intermedia, spirochetes, and
fusiform bacteria
(2) Necrotizing ulcerative periodontitis (NUP)
(a) Appearance—necrosis of gingival tissues, periodontal ligaments, and
alveolar bone
(b) Indications—client presents with pain and excessive necrosis
(c) Severe and rapid periodontal destruction; lack of deep-pocket
formation
(d) Occurs in persons infected with HIV and those undergoing
immunosuppressive therapies
(e) Predominant microflora include C. albicans, Haemophilus
actinomycetemcomitans, F. nucleatum, and Porphyromonas gingivalis
b. Chronic periodontitis (slight or early; moderate; severe or advanced)
(Box 9-3)

Box 9-3
Some Bac terial Spec ies That Have Been
Commonly Implic ated in Chronic Periodontitis

Gram-Positive Bacteria Gram-Negative Bacteria

806
Gram-Positive Bacteria Gram-Negative Bacteria
Eubacterium brachy Tannerella forsythensis
Eubacterium nodatum Dialister pneumosintes
Eubacterium timidium Fusobacterium nucleatum
Peptostreptococcus anaerobius Porphyromonas gingivalis
Peptostreptococcus micros Prevotella intermedia
Prevotella loescheii
Prevotella oralis
Campylobacter rectus
Treponema spp.

Aggregatibacter actinomycetemcomitans

(1) Extension of inflammatory changes into deeper periodontal

structures, with resulting bone loss
(2) May indicate multiple diseases that share similar characteristics
(3) Pockets provide a favorable environment for bacterial growth
(4) Different bacterial populations associated with destructive
periodontitis have been described (Boxes 9-4 and 9-5)

Box 9-4
Spec ies of Bac teria for Whic h Proportions in
Plaque Rise with Inc reasing Severity of
Periodontal Disease
Gram-Positive Bacteria Gram-Negative Bacteria
Eubacterium alactolyticum Aggregatibacter actinomycetemcomitans
Eubacterium brachy Bacteroides gracilis
Eubacterium nodatum Campylobacter concisus
Eubacterium saphenum Campylobacter rectus
Eubacterium timidium Campylobacter curvus
Eubacterium spp. Filifactor alocis
Atopobium rimae Fusobacterium nucleatum
Peptostreptococcus anaerobius Prevotella denticola
Prevotella intermedia
Prevotella nigrescens
Prevotella melaninogenica
Prevotella oris
Prevotella tannerae
Prevotella veroralis
Porphyromonas gingivalis
Selenomonas flueggei
Selenomonas infelix
Selenomonas noxia
Selenomonas sputigena

Box 9-5
Princ ipal Bac teria Assoc iated with Periodontal

807
Disease
Chronic periodontitis Porphyromonas gingivalis, Prevotella intermedia, Campylobacter rectus, Fusobacterium
nucleatum, Tannerella forsythensis
Aggressive Aggregatibacter actinomycetemcomitans, P. intermedia, Eikenella corrodens, Capnocytophaga
periodontitis sputigena
Necrotizing P. gingivalis, A. actinomycetemcomitans, F. nucleatum, P. intermedia, Streptococcus spp., Candida
periodontal diseases albicans, Treponema, Selenomonas

(5) Periodontitis can be a manifestation of systemic diseases such as

hematologic or genetic disorders
(6) Associated with abscesses of the periodontium and endodontic
lesions
(7) Causative organisms include P. intermedia, Aggregatibacter
actinomycetemcomitans, P. gingivalis, Eubacterium spp., F. nucleatum,
spirochetes, Tannerella forsythensis, and Campylobacter rectus
c. Aggressive periodontitis
(1) Onset occurs before age 35 years and is associated with a rapid rate of
progression of tissue destruction, host defense defects, and composition
of subgingival flora
(2) Subclassifications are identified as:
(a) Prepubertal periodontitis
(b) Juvenile periodontitis—localized and generalized forms
(3) Primary organism—Aggregatibacter actinomycetemcomitans
(4) Clinical findings and symptoms
(a) Periodontitis as a manifestation of systemic diseases such as
hematologic or genetic disorders
(b) Abscesses of the periodontium
(c) Periodontitis associated with endodontic lesions
(d) Developmental or acquired deformities and conditions
B. Bacterial plaque (dental) biofilm and periodontal disease
1. Factors that determine the severity of periodontal disease
a. Level of oral hygiene
b. Type of bacteria in plaque biofilm
c. Host resistance and immunity
2. Evidence supports microbial cause of periodontal disease (Box 9-6)

Box 9-6
Identific ation of the Bac terial Cause in
Periodontal Diseases
1. Large numbers of the bacteria are associated with the disease state,

808
 and absence or reduced numbers are associated with health.
2. Elimination or suppression of the organism reverses or reduces the
disease.
3. Elevated host responses are associated with the disease.
4. Animal pathogenicity similar to periodontal disease occurs on
implantation of the organism(s) into germ-free animals.
5. Bacteria possess potentially pathogenic mediators that could
contribute to the disease process.
From Newman MG, Nisengard R: Oral microbiology and immunology, ed 2, Philadelphia, 1994,
Saunders.

a. Gram-negative microorganisms are the principal bacteria associated

with disease
b. Plaque associated with gingivitis and periodontitis has different
bacterial populations
3. Pathogenic mechanisms of plaque bacteria
a. Attachment mechanisms—attachment to the tooth surface may
depend on early colonizers of tooth surface and pellicle (e.g., Streptococcus
and Actinomyces, which are gram-positive organisms)
b. Products of bacteria
(1) Bacteria themselves may invade tissue
(2) Products may cause tissue destruction
(a) Endotoxins
(b) Enzymes (collagenase, lysozyme, and hyaluronidase)
c. Survival mechanism—slime layer and biofilm formation
4. Immunologic aspects of periodontal disease
a. Bacteria in biofilm are antigenic in varying degrees; present a challenge
to the immune system
b. Immune responses are just as likely to be protective as they are
injurious to tissue
c. Mechanisms of tissue destruction may involve anaphylactic, cytotoxic,
immune complex, and cell-mediated or delayed hypersensitivity
reactions
d. Participation of the humoral immune system
(1) Lymphocytes and plasma cells are the predominant cells in the
gingiva in the vicinity of plaque
(2) Antibody production is stimulated
(3) Complement system is activated
(a) Mediates inflammatory response and immunologic reactions
(b) Complement is activated by plaque bacteria, either by endotoxin

809
(lipopolysaccharide) or by bacterial antigen-antibody complexes
(c) Involved in chemotaxis (directed migration of inflammatory cells)
e. Participation of the cell-mediated immune system
(1) Cell-mediated immunity leads to release of lymphokines (e.g.,
osteoclast-activating factor)
(2) Reports on the relationship between cell-mediated reactivity and the
severity of periodontal disease are conflicting
(3) Clinically not possible to distinguish between cell-mediated
immunity (resistance) and delayed hypersensitivity (damaging) reactions
in humans; both reactions depend on the same cellular participants

Periapical infections and oral-facial tissue infections

A. Infections
1. Abscesses (periodontal and periapical)
2. Postsurgical and postextraction wound infections
3. Endodontically involved infections
4. Sinus tract infections
5. Cellulitis
6. Traumatic injuries
7. Osteomyelitis
8. Postextraction alveolar osteitis (dry socket)
9. Pericoronitis
10. Periodontally involved infections
B. Bacteria cultivated from such infections
1. Polymicrobial and opportunistic in nature
2. Obligate anaerobic bacteria predominate in acute endodontic
infections
C. Ludwig’s angina
1. Mixed infection
a. Fusobacterium spp., Prevotella spp., Porphyromonas spp., and
streptococci
b. Often caused by the normal oral flora gaining access through
the infected tooth
2. Symptoms
a. Rapidly spreading, diffuse bilateral cellulitis of the floor of the
mouth and neck
b. Swelling that may block air passages
c. Fever and malaise
3. Predisposing factors
a. Infected mandibular molars

810
 b. Thin lingual cortical plate of the mandible

Opportunistic infections of the oral cavity

A. Definition—opportunistic organisms take advantage of a
compromised situation in the host and subsequently invade and cause
infections of the oral cavity
B. Actinomycosis
1. Etiology
a. Actinomyces israelii most common
b. A. naeslundii and Arachnia propionica found in some lesions
2. Pathogenesis
a. Gram-positive bacteria; member of the normal oral flora
b. Infection may follow injury with introduction of contaminated
debris into tissue
3. Clinical findings and symptoms
a. Facial swelling, most frequently in soft tissue below the angle of
the jaw
b. Small, chronic, superficial mass
c. Abscess with sinus and chronic discharge develops
C. Oral candidiasis—four clinically distinct forms:
1. Pseudomembranous candidiasis
a. A removable soft, creamy, white plaque; red or bleeding base
b. Predominantly found on the buccal and labial mucosa, tongue,
hard and soft palates
2. Erythematous candidiasis
a. A smooth, flat, red lesion on the dorsum of the tongue;
associated with loss of papillae
b. Can also be found on the hard palate
3. Angular cheilitis—cracking or redness around the corners of the
mouth
4. Hyperplastic candidiasis
a. A raised, white, nonremovable plaque
b. Appears on the buccal mucosa, hard palate, or dorsum of the
tongue
D. Staphylococci
1. Etiology—S. aureus and S. epidermidis
2. Pathogenesis—normal flora of the skin, oral cavity, and anterior
nares
3. Clinical manifestations
a. Mandibular osteomyelitis

811
 b. Acute suppurative parotitis
E. Other oral diseases
1. Mumps
a. Etiology—mumps virus
b. Clinical findings and symptoms
(1) Painful, swollen parotid or submaxillary glands
(2) Fever and malaise
(3) Red and swollen papilla of Stensen’s duct
c. Prevention through vaccine
2. Herpangina (vesicular pharyngitis)
a. Etiology—coxsackievirus A
b. Pathogenesis
(1) Transmitted by ingestion of contaminated materials
(2) Primarily occurs in children
c. Clinical findings and symptoms—fever and vomiting; vesicles
and later ulcers on the mucous membrane of the throat, palate,
or tongue
d. Recovery in 7 to 10 days; complications rare
3. Recurrent aphthous ulcers
a. Etiology—unknown; evidence suggests immunologic etiology
b. Clinical findings and symptoms
(1) Canker sore, small ulcer
(2) Covered by pseudomembrane
(3) Surrounding erythematous halo
(4) Occur on nonkeratinized mucosa
4. Hand-foot-and-mouth disease
a. Etiology—coxsackievirus A
b. Pathogenesis
(1) Highly infectious
(2) Typically affects many children, particularly in schools
c. Clinical findings and symptoms
(1) Vesicular stomatitis and rash
(2) Affects the buccal mucosa, tongue, gingiva, lips, hands,
and feet
(3) Pain

Website Information And Resourc es

Source Website Address Description

812
Source Website Address Description
Bergey’s http://www.bergeys.org/outlines.html Online publication, updated approximately six times
Taxonomic per year and is free to registered users
Outline
Centers for http://www.cdc.gov/ One of the 13 major operating components of the
Disease Department of Health and Human Services (HHS),
Control and which is the principal U.S. government agency for
Prevention protecting the health and safety of all Americans and
(CDC) for providing essential human services, especially for
persons who are least able to help themselves
Organization http://www.osap.org/ Promotes infection control and related science-based
for Asepsis health and safety policies and practices through
and Safety quality education and information dissemination
Procedures
(OSAP)
Morbidity and http://www.cdc.gov/mmwr/ The MMWR series is prepared by the CDC and
Mortality provides data regarding a variety of health and safety
Weekly Report concerns
(MMWR)

813
Reference
1 Centers for Disease Control and Prevention: About HIV/AIDS,
2014, http://www.cdc.gov/hiv/statistics/basics.html.

Chapter 9 review questions

Answers and rationales to review questions are available on this text’s
accompanying Evolve site. See inside front cover for details.

1. What cellular structure is involved in energy synthesis (ATP

production)?
a. Golgi complex
b. Ribosome
c. Mitochondrion
d. Nucleus
2. The type of microscopic technique used to examine unstained
microorganisms, spirochetes, and hanging drop preparations.
a. Phase-contrast microscopy
b. Darkfield microscopy
c. Bright-field microscopy
d. Scanning electron microscopy
3. Identify the type of staining procedure used to distinguish between
gram-positive and gram negative bacteria.
a. Flagellar stain
b. Acid-fast stain
c. Gram staining
d. Schaefer-Fulton stain
4. What is the CORRECT morphologic name for bacteria that do not have
a defined shape?
a. Staphylococci
b. Diplococci
c. Sarcinae
d. Pleomorphic

814
5. Heterotropic organisms do NOT require organic compounds for
growth. Autotrophic organisms do require organic compounds for
growth.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
6. The type of microbial relationship in which one organism benefits at
the expense of another organism is called:
a. Symbiosis
b. Predation
c. Commensalism
d. Parasitism
7. In which phase of metabolism is energy released?
a. Catabolism
b. Anabolism
c. Glycolysis
d. Protein synthesis
8. Which immunoglobulin plays an important role in hypersensitivity
reactions?
a. IgG
b. IgM
c. IgA
d. IgE
9. Infection acquired during a hospital stay is called:
a. Latent
b. Primary
c. Toxemia
d. Nosocomial
10. A gumma is present during which stage of a syphilis infection?
a. Primary
b. Secondary
c. Tertiary
d. Quaternary

815
11. The incubation period for hepatitis B is:
a. 28 to 47 days
b. 45 to 160 days
c. 8 to 16 hours
d. 15 to 50 days
12. The structure that functions as storage site for amino acids,
carbohydrates, and proteins is:
a. Ribosome
b. Plastid
c. Cytoplasmic membrane
d. Vacuole
13. In eukaryotes, respiration occurs through what cellular structure?
a. Cytoplasmic membrane
b. Mitochondria
c. Ribosomes
d. Lysosomes
14. The type of media used to produce visual differentiation between
several microorganisms is called:
a. Reducing media
b. Enriched media
c. Selective media
d. Differential media
15. Exotoxins are soluble microbial virulence factors secreted by gram-
positive bacteria. Endotoxins are heat-stable polysaccharide microbial
virulence factors secreted by gram-negative bacteria.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
16. All the following are clinical signs and symptoms associated with a
tetanus infection EXCEPT one. Which one is the exception?
a. Trismus
b. Spasms of facial muscles
c. Infection of the external ear canal

816
 d. Dysphagia
17. The type of bacteria associated with rheumatic fever is:
a. Streptococcal species
b. Plasmodium spp.
c. Salmonella spp.
d. None of the above
18. Warts are caused by this virus:
a. Rubella virus
b. Human parvovirus B19
c. Varicella-zoster virus
d. Papillomavirus
19. The cardinal signs of inflammation include heat, pain, redness,
swelling, and loss of function. Pus formation is NOT possible in the
inflammatory process.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
20. The bacterial species primarily responsible for root caries is:
a. Streptococcus mitis
b. Streptococcus sanguis
c. Streptococcus salivarius
d. Actinomyces naeslundii
21. An infection caused by a pathogen that does not normally cause
disease in a healthy individual is indicative of which type of infection?
a. Latent
b. Systemic
c. Local
d. Opportunistic
22. The type of immunity acquired by injection of immune serum is
called:
a. Natural active
b. Artificial active

817
 c. Natural passive
d. Artificial passive
23. Direct uptake of donor DNA by a recipient cell is called:
a. Transformation
b. Mutation
c. Transduction
d. Conjugation
24. Kaposi’s sarcoma is associated with the herpesvirus. B cell
lymphomas are associated with the AIDS virus.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
25. Gingival inflammation without the presence of periodontal pocketing
and bone loss is indicative of:
a. Chronic periodontitis
b. Necrotizing ulcerative periodontitis
c. Gingivitis
d. Aggressive periodontitis
26. Varicella-zoster viruses are responsible for the formation of:
a. Cold sores
b. Warts
c. Chickenpox
d. Measles
27. The causative agent of infectious mononucleosis is:
a. Neisseria gonorrhoeae
b. Epstein-Barr virus
c. Treponema pallidum
d. Rubella virus
28. The primary organism in necrotizing ulcerative gingivitis is:
a. Streptococcus mutans
b. Aggregatibacter actinomycetemcomitans
c. Candida albicans

818
 d. Prevotella intermedia
29. All the following are prerequisites for caries development EXCEPT:
a. Cariogenic bacteria
b. Supply of substrate for acid production
c. Susceptible host
d. Calculus
30. The causative agent of syphilis is:
a. Chlamydia psittaci
b. Treponema pallidum
c. Borrelia burgdorferi
d. Mycobacterium tuberculosis
31. Transmission of hepatitis A occurs through the fecal-oral route.
Transmission of hepatitis B occurs through the parenteral route.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
32. Skin and oral lesions are clinical symptoms of what disease?
a. Trismus
b. Leprosy
c. Lyme
d. Ringworm
33. Escherichia coli is a gram-positive bacillus. Escherichia coli is the
causative agent of urinary tract infections.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
34. Endospores are formed during a process called:
a. Sporulation
b. Germination
c. Binary fission
d. None of the above

819
35. The causative agent of urinary tract infections is:
a. Yersenia pestis
b. Bacillis anthracis
c. Escherichia coli
d. Bordetella pertussis
36. In which phase of bacterial growth is there a decrease in the number
of cells?
a. Lag phase
b. Log phase
c. Stationary phase
d. Phase of decline
37. Necrotizing ulcerative gingivitis is an anaerobic infection.
Predominant microflora present include Prevotella intermedia,
spirochetes, and fusiform bacteria.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
38. The antibacterial agent used to treat tetanus is:
a. Doxycycline
b. Erythromycin
c. Penicillin
d. Metronidazole
39. Coxsackievirus A is responsible for causing:
a. Herpangina
b. Mumps
c. Recurrent apthous ulcers
d. Orthomyxovirus
40. Hand-foot-and-mouth disease is frequently seen in the elderly
population. The causative agent in hand-foot-and-mouth disease is
coxsackievirus A.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.

820
 d. The first statement is FALSE; the second statement is TRUE.
41. Acidophiles prefer a pH of:
a. 0 to 4
b. 5 to 9
c. Greater than 9
d. None of the above
42. Prokaryotes reproduce via binary fission. Binary fission is a form of
asexual reproduction.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
43. A person presents with raised, white, nonremovable plaques on the
buccal mucosa, hard palate, and dorsum of tongue. This condition is
most likely:
a. Herpetic whitlow
b. Recurrent apthous ulcer
c. Hyperplastic candidiasis
d. Ludwig’s angina
44. All the following are functions of the cell wall EXCEPT:
a. Determines and maintains the shape of the microorganism
b. Provides support for flagella
c. Prevents rupture of the cell resulting from differing osmotic
pressures
d. Protein synthesis
45. During the initiation phase of plaque formation, the predominant
bacteria present are:
a. Gram-positive cocci and rods
b. Gram-negative cocci
c. Filamentous organisms
d. None of the above

A 50-year-old woman with a full dentition presents for a continued

dental hygiene care appointment. Her chief complaint is that her lower-

821
right mandibular molar is hurting her. Extraoral examination reveals a
bilateral swelling of her neck and floor of the mouth and a cold sore on
her right lip near the commissure. Intraoral examination reveals a
cavitated lesion on tooth #30 occlusal; a raised, white, nonremovable
plaque on her hard palate; and generalized probing depths of 5 to 6 mm.

46. The bilateral swelling is MOST likely indicative of what disease?

a. Syphilis
b. AIDS
c. Ludwig’s angina
d. Shingles
47. Which of the following infections is the MOST likely cause of the cold
sore?
a. Herpesvirus
b. Candida
c. Influenza
d. Cytomegalovirus
48. The raised, white, nonremovable plaque on the hard palate is MOST
likely:
a. Angular cheilitis
b. Hyperplastic candidiasis
c. Erythematous candidiasis
d. Pseudomembranous candidiasis
49. The bacteria primarily responsible for the lesion on #30 occlusal is:
a. S. mutans
b. A. actinomycetemcomitans
c. C. albicans
d. P. intermedia
50. The cause of the bilateral swelling in the neck and floor of the mouth
is MOST likely a result of:
a. Infected tooth #30
b. Immunocompromised health history
c. Candida infection
d. None of the above

822
*Jessica Peek Scott and the publisher acknowledge the past contributions of Marie
Collins to this chapter.

823
C HAPT E R
10

824
Infection Control and Prevention of
Disease Transmission in Oral
Health Care
Darnyl M. Palmer

Preventing disease transmission in dental hygiene practice requires an

understanding of microbial transfer, infection, and disease in the oral
health care environment. Implementing and practicing the elements of
standard precautions is essential.

825
Disease transmission
See the section on “Microbial Virulence and Disease Transfer ” in Chapter
9.
A. Development of an infectious disease
1. Source of microorganism or pathogen (microorganism capable of
causing infectious disease)
a. Primarily originating from a person’s mouth
b. May originate from a dental team member (this mode less likely
than from a client’s mouth)
c. Microbes may be present in saliva, blood, respiratory secretions,
and other bodily fluids
2. Portal of exit—escape of microorganism from a person
a. Coughing, sneezing, and talking
b. Contaminated dental equipment, instruments, and supplies
used in a client’s mouth
c. Spatter droplets and aerosol particles generated by using power
instrumentation, low-speed and high-speed handpieces, and
air/water syringe
(1) Spatter droplets—large, visible particles that settle quickly,
contaminating the clinician and the surfaces of the
treatment area
(2) Aerosol particles—small, invisible particles that may be
inhaled or remain airborne for an extended period
3. Transfer of microorganisms to another person
a. Direct contact with microorganisms in a client’s mouth that
penetrate through nonintact skin
b. Indirect contact with items contaminated by a client’s
microorganisms, including sharps (all items that can puncture
skin), instruments, surfaces, hands, and equipment
c. Droplet infection from spatter that contacts nonintact skin or
mucous membranes (oral, nasal, ocular)
d. Airborne infection from inhaling aerosols
4. Portal of entry—entry of microorganisms into a person
a. Inhalation—breathing aerosol particles
b. Ingestion—swallowing droplets of saliva or blood spattered into
the mouth
c. Through mucous membranes—droplets of saliva or blood
spattered into the eyes, nose, or mouth
d. Through breaks in the skin—by touching contaminated objects,
spattering of microorganisms onto nonintact skin, or punctures

826
 with contaminated sharps
(1) Percutaneous injury—injury that penetrates the skin
(2) Parenteral—piercing mucous membranes or skin
5. Infection
a. The infectious agent has a portal of entry into a susceptible (not
immune) host
b. Establishment and survival of microorganism in the body
6. Damage to the body—the disease occurs when microorganisms
multiply to a harmful level
7. Pathogenic agents and diseases associated with oral health care
(Table 10-1)

Table 10-1
Pathogenic Agents Important in Oral Health Care

827
 Modified from Miller CH: Infection control and management of hazardous materials for the dental team, ed 5, St
Louis, 2014, Mosby.

B. Infection control
1. Goal—to prevent oral health care–related infections, injuries, and
illnesses among clients and dental health care personnel (DHCP)
2. Reducing the numbers of microorganisms that may be transmitted
from person to person or from persons to the oral health care

828
 environment, and vice versa
3. Infection control protocols seek to reduce or eliminate the likelihood
of disease transmission by eliminating one or more factors required
for disease transfer (Fig. 10-1)

FIG 10-1 Factors related to infection and disease transfer. OHCW, Oral
health care worker.

a. Asepsis—absence of infectious materials; achieved by removing

or killing microorganisms
b. Disinfection—reducing the number of pathogenic organisms in
or on an object, thereby minimizing the potential for disease
transmission
(1) Disinfectants are applied to inanimate objects
(2) Antiseptics are applied to living tissues
c. Engineering controls—devices that reduce the risk of exposure
to potentially infectious materials (e.g., self-sheathing needles
and instrument cassettes)
d. Personal protective equipment—items designed to protect
DHCP from exposure to bloodborne and other pathogens (e.g.,

829
 gloves, masks, safety glasses, face shields, barrier gowns)
e. Standard precautions—treating all blood and bodily fluids
(including secretions and excretions, except sweat), nonintact
skin, and mucous membranes as potentially infectious in all
clients
(1) In the oral health care setting, saliva is an important
source of contamination; although invisible, it is capable of
containing infectious agents that can survive on surfaces for
a long period
f. Transmission-based precautions—additional measures beyond
standard precautions provided during urgent care to clients
with certain diseases having multiple modes of transmission
(e.g., tuberculosis); in this situation, care would be provided in a
facility equipped with a respiratory protection program
including an airborne infection isolation room (AIIR)
g. Sterilization—the destruction or removal of all microorganisms
in or on an object
h. Work practice controls—procedures that reduce the chance of
exposure to potentially infectious materials (e.g., using a one-
handed technique to recap needles; maintaining a 14-inch to 18-
inch working distance to reduce exposure to droplets;
fulcruming one to four teeth away from tooth being treated)
i. DHCP-related controls
(1) Maintaining a healthy lifestyle and immune status
(2) Receiving recommended vaccinations
(3) Obtain a baseline tuberculin skin test
(4) Abiding by the recommended U.S. Public Health Service
(PHS) work restrictions for DHCP in the case of certain
infections and after exposure to some diseases
j. Client-related controls
(1) Prophylactic antibiotic premedication to reduce the
possibility of infection in immunocompromised individuals
and others with various conditions
(2) Preprocedural rinse to decrease the microbial load in
spatter and aerosols and to help protect against autogenous
(self-derived) infection
(3) Avoiding treatment of clients with known communicable
illnesses (e.g., influenza) or contagious lesions (e.g., herpes)
4. Infection control protocols are designed to reduce or prevent the
spread of pathogens from:
a. Client to DHCP

830
 b. DHCP to client
c. Client to client
d. Dental office to community, including families of DHCP
e. Community to client
5. Table 10-2 outlines the mechanisms of the spread and the prevention
of diseases

Table 10-2
Mechanisms of Disease Spread and Prevention

831
Modified from data from US Department of Labor, Occupational Safety and Health Administration: Controlling
occupational exposure to b loodb orne pathogens, Washington, DC, 1996, 2001, OSHA 3127 (revised).
DHCP, Dental health care personnel; OHC, oral health care.

832
Infection control procedures for dental
health care personnel
A. Health history
1. Obtain, review, and update clients’ health histories at all visits
2. Address specific questions related to present health status,
physician care, hospitalizations, surgery, diseases, medications,
allergies, current or chronic illness, review of major organ systems,
and recent overseas travel
3. Be aware that obtaining health histories will not identify all
infectious clients; clients may suppress information purposely or
unknowingly (many persons with hepatitis B virus [HBV], hepatitis
C virus [HCV], and human immunodeficiency virus [HIV] are
asymptomatic)
4. Health history may identify conditions requiring:
a. Diagnostic evaluation and laboratory testing
b. Medical consultations
c. Prophylactic antibiotic premedication to reduce the incidence of
autogenous infections, that is, conditions caused by introducing
the microflora of clients into injured tissues (e.g., bacteremia,
abscess)
5. The U.S. Centers for Disease Control and Prevention (CDC)
recommends conducting a tuberculosis risk assessment for an oral
health care setting and then formulating a prevention program
appropriate for its designated risk category; most dental settings will
be low or very low risk
B. Immunizations are recommended for DHCP
1. Essential component of an infection control program
2. Most effective method to prevent contracting a vaccine-preventable
disease
3. Immunizations are recommended for the following diseases, unless
evidence of past infection and immunity: hepatitis B, varicella,
influenza, measles, mumps, rubella, tetanus, diphtheria, pertussis,
and meningococcal disease; consult with a primary care physician
before vaccination because some vaccines are contraindicated for
immunocompromised and pregnant persons
4. The U.S. Occupational Safety and Health Administration (OSHA)
policies regarding hepatitis B vaccination
a. OSHA requires employers to make hepatitis B vaccine available
at no cost to employees who are or may be exposed by

833
 occupation to bloodborne pathogens and within 10 working
days
b. Employers must provide information about the vaccine and
ensure that all medical records concerning the vaccination are
kept confidential
c. Employees have the right to refuse vaccination but must read
and sign an OSHA declination statement
d. Employers cannot demand that employees be serologically
prescreened before vaccination
5. Hepatitis B vaccine
a. Two single-antigen vaccines available:
(1) Recombivax HB (Merck & Co., Inc.)
(2) Engerix-B (GlaxoSmithKline)
b. Process
(1) Serologic screening for antibodies to hepatitis B surface
antigen (HBsAg) before vaccination is not recommended,
unless infection is suspected
(2) Pregnancy is not a contraindication for vaccination
(3) A series of three injections in the deltoid muscle given at 0,
1, and 6 months
(4) Seroconversion rates are 95% to 97% in healthy younger
adults; lower rates (approximately 70%) in persons over 40
years old, smokers, overweight persons, and those receiving
injections in the buttocks
(5) Genetic factors may influence seroconversion rates
(6) Testing for antibody (anti-HBsAg) is recommended after
vaccination to ensure protection against HBV; testing
should be conducted 1 to 2 months after the final injection
(7) With successful seroconversion, protective antibodies have
been sustained for at least 20 years
(8) Failure to seroconvert requires a second series of three
injections
(9) Continued failure to seroconvert could signal chronic HBV
infection in a person who is unable to produce antibodies;
nonresponders should be evaluated by a medical provider
(10) The CDC currently does not recommend a booster
injection
(11) Minimal side effects of vaccine include injection site
soreness, headache, and fever
(12) Individuals with allergies to yeast or iodine (vaccine
preservatives) must consult a physician before the

834
 vaccination
6. Recommended screenings for DHCP
a. DHCP should know their HBV status
b. Tuberculin skin test (TST), also known as the Mantoux test for
tuberculosis (TB), should be administered annually according to
the CDC risk level of dental setting
(1) In the majority of cases, a positive test indicates previous
infection with Mycobacterium tuberculosis but not active
disease; in some persons, 6 months of preventive
chemotherapy is advised
(2) Only 10% of individuals infected will eventually develop
disease
(3) Drug-resistant TB does not respond to medication, which
ultimately leads to death
C. Hand hygiene
1. Extremely important disease prevention practice
2. Hands are a primary source of microorganisms capable of disease
transmission
3. Rationale
a. Handwashing reduces both resident and transient flora on skin
(1) Resident flora are permanent residents that colonize several
skin layers and cannot be completely removed; this type is
less important and less likely to transmit disease than
transient flora
(2) Transient flora contaminate hands when hands touch
contaminated surfaces; this type colonizes the outer layers
of skin, only survive for a limited time, and can be easily
removed by routine handwashing
b. Protects clients and DHCP by reducing the spread of
microorganisms and subsequent infections by the hands
c. Unwashed, contaminated hands can transfer microbes to sterile
instruments, dental equipment, and environmental surfaces
4. Use of gloves is not a substitute for routine handwashing
5. Hands must be washed before gloves are put on to minimize
organisms that can multiply rapidly when enclosed in a moist, warm
environment; bacteria and yeast growth can cause skin irritation
6. Hands must be washed after removal of gloves because defects,
tears, and punctures may occur in gloves, permitting
microorganisms to be transferred to hands; this also helps remove
glove powder, which contains latex protein and other glove
chemicals that can elicit irritant contact dermatitis or an allergic

835
 reaction in sensitized individuals
7. Watches, bracelets, and rings must be removed to prevent harboring
of microorganisms; also, rings may perforate glove materials
8. Nails must be kept short and clean and the cuticles well maintained;
artificial nails and nail jewelry should not be worn, since current
research has implicated them in disease transmission in hospitals
9. Intact skin is the best protection against infection; this can be
achieved by:
a. Minimizing trauma to hands (e.g., cuts, scrapes) while outside
the dental setting
b. Protecting hands from drying and chapping during cold
weather
c. Frequent use of lubricating hand lotions
(1) When at work, use hand lotion containing petroleum or oil
emollients at the end of the day, because these ingredients
can negatively affect the integrity of latex gloves
10. DHCP who have open or weeping lesions or dermatitis on hands
should not provide client care until the condition resolves, since
dermatitis reduces the effectiveness of handwashing, and nonintact
skin provides a portal of entry for microorganisms
11. Hand hygiene procedures for routine dental hygiene care include:
a. Vigorous lathering of hands using an interlacing finger motion
with either antimicrobial or plain soap for 15 seconds
(1) Plain soap will remove soil and transient microorganisms
(2) Antimicrobial soap will remove or destroy transient
microorganisms and reduce resident flora
(3) Disposable soap containers should not be refilled, and
when empty should be discarded and replaced
(4) Soap dishes accumulate microorganisms and are not
recommended
(5) Sinks and soap dispensers should be electronically
operated or have foot controls; if not, paper towels should
be used to turn off sink faucet
b. Rinsing with cool to lukewarm water while rubbing hands
together for 10 seconds
c. Drying hands with single-use paper towels
d. Using alcohol-based hand sanitizers as an alternative to
handwashing
(1) Used when no visible soil appears on the hands
(2) Have been shown to be effective, sometimes reducing
bacterial counts more effectively than soap and water

836
 (3) Most effective at inactivating microorganisms at 60% to
95% alcohol concentrations
(4) May increase the frequency of hand hygiene because of
ease of use
(5) According to manufacturer ’s directions, place an adequate
amount of alcohol-based hand sanitizer in hand and then
vigorously rub hands until dry
(6) Alcohol-based hand sanitizers may cause dry skin (choose
ones that contain emollients)
e. Washing hands between clients, before and after lunch, before
and after restroom visits, or any time hands become
contaminated
f. Maintaining asepsis by touching only sterile instruments or
disinfected surfaces
12. For surgical procedures, use an antimicrobial soap with persistent
or residual activity (inhibits growth and survival of microorganisms);
chlorhexidine digluconate or triclosan
D. Personal protective equipment (PPE)
1. Protective barriers used to reduce exposure of mucous membranes,
hands, and body of DHCP to microorganisms and also to prevent
injury from chemicals and particles of debris
2. Used during client care, laboratory, disinfection, and sterilization
procedures
3. PPE includes gloves, masks, protective eyewear, and protective
clothing
4. Sequence for donning PPE: protective clothing, then mask and
eyewear, and finally, after handwashing, gloves
5. The employer is responsible for providing and maintaining
appropriate PPE for employees
6. Gloves
a. The use of gloves provides a high level of protection for both
DHCP and clients
(1) Prevents direct contact with microorganisms in the client’s
mouth and on contaminated surfaces (bare hands often will
have areas of nonintact skin providing portals of entry for
pathogenic microorganisms)
(2) Prevents saliva and blood from being retained under
fingernails; saliva and blood have been shown to persist for
several days even with handwashing
(3) Protects against contact with disinfecting and cleaning
chemicals and x-ray solutions

837
 (4) Protects clients from the microorganisms on the hands of
DHCP
(5) Examination gloves provide minimal protection against
sharps injuries; utility gloves provide more protection;
however, injuries still can occur
b. Risks associated with not routinely wearing gloves
(1) DHCP exposure to potentially infectious client tissues and
contaminated surfaces—most likely route by which DHCP
have acquired HBV from clients
(2) Client exposure to infectious agents originating from the
DHCP
(a) Documented source of transmission of HBV from
ungloved dentist to clients
(b) Documented case in which an ungloved hygienist
transmitted herpes to 20 of her clients
(3) Skin irritation from contact with disinfecting chemicals
(4) Burns resulting from contact with hot items from sterilizer
c. Protocol for glove use
(1) Wear during intraoral procedures and when in contact
with contaminated items or surfaces (e.g., contaminated
laundry or waste)
(2) If it is necessary to leave the chairside during client care,
remove gloves, and after hand hygiene, don a new pair on
returning (prevents contamination of additional surfaces
one may touch and also prevents contamination of the
client with microorganisms that already may be present on
those surfaces)
(3) Ensure that gloves cover the cuff of a long-sleeved gown
(4) Change gloves between clients and during long
appointments because defects in gloves increase with use
beyond 60 minutes
(5) Do not wash or disinfect gloves; may cause “wicking” or
enhanced penetration of liquids through undetected defects
in gloves
(6) Remove torn or punctured gloves as soon as possible; wash
hands and don new gloves
(7) If using latex gloves, do not use petroleum or oil-based
hand lotion or apply petroleum-based lubricants to client’s
lips
d. Types of gloves—Table 10-3 outlines glove materials

838
Table 10-3
Types of Gloves Used in Oral Health Care

Type Material
Nonsterile (examination) gloves Latex
Nitrile
Neoprene
Vinyl
Polyurethane
Styrene-based co-polymer
Butadiene methyl methacrylate
Sterile (surgical) gloves Latex
Nitrile
Neoprene
Polyurethane
Styrene-based co-polymer
Synthetic polyisoprene
Utility gloves Latex
Nitrile
Neoprene
Butyl rubber
Fluoroelastomer
Polyethylene and ethylene vinyl
Alcohol co-polymer
Overgloves Thin co-polymer
Thin plastic (“food handlers”)

(1) Nonsterile, ambidextrous gloves in sizes extra-small,

small, medium, and large are adequate for most
procedures; proper glove fit is important to ensure efficient
instrumentation and to prevent hand fatigue and possibly
carpal tunnel syndrome
(2) Sterile gloves are recommended for surgical procedures
(3) Use puncture-resistant and chemical-resistant utility
gloves to prepare chemicals, handle contaminated
instruments, and clean and disinfect surfaces
(a) Utility gloves are reusable and can be disinfected or
sterilized in an autoclave
(b) Replace utility gloves when they show any signs of
wear (e.g., cracks, punctures, discoloration)
(4) Overgloves are worn over treatment gloves to prevent
cross-contamination of items and surfaces such as pens,
charts, and drawers
(5) Heat-resistant gloves are worn when handling hot items
(e.g., unloading sterilizers)

839
e. Dermatitis and latex allergy
(1) Irritant contact dermatitis
(a) Nonimmunologic (nonallergic) reaction of skin to
chemicals used in glove manufacturing
(b) Skin on hands becomes dry, red, itchy, and cracked
(c) The condition is aggravated by soaps, not rinsing or
drying hands completely, perspiration, or cornstarch
powder
(d) Most skin reactions from wearing gloves are caused
by irritant contact dermatitis and are not true allergic
reactions
(2) Allergic contact dermatitis
(a) Type IV, or delayed, hypersensitivity occurring within
hours or days because of allergy to glove chemicals
(b) Limited to area of contact, causing itching, redness,
and vesicles to appear within 24 to 48 hours, followed
by dry skin, fissures, and sores
(c) Patch test identifies sensitivity to specific chemical
(3) Latex allergy
(a) Type I, or immediate, hypersensitivity within minutes
or hours
(b) Allergy to naturally occurring latex proteins
(c) Symptoms: skin (hives, swelling, burning, tightness,
itching, redness, tingling), lungs (asthma, wheezing,
constriction, coughing, sneezing, rhinitis, angioedema),
and other (nausea, vomiting, diarrhea, cramps,
hypertension, tachycardia, shock)
(d) Anaphylactic shock and death can occur with
subsequent exposures to latex
(e) High-risk individuals for latex allergy include: persons
who have had multiple surgeries and persons with
spina bifida, urogenital anomalies, spinal cord injuries,
and allergies to bananas, kiwis, chestnuts, or avocados
(f) Reductions in exposure to latex proteins are known to
decrease sensitivity (important for DHCP to reduce
their daily exposure to airborne latex proteins by
wearing powder-free, reduced-protein latex or latex-free
gloves)
(g) The CDC indicates that DHCP need to be educated
about skin problems that can occur with frequent hand
hygiene and the use of gloves

840
 (h) Latex-free environment should be provided to clients
and DHCP with a latex allergy
(4) Procedures for management of persons with latex allergy
(a) Include questions in health history appropriate for
identifying possible latex allergy
(b) Document latex allergy in health history record in a
way that will ensure observation by DHCP
(c) Schedule allergic clients for the first appointment of
the day, when airborne latex proteins are at their lowest
levels (still risky)
(d) Ensure that DHCP uses latex-free gloves for treatment
area preparation and for touching all items that will
come in contact with the client
(e) Use latex-free gloves and dental materials during
client care
7. Masks
a. Purpose
(1) Worn to protect the mucous membranes of the nose and
mouth from spatter of oral fluids
(2) Provide a lesser degree of protection from inhalation of
aerosol particles
(a) Surgical masks will not provide protection from
airborne infections (e.g., SARS)
(b) The N-95 respirator is needed to protect against
airborne infections
(3) May provide some protection to client from nasal or oral
secretions of DHCP
b. Composed of synthetic material that should filter at least 95% of
small particles
c. Types of masks
(1) Dome mask with elastic band
(2) Tie-on or ear-loop mask
d. Should have a seal against the face to minimize leakage around
the margins
e. Maximizing effectiveness and minimizing cross-contamination
(1) Use a new mask for each client
(2) Change the mask if it becomes moist; moistness
compromises its effectiveness by increasing the passage of
unfiltered air around the edges of the mask and may wick
contaminants through the mask
(3) Don a new mask every 20 to 30 minutes to maintain high

841
 filterability
(4) Adjust the mask so that it fits snugly against the face,
covering nose and mouth
(5) Avoid touching the mask during the appointment
(6) Keep the mask on after completing the procedure to
reduce inhalation of aerosols
(7) When removing the mask, handle it by its strings or elastic
(8) Do not leave the mask on the head, dangling around neck,
or in your pocket
8. Protective eyewear
a. Purpose—protect the eye from microbial invasion, chemicals,
physical projectiles, ultraviolet (UV) light, and lasers
b. Risks for unprotected eyes
(1) Conjunctivitis
(2) Ocular herpes (can cause blindness)
(3) Hepatitis B (eye as portal of entry)
(4) Eye injury (physical or chemical)
c. Types of eyewear
(1) Regular glasses offer limited side or top protection and are
not recommended
(2) Safety glasses, goggles, or loupes
(a) Cover entire eye orbit (providing protection on all
sides)
(b) Some may be worn over prescription glasses
(c) Are more shatter resistant than regular glasses
(d) Provide minimal visual distortion
(e) Are able to withstand disinfection (should be cleaned
and disinfected between clients)
(f) Should meet American National Standards Institute
(ANSI) guidelines for spatter and impact protection
(3) Face shields
(a) An alternative to safety glasses
(b) Should be chin-length and provide top and side
protection
(c) Masks should still be worn to reduce inhalation of
aerosols
(d) Provide maximum coverage of face for high-spatter
procedures (e.g., air polishing, power scaling)
(e) Face shields made of thin plastic may have limited
impact resistance
(4) Protective eyewear should be provided to clients

842
 (a) Protection against damage from UV (curing) light and
lasers
(b) Protection against physical and chemical injury to the
client’s eyes during treatment
9. Protective (barrier) clothing
a. Purpose
(1) Protects nonintact skin from contamination by
microorganisms
(2) Reduces the risk of bringing contaminants on unprotected
clothing beyond dental setting
(3) May protect client from microorganisms on street clothing
or may provide protection against disease transmission
when soiled protective clothing is changed between clients
(fomites—clothing and paper that can absorb and transmit
infectious agents)
(4) Microorganisms adhere to clothing; however, lack of
evidence exists to support the extent to which barrier
clothing protects against disease transmission
b. Characteristics of protective clothing
(1) Reusable or disposable
(2) Gowns, aprons, laboratory coats, or uniforms used as a
covering for street clothing or scrub uniforms
(3) High collar that fits closely around the neck
(4) Long-sleeved garments with fitted cuffs allow gloves to
extend over them for complete coverage
c. To maximize effectiveness and minimize cross-contamination
(1) Use fabric made of synthetic material, which is more fluid
resistant
(2) Do not wear protective clothing outside treatment area
(remove before going out [e.g., to lunch] or leaving the
dental setting)
(3) Change protective clothing daily or when visibly soiled
(4) Avoid touching clothing during client care and throughout
the day
(5) Roll protective clothing inside out to minimize contact
with exposed surface
10. Additional barrier protection used when cleaning or performing
surgery
a. Plastic aprons or other fluid-proof garments
b. Head covers
c. Shoe covers

843
11. Laundering of reusable clothing
a. Laundered in the office following the manufacturer ’s
instructions
b. Sent to a laundry service in a leak-proof bag labeled with the
biohazard symbol
c. It is against OSHA regulations for DHCP to take contaminated
protective clothing home for laundering

844
Oral health care environment and
promotion of infection control
A. Design and equipment selection emphasizes:
1. Smooth construction—eliminates knobs, hooks, and crevices
2. Design of client chairs and operator stools that:
a. Minimize buttons and seams
b. Use vinyl upholstery instead of cloth
c. Provide foot-control operation
3. Avoidance of fabric-covered, coiled, or mechanically retracted
tubings
4. Sink faucets and soap dispensers with foot or electronic controls
5. Paper towel dispenser designed to avoid touching hardware or
electronically controlled
6. Plastic-lined waste containers recessed under cabinet, with opening
on countertop
7. Surfaces that are compatible with disinfectants and detergents
8. Plastic laminate instead of wood for cabinets and countertops
9. Vinyl flooring and walls that are smooth and seamless
10. Carpeting or wallpaper not recommended
11. Dental unit water lines (DUWLs) that provide:
a. Antiretraction valves to prevent the aspiration of
microorganisms into water lines
b. Equipment, devices, and treatments for DUWLs
(1) Filtration unit
(2) Sterile-water delivery system
(3) Flushing the lines with antimicrobial agents
(4) Independent water reservoirs
12. Reduction of airborne microbes
a. Air circulation exchange system or single-room filtration units
b. Ventilation systems to control noxious sterilization and
laboratory vapors
c. Prevention of recirculation of contaminated air or transport of
microbes
d. Cooling and heating system filters that prevent transfer of
microbes
13. Housekeeping surfaces are surfaces that are not contaminated by
hands or equipment (e.g., walls, floors) and should be cleaned and
disinfected routinely or when visibly soiled with detergents or low-
level hospital disinfectants

845
 a. Clean mops and cloths after use and allow to dry before reuse,
or use single-use items
b. Clean walls, blinds, and window treatments in client care areas
c. Perform cleaning with a wet cloth or mop to prevent distribution
of microorganism-laden dust particles
14. Keep treatment area free of unnecessary or seldom-used equipment
and items

Maintaining Asepsis in the Oral Health Care

Environment
A. Items associated with oral health care are classified as:
1. Critical—instruments that penetrate oral soft tissue or bone, enter
the bloodstream, or enter other sterile tissues of the mouth (e.g.,
curette); must be heat-sterilized or a single-use (disposable) device
(SUD)
2. Semi-critical—items that come in contact with mucous membranes
(used in the mouth) but will not penetrate soft tissue, contact bone,
enter the bloodstream, or enter other sterile tissues of the mouth
(e.g., radiographic positioning devices)
a. Preferably heat-sterilized or an SUD (disposable)
b. If heat sensitive, decontaminate using a chemical sterilant or
cover the device with a Food and Drug Administration (FDA)–
approved barrier to prevent contamination (e.g., digital
radiography sensors)
3. Noncritical—items that contact intact skin (e.g., blood pressure cuff)
a. If contamination is possible, cover the device to prevent
contamination
b. If the device is contaminated, clean and disinfect
(1) If contaminated by blood, use intermediate-level
disinfectant
(2) If not contaminated by blood, use low-level disinfectant
B. Maintaining asepsis with the use of chemicals and surface covers
1. Categories of disinfecting or sterilizing chemicals (Table 10-4)

846
Table 10-4
Categories of Disinfecting or Sterilizing Chemicals

Modified from Centers for Disease Control and Prevention: Guidelines for infection control in dental health-care
settings, MMWR 52(RR-17):1-66, 2003.
* Some, but not all, of these products can serve as high-level disinfectants and sterilants, depending on the
immersion time used.
† A hospital disinfectant is one that has been shown to kill Staphylococcus aureus, Pseudomonas aeruginosa,
and Salmonella choleraesuis.
‡ The Centers for Disease Control and Prevention (CDC) indicates that low-level disinfectants can be used on
clinical contact surfaces if the product has a label claim of killing human immunodeficiency virus (HIV) and
hepatitis B virus (HBV) in addition to being an EPA-registered hospital disinfectant.

a. Sterilant—destroys all microorganisms, including high numbers

of bacterial spores
b. High-level disinfectant—destroys all microorganisms but may
not destroy bacterial spores (depending on contact time, can be
either a disinfectant or sterilant)
c. Intermediate-level disinfectant—destroys vegetative bacteria,
most fungi, and most viruses; inactivates Mycobacterium
tuberculosis var. bovis
d. Low-level disinfectant—destroys vegetative bacteria, some fungi
and viruses; does not inactivate M. tuberculosis var. bovis (Fig. 10-
2)

847
 FIG 10-2 Decreasing order of resistance of microorganisms to
germicidal chemicals. (Modified from Centers for Disease Control and
Prevention: Guidelines for infection control in dental health-care settings,
MMWR 52(RR-17):1-68, 2003.)

C. Surface disinfection of clinical contact surfaces

1. Any surface that is touched by contaminated hands, instruments,
devices, or other items during the provision of oral health care (e.g.,
light handles, dental equipment)
2. Identify and list surfaces that will be contaminated during treatment
3. Post the list in the treatment area to increase effectiveness and
efficiency of decontamination procedures
4. Approaches to clinical contact surface asepsis
a. Avoid unnecessarily contaminating surfaces during treatment
by:
(1) Using unit doses of materials to avoid contamination of
multiple-use containers
(2) Using prearranged tray setups and cassettes containing a
complete selection of instruments needed for a particular
procedure
(3) Gathering the needed supplies and equipment at the
beginning of treatment to eliminate the need to open
drawers and cabinets or to leave the treatment area to
retrieve supplies during client care
(4) Having sterile pliers, overgloves, gauze, and paper towels
available for use as barriers between contaminated gloved
hands and uncontaminated objects (e.g., drawer handle,
dental record)
b. Prevent contamination by using a surface cover or barrier
protection

848
 (1) Surface covers protect surfaces that are difficult to
preclean adequately
(2) May be less time-consuming than precleaning or
disinfecting surfaces before and after client care
(3) Surface covers include clear plastic wrap, bags, and tubing
(4) May be placed using bare hands on cleaned and
disinfected surfaces
(5) Should be placed to protect the entire surface and to
ensure that the barrier protection will not come off when
the surface is touched
(6) Reduce the use of chemicals that may stain or corrode and
are hazardous to DHCP and the environment
c. Disinfection of surfaces not covered by barriers
(1) Requires purchase and proper use of disinfecting
chemicals
(2) Chemical use requires that Safety Data Sheets (SDSs) be
filed on site and that DHCP be provided information and
training on the hazards and proper use of chemicals
(3) Disinfection is best reserved for surfaces that are difficult
to cover, smooth surfaces, and those not involving
electricity
d. A dual approach consisting of both barrier protection and
disinfection with chemicals is most often used in oral health
care settings
5. Clinical contact surfaces to be covered or disinfected
a. Mobile cart, master control unit, countertop, and radiographic
equipment
b. Air/water syringe, high-volume and low-volume evacuators
(parts of these may be sterilized or disposable, which is
preferred because these items come in contact with mucous
membranes)
c. Hoses, tubing, and controls attached to handpieces
d. Supports for handpieces, air/water syringe, and suction devices
e. Chairs, including switches and levers
f. Control switches
g. Light handles
h. Faucet handles and soap dispenser (if manually operated)
i. Instrument tray (if it cannot be sterilized)
j. Stethoscope earpieces
k. Floss dispenser, hand mirror, pens, pencils
l. Chairside computers and keyboards

849
 m. Phones, intercoms
6. Factors influencing effectiveness of surface disinfection with
chemicals
a. Numbers and types of organisms present; some organisms have
a higher resistance to destruction by chemicals (e.g.,
Mycobacterium species)
b. Amount of bioburden (blood, saliva, and microorganisms)
(1) Organic materials in blood and saliva insulate
microorganisms from chemicals
(2) May partially inhibit the active ingredient in the
disinfectant
c. Selection of an Environmental Protection Agency (EPA)–
registered disinfectant that is tuberculocidal (sterilant or high-
level disinfectant should not be used for clinical contact
surfaces)
d. Use of a water-based disinfectant is reported to clean organic
material better than alcohol-based disinfectants
e. Performing procedures carefully and following manufacturer ’s
instructions by using appropriate disinfectant concentration,
use life, and contact time
(1) Do not store gauze squares or other materials moistened
in disinfectant; instead, wet material before use
(2) If using container of disinfectant towelettes, keep lid
closed to prevent drying
f. Clean surfaces with a combination of a detergent and a
disinfectant to maximize the removal of bioburden before the
disinfection step
(1) The detergent or disinfectant used for the cleaning step
must contain a surfactant
(a) Surfactant—an agent that loosens, emulsifies, and
holds soil in suspension, allowing for easier removal of
debris and for more thorough cleaning
(2) An advantage to using a combination agent is that a
chemical disinfectant starts the killing process during the
cleaning step and reduces the opportunity for contaminants
to spread to other surfaces
7. Cleaning or disinfection technique for clinical contact surfaces
a. Exercise care when using disinfectants, and wear PPE, including
utility gloves
(1) To prevent irritation or injury to eyes, mucous membranes,
and skin

850
 (2) To avoid breathing in noxious vapors
b. Step 1—clean; spray the detergent or disinfectant, or apply with
a premoistened cloth
c. Step 2—wipe; vigorously wipe surfaces with a paper towel to
remove stuck-on debris
d. Step 3—reapply the disinfectant
(1) Leave surfaces undisturbed for a specified contact time,
usually 10 minutes
(2) Wipe any remaining wet areas with a paper towel
8. Chemical disinfectants for surface disinfection (Table 10-5)—
selection criteria

Table 10-5
Chemical Agents for Surface Disinfection

Chemical
Advantages Disadvantages
Classification
Chlorines Rapid acting Prepare solution daily
Broad spectrum Diminished activity by organic matter
Economical Corrosive
Strong odor
Iodophors Broad spectrum Unstable at high temperatures
Few reactions Dilution and contact time critical
Residual biocidal Prepare solution daily
activity Discoloration of some surfaces
Inactivated by hard water
Synthetic phenolics Broad spectrum Degrades certain types of plastic over time
Residual biocidal Difficult to rinse
activity Film accumulation
Compatible with Alcohol-based products are only fair to poor
most metals in cleaning ability
Dual or synergized Broad spectrum Easily inactivated by anionic detergents and
quaternaries Contains detergent organic matter
for cleaning Damaging to some materials

a. EPA-registered intermediate-level disinfectant that is

tuberculocidal (kills M. tuberculosis var. bovis)
b. Effective within 10 minutes or less
c. Does not have an offensive odor
d. Reasonable cost
e. Provides persistent or residual effect on treated surfaces
f. Retains stability and effectiveness in the presence of bioburden,
preferably water-based
g. Good penetrating and cleaning ability

851
 h. Compatible with and innocuous to equipment and clinical
surfaces (consult product manufacturer for recommendations)
i. The CDC does not recommend alcohol, household bleach, or
early-generation quaternary ammonium compounds as surface
disinfectants
D. Dental unit water line asepsis
1. High concentrations of bacteria have been found in untreated
DUWLs (e.g., power instrumentation, air-polishing units, high-speed
handpieces, air/water syringes)
a. Municipal water entering the dental unit is not sterile and
contains 0 to 500 colony-forming units per milliliter (CFU/mL) of
heterotrophic bacteria
b. Water exiting untreated DUWLs may contain more than
100,000 CFU/mL
(1) Consists of waterborne bacteria of low pathogenicity or
opportunistic pathogens, which pose the greatest risk to
immunocompromised individuals
(2) Organisms of greatest concern are Pseudomonas, Legionella,
and Mycobacterium species
2. Microorganisms attach to and accumulate on the inside of the water
line tubing, creating biofilm colonies (an organized, protected, and
highly resistant colony of live microorganisms attached to a surface)
(see the section on “Bacterial Dental Biofilm” in Chapter 14);
formation of biofilm:
a. Biofilm includes naturally occurring waterborne bacteria and
may include microorganisms from the oral cavities of clients
treated before the current client
b. Stagnation of water and small-diameter tubing in DUWLs
encourages biofilm formation
c. Incoming water brings a continuous source of nutrients to
bacteria
d. As water flows past the biofilm in the water line, it picks up
detached bacteria before exiting through dental equipment
3. Dental unit water and infection control
a. No epidemiologic evidence of a widespread public health
problem caused by dental unit water
(1) In 2011, one confirmed case of an 82-year-old woman in
Italy who died after contracting legionnaires disease from
aspirating Legionella-contaminated dental unit water at her
dental office
b. Using water that does not meet the standards for drinking water

852
 increases client and DHCP exposure to microorganisms
(immunocompromised individuals most at risk)
c. Oral health care facilities should use water that meets the
American Dental Association (ADA) recommendation of no
more than 200 CFU/mL of aerobic mesophilic heterotrophic
bacteria for routine dental care
d. Dental unit water from a municipal supply should not be used
for oral surgery or in the treatment of immunocompromised
persons (sterile water delivery systems must be used)
e. Boil water notices in the community
(1) Do not use dental unit or faucet water until the notice is
lifted
(2) After the notice is lifted, flush all water lines for 1 to 5
minutes, and disinfect them following manufacturer ’s
recommendations
4. Improving the quality of dental unit water
a. Routinely check antiretraction valves (valves can become stuck
in the open position with age)
b. Flush water lines for 3 to 5 minutes at the beginning of each
day; flush for 30 seconds between clients
(1) Flushing does not remove biofilm but may temporarily
reduce planktonic (free-floating) microbes
(2) Flushing may help remove client materials that have
entered the turbine, air, and water lines
c. Use an independent water reservoir—a bottle that supplies
nonmunicipal water to dental unit
d. Chemical treatment of DUWLs is still necessary to control
biofilm formation, even when an independent water reservoir is
used

Maintaining the Treatment Area During Client Care

A. Spatter and aerosol management to reduce the number of
microorganisms escaping from the source
1. Use a preprocedural, antimicrobial rinse containing chlorhexidine,
essential oils, or iodophor to reduce microbial counts in spatter and
aerosols
2. Use air and water separately instead of a combination spray
3. Use high-volume evacuation, whenever possible
a. When using the saliva ejector, do not allow the client to close the
lips around the tip, creating a seal

853
 b. Research has shown that in one in five cases, previously
suctioned fluids might enter a client’s mouth by way of a reverse
flow in the vacuum line
4. Use of a rubber dam will not only reduce spatter and aerosols but
also will lessen the chance of a client’s saliva retracting into the
dental handpiece and the air/water syringe
B. Reducing the risk of contamination and disease transmission
1. Limit the areas of contamination; use overgloves when touching
clinical contact surfaces
2. Disinfect anything not covered with barriers when touched by
contaminated hands
3. Avoid accessing drawers, cabinets, and other storage areas with
contaminated gloves; ask for assistance if additional supplies are
needed
4. Protect dental records from contamination
a. Ask for the help of a hygiene assistant or other personnel to
record
b. Use overgloves
c. Record data on audio, and make manual entries in client record
after glove removal
d. Generate client record with voice-activated computer software
5. Eating, drinking, smoking, applying of cosmetics or lip balm, and
handling of contact lenses are prohibited in client care areas
6. Food and drink cannot be stored in refrigerators, freezers, or
cabinets or on shelves and countertops where blood or saliva is
present
C. Waste disposal during treatment
1. Immediately discard blood-soaked items in a small biohazard bag
taped to the mobile cart or the cabinet
2. Do not allow contaminated waste to accumulate on trays
D. Precautions and care in handling syringes or sharp instruments
1. Needlestick injuries are a major cause of disease transmission to
health care personnel
a. Never permit “sharps” to be directed toward the body
b. Do not allow uncovered needles to remain on tray
c. Never recap a needle using a two-handed technique
(1) Using one hand, the cap is scooped up from the tray
(2) Use the sheath holder
(3) Use self-sheathing disposable needles
d. Never bend, break, or otherwise manipulate a needle
e. DHCP giving an injection should appropriately recap the needle

854
 to eliminate the danger of passing an uncovered needle to
another worker for recapping
f. Sharps containers should be located in each treatment area
2. Instrument sharpening
a. Sharpening contaminated instruments poses risk of disease
transmission
(1) Avoid sharpening during a procedure
(2) Instead, include duplicates of most-used instruments in
the cassette for difficult cases
b. The ideal method involves sharpening sterile instruments and
then sterilizing again before use
3. Avoid injury with contaminated instruments during client care (i.e.,
curettes and scalers)
a. Avoid fulcruming on the same tooth being treated
b. Never wipe instruments on gauze held in your hand or wrapped
around your finger
c. Instruments should be organized and lying flat (instruments
should not be on top of each other, sticking up, or balancing
crosswise on the edges of cassettes)
d. Never grab instruments by the working end
e. Avoid holding more than one instrument in each hand
f. Do not adjust dental light while holding an instrument
E. Exposure incident protocol (Box 10-1)

Box 10-1
Rec ommendations for Contents of the
Oc c upational Exposure Report
Date and time of exposure
Details of the procedure being performed, including when and how the
exposure occurred
If related to a sharps device, the type and brand of device and how and
when in the course of handling the device the exposure occurred
Details of the exposure, including the type and amount of fluid or
material and the severity of exposure; for example:
For a percutaneous exposure, depth of injury and whether fluid was
injected
For a skin or mucous membrane exposure, the estimated volume of
material and the condition of the skin (e.g., chapped, abraded,
intact)

855
Details about the exposure source; for example:
Whether the source material contained hepatitis B virus (HBV),
hepatitis C virus (HCV), or human immunodeficiency virus (HIV)
If the source is HIV infected, the stage of disease, history of
antiretroviral theapy, viral load, and anitiretroviral resistance
information, if known
Details about the exposed person (e.g., hepatitis B vaccination and
vaccine response status)
Details about counseling, postexposure management, and follow-up

1. Includes all needlesticks, puncture wounds, cuts, and scrapes with

contaminated instruments and all nonintact skin and mucous membrane
exposure to blood and saliva
a. In DHCP, 90% of exposures result from sharps penetrating the hands
and fingers
2. Immediately wash the injured area with antimicrobial soap and water
or flush with water for a mucous membrane exposure (eye)
3. Inform the employer about the incident
4. If the source individual can be identified, request his or her consent for
blood testing for HBV, HCV, and HIV as soon as possible (if the source
individual’s disease status is not already known)
5. Results of the source individual’s tests are confidential and are
revealed only to the exposed employee, not to the employer
6. The employer is responsible for providing to the exposed employee
laboratory testing for HBV, HCV, and HIV (30-minute rapid test
available), medical evaluation, and counseling by a preselected, qualified,
licensed health care provider (HCP)
7. HCP should be familiar with most current PHS recommendations for
testing and postexposure prophylaxis (PEP)
8. Within 2 hours of exposure, the employee should seek medical care
allowing PEP, if indicated, which offers the greatest chance of success in
preventing disease transmission (seroconversion)
a. Seroconversion depends on dose of blood transferred, titer of virus
(viral load), resistant viral strain, depth of injury, and host factors
b. PEP may reduce the risk of infection by 80%
9. If the employee declines testing, a blood sample from the employee
may be preserved for 90 days in case the employee later consents to
testing
10. The HCP informs the employee about both his or her own test results
and the source client’s test results and of any conditions that require
further evaluation and treatment

856
11. The employer receives a written report from the HCP confirming that
the employee was tested, informed of results, and counseled if further
evaluation or treatment was needed
a. Report notes if hepatitis B vaccine was administered
b. Report does not include test results, diagnoses, or treatment because
this information is confidential and protected employee health
information
F. Prevention of disease transmission during radiographic procedures
(see the section on “Infection Control” in Chapter 6)
1. Although radiographic procedures are generally noninvasive, the
potential for disease transmission does exist
2. The use of barriers on equipment will prevent contamination and
promote efficiency
a. Plastic bag to cover position-indicating device (PID), tubehead,
and swivel arms
b. Plastic cover for exposure control switch
c. Cover for headrest and chair controls
d. FDA-approved plastic barrier for digital sensor
e. Plastic barrier underneath exposed films and on countertop
3. If contamination occurs, disinfect
a. Use EPA-registered intermediate-level disinfectant
b. Disinfect all touched surfaces that are unprotected by barriers
c. Do not directly spray disinfectant on the control panel because
it has electrical components
d. Follow manufacturer ’s directions for digital sensors (most
cannot be disinfected)
4. Radiographic film holders—use reusable film holders that can be
heat-sterilized, or use disposable items (SUDs)
5. Radiographic film options
a. Digital radiographs (no film processing necessary for some
methods)
b. Film in plastic covering or pouch (best option when using film)
c. Film without plastic covering (during processing, special
handling is necessary when removing the film from the packet
to avoid contaminating the film)
6. Aseptic procedure for imaging and processing dental radiographs in
plastic pouches
a. Drape the client with lead apron and thyroid shield, and
position the client’s bib to act as a barrier; if shields become
contaminated, disinfect with an intermediate-level disinfectant
b. Wear PPE

857
 c. After exposing the film, drop it into a disposable cup
d. Remove the plastic pouches, and drop the film packet into a
new cup without contaminating the film packet or the outside of
the cup
e. Remove gloves, and wash hands before transporting the film to
the processing area
f. With ungloved hands, unwrap the film and put it into the
automatic processor
7. Aseptic procedure for processing dental radiographs without plastic
covering
a. After exposure, contaminated film should be placed in a plastic
cup without contaminating the outside of the cup
b. Don a new pair of gloves before transporting the film to the
darkroom
c. Open the film packet, and drop the film on a paper towel
(proceed carefully to avoid contaminating the film)
d. Remove gloves, wash hands, and with bare hands, feed the film
into the automatic processor
G. Infection control for the dental laboratory
1. Prevention of disease transmission between the treatment area and
the dental laboratory
2. OSHA regulations include measures for the protection of dental
laboratory personnel from bloodborne pathogens
3. Impression materials, prostheses, and appliances are exposed to oral
microflora
4. Protective attire and barrier techniques
a. When performing laboratory procedures, PPE should be worn;
use caution with lathes because gloves can become caught and
cause injury
b. Masks and eyewear protect against chemicals, aerosols, spatter,
and projectiles
5. Preparation of materials and transport to laboratory
a. Clean and disinfect impressions, prostheses, and casts before
transport
b. Always disinfect prostheses before sending them to another
location or returning to the client
c. Use new packing material every time the prosthesis is
transported between the laboratory and the oral health care
facility to prevent contamination of shipping materials
d. Communicate the infection control protocol to the laboratory
and DHCP

858
 6. Minimizing contamination of common areas in laboratory
a. Use paper covers on countertops
b. Place plastic barriers on frequently touched areas
c. Procedures for using the lathe
(1) Use fresh pumice each time
(2) Use disposable trays
(3) Use sterile or disposable ragwheels (polishing devise made
of cloth)
7. Use a shielding device and air-suction motor with the polishing
lathe, model trimmer, or grinding bench to minimize aerosol spray
8. An EPA-registered intermediate-level disinfectant should be used to
disinfect contaminated laboratory materials (e.g., impressions, fixed
and removable prostheses, retainers, crowns)
a. Spray the chemical or, preferably, immerse the material in the
chemical using minimal effective exposure time (at least 15
minutes) to prevent damage to the material
b. Consult with the manufacturer to determine which chemicals
are compatible with the item to be disinfected and the
immersion time required
9. Professional cleaning of removable prostheses
a. Use of denture-cleaning solutions is not a substitute for
disinfection
b. To prevent microbial contamination:
(1) Use resealable plastic bags
(2) Do not reuse the denture-cleaning solution or plastic bags
(3) Place sealed bags in a disinfected beaker in the ultrasonic
unit
(4) Sterilize or dispose of the equipment used in cleaning
(e.g., brushes)
c. Rinse the prosthesis with water to remove any residual chemical,
and place it in a mouthwash solution to ensure a pleasant taste
for the client

Maintaining the Oral Health Care Environment After

Client Care
A. Decontamination of the treatment area
1. Wear PPE, including utility gloves
2. Seal and transport the biohazard bag (that is taped to the mobile
cart) containing blood-soaked gauze to the biohazard waste
container

859
 3. Deliver instruments in a closed, puncture-proof container (cassette)
to the instrument-processing area
4. Remove surface barriers carefully to avoid contamination of the
surfaces underneath, and dispose of in a trash receptacle
5. Remove and dispose of SUDs (air/water syringe tip, saliva ejector)
6. Using air/water syringe, flush low-volume and high-volume (if used)
evacuator tubing for 30 seconds
7. Flush all other water lines for 30 seconds between clients (ultrasonic
unit)
8. If instrument sterilization is delayed, place the instruments in a
holding solution to prevent bioburden from drying on the
instruments
9. At the end of the workday, flush high-volume and low-volume
evacuator tubing with a cleaning and disinfecting solution; at least
weekly, clean the trap of the evacuation system, or preferably, replace
with a disposable trap
B. Regulated infectious waste
1. Medical waste that has the potential for disease transmission and
requires special handling and disposal
2. OSHA regulates the handling of infectious waste; EPA regulates the
disposal of infectious waste for three categories:
a. Sharps (e.g., needles, scalpel blades, instruments)
b. Tissue and extracted teeth; CDC allows extracted teeth to be
returned to the client
c. Blood, items soaked or caked with blood, or items that could
release potentially infectious materials when compressed; CDC
considers saliva as infectious material but not as regulated
medical waste
3. Unregulated medical waste—solid waste that is generated, including
all disposable items other than sharps, tissues, extracted teeth, and
blood-soaked items (e.g., gloves, saliva ejectors, cups, surface
barriers); unregulated medical waste may be potentially infectious;
however, it is unregulated and may be disposed of as common trash
unless restricted by state and local laws
4. Contact state and local governments for regulations on the disposal
of regulated and unregulated medical waste
C. Waste management
1. Line trash receptacles with plastic bags
2. Sharps containers should be placed in each treatment area
D. Waste disposal
1. Regulated infectious waste must be separated from other waste, put

860
 in a color-coded (“red bagged”) container, and labeled with the
biohazard symbol (Fig. 10-3)

FIG 10-3 Biohazard symbol: (Sorrentino SA, Gorek B: Mosb y's textb ook for long-
term care nursing assistants, ed 6, St Louis, 2011, Mosby.)

a. Sharps must be in a closed, leakproof, and puncture-resistant

sharps container
b. Nonsharp items must be placed in a leakproof container (e.g.,
biohazard bag)
2. Disposal options
a. Sterilization on-site and disposal according to local and state
regulations
(1) Do not process instruments and waste in same load
(2) Properly perform biologic monitoring during sterilization
(3) Extracted teeth, to be used for educational purposes, with

861
 amalgam restorations must not be heat-sterilized because
this will generate toxic vapors; use a chemical sterilant
instead; teeth without restorations must be heat-sterilized
b. Hazardous waste removal service by an EPA-approved waste
hauler
(1) The oral health care facility is ultimately responsible for
the proper disposal of infectious waste; therefore the waste
hauler ’s credentials should be checked carefully
(2) A manifest should be provided by the waste hauler
indicating the method by which the waste was treated and
its final disposal site
E. Instrument processing
1. Organization of sterilization area
a. For efficiency, the instrument-processing area should be
centrally located
b. The area is designed to allow for linear progression of
instrument processing and for the separation of contaminated
and clean or sterile items
c. The area should be divided into three designated areas:
(1) Decontamination area—receiving area for contaminated
instruments (soaking and waste disposal), ultrasonic
cleaning, rinsing, and drying
(2) Packaging area—instruments are arranged in sets;
chemical and biologic indicators are added; instruments are
wrapped or bagged, sealed, and labeled
(3) Sterilization and storage area—instruments are processed
and stored
2. Decontamination area procedures
a. Use PPE, including utility gloves
b. If a delay occurs before decontamination, soak instruments in a
holding solution to prevent the drying of saliva and blood
(1) Extended soaking is not recommended because it can
damage the instruments
(2) The holding solution can be water, enzyme solution,
heparin solution (dissolves blood), or detergent
c. Cleaning instruments in an ultrasonic unit or instrument washer
is an important step; otherwise, stuck-on blood or other organic
material will remain on the instruments even after sterilization
(instruments with adhered debris are not sterile)
d. Ultrasonic cleaning
(1) Vibrations dislodge and dissolve organic material

862
 (2) The safest and most efficacious method of cleaning
(3) Eliminates the need for hand scrubbing and potential for
injury with contaminated instruments
(4) Procedure for using ultrasonic instrument cleaner
(a) Use solution specifically designed for ultrasonic
cleaners; may contain antimicrobial properties
(b) Time—4 to 16 minutes, depending on the unit, the
instruments, and the amount of material on the
instruments (instruments in cassettes require longer
exposure time)
(c) Keep the unit covered to prevent exposure to aerosols
(d) Rinse the instruments, and let excess water drain from
the cassettes
(e) Open cassette and inspect instruments to ensure
absence of debris
(f) Replenish the ultrasonic solution, and disinfect the
unit daily
(g) Periodically test the unit (aluminum foil test)
e. Manual scrubbing technique—used rarely when bioburden
remains on instruments or when ultrasonic exposure would
cause damage to instruments or devices (ultrasonic inserts,
some handpieces)
(1) Scrub with a long-handled, stiff brush; wear utility gloves
(2) Scrub the item, holding it low in the sink to minimize
spatter
(3) Manual scrubbing is not advised because it poses an
increased risk for injury
f. Asepsis for high-speed and low-speed dental handpieces
(1) Refer to the manufacturer ’s instructions for cleaning,
lubrication, and sterilization
(2) Some handpieces can be cleaned ultrasonically; all
handpieces must be able to withstand heat sterilization
(3) Flush the water lines of high-speed handpieces for 30
seconds after use
g. Prophylaxis angles; should be heat-sterilized or SUDs
(disposable); consult the manufacturer ’s instructions for
cleaning, lubrication, and sterilization
3. Packaging area procedures
a. Surgical and hinged instruments
(1) Instruments can be dipped in surgical milk to prevent
rusting and to lubricate hinged instruments (rusted

863
 instruments should be discarded and never used because
sterility of these instruments cannot be ensured)
(2) Hinged instruments should be opened before packaging
b. The instruments to be bagged should be dry to avoid
penetrating the packaging, and excess moisture can interfere
with sterilization
c. Packaging materials vary according to the type of sterilization
method (Table 10-6)

Table 10-6
Comparison of Heat Sterilization Methods

Modified from Miller CH: Infection control and the management of hazardous materials for the dental team,
ed 5, St Louis, 2014, Mosby.
* These conditions do not include warm-up or cool-down time, and they may vary, depending on the
contents and volume of the load and brand of the sterilizer.
† Biologic indicator must be used to ensure sterility.

‡ Tears or punctures easily.

d. Packaging materials include plastic or paper pouches, plastic

tubing, cassettes, or trays to be wrapped with paper or cloth,
sealed with appropriate tape, dated, and labeled with the type of
instrument setup and sterilizer used (in the case of more than
one sterilizer)
(1) With more than one sterilizer in use, if one was to
malfunction, it would be important to identify the packages
that had been processed in that sterilizer
e. To maintain package integrity, do not seal the package using

864
 staples, pins, or paper clips
f. Packages should be tightly sealed, eliminating gaps
g. Autoclave bags are designed for single use because of pores in
the paper that open during sterilization, allowing steam to
penetrate, and then close on cooling to inhibit microbes from
entering into package
h. The packaging materials used must NOT:
(1) Melt or char
(2) Prevent the sterilizing agent from penetrating
(3) Be easily torn by sharp instruments
i. Instruments should be packaged loosely to allow for maximum
contact with steam or chemical vapors; overloaded packages can
lead to incomplete sterilization
j. Biologic and chemical indicators are added during packaging
procedures
4. Sterilization area procedures
5. Sterilization methods (see Table 10-6)
a. Steam (moist heat under pressure) sterilization—autoclave
(1) Types based on how air is removed the chamber
(a) Gravity displacement
(b) Vacuum pump (type B sterilizer)—perform air
removal test (Bowie-Dick) at the beginning of each day
to ensure complete air removal from the chamber
(c) Pressure pulse
(2) Moist heat denatures and coagulates microbial proteins;
pressure serves to elevate temperature
(3) Periodically check gasket on door to ensure a tight fit
(4) Steam must be able to penetrate the instrument package;
pack loosely to allow for free passage of steam
(5) Packages and cassettes should be placed on their edges,
not laid flat
(6) Avoid the package coming in contact with chamber walls
(7) Use distilled or deionized water to prevent deposits on
instruments
b. Dry-heat sterilization
(1) Sterilizes by oxidizing cell parts
(2) Keeps air spaces between packages
(3) If the sterilizer is opened, timer must be restarted
c. Unsaturated chemical vapor sterilization
(1) Alcohols, formaldehyde, ketone, acetone, and water are
heated under pressure to produce the gas that permeates

865
 and destroys microbes
d. Ethylene oxide gas sterilization
(1) Used mostly in hospitals and large clinics
(2) Operation
(a) Sterilize at room temperature, 75°F (25°C), for 10 to 16
hours
(b) Alternatively, sterilize at 120°F (49°C) for 2 to 3 hours
(c) Aerate plastic and rubber materials for at least 16
hours after sterilization to remove gas molecules
(d) Warning: Residual gas can cause tissue burns
e. Liquid chemical sterilants
(1) Used for heat-sensitive, semi-critical items when ethylene
oxide gas is not available
(a) Should not be used as a substitute for heat
sterilization of semi-critical items that are not heat
sensitive
(b) Should be avoided because mostly heat tolerant, or
SUDs are available
(c) Biologic monitoring is not possible, so this method
cannot ensure sterility
(2) Follow the manufacturer ’s instructions for dilution,
temperature, and contact time
(3) Ensure that the instruments are dry to avoid diluting the
solution
(4) Remove the instruments with sterile forceps, rinse with
sterile water, and package or cover with sterile towel
(5) Chemicals used for sterilization (see Table 10-4); the
disadvantages of chemicals are:
(a) They produce toxic fumes and are irritating to tissues
(b) Biologic indicators (BIs) are not available with the use
of chemical sterilants; therefore, the sterility of items
cannot be verified
(c) When removed from chemicals, items are exposed to
the environment and can easily become contaminated
because of lack of packaging
(d) Chemical sterilization requires an extended contact
time of 3 to 12 hours, depending on the chemical
6. Verification of sterilization
a. Failure of sterilization can occur as a result of operator or
mechanical failure
(1) Overloading—the reason for failure in the majority of

866
 cases
(2) Improper packaging
(3) Improper timing
(4) Improper unit operation
(5) Unit malfunction
(6) Improper maintenance of equipment
b. The CDC recommends routine use of BIs (spore tests) for
verification of sterility
(1) Biologic monitoring is a process in which highly resistant
spores are passed through the sterilizer and then cultured
to determine whether they have been killed
(a) If spores have been killed, all the less-resistant
microorganisms exposed to the same conditions will
also have been destroyed
(b) Primary method to ascertain sterility
(c) Biologic monitoring with BIs can be done in the dental
setting or in a processing facility
(2) Types of BIs
(a) Spore strips—paper strips containing one or two types
of spores enclosed in a glassine envelope
[1] After sterilization, remove the spore strip
aseptically, place it in a culture medium, and
incubate for 7 days
[2] If spores are present, they will grow and change
the color of the growth medium, indicating
sterilization failure
[3] Strips can be used for all methods of heat
sterilization
(b) Self-contained vial—contains spore strip with an
ampule of growth medium in a plastic vial
[1] After sterilization, squeeze the vial to break the
internal ampule, which would mix the growth
medium with the spores
[2] Incubate the vial; if spores are present, they will
multiply and change the color of the growth
medium, indicating sterilization failure
[3] Vials can only be used in a steam autoclave
(c) Specific bacterial endospores used in BIs
[1] Steam autoclave and chemical vapor sterilizer—
spores of Geobacillus stearothermophilus
[2] Dry heat and ethylene oxide gas sterilizer—spores

867
 of Bacillus atrophaeus
(3) Use of BIs
(a) Place a strip inside one of each type of package (e.g.,
autoclave bag, cassette)
(b) Incubate a control BI that has not been sterilized,
along with the test BI
(c) Growth of spores from the control BI confirms that
live spores were present
(d) No growth from the test BI indicates that sterilization
has been achieved
(4) Use BIs once a week to test sterilization equipment and
when:
(a) The equipment has been repaired
(b) New packaging material is used
(c) A new sterilizer is operated
(d) Training new staff
(e) The loading procedure is changed
(f) Sterilizing an item to be implanted
(5) Sterilization failure (growth on the BI test, or positive
spore test)
(a) Review the procedures to determine any operator
error
(b) Take the sterilizer out of operation, and retest with
mechanical, chemical, and biologic monitors
(c) If the repeat BI test is negative, put the sterilizer back
in service
(d) If the repeat BI test is positive, determine the cause of
failure, and repeat the BI test three times before
putting the sterilizer back into service
(e) Withdraw the instruments, and repeat the process
(6) Documentation
(a) Record the results of biologic monitoring in a log book
(b) Necessary for compliance with federal regulations
(c) Serves quality assurance and risk management
purposes
c. Chemical monitoring
(1) Chemical indicators—items containing heat-sensitive
chemicals that change color when exposed to certain
temperatures to assess conditions during the sterilization
process (e.g., autoclave tape, special markings on autoclave
bags, chemical indicator strips)

868
 (2) Chemical monitoring does not provide proof of
sterilization
(3) Types of chemical indicators
(a) Integrated indicator (class V)—changes color slowly
when exposed to a combination of time, temperature,
and steam; placed inside each instrument package to
confirm whether instruments have been exposed to
sterilizing conditions
(b) External chemical indicator—changes color after a
certain temperature has been reached (e.g., autoclave
tape)
[1] Distinguishes those instruments that have been
in the sterilizer from those that have not,
preventing accidental use of unprocessed items
[2] Should be present on packaging material or
applied on the outside of every instrument
package and cassette
d. Mechanical monitoring
(1) Observation of sterilizer gauges, including temperature,
pressure, and exposure time
(2) Incorrect reading indicates a functional problem
7. Storage area procedures
a. After sterilization, allow the instrument packages to cool and
dry before storage
(1) Microorganisms and instrument tips can penetrate wet
packaging material and compromise sterility
(2) Microorganisms on contaminated surfaces can wick
through wet packaging
b. Instruments must not be stored unwrapped or unpackaged
(unpackaged instruments are immediately contaminated when
exposed to the environment)
c. Packaged instruments should not be stored above the sterilizers
and should be stored away from treatment areas to lessen
chances of contamination
d. Sealed packages should be kept on shelves protected by doors
for dry, low-dust storage
e. Sealed instrument packages have been shown to maintain
sterility for up to 6 months; however, to err on the side of
caution, repackage and sterilize after 30 days
f. Instrument packages should be rotated so that the oldest dated
instrument pack is used first

869
g. Packages that are dropped on the floor, punctured, torn, or wet
are considered contaminated and must be reprocessed
h. Wrapped cassettes are ideal for storing and then serving as
sterile instrument trays

870
Governmental agencies and infection
control
A. U.S. Food and Drug Administration (FDA)
1. Regulates all medical devices
a. Examples in oral health care include liquid sterilants, biologic
and chemical indicators, ultrasonic cleaners, PPE, dental
instruments, and sterilizers
2. Ensures products are safe and effective
3. Ensure devices fulfill performance standards before marketing
B. U.S. Environmental Protection Agency (EPA)
1. Mission to protect human health and the environment
2. Ensures the safety and effectiveness of chemical disinfectants (EPA
registration number displayed on container)
3. Regulates medical and chemical waste after leaving the OHC setting
C. Centers for Disease Control and Prevention (CDC)
1. Under the auspices of the U.S. Department of Health and Human
Services
2. Health and quality-of-life promotion mitigating injury, disability, and
disease
3. Infection control guidelines and recommendations for dentistry
(infection procedures used in oral health care settings are based on
2003 recommendations)
4. Regulatory agency only; does not have authority to enforce
guidelines
D. Occupational Safety and Health Administration (OSHA)
1. Within the U.S. Department of Labor (federal and state divisions)
2. Ensuring a safe and healthy working environment for employees
a. Instrument sterilization is not covered by OSHA regulations
because it is considered a procedure involved in client
protection instead of DHCP (employee) protection
3. OSHA formulates and has the authority to enforce regulations
related to occupational safety and health
4. Protection of DHCP against exposure to bloodborne pathogens
5. OSHA Bloodborne Pathogens Standard
a. The most important infection control regulation in dentistry for
the protection of DHCP
b. The final Bloodborne Pathogens Standard was published in 1991
and became effective in 1992
c. The Needlestick Safety and Prevention Act was added to the

871
 Standard in 2001
(1) On an annual basis, employers must solicit input from
DHCP to identify, evaluate, and select safer medical devices
to minimize or eliminate occupational exposures (e.g., self-
sheathing needles)
d. Employers are responsible for staff compliance with the
Standard; this includes:
(1) Review of the Standard and ensuring that a copy is
available on-site
(2) Formulation of a written exposure control plan that
contains:
(a) Clarification of which employees face a potential risk
for occupational exposure and will be covered under
the Standard
(b) Description of how and when provisions will be
implemented (i.e., communication of the hazards to
employees, hepatitis B vaccination, postexposure
evaluation and follow- up, record keeping, use of PPE,
engineering and work practice controls, and
housekeeping)
(c) Prevention and evaluation of exposure incidents
(sharps injuries)
(d) In 2005, OSHA determined that oral health care
settings are of low hazard and are exempt from keeping
an injury and illness log unless the government
requires it
(e) Employers still must report any workplace incident
that results in the hospitalization of three or more
employees or a fatality
(3) Training of employees
(a) Training that provides information about the hazards
and preventive measures related to occupational
exposure to bloodborne pathogens
(b) Training to be completed at the initial time of
assignment and annually thereafter
(c) Person conducting the training must be qualified and
knowledgeable
(d) Training must provide an opportunity for interactive
questions and answers with the person conducting the
training
(4) Providing employees with necessary materials to comply

872
 with the Standard
(a) Offer and pay for hepatitis B vaccination
(b) Provide, maintain, and ensure use of PPE and
engineering controls
(c) Establish appropriate work practices and
decontamination procedures in the oral health care
setting to ensure the safety of DHCP (appropriate
decontamination, laundry handling, and infectious
waste disposal)
(d) Establish and provide postexposure medical
evaluation and follow-up without any cost to employees
(e) Provide appropriate biohazard communication by
posting signs, biohazard waste labels, and red
containers that indicate infectious waste on-site
(5) Maintain appropriate records
(a) Training sessions (participants, trainers, summary of
content, evaluations)
(b) Employee medical records (HBV immunization status,
postexposure evaluation and follow-up)
6. Inspections conducted by OSHA
a. Initiated by employee complaints or other interested parties
b. Programmed inspections of randomly selected worksites
employing 11 or more people
c. Noncompliance with any provision in the Standard can result in
the imposition of fines

Evaluation of Infection Control Programs

Table 10-7 lists program elements with corresponding activities in the
evaluation of infection control programs. The websites listed in the
Website Information and Resources table provide the oral health care
professional with immediate access to current recommendations and
regulations concerning infection control.

873
Table 10-7
Evaluating Infection Control Programs

From Centers for Disease Control and Prevention: Guidelines for infection control in dental
health-care settings, MMWR 52(RR-17):1-68, 2003.

Legal and Ethical Issues in Disease Prevention

Box 10-2 lists recommendations to address legal and ethical
considerations in infection control measures.

Box 10-2
Legal and Ethic al Guidelines in Disease
Prevention
Treat all clients regardless of disease status
Practice infection control according to the standard of care
Adhere to the Centers for Disease Control and Prevention (CDC) and
the Occupational Safety and Health Administration (OSHA)
guidelines
Adhere to state and federal laws

874
 Use evidence-based protocols
Follow state board of dentistry laws and regulations
Follow expert opinion related to infection control
Stay current of new protocols and guidelines
Abide by U.S. Public Health Service (PHS) guidelines for employee work
restrictions

Website Information And Resourc es

Source Website Address Description
Association for Professionals in http://www.apic.org Infection control organization for health
Infection Control and Epidemiology care
(APIC)
Centers for Disease Control and http://www.cdc.gov U.S. government agency that provides
Prevention (CDC) resources and recommendations for
numerous health and safety topics
Organization for Safety, Asepsis, and http://www.osap.org Organization that promotes infection
Prevention (OSAP) control and safety policies to the dental
community
Occupational Safety and Health http://www.osha.gov U.S. government agency responsible for
Administration (OSHA) ensuring the health and safety of
employees at workplaces
National Institutes for Occupational http://www.cdc.gov/niosh U.S. government agency that provides
Safety and Health (NIOSH) national and world leadership to prevent
illness and injury

875
Suggested readings
Centers for Disease Control and Prevention. Guidelines for
infection control in dental health-care settings. MMWR. 2003;57.
Centers for Disease Control and Prevention. Guidelines for
disinfection and sterilization in healthcare facilities. MMWR.
2008;57.
Miller C.H. Infection control and management of hazardous materials
for the dental team. ed 5 St Louis: Mosby; 2014.
US Department of Labor, Occupational Safety and Health
Administration. Controlling occupational exposure to bloodborne
pathogens. 2001, Washington, DC: OSHA; 1996 3127 (revised).

Chapter 10 review questions

Answers and rationales to review questions are available on this text’s
accompanying Evolve site. See inside front cover for details.

Case A
Isabelle Sanchez, RDH, has been practicing dental hygiene for 7 years
and has decided to return to college to pursue her master ’s degree in
dental hygiene. She has moved to another state and is currently working
during the summer as a temporary hygienist to earn money for living
expenses. For the last two consecutive Mondays, she has been working in
the same practice, substituting for a hygienist who is on maternity leave.
Today, when she reports to work, Isabelle is told by the dental assistant
that the elderly man whom Isabelle treated last Monday is in the
hospital and has been diagnosed with legionnaires disease. During the
last week, he had only left his house to go to his dental visit, and the
water tested in his house was negative for Legionella. In hindsight,
Isabelle realizes that in her treatment room, she did not see a water
bottle attached to the master control unit that would have indicated use
of an independent water system. She just assumed that the dental unit
water lines were being treated with another method.

Use Case A to answer questions 1 to 6.

1. Which of the following pathways of cross-contamination is depicted

876
in this case?
a. Client to DHCP
b. DHCP to client
c. Client to client
d. Community to client
2. Which of the following modes of disease spread is depicted in this
case?
a. Direct contact
b. Indirect contact
c. Droplet infection
d. Airborne infection
3. What is the source of the microbes in this case?
a. Client’s oral cavity
b. Hygienist’s hands
c. Contaminated instrument
d. Dental unit water
4. In this case, which of the following infection control procedures likely
would have prevented disease transmission?
a. Using barriers
b. Cleaning the housekeeping surfaces
c. Treating dental unit water lines
d. Wearing proper PPE
5. Which of the following microorganism types is responsible for
legionnaires disease?
a. Bacterium
b. Prion
c. Virus
d. Fungus
6. What was the portal of entry of Legionella into the elderly client’s
body?
a. Breathing in contaminated water vapor
b. Swallowing contaminated water
c. Infiltrating microbes into nonintact mucosa
d. Splashing of droplets on mucous membranes

877
Case B
After dismissing his last client of the day, Preston Miller, RDH, returns
to his treatment room. He is in a rush because his son’s baseball team
has a game tonight and he is the coach. Preston hurriedly closes his
instrument cassette, not taking care to arrange the instruments
beforehand. In the instrument-processing area, he lifts the cassette off
the metal tray to place it into the ultrasonic unit. Unknowingly, an
explorer is protruding from a hole in the cassette and penetrates his
finger through the exam glove. He removes his gloves and sees a small
amount of blood forming on his index finger.

Use Case B to answer questions 7 to 13.

7. What should Preston the dental hygienist do next?
a. Scrub the finger using a stiff brush
b. Squeeze the finger to let out the contaminants
c. Wash the finger with antimicrobial soap
d. Immerse the finger in bleach for 1 minute
8. Preston, the employee, has sustained a percutaneous injury and may
have been exposed to a bloodborne pathogen. In this situation, what is
the responsibility of the employer (dentist) according to OSHA?
a. None; an employee works at his own risk
b. Pay for the treatment of any acquired disease
c. Give the employee the following day off with pay
d. Arrange for a consultation with a qualified HCP
9. Which of the following modes of disease spread is depicted in this
case?
a. Direct contact
b. Indirect contact
c. Droplet infection
d. Airborne infection
10. What is the source of the microbes in this case?
a. Contaminated droplets
b. Hygienist’s hands
c. Contaminated instrument
d. Dental unit water

878
11. The dental hygienist elects to be tested for bloodborne pathogens
(HCV and HIV), and he is informed of the results. Which of the
following actions is he then required to take?
a. Inform his employer of the results
b. Document the results in his employee file
c. Inform the CDC and OSHA
d. None of the above is required
12. According to OSHA, which of the following does NOT need to be
included in a dental office’s record keeping?
a. Employee vaccine declination statements
b. Records of annual staff trainings on infection control
c. Log of employee injuries and illnesses
d. Employees’ Social Security numbers
13. What is the level of risk related to the transmission of HCV or HIV
from this exposure?
a. High
b. Moderate
c. Low
d. Very low
14. All the following viruses are bloodborne pathogens EXCEPT:
a. Human immunodeficiency virus
b. Hepatitis B virus
c. Hepatitis C virus
d. Varicella-zoster virus
15. Which term is used for the practice of treating a client’s blood, body
fluids, nonintact skin, and mucous membranes as potentially infectious?
a. Standard precautions
b. Pervasive precautions
c. Universal precautions
d. Protective precautions
16. Glutaraldehyde is a high-level disinfectant; therefore it can be used
to sterilize critical items.
a. Both statements are TRUE.
b. Both statements are FALSE.

879
 c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
17. A dental health care employee has occupationally acquired
tuberculosis. Which of the following modes of disease spread would be
implicated in this case?
a. Direct contact
b. Indirect contact
c. Droplet infection
d. Airborne infection
18. Which of the following methods will achieve sterilization?
a. Dry heat at 320°F for 50 minutes
b. Steam autoclave at 200°F for 30 minutes
c. Chemical vapor at 270°F for 20 minutes
d. Ethylene oxide gas for 5 hours
19. The CDC recommends disinfecting clinical contact surfaces with an
intermediate-level disinfectant that is tuberculocidal, because
Mycobacterium tuberculosis var. bovis is a resistant microbe and all
other, less resistant microbes would also be killed.
a. Both the statement and the reason are TRUE.
b. Both the statement and the reason are FALSE.
c. The statement is TRUE, but the reason is FALSE.
d. The statement is FALSE, but the reason is TRUE.
20. What is the ultimate goal of disease prevention in the oral health care
(OHC) setting?
a. Prevent pathogens from entering the OHC setting
b. Sterilize clinical contact surfaces between clients
c. Prevent OHC-related infections and diseases
d. Eliminate all microbes in the OHC setting
21. Alcohol-based sanitizers may be used instead of handwashing when
no visible soil is present, because the sanitizers have been found to be as
effective as handwashing.
a. Both the statement and the reason are TRUE.
b. Both the statement and the reason are FALSE.
c. The statement is TRUE, but the reason is FALSE.

880
 d. The statement is FALSE, but the reason is TRUE.
22. All the following are TRUE related to using instrument cassettes
EXCEPT:
a. Unwrap the cassette in view of the client.
b. Sterilized cassettes are used as instrument trays.
c. Exposure to sharps is decreased.
d. Using cassettes is less time-efficient.
23. Many DHCP experience skin problems on their hands related to the
use of gloves. In most cases, these problems are caused by an allergic
response to latex proteins in gloves.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
24. Which of the following indicators is used to determine sterility?
a. External indicator
b. Integrated indicator
c. Biologic indicator
d. Chemical indicator
25. Which of the following is OSHA primarily concerned with
protecting?
a. Employee
b. Employer
c. Client
d. Community
26. Which of the following characteristics is an advantage of chemical-
vapor sterilization?
a. A ventilation system is not required.
b. It can sterilize closed containers.
c. Extra drying time is not needed.
d. It is the least costly method of sterilization.
27. All the following are vaccine-preventable illnesses EXCEPT:
a. Hepatitis B virus (HBV)
b. Hepatitis A virus (HAV)

881
 c. Hepatitis C virus (HCV)
d. Varicella-zoster virus (VZV)
28. Which of the following statements BEST characterizes the resident
flora on hands?
a. They colonize the deeper layers of the skin.
b. They are less resistant to removal by handwashing.
c. They are the primary source of disease transmission.
d. They are associated with allergic contact dermatitis.
29. Which of the following statements is TRUE regarding the handling
of regulated infectious waste?
a. Containers of infectious waste must be identified with the biohazard
symbol.
b. Infectious waste can be disinfected and then combined with the
regular trash.
c. Infectious waste must be sterilized before leaving the oral health
care setting.
d. Infectious waste does not require any special handling in some
states.
30. Examination gloves to be used intraorally should be donned before:
a. Operatory setup
b. Unwrapping the cassette
c. Taking the blood pressure
d. Entering the client’s mouth
31. Which of the following packaging materials should NOT be used
with chemical vapor sterilization?
a. Paper wrap
b. Paper pouches
c. Plastic pouches
d. Cloth wrap
32. Which of the following characteristics BEST describes the use of
protective barriers for clinical contact surfaces?
a. They need to be changed only when visibly soiled.
b. They should be used after sterilization of the surface.
c. They are ideally used for surfaces that are difficult to disinfect.

882
 d. They decrease the cost of maintaining asepsis.
33. All following characteristics describe EPA-registered intermediate-
level disinfectants EXCEPT:
a. Must inactivate Mycobacterium tuberculosis var. bovis
b. Will kill vegetative bacteria and most viruses
c. Must be used on surfaces with visible blood
d. Will achieve sterilization if long contact time is used
34. All DHCP who are vaccinated for hepatitis B will become immune to
the virus. Therefore, the CDC does not recommend booster injections.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
35. Face shields provide maximum coverage for the face and protection
from spatter during oral health care procedures. Therefore, wearing a
facemask is not required when using a face shield.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
36. Which of the following pathogens has been identified in the biofilm
that accumulates inside dental unit water lines?
a. Pseudomonas aeruginosa
b. Neisseria meningitidis
c. Candida albicans
d. Treponema pallidum
37. Which of the following governmental agencies is responsible for
approving the safety and effectiveness of small office sterilizers and
ultrasonic units?
a. EPA
b. FDA
c. CDC
d. OSHA
38. An individual should be tested for antibodies to HBV 1 to 2 months

883
after receiving the last dose of the hepatitis B vaccine. The reason for
this testing is that not all individuals will seroconvert.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
39. In which of the following methods are biologic monitors containing
spores of Geobacillus stearothermophilus used to verify sterilization?
a. Steam autoclave
b. Dry-heat oven
c. Ethylene oxide gas
d. Rapid heat transfer
40. Which of the following is NOT considered a safe work practice
control?
a. Using an instrument cassette instead of autoclave bags
b. Hand scrubbing instruments using exam gloves
c. Using a one-handed technique to recap needles
d. Fulcruming a couple of teeth away from instrumented tooth
41. Sterilization failure is most often caused by:
a. The autoclave not working properly
b. Improper packaging materials used
c. Overloading the office sterilizer
d. Inadequate sterilization time
42. A chemical indicator is used on the outside of packaging to identify
the items that have been processed through the sterilizer. The chemical
indicator changes color when the packages are sterile.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
43. Dental handpieces are considered semi-critical items, and therefore
they can be disinfected by wiping with an intermediate-level
disinfectant.
a. Both statements are TRUE.

884
 b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
44. What is the maximum level of bacteria that the ADA has
recommended in dental unit water?
a. 100 CFU/mL
b. 200 CFU/mL
c. 300 CFU/mL
d. 400 CFU/mL
45. In most cases, what is the number of bacteria in the water exiting
from an untreated dental unit water line?
a. Lower than in drinking water
b. The same as in drinking water
c. Slightly higher than in drinking water
d. Much higher than in drinking water
46. All the following materials are considered regulated infectious waste
EXCEPT:
a. Extracted tooth
b. Blood-soaked gauze
c. Anesthetic needle
d. Contaminated exam gloves
47. The primary reason for clients to perform a preprocedural rinse
before undergoing oral health care is to:
a. Remove malodorous breath
b. Remove adherent food debris
c. Reduce the microbes in aerosols
d. Eliminate oral infections
48. Using biologic indicators to test sterilizing equipment, biologic
monitors should be used once every:
a. Day
b. Week
c. Month
d. Quarter
49. All the following methods inhibit the formation of biofilm in dental

885
unit water lines EXCEPT:
a. Flushing water lines for 2 minutes
b. Independent water reservoir
c. Chemical disinfection of water lines
d. Sterile water delivery systems
50. To prevent cross-contamination, the practice of using a cotton roll
taped to the bracket tray for wiping debridement instruments, instead of
a gauze square wrapped around the finger, is considered:
a. Standard bioburden control
b. Safe practice control
c. Engineering control
d. Work practice control

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C HAPT E R
11

887
Pharmacology
Elena Bablenis Haveles

As a health care provider responsible for client assessment and care, a

dental hygienist must understand drugs, the conditions for which these
drugs are used, and the actions, range of effects, and interactions of the
drugs. The health, dental, and pharmacologic histories are the
foundation on which decisions regarding client care rest. For example,
some clients may need prophylactic antibiotic premedication before
dental and dental hygiene care. Therefore, before care is planned, the
client’s medical conditions and medications used to manage them are
assessed and recorded in the client’s permanent record.
Contraindications or cautions to professional care concerning these
drugs are determined using appropriate references and consultations.
Through this knowledge, medical emergencies may be prevented; and, if
an emergency occurs, the oral health care team can act within the
standard of care.

888
General considerations
Definitions
A. Pharmacology—the study of drugs and their effects on living
organisms
B. Pharmacotherapy—the use of medications to treat different disease
states
C. Pharmacodynamics—the action of drugs on living organisms
D. Pharmacokinetics—what the body does in response to the drugs (e.g.,
absorption, distribution, metabolism, excretion)
E. Pharmacy—the practice of compounding, preparing, and dispensing
drugs and of counseling clients about their medications
F. Toxicology—the study of the harmful effects of drugs on living
organisms
1. Drugs—biologically active substances that can modify cellular
function; used in the prevention, diagnosis, treatment, and cure of
disease or in the prevention of pregnancy
2. Nomenclature—each drug has several names
a. Chemical name—based on the drug’s chemical formula (e.g., N-
acetyl para-amino phenol)
b. Trade (proprietary) name—each drug company makes up its
own product trade name (e.g., Tylenol, Peridex, Atridox, Arestin)
c. Brand name—technically, the name of the drug company itself,
but often used interchangeably with the trade name (e.g., either
Astra [company that makes Xylocaine] or Xylocaine can be
considered the brand name)
d. Generic name—official name of the drug determined by the
U.S. Adopted Names Council that is used by all manufacturers
of a particular drug (e.g., acetaminophen, chlorhexidine
gluconate)
G. Table 11–1 lists the Latin abbreviations used in prescription writing

889
Table 11–1
Common Latin Abbreviations Used in Prescription Writing

Abbreviation* Interpretation
a., ante Before
a.c., ante cibum Before meals
A.D., aurisdextra Right ear
A.L., aurislaeva Left ear
b.i.d., bis in die Twice per day or twice daily

gt., gutta Drop (plural gtt.)

h., hora Hour
h.s., hora somni At bedtime
o.d., oculus dexter Right eye
o.s., oculus sinister Left eye
o.u., oculus uterque Each eye
p.c., post cibum After meals
p.o., per os By mouth
p.r. By rectum
p.r.n., pro re nata As needed
q.d., quaque die Once per day or once daily
q.i.d., quater in die Four times per day
q.o.d. Every other day
q.h. Every 6 hours
sl. Sublingual
supp. Suppository
t.i.d., ter in die Three times per day
u.d. As directed
* Periods usually omitted (e.g., bid, po) when abbreviations used (as with dosages).

Agencies and Legislation

A. U.S. Food and Drug Administration (FDA)—determines drugs to be
marketed in the United States; after considering safety, efficacy, and
physical and chemical data, the FDA requires quality control of
manufacturing facilities, determines what drugs are sold by prescription,
and regulates the advertising and labeling of prescription drugs
B. U.S. Drug Enforcement Administration (DEA)—branch of the
Department of Justice; determines the degree of control for substances
with abuse potential; controlled substances used in dentistry are
classified under schedules I to V (Table 11–2)

890
Table 11–2
Drug Enforcement Administration Schedules Used in Dentistry (I Through V)

Drug Action
A. Log dose–response curve—as the dose of a drug increases (x axis), the
percentage of maximum response increases (y axis) until increasing the
dose further produces no increase in the percentage of response (the
effect of the drug reaches a plateau) (Fig. 11–1)

FIG 11–1 Log dose-effect curve. ED, Effective dose.

B. Definitions
1. Effective dose (ED) 50—dose that produces 50% of the maximum
response, or the dose of a drug that produces a specific response in

891
 50% of the subjects
2. Lethal dose (LD) 50—dose that is lethal to (kills) 50% of the subjects;
laboratory animals are used to derive LD
3. Therapeutic index (TI)—LD50 divided by ED50; a measure of the
safety of a drug
4. Onset—time required for a drug’s effect to begin; onset is short if the
drug is given intravenously, longer if administered orally
5. Duration—length of time a drug’s effect lasts; related to a drug’s
half-life
6. Half-life (t½)—time required for a drug’s serum concentration to
decrease by 50%; five half-lives are required for a drug to be
eliminated from the body
7. Potency—amount of drug (e.g., in milligrams) needed to produce an
effect; the more potent an agent is, the lower is the dose needed to
produce an effect (Fig. 11–2)

FIG 11–2 Potency and efficacy of a drug. Curve A has high potency and
low efficacy; Curve B has low potency and high efficacy.

8. Efficacy—the desired effect elicited by a drug, independent of dose

(see Fig. 11–2)
9. Tolerance—physiologic response to the same dose produces less
effect, or a higher dose is required to achieve the same effect
10. Therapeutic effect—desired pharmacologic effect
C. Routes of administration

892
 1. Oral (PO)—by mouth; easiest to use; good client acceptance;
however, a latency period exists
2. Rectal—administration by suppository or enema; produces either
local or systemic effect
3. Parenteral—a route other than an oral route; usually refers to an
injection
4. Intravenous (IV)—administration into a vein; shortest onset of
action and higher risk of adverse events compared with other routes
of administration
5. Intramuscular (IM)—administration into the muscle; sometimes
painful
6. Subcutaneous (SC, SQ)—injected beneath the skin (e.g., insulin)
7. Oral or nasal—particles, volatile liquids, or gasses that are inhaled
(e.g., nitrous oxide–oxygen [N2O-O2] analgesia; as are some
medications used to treat allergies and asthma)
8. Topical—ointments or creams applied to the skin or mucous
membranes (e.g., hydrocortisone)
9. Sublingual—a tablet that dissolves or a solution that is sprayed
under the tongue (for systemic effect)
D. Dosage forms
1. Capsule—gelatin shell
2. Tablet—compressed or molded dosage form
3. Ointment or cream—semi-solid for topical application
4. Suppository—penile, rectal, or vaginal; systemic or local
5. Solution—single-phase system consisting of more than one
constituent
6. Suspension—insoluble particles in liquid (e.g., milk of magnesia)
E. Dosage
1. Varies depending on the client’s:
a. Age—older adults may require lower doses because they may
metabolize and excrete drugs more slowly
b. Weight—total body weight, muscle-to-fat ratio, and body size
can affect drug absorption
c. Condition (disease)—many different disease states can affect
drug absorption, metabolism, or excretion (e.g., congestive heart
failure slows down metabolism; hyperthyroidism speeds up
metabolism)
d. Route of administration
2. Pediatric dose
a. Less than the adult’s dose
b. Based on:

893
 (1) Manufacturer ’s recommendations—best method
(2) Surface area—good method
(3) Weight—adequate method
(4) Age—very poor method

Adverse Reactions
Side Effect
A. Side effect on a nontarget organ—effect on an organ other than that
intended to be altered (e.g., insomnia resulting from a β2-agonist or
theophylline); dose related and often predictable
B. Toxic reaction—predictable and dose-related effect on a target organ
(e.g., insulin can lower blood glucose levels to the point of hypoglycemia)
C. Allergic reaction—varies from mild rash to anaphylaxis; involves an
antigen-antibody reaction (e.g., rash from penicillin); can include
urticaria, soft tissue swelling, and difficulty breathing; not predictable
and not dose related
D. Idiosyncrasy—abnormal drug response that is genetically related
E. Interference with natural defense mechanisms—body is less able to
fight infection (e.g., steroids weaken the immune system)
F. Teratogenic effect—adverse effect on a fetus (e.g., alcohol intake during
pregnancy produces fetal alcohol syndrome)

Pharmacokinetics
Pharmacokinetics is the way in which the body responds to drugs
through the four processes of absorption, distribution, metabolism, and
excretion (ADME).
A. Absorption depends on:
1. Degree of ionization—the more ionized (charged) the drug, the less
it will be absorbed; conversely, the less ionized the drug, the more it
will be absorbed; with weak acids or bases, this is a function of pH
2. Lipid solubility—the more lipid soluble the drug, the more readily it
will be absorbed; the less lipid soluble it is, the less readily it will be
absorbed
3. Factors that affect absorption
a. Client compliance
b. Age
c. Gender
d. Other disease states
e. Genetic variations

894
 f. Placebo effect
B. Distribution of the drug (Fig. 11–3)1

FIG 11–3 Absorption and outcome of a drug. (Modified from Holroyd SV, Wynn RL,
Requa-Clark B: Clinical pharmacology in dental practice, ed 4, St Louis, 1989, Mosby.)

1. Drugs are transported to the site of action

2. Only the free, or unbound, drug can cross cell membranes (indicated
by arrows between boxes in Fig. 11–3)
3. In each cellular compartment, equilibrium is reached between the
bound and unbound (free) drug
4. Redistribution—the drug moves from one tissue (where it exerts an
effect) to another tissue (where it is inactive); this is one method of
terminating a drug’s effect
5. Protein binding—drugs bind to protein receptors to varying degrees;
once the drug binds to a protein receptor, it cannot exert its
pharmacologic effect; when more than one drug is present in the
system, the drugs may compete for the same receptor site; the drug
with the stronger affinity will bind to the receptor site, and the drug
with the weaker affinity will then exert its pharmacologic effect
6. Tissue binding—some drugs can also bind to body tissues and cause
significant chemical effects (e.g., tetracycline has an impact on
developing bones and teeth of the fetus and of a young child)
C. Metabolism (biotransformation)—takes place mainly in the liver by
hepatic microsomal enzymes; metabolites are more polar, less protein
bound, and more easily excreted; drugs metabolized by microsomal
enzymes can affect their own metabolism or that of other drugs (e.g.,
either increasing [as with barbiturates] or decreasing [as with cimetidine,
erythromycin] the rate of metabolism); biotransformation is a source of
drug interactions

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D. Excretion—usually by way of kidneys (urine); can also occur through
feces (enterohepatic circulation), sweat, tears, or lungs (e.g., N2O is
exhaled)

Receptors
A receptor site is an area in the body to which a drug binds.
A. Agonist—a drug that has an affinity for a receptor site and binds to it,
producing an effect (e.g., opioid [narcotic] analgesic agent)
B. Antagonist—a drug has an affinity for a receptor site and binds to it
but produces no effect; competitively blocks the effect of an agonist (e.g.,
naloxone, an opioid [narcotic] antagonist blocks the effect of the agonist,
an opioid)

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Autonomic nervous system agents
Agents affecting the autonomic nervous system (ANS) are divided into
four groups: parasympathetic (P) nervous system stimulation (P +) and
inhibition (P −), and sympathetic (S) nervous system stimulation (S +)
and inhibition (S −).

Sympathetic (Adrenergic) Agents

Mimic the action of the sympathetic autonomic nervous system (SANS);
act like norepinephrine (NE) in the SANS, producing stimulation of the
SANS; epinephrine produces the same effect (Fig. 11–4)

FIG 11–4 Typical neurons with neurotransmitters (ACh,

acetylcholine; NE, norepinephrine), and the typical parasympathetic
nervous system (PANS); the sympathetic nervous system (SANS);
somatic nerves; and muscarinic (A) and nicotinic (B and C)
receptors.

A. Adrenergic agonists
1. The SANS is activated by fear (the “fight-or-flight” response)
2. Catecholamine—chemical structure of some adrenergic agents
3. Receptors in the SANS include alpha (α) and beta (β) types:
a. α1-Receptors—produce constriction of smooth muscles and
blood vessels (vasoconstriction)

897
 b. β-Receptors
(1) β1-Receptors—stimulate the heart, increase heart rate
(HR), increase the contractility and conduction velocity of
the heart, and cause bronchodilation
(2) β2-Receptors—relax smooth muscles, causing dilation of
the blood vessels of skeletal muscle (vasodilation) and
bronchodilation
B. Pharmacologic effects and adverse reactions
1. The central nervous system (CNS)—stimulation produces increased
alertness; may also cause anxiety, anorexia
2. Stimulation of the heart—S +, produces
a. Positive chronotropic effect (increased HR)
b. Positive inotropic effect (increased strength of contraction of the
heart)
c. Arrhythmias, with higher doses
d. α-Receptor stimulation—decreases HR because of the indirect
(reflex vagal) effect
3. Vascular effects (on the arterial tree) result from
a. α-Receptors—causing vasoconstriction of blood vessels
b. β-Receptors—causing vasodilation of skeletal muscle blood
vessels
c. Total peripheral resistance (TPR)—force against which the heart
works to circulate blood
(1) α-Receptors—increased TPR
(2) β-Receptors—decreased TPR
4. Mydriasis (pupil dilation) and reduced intraocular pressure; useful
in treating glaucoma
5. Bronchodilation (by action of β2-agonist); useful in treating clients
with asthma
6. Production of thick, viscous saliva
C. Drug interactions—examples of interactions caused by adrenergic
agents:
1. Tricyclic antidepressants (TCAs; e.g., amitriptyline [Elavil],
imipramine [Tofranil])—interaction increases blood pressure;
produces dysrhythmias
2. β-Blockers (e.g., propranolol [Inderal])—produce hypertension and
bradycardia (slowed HR)
3. Antidiabetic agents (e.g., insulin, glipizide [Glucotrol], glyburide
(DiaBeta)—increase the blood glucose level
4. Monoamine oxidase inhibitors (MAOIs)— no problem with

898
 epinephrine; indirect-acting amines (e.g., pseudoephedrine) must be
avoided
5. General anesthetics—halogenated hydrocarbons (e.g., halothane
[Fluothane]) sensitize the myocardium to catecholamines;
epinephrine is a catecholamine; increase the risk of
arrhythmia/dysrhythmias
D. Dental hygiene considerations—the client’s pulse and blood pressure
(BP) must be checked; all these medications can increase HR and BP
E. Therapeutic uses (Table 11–3)

Table 11–3
Adrenergic Agents and Their Use

Receptor
Adrenergic Agent Comments
Stimulated
Epinephrine (Adrenalin) αβ Endogenous catecholamine; local anesthetic
additive
Methylphenidate (Ritalin) α Attention deficit hyperactivity disorder
(ADHD)
Phenylephrine (Neo- α Nasal decongestant
Synephrine)
Levonordefrin (Neo- α>β Local anesthetic additive
Cobefrin)
Amphetamine αβ Diet pill (abused)
Pseudoephedrine (Sudafed) αβ Orally active nasal decongestant

1. Medical purposes—treatment of:

a. Anaphylaxis
b. Cardiac arrest
c. Nasal congestion—decongestant
d. Asthma (β2-agonist)
e. Attention deficit hyperactivity disorder (ADD or ADHD)
f. Glaucoma
2. Dental purposes
a. Local anesthetic additive (vasoconstrictor)
b. Hemostatic additive to reduce bleeding; provides adequate
tissue retraction (cord)
F. Adrenergics as vasoconstrictors are contained in local anesthetic
solutions
1. Examples
a. Epinephrine (Adrenalin)
b. Levonordefrin (Neo-Cobefrin)
2. Advantages of adrenergic vasoconstriction

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 a. Prolongs duration of anesthesia
b. Reduces systemic toxicity
c. Provides hemostasis
d. Reduces absorption (vasoconstriction)
e. Increases concentration of anesthetic at the nerve membrane
3. Disadvantages of adrenergic vasoconstriction
a. Excessive amount produces systemic toxicity
b. In persons with cardiovascular disease:
(1) Reasonable amounts can be used in local anesthetic
additives for clients whose cardiovascular conditions are
stable
(2) Avoid using epinephrine-impregnated retraction cords
(3) Maximum (safe) dose (MD) varies for normal and clients
with cardiovascular disease
(a) Epinephrine—dose for normal clients, 0.2 mg; for
clients with cardiovascular disease, 0.04 mg
(b) Levonordefrin (Neo-Cobefrin)—dose for normal
clients, 1 mg; for clients with cardiovascular disease,
0.2 mg (some sources state 1.0 mg)
c. Hyperthyroidism—vasoconstrictors may produce a thyroid
storm in clients who have not received treatment and in those
receiving drug therapy
(1) Thyroid storm or thyroid crisis is characterized by an
acceleration of all body processes (e.g., increases in HR, BP,
respiration, body temperature, and pulse)
(2) Pulmonary edema and congestive heart failure can occur
4. Minimize toxicity by:
a. Injecting slowly
b. Aspirating before injecting
c. Calming the client
d. Using the lowest effective dose
5. Dental hygiene considerations
a. Use is contraindicated in clients with uncontrolled
cardiovascular disease
b. Check blood pressure and pulse

α-Adrenergic Blockers (α-Blockers)

See the section on “Cardiovascular Agents” for a more detailed
discussion.
A. Mechanism of action—block α-receptors, which block action of the

900
SANS
B. Used to treat hypertension (e.g., Raynaud disease)
C. Examples (note generic names ending with “-sin”)
1. Prazosin (Minipress)
2. Terazosin (Hytrin)
3. Doxazosin (Cardura)

β-Adrenergic Blocker (β-Blocker) Antagonists

See the section on “Cardiovascular Agents” for more information.
A. Mechanism of action—drug blocks SANS action (β-receptors); some
β-blockers are more selective for the β1-receptor than β2-receptor; some
drugs are formulated to target β1-receptors, others to β2-receptors; other
drugs target both β1- and β2-receptors
B. Used to treat hypertension, angina, arrhythmias; also congestive heart
failure, anxiety, and glaucoma; used to prevent myocardial infarction (MI,
heart attack)
C. Examples (note generic names ending with “-olol”)
1. Propranolol (Inderal)—nonselective β1- and β2-blocker
2. Metoprolol (Lopressor)—selective β1-blocker
3. Atenolol (Tenormin)—selective β1-blocker
D. Dental hygiene considerations
1. Check the client’s BP and pulse—these medications can increase or
decrease HR
2. Raise the dental chair slowly, and allow the client to remain seated
for a few minutes to minimize the risk of orthostatic hypotension

Adrenergic Neuronal Agonists and Antagonists

A. Pharmacologic effects—affect the release of norepinephrine from
nerve endings and the level of adrenergic activity; influence α-receptor
and β-receptor activities
B. Therapeutic use—treatment of hypertension; use is limited by adverse
effects (e.g., can cause xerostomia and sedation)
C. Examples
1. Reserpine (Serpasil)
2. Methyldopa (Aldomet)
3. Clonidine (Catapres)

Parasympathomimetic (Cholinergic) Agents

901
A. Cholinergic agonists—mimic the action of the parasympathetic
autonomic nervous system (PANS); stimulation of the PANS
1. Receptors—see Fig. 11–4 for an illustration of a typical cholinergic
nerve
a. Muscarinic—receptor stimulated by the compound found in the
poisonous mushroom Amanita muscaria (Fig. 11–4, A)
(1) Areas affected (A)
(a) Smooth muscle
(b) Cardiac muscle
(c) Gland cells
(2) Neurotransmitter—acetylcholine (ACh)
(3) Location—the synapse between the postganglionic fiber
and the neuroeffector organ in the PANS
(4) Stimulated by muscarine
(5) Blocked by atropine
b. Nicotinic—receptor stimulated by nicotine; found in cigarettes
(Fig. 11–4, B and C)
(1) Areas affected
(a) Postganglionic neurons (B)
(b) Skeletal muscle end plates (C)
(2) Neurotransmitter—acetylcholine (ACh)
(3) Location—autonomic ganglia (B) and neuromuscular
junction (C)
(4) Stimulated by nicotine
(5) Blocked by hexamethonium (autonomic, B) and d-
tubocurarine at the neuromuscular junction (C)
2. Acetylcholine—the following diagram illustrates synthesis and
inactivation of ACh

3. Classification and mechanism of action

a. Direct-acting drugs—act just as ACh at the receptor site, such
as:
(1) Choline derivatives

902
 (2) Pilocarpine (Salagen)
b. Indirect-acting drugs—increase the amount of ACh indirectly;
block ACh inactivation by inhibiting acetylcholinesterase
(AChE), the enzyme that normally destroys ACh
(1) “Reversible” cholinesterase inhibitors—drugs that block
action of AChE, but whose action is terminated (ACh is
then destroyed)
(a) Edrophonium (Tensilon)
(b) Physostigmine (Eserine)
(c) Neostigmine (Prostigmin)
(2) “Irreversible” cholinesterase inhibitors—drugs that attach
to and inactivate AChE (e.g., organophosphates used as
insecticides [malathion, parathion])
4. Pharmacologic effects—similar to stimulation of the PANS
a. Smooth muscle stimulation
(1) Increase in gastrointestinal (GI) motility—diarrhea may
result; advantageously used to treat postoperative GI and
genitourinary (GU) retention
(2) Bronchoconstriction—causes constriction of bronchial
smooth muscle, an adverse reaction
b. Glands—increased secretion of saliva; used to treat dry mouth
(xerostomia)
c. Eye—decreased intraocular pressure; used to treat glaucoma
5. Toxic reactions—symptoms of overdose are extensions of the
pharmacologic effects; the “too much” effect
a. SLUD—excessive salivation, lacrimation (tearing), urination,
and defecation
b. Treatment of overdose
(1) Pralidoxime (2-PAM, Protopam)—regenerates AChE
(2) Atropine—antimuscarinic; blocks the muscarinic effects of
ACh excess (not nicotinic effects)
6. Dental hygiene considerations
a. Oral forms can cause increased salivation and may cause
hypotension and bradycardia
b. Clients should maintain good oral hygiene
c. Have client rise slowly from the dental chair to minimize
orthostatic hypotension
7. Dental use—treatment of xerostomia; pilocarpine tablets may
increase salivary flow
B. Anticholinergic agents—block muscarinic actions of the PANS
1. Basic principles

903
 a. Decreased salivary flow; used advantageously to dry up saliva
b. Many drugs can have an anticholinergic, atropinic, or atropine-
like effect
c. Anticholinergic agents block the muscarinic receptors
2. Pharmacologic effects on the:
a. Heart—tachycardia (increased HR; useful during general
anesthesia when HR may fall too low)
b. Eye—produces:
(1) Mydriasis—dilation of pupils; results in photophobia
(2) Cycloplegia—paralysis for distant vision; client cannot
focus or read up close
(3) Avoid repeated doses in clients who have narrow-angle
glaucoma (this is the only autonomic drug group relatively
contraindicated in certain forms of glaucoma)
c. Salivary secretions—salivary flow reduced; useful in dentistry
(Table 11–4 lists several drug groups that produce xerostomia)

Table 11–4
Xerostomia-Producing Drug Groups with Examples

Drug Group Examples

Antiacne Isotretinoin
Anticholinergics* (P-) Atropine
Anticonvulsants Carbamazepine, felbamate, gabapentin,
lamotrigine
Antidepressants Amitriptyline, imipramine, fluoxetine,
fluvoxamine
Antihistamines Astemizole, brompheniramine, chlorpheniramine,
loratadine
Antihypertensives* Clonidine, guanethidine, methyldopa, captopril
Antinauseants Cyclizine, diphenhydramine, meclizine
Antiparkinson drugs Benztropine mesylate, biperiden, carbidopa,
levodopa, trihexyphenidyl
Antipsychotics Chlorpromazine, clozapine, fluphenazine,
haloperidol, thioridazine
Antispasmodics Dicyclomine, propantheline
Antidiarrheal Diphenoxylate, loperamide
Benzodiazepines Diazepam, alprazolam, lorazepam
Decongestants Pseudoephedrine
Diuretics Hydrochlorothiazide, furosemide
Muscle relaxants Baclofen, orphenadrine
Nonsteroidal anti-inflammatory Diflunisal, ibuprofen, naproxen
drugs (NSAIDs)
* More likely to produce xerostomia; effect still dose related.

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 d. CNS—can cause sedation or excitation
3. Adverse reactions and toxicity—contraindications to use
a. Xerostomia, dry skin, and dry eyes—caution in persons wearing
contact lenses; reduces lactation in nursing mothers
b. Eyes—blurred vision; avoid use in clients with narrow-angle
glaucoma; careful use of eyedrops in persons with wide-angle
glaucoma is usually acceptable
c. Urinary retention—avoid use in persons with prostatic
hypertrophy (enlarged prostate)
d. Dizziness and fatigue—toxic levels can cause delirium,
hallucinations, coma, and convulsions
e. Tachycardia—monitor persons with cardiovascular disease
f. Reduced GI motility—avoid in persons with gastric retention or
intestinal obstruction
4. Clinical uses—effects offer advantageous treatment in:
a. GI activity—has antispasmodic properties (reduced GI
overactivity) and reduces secretions (e.g., stomach acid)
b. Ophthalmology—dilates eyes and paralyzes the muscles of
accommodation (the person can see only distant objects); used
for eye examinations
c. Parkinson’s disease
d. Drug-induced Parkinson’s disease
e. Dental
(1) Used before general anesthesia to dry up saliva and to
prevent vagal slowing of the heart
(2) Used to prepare the mouth for procedures that require a
drier field
5. Dental hygiene considerations
a. Xerostomia—instruct the client to drink plenty of water, suck on
tart sugarless gum or candy with xylitol or ice chips, avoid
products containing alcohol and caffeine, and avoid juices and
soft drinks to reduce the risk of dental caries; saliva substitutes
(Xero-lube, Salivart) can also be recommended
b. Tachycardia—check the client’s BP and pulse
c. Sedation—an increased risk of sedation exists if combined with
other sedating agents; client should be instructed to avoid
driving or operating heavy machinery or any task that requires
thinking or concentration
6. Examples of anticholinergic agents
a. Atropine
b. Benztropine mesylate (Cogentin)

905
 c. Dicyclomine (Bentyl)
d. Methantheline (Banthine)
e. Propantheline (Pro-Banthine)
f. Trihexyphenidyl hydrochloride (Artane)

Local Anesthetic Agents

See the section on “Management of Pain and Anxiety” in Chapter 18.
A. Chemistry
1. Three components common to local anesthetics (LAs)
a. Aromatic lipophilic group—contains a benzene ring
b. Intermediate chain—either ester or amide
c. Hydrophilic amino group—secondary or tertiary amine
2. Intermediate chain
a. Composed of esters
(1) Tetracaine (Pontocaine)
(2) Procaine (Novocain)
(3) Propoxycaine (in Ravocaine)
b. Composed of amides
(1) Articaine (Septocaine)
(2) Lidocaine (Xylocaine)
(3) Mepivacaine (Carbocaine)
(4) Prilocaine (Citanest)
(5) Bupivacaine (Marcaine)
B. Mechanism of action by:
1. Nerve fiber susceptibility—nerves and sensations generally are
affected in this order: autonomic, cold and warmth, pain, touch
pressure, vibration, proprioception, and motor; sensations and nerve
functions are regained in reverse order
2. Specific receptor theory—the anesthetic agent binds to receptors on
the sodium channel; permeability to sodium ions is decreased, and
nerve conduction is interrupted
3. Base and salt forms of LAs (Fig. 11–5)—both forms are needed; the
base penetrates the lipid membranes, and the salt traverses the
cellular fluid

906
 FIG 11–5 Base and salt forms of local anesthetics. The pH determines
the amounts on each side (in equilibrium).

4. Inflammation—reduces LA effect
a. Acid environment (pH 5.5) of inflammation increases the
ionized form and reduces the anesthetic effect
b. Edema—dilutes the LA because of an increase in fluids
c. Increased tissue vasculature—increased blood supply carries
away the LA; duration of action is shortened
C. Pharmacokinetics
1. Absorption
a. Effect on the vasculature—LAs produce vasodilation (except
cocaine); vasoconstrictors are added to counteract dilation
b. Absorption and distribution of LAs are determined by the pH
of the environment, as shown in the following reaction:

c. Solubility
(1) Lipid-soluble—the nonionized form penetrates membranes

907
(2) Water-soluble—the ionized form crosses the cell membrane and
exerts its effect at the nerve
d. Rate of absorption
(1) The faster the rate of absorption, the greater the chance of systemic
toxicity and the shorter the duration of action
(2) Route of administration alters the rate of absorption; the topical
anesthetic agent can be absorbed quickly
2. Distribution—the level of the LA in the blood is determined by
movement of the LA around the body; side effects occur if the LA reaches
a high enough level in other organs (e.g., CNS, heart); blood level is
determined by:
a. Rate of injection
b. Speed of absorption (depends on proximity to blood vessels)
c. Speed of distribution to other tissues
d. Speed of metabolism and excretion
3. Metabolism (biotransformation)
a. Esters—hydrolyzed by plasma pseudo-cholinesterases
(1) Procaine—metabolized to para-aminobenzoic acid (PABA)—
allergenic
(2) Congenital cholinesterase deficiency—LAs containing esters are
absolutely contraindicated
b. Amides—metabolized in the liver
(1) Liver dysfunction—LAs containing amides should be given
cautiously; they may be metabolized more slowly; toxic levels can build
up if repeated doses are administered
(2) Prilocaine—metabolized to orthotoluidine, which can produce
methemoglobinemia, a condition in which excess methemoglobin in the
blood results in lowered oxygen-carrying capacity; not usually a problem
in healthy clients
4. Excretion capacity
a. Esters are almost completely metabolized before they are excreted
b. Amides are mostly metabolized before they are excreted
c. The presence of significant renal disease can cause all LA metabolites
to accumulate
D. Adverse reactions
1. Factors influencing toxicity
a. Drug
b. Concentration
c. Route
d. Tissue inflammation
e. Vasoconstriction

908
 f. Body weight
g. Rate of metabolism and excretion
2. Symptoms of LA toxicity—the CNS and the cardiovascular system
(CVS) are affected most; the severity of effects is related directly to
the amount of the LA in blood
a. CNS response—stimulation followed by depression
(1) CNS stimulation (excitatory)—produces restlessness,
shivering, tremors, convulsions
(2) CNS depression—results in sedation, drowsiness,
respiratory and cardiovascular depression, coma; can occur
without previous excitation
b. CVS response
(1) Antidysrhythmic action—lidocaine used intravenously to
treat dysrhythmias
(2) Vasodilation produces hypotension; releases vascular
smooth muscle; lowers resistance
3. Malignant hyperthermia—life-threatening complication associated
with the administration of general anesthesia, characterized by
tachycardia, tachypnea, cardiac dysrhythmia, muscle rigidity, and
extreme increase in body temperature; LA agents containing amide
administered in standard doses in oral health care appear to be safe for
individuals susceptible to malignant hyperthermia
4. Allergic reactions
a. Range of reactions—mild rash to anaphylaxis
b. Esters—much more allergenic than amides; note that the presence
of true allergic reactions to amides is still debated; it is unclear
whether people are actually allergic to amides
c. Other ingredients may produce allergic reactions (preservatives,
antioxidants); see H. Composition of LA solutions
d. Administer LAs containing amides to clients allergic to esters, and
vice versa
E. Drug interactions
1. Esters administered in the presence of sulfonamides—esters may
interfere locally with the sulfonamides’ anti-infective action
2. Lidocaine administered in the presence of cimetidine (Tagamet)—
cimetidine prolongs the metabolism of lidocaine in the liver; levels
of lidocaine in blood may increase with repeated doses; not
important to dentistry
F. Dental hygiene considerations
1. CNS stimulation—calm client with a soothing voice and manner
a. Administer a lower dose of the LA

909
 b. Switch to another LA
2. Sedation
a. Have someone drive the client home
b. Have the client sit in the reception area until he or she no longer
feels tired
c. Use caution while using opioid analgesics, antianxiety drugs, or
other sedating drugs if sedation persists
3. Have the client refrain from imbibing very hot and very cold foods or
drinks
4. Advise patient to be conscious of accidentally biting the cheek until
all feeling has returned after LA
G. Vasoconstrictors and cardiovascular disease
1. Clients with controlled cardiovascular disease (e.g., hypertension,
angina, arrhythmias) can receive LAs
2. Do not exceed the maximum dose of a vasoconstrictor in clients with
cardiovascular disease; use caution
3. Check the client’s pulse rate and BP before administering an LA that
contains a vasoconstrictor
H. Composition of LA solutions
1. Other ingredients
a. Vasoconstrictors—epinephrine (Adrenalin), levonordefrin (Neo-
Cobefrin)
b. Preservatives (antiseptics)—methylparabens and
propylparabens are no longer present in dental anesthetic
cartridges
c. Antioxidant (preservative)—sodium bisulfite, acetone sodium
bisulfite, or sodium metabisulfite; the antioxidant is present if
the LA contains a vasoconstrictor
(1) May precipitate asthma attacks in susceptible persons
(2) Sulfite, sulfa, and sulfur are not cross-allergenic
d. Alkalinizing agent—sodium hydroxide; adjusts pH; maintains
the LA in salt form so that it will be soluble in water
e. Sodium chloride—makes the solution isotonic
2. LAs in dental cartridges (Table 11–5)

910
 Table 11–5
Local Anesthetic Agents in Dental Cartridges*

* Cartridge = 1.8 mL.

I. Topical LAs and injection-free local anesthesia

1. Benzocaine—ester-based anesthetic; used topically because it cannot
be used systemically; some sensitization occurs; use gloves to avoid
skin contact with the drug, rash, and sensitization
2. Lidocaine—topically effective
3. Tetracaine—avoid use because of toxicity and slow onset
4. Lidocaine and prilocaine (injection-free local anesthesia)
a. Used in adults who require limited pain control during root
debridement or in those who fear injections
b. Gel applied into the periodontal pocket to provide pain relief
during scaling and root-planing procedures (e.g., Oraqix)
c. Amide-type topical anesthetic agent
5. Dental hygiene considerations
a. Use the smallest volume and the lowest concentration to avoid
adverse effects
b. Limit area of application
c. Instruct the client not to swallow the topical LA
d. Instruct the client to avoid very hot and very cold foods; client
may not be able to sense temperature changes because of the
topical LA

911
Local anesthetic reversal agent
General Considerations
A. Dental use—for reversal of soft tissue anesthesia (lip, tongue) and
functional deficits resulting from an intraoral submucosal injection of an
LA with a vasoconstrictor; reduces recovery time of normal sensation
B. Contraindications—not recommended for use in children less than 6
years of age or weighing under 15 kg (33 lb)
C. Mechanism of action—expands blood vessels and increases blood
flow, thereby accelerates the reversal of soft tissue numbness
D. Adverse effects
1. Transient pain at injection site
2. Tachycardia and arrhythmia may occur with parenteral
administration but are uncommon after submucosal administration
E. Example—phentolamine mesylate (OraVerse)

912
General anesthetics
General Considerations
A. Dental use—in extensive oral surgery and in an anxious client, a
mentally challenged client who cannot cooperate, and any client who
cannot control behavior during dental care
B. Stages and planes of anesthesia
1. Stage I—analgesia
2. Stage II—excitement and delirium; avoid, if possible
3. Stage III—surgical anesthesia; divided into four planes
4. Stage IV—respiratory paralysis (medullary paralysis); death ensues
without intervention
C. Routes of administration
1. Intravenous anesthetics—fixed anesthetics (cannot be removed by
respiration)
a. Barbiturates (e.g., thiopental [Pentothal])
b. Dissociative—ketamine (Ketalar, Ketaject)
c. Neuroleptanalgesic—fentanyl (Sublimaze) plus droperidol
(Inapsine, Innovar)
2. Inhalation gases
a. Nitrous oxide combined with oxygen
3. Inhalation volatile liquids
a. Halogenated hydrocarbons (e.g., halothane [Fluothane])

Specific Agents
A. Nitrous oxide–oxygen (N2O-O2) analgesia
1. Incomplete anesthetic; if used alone, the client cannot reach stage III
2. Usual concentration maintained at 30% to 50% to prevent O2
deprivation
3. Administration
a. Begin with 100% O2 for 2 to 3 minutes
b. Then add N2O in 5% to 10% increments until the desired state
of sedation is reached (usually 3 to 5 minutes)
c. Once the procedure is terminated, the client should receive O2
for 5 minutes
4. Advantages
a. Rapid onset and recovery
b. Least toxic; safe when used appropriately
c. May be used in children

913
 d. Nonflammable
e. Nonirritating to the GI tract
f. Good analgesic properties; anxiolytic (antianxiety) effect
5. Disadvantages
a. “Misuse” potential exists with both clients and oral health care
professionals
b. Reduces fertility
c. Associated with high rate of miscarriages
d. Improper use (without concomitant LA block injection) gives
N2O a “bad name”; analgesia from N2O-O2 still requires the use
of an LA agent
e. Nausea—most common complaint; caused by rapid changes in
N2O concentration of inspired air, change levels slowly
f. Diffusion hypoxia—low level of O2 in lungs because of diffusion
of O2 into the blood supply rarely occurs; administer 100%
oxygen at the end of the procedure to prevent this
6. Adverse effects
a. Misuse or faulty installation of equipment
b. Nausea, vomiting
c. Headache, if oxygen is not given at the end of the procedure
d. N2O abuse
7. Drug interactions—occur with any drug that can cause CNS
depression or sedation
8. Contraindications
a. Respiratory problems
(1) Upper respiratory tract infection (URI)—difficult to
administer N2O-O2 analgesia when nasal passages are
congested
(2) Chronic obstructive pulmonary disease (COPD), such as
emphysema or bronchitis
(a) Administering O2 at the usual concentration with N2O
could produce apnea (cessation of respiration)
(b) The client’s respiration is driven by carbon dioxide
(CO2) levels
b. Pregnancy—the first trimester is the most critical; the greatest
number of spontaneous abortions occur at this stage (especially
in oral health care personnel); teratogenic effect unknown, but
not probable
c. Epilepsy
d. Emotional instability

914
 e. Multiple sclerosis
f. Previous negative experience
9. Dental hygiene considerations
a. The client’s emotional and psychiatric history
b. Clients may have fanciful dreams while under the effects of
N2O-O2; male dental personnel should ensure that female dental
personnel are always present with female clients to avoid
unfounded accusations
B. Halogenated hydrocarbons
1. Examples
a. Halothane (Fluothane)
b. Enflurane (Ethrane)
c. Isoflurane (Forane)
d. Desflurane
e. Sevoflurane
2. Does not cause irritation of the mucosal membrane; not explosive;
poor muscle relaxation; no analgesia; little nausea or vomiting
3. The myocardium is sensitized to catecholamines (epinephrine)—can
produce dysrhythmias
4. Hepatotoxic—greater with more exposures
5. Drug interaction—can occur if administered with drugs that cause
CNS depression or sedation (e.g., opioid analgesics, barbiturates,
benzodiazepines, antipsychotic drugs, antidepressants,
antihistamines)
6. Dental hygiene considerations
a. Sedation and amnesia—clients should have someone to drive
them home after the procedure
b. Clients should be instructed to avoid driving or operating heavy
machinery or any task that requires thinking or concentration
C. Ultrashort-acting barbiturates
1. Examples
a. Thiopental (Pentothal); also known as “truth serum”
b. Methohexital (Brevital)
c. Thiamylal (Surital)
2. Rapid onset; short duration secondary to redistribution to brain,
muscles, and adipose tissue
3. Used to induce general anesthesia; the client advances rapidly to
stage III
4. Adverse reaction—laryngospasm
5. Contraindicated in porphyria and status asthmaticus
D. Ketamine (Ketalar, Ketaject) produces dissociative anesthesia

915
 1. Not a complete anesthetic
2. The client is not asleep and does not respond to stimuli in the
environment (trance-like state)
3. Reactions—bad dreams, may be described by the client as “bad
trip”; more likely to occur in adults
4. Can produce hyperactive reflexes such as coughing, gagging, or
tongue movements
E. Neuroleptanalgesia—anesthetic, analgesic (Innovar)
1. Fentanyl (opioid) plus droperidol (tranquilizer)
2. Adverse reaction—produces “board-like” chest, which requires
ventilatory action; performing cardiopulmonary resuscitation (CPR)
is difficult

916
Sedative-hypnotic medications
General Considerations
A. Used to treat anxiety disorder, situational anxiety, and insomnia
B. Other drugs, in addition to sedative-hypnotics, can cause sedation; all
can increase a client’s risk for sedation when used together (Box 11–1)

Box 11–1
Selec t Pharmac ologic Groups Produc ing
Sedation
Alcohol, ethyl
Antihistamines
Antipsychotics (phenothiazines)
Barbiturates
Benzodiazepines
Centrally acting muscle relaxants
Nonbarbiturate sedative-hypnotics
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Opioid (narcotic) analgesic agents
Tricyclic antidepressants

C. Dental concerns
1. Additive CNS depressant effects when taken with alcohol, opioid
analgesics, or other CNS depressants
2. The client should be instructed to avoid driving or operating heavy
machinery or any task that requires thinking or concentration

Benzodiazepines
A. Mechanism of action—potentiates the inhibitory neurotransmitter γ-
aminobutyric acid (GABA); GABA-ergic neurotransmission increases
sedation
B. Wide therapeutic index when ingested alone; much safer than
barbiturates
C. Adverse reactions
1. Sedation—the client should be instructed to avoid driving or
operating heavy machinery or any task that requires thinking or
concentration
2. Addiction potential—some potential exists but less than that for

917
 barbiturates
3. Teratogenicity—increased incidence of birth defects if taken during
the first trimester; this is an FDA (U.S. Food and Drug
Administration) category D or X drug
4. Thrombophlebitis—when administered intravenously; local
irritation may occur with diazepam because of the use of propylene
glycol as diluent; midazolam (Versed) is soluble in water, so no
propylene glycol is used
5. Overdose—treated with flumazenil (Mazicon), a benzodiazepine
antagonist
D. Specific agents
1. Examples of benzodiazepines and typical doses are provided in
Table 11–6 (see also Table 11–3)

Table 11–6
Examples of Benzodiazepines

Drug Usual Dose (oral) (mg/day)

Alprazolam (Xanax) 0.5-4.0
Chlordiazepoxide (Librium) 15.0-100.0
Diazepam (Valium) 2-10
Flurazepam (Dalmane) 15-30
Lorazepam (Ativan) 2-6
Midazolam (Versed) Intravenous
Oxazepam (Serax) 15-30
Temazepam (Restoril) 15-30
Triazolam (Halcion) 0.125-0.5

2. Differences between benzodiazepines

a. Equivalent dose—usual dose varies with agent
b. Duration—varies from a few hours to a few days
c. Metabolism
(1) Most benzodiazepines are metabolized by oxidation to
active metabolites
(2) Oxazepam, lorazepam, and temazepam are inactivated by
glucuronidation
(3) The client’s age is a factor that can reduce the metabolism
of oxidized benzodiazepines
3. Drug interactions—the presence of cimetidine reduces the
metabolism of oxidized benzodiazepines; clients who smoke
experience less sedation (smoking induces liver enzymes)
E. Dental hygiene considerations
1. Can cause anterograde amnesia (limited to events occurring after

918
 drug administration); clients should be cautioned about making life-
changing decisions after taking a benzodiazepine
2. All other dental hygiene considerations are the same as the general
considerations

Barbiturates
A. Pharmacologic effects
1. Continuum with increasing doses—from sedation and anxiety relief,
to sleep, and then anesthesia
2. Anticonvulsant—long-acting agents are usually the most useful
3. Muscle relaxation—this action is inseparable from CNS sedation
effects
4. No analgesic action—in the presence of pain, agitation may result if
an analgesic is not given concurrently
B. Adverse reactions
1. CNS depression—drowsiness and impaired performance and
judgment; the client should be instructed to avoid driving or
operating heavy machinery, or anything that requires thinking or
concentration (see Box 11–1 for drugs that produce sedation)
2. Abuse—euphoria, habituation, withdrawal, increased tolerance
3. Acute overdose—causes depression of respiratory system and
respiratory arrest
4. Barbiturates—contraindicated in porphyria; stimulate liver
microsomal enzymes (drugs metabolized by the liver disappear
more quickly)
C. Therapeutic uses
1. Medical uses—treatment of epilepsy, sedation, or anxiety
2. Dental uses
a. Preoperative anxiety reduction—oral or intramuscular
administration
b. Induction of general anesthesia—intravenous barbiturates
d. Dental hygiene considerations—same as earlier “General
Considerations” under “Sedative-Hypnotic Medications”
E. Examples—barbiturates
1. Ultrashort-acting—for induction of general anesthesia
a. Thiopental (Pentothal)
b. Methohexital (Brevital)
2. Short-acting—for insomnia; most abused form
a. Pentobarbital (Nembutal)
b. Secobarbital (Seconal)

919
 3. Intermediate-acting—for insomnia or daytime sedation; frequently
abused
a. Amobarbital (Amytal)
b. Butabarbital (Butisol)
4. Long-acting—treatment of seizure disorders, anticonvulsant; seldom
abused
a. Phenobarbital (Luminal)
b. Primidone (Mysoline)

Nonbarbiturate Nonbenzodiazepines
A. Nonbenzodiazepine—benzodiazepine receptor agonists
1. Zolpidem (Ambien)
2. Zaleplon (Sonata)
3. Eszopiclone (Lunesta)
B. Melatonin receptor agonist—ramelteon (Rozerem); used to treat
insomnia characterized by difficulty falling asleep
1. Centrally acting muscle relaxants
a. Carisoprodol (Soma)—Class 2 (CII) drug
b. Chlorzoxazone (Paraflex)
c. Methocarbamol (Robaxin)
d. Orphenadrine (Norflex)
2. Miscellaneous
a. Baclofen (Lioresal)
b. Tizanidine (Zanaflex)
c. Dantrolene (Dantrium)
C. Dental hygiene considerations—same as earlier “General
Considerations”

Analgesics
See Table 11–7.

920
Table 11–7
Analgesic Summary

+, Very low; ++, low; +++, moderate; ++++, high; 0, no effect.

a Poisoning—salicylism.
b Very high doses.
c Upset stomach, ulcers, pain.
d Nausea, constipation.
e Aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen.
f Hepatitis in persons with systemic lupus erythematosus or rheumatoid arthritis.
g With acute overdose.

General Considerations
A. Pain is characterized by:
1. Perception—experienced uniformly through the nerve (signal from
the site of pain to the CNS)
2. Reaction—varies greatly from person to person (interpretation of the
signal within the CNS)
B. Variables—client’s age, gender, race, ethnic group, fatigue, and pain

921
threshold

Salicylates (Aspirin)
A. Mechanism of action—primarily peripheral; prostaglandin synthesis
inhibitor functions by inhibiting the enzyme cyclooxygenase (COX) or
prostaglandin synthetase
B. Pharmacologic effects—“the three As”
1. Analgesic—reduces pain
2. Antipyretic—therapeutic dose reduces elevated body temperature
3. Anti-inflammatory—higher dose reduces inflammation
C. Adverse reactions
1. GI upset—minimized by ingesting the drug with food, water, or
antacids
2. Alteration in bleeding
a. Platelet adhesiveness—reduced platelet adhesion for the life of
the platelet (4 to 7 days); normal clotting reappears 72 hours
after ingestion; reduced clotting effect requires only a low single
dose; useful in low doses to prevent clotting
b. Hypoprothrombinemia—reduced prothrombin levels; requires
several consecutive doses to reduce prothrombin levels
3. Salicylate toxicity (“salicylism”)—symptoms include tinnitus,
hyperthermia (increased body temperature), electrolyte and glucose
problems, and altered sensorium
4. Allergic reactions—true allergy is uncommon; if person is allergic,
some cross-reactivity exists with other agents (e.g., nonsteroidal anti-
inflammatory drugs [NSAIDs]); can produce an acute asthma attack;
persons with asthma and nasal polyps are more susceptible
5. Reye syndrome—children with chickenpox or influenza should not
be given aspirin; avoid aspirin in children and adolescents up to 18
years of age
D. Drug interactions—adverse reactions occur with aspirin used in
conjunction with:
1. Warfarin (Coumadin)—used as an anticoagulant; bleeding or
hemorrhage
2. Probenecid (Benemid)—used to treat gout; acute attack of gout
3. Tolbutamide (Orinase)—used to control diabetes; altered blood
glucose level
4. Methotrexate (MTX)—used to treat cancer or control arthritis; MTX
toxicity in bone marrow
5. Alcohol—can increase bleeding or hemorrhage

922
 6. Other anti-inflammatory drugs—can increase bleeding or
hemorrhage
E. Dental hygiene considerations
1. Avoid drugs that can cause GI upset or prolong bleeding time
2. Check for aspirin allergies
3. If taken before procedure, client may experience more bleeding than
normal

Nonsteroidal Anti-Inflammatory Agents (NSAIAs)

and Drugs (NSAIDs)
A. Mechanism—similar to that of aspirin, drug inhibits prostaglandin
synthesis (COX)
B. Pharmacologic effects—“the three As” (similar to aspirin)
1. Analgesic
2. Antipyretic
3. Anti-inflammatory
C. Adverse reactions
1. GI—more severe than aspirin; abdominal problems range from
discomfort to ulcers; treated or managed with prostaglandin—
misoprostol (Cytotec); increased risk for severe GI events, including
bleeding and ulcers
2. CVS—may increase the risk for serious cardiovascular thrombotic
events, stroke, and MI
3. CNS—dizziness, sedation; the client should be instructed to avoid
driving or operating heavy machinery, or any task that requires
thinking or concentration
4. Blood coagulation—reduction in platelet aggregation and possible
prolongation of bleeding time; alteration is reversible, unlike the
effect of aspirin, which is not reversible
5. Oral—can produce stomatic gingival ulceration and xerostomia
6. Renal—can result in renal failure or cystitis
7. Hypersensitivity—ranges from mild rash to anaphylaxis
D. Drug interactions
1. Lithium—can increase lithium levels
2. Digoxin—can increase the effects of digoxin
3. Methotrexate—can increase the effects of MTX
4. Antihypertensives—can reduce the antihypertensive effects of
diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-
blockers
5. Other inflammatory drugs—can increase bleeding and hemorrhage

923
 6. Alcohol—can increase bleeding or hemorrhage
E. Contraindications
1. Contraindicated in patients that have experienced asthma or allergic
reaction to aspirin therapy
2. Fluid-retention problems
3. Coagulation problems
4. Peptic ulcer disease
5. Ulcerative colitis
6. Renal disease; especially in patients at risk for renal disease or for
patients taking ACE inhibitors or angiotensin receptor blockers
(ARBs)
F. Dental hygiene considerations
1. Same as for aspirin
2. CNS sedation—the client should be instructed to avoid driving or
operating heavy machinery or any task that requires thinking or
concentration
G. Therapeutic uses
1. Pain control—analgesic; stronger than aspirin, equal to or stronger
than some opioids; strength of effect is dose dependent; anti-
inflammatory effect makes NSAIDs especially useful in dentistry
2. Arthritis—anti-inflammatory action
3. Dysmenorrhea (painful menstruation)—effective because the
mechanism of action is specific for the problem of excess
prostaglandins caused by excessive uterine contractions
H. Examples
1. Ibuprofen (Motrin-IB, Rufen, Nuprin, Advil); naproxen sodium
(Anaprox; Aleve); available without a prescription
2. Naproxen (Naprosyn)
3. Indomethacin (Indocin)—prescription only
4. Celecoxib (Celebrex)—prescription only
a. Caution should be exercised because COX-2 inhibitors can
increase the risk of a heart attack
b. Caution should be exercised because of an increased risk for
significant GI bleeding

Acetaminophen (N-Acetyl-p-Aminophenol [NAPAP];

Tylenol [Available Over the Counter; OTC])
A. Pharmacologic effects—“the two As”
1. Analgesic
2. Antipyretic

924
 3. Not an anti-inflammatory
B. Adverse reactions
1. Analgesic nephropathy—adversely affects the kidneys; more likely
to occur if used chronically in combination with aspirin or NSAIDs
2. Hepatotoxicity—may occur with acute overdose or chronic use;
delayed reaction; treated with N-acetylcysteine; may be fatal without
liver transplantation
C. Drug interactions—alcohol increases the risk of acetaminophen
toxicity
D. Contraindications
1. Hepatotoxicity
2. Renal toxicity
3. Clients with alcohol-abuse problems
E. Dental hygiene considerations—avoid use in clients with
hepatotoxicity, renal toxicity, or alcohol abuse problems

Opioid (Narcotic) Analgesic Agents

A. Pharmacologic effects—proportional to the “strength” of the opioid
1. Analgesia
2. Sedation (anxiety relief)
3. Euphoria
4. Dysphoria
5. Cough suppressant
6. GI effects
7. Respiratory effects
B. Examples of agonists (combine with opioid receptor and produce an
effect) are provided in Table 11–8)

Table 11–8
Examples of Agonists

Drug Usual Dose (Oral) (mg/day) “Strength”

Morphine 10-30 po q4h Stronger
Hydromorphone (Dilaudid) 1-6 q4-6 h
Meperidine (Demerol) 50-150 po q4h
Oxycodone (in Percodan) 5 q6h
Hydrocodone (in Vicodin) 5-10 po q4-6 h
Codeine (in Tylenol No. 3, Empirin No. 3) 30-60 q4-6 h Weaker
po, By mouth; q4h, every 4 hours; q4-6 h, every 4 to 6 hours; q6h, every 6 hours.

1. Agonist–antagonist agents
a. Example—pentazocine (Talwin-NX)

925
 b. Principle
(1) Maintain analgesic properties
(2) Have lower abuse potential
c. Can precipitate withdrawal in opiate addicts
2. Antagonists
a. Example—Naloxone (Narcan), Naltrexone (Vivitrol), Nalmefene
(Revex)
b. Combine with opioid receptor; produces no effect; reverses
opioid overdose
c. Therapeutic uses
(1) Treat opioid overdose
(2) Counteract respiratory depression
(3) Include in any dental emergency kit
C. Adverse reactions—proportional to the “strength” of the opioid
1. CNS effects—sedation, euphoria, dysphoria
2. Respiratory depression—dose related; overdose can result in death;
reversed with naloxone
3. GI—nausea, vomiting, constipation; diphenoxylate can be useful
therapeutically
4. Abuse—can occur with all opioid analgesics; tolerance develops to
all pharmacologic effects except miosis (pupillary constriction) and
constipation; withdrawal produced if the drug is abruptly stopped
5. Miosis
6. Urinary retention
7. Cardiovascular effects—orthostatic hypotension
D. Therapeutic uses
1. Pain relief—this is the central mechanism; agent affects a person’s
perception of pain; some opioids can relieve severe pain
2. Sedation and anxiety relief—not the main use of opioids; used
preoperatively
3. Cough suppression—antitussive action (cough suppressant); low
dose needed (e.g., codeine-containing cough syrups)
4. Diarrhea—symptomatic relief only; reduce GI motility by increasing
tone and spasm; diphenoxylate (in Lomotil)
E. Drug interactions
1. Increase sedation when used with other CNS depressant drugs
2. Increase constipation when combined with anticholinergic drugs
F. Dental hygiene considerations
1. Decrease the dose in hypertensive clients because of associated
urinary retention caused by opioids
2. Increased risk for sedation—as with other CNS depressant drugs

926
 3. Increased risk for xerostomia—as with anticholinergic drugs

Drugs Used for Gout

A. Disease—gout is a metabolic condition involving increased serum uric
acid, with episodes of acute attacks of pain in joints (big toe, knee) and
severe inflammation caused by deposition of monosodium urate
B. Prevention
1. Probenecid (Benemid)—uricosuric (promotes uric acid excretion);
aspirin interferes with this effect of probenecid
2. Allopurinol (Zyloprim)—xanthine oxidase inhibitor (inhibits uric
acid synthesis); also used in clients with cancer before chemotherapy
or radiation therapy when many cells are killed and release their
amino acids, which leads to accumulation of uric acid and attacks of
gout
C. Treatment
1. Colchicine—binds to microtubular protein tubulin (prevents
leukocyte migration and phagocytosis); inhibits formation of
leukotrienes; GI toxicity—nausea, vomiting, diarrhea are end points
of treatment and adverse reactions
2. NSAIDs—anti-inflammatory action ameliorates symptoms (e.g.,
indomethacin)

927
Anti-infectives (antibiotics)
General Considerations
A. Prevention of infection (see the section on “Disease Transmission” in
Chapter 10)
1. Sterilization measures prevent infection
2. Many infections—treat with local measures (e.g., incision and
drainage), antibiotics are often not needed; the client’s resistance
and the development of resistant strains of bacteria must be
considered
3. Antibiotic administration carries risks
4. Prophylaxis is rarely indicated except for decreasing the likelihood of
infective endocarditis in persons who have the highest risk,
prosthetic joint infection, or when client is immunosuppressed2 (see
Chapter 15, Table 15-2).
B. Definitions
1. Antimicrobial—agent that acts against microbes
2. Anti-infective—agent that acts against the organisms that cause
infections
3. Antibacterial—agent that acts against bacteria
a. Bactericidal—kills bacteria
b. Bacteriostatic—retards or incapacitates bacteria (reversible)
4. Antiviral—agent that acts against viruses
5. Antifungal—agent that acts against fungi
6. Antibiotic—agent that is effective in low concentrations; produced
by microorganisms; kills or suppresses growth of other organisms
7. Spectrum—range of an antibiotic’s anti-infective properties; can be
narrow (acting on few organisms) to wide or broad (acting on many
organisms); may include effectiveness against gram-positive and
gram-negative bacteria
8. Resistance—the organism is unaffected by an anti-infective; the
resistance may be natural (always has been resistant) or acquired
(resistance has developed); prolonged exposure to antibiotics allows
for the organism to develop resistance towards the antibiotic.
9. Suprainfection (superinfection)—onset of a new infection from an
organism other than the original organism; occurs after taking an
antimicrobial agent; the new infection is usually more difficult to
treat, and commonly occurs when the spectrum is the widest; for
example, Candida infection may arise in person taking tetracycline
10. Synergism—agent’s effect is more than additive (1 + 1 > 2)

928
 11. Antagonism—agent’s effect is less than additive (1 + 1 < 2)
C. General side effects
1. GI side effects—variable, depending on antibiotic; includes nausea,
vomiting, diarrhea, dyspepsia
2. Suprainfection from antibiotic-resistant bacteria is possible, usually
in the form of a vaginal yeast infection
3. Drug interactions
a. Oral contraceptives—some antibiotics may reduce effectiveness;
inform the client that alternative forms of birth control should
be used for the duration of the prescription, plus an additional 7
days or until the end of their menstrual cycle
b. Warfarin (Coumadin)—antibiotics alter the GI flora that make
vitamin K, which then can potentiate warfarin’s effect
D. Treatment versus prophylaxis
1. Treatment—the anti-infective is used to treat an infection that is
present
2. Prophylaxis—used to prevent some potential future infection; only
proven beneficial in a few instances
E. General dental concerns for all antibiotics—make sure that the client:
1. Knows the name of the antibiotic and how to take it
2. Understands the need to complete the full course of therapy
3. Understands the rationale for prophylactic antibiotic medication
4. Takes all antibiotics with a full glass of water
5. Takes antibiotics on an empty stomach; if the medicine causes
nausea, it should be taken with food

Penicillins
A. Mechanism—inhibit cell wall synthesis; bactericidal
B. Spectrum—three penicillin subgroups:
1. Penicillin G, penicillin V
2. Penicillinase-resistant penicillin
3. Extended-spectrum penicillins
a. Ampicillin-like
b. Carbenicillin-like
C. Stability
1. Acid labile—degrades in stomach acid; therefore administered
parenterally (e.g., penicillin G, methicillin, carbenicillin)
2. Acid stable—may be used orally (e.g., penicillin VK, amoxicillin)
D. Pharmacokinetics
1. Peak—penicillin blood levels peak between 30 minutes and 1 hour

929
 when administered by the oral or intramuscular route; peak
immediately when administered intravenously
2. Half-life (t½)—between 30 minutes and 1 hour
3. Excretion very rapid, actively secreted; duration prolonged by
concomitant probenecid (Benemid) administration
E. Adverse effects
1. GI—mild GI upset to nausea and vomiting
2. Allergic reactions—range from mild rash to anaphylaxis
3. Nephrotoxicity—occurs occasionally; kidney damage more likely
with broader-spectrum penicillins

Penicillin G and Penicillin V

A. Examples
1. Penicillin G potassium
2. Penicillin G procaine (Wycillin, Crysticillin)
3. Penicillin G benzathine (Bicillin)
4. Penicillin VK (V-Cillin K, Pen-Vee K)
B. Spectrum—potent against many gram-positive aerobic organisms,
such as Streptococcus and Staphylococcus, certain gram-negative aerobic
cocci, such as Neisseria gonorrhoeae, and some anaerobic organisms; not
resistant to penicillinase
C. Penicillin G—parenteral administration
1. Dose specified in units (e.g., 5 million units [MU])
2. Intramuscular salts (procaine and benzathine) provide longer
duration of action than do sodium and potassium salts
D. Penicillin V—more acid stable than penicillin G, thus, can be used
orally; potassium salt better absorbed; therefore, penicillin VK is the
most frequently used antibiotic in dentistry; 400,000 units (U) = 250 mg

Penicillinase (β-Lactamase)–Resistant Penicillins

A. Examples
1. Methicillin (Staphcillin)
2. Nafcillin (Unipen, Nafcil)
3. Oxacillin (Prostaphlin, Bactocill)
B. Therapeutic use—limited; used against penicillinase-producing
staphylococci

Extended-Spectrum (“Broader-Spectrum” or “Wider-

Spectrum”) Penicillins

930
A. Ampicillin-like
1. Examples
a. Ampicillin (Omnipen, Totacillin, Polycillin)
b. Amoxicillin (Amoxil, Larotid, Polymox)
2. Spectrum—effective against many gram-positive and some gram-
negative bacteria such as Haemophilus influenzae, Escherichia coli, and
Proteus mirabilis
3. Not penicillinase resistant
4. Augmentin—amoxicillin combined with clavulanic acid, which binds
with penicillinase, so amoxicillin is not inactivated; can be used with
penicillinase-producing organisms
B. Extended-spectrum penicillins
1. Examples
a. Ticarcillin (Ticar)
b. Carbenicillin (Geopen, Pyopen)
c. Piperacillin (Pipracil)
2. Spectrum—provides coverage against gram-negative bacteria such
as Pseudomonas aeruginosa, Proteus, and organisms resistant to
ampicillin-like drugs
3. Administered parenterally (in hospitalized clients) for systemic
action

Macrolides
A. Mechanism—interfere with protein synthesis by binding to the 50S
ribosomal subunit; provide bacteriostatic action
B. Spectrum
1. Erythromycin
a. Effective primarily against gram-positive microorganisms;
ineffective against anaerobes
b. Used against certain strains of Rickettsia, Chlamydia, and
Actinomyces; drug of choice for treating infections caused by
Mycoplasma pneumoniae and Legionella pneumophila
2. Azithromycin (Zithromax)
a. Recommended by the American Heart Association (AHA) for
use in the prevention of bacterial endocarditis before certain
dental procedures, in persons who are allergic to penicillin2
b. Adverse effects—stomatitis, candidiasis, angioedema (allergic
reaction), heart palpitations, chest pain, nausea, vomiting,
diarrhea, abdominal pain, hepatotoxicity, heartburn, flatulence
c. Alternative drug of choice for mild infection caused by

931
 susceptible organisms in persons allergic to penicillin
3. Clarithromycin (Biaxin)
a. Recommended by the AHA for use in the prevention of bacterial
endocarditis prior to certain dental procedures in persons who
are allergic to penicillin2
b. Adverse effects—abnormal taste, candidiasis, stomatitis,
nausea, abdominal pain, diarrhea, hepatotoxicity, heartburn,
anorexia, vomiting, vaginitis, moniliasis, urticaria, rash, pruritus
c. Alternative drug of choice for mild infection caused by
susceptible organisms in persons allergic to penicillin
C. Pharmacokinetics of erythromycin
1. Erythromycin—high acid lability (instability) requires enteric
coating (does not dissolve in the stomach; dissolves in the intestine)
or formulation as an ester to protect against stomach acid (e.g.,
ethylsuccinate, erythromycin ethylsuccinate [EES])
2. Effect peaks in 2 to 4 hours
D. Adverse effects
1. GI upset is very common; must be taken with food to decrease
2. Cholestatic jaundice is primarily associated with the estolate ester
E. Drug interactions—theophylline and erythromycin; increase
theophylline levels
F. Examples—erythromycin
1. Erythromycin base (E-mycin)
2. Erythromycin estolate (Ilosone)
3. Erythromycin ethylsuccinate (EES, Pedia-mycin)
4. Erythromycin stearate (Erythrocin)
G. Therapeutic uses
1. Treatment of dental infections in persons allergic to penicillin
2. Specific suspected infections (see earlier B. Spectrum)

Cephalosporins
A. Mechanism—similar to penicillins; inhibits cell wall synthesis;
bactericidal
B. Chemistry similar to penicillins
C. Spectrum—effective against many gram-positive and gram-negative
bacteria; the third-generation cephalosporins and the newest fourth-
generation cephalosporins have the widest spectrum of action
D. Adverse reactions
1. GI upset common (33%)
2. Other—similar to those of the broader-spectrum penicillins (e.g.,

932
 nephrotoxicity, suprainfection)
3. Allergy—some cross-hypersensitivity (10%) with penicillin allergy
(possess a similar chemical structure)
E. Examples
1. Cefuroxime (Ceftin)
2. Cephalexin (Keflex)
3. Cephradine (Velosef, Anspor)
F. Suggested oral antibiotic regimen for the client with joint prosthesis
less than 2 years after surgery2

Clindamycin (Cleocin)
A. Mechanism—inhibits protein synthesis (binds to the 50S ribosomal
subunit); bacteriostatic protection
B. Spectrum—effective against gram-positive organisms and many
anaerobes such as Bacteroides
C. Adverse reactions
1. GI—diarrhea; pseudomembranous colitis (PMC) or antibiotic-
associated colitis (AAC, incidence up to 10%); drug must be
discontinued if bloody stools with mucus occur
2. The FDA states that this agent should be “reserved for serious
anaerobic infections”
D. Dental use—used against certain anaerobic infections thought to be
caused by Bacteroides species (spp.), jaw infections, and periodontal
infections; and for the prophylaxis of infective endocarditis2

Tetracyclines
A. Mechanism—inhibit protein synthesis by binding to the 30S
ribosome; provide bacteriostatic action
B. Spectrum—truly broad spectrum; effective against many gram-positive
and gram-negative bacteria
C. Pharmacokinetics
1. Tetracyclines—divalent and trivalent cations (e.g., calcium [Ca+ 2; in
dairy products], magnesium [Mg+ 2] and aluminum [Al+ 3] in antacids,
iron [Fe+ 2]); inhibit the absorption of tetracycline by chelation
2. Doxycycline (Vibramycin) and minocycline (Minocin)—less affected
by food or dairy products than is tetracycline; avoid taking antacids
or Ca+ 2 supplementation concomitantly
D. Resistance—cross-transference can occur; organisms can become
resistant without being exposed to drug

933
E. Adverse effects
1. GI upset—relatively common
2. Suprainfection—very common because of the wide spectrum of
action; drug alters normal flora (e.g., may result in vaginal
candidiasis)
3. Photosensitivity—exaggerated sunburn with exposure to ultraviolet
(UV) light
4. Teeth—both hypoplasia and intrinsic stain can occur if the drug is
taken during enamel development; primary teeth affected from the
last half of the pregnancy to age 4 to 6 months; permanent teeth are
affected from age 2 months to 7 to 12 years
F. Examples
1. Doxycycline (Vibramycin, Atridox)
2. Minocycline (Minocin, Arestin)
3. Tetracycline (Achromycin-V)
4. Tetracycline fibers (Actisite)
G. Therapeutic uses
1. Medical—treatment of acne, respiratory tract infections in clients
with COPD (emphysema or bronchitis), certain sexually transmitted
diseases (STDs)
2. Dental—management of periodontal diseases; drug placed in
periodontal pocket (e.g., tetracycline fibers [Atridox, Actisite,
Arestin])
H. Dental hygiene considerations
1. Must be taken 1 hour before or 2 hours after eating
2. Should be taken with crackers if stomach upset occurs
3. Should not be taken with antacids or dairy products
4. Clients must be counseled about photosensitivity

Quinolones
A. Mechanism—inhibition of bacterial gyrase so that the daughter
segment of deoxyribonucleic acid (DNA) cannot acquire the proper
configuration to divide
B. Spectrum—effective against gram-negative bacteria, including
Enterobacter spp., Escherichia coli, and Morganella morganii
C. Adverse reactions—abdominal pain, nausea, vomiting, diarrhea, rash,
urticaria, angioedema
D. Dental concerns—the client must avoid direct light (e.g., dental light);
offer the client dark glasses to be worn during dental procedures; the
client must also avoid direct sun exposure

934
E. Examples
1. Ciprofloxacin (Cipro)
2. Enoxacin (Penetrex)
3. Ofloxacin (Floxin)

Aminoglycosides
A. Mechanism—inhibit protein synthesis by binding to the 30S
ribosomal subunit; provide bactericidal action (the only group that
combines the inhibition of protein synthesis with “cidal” action)
B. Spectrum—effective against some gram-positive and many gram-
negative bacteria
C. Pharmacokinetics—not effective systemically when administered
orally; must be administered parenterally, intravenously, or by
intramuscular injection
D. Adverse reactions—toxicity usually results from excessive levels in
blood
1. Ototoxicity—adverse effect on cranial nerve VIII; both vestibular
(balance) and auditory functions are affected
2. Nephrotoxicity—adverse effect on kidney
E. Examples
1. Gentamicin (Garamycin)
2. Kanamycin (Kantrex)
3. Neomycin (Mycifradin)
4. Tobramycin (Tobrex)

Sulfonamides (“Sulfa” Drugs)

A. Mechanism—competitive antagonist of para-aminobenzoic acid
(PABA); prevents the use of PABA to make the folic acid needed in an
organism
B. Adverse reactions
1. Allergic reactions—rash
2. Photosensitivity
C. Examples
1. Sulfisoxazole (Gantrisin)
2. Trimethoprim-sulfamethoxazole (TMP-SMX; Bactrim, Septra)
D. Therapeutic uses
1. Urinary tract infections (UTIs)
2. Otitis media (children’s ear infections)
3. Respiratory infections

935
 4. Dental use unclear; probably not useful

Metronidazole (Flagyl)
A. Mechanism—breaks DNA structure, which inhibits protein synthesis;
provides bactericidal action
B. Spectrum
1. Trichomonicidal (effective against Trichomonas vaginalis)
2. Bactericidal (effective against anaerobes such as Bacteroides spp.)
C. Adverse reactions
1. GI—anorexia, nausea, vomiting, headache, dizziness
2. CNS—disulfiram (Antabuse)–like reaction; concurrent alcohol
ingestion produces nausea and vomiting
3. Carcinogenic in animals; mutagenic in bacterial organisms; however,
significance with regard to cancer is unknown
D. Dental use—management of periodontal clients with anaerobic
infections; effective against organisms; inexpensive
E. Dental hygiene considerations
1. Clients must avoid alcohol-containing products, including
beverages, foods cooked with alcohol, colognes, aftershaves,
perfumes
2. Clients must avoid mouth rinses with alcohol; recommend alcohol-
free mouth rinses

Antituberculosis Agents
A. Tuberculosis (TB)—a chronic disease
1. Resistant organisms develop easily
2. Treatment is difficult, so drug combinations are frequently required;
multidrug-resistant (MDR) organisms are common
3. Requires drug treatment regimen of 6 to 9 months
B. Drugs
1. Isoniazid (INH)—used alone as prophylaxis; used in combination
with other agents; hepatitis is an adverse side effect
2. Rifampin (Rifadin, Rimactane)
3. Pyrazinamide
4. Ethambutol (Myambutol)
C. Dental implications—use standard precautions; affected persons are
treated for 6 weeks to 2 months; the client is generally not contagious if
compliant with TB treatment regimen; direct observation and monitoring
of the client are needed

936
Antifungal Agents
A. Disease—candidiasis (Candida albicans), called thrush in infants
B. Nystatin (Mycostatin, Nilstat)—dosage forms: oral suspension or
pastille (rubbery lozenge)
C. Clotrimazole (Mycelex)—lozenges available
D. Ketoconazole (Nizoral)
1. Tablets—dose: once per day
2. An acid stomach environment is required for adequate absorption—
be alert to histamine (H2)-blockers
3. Adverse reactions
a. Nausea and vomiting
b. Hepatocellular dysfunction
c. Teratogenic potential
d. Drug interactions
E. Fluconazole (Diflucan)
1. Tablets, oral suspension, and intravenous administration
2. Therapeutic use—systemic fungal infections
3. Adverse reactions—headache, abdominal pain, nausea, diarrhea,
hepatic toxicity
F. Itraconazole (Sporanox)
1. Capsules
2. Therapeutic use—indicated for the treatment of certain fungal
infections in both immunocompromised clients and those who are
not
3. Adverse reactions—nausea, vomiting, diarrhea, abdominal pain,
anorexia, edema, rash, fatigue, fever, malaise

Antiviral Agents
A. Acyclovir (Zovirax)
1. Topical, oral, and intravenous forms available
2. Therapeutic uses
a. Treatment of initial genital herpes in clients who are not
immunocompromised
b. Treatment of recurrent genital herpes in immunocompromised
clients
c. Oral administration is recommended with continuous use as a
prophylactic
B. Docosanol (Abreva)
a. Treatment of oral herpes simplex labialis (cold sores)

937
 b. Available without a prescription
c. Adverse effects—stinging at the site of application
d. l-lysine (an amino acid) is often recommended with docosanol to aid
in tissue repair and growth
C. Ganciclovir (Cytovene)
1. Inhibits replication of most herpesviruses
2. Therapeutic use—prevention and treatment of cytomegalovirus
(CMV) in persons with acquired immunodeficiency syndrome
(AIDS)
3. Adverse effects—fever, coma, chills, confusion, abnormal thoughts,
dizziness, bizarre dreams, headaches, psychosis, tremors,
paresthesia, dysrhythmia, hypertension, hypotension, hemorrhage,
anorexia, blood dyscrasia
D. Antiretroviral drugs—indications: HIV-positive clients and those with
AIDS
1. Zidovudine (AZT, Retrovir)
2. Didanosine (ddI, Videx)
3. Zalcitabine (ddC, Hivid)
E. Dental hygiene considerations—use standard precautions

938
Cardiovascular agents
See Chapters 8 and 19 for contraindications and cautions involving
dental treatment in persons with cardiovascular disease.3

Digitalis Glycosides
A. Pharmacologic effects—heartbeats are stronger (positive chronotropic
effect) but usually slower (bradycardia); therefore, efficiency is increased
B. Adverse reactions
1. GI disturbances—nausea, vomiting
2. CVS—arrhythmias/dysrhythmias
3. CNS—yellow-green vision; halos around lights
C. Therapeutic uses—heart failure, certain arrhythmias
D. Dental hygiene considerations
1. Hypokalemia—decreased potassium levels because of diuretics;
digitalis toxicity may exacerbate dysrhythmias; epinephrine
exacerbates dysrhythmias
2. Epinephrine—use of epinephrine may increase the risk for
arrhythmias (dysrhythmias)
3. Pulse rate must be monitored
4. Tetracycline and erythromycin can increase the levels of digoxin in
blood, causing digoxin toxicity (signaled by nausea, vomiting, and
copious salivation)
E. Example—digoxin (Lanoxin)

939
Antiarrhythmics
A. Pharmacologic effects—suppress arrhythmias
B. Dental considerations—in clients with cardiac problems, use caution
when administering local anesthetics with epinephrine
C. Examples
1. Lidocaine (Xylocaine)—local anesthetic agent can be used
parenterally as an antidysrhythmic agent
2. Procainamide
3. Propranolol (Inderal)
4. Quinidine
D. Dental hygiene considerations
1. Review health history to determine the client’s state of health
2. Check BP and pulse

Antianginal Agents
A. Pharmacologic effects—reduce the “work” of the heart because these
agents function as nonspecific vasodilators, thereby reducing the amount
of blood returning to the heart
B. Adverse reactions—hypotension and severe headache are common;
client should be in the sitting position to take nitroglycerin (NTG)
C. Drug interactions – phosphodiesterase-5 inhibitors (sildenafil,
tadalafil, vardenafil)
D. Therapeutic use—angina pectoris
E. Dental hygiene considerations
1. Storage—unstable products; must be stored properly; heat, light,
and moisture cause further degradation; discard opened containers
after 2 months or on the basis of the expiration date on the original
vial, whichever comes first
2. Acute anginal attack—administer NTG sublingually
3. Routes of NTG administration
a. Sublingual (SL)—tablets or spray
b. Transdermal—patches applied to chest or arm
c. Ointment—in ointment applied to skin
4. Anxiety about the dental appointment may cause the angina attack;
the client can take tablet prophylactically
F. Examples
1. Nitroglycerin (Nitrostat), SL tablet or spray (Nitrolingual SL spray)
2. Isosorbide dinitrate (Isordil) or mononitrates

940
Antihypertensives
See Table 11–9.

Table 11–9
Selected Antihypertensives: Examples, Mechanisms, and Adverse
Reactions

CO, Cardiac output; D/C, discontinue; NE, norepinephrine. NSAIDs, nonsteroidal anti-
inflammatory drugs; PVR, peripheral vascular resistance.

A. Pharmacologic effects—reduce elevated BP

B. Adverse reaction—CNS depression, fatigue, xerostomia, orthostatic
hypotension, constipation and diarrhea, sexual dysfunction, upset
stomach
C. Therapeutic use—treatment of hypertension
D. Dental hygiene considerations

941
 1. Take BP reading to ensure it is normal
2. Xerostomia—instruct the client to drink plenty of water; suck on tart
sugarless gum or candy that contains xylitol, or ice chips; avoid
products containing alcohol and caffeine; and avoid juices and soft
drinks to reduce the risk of dental caries; saliva substitutes (Xero-
lube, Salivart) can also be recommended
3. Have the client rise slowly from the dental chair
4. Some calcium channel blockers can cause drug-influenced gingival
enlargement; clients should perform meticulous oral hygiene and
obtain frequent periodontal maintenance care
5. CNS sedation—several antihypertensive medications can cause
sedation; the client is at an increased risk for sedation if an opioid
analgesic or benzodiazepine is prescribed; the client should be
instructed to avoid driving or operating heavy machinery, or any task
that requires thinking or concentration
6. GI effects—several antihypertensives can cause GI irritation;
NSAIDs may increase the risk of GI irritation; these agents must be
taken with food, milk, or an antacid
7. Constipation—may be further aggravated by the addition of an
opioid analgesic; have the client drink plenty of water and eat fruits,
vegetables, and other high-fiber foods

Diuretics
A. Pharmacologic effects—remove excess water and sodium by way of the
kidneys; direct vasodilating action on blood vessels lowers total
peripheral resistance and BP
B. Adverse reactions
1. Hypokalemia (low potassium)—the client may need to take a
potassium replacement
2. Hyperglycemia, hyperuricemia
3. The client may urinate more frequently after taking the medicine
(usually in the morning)
C. Therapeutic uses—treatment of hypertension, edema
D. Dental hygiene considerations—hypokalemia (reduced potassium
level) potentiates epinephrine-induced arrhythmias; pulse rate must be
monitored
E. Examples
1. Thiazide diuretics—hydrochlorothiazide (HCTZ, HydroDiuril)
2. Loop diuretics—furosemide (Lasix)
3. Combinations of thiazide diuretics with potassium-sparing diuretics

942
 —Dyazide, Max-zide; reduce the side effect of hypokalemia

Anticoagulants
Warfarin (Coumadin)
A. Mechanism—interfere with vitamin K–dependent clotting factors (II,
VII, IX, X)
B. Pharmacologic effects—reduce the ability of blood to clot; latent time
required before full effect is seen (several days); a certain amount of time
is required for the effect to subside after discontinuation of treatment
C. Adverse reactions—bleeding, hemorrhage
D. Therapeutic uses—used after MI, thrombophlebitis, atrial fibrillation,
emboli, valve replacement (any condition in which too much blood
clotting occurs)
E. Dental hygiene considerations
1. Excessive bleeding may result; assess health history at every
appointment
2. Monitoring—performed using international normalized ratio
(INR);3,4 older test is prothrombin time (PT)—clients with INR of 3
or less can safely receive periodontal debridement
F. Examples—warfarin (Coumadin)
G. Drug interactions—occur with warfarin given with:
1. Aspirin or NSAID—potentiates bleeding problems; do not use
concomitantly; alternative is acetaminophen
2. Vitamin K—helps blood clot; used to treat overdose or to reduce the
latent period for improving the clotting status; antibiotics may
reduce vitamin K levels by altering the intestinal flora that would
potentiate the anticoagulant’s effect
H. New oral anticoagulants
1. Factor XA inhibitors—Rivaroxaban (Xarelto); apixaban (Eliquis)
2. Direct thrombin inhibitor—Dabigatran (Pradaxa)
I. Others—Ticlopidine (Ticlid); clopidogrel (Plavix)

Anticonvulsants
A. General properties of anticonvulsants (Table 11–10)

943
Table 11–10
Antiepileptic Drugs of Choice for Seizures

FDA, U.S. Food and Drug Administration.

1. Pharmacologic effects—reduction of frequency or elimination of

seizures (see Table 11–10)
2. GI upset—common side effect
3. Teratogenicity—variable teratogenic potential (pregnant women with
epilepsy need to be treated)
4. Sedation—tolerance to sedative effect occurs without tolerance to
anticonvulsant effect
5. Blood dyscrasias—sudden and drastic drops in either white blood
cell (WBC) count or red blood cell (RBC) count, or both, which can
be serious; laboratory monitoring is important
6. Dental hygiene considerations

944
 a. Sedation—client should be instructed to avoid driving or
operating heavy machinery, or any task that requires thinking or
concentration
b. GI upset—need to avoid NSAIDs and aspirin because they
increase the risk of GI upset
c. Increased risk for sedation with CNS depressants or sedating
drugs
d. CNS stimulant effects—may be difficult to treat a client who
cannot sit still
e. Xerostomia—instruct the client to drink plenty of water; suck on
tart sugarless gum or candy containing xylitol, or ice chips;
avoid products containing alcohol and caffeine; and avoid juices
and soft drinks to reduce the risk of dental caries; saliva
substitutes (Xero-lube, Salivart) can also be recommended
B. Barbiturates—CNS adverse effects: sedation, hyperactivity in children,
confusion, excitation, or depression in older adults
C. Phenytoin (Dilantin)—adverse effects
1. Drug-influenced gingival enlargement—meticulous oral hygiene
reduces the enlargement
a. Wait 1 year after medication change before performing surgical
interventions
2. Vitamin deficiencies—may induce deficiency in vitamins D and
folate
3. Fetal hydantoin syndrome—associated with teratogenic conditions
D. Valproic acid (Depakene, Depakote)—adverse effects
1. Hepatic failure—liver function tests are required to monitor the
client’s liver status
2. Thrombocytopenia—bleeding; use caution when combining with
aspirin, NSAIDs, or warfarin
3. GI—nausea, vomiting
4. CNS—sedation, drowsiness; hyperactivity, aggressiveness in
children
E. Carbamazepine (Tegretol)—adverse effects
1. Induces metabolism of itself and other drugs
2. CNS—drowsiness, dizziness
3. GI—nausea and vomiting
4. Hematologic—can cause agranulocytosis; frequent monitoring of
WBC count is necessary; signs and symptoms of a low count include
fever, chills, aches, and pains
5. Hepatic—liver function tests are necessary
6. Indications—various seizures and trigeminal neuralgia

945
 7. Drug interactions—carbamazepine increases the metabolism of
warfarin, theophylline, and doxycycline; the drug’s metabolism is
inhibited by erythromycin, verapamil, and diltiazem; increases the
effect of lithium
F. Benzodiazepines
1. Diazepam (Valium)—used for status epilepticus and emergency
treatment of seizures; usually administered through an IM injection
(adults) or rectally (children)
2. Clonazepam (Clonopin)—taken orally for absence seizures
(nonconvulsive seizures characterized by “staring off ”) and
psychiatric conditions; oral adverse effects include coated tongue,
xerostomia, encopresis, abnormal thirst, tender gums
G. Ethosuximide
1. Used to treat absence seizures
2. GI—anorexia, GI upset, nausea, vomiting
3. CNS—drowsiness, dizziness, lethargy, hyperactivity
4. Oral adverse drug reactions—drug-influenced gingival enlargement,
swollen tongue
H. Newer agents
1. Gabapentin—no reported drug interactions
2. Felbamate—increased risk for developing aplastic anemia, severe
liver disease
3. Lamotrigine
4. Topiramate
5. Tiagabine
6. Fosphenytoin—parenteral use only
7. Levetiracetam
8. Oxcarbazepine
9. Pregabalin—a schedule V drug, because of reported euphoria in
some clinical trials
10. Zonisamide

946
Psychotherapeutic agents
Antipsychotics
A. Pharmacologic effects
1. Antipsychotics—used in the management of psychoses; the client
may perceive comments as threats (paranoia)
2. Sedation and drowsiness—additive CNS depression with other CNS
depressants
3. Antiemetics—depress the chemoreceptor trigger zone (CTZ); reduce
nausea and vomiting
B. Adverse reactions
1. Orthostatic hypotension—dizziness or fainting on rising from a
supine position
2. Extrapyramidal effects—areas in the brain affecting body
movements
a. Dyskinesia—uncontrollable movements of the tongue or face
b. Tardive dyskinesia—abnormal involuntary movements that
occur with prolonged use of conventional antipsychotic agents
c. Parkinsonian symptoms—tremors and rigidity resembling
Parkinson’s disease
d. Akathisia—motor restlessness (e.g., swinging legs)
e. Acute dystonic reaction—difficulty in opening the mouth; jaw
muscles are contracted; dislocation of the jaw might occur
3. Anticholinergic—xerostomia increases the risk of dental caries
C. Drug interactions—occur with antipsychotic agent given with:
1. CNS depressants—additive CNS depression
2. Anticholinergic—additive anticholinergic toxicity
D. Dental hygiene considerations
1. Dyskinesia, akathisia, and tardive dyskinesia—the client may not be
able to perform self-care
2. Acute dystonic reaction—can occur during a procedure; the client
needs to be treated with an anticholinergic drug
3. Orthostatic hypotension—raise the dental chair slowly; have the
client remain seated for a few minutes before standing to prevent a
fall
4. Xerostomia—instruct the client to drink plenty of water; suck on tart
sugarless gum or candy containing xylitol, or ice chips; avoid
products containing alcohol and caffeine; and avoid juices and soft
drinks to reduce the risk of dental caries; saliva substitutes (Xero-
lube, Salivart) can also be recommended

947
E. Therapeutic uses
1. Treatment of psychosis (e.g., schizophrenia) and bipolar disorder
2. Antiemetic—for nausea or vomiting
3. Opioid potentiation—combined with an opioid to potentiate
analgesia and sedation; reduce the dose of the opioid if an
antipsychotic is added
F. Table 11–11 provides examples of select antipsychotic agents

Table 11–11
Selected Antipsychotic Drugs

Antidepressants
A. Pharmacologic effects
1. Affect norepinephrine and serotonin levels in the brain (require 4 to
6 weeks to be effective)
2. Adverse reactions

948
 a. Cardiotoxic in overdose— arrhythmias (mainly with TCAs);
usual cause of death when used in a suicide attempt
b. Xerostomia (anticholinergic action)
c. Sedation
d. GI—nausea resulting from selective serotonin reuptake
inhibitors (SSRIs)
e. Orthostatic hypotension
B. Drug interactions—occur with TCAs given with:
1. Epinephrine—results in hypertension (increased vasopressor
response); low doses contained in local anesthetic solutions can be
used safely in normotensive persons (those with normal BP)
2. Anticholinergic—results in additive anticholinergic action and
excessive xerostomia
C. Therapeutic uses
1. Treatment of depression
2. Migraine headache prophylaxis
3. Treatment of nocturnal enuresis (bedwetting) in children
4. Chronic pain treatment adjuvant
D. Drugs
1. Select tricyclic antidepressants (TCAs)
a. Amitriptyline (Elavil)
b. Imipramine (Tofranil)
2. MAOIs—phenelzine (Nardil); tranylcypromine (Parnate)
a. Infrequently used for depression
b. Potential for numerous severe drug-food interactions (e.g., wine,
sausage, cheese; indirect-acting adrenergic agents, meperidine)
3. Dopamine-norepinephrine reuptake inhibitors
a. Bupropion (Wellbutrin, Zyban)
b. Bupropion, sustained release (Wellbutrin SR)
c. Bupropion, extended release (Wellbutrin ER)
4. Select SSRIs
a. Fluoxetine (Prozac)
b. Sertraline (Zoloft)
c. Paroxetine (Paxil)
d. Citalopram (Celexa)
5. Serotonin and norepinephrine reuptake inhibitors
a. Venlafaxine (Effexor)
b. Venlafaxine, extended release (Effexor XR)
6. Serotonin modulators
a. Nefazodone (Serzone)
b. Trazodone (Desyrel)

949
 7. Norepinephrine-serotonin modulator—mirtazapine (Remeron)

Other Psychotherapeutic Agents

A. Lithium—for treating bipolar-affective disorder (manic depression);
blood level is difficult to maintain; NSAIDs increase serum lithium
levels
B. Carbamazepine, valproate—these drugs are also used to treat seizure
disorders; drug interactions and dental concerns are the same as those in
the treatment of seizure disorders

950
Endocrine agents
Adrenocorticosteroids (Steroids)
A. Classification
1. Glucocorticoids—regulate glucose metabolism and have an anti-
inflammatory effect
2. Mineralocorticoids—regulate sodium (minerals) and water
B. Pharmacologic effect—anti-inflammatory, antiallergenic, involved in
carbohydrate metabolism, and have catabolic effects
C. Adverse reactions
1. Cushing syndrome—long-term, high-dose steroids produce
symptoms including:
a. Metabolic effects—“moon face,” “buffalo hump,” truncal
obesity
b. Peptic ulcers—exacerbation or stimulation of stomach acid
secretion
c. Skin conditions—bruising, striae, delayed healing
d. Mental changes—euphoria, depression, psychosis, mood swings
e. Infection—caused by suppression of immunity, symptoms may
be masked; close observation and aggressive treatment are
necessary
f. Osteoporosis—bones break more easily
g. Hypertension—elevated water and sodium retention
(mineralocorticoid action)
h. Hyperglycemia—exacerbation of diabetes
2. Adrenal crisis (thyroid storm)—abrupt withdrawal or stress (e.g., a
dental appointment) can precipitate a crisis; can be prevented by
premedicating with additional steroids; potentially serious situation
D. Contraindications and cautions
1. Ulcers—ulcerogenic
2. Cardiovascular disease—can precipitate congestive heart failure,
edema (result of mineralocorticoid effect)
3. Acute psychoses
4. Infection—increased susceptibility to bacterial, fungal, or viral
infections
5. Diabetes—hyperglycemia is induced
E. Dental hygiene considerations
1. Check BP before procedure or administration of a vasoconstrictor
2. Avoid NSAIDs, aspirin, and opioid analgesics because of the
increased risk of GI upset

951
 3. Steroids can delay wound healing and mask the symptoms of
infection; consider administration of prophylactic antibiotic before
procedure
4. Osteoporosis may be evident on dental radiographs
5. The steroid-dependent client may need short-term increase in
steroid dose before a dental procedure to avoid an adrenal crisis
F. Therapeutic uses
1. Medical—treatment of many inflammatory conditions (e.g., arthritis,
asthma, dermatitis)
2. Dental—treatment of:
a. Aphthous lesions—palliative treatment; topical or intralesional
therapy
b. Oral lesions secondary to collagen vascular diseases—respond
to topical, intralesional, or systemic therapy
c. Temporomandibular joint disease—intra-articular injection (into
the joint) if the patient has arthritis
G. Table 11–12 provides examples of steroid agents

Table 11–12
Common Steroids

Steroid Comments Equivalent Dose (mg/day)

Hydrocortisone Some mineralocorticoid action 20-240
Prednisone Most commonly used orally 5-60
Triamcinolone (Kenalog) Used topically and injected into joints 2-20
Dexamethasone (Decadron) Very potent, thus lower dose used 0.75-9.0

Agents for Diabetes Mellitus

See also the section on “Diabetes Mellitus” in Chapter 19.
A. Definition
1. Symptoms
a. Polyuria—increased urination
b. Polydipsia—increased thirst
c. Polyphagia—increased hunger
d. Weight loss
e. Xerostomia
2. Classifications
a. Type 1 diabetes (insulin-dependent diabetes mellitus)—
circulating insulin is absent; usually is a result of autoimmune
destruction of pancreatic beta (β-) cells; requires insulin therapy

952
 b. Type 2 diabetes (non–insulin-dependent diabetes mellitus)—
decreased tissue sensitivity to insulin and impaired β-cell
response to glucose; controlled by diet, oral hypoglycemic
agents, and insulin, alone or in combination
3. Microvascular and macrovascular complications
a. Cardiovascular problems—circulation and heart problems, MI,
stroke
b. Retinopathy—vision problems, cataracts, blindness
c. Neuropathy—reduced sensations in the extremities
d. Renal failure—nephropathy (kidney problems)
e. Immunity—reduced ability to fight infections
f. Healing—slower or delayed
g. Oral manifestations—reduced immunity caused by WBC
dysfunction; reduced vascular supply (small-vessel disease), and
other alterations in immune system function; predisposes a
client to periodontal disease; loss of alveolar bone is
characteristic
B. Dental hygiene considerations
1. Reinforce the importance of good oral hygiene to minimize the risk
of xerostomia, candidiasis, and dental caries
2. Keep at hand a source of glucose that will act quickly (e.g., tube of
cake frosting or orange juice) in case the client experiences
hypoglycemia
3. Clients with diabetes are at increased risk for periodontal disease
and disease progression
4. These clients are at a higher risk for delayed wound healing and
infection; those with poorly controlled diabetes may require
prophylactic antibiotic premedication
5. Epinephrine, steroids, and opioid analgesics can decrease insulin
release or increase insulin requirements; therefore must be used
with caution in clients with diabetes
C. Adverse reactions
1. Hypoglycemia—too much drug or too little food (intakes are not
balanced)
a. Symptoms—nervousness, sweating, tremulousness, compulsive
talking, mental confusion, nausea, convulsions, coma
b. Treatment—administer glucose orally if the client is conscious
and able to swallow; if the client is unconscious, administer
glucose intravenously, or administer glucagon subcutaneously
or intramuscularly
2. Hyperglycemia—less common cause of problems in the person with

953
 diabetes; treated in the emergency room with insulin and fluids
3. Lipodystrophy—occurs when insulin is injected into the same site
for a prolonged period
D. Examples of hypoglycemic agents
1. Insulin
a. Rapid-acting—insulin lispro, insulin aspart
b. Short-acting—regular insulin (Humulin R, Novolin R) and
prompt insulin zinc suspension (Semilente, Semilente Insulin,
Semitard)
c. Intermediate-acting—insulin time suspension (Lente, Humulin
L); isophane insulin suspension (Humulin, WPH, Novolin N)
d. Long-acting—extended insulin zinc suspension (Ultralente,
Humulin U Ultralente)
e. Mixed preparations—isophane insulin suspension and regular
insulin injection (Humulin 70/30)
2. Use and sources
a. Combined regular and neutral protamine Hagedorn (NPH)
insulin—given one to two times per day
b. Human insulin—from gene splicing (made from E.coli) or
altered pork insulin
3. Oral hypoglycemic agents (sulfonylureas)
a. First-generation agents
(1) Chlorpropamide (Diabinese)
b. Second-generation agents
(1) Glyburide (DiaBeta, Micronase)
(2) Glipizide (Glucotrol)
(3) Glimepiride (Amaryl)
4. Other, newer agents
a. Biguanides—metformin (Glucophage)
b. α-Glucosidase inhibitors—acarbose (Pre-cose); miglitol (Glyset)
c. Thiazolidinediones—pioglitazone (Actos); rosiglitazone
(Avandia)
d. Meglitinides—nateglinide (Starlix); repaglinide (Prandin)
e. GLP-1 receptor agonist—exenatide (Byetta)
f. Bile acid sequestrant—colesevelam (Welchol)
g. DPP-4 inhibitors—alogliptin (Nesina); linagliptin (Tradjenta);
saxagliptin (Onglyza); sitagliptin (Januvia)

Thyroid Agents
A. Hypothyroidism—also hypothyroidosis, athyroidosis, hypothyrosis,

954
thyroid insufficiency; deficient thyroid activity results in lowered
metabolism, fatigue, lethargy; more common in women than in men; can
lead to cretinism in infants
1. Thyroid replacements used; leads to a euthyroid condition (normal
thyroid)
2. Examples of hypothyroidism agents
a. Levothyroxine (Synthroid, Levothroid)
b. Liotrix (Euthroid, Thyrolar)
3. The client requires no special handling if the dose is adequate
4. Dental hygiene considerations
a. Carefully examine children suspected of having hypothyroidism
and children diagnosed with hypothyroidism; the client with
hypothyroidism must maintain good oral health
b. Clients with hypothyroidism are more sensitive to medications
that depress the CNS; lower doses may therefore be necessary;
counsel the client about the CNS side effects
B. Hyperthyroidism—also Graves disease; various causes lead to the
excessive production of thyroid hormones; produces goiter,
cardiopulmonary dysfunction (atrial fibrillation, palpitations, widened
pulse rate), skin and behavioral conditions (tremor, excessive sweating,
heat intolerance, nervousness, fatigue), and ocular symptoms
(exophthalmos)
1. Partial thyroidectomy (treated surgically or with radioactive iodine
[131I]) ablates part of the thyroid gland—the client requires
supplemental thyroid hormone therapy; no unusual dental
considerations if the client is taking drug treatment
2. Clients awaiting surgery or those who are poor surgical candidates
are maintained on a regimen of thyroid suppressants
a. Drugs suppress thyroid function—propylthiouracil (PTU)
b. β-Blockers are given to bring down elevated HR (e.g.,
propranolol)
c. Dental hygiene considerations—avoid epinephrine because it
can trigger a thyroid storm; clients have a lower pain threshold
and may require higher doses of local anesthetic agents or
higher doses of CNS-depressing medications

Estrogens and Progesterone

Estrogen
A. Responsible for female sex characteristics, reproduction development,

955
and preparing for conception
B. Adverse reactions
1. Nausea, vomiting
2. Uterine bleeding, vaginal discharge
3. Edema
4. Thrombophlebitis
5. Weight gain
6. Headache
7. Hypertension
C. Dose forms
1. Oral tablets
2. Creams
3. Transdermal patches
D. Clinical uses include treatments for:
1. Symptoms of menopause
2. Menstrual disturbances
3. Osteoporosis

Progesterone
A. Responsible for preparing the uterus for implantation of the fertilized
egg
B. Adverse reactions
1. Abnormal menstrual bleeding
2. Breakthrough bleeding
3. Spotting between menstrual periods
4. Change in amount of menstrual blood flow
5. Amenorrhea
C. Dose forms
1. Oral
2. Parenteral
D. Clinical uses include treatments for:
1. Dysfunctional uterine bleeding
2. Endometriosis
3. Dysmenorrhea
4. Premenstrual tension

Oral Contraceptives
A. Pharmacologic activity—inhibits the release of follicle-stimulating
hormone (FSH) and luteinizing hormone (LH), which prevent ovulation

956
and pregnancy
B. Contain either progesterone alone or a combination of estrogen and
progesterone; both come in varying doses
C. Adverse reactions
1. Nausea, dizziness, weight gain, headache, breast tenderness
2. Hypertension, liver damage, thrombophlebitis, thromboembolism
3. Oral—increased gingival fluid, susceptibility to gingivitis, gingival
inflammation, increased risk of dry socket after extraction (newer
formulations contain less hormone and therefore are less likely to
cause these conditions)
D. Dental hygiene considerations
1. Review with the client the importance of good oral hygiene because
of the potential for gingivitis
2. Extractions should be performed on days 23 to 28 of the oral
contraceptive cycle to reduce the risk of dry socket
3. Check BP at each appointment because of the risk of hypertension
4. During long procedures, have scheduled breaks to minimize risk of
thrombophlebitis; have the client stretch the legs and walk around, if
possible
5. Instruct clients to use a contingent method of birth control if they
require antibiotic therapy

957
Respiratory system agents
Agents for Asthma
A. Disease—dyspnea, cough, and wheezing, secondary to bronchospasm
(hyperirritable bronchioles), inflammation of bronchioles with secretions
B. Drugs
1. Adrenergic agonists (sympathomimetics)—see the earlier section on
“Autonomic Nervous System”
a. Dose forms—oral inhalers, tablets, liquid
b. Inhalers—β2-adrenergic agonists
(1) Short-acting β2-agonists
(a) Albuterol (Proventil, Ventolin)
(b) Metaproterenol (Alupent, Metaprel)
(2) Long-acting β2-agonists
(a) Salmeterol (Serevent)
(b) Formoterol (Foradil Aerolizer)
c. Epinephrine—administered intravenously for an acute attack
d. Used for maintenance and prophylactic therapy
e. Adverse reactions—nervousness, tachycardia, insomnia,
xerostomia with oral inhalers
f. Dental hygiene considerations for short-acting and long-acting
β2-agonists
(1) Measure the client’s BP and pulse rate before the
procedure because of the potential for tachycardia
(2) Have the client “rinse, swish, and expectorate” after each
inhaler use to reduce xerostomia
(3) Instruct the client to maintain good oral hygiene,
especially with the use of oral inhalers
2. Methylxanthines
a. Examples
(1) Theophylline (Theo-dur, Slo-bid)
b. Pharmacologic effects
(1) Bronchodilation (smooth muscle relaxation) helps reduce
the symptoms of asthma
(2) CNS stimulation—alertness, insomnia
(3) Diuresis—increased urination
3. Cromolyn sodium (Intal, Nasalcrom)
a. Used for asthma prophylaxis by inhalation, for allergic rhinitis,
and for maintenance therapy for asthma
b. Adverse reactions—nausea, vomiting, restlessness, anxiety

958
 c. Dental concerns—same as with β2-adrenergic agonists
4. Ipratropium bromide (Atrovent); tiotropium bromide (Spiriva)
a. Anticholinergic bronchodilator; used mainly to treat
emphysema
b. Adverse reactions—xerostomia and bad taste
c. Dental concerns
(1) Counsel the client to rinse well and expectorate after each
use
(2) Counsel the client about the importance of good oral
hygiene
5. Adrenocorticosteroids
a. Used for acute and maintenance therapy
b. Dose forms—oral, parenteral, metered-dose inhaler (MDI),
tablets
c. Adverse reactions with MDI—dysphonia (hoarseness),
xerostomia, cough, and candidiasis
d. Dental hygiene considerations
(1) MDI—same as with other oral inhalers
e. Examples
(1) Flunisolide (Aerobid)
(2) Fluticasone (Flovent)
C. Dental hygiene considerations
1. Disease considerations
a. Degree of control—avoid elective treatment if the asthma is
poorly controlled
b. The client’s anxiety may precipitate an acute attack; an
antianxiety agent may be useful (e.g., benzodiazepine)
2. Analgesic choice—sometimes difficult to make
a. Aspirin-containing compounds—may precipitate an attack
b. NSAIDs—if aspirin causes bronchospasm, NSAIDs are
contraindicated
c. Acetaminophen—best choice; may be used in combination with
a weak opioid (e.g., Tylenol No. 3)

959
Gastrointestinal agents
Agents Affecting Gastrointestinal Motility
A. Laxatives—increase GI motility; symptomatically used to treat
constipation (e.g., milk of magnesia)
B. Antidiarrheals—reduce GI motility; symptomatically used to treat
diarrhea (e.g., Lomotil, Imodium, any opioid)
C. Dental hygiene considerations
1. CNS sedation—the client should be instructed to avoid driving or
operating heavy machinery, or anything that requires thinking or
concentration
2. Xerostomia—instruct the client to drink plenty of water; suck on tart
sugarless gum or candy containing xylitol, or ice chips; avoid
products containing alcohol and caffeine; and avoid juices and soft
drinks to reduce the risk of dental caries; saliva substitutes (Xero-
lube, Salivart) can also be recommended

Agents for Gastroesophageal Reflux Disease—

Histamine (H2-) Blockers
A. Mechanism of action—block stomach acid secretion; pain subsides
and no further damage occurs from esophageal exposure to stomach acid
B. Examples (all available OTC [over the counter])
1. Cimetidine (Tagamet HB)
2. Famotidine (Pepcid AC)
3. Nizatidine (Axid AR)
4. Ranitidine (Zantac 75)
C. Dental hygiene considerations
1. These agents interfere with the absorption of drugs that need acid
for absorption (e.g., ketoconazole [Nizoral])
2. Avoid ulcerogenic medications unless absolutely necessary (e.g.,
aspirin, NSAIDs, glucocorticoids)
3. Cimetidine
a. Reduces hepatic blood flow
b. Inhibits the metabolism of certain drugs (diazepam, warfarin)

Proton Pump Inhibitors

A. Mechanism—irreversibly bind to the proton pump, resulting in acid
suppression lasting more than 24 hours

960
B. Examples
1. Omeprazole (Prilosec)
2. Lansoprazole (Prevacid)
3. Esomeprazole (Nexium)
C. Adverse reactions
1. Esophageal candidiasis
2. Mucosal atrophy of the tongue
3. Xerostomia
D. Dental hygiene considerations
1. Evaluate for adverse oral reactions
2. Xerostomia—instruct the client to drink plenty of water; suck on tart
sugarless gum or candy that contains xylitol, or ice chips; avoid
products containing alcohol and caffeine; and avoid juices and soft
drinks to reduce the risk of dental caries; saliva substitutes (Xero-
lube, Salivart) can also be recommended

Emetics and Antiemetics

A. Emetics—induce vomiting; used to treat most poisonings (e.g., syrup
of ipecac, which is available without a prescription); abused by persons
with bulimia
B. Antiemetics
1. Reduce nausea or vomiting
2. Examples
a. Benzquinamide (Emete-Con)
b. Prochlorperazine (Compazine)
c. Trimethobenzamide (Tigan)
C. Dental hygiene considerations
1. CNS sedation—the client should be instructed to avoid driving or
operating heavy machinery or performing any task that requires
thinking or concentration
2. Xerostomia—instruct the client to drink plenty of water; suck on tart
sugarless gum or candy containing xylitol, or ice chips; avoid
products containing alcohol and caffeine; and avoid juices or soft
drinks to reduce the risk of dental caries; saliva substitutes (Xero-
lube, Salivart) can also be recommended

961
Antineoplastic agents
A. Mechanism—interfere with the metabolism or reproductive cycle of
malignant cells; also affect normal cells
B. Drugs
1. Alkylating agents
a. Nitrogen mustards
(1) Cyclophosphamide (Cytoxan)
(2) Chlorambucil (Leukeran)
(3) Melphalan (Alkeran)
b. Nitrosureas—carmustine (BiCNU)
c. Busulfan (Myleran)
2. Antimetabolites
a. Folic acid analog—methotrexate (MTX)
b. Purine antagonists
(1) Mercaptopurine (6-MP)
(2) Thioguanine (6-TG)
c. Pyrimidine antagonists
(1) 5-Fluorouracil (5-FU)
(2) Cytarabine (Cytosar-U, ara-C)
3. Other antineoplastics
a. Plant alkaloids
(1) Vinblastine (Velban)
(2) Vincristine (Oncovin)
b. Antibiotics
(1) Dactinomycin (actinomycin D, Cos-megen)
(2) Daunorubicin (Cerubidine)
(3) Doxorubicin (Adriamycin)
(4) Mitomycin (Mitocin-C)
c. Hormones
(1) Adrenocorticosteroids
(2) Androgens
(3) Estrogens
(4) Progestin
(5) Tamoxifen (Nolvadex)—antiestrogen
d. Aminobisphosphonates
(1) Alendronate (Fosamax)
(2) Ibandronate (Boniva)
(3) Pamidronate (Aredia)
(4) Risedronate (Actonel)
(5) Zoledronic acid (Zometa)

962
 e. Miscellaneous
(1) Asparaginase (Elspar)
(2) Bleomycin (Blenoxane)
(3) Cisplatin (Platinol)
(4) Hydroxyurea (Hydrea)
C. Adverse reactions
1. Lack of specificity against tumor cells because normal cells are also
destroyed; cells with the fastest life cycle are affected first
2. Bone marrow activity suppression
a. Leukopenia—lowered WBC count; infections are more likely
b. Thrombocytopenia—lowered platelets; risk of bleeding is
increased
c. Anemia
3. GI—stomatitis, mucosal sloughing
4. Infection—reduced immunity and ability to fight infection
5. Skin and hair—rash, alopecia (baldness)
6. Oral effects
a. Symptoms—pain, ulcers, dryness, impaired taste, gingival
hemorrhage, sensitivity of teeth and gingivae
b. Treatment—avoid mouth rinses with alcohol; substitute saline
or sodium bicarbonate; avoid alcohol
c. Candidiasis—use antifungal agents (e.g., Nystatin)
d. Xerostomia—instruct the client to drink plenty of water; suck on
tart sugarless gum or candy with xylitol, or ice chips; avoid
products containing alcohol and caffeine; and avoid juices and
soft drinks to reduce the risk of dental caries; saliva substitutes
(Xero-lube, Salivart) can also be recommended
7. Osteonecrosis of the jaw (ONJ)
a. In cancer, primarily breast cancer, patients receiving
intravenous bisphosphonates, 94% of cases with ONJ have been
reported; the incidence is much lower in patients taking oral
bisphosphonates for osteoporosis
b. Prolonged use may suppress bone turnover—leads to
microdamage
c. Most cases of ONJ occur after tooth extractions or other
procedures that cause trauma to the jawbone
d. Very difficult to treat once it occurs
e. Oral health examinations and other dental procedures should
be performed before starting bisphosphonate therapy and
continued every 3 months thereafter
f. Any dental procedures that are performed should involve

963
 minimal trauma to the jaw and adjacent tissue
g. ONJ treatment by oral and maxillofacial surgeons; treatment
varies according to size of the lesion
h. If clinically necessary, 0.12% chlorhexidine gluconate rinses,
systemic antibiotics, and analgesics can be used
D. Dental hygiene considerations
1. Have clients improve their oral hygiene before chemotherapy, if
possible
2. Avoid elective procedures during chemotherapy; timing is
important; the best time for procedures is the day on which
chemotherapy begins (period of highest blood counts)
3. Check the coagulation status before any emergency surgery
4. Use of prophylactic antibiotic premedication is controversial
5. If xerostomia is a problem, client will need custom-fitted mouth
trays for at-home, self-administered fluoride therapy

964
965
Substance abuse
See the section on “Chemical Dependency” in Chapter 19.

Definitions
A. Tolerance—increasingly higher doses are required to produce the
same effect; the same dose produces less effect; occurs with repeated
administration
B. Physical dependence—symptoms of withdrawal occur if the drug is
abruptly discontinued
C. Psychological dependence—craving occurs if the drug is stopped; no
physical withdrawal syndrome; however, psychological dependence is
just as likely to result in relapse (e.g., cocaine)
D. Abuse—improper or excessive self-administration of a drug that
results in an adverse outcome
E. Addiction—pattern of abuse that continues despite medical or social
complications
F. Withdrawal—a physical reaction attributable to physical dependence
G. Abstinence—drug-free state
H. Enabling—a pattern of coping methods (e.g., making excuses for
absences) used by the associates of those addicted, which allows the
addicted person to continue the drug use

Drugs of Abuse
A. Depressants
1. Alcohol—impaired judgment, slurred speech, ataxia, seizures, coma,
death; withdrawal produces autonomic hyperactivity, hallucinations,
or seizures; cirrhosis with chronic use
2. Opioids (hydrocodone, heroin, codeine, morphine)—euphoria,
abscesses, constipation, respiratory depression; withdrawal produces
“cold turkey” syndrome; methadone maintenance and naltrexone
(acts similar to orally active naloxone) used to suppress a “high”
3. Barbiturates—secobarbital, pentobarbital
4. Volatile solvents—glue sniffing and paint solvent inhaling; called
“huffing”
5. Benzodiazepines—diazepam
6. Anesthetics—N2O-O2 analgesia
B. Stimulants
1. Amphetamines—methamphetamine; highly addictive; street name

966
 “ice”
2. Cocaine—most psychologically addicting drug; produces euphoria,
hyperactivity, paranoia; risk of acute MI; street names include coke
and crack
3. Nicotine—in cigarettes, chewing tobacco, and cigars
4. Caffeine—in soft drinks, coffee, and tea
C. Psychedelics
1. Lysergic acid diethylamide (LSD)—flashbacks occur (without the
drug); called “bad trip”
2. Psilocybin—hallucinogen derived from mushrooms of the genus
Psilocybe
3. Phencyclidine (PCP)—disorientation, seizures; treatment consists of
“talking down”
4. Marijuana (cannabis)—active ingredient is tetrahydrocannabinol
(THC); causes silliness, relaxation, euphoria, paranoia, confusion,
chronic amotivational syndrome; entrance drug (used first before
trying other addictive drugs)
D. Dental hygiene considerations
1. Cocaine—cardiac stimulant effect; causes addictive effect on heart
with local anesthetic agents with vasoconstrictors
2. Nitrous oxide (N2O)—sense of euphoria; incidence of dental
personnel abuse (unsupervised use); abuse produces neuropathy
(sometimes irreversible); without adequate O2, hypoxia is produced
3. Addicts—“shopper ” clients attempt to obtain prescriptions for
controlled substances from several dental offices; feign dental pain
but refuse definitive treatment; suspicion is warranted
4. Caffeine—increased HR and BP with excessive caffeine intake
5. Nicotine—check for oral manifestations of tobacco use (e.g., nicotine
stomatitis, periodontal disease, oral leukoplakia, precancerous
lesions, hairy tongue, halitosis)

967
Drug use during pregnancy
A. General—pregnant women must:
1. Avoid any unnecessary drugs
2. Consult with an obstetrician
B. Pregnancy and professional oral health care
1. First trimester—period of highest risk for drug effects on the fetus;
negative organogenic effects possible
2. Second trimester—best for elective dental treatment
3. Third trimester—use of any unnecessary drugs must be avoided
because of client comfort and proximity to delivery
C. Drugs used in dental practice that are probably safe
1. Amoxicillin
2. Penicillin
3. Erythromycin
4. Lidocaine
5. Epinephrine (limit dose)
D. Drugs used in dental practice that must be avoided
1. Aspirin
2. NSAIDs
3. Metronidazole
4. N2O—dental personnel who are pregnant should be especially
careful
a. Women exposed to high levels of N2O (more than 5 hours per
week) were significantly less fertile than unexposed women;
levels of allowable exposure vary from state to state
b. Dental practices should improve room air circulation and
cleaning procedures and use an air evacuation system to reduce
adverse outcomes5,6
c. More information is available at
http://www.osha.gov/dts/osta/anestheticgases/index.html#C1

Smoking Cessation
A. Nicotine reduction systems
1. Nicotine is a ganglionic cholinergic receptor agonist
2. Nicotine reduction (also known as replacement) therapies reduce the
withdrawal symptoms associated with smoking cessation
3. Smoking cessation reduces the risk of oral and lung cancers, heart
disease, and other lung diseases
B. Types of nicotine reduction systems

968
 1. Chewing gum—Nicorette 2 or 4 mg; available without a prescription
2. Transdermal systems—all available without a prescription
a. Habitrol
b. Nicoderm
c. Nicotrol
d. Prostep
3. Nasal spray—Nicotrol NS
4. Adverse effects
a. Chewing gum—sore mouth, hiccups, dyspepsia, jaw ache,
nausea
b. Chewing gum can stick to dentures and dental work
c. Transdermal systems—nausea, hypersalivation, abdominal pain,
vomiting, diarrhea, perspiration, headache, dizziness, hearing
and visual disturbances, confusion, weakness
d. Nasal spray—runny nose, throat irritation, watery eyes,
sneezing, cough
5. Dental hygiene considerations
a. Evaluate the client who smokes for oral benign and malignant
changes
b. Stress the importance of tobacco cessation
c. Evaluate clients using the chewing gum for any problems(e.g.,
gum sticking to dentures or dental work); recommend using
another form of smoking cessation aid
C. Bupropion (Zyban)
1. Antidepressant used to reduce nicotine cravings
2. Also called Wellbutrin; the pills are identical and made by the same
manufacturer, but coded differently for insurance purposes
3. Concomitant treatment modalities are encouraged (behavior
modification)
4. Recommended dosing—150 mg once daily for 3 days, followed by
150 mg twice daily for 2 to 3 months if the client is experiencing
success
D. Varenicline (Chantix)
1. Nicotine receptor blocker; amount of dopamine released into the
brain is reduced; thereby blocking the feelings of pleasure
associated with tobacco use
2. Dosing—once daily for the first 3 days, twice daily thereafter for the
full course of therapy (usually 12 weeks)
3. Taken after meals and with a full glass of water
4. Adverse effects include nausea, sleep problems, constipation, gas,
vomiting, and changes in mood and behavior

969
 5. Cannot be used in conjunction with other smoking cessation
products

Website Information And Resourc es

Source Website Address Description
RxList, The Internet http://www.rxlist.com A HealthCentral.com Network site
Drug Index providing information about
medications, indications,
contraindications, dosages, and
client information
Drug Topics http://www.drugtopics.modernmedicine.com Current news on drug-related
topics
FDA - Drugs http://www.fda.gov/Drugs/ Information on new drug
development and regulatory issues
Med Watch http://www.fda.gov/medwatch/safety.htm Safety information
American Herbal http://www.ahpa.org Current information on herbal
Products Association remedies
Malignant http://www.mhaus.org Online brochures, including an
Hyperthermia explanation of malignant
Association of the hyperthermia as a concern in
United States dentistry and oral and maxillofacial
surgery

970
References
1 Holroyd S.V. Clinical pharmacology in dental practice. ed 4 St Louis:
Mosby; 1989.
2 Wilson W., Taubert K.A., Gewitz M., et al. Prevention of infective
endocarditis: guidelines from the American Heart Association.
Circulation. 2007;116:1736.11.
3 Hirsh J, Dalen J, Guyatt G, editors: The sixth (2000) ACCP
guidelines for antithrombotic therapy for prevention and
treatment of thrombosis. American College of Chest Physicians.
In Chest 119(I suppl):1S–2S.
4 American Hospital Formulary Service. Drug information. Bethesda,
Md: American Society of Hospital Pharmacists; 2013.
5 Crawford J.S., Lewis M. Nitrous oxide in early pregnancy.
Anaesthesia. 1986;41:900–905.
6 Little J.W., Falace D.A., Miller C.S., Rhodus N.L. Dental
management of the medically compromised patient. St Louis: Mosby;
2008.

Chapter 11 review questions

Use Case D to answer questions 41 to 50.
41. The distribution of a drug across biologic membranes is determined
by all the following EXCEPT:
a. Blood flow to the organ
b. Presence of certain barriers
c. Plasma-protein binding capacity
d. Half-life
42. A drug effect that is NEITHER predictable NOR dose related is called
a:
a. Therapeutic effect
b. Toxic reaction
c. Side effect
d. Allergic reaction
43. Infective endocarditis prophylaxis with an anti-infective agent is
indicated for patients who have had:
a. Mitral valve prolapse

971
 b. Prosthetic cardiac valve
c. Rheumatic heart disease
d. Atrial septal defect
44. Which drug should be used as an antibiotic premedication before
invasive dental or dental hygiene care for a patient who has a history of
congenital heart disease, artificial heart valves, and an allergy to
penicillin?
a. Amoxicillin
b. Tetracycline
c. Clindamycin
d. Cephalexin
45. Which of the following drugs can result in a severe drug interaction
with alcohol?
a. Erythromycin
b. Tetracycline
c. Metronidazole
d. Aminoglycosides (e.g., streptomycin)
46. Which organ is involved in the “first-pass” effect after oral
administration of a drug?
a. Kidney
b. Lungs
c. Liver
d. Spleen
47. All the following are TRUE with regard to cytochromes P450 EXCEPT
for which one?
a. Cytochromes P450 are located in the endoplasmic reticulum.
b. Cytochromes P450 exist as numerous isozymes.
c. Cytochromes P450 are involved in the first-pass effect.
d. Cytochromes P450 inactivate drugs through conjugation reactions.
48. NSAIDs, such as ibuprofen, can antagonize the effects of which of the
following antihypertensive medications?
a. ACE inhibitors
b. β-Adrenergic antagonists
c. Calcium channel blockers

972
 d. Diuretics
49. Which anticonvulsant medication has been documented to cause
osteomalacia?
a. Carbamazepine
b. Phenytoin
c. Ethosuximide
d. Gabapentin
50. Alopecia may be an adverse effect of phenytoin. Carbamazepine can
cause hirsutism.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.

Case D
Synopsis of Patient History
Age: 76
Sex: F
Height: 5′3″
Weight: 140 lbs (63.6 kg)

Vital Signs
Blood pressure: 115/75 mm Hg
Pulse rate: 70 bpm
Respiration rate: 22 rpm

Current Medications
Ibuprofen 400 mg tid
Hydrochlorothiazide 25 g qd
Phenytoin (Dilantin)

Medical History
Patient has a history of arthritis, seizure disorders, and hypertension.
She is being treated by a general physician for all three. She often
complains of GI upset after taking ibuprofen. She is also 1 year post–

973
joint replacement surgery on her right knee.

Dental History
Visits the dental office for regular examination and cleaning.

Social History
She is widowed and lives alone.
She enjoys volunteering, reading, gardening and traveling

Chief Complaint
Routine visit
Requires antibiotic prophylaxis: amoxicillin 2 g 1 hour before procedure

Use Case C to answer questions 26 to 40.

26. Patients should be warned that an acute overdose with
acetaminophen can result in damage to the:
a. Eyes
b. Liver
c. Spleen
d. Kidney
27. Alcohol consumption in combination with acetaminophen stimulates
the breakdown of acetaminophen, thereby increasing the toxic potential
of acetaminophen use.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
28. Approximately 90% of dental pain is BEST managed with:
a. Codeine 60 mg
b. Ibuprofen 400 mg
c. Acetaminophen 650 mg
d. Aspirin 650 mg
29. Which of the following drugs should you avoid recommending to a
person taking lithium?
a. Aspirin
b. Ibuprofen

974
 c. Acetaminophen
d. Oxycodone
30. Patients taking ibuprofen should be counseled about all the following
EXCEPT:
a. Gastrointestinal upset
b. Heartburn
c. Sedation
d. Increased risk for bleeding
31. Both opioid and nonopioid analgesics relieve pain by raising the pain
threshold. Raising the pain threshold increases one’s reaction to pain.
a. Both statements are TRUE.
b. The first statement is TRUE; the second statement is FALSE.
c. The first statement is FALSE; the second statement is TRUE.
d. Both statements are FALSE.
32. Following the dental procedure, the patient developed itching and
urticaria after taking her acetaminophen with codeine. This response
MOST likely represents a:
a. Pharmacologic action of codeine
b. Hypersensitivity reaction to codeine
c. Placebo effect from receiving codeine
d. Reaction unrelated to codeine administration
33. Which of the following is the major symptom of opioid overdose?
a. Miosis
b. Respiratory depression
c. Urticaria
d. Mydriasis
34. For pain control, often an opioid analgesic is combined with a
nonopioid analgesic. This combination produces an additive analgesic
effect with fewer adverse reactions.
a. Both statements are TRUE.
b. The first statement is TRUE; the second statement is FALSE.
c. The first statement is FALSE; the second statement is TRUE.
d. Both statements are FALSE.
35. Which of the following is an adverse reaction to codeine?

975
 a. Diarrhea
b. Miosis
c. CNS excitation
d. Hepatotoxicity
36. Antianxiety agents are most frequently administered as the oral dose
form. This is because the blood levels achieved from the oral
administration of the antianxiety agent are very predictable.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
37. Once a benzodiazepine is absorbed into the systemic circulation, all
the following contribute to the rate at which it reaches its site of action
EXCEPT:
a. Lipid solubility
b. Protein binding
c. Ionization
d. Client’s gender
38. The patient has begun to inhale nitrous oxide and oxygen (N2O-O2) as
part of conscious sedation. The BEST way to determine her level of
sedation under N2O-O2 is:
a. Response to a painful stimulus
b. Percent N2O being delivered
c. Response to questions
d. Muscle tone
39. Conscious sedation with N2O-O2 is CONTRAINDICATED in a patient
with:
a. Diabetes
b. Emotional instability
c. Hypertension
d. Glaucoma
40. Nitrous oxide and oxygen (N2O-O2) is often combined with a
halogenated inhalational anesthetic because it:
a. Increases the minimum alveolar concentration (MAC)

976
 b. Decreases the MAC
c. Typically precipitates a toxic reaction
d. Inhibits the metabolism of the halogenated anesthetic

Case C
Synopsis of Patient History
Age: 49
Sex: F
Height: 5′2″
Weight: 125 lbs (57 kg)

Vital Signs
Blood pressure: 95/68 mm Hg
Pulse rate: 65 bpm
Respiration rate: 20 rpm

1. Hospitalized within the last 3 years: ___ YES x NO

Current Medications
LoEstrin 24
Occasional over-the-counter ibuprofen and acetaminophen

Medical History
Menopausal; otherwise healthy

Dental History
Visits the dental office for regular examination and cleaning.
Predental anxiety, requires pretreatment with a benzodiazepine

Social History
Married with two children
She enjoys golf, gardening. scrapbooking, reading, and traveling.
She is a pharmacist.

Chief Complaint
Requires a crown

Anticipated Medications

977
Lorazepam 2 mg the night before the appointment
N2O-O2 conscious sedation during procedure
Acetaminophen with codeine post procedure

Use Case B to answer questions 11 to 25.

11. What is meant by the term essential hypertension?
a. Hypertension of unknown cause
b. Iatrogenic hypertension
c. Hypertension precipitated by another disorder
d. A rapidly developing form of hypertension, requiring aggressive
therapy
12. Eating a banana or drinking a glass of orange juice when taking a
thiazide diuretic will:
a. Deplete calcium
b. Prevent diuresis
c. Replenish potassium
d. Inhibit the drug’s metabolism
13. Patients who have experienced a myocardial infarction 9 months prior
to an office visit would be considered a CONTRAINDICATION to dental
treatment. After 9 months, if treatment is provided, the patient should
receive prophylactic antibiotic premedication.
a. Both statements are TRUE.
b. The first statement is TRUE; the second statement is FALSE.
c. The first statement is FALSE; the second statement is TRUE.
d. Both statements are FALSE.
14. One of the main differences between angiotensin-converting enzyme
(ACE) inhibitors and angiotensin receptor blockers (ARBs) is that ACE
inhibitors cause a dry, nonproductive cough. ARBs do not cause a dry,
nonproductive cough.
a. Both statements are TRUE.
b. The first statement is TRUE; the second statement is FALSE.
c. The first statement is FALSE; the second statement is TRUE.
d. Both statements are FALSE.
15. Clients taking antihypertensive agents who have been supine for
some time should rise from that position slowly. They should dangle

978
their legs over the side of the chair and wiggle them before rising to the
standing position.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is false.
d. The first statement is FALSE; the second statement is true.
16. Which of the following drugs inhibits hydroxymethylglutaryl
coenzyme A (HMG-CoA) reductase?
a. Pravastatin
b. Ramipril
c. Nifedipine
d. Ezetimibe
17. Which agent reduces serum cholesterol by increasing its use for bile
acid synthesis?
a. Niacin
b. Atorvastatin
c. Gemfibrozil
d. Cholestyramine
18. Which class of drugs is recommended in persons with diabetes?
a. β-Adrenergic blockers
b. Ca+ 2 channel blocker
c. Angiotensin-converting enzyme (ACE) inhibitors
d. Anticholinergic agents
19. All the following drugs inhibit platelet function EXCEPT:
a. Clopidogrel
b. Dipyridamole
c. Ticlopidine
d. Aspirin
20. Patients taking nitroglycerine (NTG) sublingual tablets should be
instructed to:
a. Store their NTG in plastic
b. Keep their NTG in the refrigerator
c. Use NTG once every 5 minutes until the anginal attack has stopped
d. Bring their NTG to the dental appointment and make it available to

979
 the practitioner in the event that the patient experiences an acute
anginal attack
21. Your patient complains of chest pain while sitting in the dental chair.
Even though the information is not recorded on his health history or
pharmacologic history form, it is a good idea for you to ask if he has
taken sildenafil (Viagra) within the last 24 hours. The use of
nitroglycerine is contraindicated if sildenafil has been taken within 24
hours because the nitroglycerine-sildenafil combination can precipitate a
hypertensive crisis.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
22. Which oral antidiabetic agent produces lactic acidosis as a significant
adverse effect?
a. Tolbutamide
b. Metformin
c. Repaglinide
d. Acarbose
23. Patients taking glipizide should be instructed to:
a. Schedule their dental appointments after mealtimes and take their
medicine on time
b. Schedule their dental appointments around the time they take their
medicine
c. Schedule their dental appointments around mealtimes only
d. Schedule their dental appointment any time, as the timing of the
appointment is not a significant factor
24. Which antidepressant is LEAST likely to cause xerostomia?
a. Bupropion
b. Citalopram
c. Chlorpromazine
d. Amitriptyline
25. Selective serotonin reuptake inhibitors (SSRIs) tend to produce
central nervous system (CNS) stimulation rather than CNS depression.
Therefore, SSRIs are less sedating.

980
 a. Both statements are TRUE.
b. The first statement is TRUE; the second statement is FALSE.
c. The first statement is FALSE; the second statement is TRUE.
d. Both statements are FALSE.

Case B
Synopsis of Patient History
Age: 55
Sex: M
Height: 5′10″
Weight: 220 lbs (100 kg)

Vital Signs
Blood pressure: 145/85 mm Hg
Pulse rate: 75 bpm
Respiration rate: 25 rpm

Current Medications
Lisinopril (Zestril)
Hydrochlorothiazide
Baby aspirin
Atorvastatin (Lipitor)
Glipizide (Glucotrol) 10 mg bid
Metformin (Glucophage)
Citalopram (Celexa) 40 mg qd
Sublingual nitroglycerin as needed

Medical History
Client has a history of cardiovascular disease, type 2 diabetes,
depression, and high cholesterol. Patient being treated by a cardiologist
and his general physician.

Dental History
Visits the dental office for regular examination and cleaning.

Social History
Married with three children

981
Enjoys golf, football, television, and good meals
Currently employed as a government contractor

Chief Complaint
Presents for routine oral health examination

Use Case A to answer questions 1 to 10.

1. Which of the following drugs could be causing the sore throat and dry
mouth?
a. Albuterol
b. Montelukast
c. Multivitamins
d. Doxycycline
2. Albuterol is a bronchodilator that can be administered via a metered-
dose inhaler. It is recommended for treating an acute asthma attack.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE
d. The first statement is FALSE; the second is TRUE
3. Which one of the following drugs can result in oral candidiasis?
a. Cetirizine
b. Ibuprofen
c. Acetaminophen
d. Fluticasone
4. All the following are recommendations that you should make to
patients with asthma EXCEPT one. Which one is the exception?
a. Bring your inhaler (albuterol) to the dental appointment.
b. Rinse after using corticosteroid inhaler.
c. Avoid erythromycin.
d. Avoid aspirin.
e. Avoid acetaminophen.
5. Although this teenager with asthma does not have emphysema,
several of the drugs used to treat asthma are also used to treat
emphysema. Which of the following is the drug of choice for treating
emphysema?

982
 a. Albuterol
b. Zileuton
c. Ipratropium
d. Cetirizine
6. Which of the following orally inhaled drugs should the patient bring
with him to each appointment in case of an acute asthma attack?
a. Salmeterol
b. Albuterol
c. Flunisolide
d. Ipratropium bromide
7. Which of the following is the BEST recommendation you could make
to your patient if he required oral prednisone (steroid therapy)?
a. Continue to rinse, swish, and spit after taking your oral tablet.
b. Rinse, swish, and swallow after taking your oral tablet.
c. Check for any signs of infection, since this medication can mask the
signs of infection and can delay wound healing.
d. Be careful, since this drug can cause significant dry mouth.
8. Patients using the fluticasone/salmeterol inhaler should be instructed
about all the following EXCEPT:
a. Rinse, swish, and spit after each use of the inhaler.
b. The inhaler must be discarded 1 month from the date of first use.
c. It is a good idea to brush your teeth after each inhaler use.
d. This inhaler can be used for acute attacks.
9. Patients taking doxycycline should be counseled about all the
following EXCEPT:
a. Esophageal irritation
b. Photosensitivity
c. Gastrointestinal upset
d. Sedation
10. Histamine-1 (H1)–blocking drugs such as cetirizine are preferred over
drugs such as diphenhydramine because they are less sedating.
Cetirizine is a nonsedating H1-blocking drug.
a. Both statements are TRUE.
b. The first statement is TRUE; the second statement is FALSE.

983
 c. The first statement is FALSE; the second statement is TRUE.
d. Both statements are FALSE.

Case A
Synopsis of Patient History
Age:16
Sex: M
Height: 5′9″
Weight: 162 lbs (73.6 kg)

Vital Signs
Blood pressure: 102/60 mm Hg
Pulse rate: 70 bpm
Respiration rate: 22 rpm

Current Medications
Albuterol inhaler: as needed
Montelukast (Singulair) 10 mg: one tablet daily
Fluticasone/salmeterol (Advair HFA) inhaler: one inhalation twice daily
Multivitamin: once daily
Doxycycline
Cetirizine (Zyrtec) 10 mg daily

Medical History
Patient has a history of asthma and is under the care of his pediatrician.
Patient also has acne, which is being treated by his pediatrician.

Dental History
Visits the dental office for regular examination and cleaning.

Social History
He lives with his mother, father, and brother.
He enjoys golf, soccer, movies, and traveling.
He is a junior at a local high school.

Chief Complaint
Sore and dry throat

984
 Answers and rationales to review questions are available on this text’s
accompanying Evolve site. See inside front cover for details.

985
C HAPT E R
12

986
Biochemistry, Nutrition, and
Nutritional Counseling
Lisa F. Harper Mallonee

Humans require specific chemicals or nutrients from food to grow,

maintain homeostasis, and achieve optimal health. An understanding of
cellular biochemistry and nutrition is essential for preventing and
treating disease and for promoting health. Nutrition science includes the
intake of food and the processes involved in digestion, absorption,
transportation, metabolism of nutrients, and excretion. As an applied
science, it involves counseling people to adapt food patterns to
nutritional needs within the cultural, economic, and psychosocial
environment. Nutrition assessment counseling, when performed
effectively, motivates individuals to modify eating behaviors so that
optimal health can be achieved.
This chapter reviews the six major nutrient groups and their metabolic
activities in mammalian cells, dietary modifications for diseases,
nutritional diseases and disorders, and oral manifestations of nutritional
deficiencies and toxicities. The effects of nutrients on oral tissues and the
dietary assessment tools and techniques available for counseling
individuals with various types of oral diseases are also described.
Because nutritional problems in the developed countries are a result of
overeating and undereating, a review of energy balance and weight
control is included. Cellular biochemistry is fundamental to the study of
nutrition; therefore the reader is referred to the section on “General
Histology” in Chapter 2 for a review of structural and functional
similarities in cells.

987
Six major classes of essential nutrients
Carbohydrates
A. Definition—polyhydroxy aldehydes or ketones that serve as the body’s
primary sources of quick energy; carbohydrates (CHO) are composed of
monosaccharides, basic units that contain carbon, hydrogen, and oxygen
B. Basic chemical structure
1. The ratio of carbon, hydrogen, and oxygen is 1:2:1
2. The reactive portion of the molecule may be in a ketose form or an
aldose form

3. The position of the hydroxyl (–OH) groups

determines properties such as sweetness and
absorbability
C. Classification
1. Simple carbohydrates
a. Monosaccharides
(1) Trioses (C3) and tetroses (C4)—usually formed during
intermediary metabolism and are not important dietary
components
(2) Pentoses (C5)—important in nucleic acids and coenzymes;
do not occur in free form (uncombined); not important
dietary components (e.g., ribose)
(3) Hexoses (C6)—most important group physiologically
(a) Glucose—blood sugar; primary energy source

988
 (b) Galactose—seldom found free; but found in lactose
(c) Fructose—fruit sugar; sweetest tasting sugar; found in
honey and fruits
b. Disaccharides—composed of two monosaccharide units
(1) Sucrose—glucose plus fructose (e.g., cane and beet sugar)
(2) Lactose—glucose plus galactose (e.g., milk sugar)
(3) Maltose—glucose plus glucose (intermediate of starch
hydrolysis [digestion])
D. Oligosaccharides—composed of two to six monosaccharide units
1. Complex carbohydrates
a. Homopolysaccharides—made up of more than six identical
monosaccharide units
(1) Starch—plant storage form of glucose; source of half of
dietary carbohydrates
(a) Amylose—straight chain
(b) Amylopectin—branched chain
(2) Glycogen—animal storage form of glucose; found in the
liver and muscle of living animals; insignificant source of
dietary carbohydrates
(3) Cellulose—chief constituent of the framework of plants;
glucose units are in β-linkages, not capable of being
hydrolyzed by human digestive enzymes; provides bulk and
fiber in the diet
b. Heteropolysaccharides—carbohydrates associated with
noncarbohydrates or carbohydrate derivatives
(1) Pectin, lignin—important contributors to fiber in the diet
(2) Glycoproteins—carbohydrate and protein in a specific,
functional arrangement (e.g., blood group substances and
many hormones)
(3) Glycolipids—carbohydrate and lipid, as in gangliosides
(4) Mucopolysaccharides—protein and carbohydrate in a
loose binding
(a) Hyaluronic acid—vitreous humor and joint lubricant
(b) Heparin—anticoagulant
(c) Chondroitin sulfate—cartilage, skin, bone, and teeth
(d) Keratin sulfate—nails and teeth
E. Digestion, absorption, and transport
1. Digestion (Table 12-1)

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 Table 12-1
Digestive Action at Various Points Along the Gastrointestinal Tract

* A minor role in total fat digestion.

a. Mouth
(1) Teeth and tongue—mechanical breakdown and mixing of
food
(2) Saliva—hydration and lubrication of food
(3) Salivary amylase (ptyalin)—initial enzymatic hydrolysis of
starch
b. Stomach—no digestive enzymes for carbohydrates; initial
enzymatic hydrolysis of starch by salivary amylase may continue
c. Small intestine
(1) Pancreatic juices—pancreatic amylases
(2) Intestinal villi (brush border) enzymes— disaccharidases
(a) Sucrase—converts sucrose to glucose and fructose
(b) Lactase—converts lactose to glucose and galactose
(c) Maltase—converts maltose to glucose
d. Large intestine—bacterial “fermentation” of some undigested
carbohydrates
(1) No significant contribution to absorbable carbohydrates
(2) May be the cause of gas production and bloating during
primary or secondary disaccharidase deficiency (e.g.,
“lactose intolerance”)
2. Absorption (Fig. 12-1)

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 FIG 12-1 Absorption of major nutrients, vitamins, and minerals. (From
Mahan LK, Escott-Stump S: Krause’s food and nutrition therapy, ed 13, St Louis, 2012,
Saunders.)

a. Factors affecting absorption

(1) Intestinal motility
(2) Type of food mixture
(3) Integrity of intestinal mucosa
(4) Endocrine activity
b. Mechanism
(1) Passive diffusion along the osmotic gradient—when the
intestinal concentration of carbohydrates is greater than the
level of carbohydrate in the blood
(2) Facilitated diffusion—only certain molecules allowed to
pass across a membrane using an ion channel or a carrier
protein
(3) Active transport—requires energy and allows molecules to
pass against a concentration gradient with the aid of an ion
channel or a carrier protein at the brush border
c. Route
(1) Carbohydrates are water soluble and are absorbed directly

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 into the capillaries of the intestinal mucosa
(2) Carried by the portal circulation to the liver
F. Metabolism—glucose is the main immediate source of energy for the
body; a glucose level of 70 to 120 mg/100 mL blood is maintained by most
healthy persons (Fig. 12-2)

FIG 12-2 An overview of metabolism.

1. Sources of blood glucose

a. Dietary carbohydrates—sugars, starches
b. Stored liver glycogen breakdown—glycogenolysis
c. Synthesis from intermediary metabolites such as pyruvic acid—
glyconeogenesis
d. Synthesis from noncarbohydrate sources— gluconeogenesis
(1) Deaminated (glucogenic) amino acids
(2) Glycerol portion of lipids
2. Reactions of blood glucose—”burned” (oxidized) for energy

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 a. Glycolysis—end product is pyruvate or lactic acid in the absence
of oxygen (anaerobic conditions) or acetyl–coenzyme A (acetyl-
CoA) in the presence of oxygen (aerobic conditions)
b. Tricarboxylic acid cycle (TCA) or Krebs cycle—oxidation of
acetyl-CoA with the release of carbon dioxide (CO2)
c. Oxidative phosphorylation and electron transport—production
of adenosine triphosphate (ATP, a high-energy molecule) and
water
3. Storage for reserve use
a. Glycogenesis—glycogen is the short-term storage form of
glucose in the liver and muscle (6 to 18 hours)
b. Lipogenesis—excess carbohydrate in the diet is converted to fat
to be stored in adipose tissue as a long-term energy storage
form
4. Conversion to other molecules, such as:
a. Other carbohydrates needed for structural or functional roles
b. Keto acids to be used in protein synthesis
G. Metabolic regulators
1. Anabolic hormones—lower the blood glucose level (e.g., insulin)
a. Increase the entry of glucose into cells
b. Increase glycogenesis
c. Increase lipogenesis
2. Catabolic hormones—raise the blood glucose level
a. Glucagon—stimulates glycogenolysis
b. Steroid hormones—stimulate gluconeogenesis
c. Epinephrine—stimulates glycogenolysis
d. Growth hormone and adrenocorticotropic hormone (ACTH)—
act as insulin antagonists
e. Thyroxine—increases insulin breakdown, intestinal absorption
of glucose, and epinephrine release
3. Coenzymes—B-complex vitamins are important precursors of the
coenzymes involved in the catabolism of carbohydrates
H. Fiber
1. Definition—substance, usually nonstarch polysaccharide, found in
plants; not broken down by human digestive enzymes; some of it is
digested by bacteria in the gastrointestinal (GI) tract
a. Insoluble fiber—substance (e.g., cellulose, hemicellulose,
lignin) that gives structure to plant cell walls; adds bulk and
softness to stools; reduces contact with possible carcinogens by
decreasing transit time through the colon; foods high in
insoluble fiber include wheat bran, raw fruits, and vegetables

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 b. Soluble fibers—substances (e.g., gums, mucilages, pectin, oat
bran) that dissolve to become gummy or viscous; lower blood
cholesterol; regulate the use of sugars and slow down gastric
emptying; foods high in soluble fiber include legumes, raw
apples, and whole oats
2. Epidemiologic studies indicate that individuals whose diets include
a significant amount of fiber have a low incidence of chronic
“Western” diseases, such as coronary heart disease, diabetes,
atherosclerosis
3. Specific fibers are believed to play roles in decreasing the incidence
of obesity, irregularity, hemorrhoids, appendicitis, diverticulosis,
colon cancer, hyperlipidemia, and fluctuations in blood glucose
4. Excessive dietary fiber
a. For persons with a limited intake, diets high in fiber bulk may
cause nutritional deficiency
b. Use of large doses of purified fiber may inhibit absorption of
calcium, potassium, zinc, and iron
c. Phytic acid, often found in high-fiber foods such as cereal
grains, can bind and prevent absorption of minerals such as
iron, calcium, and zinc
5. Recommended fiber intake—for adults, 21 to 38 grams per day
(g/day), depending on age and gender
I. Biologic role and functions of carbohydrates
1. Provide precursors of structural and functional molecules (e.g.,
gangliosides)
2. Energy source (4 kilocalories per gram [kcal/g])
3. Spare protein
4. Provide bulk and palatability to the diet
J. Role in oral biology
1. Preeruptive effect on teeth
a. Energy source for growth and development
b. Protein-sparing nutrient
2. Posteruptive effect on teeth
a. Energy source for oral cariogenic bacteria (e.g., Streptococcus
mutans)
b. Acidogenic bacteria metabolize monosaccharides and
disaccharides, particularly sucrose, for the production of energy
through glycolysis that results in the formation of lactic acid,
pyruvate, and other acetyl-CoA, dependent on the conditions
c. S. mutans synthesizes polysaccharides (glucans, levans, and
glycogen) from sucrose

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 (1) Polysaccharides are used for energy when sucrose is
unavailable
(2) Glucans form insoluble complexes with S. mutans and have
a strong affinity for enamel, thus enhancing bacterial
plaque formation
(3) The organic acids are liberated into the interface between
the bacterial plaque and surface enamel
(4) At pH 5.5, decalcification and demineralization begin
d. The firm texture of some complex carbohydrates, as found in
raw fruits and vegetables, can help to remove food debris
retained between teeth; the chewing action can also stimulate
salivary flow
3. Dietary sweeteners (Table 12-2)

Table 12-2
Dietary Sweeteners

Modified from Hubrich B, Nabors LO. Glycemic response. In Formulating glycemic strategies, a supplement to
Food Product Design. July 2006, pp 1-9. Adapted from Davis JR, Stegeman CA: The dental hygienist’s guide to
nutritional care, ed 4, Philadelphia, 2015, Saunders; and Palmer C: Diet and nutrition in oral health, ed 2, Upper
Saddle River, NJ, 2007, Pearson Prentice Hall, p 68.
N/A, Not applicable.
* Sucrose = 1.0

a. Nutritive sweeteners are used by the body as an energy source;

they provide calories
(1) Sugar alcohols (xylitol, sorbitol, and mannitol) are

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 noncariogenic nutritive sweeteners that are slowly
fermented through anaerobic metabolism by oral bacteria;
excessive intake of these polyols can cause diarrhea because
of the osmotic transfer of water into the bowel
(2) Xylitol is found naturally in plants and is equal to or
sweeter than sucrose; consumption of xylitol-containing
products after eating food has been shown to interfere with
the metabolism of S. mutans and decrease the
demineralization of enamel
b. Nonnutritive sweeteners are calorie free and have no nutritive
value; aspartame, saccharin, and acesulfame-K are nonnutritive
sweeteners approved by the United States Food and Drug
Administration (FDA); are noncariogenic
c. Aspartame should be avoided by patients who have
phenylketonuria, a genetic disorder characterized by an inability
to metabolize the amino acid phenylalanine
d. Food labels often list sugar content in its various forms (e.g.,
invert sugars, dextrose, fructose, corn sweeteners) to give an
appearance of lower sugar content
4. Cariogenicity factors of diet habits (from most important to least
important)
a. Intake frequency of simple sugars—the more frequent the
exposure to sugar, the more cariogenic is the diet; six candy bars
eaten at six different times during the day are more harmful in
terms of acid and bacterial plaque formation than six candy bars
consumed at the same time
b. Form of simple sugars (liquid or retentive)—liquid sweets clear
the oral cavity faster than solid or retentive sweets do and
therefore are less cariogenic
c. Time of ingestion of simple sugars—combining sweets with
liquids and other noncariogenic foods during a meal is less
cariogenic than a concentrated exposure to sweets between
meals as a snack
d. Total intake of simple sugars—average daily intake of sugar is
22 teaspoons (tsp); the majority of our simple sugar intake
comes from soft drinks, fruit drinks, desserts, candies, and
ready-to-eat cereals; the American Heart Association (AHA)
recommends 6 tsp/day for women and 9 tsp/day for men1
e. Starch-rich foods that are retained on the teeth for prolonged
periods are ultimately degraded to organic acids and can
contribute to the production of dental caries

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 f. Combining cariogenic foods with noncariogenic foods—recent
studies indicate that certain cariogenic foods (e.g., canned pears
in syrup) are less cariogenic when combined with a particular
noncariogenic food (e.g., cheese)
5. Importance of carbohydrates in periodontal health
a. Energy source for the growth and repair of periodontal tissues
b. Protein-sparing nutrient
c. Firm texture of complex carbohydrates can promote circulation
in gingival tissue
d. Dietary monosaccharides and disaccharides enhance
supragingival bacterial growth and plaque formation; these
bacteria set the stage for the growth and development of
subgingival bacteria and plaque, which are responsible for the
destructive effects of periodontitis
K. Requirements
1. The recommended daily allowance (RDA) of digestible carbohydrate
is 130 g/day for adults and children
a. Minimum adult intake (50 to 100 g) prevents use of body protein
as an energy source
b. Pregnant and lactating women need additional carbohydrates to
prevent ketosis
2. Recommendations
a. The Food and Nutrition Board recommends that 45% to 65% of
calories should come from carbohydrates2
b. Calories from simple carbohydrates (monosaccharides and
disaccharides)—10% or less of the total caloric intake
c. The majority of calories should come from complex
carbohydrates (including fiber)
L. Dietary modifications for persons with disease conditions
1. Obesity—reduce total calories and percentage of simple
carbohydrates (concentrated sweets) to increase the nutrient density
of a lower-calorie diet
2. Genetic defects
a. Lactose intolerance (inability to hydrolyze lactose)—eat fewer
milk products, use fermented products, or add a commercial
lactose enzyme (lactase) to milk
(1) Yogurt with active-bacteria culture is recommended
because the lactose is digested by the yogurt
(2) The main concern for oral and systemic health is an
inadequate intake of calcium and vitamin D; a hydrogen
breath test can be used for diagnosis

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 (3) Types of lactose intolerance
(a) Primary—congenital absence of lactase (a brush-
border enzyme)
(b) Secondary—temporary or permanent loss of lactase
activity resulting from intestinal injury, diseases (e.g.,
Crohn), or infections which cause injury to the GI
mucosa
b. Galactosemia—congenital inability to metabolize galactose;
lactose and milk products should be removed from the diet
c. Fructose intolerance—congenital inability to metabolize
fructose; fructose and sucrose should be removed from the diet;
individuals with fructose intolerance have significantly fewer
dental caries
3. Dental caries and periodontal disease—a protective diet should be
implemented
a. A diet that is low in retentive carbohydrates
b. Avoidance of cariogenic snacks
c. A diet that is adequate in all nutrients (Table 12-3)

Table 12-3
Dietary Reference Intake, Adequate Intake, and Tolerable Upper Limits of
Nutrients Specific to Bone Health

* Recommended dietary allowance values meet the needs of 97% of individuals in a group. Daily
reference intake values are groups of values that provide quantitative estimates of nutrient intake for
planning and assessing diets for all healthy individuals.
† Adequate intake (AI), also known as a therapeutic range, is the mean intake for healthy individuals that is
used when an RDA value cannot be determined. The lower number represents the adequate intake for
infants and children, and the higher range of numbers will vary depending on life stage and gender group.
Refer to the National Academies Press website (http://nap.edu/) for more in-depth information. The
therapeutic range (AI) is the dose at which physiologic benefits for healthy individuals and decreased risk
for toxicity may exist.
‡ The lower number represents the upper limits for infants and children, and the higher number
represents upper limits for males and females (pregnant and lactating). The tolerable upper limit is the
highest level of daily nutrient intake that is likely to pose no risk of adverse health effects.

d. Inclusion of foods of firm or hard texture

4. Diabetes (inability to regulate glucose because of insufficiency or
relative ineffectiveness of insulin)—dietary treatment (see the

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 section on “Diabetes Mellitus” in Chapter 19)
a. Two major forms
(1) Type 1 diabetes—persons with type 1 diabetes require:
(a) Daily injections of insulin
(b) Routine blood testing to monitor blood sugar levels
(c) Routine urine testing to monitor ketone levels
(2) Type 2 diabetes—persons with type 2 diabetes require:
(a) Medication to facilitate glucose metabolism
(b) Specialized diet to help control the disease
(c) Routine blood testing to monitor blood sugar levels
b. Signs and symptoms of diabetes mellitus
(1) Frequent urination (polyuria)
(2) Excessive thirst (polydipsia)
(3) Recurring gingival infections
(4) Extreme hunger (polyphagia)
c. Dietary recommendations
(1) Type 1 diabetes
(a) Is managed primarily with insulin therapy
(b) A regular pattern of three meals per day, with one or
more snacks between meals
(c) A diet that is rich in complex carbohydrates and
dietary fiber
(d) A diet high in carbohydrates replaced with
unsaturated fat and dietary fiber, if elevated
triglycerides are present
(2) Type 2 diabetes
(a) Regular meal patterns
(b) Regular physical activity
(c) Monitoring carbohydrate intake and increasing the
consumption of unsaturated fat and dietary fiber, if
elevated triglycerides are present
5. Reactive hypoglycemia—rare; symptoms of dizziness, hunger, and
heart palpitations are lessened with a low-carbohydrate diet
6. Dumping syndrome—occurs after gastric surgery; postprandial
symptoms of nausea, dizziness, cramping, and diarrhea are lessened
by a low-monosaccharide, low-disaccharide diet
7. Alcoholism—overconsumption of alcohol may cause malnutrition
(see the section on “Chronic Alcohol Abuse and Dependence” in
Chapter 19)
a. Depresses the appetite
b. Empty-calorie food—provides energy but few other nutrients

999
 (e.g., concentrated sweets, alcohol, and fats)
c. Causes vitamin B depletion because the liver needs niacin and
thiamine to metabolize alcohol
d. Causes folate and iron deficiency
e. Depresses antidiuretic hormone, causing loss of magnesium,
potassium, and zinc in urine
8. Alcohol consumption during pregnancy—has a direct teratogenic
effect on the developing fetus: fetal alcohol syndrome (see the
section on “Fetal Alcohol Spectrum Disorders” in Chapter 19)
9. Carbohydrate regulation in some hyperlipoproteinemias—total
carbohydrate and alcohol intake is controlled; concentrated sweets
are restricted

Proteins
A. Definition—complex biologic compounds of high molecular weight
that contain nitrogen, hydrogen, oxygen, carbon, and small amounts of
sulfur; each protein has a specific size and is made up of amino acid
building blocks linked through peptide bonds in a specific arrangement
B. Classifications
1. Chemical
a. Simple proteins—contain amino acids only
b. Compound (conjugated) proteins—contain simple proteins and
a nonprotein group
(1) Nucleoproteins
(2) Metalloproteins
(3) Phosphoproteins
(4) Lipoproteins
c. Derived proteins—fragments produced during digestion or
hydrolysis (e.g., peptides, peptones, proteases)
2. Biologic
a. Complete proteins contain sufficient amounts of the essential
amino acids for normal metabolic reactions; found in foods of
animal origin
(1) A total of 20 essential amino acids that cannot be
synthesized by humans and must be provided in the diet in
sufficient amounts to meet the body’s needs
(a) Adult—histidine, isoleucine, leucine, lysine,
methionine, phenylalanine, threonine, tryptophan, and
valine
(b) Infant—all the above plus histidine and probably

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 taurine
(c) Premature infant—all the above plus cysteine
(2) Nonessential amino acids can be synthesized by the body
and need not be provided by the diet but are necessary for
normal metabolic reactions; include alanine, arginine,
aparagine, aspartic acid, cysteine, glutamic acid, glutamine,
glycine, proline, serine, and tyrosine
b. Incomplete proteins have insufficient quantities of one or more
essential amino acids to support protein synthesis in humans;
plant proteins are often incomplete (e.g., corn protein is low in
lysine; legume protein is low in methionine)
c. Complementary proteins are proteins that are incomplete when
ingested singly but, when combined, provide sufficient essential
amino acids
(1) In a “vegan” (or strict vegetarian) diet, the complementing
of plant proteins can be accomplished by combining
appropriate incomplete proteins
(a) The amino acids in different foods can complement
one another, even when eaten at different meals
(b) Persons on a strict vegetarian diet are at the greatest
risk for developing deficiencies in calcium, iron, zinc,
and vitamin B12 because the major food sources of
these nutrients come from animal products
(2) In an “ovolacto”-vegetarian diet, milk and egg proteins can
provide the essential amino acids that are inadequate in
incomplete plant proteins; however, this diet still may be
deficient in iron
d. Protein quality is a measure of a protein’s ability to support
protein synthesis; it is measured by comparing the test protein
with a reference protein, usually egg protein
(1) Amino acid or protein chemical score (CS)—compares the
essential amino acid content in a dietary protein to that of a
reference protein
(2) Protein efficiency ratio (PER)—measures a protein’s ability
to support growth
(3) Biologic value (BV)—expression of the percentage of
nitrogen retained for maintenance and growth compared
with the amount absorbed
(4) Net protein utilization (NPU)—expression of the
percentage of retained nitrogen compared with the amount
ingested; differs from BV because it takes into account the

1001
 protein’s digestibility
(5) Protein digestibility–corrected amino acid score
(PDCAAS)—compares the amino acid balance of a food
protein with the amino acid requirements of preschool-aged
children and then corrects for digestibility; used by the FDA
for labeling
C. Structure
1. Primary—linear sequence of the component amino acids
2. Secondary—steric interaction of amino acids that are close to one
another in the linear sequence (e.g., the α-helix and β-sheet)
3. Tertiary—steric interaction between amino acids that are far apart in
the linear sequence, which causes folding and the ultimate
functional structure of the protein (e.g., disulfide bonds)
4. Quaternary—steric interaction between subunits of proteins with
more than one polypeptide chain (e.g., hemoglobin)
D. Digestion, absorption, and transport (see Table 12-1 and Fig. 12-1)
1. Mouth—mechanical breakdown and moistening
2. Stomach
a. Hydrochloric acid from parietal cells denatures or unfolds
proteins and activates pepsinogen to give pepsin
b. Pepsin begins the hydrolysis of the peptide bonds of proteins to
form peptides and proteoses
3. Small intestine
a. The pancreas secretes bicarbonate into the duodenum to
neutralize the acidic products from the stomach and proteolytic
enzymes into an inactive form; enzymes activated by trypsin
through a hormonal feedback mechanism are chymotrypsin,
aminopeptidase, and carboxypeptidase; each hydrolyzes peptide
bonds formed by different classes of amino acids
b. Enzymes of the brush border are dipeptidases that hydrolyze
dipeptides to amino acids
4. Absorption—at the brush border of the microvilli of the small
intestine, absorption occurs both by simple diffusion along a
concentration gradient and by active transport at specific amino acid
sites involving carrier enzymes, a sodium-ATP pump, and vitamin B6
5. Transport—absorbed amino acids collected by the portal blood
system and transported to the liver
E. Metabolism (see Fig. 12-2)
1. Amino acid pool—a collection of amino acids in a dynamic
equilibrium in the liver, blood, and other cells that provides the raw
material for the body’s protein and amino acid needs

1002
 a. Input into the pool comes from proteins in the diet, breakdown
of body proteins, and synthesis of nonessential amino acids
b. Output from the pool is for synthesizing body structures,
specialized substances (e.g., melanin from tyrosine), and energy,
as needed
2. Anabolism
a. De novo synthesis—requires deoxyribonucleic acid (DNA),
messenger ribonucleic acid (mRNA), and ribosomal ribonucleic
acid (rRNA)
(1) In the nucleus, DNA carries the genetic information in
groups of three bases that provide the code for the
individual amino acids comprising a specific protein
(2) mRNA transports a copy of the code from DNA into the
cytoplasm
(3) mRNA attaches to a ribosome and acts as a template for
the alignment of amino acids that are attached to transfer
RNA (tRNA)
(4) If the proper amino acids are in the correct proportions
and the synthetic enzymes and energy are available, the
polypeptide chain is synthesized
b. Transamination
(1) Nonessential amino acids can be synthesized from the
corresponding α-keto acids, an α-amino acid (as the
NH3+donor), a specific transaminase enzyme, and the
coenzyme pyridoxal phosphate (vitamin B6)
(2) The intermediate complex formed in this reaction is called
a Schiff base
3. Catabolism—amino acids in excess of those needed for the synthesis
of proteins and other biomolecules cannot be stored or excreted;
they may, however, be deaminated and the α-keto acid used as a
metabolic fuel for immediate energy needs or for long-term energy
storage as fat
a. Amino group
(1) Deamination—loss of the α-amino group, usually in the
liver, through transfer to α-ketoglutarate to form glutamate;
glutamate is then oxidatively deaminated to yield ammonia
(NH3)
(2) Urea cycle—series of steps whereby the ammonia
produced during deamination is converted to urea for
excretion

1003
 b. α-Keto acid
(1) Ketogenic amino acids are those whose carbon skeleton,
after deamination, yields acetyl-CoA or acetoacetyl-CoA,
which then yields ketone bodies; high concentrations of
ketone bodies lead to some of the undesirable side effects
of high-protein, low-carbohydrate diets (e.g., ketoacidosis)
(2) Glucogenic amino acids are those that yield pyruvate, α-
ketoglutarate, and other intermediates of the citric acid
cycle that, if needed, can be converted to glucose
4. Nitrogen balance—comparison measurement of the amount of
nitrogen ingested with the amount excreted (e.g., urinary nitrogen
plus approximately 1 g/day for nail, hair, skin, and perspiration
losses) made to determine whether net protein catabolism,
anabolism, or equilibrium exists
a. Positive balance—intake is greater than output; indicates net
protein synthesis and is the normal situation for anyone
building protein-containing tissue, such as during childhood,
pregnancy, and recovery from undernutrition, surgery, or illness
b. Negative balance—intake is less than output; indicates net
protein breakdown, when the body must break down its own
protein to meet energy or metabolic needs; can result from
insufficient protein (or essential amino acids) or energy intake
or from fever, infection, anxiety, or prolonged stress
F. Metabolic regulation
1. Hormones
a. Anabolic—growth hormone, insulin, normal thyroid hormone,
and sex hormones
b. Catabolic—adrenocortical hormones and large amounts of
thyroid hormone
2. Vitamins—pyridoxine and riboflavin are necessary for protein
synthesis; when they are deficient in the diet, synthesis may be
limited
G. Functions
1. Structural—formation of:
a. Collagen and elastin
b. Bone and tooth matrix
c. Myosin fibrils
d. Keratin
2. Dynamic
a. Transport of nutrients by:
(1) Lipid-soluble and fat-soluble vitamins

1004
 (2) Iron—transferrin
(3) Hemoglobin and myoglobin—oxygen
(4) Protein-bound molecules
(5) Membrane transport
b. Regulation and control by:
(1) Immunoglobulins
(2) Buffers
(3) Hormones
(4) Enzymes
(5) Blood coagulation—fibrin
(6) Muscle contraction—actin and myosin
3. Energy source (4 kcal/g)
4. Role of proteins in oral biology
a. Preeruptive effects on teeth—essential for all cells and therefore
necessary for normal tooth bud and pulp formation and
synthesis of protein matrix for enamel and dentin
b. Posteruptive effects on teeth
(1) Essential for maintaining the integrity of pulpal tissue
throughout life
(2) Chemical nature of protein foods can neutralize acids
produced by oral bacteria
c. Periodontal health and disease
(1) Essential for all cells in the growth, development, and
maintenance of the periodontium
(2) Essential for the normal function of cellular defenses
against subgingival bacteria and toxins
(3) Necessary in the healing and repair of injured tissues from
periodontitis or periodontal surgery
H. Requirements
1. Determination and estimates of protein requirements
a. Studies of nitrogen balance are used to determine the lowest
protein intake that will support homeostasis or equilibrium
b. Average requirement for reference proteins of 0.8 g/kg/day for
young adult males; other groups by extrapolation or
interpolation
c. Estimates for growth needs in infants are based on the amount
of protein provided by that quantity of human milk that ensures
a satisfactory growth rate
2. Recommended dietary allowances—developed by the National
Research Council; based on 1985 World Health Organization (WHO)
recommendations, which use nitrogen balance data; these

1005
 allowances assume ingestion of good-quality protein in a mixed diet;
adjustments are made for growth, pregnancy, and lactation
3. Food sources—protein needs of an average adult can be met by
choosing two or more servings per day of meats, poultry, fish, eggs,
dried beans, and nuts
I. Dietary modifications for disease
1. Genetic disorders
a. Phenylketonuria (PKU)—inherited enzyme defect in which
individuals cannot metabolize the phenylalanine found in
almost all proteins; the prescribed diet provides only enough
phenylalanine to meet growth and maintenance needs; dietary
protein is restricted, but amino acids are provided by a synthetic
formula from which the phenylalanine has been removed
b. Other genetic disorders—maple syrup urine disease,
homocystinuria, tyrosinemia, methylmalonic aciduria, propionic
acidemia, and isovaleric acidemia are genetic disorders in which
amino acid metabolism is altered; treated with low-protein diets
and synthetic amino acid formulas
c. Gout—characterized by excessive uric acid production leading
to the formation of urate crystals deposited in the joints;
treatment often includes restriction of protein to limit purine
and uric acid production
2. Protein needs are increased during fever, after severe injury and
surgery, and by intestinal malabsorption, increased protein loss from
the kidneys, or diminished protein synthesis by the liver
3. Dietary protein must be restricted when the kidneys can no longer
remove nitrogenous wastes from the body or in severe liver disease
when the nitrogenous byproducts of protein catabolism can no
longer be synthesized
4. Protein-energy (or protein-calorie) malnutrition (PEM or PCM)
a. Kwashiorkor (classic)—failure of the young child to grow
because of insufficient protein intake (usually following
weaning from mother ’s milk); edema often masks muscle
wasting
b. Marasmus (classic)—failure of the infant or young child to grow
because of partial starvation; total caloric and protein intakes
are insufficient
c. Adult PEM or PCM—seen even in the developed countries
among alcoholic persons and long-term hospitalized patients
with acquired immunodeficiency syndrome (AIDS),
tuberculosis, or anorexia nervosa

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Lipids (Fats)
A. Definition—biochemical compounds composed of carbon, hydrogen,
oxygen, and small amounts of phosphorus; insoluble in water and
soluble in fatty substances and organic solvents
B. Classification
1. Simple lipids
a. True fats—contain fatty acids attached to glycerol (a trihydroxy
alcohol) through an ester linkage; these may be monoglycerides,
diglycerides, or triglycerides, depending on the number of
glycerol-hydroxyl groups esterified; chemical and biochemical
characteristics of glycerides depend on the number, order, and
types of fatty acids attached
(1) Saturated fatty acids—contain no double bonds and are
found in lipids from animal sources; are solids at room
temperature (high melting point)
(2) Unsaturated fatty acids—contain one or more double
bonds and come from plant sources; are usually liquids at
room temperature (low melting point)
(3) Hydrogenation—addition of hydrogen to some or all of the
double bonds; used in the manufacture of margarine or
butter substitutes from vegetable oils; in partial
hydrogenation, some trans bonds are formed and may
present a health risk
(4) Rancidity—addition of oxygen to some of the double
bonds of fatty acids that contributes to spoilage; occurs
spontaneously in foods and can be reduced by the addition
of antioxidants, such as butylated hydroxytoluene (BHT)
(5) Iodine number—chemical indication of the degree of
unsaturation of a fatty acid; the more molecules of iodine
bound by the fatty acid, the more unsaturated and the
higher the iodine number
b. Waxes—esters of a fatty acid and an alcohol other than glycerol;
the body is unable to use waxes because digestive enzymes do
not hydrolyze their ester linkage
2. Compound lipids contain compounds added to the glycerol and fatty
acids
a. Phospholipids (glycerol + 2 fatty acids + phosphate group = R
group)
(1) Water-soluble emulsifiers (e.g., lecithin, with choline as the
R group)

1007
 (2) Membrane constituents (e.g., sphingomyelin)
(3) Active intermediates in metabolism of lipid compound
(e.g., CoA)
b. Glycolipids—contain a carbohydrate component and are found
in the brain and nervous tissue (e.g., cerebrosides)
c. Lipoproteins—are water soluble and responsible for carrying
lipids throughout the body
(1) Chylomicrons—approximately 2% protein; carry
exogenous (absorbed from the diet) triglycerides
throughout the body
(2) Very-low-density lipoproteins (VLDLs)—9% protein; carry
endogenous triglycerides around the body
(3) Low-density lipoproteins (LDLs)—21% protein; carry
mostly cholesterol from the liver to peripheral sites
(4) High-density lipoproteins (HDLs)—50% protein; carry
cholesterol back to the liver; can be elevated by exercise
3. Derived lipids are compounds whose synthesis begins like fatty acid
synthesis, with acetyl groups added on one at a time
a. Sterols—all have a polycyclic nucleus
b. Cholesterol is a precursor for the synthesis of many steroid
compounds and a constituent of cell membranes
(1) Sources
(a) Exogenous—average dietary intake is 400 to 600
milligrams (mg) from foods of animal origin
(b) Endogenous—average synthesis in the body is 1 to
2 g/day
(2) Regulation of cholesterol—dietary cholesterol, percentage
of fat, ratio of polysaturated to monosaturated to
unsaturated fat, and amount of certain fibers in the diet
c. Steroids—similar to sterols but with side-chain modification
(e.g., bile acids, sex hormones, adrenocortical hormones,
vitamin D)
4. Artificial fats—substances developed for use in foods; have the
flavor, appearance, and feel of dietary fats without their physiologic
effects
a. Olestra—a zero-kilocalorie (0-kcal) artificial fat made from an
indigestible combination of sucrose and fatty acids; may help
serum cholesterol levels by directly interfering with cholesterol
absorption; may increase the requirement for vitamin E;
approved for use in snack foods
b. Simplesse—has approximately 15% of the kilocalorie of the fat it

1008
 replaces; made by microparticulation of protein; the small
protein particles have the feel of fat; not suitable for use in
cooking but used in fat-free dairy products and salad dressings
c. Oatrim and maltodextrim—carbohydrate-based fat
replacements; mimic the texture and feel of fat by forming gels;
are digestible and contribute some calories
C. Digestion, absorption, and transportation (see Table 12-1 and Fig. 12-1)
1. Digestion
a. Mouth—no enzymatic action; mechanical and moistening action
only
b. Stomach—gastric lipase hydrolyzes some short-chain and
medium-chain fatty acids from triglycerides
c. Small intestine
(1) Gallbladder—bile salts emulsify fats before digestion
(2) Pancreas—pancreatic lipase hydrolyzes fatty acids from
triglycerides to form diglycerides and monoglycerides
(3) Intestinal mucosa—lecithinase converts lecithin to fatty
acids, monoglyceride, phosphate, and choline
2. Absorption and transport
a. Short-chain fatty acids can be absorbed into the portal system
b. Medium-chain and long-chain fatty acids are water insoluble,
require bile as a carrier (emulsifier), and are absorbed in stages
(1) Bile separated out at the intestinal wall and recirculated
(2) Complete breakdown of triglycerides within the mucosal
cells by mucosal lipase
(3) Resynthesis of new triglycerides that combine with protein
carriers to form chylomicrons
(4) Passage into the lymph system (lacteals) and blood
through the thoracic duct
(5) At its destination, lipoprotein lipase hydrolyzes the
triglycerides, clearing chylomicrons from blood
(6) Lipoprotein carriers (VLDLs, LDLs, and HDLs) carry
endogenous lipids and cholesterol
D. Metabolism (see Fig. 12-2)
1. Anabolism
a. Lipogenesis—synthesis of triglycerides for long-term storage of
energy; starting material is acetyl-CoA, which can come from
glucogenic amino acids, carbohydrates, or breakdown of dietary
lipids; lipogenesis takes place in almost all cells but is most
active in adipose cells
b. Synthesis of steroids occurs in all cells

1009
 c. Synthesis of lipoproteins occurs mainly in the liver
2. Catabolism
a. β-Oxidation—fatty acids are broken down in a stepwise manner
to yield one molecule of acetyl-CoA for every two carbon atoms;
acetyl-CoA can be catabolized further by means of the TCA and
oxidative phosphorylation
b. Ketone production—when the body’s supply of carbohydrates is
low, the TCA is depressed and acetyl-CoA from β-oxidation
accumulates; alternative route for acetyl-CoA is ketone
production; acetoacetone, acetone, and β-hydroxybutyrate are
the ketone bodies; excess ketone production can cause ketosis,
ketonuria, and ketoacidosis (which is sometimes fatal)
E. Metabolic regulators
1. Vitamins as coenzyme precursors
a. Anabolism—biotin, riboflavin (in flavin adenine dinucleotide
[FAD]), niacin (in nicotinamide adenine dinucleotide [NAD]),
and pantothenic acid (in CoA) (see Fig. 12-2)
b. Catabolism—riboflavin, niacin, and pantothenic acid
2. Hormones
a. Anabolism—insulin
b. Catabolism—ACTH, thyroid-stimulating hormone (TSH),
epinephrine, and glucagon
3. Enzymes necessary for the metabolism of lipids are synthesized or
inhibited in response to the relative amounts of substrates and
products available
F. Biologic role and functions of lipids
1. Structural components of cell membrane
2. Energy source
a. Provide 9 kcal/g (compared with 4 kcal/g for protein or
carbohydrates)
b. Long-term storage of energy
3. Carrier medium of fat-soluble vitamins
4. Protective padding for body organs
5. Insulation for the maintenance of body temperature
6. Role of lipids in oral biology
a. Cariostatic properties
(1) Lipids provide a coating on the tooth’s surface and form a
protective pellicle on the tooth
(2) Lipids act by neutralizing the acids produced by bacterial
metabolism of the plaque biofilm; they raise the pH and
decrease risk of the demineralization of enamel

1010
 b. No relationship between dietary fat and periodontal disease
c. A review of the literature on obesity and periodontal disease
suggests that they both confound each other, and obesity itself
has been recognized as a major risk factor for periodontal
disease; adverse effects of obesity on periodontium may be
mediated through proinflammatory cytokines and various other
bioactive substances
G. Nutritional requirements
1. Essential fatty acids (EFAs)—cannot be synthesized in sufficient
amounts to meet the body’s needs; must be supplied in the diet; for
humans the only EFAs are linoleic (ω-6) and linolenic (ω-3) (omega
fatty acids); requirement is approximately 3% of total kilocalories
a. Function—necessary for the synthesis of membranes and
prostaglandins (local hormone)
b. Deficiency symptoms—seen in infants on low polyunsaturated
fatty acid (PUFA) diets and in adults receiving total parenteral
nutrition feedings without lipids; the deficiency is characterized
by slow growth, reproductive failure, and skin lesions
2. Recommendations (dietary goals as recommended by the AHA)
a. Total fats: 30% or less of total kilocalories; majority of calories
should come from monounsaturated and polyunsaturated fatty
acids
b. Cholesterol: 300 mg/day or less; 200 mg/day for high-risk
individuals
c. Saturated fats—avoid saturated and trans fatty acids (found in
processed foods); less than 10% of total kilocuries should come
from saturated fatty acids
d. Two weekly servings of fatty fish such as tuna or salmon
3. The seventh edition of Dietary Guidelines for Americans (2010) makes
similar recommendations for healthy persons age 2 years and older
H. Dietary modifications for disease
1. Cardiovascular disease (CVD)—blood vessel lumens become
narrower and sometimes completely blocked because of the plaques
caused by the accumulation of fatty substances, cellular debris, and
calcium; blood pressure and the work required of the heart increase;
formation of clots increase, and the result may be a heart attack
(myocardial infarction) or stroke (cerebrovascular accident)
a. Hyperlipoproteinemias—for diagnosis, elevation of serum
VLDL, LDL, and chylomicron levels indicates that a client is at
risk for CVD; a genetic predisposition for certain
hyperlipoproteinemias exists; elevated HDL levels may exert a

1011
 protective effect against CVD; routine exercise elevates HDL
levels in most people
b. Dietary factors that may increase serum lipids—high intake of
cholesterol, saturated fats, total fats, sucrose, fructose, and
ethanol (alcohol)
c. Dietary factors that may decrease serum lipids—
monounsaturated and polyunsaturated fatty acids, omega fatty
acids (fish oils), and pectin; ethanol in moderate amounts may
have a protective effect by increasing HDL levels; unidentified
substances in garlic, yeast, onions, and some wines may also
have a protective effect
2. Obesity—because fats are a concentrated source of calories
(9 kcal/g), most reducing diets recommend a decrease in fat intake;
fat should not be too severely restricted because it adds to the
palatability and satiety of the diet
3. Gallbladder disease and chronic pancreatitis—often cause pain after
lipid ingestion; diet may have to be restricted in fats until the
conditions are corrected
4. Cystic fibrosis and malabsorption disorders—often treated with
synthetic medium-chain triglyceride formulas that are more easily
absorbed
5. Dumping syndrome and gastric ulcers—often treatment involves
increasing fat in the diet to delay gastric emptying
6. Epilepsy—children with some types of epilepsy may be effectively
treated with a ketogenic diet that is high in fats, is low in
carbohydrates, and causes a ketotic condition

Vitamins
A. Definition—organic substances that are essential to life and are
needed in very small amounts; serve in regulatory functions and often act
as coenzymes or precursors of coenzymes; some vitamins can be
produced in precursor form or activated in the body
B. Classification
1. Water-soluble vitamins
a. Vitamin C
b. B-complex vitamins
2. Fat-soluble vitamins
a. Vitamin A
b. Vitamin D
c. Vitamin E

1012
 d. Vitamin K
C. Chemistry and general properties
1. Water-soluble vitamins
a. Soluble in water
b. Sensitive to heat, light, and oxygen
c. Contain the elements carbon, hydrogen, oxygen, and nitrogen,
and, in some cases, other elements such as cobalt or sulfur
d. Absorbed into blood by both active and passive transport from
the upper portion of the digestive tract (see Fig. 12-1); vitamin
B12 requires the intrinsic factor for absorption
e. Transported free and unbound to cells by blood
f. Minimal storage of excess dietary vitamins except for:
(1) Vitamin C—stores may last 30 to 90 days
(2) Vitamin B12—stores may last many years in those without
pernicious anemia
(3) Folic acid—stores may last 4 to 5 months
g. Are excreted in urine
h. Should be supplied in the diet almost every day
i. Deficiency symptoms often develop rapidly
j. Are relatively nontoxic with excessive dietary intake, although
the increased use of over-the-counter (OTC) “megavitamin”
preparations has caused the appearance of toxic symptoms
2. Fat-soluble vitamins
a. Soluble in fat and fat solvents (some water-soluble derivatives
are available)
b. More stable than water-soluble vitamins in light, heat, and
oxygen
c. Contain only elements of carbon, hydrogen, and oxygen
d. Must be emulsified and carried across the membranes of the
intestinal cells in the presence of fat and bile (see Fig. 12-1); any
conditions that decrease the digestion, absorption, or transport
of lipids will lower the usable amount of fat-soluble vitamins
e. Absorbed into the lymphatic system and transported by
attachment to protein carriers
f. Not readily excreted
g. Not absolutely necessary in the diet every day
h. Amount ingested in excess of the daily need is stored in the
liver and fatty tissues
i. Deficiency symptoms slow to develop
j. Toxic with chronic excessive intake

1013
D. General functions
1. Water-soluble vitamins
a. Form coenzymes for energy metabolism
b. Synthesis of red blood cells and DNA
2. Fat-soluble vitamins—play a role in:
a. Vision
b. Maintenance of the body’s mucosal linings and epithelial cells
c. Integrity of mineralized tissues of bone and teeth by regulating
the calcium and phosphorus levels in the body
d. Cellular antioxidant
e. Normal blood clotting
E. Nutritional requirements—dietary reference intake (DRI) and RDA are
based on vitamin and mineral intake from food, not supplements; for an
elaboration of DRI and RDA, see the section on “Methods for
Assessment of Dietary Intake” later in this chapter. Refer to “Food and
Nutrition” at the National Academies Press website of the National
Academy of Science, available at http://nap.edu/; also see Website
Information and Resources table at the end of this chapter
F. Dietary sources, specific body functions, and symptoms of deficiencies
and toxicities (Table 12-4)

Table 12-4
Nutrients and Their Related Effects on the Oral Cavity

1014
1015
1016
Data from DePaola DP, Touger-Decker R, Rigassio-Radler D, Faine MP: Nutrition and dental medicine. In Shils ME et al,
editors: Modern nutrition in health and disease, ed 11, Baltimore, 2012, Williams & Wilkins; Davis JR, Stegeman CA: The
dental hygienist’s guide to nutritional care, ed 4, Philadelphia, 2015, Saunders; and Palmer C: Diet and nutrition in oral
health, ed 2, Upper Saddle River, NJ, 2007, Pearson Prentice Hall.

G. Role of vitamins in oral biology

1. Functions
a. Tooth formation (Table 12-5)

1017
 Table 12-5
Effects of Nutrients on Oral Tissues and Their Role in Tooth Formation

Data from DePaola DP, Touger-Decker R, Rigassio-Radler D, Faine M: Nutrition and oral medicine. In Shils
ME et al, editors: Modern nutrition in health and disease, ed 12, Baltimore, 2012, Williams & Wilkins.

b. Periodontium (Table 12-5)

2. Oral manifestations of deficiencies and toxicities (see Table 12-4)

1018
Minerals
A. Definition—inorganic elements that are essential to life; serve both
structural and regulatory functions
B. Classification (see Table 12-4)
1. Macrominerals—present in relatively high amounts in body tissues
2. Trace elements—present at less than 0.005% of body weight
C. Chemistry and general functions
1. Exist as inorganic ions
2. Chemical identity not altered in the body or in food
3. Indestructible
4. Soluble in water and tend to form acidic or basic solutions
5. Vary in amounts absorbed and in pathways of excretion (see Fig. 12-
1)
6. Some readily absorbed into blood and transported freely
7. Some require carriers for absorption and transportation
8. Excessive intake can be toxic
D. General functions
1. Maintenance of acid-base balance
2. Coenzymes or catalysts for biologic reactions
3. Components of essential body compounds
4. Maintenance of water balance
5. Transmission of nerve impulses
6. Regulation of muscle contraction
7. Growth of oral and other body tissues
E. Nutritional requirements (see information on the National Academies
Press website)
F. Dietary sources, specific body functions, and symptoms of deficiencies
and toxicities (see Table 12-4)
G. Role of minerals in oral biology
1. Function (see Table 12-5)
a. Tooth formation
b. Periodontium
2. Oral manifestations of deficiencies and toxicities (see Table 12-4)

Water
A. Definition—essential nutrient abundantly found in foods and
beverages; makes up 50% to 60% of total body weight; survival without
water is possible only up to 2 or 3 days
B. Total body water
1. Body water, as a percentage of body weight, decreases with age,

1019
 ranging from 69% in newborn infants to 49% in women
2. Distribution—majority is intracellular, with the remainder being
extracellular in serum, cerebrospinal fluid, tissue spaces, and saliva
a. Intracellular
(1) Enclosed within the cell membrane
(2) Accounts for two thirds of the total
(3) Increases with increased body cell mass
b. Extracellular compartment
(1) Intravascular
(a) Approximately 3 liters (L)
(b) Includes water in blood vessels
(2) Intercellular (interstitial)
(a) Approximately 12 L
(b) Fluids that leave blood vessels
(c) Fluids present in spaces between and surrounding
each cell
C. Biologic role and functions
1. Is the medium in which most of the body’s reactions take place
2. Is the means for transporting vital materials to cells and waste
products away from cells
3. Regulates a constant body temperature
4. Maintains a constant composition of elements in body fluids (e.g.,
calcium, sodium, fluoride)
5. Is part of the chemical structure of compounds that form cells (e.g.,
proteins)
6. Is active in many chemical reactions (e.g., digestion of a
disaccharide)
7. Serves as a solvent (e.g., amino acids dissolve in water); this permits
their transport to body cells
8. Lubricates and protects sensitive tissue around joints and mucosal
linings
D. Water balance
1. Intake—controlled by thirst sensations; total daily intake need
ranges from 1 to 3 L at a minimum to replace daily water losses;
sources of water intake are:
a. Ingested liquids and foods—1200 to 2000 milliliters (mL) per
day
b. Metabolic water from the oxidation of foods—300 to 350 mL/day
2. Elimination—total water output is 1500 to 3000 mL/day
a. Sensible or measurable losses—occur through the kidneys as
urine and through the bowel as feces; constant daily losses

1020
 amount to 500 to 800 mL
b. Insensible or unmeasurable losses—occur through the lungs
with expired air and through the skin as perspiration; daily
losses vary considerably, with an average of 850 to 1200 mL
E. Regulation
1. Potassium and sodium concentrations are responsible for
maintaining water balance; when extracellular sodium equals
intracellular potassium, water will not move into or out of the cell
2. Mechanisms of regulation
a. Thirst response—when sodium increases, it stimulates the
hypothalamus and increases the urge to drink
b. Excretion regulation
(1) Increased sodium stimulates the hypothalamus to signal
the pituitary to release antidiuretic hormone (ADH), and
water is resorbed in the kidney tubules
(2) Decreased sodium causes the release of aldosterone, which
causes resorption of sodium at the kidney tubules
F. Requirements—include water from liquids and food
1. For men, the adequate intake (AI) is 15 to 16 cups (3.7 L) per day
2. For women, the adequate intake (AI) is 11 to 12 cups (2.7 L) per day
G. Causes of water deficiency and conditions of toxicity
1. Dehydration
a. Malfunction of kidneys
b. Blood loss
c. Vomiting
d. Diarrhea
e. Inadequate fluid intake
2. Water intoxication
a. Edema
b. Hypertension
c. Sodium retention

1021
Specialized cells of oral tissues: effects of
nutrients
A. Epithelial cells
1. Important in tooth formation during the embryonic period
2. Make up the outer layers of tissue in the oral mucosa
a. Rapid cell renewal, especially in the sulcular area
b. Cell renewal more frequent with increasing age
3. Important in the normal development of salivary glands
4. Vitamin A and protein are essential for the normal proliferation of
epithelial cells
B. Fibroblasts
1. Synthesize collagen fibrils in connective tissues of the gingiva,
periodontal ligament, and pulp
2. Throughout life, fibroblasts maintain a rate of collagen synthesis
equal to that of collagen breakdown; nutrient deficiencies can
interfere with this equilibrium and cause a net loss of collagen tissue
3. Vitamin C, zinc, copper, and protein are important in collagen
formation
C. Cementoblasts and cementocytes
1. Synthesize the protein matrix for cementum; vitamin C, zinc, copper,
and protein are essential
2. Calcify the protein matrix; protein, calcium, phosphorus, and
vitamin D are essential
3. Cementum is avascular and part acellular
4. Cellular cementum consists of cementocytes that depend on
diffusion from the periodontal ligament for their nutrient supply
D. Ameloblasts
1. Synthesize the protein matrix for enamel; vitamins A and C, zinc,
copper, and protein are essential
2. Calcify the protein matrix; protein, calcium, phosphorus, and
vitamin D are essential; fluoride improves the quality of the apatite
crystals formed
3. Once enamel is formed, no metabolic cells are present
E. Odontoblasts
1. Synthesize the protein matrix for dentin; vitamins A and C, zinc,
copper, and protein are essential
2. Calcify the protein matrix; protein, calcium, phosphorus, and
vitamin D are essential; fluoride improves the quality of the apatite
crystals formed

1022
 3. Once dentin is formed, no metabolic cells are present, except in
reaction to trauma; with trauma, new odontoblasts can form
(possibly from pulpal tissue), and secondary dentin can be laid down
F. Osteocytes—osteoblasts and osteoclasts
1. Function in the synthesis of the alveolus
2. Function in the lifelong process of bone apposition (osteoblasts) and
resorption (osteoclasts) in the alveolus
3. Nutrients important in the formation and maintenance of the
alveolus are protein; vitamins A, C, and D; zinc; copper; calcium; and
phosphorus

1023
Energy balances and weight control
A. Definition—energy balance is a dynamic state in which the calories
from food are equal to the caloric needs of the body; changes in energy
balance result in a relative gain or loss in body weight
1. Lean body mass is highly metabolically active; basal metabolism is
generally higher in people with greater amounts of lean body mass
2. In older adults, increases in body weight and body fat are not
attributed to increased intake but are related to decrease in energy
expenditure from loss of lean body mass
B. Measurement of energy
1. By calorimetry—food sample is burned in oxygen in an enclosed
vessel surrounded by water; 1 kcal is the amount of heat produced
sufficient to raise the temperature of 1 kg of water to 1°C; the
commonly used term calorie has the same definition
2. In the body—carbon, hydrogen, and oxygen (from protein,
carbohydrates, alcohol, or fats) are converted to carbon dioxide,
water, and energy; energy is produced in the form of ATP; when
needed, each ATP molecule loses a high-energy phosphate bond and
becomes adenosine diphosphate (ADP) with a release of
approximately 7.3 kcal/mole
C. Energy-producing systems
1. Blood glucose—immediate and preferred source of energy for
cellular metabolism; glycogen stores provide glucose through
glycogenolysis during the short periods of fasting between meals
and in response to hormonal signals during sudden movement or
intense exercise
a. Protein—can be used as an energy source when the blood
glucose level falls; glucogenic amino acids are converted to
glucose after deamination by gluconeogenesis; in a starvation
state, body proteins are used for energy, which may cause
irreversible damage if the essential protein components of the
body are catabolized
b. Fat—mobilized from adipose tissue; triglycerides are broken
down into glycerol and fatty acids in the liver; fatty acids are
catabolized by β-oxidation to acetyl-CoA
c. Ethanol (alcohol)—can be oxidized to acetaldehyde, which is
then converted into acetyl-CoA
2. Acetyl-CoA—enters the TCA from many sources
3. ATP—made during the process of oxidative phosphorylation in the
mitochondria; proteins, carbohydrates, and fats do not yield the

1024
 same number of ATP molecules per molecule of starting material
because of their difference in molecular structure; to estimate the
stored energy of foods, use these approximations: protein, 4 kcal/g;
carbohydrate, 4 kcal/g; fat, 9 kcal/g; and ethanol, 7 kcal/g
D. Energy-using systems—ATP produced during catabolism is used by
the body for biosynthetic activities, muscle contraction, ion transport,
nerve conduction, and maintenance of body temperature
1. Energy for basal metabolism—basal metabolic rate (BMR) is a
measure of the energy required to maintain a living state while at
rest and without food; includes respiration, circulation, maintenance
of body temperature, muscle tone, glandular activities, and cellular
metabolism
a. Conditions for BMR measurement—postabsorptive state;
muscles totally relaxed; awake; environmental temperature
between 20°C and 25°C (68°F and 77°F); free of emotional stress;
not during ovulation
b. Factors influencing the BMR—age, genetics, gender, body size,
nutritional state, muscular training, pathologic conditions,
thyroid gland activity, climate, and altitude
2. Energy for activity—the activity component of the energy
requirement is for voluntary physical activity and varies from 20% of
the BMR for sedentary activity to 50% or more of the BMR for heavy
activity; factors influencing energy needs for the activity component
include the size of the individual and the intensity and duration of
the activity
3. Thermic effect of food (TEF)—energy required to digest, absorb, and
metabolize food; also called nonshivering thermogenesis because a
slight elevation in body temperature occurs after a meal; not a clearly
defined phenomenon; believed to include the energy needed to
increase muscular contractions of the digestive tract, increases the
synthesis of digestive enzymes and transports molecules; amounts
to about 5% to 10% of the BMR and activity energy components
E. Nutritional requirements: determined by intake of food energy that
allows the maintenance of ideal weight; data have been gathered from
animal studies, balance studies, and intake surveys
1. Recommendations represent the average needs of people in each age
group and within a given activity category
2. Recommendations are influenced by body size, gender, climate, age,
and activity level
F. Weight management and control
1. Calculating caloric intake needs—body mass index (BMI) and ideal

1025
body weight (IBW); see the section on “Complete Nutritional
Assessment” later in this chapter
a. BMI—approximate positive correlation of height and weight
with body fat (r = + 0.7 – 0.8); used to assess obesity and as an
indicator of optimal weight for health (Table 12-6); for example,
overweight adults with a BMI greater than 25 are at risk for
comorbid diseases

Table 12-6
Body Mass Index Classification Chart

Modified from National Institutes of Health: Clinical guidelines on the identification, evaluation, and
treatment of overweight and ob esity in adults: The Evidence Report. Washington, DC, 1998, NIH.

(1) Calculate BMI by dividing body weight in kilograms (kg)

by the height in square meters (m2); for example, a man
weighing 270 pounds (122.7 kg) who is 6 feet (3.34 m2) tall
has a BMI of approximately 37
(2) BMI does not differentiate between lean body mass and fat
mass; thus could inaccurately label an individual as “obese”
b. Waist circumference is a more accurate method of determining
central obesity, also known as abdominal obesity in an individual;
puts an individual at greater risk of CVD
(1) Women with waist measurements greater than 35 inches
are at risk for comorbid conditions
(2) Men with waist measurements greater than 40 inches are
at risk for comorbid conditions
(3) Waist circumference standards used for the general
population may not apply to individuals under 5 feet in
height or with a BMI of 35 or greater

1026
 c. Determining ideal body weight (IBW)
(1) Male IBW = 106 + (6 × inches over 5 feet tall)
(2) Female IBW = 100 + (5 × inches over 5 feet tall)
(3) For individuals under 5 feet, subtract 2 lb for each inch
below 5 feet
d. Alternative method—decreasing usual caloric intake by
500 kcal/day usually allows a weight loss of 1 lb per week; this
loss may reach a plateau as the body adjusts to a new BMR
e. Refer to www.choosemyplate.gov to determine individual caloric
needs
2. Types of diet modifications
a. Balanced, low-calorie diet—the safest and healthiest reducing
diet (e.g., Weight Watchers diet), if calories are approximately
1200 kcal/day and the intake is balanced and varied
b. Low-carbohydrate, high-protein diet—risk of development of
ketosis (e.g., Atkins diet, the Zone diet, South Beach diet) exists
c. Low-fat diet—may deprive the individual of essential fatty acids
and fat-soluble vitamins; causes rapid emptying of the stomach
(low satiety) and may make food seem flavorless; most
individuals can decrease their usual fat intake without any
harmful effects
d. High-fiber diet—increases fiber and bulk in the diet and allows
a more rapid transit time for food in the GI tract; fiber also
binds other nutrients, so they are not completely absorbed;
moderate increases in the fiber content of the diet (e.g., in well-
designed vegetarian diets) appear to be helpful in treating
diabetes, diverticulosis, and hypercholesterolemia as well as in
decreasing the total caloric intake of reducing diets; very-high-
fiber diets cause GI discomfort and may induce mineral
deficiencies
e. Single-food (monotonous) diet—no one food by itself can
provide a balance of nutrients; diets that promote a single food
with unrealistic claims are not recommended (e.g., the
grapefruit diet, the cabbage soup diet)
f. Liquid formulas (protein)—very-low-calorie diets; have been
successfully used in treating morbidly obese persons in
carefully monitored hospital settings but are not recommended
for the individual (e.g., Optifast)
3. Prescription drugs used for weight loss are recommended for
individuals with a BMI of 30 or greater with no obesity-related risk
factors or for those with a BMI of 27 to 29.9 with obesity-related risk

1027
 factors; adverse side effects have been observed in long-term use of
such drugs; prescription drugs include:
a. Noradrenergic drugs for short-term weight loss
(1) Diethylpropion
(2) Phentermine (e.g., Zantry, Adipex-P, Fastin)
(3) Mazindol
b. Serotonergic drugs
(1) Fenfluramine (also phentermine plus fenfluramine, or
Phen-Fen) and dexfen-fluramine (Redux) were removed
from the U.S. market because of reports of primary
pulmonary hypertension, heart valve abnormalities, and
death associated with their use
(2) Fluoxetine (not FDA approved for treating obesity)
c. Sibutramine (Meridia) is an approved combination of serotonin
and adrenergic drugs; centrally acting agent that increases
satiety but has little effect on hunger
d. Orlistat (Xenical prescription or alli OTC) is a lipase inhibitor;
interferes with fat digestion; taking the drugs with meals
inhibits fat absorption by 30%
4. Activity in weight management—even moderate activity such as
walking will increase caloric expenditure and should be considered
in every weight loss program; moderate exercise also improves
muscle tone, stimulates circulation, increases BMR, and often creates
a sense of well-being
5. Behavior modification—eating habits and attitudes often must be
changed to prevent weight regain; many successful diet programs
combine decreased food intake and increased activity with an
analysis and modification of eating behaviors; group programs such
as Weight Watchers help make behavioral changes
6. Dietary aids—represent a multimillion-dollar business, and
although they may help cause an initial rapid weight loss, they are
no more effective than mere calorie cutting in long-term weight
maintenance; moreover, most diet drugs have the potential for
serious side effects if used habitually over a long period or by
persons with certain medical conditions; types most often used are
appetite suppressants, stimulants, laxatives, diuretics, and bulk-
producing agents
7. Surgical therapy—gastric bypass surgery may be recommended to
individuals with BMI of 40 or greater and for those with BMI greater
than 35 and comorbid conditions
a. This surgical approach is used to reduce the size of the stomach

1028
 to decrease its reserve capacity
b. Bloating, nausea, vomiting, dumping syndrome, anemia, and
nutrient deficiencies may result if diet instructions are not
followed after surgery
c. Fluids are consumed separately from meals; more frequent
small meals throughout the day are recommended
d. Increased risk of caries because of alterations in eating habits
G. Eating disorders
1. Treatment
a. Correction of any underlying physiologic causes of weight loss
b. Increased caloric intake with foods that are concentrated
sources of energy; several small meals per day
c. Limiting weight gain goals to 1 to 2 lb per week
d. Team approach; physician, registered dietitian, psychotherapist,
or all should be involved in the treatment
2. Signs and symptoms of disordered eating
a. Erosion of tooth enamel (perimylolysis)
b. Halitosis
c. Severe weight loss
d. Dental caries
e. Lanugo
f. Enlarged tongue
g. Angular cheilosis
h. Enlarged parotid glands
i. Xerostomia
j. Goosebumps on skin
k. Glossitis
3. Anorexia nervosa—state of protein-energy malnutrition brought on
by voluntary starvation (and often with the use of diet aids, intense
exercise, and self-induced vomiting)
a. Seen most often in middle-income and upper-income adolescent
females, who are typically described as perfectionists,
overachievers, and models of good behavior; they begin dieting
because they have a distorted perception of body shape and
weight
b. Death may occur from failure of multiple organ systems
c. Treatment usually includes specially tailored counseling and
hospitalization before voluntary weight gain is possible;
treatment encourages regular mealtimes, varied and moderate
intake, and gradual introduction of feared foods
d. The client should be referred to a physician, a registered

1029
 dietitian, or a psychologist for treatment
4. Bulimia—condition of alternate food gorging and purging by
vomiting; occasional use of laxatives to maintain weight
a. Most often found in adolescent females who appear to be of
normal weight
b. Is more prevalent than anorexia nervosa
c. Treatment involves counseling; self-induced vomiting can cause
swelling of the salivary glands and esophagus and the
destruction of tooth enamel by acid that results in sensitive
teeth
d. The client should be referred to a physician, a registered
dietitian, or a psychologist for treatment
5. Eating disorders not otherwise specified (EDNOS)—a broad category in
which individuals do not meet the strict criteria for anorexia nervosa
or anorexia bulimia; binge-eating disorder falls into this category

1030
Nutritional assessment and counseling
Malnutrition
A. Overconsumption of nutrients such as:
1. Fat—can result in excess weight gain; associated with coronary heart
disease (CHD), obesity, and certain types of cancers
2. Sugar—can result in excess weight gain; associated with obesity,
dental caries, and plaque-induced gingivitis
3. Salt or sodium—can result in retention of excess body fluid;
associated with high blood pressure; increased sodium may also
decrease calcium levels
4. Excess calories—can result in obesity; associated with CHD,
hypertension, and diabetes mellitus type 2
5. Vitamin and mineral supplements—“megadoses” may result in
toxicity of one or many nutrients and inhibition of others
B. Nutrient deficiencies—the health of a person is at risk because of the
unavailability of nutrients for cellular activities; end result of deficiencies
is the same, but the multiple causes can be classified as primary or
secondary
1. Primary deficiency is a result of an inadequate food intake and can
result from the following conditions:
a. Fad diets—low-calorie or imbalanced diet plans
b. Economics—inadequate resources to obtain a healthy diet
c. Illness—loss of appetite
d. Improper food preparation—destruction of nutrients because of
delayed storage and overcooking of foods
e. Accessibility to food—nutritious foods unavailable because of
problems with transportation or market supplies encountered
by individuals
f. Ignorance—lack of nutritional knowledge
g. Flavor preferences—palatability of sweets and fats can lead to a
diet high in empty-calorie foods
h. Time constraints—inadequate time for food preparation can
lead to the use of highly processed convenience foods, which
tend to have low nutrient density
i. Poor oral health—inability to masticate food because of
edentulism or oral disease; altered taste perceptions result from
oral disease
2. Secondary deficiency is the result of inability to digest, absorb, and use
foods consumed; an individual may eat a balanced diet, but other

1031
 factors interfere with the body’s use of nutrients in foods; examples
of these conditioning factors include:
a. Disease—any GI or metabolic disease can interfere with the
digestion and use of foods and nutrients (e.g., ulcers, lactase
deficiency, partial obstruction of the GI tract, inborn errors of
metabolism)
b. Drug-nutrient interactions—certain drugs can interfere with
and reduce the absorption, transportation, and metabolism of
nutrients (e.g., grapefruit juice with high blood pressure
medication)
c. Nutrient-nutrient interactions—excess or deficiency of certain
nutrients can affect the absorption of other nutrients (e.g.,
vitamin C and iron)
d. Allergies—sensitivity to certain foods or chemicals in foods can
lead to malabsorption syndromes (e.g., gluten sensitivity, as in
celiac disease)
3. Manifestations of primary and secondary deficiencies
a. Gradual decreases in the tissue level of nutrients
(1) Earliest sign of malnutrition
(2) Determined by blood and urine analyses for each nutrient
b. Biochemical disturbances
(1) Occur if duration of deficiency is long enough to deplete
the body’s stores and interfere with cellular metabolism
(2) Determined by blood and urine analyses for alterations in
cellular levels of enzymes and metabolites
c. Anatomical lesions
(1) Signs of chronic and severe malnutrition, leading to
destruction of body tissues
(2) Determined by clinical examination of body tissues

Complete Nutritional Assessment

A. Health and pharmacologic history
1. Factors that influence food intake
a. Socioeconomic conditions—food-purchasing power
b. Home environment—culture, family values, and eating practices
c. Client motivation and education—interest and awareness of the
principles of a nutritious diet
d. Prescriptive drugs that may suppress appetite, alter taste
perception, or negatively interact with foods
2. Factors that influence food use

1032
 a. Oral health—ability to masticate, saliva production, and
presence of oral disease
b. Systemic health—ability to digest, absorb, and metabolize
nutrients in food; therapeutic diets for disease control
c. Mental health—desire to eat
d. Drug use—alcohol abuse and illegal drugs
B. Assessment of dietary intake
1. Collection of objective data on what a person eats
a. Assessment tools—screening questionnaire for food intake
frequency, 24-hour recall method, and food record or diary
(1) Food-frequency questionnaires—ask how often food items
are consumed; elicit specific details; work better with large
groups in the community setting
(2) A 24-hour recall method—mental recall of everything
eaten in the previous 24 hours; useful for individual
counseling in a clinical setting; does not represent “usual”
diet
(3) Food record diary—exact record of everything eaten in a
specific period; more accurate account
(4) Combining 3- to 7-day food record with a 24-hour recall
method presents a more accurate measure of intake
b. Specific amounts or quantities of foods eaten must be recorded
to use assessment tools effectively
2. Analysis and evaluation of food intake
a. Methods of analysis—the USDA MyPlate (Fig. 12-3)

1033
 FIG 12-3 Anatomy of USDA MyPlate. (From www.choosemyplate.gov.
Accessed October 27, 2014.)

b. Methods of evaluation—comparing results of diet analysis with

standards of adequacy
3. Diet modifications
a. Adding foods to the diet to correct for nutrient deficiencies
b. Eliminating or reducing excessive nutrient intake for disease
control and prevention (e.g., sugar, fat, oils, sodium)
c. Collaborate with a registered dietitian for in-depth analysis and
modification of dietary intake
C. Biochemical analysis and immune function
1. Blood and urine analyses
a. Most objective and precise assessment data
b. Determine marginal nutritional deficiencies before overt
clinical signs appear by measuring either the concentration of a
nutrient or the functional activity of the nutrient
2. Delayed cutaneous hypersensitivity skin tests
a. Assessment of host defense mechanisms by evaluating the
client’s reaction to common skin test antigens as a nonspecific
indicator of malnutrition
b. Most useful for evaluating the critically ill client’s ability to

1034
 withstand the stresses of surgery
D. Clinical examination of body tissues—indicator of systemic health and
nutritional status (see Table 12-4)
1. Oral tissues
a. Dental caries—excessive sugar or acid exposure (supports S.
mutans and Lactobacillus acidophilus)
b. Gingivitis and periodontal disease—excessive sugar intake
(supports growth of plaque biofilm and nutritional deficiencies)
c. Glossitis—nutritional deficiencies affecting the papillae and
color of the tongue
d. Stomatitis—nutritional deficiencies affecting oral soft tissues
e. Cheilosis—nutritional deficiencies affecting the lips and the
corners of the mouth
f. Necrotizing ulcerative gingivitis (NUG)—excessive sugar and
caffeine intake, smoking, stress, and poor oral hygiene
combined with nutritional deficiencies result in lowered host
resistance to bacterial plaque (dental) biofilm and bacterial
challenges
2. Anthropometric analysis—determines the body structure, form, and
composition (e.g., content of lean body mass and fat tissue); the
following tools are useful, but each has its limitations:
a. BMI, IBW, and waist circumference (see the earlier section on
“Energy Balances and Weight Control”)
b. Skinfold thickness measurements
(1) Obtained by using skinfold calipers to measure
subcutaneous fat in millimeters in selected areas (e.g.,
triceps and subscapular regions)
(2) Measurements are compared with standards to estimate
total body fat composition
c. Arm muscle circumference
(1) Sensitive indicator of the muscle mass that reflects protein
stores
(2) Determined by measuring the arm circumference at the
midpoint of the upper arm and by measuring triceps
skinfold
d. Bioelectrical impedance and ultrasound methods
(1) Potential predictors of total body fat
(2) Lean body mass conducts electricity better than fat mass
e. Underwater weighing
(1) Measures body weight when the person is under water
(2) One of the most accurate methods used to determine body

1035
 volume
f. Dual-energy x-ray absorptiometry (DEXA)—can distinguish fat
mass, fat-free mass, and bone mineral loss; most accurate
method to determine body fat

Methods for Assessment of Dietary Intake

A. Dietary intake standards
1. Dietary Reference Intake (DRI) and Recommended Dietary Allowance
(RDA)
a. Published by the Panel on Micronutrients of the Food and
Nutrition Board, Institute of Medicine, National Academy of
Sciences; principally used as measurement tools by nutrition
professionals who plan and evaluate food supplies for groups; to
establish guidelines for new food products; used as the basis for
regulatory standards in determining nutritional quality; and
used to set standards for nutritional labeling (e.g., percentage of
daily value)
b. DRI is the updated version of the RDA established by the
National Academy of Sciences, Food and Nutrition Board; DRI
values are based on the observed average or experimentally set
intake by individuals that appear to sustain a defined
nutritional status
(1) Unlike RDA values, DRI values aim to prevent nutrient
deficiency as well as reduce the likelihood of chronic
disease
(2) DRI includes five sets of standards:
(a) RDA—intake level sufficient to meet nutrient
requirements of almost all healthy individuals
(b) AI (adequate intake)—value based on approximation
of nutrient intake by a group of healthy people, used
when an RDA value cannot be determined
(c) UL (upper limit)—highest level of daily nutrient
intake that is likely to pose no risk of adverse health
effects to almost all individuals in the general
population; risk of adverse effects increases as intake
increases above the UL
(d) EAR (estimated average requirement)—nutrient
intake value that is estimated to meet the requirements
of half the healthy individuals in a group
(e) EER (estimated energy requirement)—average calorie

1036
 need estimates for various life stage groups and
genders
2. Dietary Guidelines for Americans are issued by the U.S. Department of
Agriculture (USDA) and the U.S. Department of Health and Human
Services (HHS) and are revised every 5 years
a. The seventh edition of the Dietary Guidelines for Americans (2010)
includes 23 key recommendations for the general population
and six additional key recommendations for special
populations3
b. Special populations include children and adolescents, women
capable of becoming pregnant, pregnant women, women who
are breastfeeding, older adults and adults at high risk of chronic
disease
c. The updated guidelines are intended for Americans ages 2 years
and older, including those with chronic disease
d. Two common themes are weaved throughout the updated
guidelines: encouragement of balanced caloric intake to manage
body weight and the consumption of nutrient-dense foods and
beverages
e. The key recommendations within these chapters include the
following3:
(1) Men ages 19 and older should eat between 2000 and 3000
calories a day depending on degree of activity; women
should eat 1600 and 2400 calories daily; individuals should
aim for the lower caloric levels if inactive
(2) SoFAS (solid fats and added sugars) should make up no
more than 13% of your daily caloric intake based on a 2000-
calorie diet
(3) Reduce consumption of refined grains; half of grain
consumption should come from whole grains; based on a
minimum consumption of 6 ounces, 3 ounces should come
from whole-grain foods
(4) Limit sodium intake to 2300 mg/day; African Americans
and individuals 51 and older or who have hypertension,
diabetes, or chronic kidney disease should decrease their
intake to 1500 mg/day
(5) Increase intake of fruits and vegetables; consume 2 cups of
fruit and 2.5 cups of vegetables (including beans and peas)
each day
(6) Aim for 3 cups of low-fat or fat-free dairy foods each day
(7) Consume at least 8 oz of seafood a week

1037
 (8) Limit protein foods; consume no more than 5.5 oz daily.
(9) Consume a variety of food sources to ensure optimum
intake of potassium, calcium, and vitamin D; choose whole-
food sources of nutrients; limit use of supplements
3. Dietary guidelines for oral health
a. Eat a balanced diet representing moderation and variety as
shown by MyPlate, and follow the recommendations of the
Dietary Guidelines for Americans (2010)3
b. Combine and eat foods in sequence to enhance mastication,
saliva production, and oral clearance; for example, combine
dairy foods with sweet or starchy foods, or combine protein-rich
foods with cooked or processed starches
c. Plan eating intervals that allow time for the pH of the plaque to
return to neutral; for example, up to 120 minutes may be needed
for the plaque pH to return to neutral after exposure to a
fermentable carbohydrate
d. Take care not to replace other foods needed to maintain
optimum health with sweets and soft drinks; obtain most
calories from whole grains, fruits and vegetables, low-fat or
nonfat dairy products, and lean meats or meat alternatives
e. Drink water often; consume sweetened and acidic beverages
with meals to allow for a buffering action, rather than
consuming soft drinks between meals
f. Limit the consumption of sugar-free beverages and sports
drinks; demineralization of tooth structure can still occur as a
result of the low pH of these beverages; consume these with
meals
4. The Food and Nutrition Board’s recommendations for healthy adult
Americans
a. Maintain a healthy weight by balancing energy intake and
energy expenditure
b. If the requirement for energy is low (e.g., weight-reducing diet),
reduce the consumption of foods such as alcohol, sugars, fats,
and oils that provide calories but few other essential nutrients
c. Use salt in moderation; recommended intake is no more than
2300 mg (1 teaspoon) per day; 1500 mg/day for those with
hypertension
d. Select a nutritionally adequate diet from the foods available by
each day consuming appropriate servings of low-fat dairy
products, lean meats or legumes, vegetables, fruits, cereals,
grains, and breads (Table 12-7)

1038
 Table 12-7
Daily Guide to Food Choices

Data from My Pyramid Food Intake Patterns, US Department of Agriculture, Center for Nutrition Policy and
Promotion, MyPyramid Food Guidance System, April 2005, www.choosemyplate.gov/food-
groups/downloads/MyPyramid_Food_Intake_Patterns.pdf, accessed October 30, 2014; and Johnson RK,
Appel LJ, Brands M, et al: Dietary sugars intake and cardiovascular health: a scientific statement from the
American Heart Association, Circulation 120:1011-1020, 2009.
Courtesy of Connie Mobley, RD, PhD, University of Nevada Las Vegas, School of Dental Medicine, Las
Vegas, Nevada.

e. Select as wide a variety of foods in each of the major food

groups, as practical, to ensure a high probability of adequate
quantities of all essential nutrients
5. The USDA MyPlate (see Fig. 12-3)
a. Graphic design is similar to a pie chart; organizes foods into
four colorful sections with a side portion for dairy.
(1) Red represents fruits; green is for vegetables; orange is for
grains; purple is for protein (a separate blue section for
dairy is on the side of the plate)
(2) Encourages healthier eating habits and the consumption
of a more plant-based diet
(3) Promotes balanced proportions of each food group to be
consumed at meals
(a) Half of your plate should be fruits and vegetables
(b) At least half of your grains should be whole grains
(c) Make the switch to fat-free or low-fat milk
(d) Balance calories
(e) Avoid oversized portions
(4) Recommends reduced intake of those foods high in
sodium; read labels to compare
(5) Supports the consumption of water over sugary drinks
B. Methods for collecting data on food intakes
1. Nutritional Screening and Assessment of Dietary Intake

1039
Questionnaire (Fig. 12-4)

FIG 12-4 Nutritional Screening and Assessment of Dietary Intake

Questionnaire.
*The caries risk assessment (CRA) score is determined from an oral
health evaluation tool that is used to determine the level of caries risk on
an individual basis. (Modified from Connie Mobley, RD, PhD, University of Nevada
Las Vegas, School of Dental Medicine, Las Vegas, Nevada.)

a. Description—interviewer collects data from the client about all

food consumed in the previous 24-hour period; additional
questions help determine frequency of sugar and food group
intake
b. Nutrition tools used to guide recommendations
(1) USDA MyPlate
(2) Dietary Guidelines
(3) Dietary Reference Intake (DRI) based on life stage

1040
 c. Advantages
(1) Can be filled out by the client while waiting in the oral
health care setting
(2) Requires only 15 to 20 minutes to complete
(3) Allows analysis of food group consumption
(4) Allows evaluation of sugar intake
d. Limitations
(1) No nutrient analysis
(2) Relies on the client’s memory
2. The 24-hour dietary recall
a. Description—interviewer collects data from the client about all
food consumed in the previous 24-hour period
b. Advantages
(1) Requires 20 minutes or less for the interview
(2) Allows nutrient analysis
(3) Allows analysis of food group consumption
(4) Allows evaluation of sugar intake
c. Limitations
(1) Requires a trained interviewer
(2) Relies on the client’s memory
(3) Represents only 1 day of food consumption
(4) Requires a nutrient data file on foods to analyze nutrients
3. A 3- to 7-day food record or diary
a. Description—client keeps a record of food and eating times for
3 to 7 days
b. Advantages
(1) No interviewer required except to give directions on how
to fill out the record
(2) Allows for analyses of both nutrients and food groups
(3) Allows for evaluation of sugar intake
(4) An average intake of several days may be more
representative of client’s food intake than that of just 1 day
c. Limitations
(1) Represents the food consumption of only the days
included in the record
(2) Relies on the cooperation and ability of the client to keep
the record
(3) Requires a nutrient data file for nutrient analysis
B. Methods for evaluating food intake
1. USDA MyPlate
a. Nutrient contributions (see Table 12-7)

1041
 (1) Role in general health
(2) Role in oral health
b. Advantages for use in counseling
(1) Client participation
(2) Simple
(3) Inexpensive
(4) Fairly accurate
(5) Detailed nutrient analysis
c. Limitations
(1) No provisions made for combination foods (e.g., pizza,
casseroles); need to break down into ingredients that
correspond to the six groups
(2) Website can be difficult to navigate
2. Computerized analysis of diet
a. Definition—food nutrient data are individually entered into a
computer program, and the specific amounts of each nutrient
for each food consumed are calculated
b. Nutrient data file (software)—lists foods and their nutrients;4,5
the USDA has a nutrient database website:
http://fnic.nal.usda.gov/; MyPlate has an online dietary
assessment tool MyPyramid Tracker that can be accessed at
https://www.supertracker.usda.gov/ (see Website Information
and Resources table at the end of this chapter)
c. DRI and RDA values—used as a standard for comparison with
the client’s daily nutrient intake
d. Advantages
(1) Accurate
(2) Specific
(3) Cost-efficient when technology is available
(a) Computers in oral health care settings with Internet
access
(b) Services available for a fee outside the oral health care
setting
e. Limitations
(1) Limited client participation and home use
(2) Hardware and software availability
(3) Expense
(4) Requires training for accurate interpretation of output
3. Sugar analysis and evaluation
a. Dental caries and periodontal disease are multifactorial
infectious diseases that result from the interaction of the

1042
 resistance of oral tissues (host factor) with the destructive
effects of bacterial plaque and acids (agent factor) produced
from the metabolism of dietary sugars (diet or environment
factor); dental disease occurs when all three factors exist
simultaneously; often called the “triad” of dental disease;
nutritional assessment of exposure to sugar is an essential part
of nutritional counseling in disease prevention programs and
can be conducted by using precise or simplified methods
(1) Precise analysis—computer analysis of the diet for
carbohydrate content: total carbohydrate in grams,
monosaccharides and disaccharides in grams (e.g., grams of
sucrose), and fiber in grams; percentage of the total daily
calorie intake from simple and complex carbohydrates can
be calculated and compared with the recommendations;
added sugars should contain no more than 25% of total
calories consumed; fiber needs range from 21 to 38 g,
depending on age and gender2
(2) Simplified analysis—dietary sugars (sweets and foods
processed with sugars; see Table 12-3) are circled on the
food record or recall; cariogenicity of the diet is assessed on
the basis of frequency and form of sugar exposure; frequent
exposure to retentive solid sugars, especially between
meals, is harmful; acid production potential of the diet can
be calculated by using the following formula:

The formula is based on research that shows glucose-rich food products

(either liquid or sugar) result in a decrease of oral pH below the critical
level (pH 5.5, the point at which acids decalcify enamel) and that it takes
20 minutes after consumption of liquid sugars for healthy saliva to
neutralize acids and raise the pH to a safe level; solid sugars adhere to

1043
teeth and have approximately double the potential for acid production
b. Caries activity tests—often involve counting the number of acidogenic
bacteria or measuring the acids produced by these bacteria; provide
information about the current oral environment and help to detect dental
caries risk; are valuable adjuncts in plaque control programs and can be
used to monitor a client’s progress in oral home care and diet
modifications

Nutritional Counseling Techniques

A. Direct approach—counseling technique that focuses on the dietary
problem
1. Role of the client—the client provides information about his or her
diet; is passive and listens to the counselor
2. Role of the counselor—the counselor controls the session; analyzes
and evaluates the client’s diet and makes recommendations for
improvement
3. Advantages—easier for the counselor and often requires less time
than a more client-oriented approach
4. Limitations—fosters client dependence; little chance of success if the
client is not committed to dietary changes; client is not involved in
decision making
B. Nondirect or behavior modification approach—counseling technique
that focuses on the client
1. Role of the client—the client actively participates in the diet analysis,
evaluation, and modification program
2. Role of the counselor—the counselor provides information on the
causes of dental disease, the role of the diet, and the use of dietary
assessment tools
3. Method
a. Assumption—dietary habits are learned behaviors and can be
“unlearned” and replaced with new behaviors
b. Collection of baseline data
c. Client takes ownership of his or her dietary problems and is
committed to change
d. Client determines his or her behavioral changes and goals;
develops own reward system to use when goals are met
e. Changes are gradually made in small steps; appropriate changes
are rewarded and failures ignored
f. Close monitoring of progress until new behaviors become self-
reinforcing

1044
 4. Advantages—fosters client independence; success is more likely
because the client is in control of the change process
5. Limitations—more time and effort needed to arrive at appropriate
solutions to dietary problems and rewards for behavior modification
B. Factors that influence the client’s food intake—any combination of the
following influences affects food choices and needs to be addressed in a
modification program:
1. Environmental influences—economics, lifestyle, geography, seasons,
markets
2. Social influences—family, culture, religion, social pressures,
marketing strategies
3. Psychological influences—self-image, emotions, stresses, values,
priorities
C. Determinants for dental client selection
1. High-risk clients—those with conditions that would benefit most
from nutritional counseling
a. Pregnancy—nutrient needs are high; hormonal changes may
lead to exaggerated responses to plaque and bacterial toxins;
maternal diet affects the formation of fetal oral tissues
b. Adolescence—nutrient needs are high; vulnerable to nutritional
problems from “fad” diets for weight loss and muscle building;
frequent snacking on empty-calorie foods; problems of anorexia
and bulimia can lead to enamel erosion, irritation of oral
mucosa, and infected or enlarged salivary glands, with possible
xerostomia
c. Rampant caries—high bacterial plaque and calculus and a
positive caries activity test may indicate a problem of frequent
exposure to sugar
d. Periodontal disease or NUG—frequent exposure to sugar and
nutritional deficiencies can contribute to the development and
progression of these conditions
e. Oral and maxillofacial surgery—nutritional counseling before
and after surgery is important for optimal surgical recovery;
postsurgical nutrient needs are high because of blood loss,
tissue repair, and host defense activities; modifications in food
texture (e.g., soft foods) are made according to the client’s ability
to masticate
f. Edentulism—inability to masticate can result in nutrient
deficiencies because of the limited nutrient content in soft and
liquid foods
(1) Food choices are altered because of difficulties with

1045
 chewing or fear of choking; reduced intake of meats, fresh
fruits, and vegetables; softer foods are usually eaten
(2) Lowered intake of magnesium, folic acid, fluoride, zinc,
and calcium
g. Oral cancer—nutrient needs are high because of host defense
activities and tissue repair from cancer and its treatment; cancer
or treatment may result in inadequate food intake because of
decreased appetite, altered taste perceptions, irritated oral
tissues, and xerostomia
2. Dental office resources—availability of trained personnel, time, and
facilities to conduct nutrition counseling services
3. Client factors—level of client motivation to use and benefit from
nutritional counseling and financial and intellectual capabilities for
using nutritional counseling services

Dietary Modifications for Specific Dental Conditions

A. Dental caries (see Tables 12-4 and 12-5)
1. Role of nutrients in tooth formation
a. Preeruptive effects—nutrients are used systemically for enamel,
dentin, and pulp formation; tooth bud formation begins at 6
weeks in utero, and calcification is completed at 13 years
b. Posteruptive effects—fluoride aids in the remineralization of
small enamel lesions; evidence indicates that specific minerals
or combinations of minerals and fats have local cariostatic
properties
2. Local effect of dietary carbohydrates on bacteria growth and plaque
formation
3. Role of diet and nutrients in salivary gland function
a. Nutrients are used systemically for the normal development
and secretory function of salivary glands
b. Foods of firm texture (e.g., raw vegetables) enhance mastication,
stimulate the salivary flow rate, and modify the concentration of
constituents in saliva, possibly improving antibacterial
properties and the buffering capacity to neutralize decalcifying
acids
B. Periodontal disease (see Table 12-5)
1. Role of nutrients in the formation of periodontal tissues
a. Nutrients are used systemically for the normal development of
the gingiva, periodontal ligament, cementum, and alveolus
b. Periodontal tissues are metabolically active throughout a

1046
 person’s life, and nutrients are constantly needed for
maintenance (e.g., the cell population of the sulcal epithelium
completely renews itself within 3 to 6 days)
2. Local effect of dietary carbohydrates on bacteria growth and plaque
formation
3. Role of nutrients in the host defense system
a. During the initial stages of periodontitis, the nutritional status
of the client is important in cellular immunocompetence for
combating bacterial insults to the periodontium
b. After periodontal surgery, cellular immunocompetence is
important for optimal healing and prevention of infection
C. Oral and maxillofacial surgery
1. Presurgical nutritional counseling
a. Adequate nutrient intake is needed to build up nutrient
reserves in tissues to cope with postsurgical nutrient demands
and complications
b. Counseling is helpful for advising the client to plan and
purchase appropriate foods before surgery in anticipation of
convalescence
c. Need for referral to registered dietitian prior to surgery should
be evaluated
2. Postsurgical nutritional counseling
a. Nutrient requirements are high because of blood loss, increased
catabolism, tissue repair, and host defense activities
b. Dietary intake is influenced by surgical complications of
anorexia, dysphagia, and oral discomfort; a liquid diet should be
used initially for the first few days, followed by a soft diet until
the client can eat normally; during convalescence, high-protein
liquid products fortified with vitamins and minerals (e.g.,
Ensure, Sustacal, Instant Breakfast) are helpful but contain
cariogenic sweeteners; safe levels of vitamin and mineral
supplements (100% to 200% of DRI or RDA values) may be
recommended
D. Prosthodontics
1. Nutritional counseling in the preparation of the mouth for a
prosthesis
a. Nutrients—systemically important for the health of oral soft
tissues and the alveolar ridge
(1) Surgery—if surgery is necessary, nutrient requirements
will be higher for postsurgical healing
(2) Tissue state—if any inflamed or soft tissue injuries and

1047
 bone resorption conditions exist, nutrient requirements will
be higher for repair and host defense activities
b. Dietary sugars—condition of the remaining dentition is
important for maintaining the use of a new prosthesis;
cariogenic sugars need to be restricted to control bacterial
growth, acid production, and bacterial plaque formation
c. Texture of foods—partial or fully edentulous clients will often
need to eat chopped, soft foods; if nutrient intake is
compromised, fortified liquid products or nutrient supplements
are helpful
2. Nutritional counseling after prosthesis insertion
a. Food texture—liquid foods for the first 24 hours, followed by
soft foods and chopped or cut-up foods; this minimizes biting
and chewing and allows time for the muscles and tongue to
adjust to the new prosthesis
b. Counter-dislodgement forces—for every bite of food, food
should be evenly divided in the right and left sides of the mouth
before chewing to equalize occlusal forces
c. Nutrients—adequate intake for the integrity of the oral mucosa
and alveolar ridge
d. Dietary sugars—should be restricted to prevent bacterial
growth, acid production, and bacterial plaque formation on the
remaining dentition and prosthesis
e. Food flavors—initially, flavors of foods will be altered because of
the new prosthesis, but this side effect will eventually disappear
with continued denture use
E. Orthodontics
1. Role of nutrients—systemically important for the integrity of
periodontal tissues; requirements are higher as stresses of tooth
movement result in more bone apposition and the synthesis of a
new periodontal ligament; nutrients are needed for the healing and
repair of gingival injuries and irritations from orthodontic bands
2. Role of sugars—to prevent enamel erosion and decay, dietary sugars
(especially retentive sweets) must be restricted during the wearing
of appliances
3. Role of food textures—when appliances or bands are tightened,
chewing hard-textured foods may be painful, and liquid and soft
foods should be eaten temporarily; retentive and sticky foods should
be avoided because they become trapped in the appliance and are
difficult to remove

1048
Dietary Considerations for Immunocompromised
Clients and Those with Special Needs
A. Oral cancer
1. Nutritional support for healing and cellular immunocompetence
a. Compromised nutritional status—weight loss and nutrient
deficiencies increase the risk of not withstanding the
physiologic stresses of cancer and anticancer therapies
b. Surgical treatment—primary method in treating cancer;
nutrient requirements are higher as a result of the increased
catabolic activities, tissue repair, and host defense activities
c. Chemotherapy and radiation treatment—nutrient needs are
higher because of the destruction of healthy cells and tissues
that occurs during these types of treatments
d. Possible need for referral to registered dietitian to monitor
client’s dietary intake during the compromised state
2. Diet modifications useful in treating complications from cancer or
cancer treatments
a. Client unable to ingest or digest food
(1) Home enteral feedings can provide nutrients (e.g.,
nasogastric tube feedings)
(2) Home parenteral feedings can provide nutrients (e.g.,
intravenous feedings)
b. Eating problems arising from complications or side effects of
anticancer therapies
(1) Nausea and vomiting—client should suck on ice chips; eat
frequently; eat dry, bland foods; eat and drink slowly; avoid
highly spiced and fatty foods; new antinausea medications
are effective
(2) Loss of appetite—client should eat foods that are
appealing; make up nutrient requirements at times when
the appetite is good; eat foods with a high nutrient density
(3) Food aversions and alterations in taste and smell—client
should eliminate offending foods; include highly spiced
and distinctive textures to improve taste perceptions; cook
and serve food with plastic utensils rather than metal
utensils
(4) Dry mouth (xerostomia)—client should use xylitol-
containing gum, mints, and sprays; suck on ice chips or use
synthetic saliva; drink liquids with meals; eat cold-
temperature foods rather than hot-temperature foods;

1049
 concentrate on highly nutritious liquids
(5) Radiation-induced caries—client should restrict cariogenic
foods; because of changes in both the quality and the
quantity of saliva after cancer treatment, rapid
demineralization of the tooth surface can occur
(6) Glossitis and stomatitis—client should eat a variety of soft,
easy-to-chew foods; eat stewed foods rather than broiled
and fried foods; avoid highly spiced or acidic foods; eat
moderate-temperature foods; use straws if swallowing is
difficult
B. Human immunodeficiency virus (HIV)
1. Causes of malnutrition in HIV-infected persons
a. Reduced food intake
(1) Drug treatments cause vomiting, nausea, and food
aversions
(2) Fatigue, depression, and fear cause anorexia
(3) Oral infections alter taste, cause pain, and reduce saliva
flow
(4) Esophageal infections and respiratory complications
hamper swallowing
b. Increased nutrient loss
(1) Cancers of the GI tract cause malabsorption
(2) Drugs cause diarrhea and malabsorption
(3) PEM leads to malabsorption
c. Altered metabolism
(1) Cancer, infections, and fevers increase BMR
(2) Drug therapy alters nutrient utilization
2. Nutrient support
a. Any subclinical nutrient deficiencies and weight loss should be
corrected at the time of a positive HIV test
b. At least 100% of the DRI or RDA values of all vitamins and
minerals must be provided
c. Client must avoid all foodborne illnesses
d. The nutrition plan should be designed on the basis of
individual complications, with emphasis on controlling weight
loss by eating nutrient-dense foods throughout the day
e. Dietary recommendations should be regulated only by a
medical physician (MD) or a registered dietitian (RD), or both
C. Clients with special needs (see Chapter 19)
1. Dental problems—unmet oral health care needs in this population
significantly exceed those in the general population

1050
 a. The oral caries rate may be higher than that of the general
population because of poor oral hygiene and cariogenic food
habits
b. Increased periodontal disease compared with the general
population because of:
(1) Poor oral hygiene; limited self-care
(2) Diets consisting of soft-textured foods
(3) Frequent exposures to fermentable carbohydrates
(4) Metabolic disturbances affecting disease resistance and
the reparative process
(5) Nutritional deficiencies associated with diet or metabolic
disturbance
(6) Malocclusion and developmental defects
c. Barriers to health care
2. Nutritional problems—slow growth, excessive weight loss or gain,
and nutrient deficiencies can occur in the following situations:
a. Inability to consume an adequate diet
(1) Absence or weak sucking response (e.g., cleft lip and
palate)
(2) Poor control of arm and head (e.g., cerebral palsy)
(3) Inadequate control of jaw, lip, and tongue (e.g., tongue
thrust and tonic bite)
(4) Attention deficit (e.g., intellectual disability and
hyperactivity)
b. Impaired nutrient use
(1) Malabsorption conditions (e.g., cystic fibrosis)
(2) Inborn errors of metabolism (e.g., phenylketonuria)
(3) Drug-nutrient interactions (e.g., anticonvulsant
medications can interfere with calcium and phosphorus
use)
(4) Poor muscle control (e.g., constipation)
c. Excessive intake of foods, calories, and sweets
(1) Food, especially sweets, often used to reinforce good
behavior
(2) Overfeeding because of parental guilt
(3) Overemphasis on feeding because mealtime is perceived
as the most important time for parent-child interaction
(4) Excessive calorie intake resulting from inactivity and the
pleasurable aspects of eating

1051
Web Site Information And Resourc es
Source Web Site Address Description
Food and Nutrition Center: US http://fnic.nal.usda.gov/ Resource for Dietary Nutrient
Department of Agriculture database, Dietary Guidelines for
National Agricultural Library Americans, and the Food Guide
Pyramid
Healthy People 2020 http://www.healthypeople.gov Information on Healthy People
2020; includes tips for
speakers. Oral health
objectives provide a valuable
resource for community-
based activities.
American Dental Association http://www.mouthhealthy.org/en/nutrition Provides a nutrition link for
food tips, nutrition concerns,
and nutrition during
pregnancy
National Academy of Science http://www.nasonline.org/ Information available for
purchase by the public about
food and nutrition. Specific
subtopics include diet and
health and dietary reference
intakes.
Choose My Plate http://www.choosemyplate.gov Provides guidance on
balance, moderation, and
adequate consumption of
essential food groups;
interactive resource for
individual groups
Provides specific dietary
requirement based on age,
gender, and level of physical
activity

1052
References
1 Johnson R.D., Lawrence L.J., Brands M., et al. Dietary sugars
intake and cardiovascular health scientific statement from the
American Heart Association. Circulation. 2009;120:1011–1020.
2 Institute of Medicine (IOM)National Academy of Sciences, Food
and Nutrition Board. Dietary Reference Intakes for energy,
carbohydrates, fiber, fat, fatty acids, cholesterol, protein, and amino
acids. Washington, DC: The National Academy Press; 2010.
http://www.nap.edu/openbook.php?record_id=10490 Accessed
October 26, 2014.
3 U.S. Department of Agriculture and U.S. Department of Health
and Human Services. Dietary guidelines for Americans. ed 7
Washington, DC: US Government Printing Office; 2010.
4 Axxya Systems: Nutritionist Pro Diet analysis software, PO Box
3157, Redmond, WA 98073. http://www.axxya.com. Accessed
October 30, 2014.
5 ESHA Research: Food processor nutrition and fitness analysis
software, PO Box 13028, Salem, OR 97309-1028.
http://www.esha.com. Accessed October 30, 2014.

1053
Suggested readings
Harper Mallonee L.F. Nutrition counseling. In: Darby M., ed. Dental
hygiene: theory and practice. ed 4 St Louis: Elsevier Saunders; 2015.
Harper Mallonee L., Boyd L., Stegeman C. Practice paper of the
Academy of Nutrition and Dietetics (AND). Oral health and
nutrition. J Acad Nutr Diet. 2014. ;114:958. Full article available for
purchase to the public at
http://www.sciencedirect.com/science/article/pii/S2212267214003670
Accessed October 2, 2015.
Lamster I. Primary health care in the dental office. Elsevier
Saunders; 2012. Dental clinics of North America..
Stegeman C.A., Davis J.R. The dental hygienist’s guide to nutritional
care. ed 4 St Louis: Elsevier Saunders; 2015.
Touger Decker R., Mobley C. Position paper of the Academy of
Nutrition and Dietetics (AND). Oral health and nutrition. J Acad
Nutr Diet. 2013. ;113(5):693–701.
http://www.eatright.org/About/Content.aspx?id=8384 Accessed
September 22, 2014.
Touger -Decker R., Mobley C., Epstein J.B. Nutrition and oral
medicine. ed 2 Totowa, NJ: Humana Press; 2014.

Chapter 12 review questions

Answers and rationales to the review questions are available on this
text’s accompanying Evolve site. See inside front cover for details.

1. All the following are disaccharides EXCEPT one. Which one is the
exception?
a. Glucose
b. Sucrose
c. Lactose
d. Maltose
2. Oligosaccharides are composed of how many monosaccharide units?
a. More than six identical monosaccharide units
b. Two to six monosaccharide units
c. Two monosaccharide units

1054
 d. One monosaccharide unit
3. In the mouth, salivary amylase initiates the enzymatic hydrolysis of
starch. Salivary amylase also activates pepsin and denatures proteins in
the mouth.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
4. Which of the following emulsifies fat during the digestive process?
a. Pancreatic enzymes
b. Bile salts
c. Brush-border enzymes
d. Salivary enxymes
5. All the following are monosaccharides EXCEPT:
a. Galactose
b. Sucrose
c. Glucose
d. Fructose
6. Endocrine activity can affect the absorption process. Type of food
mixture would not have an influence.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
7. One of the end products of glycolysis is
a. Carbon dioxide
b. Adenosine triphosphate
c. Lactic acid
d. Water
8. What is the process called in which glycogen is the short-term storage
form of glucose in the liver and muscle?
a. Glycogenolysis
b. Gluconeogenesis

1055
 c. Glycogenesis
d. Glyconeogenesis
9. Anabolic hormones raise the blood glucose levels. Catabolic hormones
lower the blood glucose level.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
10. Anabolic hormones are metabolic regulators of all the following
EXCEPT:
a. Lower blood glucose level
b. Stimulate gluconeogenesis
c. Increase glycogenesis
d. Increase lipogenesis
11. Which of the following is an example of a soluble fiber?
a. Oat bran
b. Cellulose
c. Hemicellulose
d. Lignin
12. All the following are biologic roles of carbohydrates EXCEPT:
a. Provides an energy source of 4 kcal/g
b. Protein sparing
c. Structural component of cell membrane
d. Precursors of structural and functional molecules
13. The congenital absence of lactase enzyme is considered a primary
lactose intolerance. Temporary or permanent loss of lactase enzyme
activity as a result of injury or illness is considered a secondary lactose
intolerance.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
14. Which of the following nonnutritive sweeteners should be avoided
by patients who have phenylketonuria?

1056
 a. Saccharin
b. Acesulfame-K
c. Sucralose
d. Aspartame
Questions 15 to 20: Order the following cariogenicity factors of the diet
(a to f) from MOST important (15) to LEAST important (20).
___15. a. Total intake of sugars (liquid or retentive)
___16. b. Form of simple sugars
___17. c. Frequency of intake
___18. d. Consumption of starch-rich foods
___19. e. Timing of ingestion
___20. f. Combining cariogenic foods with noncariogenic foods
21. What is the recommended daily allowance (RDA) for digestible
carbohydrate for adults and children?
a. 50 g
b. 65 g
c. 100 g
d. 130 g
22. All the following are TRUE about patients with type 2 diabetes
EXCEPT:
a. A specialized diet is recommended to maintain blood glucose
control.
b. Daily injections of insulin are needed.
c. Routine blood testing to monitor blood sugar levels is
recommended.
d. Medication is often prescribed to facilitate glucose metabolism.
23. All the following signs and symptoms of diabetes mellitus EXCEPT:
a. Recurring gingival infections
b. Excessive thirst
c. Poor appetite
d. Frequent urination
24. Alcoholism can cause B-vitamin depletion. It can also depress
antidiuretic hormone, resulting in a loss of magnesium, potassium, and

1057
zinc in urine.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
25. Essential amino acids can be synthesized by the body and do not
need to be provided by the diet. Nonessential amino acids are found in
food of animal origin.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
26. Although an ovolactovegetarian diet can provide essential amino
acids that are inadequate in incomplete plant proteins, which of the
following nutrients might an ovolactovegetarian be deficient?
a. Iron
b. Vitamin B12
c. Calcium
d. Zinc
27. The linear sequence of the components of amino acids is referred to
as which type of structure?
a. Primary
b. Secondary
c. Tertiary
d. Quaternary
28. Absorption of proteins occurs at the brush border of the microvilli of
the small intestine. Absorption occurs only by active transport at specific
amino acid sites.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
29. All the following are used for de novo synthesis of proteins EXCEPT:
a. Deoxyribonucleic acid

1058
 b. Alpha keto acid
c. Messenger ribonucleic acid
d. Ribosomal ribonucleic acid
30. Positive nitrogen balance is the normal situation for building protein-
containing tissue. Negative nitrogen balance indicates net protein
breakdown.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
31. All the following are examples of anabolic hormones EXCEPT:
a. Growth hormone
b. Adrenocortical hormones
c. Insulin
d. Thyroid hormone
32. The cariogenic potential of foods:
a. Can be affected by the amount of sugar in food
b. Is related to the retentive quality of the food
c. Is related to the time foods are beverages are in the mouth
d. All the above
e. Both b and c
Questions 33 to 35: For each nutrient listed below, select the
physiologic fuel value (kilocalories) associated with each.
___33. Carbohydrates a. 9 kcal/g
___34. Lipids (fats) b. 4 kcal/g
___35. Proteins
___36. The recommended daily allowance of digestible carbohydrate is:
a. 90 g/day
b. 100 g/day
c. 110 g/day
d. 130 g/day
37. All the following are TRUE about water-soluble vitamins EXCEPT:
a. They are sensitive to heat, light, and oxygen.

1059
 b. They are absorbed into the blood by both active and passive
transport.
c. Deficiency symptoms are slow to develop.
d. They are transported free and unbound.
38. Vitamins are inorganic substrates that are essential to life. Minerals
are organic substrates that are essential to life.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
39. Which of the following have cariostatic properties, providing a
coating on the tooth’s surface and forming a protective pellicle on the
tooth?
a. Proteins
b. Carbohydrates
c. Lipids (fats)
d. Vitamins
40. All the following are examples of fat-soluble vitamins EXCEPT:
a. Vitamin A
b. Vitamin C
c. Vitamin D
d. Vitamin K
41. The energy required to digest, absorb and metabolize food is known
as which of the following?
a. Basal metabolic rate
b. Kilocalories
c. Thermic effect of food
d. Adenosine triphosphate
42. What is a more accurate method of determining central or abdominal
obesity?
a. Body mass index
b. Ideal body weight
c. Waist circumference
d. Weighing on a scale

1060
43. Which of the following statements is TRUE regarding the diet of
individuals who are edentulous or who have limited mastication due to
loss of teeth?
a. There is a reduced intake of dairy products.
b. There is a reduced intake of grain products.
c. There is reduced intake of meats.
d. More fruits and vegetables are consumed.
44. All the following are important posteruptive effects of carbohydrate
on the teeth EXCEPT:
a. Streptococcus mutans synthesizes polysaccharides from sucrose, which
enhances bacterial plaque formation.
b. Carbohydrates provide an energy source for oral bacteria.
c. Lactic acid, pyruvic acid, or acetyl–coenzyme A are the end products
of glycolysis for acidogenic bacteria.
d. Carbohydrates contribute to enamel remineralization.
45. Increased caries rate is attributed to a deficiency of vitamin D. Pulp
calcification can occur if there is an excess of vitamin D.
a. The first statement is TRUE; the second statement is FALSE.
b. The first statement is FALSE; the second statement is TRUE.
c. Both statements are TRUE.
d. Both statements are FALSE.

Case A
Margaret is a 56-year-old patient who presents to the dental clinic for her
4-month recare appointment. As a divorced mother, she has been
struggling to support her three children in college. She is currently self-
employed and cleans homes and babysits for a living. Her chief
complaint is sensitivity to hot and cold when eating. She also complains
of dry mouth and states she sips on citrus-flavored water throughout the
day.
Margaret’s medical history reveals she is currently being treated by a
physician for type 2 diabetes, hyperlipidemia, hypertension, and
gastroesophageal reflux disease (GERD). Her medications include 1000-
mg metformin, 15-mg atorvastatin, 30-mg atenolol, 20-mg Prilosec, 81-
mg aspirin tablet, 600 mg of calcium twice daily, and a multivitamin. Her
height is 5 feet, 2 inches, and she weighs 150 pounds. Her BMI is 27.43.
She reports brushing her teeth morning and night, and she tries to floss

1061
but is not very compliant. Her plaque score is 43%. She has several
“watches” that are noted on previous dental charting. New bitewing
radiographs were taken at this appointment. Secondary decay was
identified on the distal of tooth #19 and mesial of tooth #30. Her
periodontal assessment reveals isolated probing depths of 4 to 5 mm on
the maxillary and mandibular posterior teeth.
The dental hygienist questions Margaret about her diet. She reports
she eats small meals throughout the day and states that she “would
rather snack than eat full meals.” She is also lactose intolerant, so she
avoids dairy products. She likes fruits and vegetables but thinks it is
time-intensive to have to prepare them, so she has developed a new
habit of juicing fruits and vegetables and having a morning “smoothie.”
Margaret states she also consumes energy drinks each day because she
believes they give her “an extra boost” to get through her day.

Answer questions 46 to 50 based on Case A.

46. The secondary decay is most likely caused by all the following
EXCEPT:
a. GERD
b. Lactose intolerance
c. Energy drink consumption
d. Flavored-water consumption
e. Juicing with fresh fruits and vegetables
47. Based on her calculated body mass index (BMI) of 27.43, Margaret
would be classified in which of the following categories?
a. Obesity
b. Oveweight
c. Underweight
d. Normal weight
e. Extreme obesity
48. The direct-approach counseling technique would be best used to
address Margaret’s dietary concerns in relation to her oral disease risk.
The counselor (dental hygienist) should provide information on the
causes of the dental disease, the role of the diet, and the use of dietary
assessment tools, with the client (Margaret) as an active participant.
a. Both statements are TRUE.
b. Both statements are FALSE.

1062
 c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
49. During nutrition counseling, it is important for the dental hygienist
to:
a. Assess patient knowledge of information provided
b. Tell the patient which diet to follow
c. Include the patient in the diet planning
d. All the above
e. Both a and c
50. Margaret has a 43% plaque score. Supragingival biofilm or plaque
formation is influenced by frequent intake of which of the following in
the diet?
a. Dietary monosaccharides and disaccharides
b. Fiber-rich foods
c. Protein-rich foods
d. Fat-rich foods

1063
C HAPT E R
13

1064
Biomaterials
Stephen C. Bayne; John M. Powers

Biomaterials, restorative materials, and tissue engineering are

fundamental to dental hygiene practice and are used in a variety of
dental hygiene roles. This chapter provides an overview of general
applications, terminology, and classification for specific biomaterials,
including preventive and restorative materials. Structure and the
properties of materials, including physical, chemical, mechanical, and
biologic characteristics, are also reviewed.
Direct applications of materials include dental amalgams; dental
composites; pit-and-fissure sealants; infiltrants for lesions; bonding
agents; cement liners and bases and luting cements; fluoride-releasing
restorative materials, topical fluorides and fluoride varnishes; dentifrices
and prophylactic pastes; and bleaching agents. Indirect applications
include impression materials, provisional materials, models, casts, dies,
waxes, investment materials, casting alloys, dental solders, chromium
alloys for partial dentures, porcelain-fused-to-metal (PFM) alloys, dental
ceramics, crown-and-bridge cements, acrylic appliances, acrylic denture
bases, denture teeth, denture liners, denture cleansers, mouth protectors,
veneers, digital scanning, computer-assisted design and computer-
assisted machining (CAD/CAM), three-dimensional (3-D) printing, and
dental implants. Indirect applications continue to move toward digital
workflow in which all fabrication operations use computer operations to
replace all traditional fabrication stages. Originally, these depended on
subtractive processes (e.g., CAD/CAM machining from blocks of ceramic
or composite), but many newer applications (e.g., stereolithography,
inkjet printing, selective layer sintering) are additive processes.

1065
Introduction
General Considerations
A. Applications for dental biomaterials
1. Direct preventive and restorative dental procedures
2. Indirect preventive and restorative dental procedures
B. Definitions and terminology
1. Materials science terminology
2. Biomaterials terminology for classification
C. Classification of materials for applications by:
1. Key parts of composition-influencing properties
2. Extent of cavity preparation

Structure
A. Composition
1. Generally, two components in a specific ratio
a. Powder and liquid (P/L)
b. Powder and powder (P/P)
c. Water and powder (W/P)
d. Paste and paste (p/p)
e. Paste and light
2. Generally, the liquid part is the major reactant
B. Reaction during use
1. Physical reaction—solidification by drying or cooling with no
chemical reaction
2. Chemical reaction—solidification by creating new primary bonds
within the composition
C. Manipulation
1. Proportioning variables
a. Ratio of parts
b. Temperature
c. Relative humidity
2. Mixing variables
a. Manual mixing
(1) Method of combining components (e.g., stirring and
stropping)
(2) Rate of mixing (e.g., fast and slow)
b. Auto-mixing and machine mixing
3. Stages of manipulation
a. Definitions of times

1066
 (1) Mixing time—time elapsed from onset to completion of
mixing
(2) Working time—time elapsed from onset of mixing to onset
of initial setting time
(3) Initial setting time—time at which sufficient reaction has
occurred to cause the materials to be resistant to further
manipulation
(4) Final setting time—time at which the material is
practically set, as defined by its resistance to indentation
b. Definitions of intervals
(1) Mixing interval—length of time of mixing stage
(2) Working interval—length of time of working stage
(3) Setting interval—length of time of setting stage
c. All water-based materials lose their gloss at the time of setting

Properties
A. Physical properties—events that do not involve changes in
composition or primary bonds
1. Descriptive properties
a. Weight—gravitational force that attracts a body
b. Mass—resistance of a body to acceleration (or being moved)
c. Volume—a defined region in three-dimensional space
d. Density—a body’s weight per unit of volume
2. Thermal properties
a. Linear coefficient of thermal expansion (LCTE, α)
(1) Rate of expansion or contraction of one dimension of a
material with temperature change (Fig. 13-1)

1067
 FIG 13-1 Linear coefficient of thermal expansion.

(2) LCTE = [(L2− L1)/(L1)]/(T2− T1), where

(a) L1 = original length
(b) L2 = new length
(c) T1 = original temperature
(d) T2 = new temperature
(3) Values reported as: in/in/°F (inch per inch per degree
Fahrenheit), 10− 6/°F; cm/cm/°C, (centimeter per centimeter
per degree Celsius), 10− 6/°C; ppm/°C (parts per million per
degree C)
(4) LCTE values—tooth, 9 to 11 ppm/°C; amalgam, 25 ppm/°C;
composite, 35 to 45 ppm/°C; inlay wax, 300 ppm/°C
(5) When the thermal expansion of restorative material does
not match the tooth structure, percolation of fluids occurs
at the margins during cyclic heating and cooling
b. Thermal conductivity
(1) Insulators transmit heat poorly (e.g., dental enamel, dental
cements, acrylic polymers, dental porcelain, ceramic
restorations)
(2) Conductors transmit heat easily (e.g., dental amalgam,

1068
 cast-gold alloys)
(3) Teeth with metal restorations may be sensitive to hot and
cold foods because of their good thermal conduction
(4) Individuals wearing dentures may not sense normal
temperature differences attributable to the thermal
insulation of the acrylic denture base
(5) To be an effective insulator, the material must be at least
0.5 mm thick
3. Electrical properties—electrical conductivity
a. Conductors transmit electrons easily (e.g., metals)
b. Semiconductors transmit electrons sometimes, including
ceramics and often composites
c. Insulators transmit electrons poorly (e.g., ceramics, polymers)
4. Surface properties
a. Contact angle—internal angle of liquid droplet with solid
surface
(1) Good wetting (angle = 0 degrees)
(2) Spreading (angle < 90 degrees)
(3) Poor wetting (angle ≥ 90 degrees)
b. Reflection—degree of surface backscattering
5. Color properties
a. Perception—physiologic response to physical stimulus by the
eye, which can distinguish three parameters
(1) Dominant wavelength—blue, green, yellow, orange, and
red
(2) Luminance—lightness of color from black to white
(3) Excitation purity—saturation of light
b. Measurement
(1) Munsell Color System (e.g., 5R 6/4)
(a) Hue—color family (R, YR, Y, GY, G, BG, B, PB, P, RP)
(b) Value—lightness from black to white (0/ to 10/)
(c) Chroma—saturation from gray upward (/0 to /18)
(2) Instrumentation techniques—record the spectral
reflectance versus wavelength curves (405 to 700 nm)
(3) L*a*b* color system
(a) L* is value
(b) a* is red, − a* is green
(c) b* is yellow, − b* is blue
(4) Dental manufacturer shade guides
(a) Custom product shades guides
(b) VITA Classical

1069
 (c) VITA Linearguide 3D-Master
(d) VITA Bleachguide 3D-Master
c. Definitions
(1) Metamerism—colors with different spectral energy
distributions that look the same under certain lighting
conditions but look different with different light sources
(2) Fluorescence—emission of light by a material when a
beam of light is shined on it
(3) Opacity—degree of light absorption by a material
(4) Translucency—degree of internal light reflection
(5) Transparency—degree of light transmission through a
material
B. Chemical properties
1. Primary chemical bonding types
a. Types
(1) Metallic (e.g., metals)
(2) Ionic (e.g., ceramics)
(3) Covalent (e.g., polymers)
b. Events related to changes in primary chemical bonding
(1) Contraction attributable to chemical reaction
(a) Rate of contraction of size of material during chemical
reaction or phase change at constant temperature
(b) Linear change (percent) = [(L1 − L0)/(L0)] × 100%, where
[1] L0 = original length
[2] L1 = final length (after 24 hours)
(c) Values reported as percentage changes
(2) Corrosion of surfaces
2. Secondary chemical bonds
a. Types
(1) Hydrogen bonding—where hydrogen is attracted to an
electronegative element; found in most water-based liquids
(2) Van der Waals forces—dispersion forces caused by
fluctuating dipoles; found in dental composites and acrylics
b. Events related to changes in secondary chemical bonding
(1) Adsorption—uptake “onto” the surface of the solid
(2) Absorption—uptake “into” the solid
(a) Example—water absorbed by denture
(b) Example—moisture absorbed by alginate (imbibition)
(3) Desorption—fluid lost from the solid; for example, water
lost from alginate (syneresis)

1070
 (4) Solubility—material loss by dissolution of surface
(5) Disintegration—material loss by disruption of solid,
usually by absorbed water
3. Corrosion
a. Chemical corrosion—chemical reaction at surface
(1) Products may be soluble
(2) Products may be insoluble and form layers (tarnish)
b. Electrochemical corrosion—chemical reaction that requires an
anode (e.g., dental amalgam), a cathode (e.g., gold crown), an
electrolyte (e.g., saliva), and an electrical circuit (e.g., contact) for
electron flow (Fig. 13-2)

FIG 13-2 Electrochemical corrosion.

(1) Galvanic corrosion—dissimilar metals in contact (previous

examples)
(2) Local galvanic corrosion (structure selective corrosion)—
dissimilar phases in the same metal in contact
(3) Crevice corrosion—corrosion in the crack under plaque,
between a restoration and the tooth structure, or in the
scratch on the surface of a restoration, where the metals
may be the same but the electrolytes are different locally
c. Corrosion potential
(1) Immune—does not corrode (i.e., cathodic)
(2) Active—corrodes readily (i.e., anodic)
(3) Passive—corrosion produces protective film, for example,
chromium oxide film on stainless steel
C. Mechanical properties
1. Resolution of forces (Fig. 13-3)

1071
 FIG 13-3 Resolution of forces.

a. Uniaxial (one-dimensional) forces—compression, tension, and

shear
b. Complex forces—torsion, flexure, and diametral tension or
compression
2. Normalization of forces and deformations
a. Stress
(1) Applied force (or material’s resistance to force) per unit
area
(2) Stress = force/area
(a) lb/in2 (pounds per square inch, psi)
(b) kg/cm2 (kilograms per square centimeter)
(c) N/m2 (megapascals, MPa)
b. Strain (Fig. 13-4)

1072
 FIG 13-4 Stress-strain curve.

(1) Change in length per unit of length because of force

(2) Strain = (L − l0)/(l0); dimensionless units
3. Stress-strain diagrams
a. Plot of stress (vertical) versus strain (horizontal)
(1) Allows convenient comparison of materials
(2) Different curves for compression, tension, and shear
(3) Curves depend on rate of testing and temperature
b. Analysis of curves (see Fig. 13-4)
(1) Elastic behavior
(a) Elastic strain—initial response to stress (elastic—when
the stress is removed, the strain returns to zero and the
material returns to its original length)
(b) Elastic modulus—slope of first part of curve;
represents the stiffness of the material, or the
resistance to elastic deformation under force
(c) Elastic limit (proportional limit)—stress above which
the material no longer behaves totally elastically
(d) Yield strength—stress that is an estimate of the elastic

1073
 limit at 0.002 permanent strain
(e) Hardness—value on a relative scale that estimates the
elastic limit in terms of a material’s resistance to
indentation
[1] Examples—Knoop hardness scale, Diamond
pyramid hardness scale, Brinnell hardness scale,
Rockwell hardness scale, Barcol scale, Shore A
hardness scale, Mohs hardness scale (Table 13-1)

Table 13-1
Mohs’ Scale for Hardness*

Number Hardness
10 Diamond
9 Corundum
8 Topaz
7 Quartz
6 Orthoclase
5 Apatite
4 Fluorite
3 Calcite
2 Gypsum
1 Talc
* Standard for checking hardness of abrasives and substrates.

[2] Hardness values are used to determine the ability

of abrasives to alter the substrates they contact
(f) Resilience—area under the stress-strain curve up to
the elastic limit; estimates the total elastic energy that
can be absorbed before the onset of plastic
deformation
(2) Elastic and plastic behavior
(a) Beyond the stress level of the elastic limit, a
combination of both elastic and plastic strain exists
(b) Ultimate strength—highest stress reached before
fracture; the ultimate compressive strength is greater
than the ultimate shear strength and the ultimate
tensile strength
(c) Elongation (percent elongation)—percent change in
length up to the point of fracture = strain × 100%
(d) Brittle materials—less than 10% elongation at fracture
(e) Ductile materials—greater than 10% elongation at
fracture

1074
 (f) Toughness—area under the stress-strain curve up to
the point of fracture (it estimates the total energy
absorbed up to fracture)
(3) Time-dependent behavior
(a) Strain rate sensitivity—the faster a stress is applied,
the more likely a material is to store the energy
elastically and not plastically
(b) Creep—strain relaxation with time in response to a
constant stress, such as dental wax deforming because
of built-in stresses created during cooling
(c) Stress relaxation—with time in response to a constant
strain
(d) Fatigue—failure caused by cyclic loading
4. Principles of cutting, polishing, and surface cleaning
a. Terminology
(1) Cutting—gross removal of excess material from the
surfaces of restorations or teeth
(2) Finishing—fine removal of surface material in an effort to
produce finer surface scratches
(3) Polishing—smoothing of surfaces by removal of fine
scratches
(4) Debriding—removal of unwanted material attached to
surfaces
(5) Air abrasion (air polishing)—removal or polishing of hard
tissue by the kinetic energy from particles sprayed against
the surface
(6) Microabrasion—removal of stains by a mixture of an
abrasive and hydrochloric acid
b. Surface mechanics for materials (Table 13-2)

1075
 Table 13-2
Hardness Values for Dental Substrates*

Hardness Value Number

CAD/CAM ceramic 6-7
Porcelain 6-7
Composite 5-7
Glass 5-6
Dental enamel 5-6
Dental amalgam 4-5
Dentin 3-4
Hard gold alloys 3-4

Pure gold 2-3

Acrylic 2-3
Cementum 2-3
* Based on Mohs hardness scale: diamond = 10; talc = 1 (see Table 13-1).

(1) Cutting—requires materials with the highest possible

hardness to produce the cuts
(2) Finishing—requires materials with the highest possible
hardness for the best effect, except at the margins of
restorations, where the tooth structure may be
inadvertently affected
(3) Polishing—requires materials with small particles and
with a Mohs hardness that is only 1 to 2 units above that of
the substrate
(4) Debriding—requires materials with a Mohs hardness that
is less than or equal to that of the substrate to prevent
scratching
c. Factors affecting cutting, polishing, and surface cleaning
(1) Applied pressure
(2) Particle size of abrasive
(3) Hardness of abrasive
(4) Hardness of substrate
(5) Speed of rotary instrument
d. Factors affecting air abrasion
(1) Abrasive particle size: 27-µm or 50-µm aluminum oxide
(2) Air pressure—higher air pressure cuts faster but may
cause discomfort
e. Precautions
(1) During cutting, heat will build up and change the
mechanical behavior of the substrate from brittle to ductile

1076
 and will encourage formation of a smear layer
(2) Instruments may transfer debris onto the cut surface from
their own surfaces during cutting, polishing, or cleaning
operations (this has important implications in cleaning
dental implant surfaces)
D. Biologic properties
1. Definitions of biohazards
a. Toxicity—cell or tissue death attributable to material
concentration
b. Sensitivity—systemic reaction to a substance
(1) Allergy—reaction to relatively small amounts of a material
(2) Hypersensitivity—reaction to minute amounts of a
material
2. Definitions of local tissue interactions with biomaterials
a. Fibrous tissue capsule formation (tissue encapsulation)
b. Integration at the interface (osseo-integration)
(1) Bone ingrowth
(2) Bone ongrowth
c. Biodegradation (desorption or resorption)
3. Classification of biologic materials—tissue interfaces
a. Intraoral and supragingival—in enamel or dentin
b. Intraoral, pulpal, or periapical
c. Transcutaneous
d. Subcutaneous
e. Intraosseous
4. Clinical analysis of biocompatibility
a. Risk versus benefits
b. Safety and efficacy
5. Agencies that oversee materials, devices, and therapeutics
a. Regulatory agencies—U.S. Food and Drug Administration
(FDA)
b. Standards development for manufacturing practices (for
physical, chemical, mechanical, and biologic properties and for
clinical testing)
(1) American Dental Association (ADA)—Council on
Scientific Affairs and Standards Committee on Dental
Products (SCDP)
(2) American National Standards Institute (ANSI)
(3) Fédération Dentaire Internationale (FDI; International
Dental Association)
(4) International Standards Organization (ISO)

1077
Direct preventive and restorative
materials
Dental Amalgam
A. General considerations
1. Applications
a. Load-bearing restorations for posterior teeth (class I, class II)
b. Pin-retained restorations
c. Buildups (foundations) or cores for cast restorations
d. Retrograde root canal filling material
2. Terminology
a. Amalgam alloy—powder particles of silver-tin-copper-(zinc), or
Ag-Sn-Cu-(Zn) (minor elements are indicated in parentheses)
b. Amalgam—reaction product of any material with mercury
c. Dental amalgam—reaction product of amalgam alloy (Ag-Sn or
Ag-Sn-Cu) with mercury
3. Classification of dental amalgam by:
a. Powder particle shape
(1) Irregular (comminuted, filing, or lathe-cut)
(2) Spherical (spherodized)
(3) Blends, including irregular-irregular, irregular-spherical, or
spherical- spherical
b. Total amount of copper
(1) Low-copper alloys (conventional, traditional); less than 5%
copper (Ag-Sn-Cu)
(2) High-copper alloys (corrosion-resistant); 12% to 28%
copper (Ag-Sn-Cu)
c. Presence of zinc
d. Other modifications
4. Examples
a. Low-copper, irregular-particle alloy (e.g., 70Ag-26Sn-4Cu)
b. High-copper, blended-particle alloy with irregular particles (e.g.,
70Ag-26Ag-4Cu) and spherical particles (e.g., 72Ag-28Cu)
c. High-copper, spherical-particle alloy (e.g., 60Ag-27Sn-13Cu)
B. Structure
1. Components
a. Mercury (Hg) mixed with amalgam alloy
b. Mercury reacts with periphery of alloy particle to produce
crystalline silver-mercury, tin-mercury, and copper-tin phases
2. Reaction (Fig. 13-5)

1078
 FIG 13-5 Amalgam reaction.

a. Setting reactions
(1) Low-copper dental amalgam

(2) High-copper dental amalgam

and

b. Phases in set amalgams

(1) Residual alloy (Ag-Sn, Ag-Sn-Cu, or Ag-Cu)—strongest; most
corrosion-resistant
(2) Ag-Hg (= γ1) = major matrix phase in low-copper or high-copper
dental amalgams
(3) Sn-Hg (= γ2) = second matrix phase in low-copper dental amalgams

1079
(4) Cu-Sn (η or ɛ) = second matrix phase in high-copper dental amalgams
3. Manipulation
a. Selection—based on clinical requirements for strength
b. Packaging
(1) Powder or pressed tablets; mercury
(2) Precapsulated powder and mercury
c. Mixing
(1) Mercury alloy—specific to each product but generally less than 1:1 so
that amalgam contains 41% to 50% mercury
(2) Mechanical amalgamators—variable time, speed (frequency and
amplitude), and amalgamator motion for different equipment; variables
affect the mixing process
(3) Each amalgamator has specific settings for each different amalgam
alloy (e.g., high-copper amalgams require 5 to 10 seconds)
(4) Amalgamator capsules are disposable
(5) Pestle may be included in the capsule for mixing efficiency
(6) Overmixed mass is difficult to remove from capsule
(7) Undermixed mass is crumbly
d. Condensation
(1) Adaptation of amalgam to cavity walls
(2) Removal of excess mercury-rich matrix produces a stronger and more
corrosion-resistant amalgam because it minimizes the formation of the
matrix phases of amalgam, which are the least desirable parts of the set
material
(3) Amalgams with spherical alloys are more fluid and require larger-
tipped condensers
(4) It is important to condense in small increments, overpack restoration,
avoid delays, and avoid saliva contamination
e. Finishing
(1) The anatomy should be carved within a few minutes after condensing
(2) The surface should be burnished or the final finish performed at least
24 hours later
C. Properties
1. Physical
a. Coefficient of thermal expansion = 25 ppm/°C
b. Thermal conductivity—high (therefore the amalgam may need
an insulating liner or base in very deep cavity preparations)
2. Chemical
a. Dimensional change on setting, should be less than ± 20 µm
(excessive expansion can produce postoperative pain)
b. The cavity varnish or the bonding agent electrically insulates a

1080
 dental amalgam restoration, but it does not prevent corrosion
c. Chemical corrosion produces a black or green tarnish on the
surface that is aesthetically unacceptable but is not detrimental
to oral health
d. Electrochemical corrosion produces penetrating corrosion of
low-copper amalgams but produces only superficial corrosion of
high-copper amalgams
3. Mechanical
a. Compressive strength—ranges from 310 to 480 MPa, comparable
with enamel (410 MPa) but is not significant in preventing
marginal fracture
b. Because of low tensile strength, enamel support is needed at the
margins
c. Spherical high-copper alloys develop high tensile strength
quickly and can be polished sooner than enamel
d. Excessive creep occurs during the Ag-Hg phase of incorrectly
mixed amalgams and contributes to early marginal fracture
e. Marginal fracture is correlated with creep and electrochemical
corrosion in low-copper amalgams (Fig. 13-6)

FIG 13-6Marginal ditching in an amalgam restoration is produced

by creep and expansion, which elevate the margins of the
amalgam, and functional stresses produce marginal fracture.

f. Bulk fracture (isthmus fracture) occurs across the thinnest

portions of amalgam restorations because of high stresses
during traumatic occlusion, the accumulated effects of fatigue,

1081
 or both
g. Dental amalgam is relatively resistant to abrasion, that is, wear;
similar to human enamel
4. Biologic
a. Mercury hygiene
(1) All personnel must be trained; all personnel must be made
aware of mercury sources in the oral care setting
(2) A proper work-area design is important; personnel must
work in well-ventilated spaces; the treatment area
atmosphere must be periodically checked for mercury vapor
(3) Precapsulated products should be stored in tight
containers
(4) Mercury should not come into contact with the skin
(5) Spills should be cleaned up immediately to minimize
mercury vaporization
(6) Amalgamators should be used with covers enclosing the
mixing arm
(7) High-vacuum suction should be used during amalgam
alloy placement, setting, polishing, or removal when
mercury may be vaporized
(8) All scrap amalgam should be salvaged and stored in
tightly closed containers and recycled in accordance with
applicable laws
(9) Mercury-contaminated items must be disposed of in
sealed bags and not in medical waste containers
(10) The dental office personnel must be aware of aerosols
created by vacuuming mercury spilled on the floor or the
carpet
(11) Floor coverings should be replaced every 5 years to
eliminate spilled mercury that might have accumulated in
carpet pores
(12) Professional clothing must be removed before leaving the
workplace
b. Mercury bioactivity
(1) Depends on whether the form is metallic, inorganic, or
organic mercury
(2) Metallic mercury is the least toxic form and is absorbed
primarily through the lungs rather than through the
gastrointestinal (GI) tract or skin
(3) Mercury accumulated in the body may come from air,
water, food, dental sources (a low amount), or medical

1082
 sources
(4) Average half-life for mercury elimination from the body is
55 days
(5) The U.S. Occupational Safety and Health Administration
(OSHA) has set the average level for mercury toxicity by
exposure as less than 50 µg/m3 per 40-hour workweek
(6) Incidence of mercury hypersensitivity is estimated to be
less than 1 per 100 million persons
c. Environment issues-important to:
(1) Use best management practices (BMPs)
(2) Use precapsulated alloys
(3) Manage mercury through recycling—recycle used
disposable amalgam capsules; salvage, store, and recycle
noncontact amalgam; salvage amalgam pieces from
restorations after removal, and recycle amalgam waste
(a) Use chairside traps to retain amalgam and recycle
contents
(b) Recycle contents retained by vacuum pump filter or
other amalgam-collecting devices
(c) Disinfect extracted teeth that contain amalgam
restorations using bleach, and recycle them with
chairside trap wastes
D. Amalgam alternatives
1. Direct esthetic filling materials (composites, compomers)
2. Indirect filling materials (cast gold, PFM, all-ceramic materials)

Dental Composites
A. General considerations
1. Applications
a. Anterior restorations created for aesthetic purposes (class III,
IV, and V cervical erosion, or abrasion lesions)
b. Low-stress posterior restorations (small class I and II)
c. High-stress posterior restorations with certain formulations
d. Veneers
e. Cores for cast restorations
f. Cements for ceramic restorations
g. Cements for resin-bonded bridges
h. Repair systems for composites or ceramic restorations
2. Terminology (Fig. 13-7)

1083
 FIG 13-7 Hybrid dental composite.

a. Composite—physical mixture of materials to average the

properties of the materials involved
b. Dental composite—restorative material resulting from the
mixture of ceramic reinforcing filler particles in a monomer
matrix that is converted to polymer on setting
c. Polymerization—reaction of small molecules (monomers) into
very large molecules (polymers)
d. Cross-linking—tying together of polymer molecules by
chemical reaction between the molecules to produce a
continuous 3-D network
3. Classification by:
a. Amount of filler—25% to 85% by volume, 45% to 90% by weight
(1) Very high—bulk-fill; packable or condensable composite
(2) High—universal composite
(3) Moderate—flowable composite
(4) Low—microfill
b. Filler particle size
(1) Average sizes—minifill = 0.1 to 1.0 µm; microfill = 0.01 to
0.1 µm; nanofill = 0.001 to 0.01 µm
(2) Mixture of sizes—hybrid (microhybrid = mini + micro)
(3) Presence of pre-cured composite (heterogeneous)
c. Polymerization method
(1) Auto-cured (also self-cured, SC)
(2) Visible light–cured (VLC)
(3) Dual-cured (VLC + SC)
d. Matrix chemistry
(1) Bisphenol A–glycidylmethacrylate (Bis-GMA) or Bis-GMA–
like monomers
(2) Urethane dimethacrylate (UDM or UDMA) monomers
(3) Tetraethylene glycol dimethacrylate (TEGDMA)—diluent
monomer to reduce viscosity
(4) Expanding monomers—to control overall polymerization

1084
 shrinkage
B. Structure
1. Components
a. Filler particles—colloidal silica or silicate glasses
(noncrystalline) of various particle sizes (containing Ba, Li, Al,
Zn, Yr, and others)
b. Matrix—Bis-GMA (or UDMA) with lower-molecular-weight
diluents (e.g., TEGDMA) that co-react during polymerization;
ring-opening monomers
c. Coupling agent—silane, which chemically bonds the surfaces of
the filler particles to the polymer matrix
2. Reaction
a. Free-radical polymerization—
monomers + initiator + accelerators → polymer molecules
b. Initiators—start polymerization by decomposing and reacting
with monomer
(1) Benzoyl peroxide typically used in SC systems
(2) Camphorquinone typically used in VLC systems
c. Accelerators—speed up initiator decomposition; different
amines used for accelerating initiators in SC and VLC systems
d. Retarders or inhibitors—prevent premature polymerization
3. Manipulation
a. Selection
(1) Microfill composites or microhybrids for anterior class III,
IV, and V restorations
(2) Microhybrids for class I, II, III, IV, and V restorations
b. Conditioning of enamel and dentin (see later section on
“Bonding Agents”)
(1) Total-etch technique:
(a) Acid-etch with 15% to 38% phosphoric acid
(b) Have the patient rinse for 5 to 10 seconds with water
(c) Air-dry enamel for 5 to 10 seconds, but do not
desiccate or dehydrate
(d) Apply bonding agent and polymerize
(2) Self-etch technique (apply bonding system)
c. Mixing (if required)—two pastes are mixed for 20 to 30 seconds
(1) Self-cured composite—working time is 60 to 120 seconds
after mixing
(2) Light-cured composite—working time is nearly unlimited;
used for most anterior and some posterior composite
restorations; natural light and dental chair lights may

1085
 slowly start the reaction
(3) Dual-cured composite—working time is 5 to 8 minutes
d. Placement—a plastic instrument or syringe or a unidose
(compule) should be used
e. Light curing—it is important to:
(1) Check the output of the light-curing unit
(2) Use high-intensity quartz-tungsten-halogen (QTH) or
light-emitting-diode (LED)
(3) Cure incrementally in 1.5 to 2.0 mm–thick layers; use a
matrix strip, where possible, to produce a smooth surface
and to contour the composite
f. Finishing and polishing—it is important to:
(1) Remove the oxygen-inhibited layer (with alcohol swab)
(2) Use stones, carbide burrs, or diamonds for gross reduction
(3) Use multi-fluted carbide burs or special diamonds for fine
reduction
(4) Use aluminum oxide strips or discs for finishing or rubber
points, cups, and discs
(5) Use fine aluminum oxide or diamond finishing pastes
(6) Microfill and nanofill composites develop smoothest finish
because of small size of filler particles
(7) Keep in mind that liquid polishes provide short-term
smooth-surface coatings
C. Properties—generally improve with filler content
1. Physical
a. Radiopacity depends on the ions in silicate glass
b. Coefficient of thermal expansion is 35 to 45 ppm/°C and
decreases with increasing filler content
c. Thermal and electrical insulators
2. Chemical
a. Water absorption is 0.5% to 2.5% and increases with polymer
content
b. Acidulated topical fluorides (e.g., acidulated phosphate fluoride
[APF]) tend to dissolve glass particles, and thus composites
should be protected with a non–petroleum-based jelly during
these procedures, or a different topical fluoride (e.g., neutral
sodium fluoride) should be used
c. In the past, major color changes occurred in resin matrix with
time because of oxidation, which produces colored byproducts,
but the modern composites are highly color stable; some
composites experience a slight shade shift when light-cured

1086
 3. Mechanical
a. The compressive strength is 310 to 410 MPa, which is adequate
b. Wear resistance—improves with higher filler content, higher
percentage of conversion in curing, use of microfiller, and closer
interparticle spacing of fillers
c. Surfaces that are rough from wear retain plaque biofilm and
stain more readily
4. Biologic—the components may be cytotoxic, but the cured composite
is biocompatible as restorative filling material

Pit-and-Fissure Sealants
A. General considerations—see the section on “Dental Sealants” in
Chapter 16.
1. Applications
a. Occlusal surfaces of newly erupted posterior teeth
b. Lingual surfaces of anterior teeth with fissures
c. Occlusal surfaces of teeth in older persons with reduced flow of
saliva (because low levels of saliva increase susceptibility to
dental caries)
2. Classification by:
a. Polymerization method
(1) Self-curing
(2) Light-curing—90% of current products
b. Filler content
(1) Unfilled—many systems are unfilled because filler tends
to interfere with and wear away from self-cleaning occlusal
areas; sealants are designed to wear away, except where no
self-cleaning action occurs; a common misconception is that
sealants should be wear resistant
(2) Lightly filled—10% to 30% by weight
B. Structure
1. Components
a. Monomer—Bis-GMA–like or UDMA monomers with TEGDMA,
a diluent monomer, to facilitate flow into pits and fissures
before cure
b. Initiator—benzoyl peroxide (in self-cured) and camphorquinone
(in light-cured)
c. Accelerator—amine
d. Opaque filler—1% titanium dioxide or other colorant to make
the material detectable on tooth surfaces

1087
 e. Reinforcing filler—silicate glass (generally not added because
wear resistance is not required within pits and fissures)
f. Fluoride—may be added for slow release
2. Reaction—free-radical reaction (see the previous section on “Dental
Composites”)
3. Manipulation
a. Preparation—this involves:
(1) Cleaning the pits and fissures of organic debris
(2) Etching the occlusal surfaces, pits, and fissures with 37%
phosphoric acid
(3) Washing the occlusal surfaces for 5 to 10 seconds
(4) Drying the etched area for 5 to 10 seconds with clean air
spray
(5) Applying the sealant and polymerizing
b. Mixing or dispensing
(1) Self-cured—equal amounts of liquids are mixed in a
Dappen dish for 5 seconds with a brush applicator
(2) Light-cured—syringes or unidose tips are used for
dispensing
c. Placement—pits, fissures, and occlusal surfaces; this involves:
(1) 60 seconds for self-cured materials to set
(2) Light-curing according to manufacturer ’s instructions
d. Finishing
(1) Unpolymerized (air-inhibited layer) and excess materials
should be removed
(2) The hardness and marginal adaptation of the sealant
should be examined
(3) Occlusal adjustments should be made, where necessary, in
the sealant; most unfilled sealant materials are self-
adjusting
C. Properties
1. Physical—wetting: low-viscosity sealants wet acid-etched tooth
structure the best
2. Mechanical
a. Wear resistance should not be too great because the sealant
should be able to wear off the self-cleaning areas of tooth
b. To prevent loss, sealants should be protected during polishing
procedures with air-abrading units
3. Biologic—no apparent biologic problems
4. Clinical efficacy
a. Effectiveness is 100% if retained in pits and fissures

1088
 b. Requires routine clinical evaluation (every 1.5 to 2 years) to
check the integrity and resealing of defective areas if sealant
loss is attributable to poor retention
c. Sealants resist attack from topical fluorides (also applied for
prevention of dental caries)

Infiltrants
A. General considerations
1. Applications—approximal and smooth-surface uncavitated lesions
where sealing would not be a permanent solution to stop lesion
growth and to create good esthetics
2. Definition—a resin system capable of penetrating through slightly
porous enamel, embedding into an existing decalcified region of
dentin, stopping lesion activity by preventing the diffusion of
organic acids below plaque and restoring the esthetics of the tooth
structure
3. Classification—this is a new and novel approach to minimally
invasive dentistry for interproximal, uncavitated lesion repair;
currently, only one system is available on the market
a. Approximal application kit
b. Smooth-surface application kit
B. Structure
1. Components—acrylic monomer infiltrant after use of a hydrochloric
acid (HCl; hydrogen chloride, hydrochloride) etchant to create
micropores in the enamel overlying the lesion and to allow resin
penetration
2. Reaction—the resin is light-cured
3. Manipulation (approximal repair)
a. Wedging of teeth to separate interproximal contacts
b. Application of acid etchant (more than 90 seconds with 15%
aqueous HCl) to create micropores through the overlying
enamel by using a unique holder and a film packet to deliver
materials
c. VLC materials
C. Properties
1. Physical—the tooth structure appears to have normal color and
opacity after infiltration
2. Chemical—no evidence of dentin decalcification after infiltration
3. Mechanical—previously decalcified dentin is restored to
approximately the same hardness

1089
 4. Biologic—no evidence of any threat to the pulp before setting

Bonding Agents
A. General considerations
1. Applications—composites, resin-modified glass ionomers,
compomers, bonded ceramic restorations, veneers, orthodontic
brackets, desensitizing dentin by covering exposed tubules, resin-
bonded bridges, composite-repair and ceramic-repair systems, and
amalgams
2. Definitions
a. Smear layer—thin layer (0.5 to 5.0 µm) of compacted debris on
enamel and dentin resulting from the cavity-preparation process
(Fig. 13-8) that is weakly held to the surface (5 to 6 MPa) and that
limits bonding agent strength if not removed

FIG 13-8 The surface of cut dentin, with a smear layer and smear
plugs occluding the dentinal tubules.

b. Etching (or conditioning)—smear layer removal and production

of microspaces for micromechanical bonding by dissolving
minor amounts of surface hydroxyapatite crystals
(1) Total-etch (or etch-and-rinse) system—phosphoric acid
should be used
(2) Self-etch system—reliance on acidic monomer to dissolve
smear layer, etch surface of intertubular dentin, and embed
collagen fibers; no rinsing
c. Priming—micromechanical (and possibly chemical) bonding to
the microspaces created by the conditioning step
d. Conditioning and priming agent (self-etching primer)—agent
that accomplishes both actions
e. Bonding—formation of resin layer that connects the primed
surface to the overlying restoration (e.g., composite)

1090
3. Classification
a. Major substrate
(1) Enamel and dentin bonding system—for bonding to
enamel and dentin composite or other restorative materials
(2) Amalgam bonding system—for bonding amalgam to
enamel and dentin to amalgam
(3) Universal bonding system—for bonding an appliance to
enamel, dentin, amalgam, ceramic, metallic alloy, or any
other substrate that may be necessary for a restorative
procedure using the same set of procedures and materials
b. Number of components and type of etching (Fig. 13-9)

FIG 13-9 Evolution of bonding system types with fewer

components.

(1) Three-component total-etch system—

etching + priming + bonding (E + P + B) (also called fourth-
generation; involves two layers of material)
(2) Two-component total-etch system—
etching + priming/bonding (E + PB) (also called fifth-
generation; involves one layer of material)
(3) Two-component self-etch system—
etching/priming + bonding (EP + B) (also called sixth-
generation type 1; involves two layers of material)
(4) One-component self-etch system—

1091
 etching/priming/bonding) (EPB)—materials are mixed (if
necessary) and scrubbed onto the surface to be bonded
using the applicator tip [also called sixth-generation type 2 or
seventh-generation (no mixing), involves one layer of
material]
(5) Universal system—etching/priming/bonding (EPB) system
is compatible with etching with phosphoric acid, system
may contain components that prime zirconia-based
ceramics, silica-based ceramics, and metals
B. Structure
1. Components of bonding systems
a. Conditioning agent—mineral (e.g., 10% to 40% phosphoric
acid), organic acid (e.g., polyacrylic acid), or acidic acrylic
monomer (e.g., phosphonate)
b. Priming agent—resin and monomer in alcohol, acetone, or
water
c. Bonding agent—Bis-GMA or UDMA monomers
2. Reaction
a. Bonding occurs primarily by intimate micromechanical
retention, with the relief created by the conditioning step
b. Chemical bonding is possible but is not recognized as
contributing significantly to the overall bond strength
3. Manipulation (manufacturer ’s instructions should be followed)
a. Conditioning
(1) Total-etch technique—this involves:
(a) Applying phosphoric acid solution or equivalent
(b) Rinsing and drying without desiccation (dentin
should be kept moist with “glistening” appearance)
(c) In case of overdried dentin, remoistening surface with
water or a rewetting solution for 10 to 15 seconds
(2) Self-etch technique—this involves applying an acidic
primer or a bonding agent, no rinsing
b. Priming—this involves:
(1) Applying a priming agent, and gently drying to remove
excess solvent (but air-thinning must not be done unless
recommended by manufacturer)
(2) Applying several layers until dentin is fully impregnated
to surface
c. Bonding—this involves:
(1) Applying one to two coats of bonding agent when bonding
composites

1092
 (2) Applying multiple coats of the bonding agent or mixing it
with a thickening agent in preparation for bonding with
amalgam restorations
C. Properties
1. Physical—thermal expansion and contraction may create fatigue
stresses that debond the interface and permit microleakage
2. Chemical—water absorption into the bonding agent may chemically
alter the bonding
3. Mechanical—mechanical stresses may produce fatigue that can
debond the interface and permit microleakage
a. Enamel bonding—adhesion occurs by macrotags (between
enamel prisms) and microtags (into enamel prisms) to produce
micromechanical retention
b. Dentin bonding—adhesion occurs by removal of smear layer
and formation of microtags within intertubular dentin to
produce a hybrid zone (interpenetration or diffusion zone) that
microscopically intertwines collagen bundles and bonding agent
polymer; macrotags within tubules do not add much to
retention because they are poorly polymerized and poorly
adapted
4. Biologic
a. Conditioning agents may be locally irritating if they come into
contact with soft tissue
b. Uncured priming agents, particularly those based on
hydroxyethyl methacrylate (HEMA), may become skin
sensitizers for dental personnel after several contacts
(1) Hands and face must be protected from inadvertent
contact with unset materials and their vapors
(2) HEMA and other priming monomers may penetrate
through rubber gloves in relatively short times (60 to 90
seconds)

Cement Liners (Calcium Hydroxide; Zinc Oxide–

Eugenol; Bioceramic)
A. General considerations—applications (if remaining dentin thickness
is less than 0.5 mm)
1. Thermal insulation where the cavity preparation is close to the pulp
2. Delivering medications to the pulp
a. Calcium hydroxide (CH) liners—in self-cured and light-cured
versions that stimulate reparative dentin

1093
 b. Zinc oxide–eugenol (ZOE) relieves pain by desensitizing nerves
c. Bioceramic promotes remineralization
B. CH structure (for ZOE types; see the section on “Dental Sealants”)
1. Components
a. Paste of CH reactant powder, ethyl toluene sulfonamide
dispersant, zinc oxide filler, and zinc stearate radiopacifier
b. Paste of glycol salicylate reactant liquid, titanium dioxide filler
powder, and calcium tungstenate radiopacifier
2. Reaction
a. Chemical reaction of calcium ions with salicylate to form
methylsalicylate salts
b. Moisture absorbed to allow CH to dissociate into ions to react
with salicylate
c. Mixture sets from outside surface to inside as water diffuses
3. Manipulation
a. Dentin should not be dehydrated, or material will not set
b. A drop each of the pastes should be mixed together for 5
seconds
c. The material should be applied to dentin; 1 to 2 minutes should
be allowed for the material to set
C. CH properties
1. Physical—good thermal and electrical insulator
2. Chemical—poor resistance to water solubility, so may dissolve
3. Mechanical—low compressive strength (0.7 to 3.4 MPa)
4. Biologic—releases constituents, which diffuse toward the pulp and
stimulate reparative dentin formation

Cement Bases
A. General considerations (limited use)
1. Applications
a. Thermal insulation below a restoration (Fig. 13-10)

1094
 FIG 13-10 Sealer, liner, and base applications for use with dental
amalgam. E, Enamel; D, dentin.

b. Mechanical protection where dentin is inadequate to support

amalgam condensation pressures
2. Classification (many materials have been used in the past)
a. Glass ionomer (GI) cement bases
b. Resin-modified glass ionomer (RMGI)—light-curing
compositions
B. Structure (see the section on “Crown-and-Bridge Cements”)
1. Components
a. Self-curing cements (ZP, PC, GI)—reactive powder (chemically
basic) and reactive liquid (chemically acidic)
b. Light-curing cements (RMGI)—paste
c. Bioceramic—paste containing calcium silicate or bioactive filler
and resin
2. Reaction
a. Self-curing cement—acid–base reaction that forms salts or
cross-linked matrix; reaction may be exothermic
b. Light-curing cements—monomer polymerization is exothermic
3. Manipulation—consistency for basing includes more powder, which
improves all of the cement properties
C. Properties
1. Physical—excellent thermal and electrical insulation
2. Chemical—much more resistant to dissolution than cement liners
a. Polycarboxylate (PC) and GI cements are chemically adhesive to
tooth structure
b. Solubility of all cement bases is lower than that of cement liners
if they are mixed at higher powder-to-liquid ratios
3. Mechanical—much higher compressive strengths (80 to 210 MPa)

1095
 than those of luting cements
a. Light-cured RMGI cements are the strongest
b. ZOE cements are the weakest
4. Biologic (see the section on “Crown-and-Bridge Cements” for
details)—PC, GI, and RMGI cements, properly handled, provide
good biocompatibility with pulp

Other Cement Applications

A. Root canal sealers
1. Applications
a. Cementing of silver cone or guttapercha point
b. Paste filling material
2. Classification
a. Zinc oxide–eugenol cement types
b. Noneugenol cement types
c. Therapeutic cement types
d. Flowable composite types
3. Important properties
a. Physical—radiopacity
b. Chemical—insolubility
c. Mechanical—flow; tensile strength
d. Biologic—inert
B. Gingival tissue packs
1. Application—provide temporary displacement of gingival tissues
2. Composition—slow-setting ZOE cement mixed with cotton twills for
texture and strength
C. Surgical dressings
1. Application—gingival covering after periodontal surgery
2. Composition—modified ZOE cement (containing tannic acid, rosin,
and various oils)
D. Orthodontic cements
1. Application—cementing of orthodontic bands
2. Composition—composite (see the sections on “Crown-and-Bridge
Cements” and “Bonding Agents”)
3. Manipulation
a. Resin (composite) cements use total-etch or self-etch bonding
systems for improved bonding
b. Band, bracket, or cement removal requires special care

Fluoride-Releasing Restorative Materials

1096
A. General considerations
1. Applications for glass ionomers (GIs), resin-modified glass
ionomers (RMGIs), compomers, and atraumatic restorative
technique (ART) materials
a. Class V restorations—GIs and RMGIs for geriatric dentistry
b. Class I and II restorations—RMGIs and compomers in pediatric
dentistry; and ART temporary restorations in people living in
the underserved regions of the world
c. Class III restorations—RMGIs and compomers
2. Classification by composition (Fig. 13-11)

FIG 13-11 Evolution of glass ionomer composites over 35 years, leading

toward composites. ART, Atraumatic restoration technique.

a. Conventional GIs—limited use

b. Metal-modified GIs—limited use
c. RMGIs (hybrid ionomers)—popular use
d. Compomers—limited use
e. Giomers—limited use
f. RMGIs (ART materials)—extremely popular use for temporaries,
ART, and permanent restorations in pediatric dentistry
applications (representing the largest use of GI restorative
material)
B. Structure
1. Components
a. Conventional glass ionomers—aluminosilicate glass powder
and liquid water solution of co-polymers (or acrylic acid with
maleic, tartaric, or itaconic acid)
b. Metal-modified glass ionomers—used for cores
c. Resin-modified glass ionomers—aluminosilicate glass powder
and liquid with water solution of co-polymers (or acrylic acid
with maleic, tartaric, or itaconic acids) and water-soluble
monomers, for example, HEMA
d. Compomers—hybrid of RMGI and composite
e. Giomers—compomers with precured GI particles blended into a

1097
 mixture
f. Resin-reinforced (ART materials)—high fluoride-releasing
conventional GI that may have small amounts of resin added for
increased tackiness
2. Reactions (may involve several reactions and stages of setting)
a. Glass ionomer reaction (acid-base reaction of polyacid and ions
released from aluminosilicate glass particles)
(1) Calcium, aluminum, fluoride, and other ions released by
the outside of the powder particle dissolving in acidic liquid
(2) Calcium ions initially cross-link acid-functional co-polymer
molecules
(3) Calcium cross-links are replaced in 24 to 48 hours by
aluminum ion cross-links, with increased hardening of
system
(4) If no other reactants are present in the cement (e.g., resin
modification), protection from saliva is required during the
first 24 hours, unless otherwise indicated by manufacturer ’s
instructions
b. Polymerization reaction (polymerization of double bonds from
water-soluble monomers or pendant groups on the co-polymer
to form cross-linked matrix)
(1) Polymerization reaction can be initiated with chemical
(self-curing) or light-curing steps
(2) Cross-linked polymer matrix ultimately interpenetrates the
GI matrix
(3) Occurs in resin-modified GI materials and compomers
3. Manipulation
a. Self-curing materials—powder and liquid components may be
manually mixed or may be precapsulated for mechanical mixing;
light-curing materials—directly placed from a syringe or a
unidose tip
b. Placement—mixture is normally placed by using a syringe
c. Finishing—can be immediate if the system is resin modified or
is a compomer system (but otherwise must be delayed 24 to 72
hours until aluminum ion replacement reaction is complete)
d. Sealing—the resin sealer is applied to smooth the surface (and
to protect against moisture affecting the GI reaction)
C. Properties
1. Physical
a. Good thermal and electrical insulation
b. Better radiopacity than with most composites

1098
 c. Linear coefficient of thermal expansion and contraction is closer
to that of the tooth structure than that of composites (but is less
well matched for resin-modified and compomer systems)
d. The esthetics of resin-modified and compomer systems is not
quite as good as those of most composites
2. Chemical
a. Reactive acid side groups of co-polymer molecules produce
chemical bonding to the tooth structure
b. Fluoride ions are released
(1) Rapid release at first because of excess fluoride ions in the
matrix
(2) Slow release after 7 to 30 days because of slow diffusion of
fluoride ions out of aluminosilicate particles (Fig. 13-12)

FIG 13-12 A, Fluoride ion release from glass ionomer.

Diffusion from cement. B, Fluoride concentration released
over time. (From Bayne SC, Thompson JY: Biomaterials. In Roberson
TM, Heymann HO, Swift EJ, editors: Sturdevant’s art and science of
operative dentistry, ed 5, St Louis, 2006, Mosby.)

(3) Presence of fluoride in topical fluorides and fluoride-

containing toothpastes may recharge the fluoride content in
the cement matrix temporarily for 2 to 3 days
c. The solubility resistance of resin-modified systems is close to
that of composites

1099
 3. Mechanical
a. Compressive strength of resin-modified systems and
compomers is much better than that of conventional glass
ionomers but not quite as strong as that of composites
b. Glass ionomers are more brittle than are composites
4. Biologic
a. Ingredients are biologically compatible with pulp
b. Fluoride ion release may reduce the incidence and severity of
secondary caries (Fig. 13-12), but no definitive clinical research
studies exist

Topical Fluorides and Fluoride Varnishes

A. General considerations (see the section on “Fluoride Agents for
Professional Application” in Chapter 16)
1. Applications—used to prevent smooth-surface caries
2. Classification
a. Acidulated phosphate fluoride (APF) gels (acid pH)
b. Neutral fluoride gels (sodium fluoride at neutral pH)
c. Fluoride varnishes (5% sodium fluoride, 2.26% fluoride,
22,600 ppm fluoride)
B. Structure for APF
1. Composition
a. Acidulated phosphate fluoride
(1) Fluoride ion concentration ranges from 1.22% to 1.32%
(2) Ingredients—2% sodium fluoride, 0.34% hydrogen
fluoride, 0.98% orthophosphoric acid, thickening agent,
flavoring agent, coloring agent, and aqueous gel
(3) pH ranges from 3 to 4; may dissolve glass in restorations,
thus those surfaces must be protected
b. Neutral fluoride gels
c. Fluoride varnishes—fluoride source mixed with urethane or
other resin and dissolved in solvent
2. Reactions
a. APF—acid demineralization of the outer layer of enamel;
fluoride accelerates the remineralization of demineralized
enamel; fluoride ions are incorporated to produce fluoride-
substituted hydroxyapatite
b. Neutral fluoride gels—form fluoride salts on surfaces of teeth
c. Fluoride varnishes—provide temporary film to allow longer-
term fluoride diffusion from varnish into enamel

1100
 3. Manipulation
a. Gels are applied in a soft, spongy tray after extrinsic stain
removal; teeth should be free from saliva; maxillary and
mandibular trays are loaded, placed in position, and squeezed
to mold the trays tightly around teeth; the tray is held in
position for 4 minutes (shorter applications are not effective);
the client is told not to eat, smoke, or drink for 30 minutes
b. Varnishes are painted onto all tooth surfaces; wear away after
several hours
C. Properties
1. Chemical—enamel solubility is decreased by fluoride ion
incorporation
2. Biologic—enamel is more resistant to carious dissolution

Dentifrices and Prophylactic Pastes

A. General considerations
1. Cleansing—removal of exogenous stains, pellicle, materia alba, and
other oral debris without causing undue abrasion to tooth structure
2. Polishing—smoothing surfaces (without significant abrasion) of
amalgam, composites, glass ionomers, ceramic, and other restorative
materials
3. Factors influencing cleaning and polishing
a. Hardness of abrasive particles versus that of the substrate (see
Tables 13-1 and 13-2)
b. Particle size of abrasive particles
c. Pressure applied during procedure
d. Temperature of abrasive materials
e. Speed of the rotating instrument used (easiest factor to control)
B. Structure
1. Composition—contain abrasives, such as kaolinite, silicon dioxide,
calcined magnesium silicate, diatomaceous silicon dioxide, pumice,
sodium-potassium–aluminum silicate, and zirconium silicate; some
pastes also may contain sodium fluoride or stannous fluoride, but
they have not been shown to produce therapeutic effects
2. Reactions—abrasion for cleansing and polishing
3. Manipulation (see the earlier section on “Properties,” B. Mechanical
properties, Principles of cutting, polishing, and surface cleaning)
C. Properties
1. Mechanical
a. Products with pumice and quartz enable more efficient

1101
 cleansing but also generate greater abrasion of enamel and
dentin
b. Coarse pumice is the most abrasive
c. Dentin is abraded five to six times faster than enamel,
regardless of the product used, and cementum is abraded even
more quickly than is dentin
d. Polymeric restorative materials such as denture bases, denture
teeth, composites, and composite veneers can easily be
scratched during polishing
e. Ceramic restorations that are externally characterized should
not be polished, or the surface color will be lost
2. Biologic—no known problems

Whitening Agents
A. General considerations
1. Lighten discolored teeth
2. Classification by:
a. Site of application
(1) External—applied to the tooth surface
(2) Internal—applied inside the pulpless (endodontically
treated) tooth
b. Method of application
(1) In-office—applied professionally
(2) At-home—dispensed by the dentist or obtained over the
counter (OTC) and applied by the client
B. Structure
1. In-office systems use light, heat, or both to “activate” a high
concentration (up to 30% to 39%) hydrogen peroxide gel or paste,
but little evidence that light or heat provides any benefit
2. At-home systems typically use a 10% carbamide peroxide (equivalent
to 3.4% hydrogen peroxide) or higher (15% to 20% carbamide
peroxide) concentration that is applied in a custom-fitted,
mouthguard-type, soft-plastic tray
3. New systems use thin polyethylene strips impregnated with 5.3%
hydrogen peroxide (OTC) and 14% hydrogen peroxide (office
dispensed)
C. Properties
1. The effectiveness of whitening depends on application time and
dose
2. In-office whitening can provide faster results but is more expensive

1102
 than at-home bleaching
3. Yellow-colored teeth bleach more rapidly than do gray-colored teeth
4. Tetracycline-stained teeth whiten very slowly (several months of
daily at-home treatment needed) or not at all
5. Most common side effects are tooth sensitivity and gingival
irritation; both are transient

1103
Indirect preventive and restorative
materials
Impression Materials
A. General considerations
1. Applications
a. Dentulous impressions
(1) For casts in prosthodontics
(2) For pediatric and orthodontic appliances
(3) For study models in orthodontics
b. Edentulous impressions for casts in denture construction
2. Terminology
a. Rigid—inflexible and cannot be removed from undercut area
b. Flexible—can be removed from undercut area
c. Hydrocolloid—gel produced by interconnection of small
particles (colloid, less than 1 µm) dispersed in water
d. Elastomeric—based on flexible polymeric material
3. Classification
a. Rigid impression materials (very limited use)
(1) Plaster
(2) Compound
(3) Zinc oxide–eugenol
b. Flexible hydrocolloid impression materials
(1) Agar-agar (reversible hydrocolloid [limited use])
(2) Alginate (irreversible hydrocolloid)
c. Flexible, elastomeric, general-purpose impression materials
(1) Polysulfide elastomer (mercaptan rubber [limited use])
(2) Silicone elastomer (condensation silicone [laboratory use])
(3) Polyether (PE) elastomer
(4) Polyvinyl siloxane (PVS) (addition silicone)
(5) PE-PVS hybrid
d. Precision impression materials used for prosthodontics
(1) Addition silicones—contain surfactants to make surface
wetting easier
(2) Polyethers—more hydrophilic
B. Structure
1. Components (Table 13-3)

1104
 Table 13-3
Impression Materials

a. Most contain fillers to control shrinkage

b. Matrix
2. Reaction (Table 13-3)
a. Physical reaction—cooling causes reversible hardening
b. Chemical reaction—irreversible reaction during setting
3. Manipulation
a. Mixing
(1) Powder-liquid (P/L) types mixed in bowl (plaster and
alginate)
(2) Thermoplastic materials not mixed (compound and agar-
agar)
(3) Hand-mix—paste-paste (p/p) types are hand-mixed on a
pad (ZOE, polysulfide rubber, silicone rubber, PE rubber,
and PVS)
(4) Auto-mix—p/p types are mixed through a disposable
nozzle on an auto-mixing gun (PVS, PE)
(5) Machine-mix—components mixed and extruded through a
disposable nozzle using small machine (e.g., Dynamix
speed, Pentamix 3)
b. Placement
(1) Mixed material—carried in a tray to the mouth (full arch,
quadrant, or triple tray)
(2) The material sets in the mouth more quickly because of
higher temperature
c. Removal—rapid removal of the impression encourages
deformation to take place elastically rather than permanently

1105
 (elastic recovery requires approximately 20 minutes)
d. Cleaning and disinfection of impressions (see the section on
“Maintaining the Treatment Area During Client Care” in
Chapter 10)
e. Problems—PVS may be inhibited from bonding at the surface of
the preparation wall by the bonding agent and also may be
dissolved by subsequent infection control solutions;
components from latex gloves can contaminate the impression

Provisional Materials
A. General considerations
1. Applications
a. While waiting for laboratory fabrication of cast restoration
b. While observing the reaction of pulp tissue
2. Terminology
a. Temporary—provisional or nonpermanent; range of use is 2 to
52 weeks
b. Short-term use—2 to 6 weeks
c. Longer-term use—6 to 52 weeks
d. Provisional materials—usually include both provisional
restoration and provisional cement
e. Direct—set intraorally (in situ)
f. Indirect—set out of the mouth
3. Objectives
a. Physiologic objectives—protection of hard and soft tissues,
pulpal protection, delivery of medication, stabilization of tooth,
provision of function for chewing, patient comfort
b. Esthetic objectives—short-term resistance to staining
c. Clinical objectives—ease of use, low cost, ease of repair, low
polymerization exotherm, minimal surface reactions on curing,
absence of sensitivity reactions
d. Material performance objectives—fracture resistance, wear
resistance
4. Classification
a. Provisional resins
b. Temporary or provisional cements
B. Structure
1. Components
a. Provisional restorations
(1) ZOE cement, with cotton fibers

1106
 (2) Acrylic P/L products
(3) Bis-acryl and bis-methacryl resin products
b. Provisional cements
(1) ZOE-based cements
(2) Calcium hydroxide cements
(3) Admix cements (cements mixed with petroleum jelly)
(4) Composite cements (without bonding systems)
2. Reaction (see the sections on “Dental Composites” and “Cement
Liners”)
3. Manipulation (see “Dental Composites” and “Cement Liners”)
C. Properties
1. Physical
a. Excellent thermal and electrical insulation
b. Percolation resistance is good for cements but poor for resins
2. Chemical—generally good resistance to dissolution
3. Mechanical
a. Good short-term resistance to fracture
b. Poor resistance to abrasion
c. Limited color stability and stain resistance
4. Biologic—cements are biocompatible, but resins with low-molecular-
weight monomers may cause pulpal inflammation if cured in situ
without caution

Model, Cast, and Die Materials

A. General considerations
1. Applications
a. Gold casting, ceramic, and porcelain-fused-to-metal veneer
fabrication procedures
b. Orthodontic and pediatric appliance construction
c. Study models for occlusal records
2. Terminology
a. Models—replicas of hard and soft tissues for study of dental
symmetry
b. Casts—working replicas of hard and soft tissues for use in the
fabrication of appliances or restorations
c. Dies—working replicas of one tooth (or a few teeth) used for the
fabrication of a restoration
d. Duplicates—second casts prepared from original casts
3. Classification by materials
a. Models (model plaster, orthodontic stone, or printed resin)

1107
 b. Casts (regular stone or printed resin)
c. Dies—may be electroplated (very limited use)
(1) Diestone—gypsum product
(2) Epoxy dies—epoxy polymer; abrasion-resistant dies
(3) Printed resin—produced from digital files using 3-D
printer
B. Structure of gypsum products
1. Components (Table 13-4)

Table 13-4
Gypsum Products

a. Powder (calcium sulfate hemihydrate = β-CaSO4 × ½ H2O)

b. Water (for mixing and reacting with powder)
2. Reaction
a. Calcium sulfate hemihydrate (one-half mole of water) crystals
dissolve and react with water
b. Calcium sulfate dihydrate (two moles of water) form and
precipitate new crystals
c. Unreacted (excess) water is left between crystals and slowly
evaporates
3. Manipulation of gypsum products
a. Selection—based on strength for models, casts, or dies
b. Mixing
(1) Appropriate proportions of water and powder are
dispensed (Table 13-4)
(2) The powder is sifted into the water in a rubber mixing
bowl
(3) A stiff-bladed spatula is used to mix the mass on the side
of the bowl

1108
 (4) The mixing is completed in 60 seconds
c. Placement
(1) Vibration is used to remove air bubbles created through
mixing
(2) Vibration is used to keep the mixture wet and help it flow
into the impression
C. Properties of gypsum products
1. Physical
a. Excellent thermal and electrical insulator
b. Dense
c. Excellent dimensional accuracy (setting expansion)
(1) Plaster: 0.20%
(2) Stone: 0.10%
(3) Diestone: 0.05%
(4) High-expansion diestone: 0.20% (for all-ceramic restoration
fabrication)
d. Good reproduction of fine detail of hard and soft tissues
2. Chemical
a. Heating will reverse the reaction, that is, decompose the
material into calcium sulfate hemihydrate, the original dry
component
b. Models, casts, and dies should be wet during the grinding or
cutting to prevent heating
3. Mechanical
a. Better powder packing and lower water content at mixing lead to
higher compressive strengths (plaster < stone < diestone)
b. Poor resistance to abrasion (polymer added to improve
resistance)
4. Biologic
a. Materials are safe for contact with external epithelial tissues
b. Masks should be worn during grinding or polishing operations,
which are likely to produce gypsum dust
D. Printed resin—produced from digital files using 3-D printer

Waxes
A. General considerations
1. Applications
a. Making impressions
b. Registering of tooth or soft tissue position
c. Creating restorative patterns for laboratory fabrication

1109
 d. Aiding in laboratory procedures
2. Terminology
a. Inlay wax—used to create a pattern for inlay, onlay, or crown for
subsequent investing and casting in a metal alloy
b. Casting wax—used to create a pattern for metallic framework
for removable partial dentures
c. Baseplate wax—used to establish the vertical dimension, plane
of occlusion, and initial arch form of a complete denture
d. Corrective impression wax—used to form a registration pattern
of soft tissues on an impression
e. Bite registration wax—used to form a registration pattern for the
occlusion of opposing models or casts
f. Boxing wax—used to form a box around an impression before
pouring a model or cast
g. Utility wax—soft, pliable adhesive wax for modifying appliances,
such as alginate impression trays
h. Sticky wax—sticky when melted and used to temporarily adhere
pieces of metal or resin in laboratory procedures
i. Printed wax—produced from digital files using 3-D printer
3. Classification
a. Pattern waxes—inlay, casting, and baseplate waxes
b. Impression waxes—corrective and bite registration waxes
c. Processing waxes—boxing, utility, and sticky waxes
B. Structure
1. Components
a. Base waxes—hydrocarbon (paraffin) or ester waxes
b. Modifier waxes—carnauba, ceresin, beeswax, rosin, gum
dammar, or microcrystalline waxes
c. Additives—colorants
2. Reaction—waxes are thermoplastic (soften on heating, harden on
cooling)
C. Properties
1. Physical
a. High coefficients of thermal expansion and contraction
b. Insulators (cool unevenly); should be placed in increments to
allow heat dissipation
2. Chemical
a. Degrade prematurely if overheated
b. Designed to degrade into CO2 and H2O during burnout for inlay
waxes
3. Mechanical—stiffness, hardness, and strength depend on modifier

1110
 waxes used and on temperature

Investment Materials
A. General considerations
1. Applications
a. Mold-making materials for casting alloys or castable ceramics to
facilitate the creation of oversize mold space to compensate for
shrinkage during cooling of casting alloy
b. Mold-making materials for denture production
2. Terminology—investment refers to the mold-making material
3. Classification
a. Gypsum-bonded investment (GBI)—based on gypsum products
for matrix
b. Phosphate-bonded investment (PBI)
c. Silicate-bonded investment (SBI)
d. Specialty investments—for glass ceramics, titanium alloys, and
other specialized fabrication procedures
B. Structure—66% filler, 33% binder (matrix forms on setting), 1%
modifiers
1. Components
a. Liquid—water or other reactant starts the formation of the
matrix binder by reacting with the powder
b. Powder—reactant powder, filler, or modifiers
2. Reactions and mold expansion
a. Setting expansion while material reacts, forming crystals that
push on each other
b. Hygroscopic expansion while setting mold placed under water
c. Thermal expansion during heating of mold to casting
temperature
d. Filler expansion caused by the inversion of crystalline lattice
during heating
3. Manipulation
a. P/L is mixed and placed in a container around the wax pattern
b. After setting, the investment is heated to eliminate the wax
pattern in preparation for casting

Casting Alloys
A. General considerations
1. Applications—inlays, onlays, crowns, and bridges

1111
 2. Terminology
a. Precious (metals)—based primarily on valuable elements (Au,
Pt, Pd, Ag, Ir, Rh, Rd)
b. Noble or immune—corrosion-resistant element or alloy
c. Base or active—corrosion-prone alloy
d. Passive—corrosion resistant because of surface oxide film
(passivation is prevention of corrosion by formation of a thin,
adherent oxide film on metal surface, which acts as a barrier to
further oxidation)
e. Purity by weight (99.99% = “4 nines pure”)
f. Karat (24 karat is 100% gold; 18 karat is 75% gold)
g. Fineness (1000 fineness is 100% gold; 500 fineness is 50% gold)
3. Classification
a. High-gold alloys are greater than 75% wt gold or other noble
metals (= 50% atoms that are immune)
(1) ADA type I alloys are 83% wt noble metals (e.g., in simple
inlays)
(2) ADA type II are ≥ 78% wt noble metals (e.g., in inlays and
onlays)
(3) ADA type III are ≥ 75% wt noble metals (e.g., in crowns
and bridges)
(4) ADA type IV are ≥ 75% wt noble metals (e.g., in partial
dentures)
b. Medium-gold alloys are 25% wt to 75% wt gold or other noble
metals
c. Low-gold alloys are less than 25% wt gold or other noble metals
d. Gold-substitute alloys do not contain gold
(1) Palladium-silver alloys—passive because of mixed oxide
film
(2) Cobalt-chromium or nickel-chromium alloys—passive
because of Cr2O3 oxide film
e. Titanium alloys are based on 90% to 100% titanium; passive
because of TiO2 oxide film
B. Structure
1. Components of gold alloys
a. Gold contributes to corrosion resistance
b. Copper contributes to hardness and strength
c. Silver counteracts orange color of copper
d. Palladium increases melting point and hardness
e. Platinum increases melting point

1112
 f. Zinc acts as oxygen scavenger during casting
2. Manipulation
a. Heated to just beyond melting temperature for casting
b. Cooling shrinkage causes substantial contraction
C. Properties
1. Physical
a. Electrical and thermal conductors
b. Relatively low coefficient of thermal expansion
2. Chemical
a. Silver content affects susceptibility to tarnish
b. Corrosion resistance is attributed to high noble metal content
or passivation
3. Mechanical
a. High tensile and compressive strengths but relatively weak in
thin sections such as margins; can be deformed relatively easily
b. Good wear resistance except in contact with ceramic

Dental Solders
A. General considerations
1. Applications—fabrication of cast bridges and metallic orthodontic
appliances
2. Terminology
a. Soldering—joining using filler metal that melts below 500°C
b. Brazing—joining using filler metal that melts above 500°C
c. Welding—melting and alloying of pieces to be joined
d. Fluxing
(1) Oxidative cleaning of area to be soldered
(2) Oxygen scavenging to prevent oxidation of alloy being
soldered
e. Numerical terminology: 16 to 650 = 650 fineness solder to be
used with 16-karat alloys; fineness refers to the gold or other
precious metal content
3. Classification
a. Gold solders—bridges
b. Silver solders—gold-substitute bridges and orthodontic alloys
B. Structure of gold solders
1. Composition—lower gold content than of alloys being soldered
2. Manipulation—solder must melt below melting temperature of alloy
C. Properties
1. Physical—similar to alloys being joined

1113
 2. Chemical—more prone to chemical and electrochemical corrosion
3. Mechanical—similar to alloys being joined but weaker
4. Biologic—similar to alloys being joined

Chromium Alloys for Partial Dentures

A. General considerations
1. Applications—casting partial denture metal frameworks
2. Classification
a. Cobalt-chromium
b. Nickel-chromium
B. Structure
1. Composition
a. Chromium—produces a passivating oxide film for corrosion
resistance
b. Cobalt—increases the rigidity of the alloy
c. Other elements—increase strength and castability
2. Manipulation
a. Require higher temperature investment materials (PBI or SBI)
b. More difficult to cast because less dense than gold alloys;
usually require special casting equipment
c. Much more difficult to finish and polish because of higher
strength and hardness
C. Properties
1. Physical—less dense than gold alloys
2. Chemical—passivating corrosion behavior
3. Mechanical—stronger, stiffer, and harder than gold alloys
4. Biologic
a. Nickel may cause sensitivity in some individuals (approximately
6% of men, and 11% to 24% of women)
b. Beryllium in some alloys forms oxide that is toxic, which is a
significant problem for dental laboratory technicians if grinding
dust is inhaled

Porcelain-Fused-to-Metal Alloys
A. General considerations
1. Applications—substructures for porcelain-fused-to-metal (PFM)
crowns and bridges
2. Classification
a. High-gold alloys

1114
 b. Palladium-silver alloys
c. Cobalt-chromium alloys
B. Structure
1. Composition
a. High-gold alloys are 98% gold, platinum, palladium, or both
b. Palladium-silver alloys are 50% to 60% palladium and 30% to
40% silver
c. Chromium-cobalt alloys are 60% to 65% chromium and 25% to
30% cobalt, with other metals
2. Manipulation
a. Must have melting temperatures above that of porcelains (low-
fusing porcelains) that will be fabricated onto their surfaces
b. More difficult to cast (see the previous section on “Chromium
Alloys for Partial Dentures”)
C. Properties
1. Physical
a. Except for high-gold alloys; others are less dense alloys
b. Alloys are designed to have low thermal expansion coefficients
that must be matched to the veneering porcelain
2. Chemical—high-gold alloys are immune to corrosion; others
passivate
3. Mechanical—high modulus and hardness
4. Biologic—biologically acceptable if they do not corrode

Dental Ceramics
A. General considerations
1. Applications
a. Veneering material for PFM crowns and bridges
b. All-ceramic, high-strength inlays, onlays, crowns, and bridges
c. Denture teeth
2. Terminology
a. Ceramic—any inorganic material containing metallic and
nonmetallic elements, generally formed at a high temperature
b. Porcelain—ceramic composition based primarily on silica,
alumina, and potassium oxide; created by mixing clay, feldspar,
and quartz, and then heating
c. PFM restoration—metal-based coping (substructure) coated
with a porcelain veneer
d. All-ceramic—inlay, onlay, crown, bridge, or veneer made entirely
of ceramic

1115
 e. Fusing—coalescence of packed layer of particles into a single
porcelain mass
f. High-strength ceramics—ceramics that include one or more
phases or strengthening mechanisms to make the composition
mechanically more crack resistant than conventional porcelains
g. Glass-ceramics—initially noncrystalline (glassy) ceramics from
which some crystalline phase is precipitated for strengthening
h. Glass-infiltrated ceramic—partially sintered ceramic particles
that are infused with a glassy matrix (e.g., InCeram)
3. Classification
a. Feldspathic porcelains—produced by traditional laboratory
fabrication with porcelain particles painted into position as a
water slurry (condensed) and then heated for particle
coalescence (sintered)
(1) High-fusing porcelains—for denture teeth
(2) Medium-fusing porcelains—for jacket crowns; not
commonly used
(3) Low-fusing porcelains—veneering material for PFM
restorations
b. High-strength ceramics—produced by specialized laboratory
fabrication technique
(1) Lucite-reinforced porcelains—pressure molded
(2) Alumina-reinforced porcelains
(3) High-density alumina core materials
(4) Infiltrated materials—glass or resin infiltrated
(5) Hydroxyapatite-based materials
c. Glass-ceramics
(1) Mica-based glass-ceramics—used as starting blanks for
CAD/CAM restorations
(2) High-strength glass-ceramic core materials, such as
lithium disilicate or lithium silicate glass-ceramic
d. High-strength crystalline single-phase materials
(1) Alumina
(2) Zirconia (yttria-stabilized tetragonal zirconia)
B. Porcelain structure
1. Components
a. Large number of oxides—principally silicon oxide (silica),
aluminum oxide (alumina), and potassium oxide, created by
combining clay, feldspar, and quartz raw materials
b. Minor oxides contribute properties of opacity, translucency, and
color

1116
 2. Manipulation
a. Traditional porcelain fabrication
(1) Porcelain powder mixed with water, padded onto
substrate, compacted, and heated to produce coalescence
with shrinkage
(2) Shrinkage is approximately 30% on firing (sintering); thus
porcelain layer must be made oversized and built up by
several stages of application
b. Special ceramic laboratory fabrication procedures—require
specialized equipment and furnaces
c. Milling—requires specialized equipment
C. Properties
1. Physical
a. Excellent electrical and thermal insulation
b. Low coefficient of thermal expansion and contraction
c. Good color and translucency; excellent esthetics (superior to all
other materials)
2. Chemical
a. Not resistant to fluorine-containing acids and can be dissolved
by contact with APF topical fluoride treatments
b. Can be acid-etched with hydrofluoric acid or other strong acids
for providing micromechanical retention for cements
3. Mechanical
a. Harder than tooth structure and will cause opponent wear,
although some glass-ceramics are comparable in hardness to
enamel
b. Can be polished with diamond pastes
c. Poor fatigue behavior of glasses when compared with metal
alloys
4. Biologic—relatively inert

Crown-and-Bridge Cements
A. General considerations (Table 13-5)

1117
Table 13-5
Luting Cements

* Principal cements in use today.

1. Applications
a. Luting inlays, onlays, crowns, and bridges
b. Luting orthodontic bands and brackets
2. Terminology—luting: attachment by gross mechanical
interdigitation with crown and tooth surfaces
3. Classification
a. Traditional cements (typically P + L) (rarely used)—zinc oxide–
eugenol (ZOE) and zinc phosphate (ZP)
b. Polymeric cements (typically precapsulated or paste-paste)—
polycarboxylate (PC), glass ionomer (GI), resin-modified glass
ionomer (RMGI), resin or composite (CC), and universal cement
(UC)
B. Structure
1. Components (see Table 13-5)
a. Traditional cements—powder (reactant; chemically basic); liquid
(reactant; chemically acidic)
b. Polymeric cements—polymer cross-linking reaction (PC, GI),
polymerization reaction (RMGI, CC, UC), or both
2. Reaction
a. Traditional cements—acid-base reaction that forms salt; great
excess of powder leaves residual powder as filler
b. Polymeric cements—setting produced by cross-linking reactions
similar to GI or composite setting reactions

1118
 3. Manipulation
a. Traditional cements—all reactions are exothermic; reaction
controlled by chilling components, chilling mixing slab, or
incrementally adding powder to the liquid
b. Polymeric cements—powder is added to liquid as quickly as
possible to complete mixing in 30 seconds or mixed in
triturators and used quickly; may include preplacement of
bonding system as well; paste-paste systems are dispensed
using auto-mix syringes
C. Properties
1. Physical properties
a. All luting cements are electrical and thermal insulators
b. All luting cements have low coefficients of thermal expansion
and contraction
2. Chemical properties
a. In acidic environments, cements tend to disintegrate
b. PC and GI cements will adhere chemically to calcium ions on
the surface of tooth structure and to oxides contained within the
set cements
c. PC and GI are most resistant to microleakage
d. GI cements release fluoride ions (and most PC cements initially
release fluoride because of small CaF2 contents included as
mixing aids)
3. Mechanical properties—compressive strength; composite has the
highest compressive strength, and ZOE has the lowest
4. Biologic properties
a. Eugenol-based cements produce obtundent (pain-soothing)
effects
b. PC and GI cements are most gentle to the dental pulp (when
manipulated correctly)

Acrylic Appliances
A. General considerations
1. Application—space maintenance and tooth movement for
orthodontics and pediatric dentistry
2. Classification—none
B. Structure
1. Components
a. Powder—PMMA (polymethylmethacrylate) powder, peroxide
initiator, and pigments

1119
 b. Liquid—MMA (methylmethacrylate) monomer, hydroquinone
inhibitor, cross-linking agents, and chemical accelerators (N, N-
dimethyl-p-toluidine)
2. Reaction
a. The PMMA powder makes mixture viscous for manipulation
before curing
b. Chemical accelerators cause the decomposition of benzoyl
peroxide into free radicals that initiate the polymerization of the
monomer
c. New PMMA is formed as a matrix that surrounds the PMMA
powder
d. Linear shrinkage of 5% to 7% during setting, but dimensions of
appliances are not critical
3. Manipulation
a. The mixture of powder and liquid is painted onto the working
cast to create the shape for the acrylic appliance
b. Orthodontic wires may be part of the appliance
c. After curing the mixture, the shape and fit are adjusted by
grinding with burrs and stones, with a slow-speed handpiece
(1) Caution—acrylic dust is irritating to epithelial tissues of
nasopharynx and skin and may produce allergic dermatitis
or other reactions
(2) Grinding may heat the polymer to temperatures that
depolymerize and release monomer vapor, which may be an
irritant
C. Properties (see “Acrylic Denture Bases”)
1. Physical
2. Chemical—may contain 2% to 3% unreacted monomer that can
cause soft tissue irritation in approximately 4% of the population
3. Mechanical
4. Biologic

Acrylic Denture Bases

A. General considerations
1. Application—used to support artificial teeth
2. Classification
a. PMMA/MMA dough systems
b. PMMA/MMA injected-resin systems
c. PMMA/MMA pour resins
d. UDMA VLC resins

1120
B. Structure of PMMA/MMA types
1. Components
a. Powder—PMMA polymer, peroxide initiator, and pigments
b. Liquid—MMA monomer, hydroquinone inhibitor, and cross-
linking agents
2. Reaction
a. Heat (or chemicals) used as an accelerator to decompose
peroxide into free radicals
b. Free radicals initiate polymerization of MMA into PMMA
c. New PMMA is formed as a matrix around residual PMMA
powder particles
d. Linear shrinkage—5% to 7% of monomer on polymerization;
reduced by processing procedures
3. Manipulation
a. P/L mixed to form dough or fluid resin to fill mold
b. Mold heated to start and control reaction
C. Properties
1. Physical
a. Thermal insulator—prevents the patient’s sensations of food
temperature
b. High coefficient of thermal expansion and contraction
c. Poor distortion resistance at higher temperatures; therefore,
dentures should not be cleaned in hot water
d. Good resistance to color change
2. Chemical
a. Stored in water before delivery to reach equilibrium absorption
level
b. Absorbs water and must be kept hydrated
c. Not resistant to strong oxidizing agents
3. Mechanical
a. Low strength, but flexible; good fatigue resistance
b. Poor scratch resistance; clean tissue-bearing surfaces of denture
with soft brush, and do not use abrasive cleaners
4. Biologic—occasional allergic reactions to minute residual monomer
have been reported in newly processed dentures

Denture Teeth
A. General considerations
1. Applications—complete or partial dentures
2. Classification

1121
 a. Porcelain teeth
b. Acrylic resin teeth—95% of all denture teeth
c. Abrasion-resistant teeth—composite veneered and
interpenetrating network (IPN) teeth
B. Structure and properties
1. Porcelain teeth (high-fusing porcelain)
a. Bonded into denture base mechanically
b. Harder than natural teeth or other restorations and are capable
of abrading those surfaces
c. Good esthetic appearance
d. Used when clients have good ridge support and sufficient room
between the arches
2. Acrylic resin teeth—PMMA
a. Bonded pseudo-chemically into the denture base; teeth are
wetted with monomer before forming denture base
b. Soft and easily worn by abrasive foods
c. Good initial esthetics
d. Used for clients with poor ridges and those who are opposed to
natural teeth
3. Abrasion-resistant teeth (composite veneered)
a. Bonded pseudo-chemically into the denture base
b. Much better abrasion resistance than acrylic resin teeth but
poorer bonding

Denture Soft Liners

A. General considerations
1. Applications—for clients with soft tissue irritation
2. Classification
a. Long-term liners (soft liners)—used over months for patients
with severe undercuts or continually sore residual ridges
b. Short-term liners (tissue conditioners)—used to facilitate tissue
healing over several days
B. Structure
1. Soft liners—plasticized acrylic co-polymers or silicone rubber
2. Tissue conditioners—PEMA (polyethylmethacrylate) plasticized with
ethanol and aromatic esters
C. Properties
1. Liners flow under low pressure, allowing adaptation to soft tissues,
but are elastic during chewing forces
2. Low initial hardness, but the liner becomes harder as plasticizers are

1122
 leached out during intraoral use
3. Some silicone rubber liners support the growth of yeasts

Denture Cleansers
A. General considerations
1. Applications—for removal of soft debris by light brushing and then
rinsing of denture; hard deposits require professional repolishing
2. Classification
a. Alkaline perborates—do not remove bad stains; may harm
liners
b. Alkaline hypochlorites—may cause bleaching, corrode base-
metal alloys, and leave residual taste on appliance
c. Dilute acids—may corrode base-metal alloys
d. Abrasive powders and creams—can abrade denture surfaces
3. Techniques recommended for denture cleaning
a. Full dentures without soft liners—immerse denture in solution
of one part 5% sodium hypochlorite (Clorox) and three parts
water
b. Full or partial dentures without soft liners—immerse denture in
solution of 1 tsp of sodium hypochlorite (Clorox) and 2 tsp of
glassy phosphate (Calgon) in a half glass of water
c. Lined dentures—clean any soft liner with a cotton swab and cold
water; clean the denture with a soft brush
B. Properties
1. Chemical—cleansers can swell plastic surfaces or corrode metal
frameworks
2. Mechanical—cleansers can scratch the surfaces of denture bases or
denture teeth

Mouth Protectors (Athletic Mouthguards)

A. General considerations
1. Applications—to protect against blows to the chin, the top of the
head, and the face or to prevent grinding of teeth; typically used by
football, basketball, soccer, and hockey players (contact sports)
2. Terminology—mouth protectors, teeth protectors, or athletic
mouthguards
3. Classification
a. Stock protectors—least desirable because of poor fit
b. Mouth-formed protectors (“boil-and-bite”)—made by client;

1123
 improved fit compared with stock type
c. Custom-made protectors—fabrication by dentist is preferred
because of durability, low levels of speech impairment, and
comfort
B. Structure
1. Components
a. Stock protectors—thermoplastic co-polymer of polyvinyl
acetate–polyethylene (PVA-PE)
b. Mouth-formed protectors—thermoplastic co-polymer
c. Custom-made protectors—thermoplastic co-polymer or
polyurethane
2. Reaction—hardening during cooling
3. Fabrication
a. Alginate impression made of maxillary arch
b. High-strength stone cast poured immediately
c. Thermoplastic material is heated in hot water and vacuum-
molded to cast
d. Mouth protector trimmed to within 2 mm of labial fold,
clearance provided at the buccal and labial frena, and edges
smoothed by flaming
e. Gagging, taste, irritation, and impairment of speech are
minimized with properly fabricated mouth protector
4. Instructions for use—client must:
a. Rinse before and after use with cold water
b. Clean protector occasionally with soap and cool water
c. Store the protector in a rigid container
d. Protect the protector from heat and pressure during storage
e. Evaluate the protector routinely for evidence of deterioration
C. Properties
1. Physical—thermal insulators
2. Chemical—absorbs water and stains during use
3. Mechanical—tensile strength, modulus, and hardness decrease after
water absorption, but elongation, tear strength, and resilience
increase
4. Biologic—nontoxic as long as no bacterial, fungal, or viral growth
occurs on surfaces between uses

Veneers
A. General considerations
1. Applications—generally anterior maxillary teeth

1124
 2. Terminology
a. Extracoronal—bonded over existing enamel, that is, no tooth
preparation
b. Intracoronal—bonded into an intraenamel cavity preparation
3. Classification by materials
a. Direct composite veneer
b. Indirect composite veneer (laboratory processed)
c. Ceramic veneer (stacked or pressed ceramic)
d. CAD/CAM ceramic veneer
B. Structure
1. Components—composite, porcelain, or ceramic
2. Manipulation
a. Bonding—enamel etching and bonding
b. Finishing and polishing must be done with care to avoid
scratching the surfaces
3. Maintenance
a. Polishing with abrasive materials or scaling with metal
instruments must be avoided
b. The protector must be protected with petroleum jelly during
topical acidulated phosphate fluoride (APF) treatments, or
neutral sodium fluoride must be used
C. Properties
1. Physical—good esthetic appearance; but some coloring may occur
because of the composite resin cement used for bonding the veneer
2. Chemical
a. Composite veneers have good acid resistance
b. Ceramic and CAD/CAM veneers should be protected from APF
or other acids
3. Mechanical
a. Composite veneers are subject to scratching
b. Ceramic and CAD/CAM veneers have good abrasion resistance
4. Biologic—no known problems

CAD/CAM Restorations
A. General considerations
1. Applications—inlays, onlays, veneers, crowns, bridges, implants,
and implant prostheses
2. Stages of fabrication of CAD/CAM restorations
a. Scanning—computerized surface digitization; acquisition of
surface contours and geometry, can be intraoral or scanning of

1125
 impressions
b. CAD—computer-aided (assisted) design; digital design of
restoration
c. CAM—computer-aided (assisted) machining; fabrication of
restoration from block of material
3. Classification
a. Chairside or in-office CAD/CAM systems
b. Laboratory CAD/CAM systems
c. Examples of CAD/CAM systems in dentistry
(1) CEREC (Sirona Dental Systems)
(2) E4D Dentist (E4D Technologies)
B. Structure
1. Materials
a. Feldspathic porcelains (Vita Mark II, ProCAD)
b. Machinable leucite-reinforced ceramic (IPS Empress CAD)
c. Machinable lithium disilicate (IPS e.Max CAD) and lithium
silicate (Obsidian)
d. Machinable high-strength zirconia ceramics (BruxZir, NexxZr,
Lava Plus, IPS e.Max ZirCAD)
e. Metal alloys (limited use)
f. Composites—CeraSmart, Lava Ultimate, Enamic
2. Cementing
a. Etching enamel and dentin for micromechanical retention—use
of phosphoric acid or self-etching primer
b. Bonding agent for retention to etched surface
c. Composite as a luting cement for reacting chemically with
bonding agent and with silanated surfaces of restoration
d. Silane for wetting and chemical bonding to etched ceramic (or
metal) restorations and for co-reaction with luting composite
cement
e. Hydrofluoric acid for gel etching of silica-based ceramics or
sandblasting of zirconia to create spaces for micromechanical
retention on surface of restoration
f. Ceramic primer for zirconia
C. Properties
1. Physical properties
a. Thermal expansion coefficient well-matched to tooth structure
b. Good resistance to plaque biofilm adsorption or retention
c. Good esthetics (for shade matching)
2. Chemical properties—silica-based ceramics are not resistant to
hydrofluoric acid and should be protected from APF

1126
 3. Mechanical properties
a. Excellent wear resistance (but may abrade opposing teeth)
b. Some wear of luting cements but self- limiting
c. Excellent toothbrush abrasion resistance
d. Limited fatigue resistance caused by brittleness (low-fracture
toughness of some glass ceramics) and initiation and
propagation of cracks
4. Biologic properties—excellent compatibility with natural tissues

Dental Implants
See the sections on “Dental Implants” in Chapter 14 and “Advanced
Instrumentation Techniques” in Chapter 17
A. General considerations
1. Applications
a. Single-tooth implants
b. Abutments for bridges (freestanding, attached to natural teeth)
c. Abutments for overdentures
2. Terminology
a. Endosseous—into the bone; represents more than 90% of all
current types
b. Subperiosteal—below the periosteum but above the bone;
second most frequently used type
c. Transosteal—through the bone
d. Endodontic—through the root canal space and into the
periapical bone
e. Intramucosal—within the mucosa
3. Classification by geometric form
a. Endosteal root forms
(1) Screws
(2) Cylinders
b. Other endosteal forms
(1) Blades
(2) Staples
c. Circumferential
4. Classification by materials type
a. Metallic—titanium (majority of types; uncoated and coated),
stainless steel, and chromium-cobalt
b. Polymeric—PMMA
c. Ceramic—hydroxyapatite, zirconia
5. Classification by attachment design

1127
 a. Bioactive surface retention by osseo-integration—integration of
bone with implant; most favored type of attachment
b. Nonactive porous surfaces for micromechanical retention by
osseo-integration
c. Nonactive, nonporous surface for ankylosis by osseo-integration
d. Gross mechanical retention designs (e.g., threads, screws,
channels, or transverse holes)
e. Fibro-integration by formation of fibrous tissue capsule
f. Combinations of the above designs
B. Structure
1. Components
a. Root (for osseo-integration)
b. Neck (for epithelial attachment and percutaneous sealing)
c. Intramobile elements (for shock absorption)
d. Prosthesis (for dental form and function)
2. Manipulation
a. Selection—based on remaining bone architecture and
dimensions
b. Sterilization—RF glow discharge leaves the biomaterial surface
uncontaminated and sterile; autoclaving or chemical
sterilization contraindicated for some designs
c. Handling—must be handled with an instrument of like
composition; that is, titanium instruments used to handle
titanium implants to avoid metallic contamination and localized
electrochemical corrosion
C. Properties
1. Physical—should have low thermal and electrical conductivity
2. Chemical
a. Should be resistant to electrochemical corrosion
b. Do not expose surfaces to acids (e.g., APFs)
c. The effects of adjunctive therapies, for example, 0.12%
chlorhexidine gluconate mouth rinse must be kept in mind
3. Mechanical
a. Should be abrasion resistant and have a high modulus
b. During scaling operations, care must be taken to avoid abrading
(e.g., with metal scalers or air-abrasive systems); see the sections
on “Advanced Instrumentation Techniques” and “Selective Stain
Removal” in Chapter 17.
4. Biologic—depend on osseo-integration and epithelial attachment

1128
Tissue Engineering
See the section on “Genetics” in Chapter 7.
A. General considerations
1. Applications—replacement of any orofacial tissues, particularly
intraoral tissues
2. Terminology
a. Tissue engineering—attempt to regenerate tissue for the body,
either in the laboratory or in the patient, through manipulation
of cellular material, biologic mediators, and natural or synthetic
matrices
b. Cells (in tissue engineering)—living cells that are either
precursors of more differentiated cells or disorganized
collections of cells that grow, divide, and organize into
physiologically functioning tissue
c. Signals—any physical, chemical, or biologic mediators
(extracellular or intracellular) that initiate, propagate, or
otherwise stimulate cellular development into fully organized
tissue
d. Scaffolds—any extracellular matrix structure (natural or
synthetic, temporary or permanent, hard or soft) that provides a
foundation for cells to become attached, organized, and
proliferate to generate the tissue of interest
3. Classification by materials by tissue replacement therapies
a. Autografts—from one’s own body
(1) Best chance of clinical success
(2) Genetic match (no immunity problems)
b. Allografts (or homografts)—from same species (usually from
cadavers)
(1) Can be antigenic (sensitize the patient)
(2) Concerns about transmitted diseases
c. Xenografts—from different species
(1) Limited range of use (e.g., porcine heart valve)
(2) Heavily treated before use
d. Synthetics—entirely man-made
(1) Can be metals, ceramics, polymers, or composites
(2) Prone to long-term mechanical breakdown
(3) Can produce a toxic response
e. Tissue-engineered replacement—rebuilding tissues in the
laboratory to be implanted, or causing the body to “rebuild the
tissue” artificially in situ

1129
 (1) Use of mixture of natural and synthetic materials
(2) Offers the possibility of a “near-perfect” replacement
(3) Can potentially solve transplant availability problems
B. Structure
1. Components
a. Cells (cellular material)
(1) Stem cells (undifferentiated)
(2) Specific cells (e.g., osteoblasts, fibroblasts)
b. Signals (biologic mediators)
(1) Growth factors, such as bone morphogenic proteins
(BMPs)
(2) Genetic material
c. Scaffolds (matrices)
(1) Polymers—native (e.g., collagen) or synthetic (e.g.,
PLA/PGA)
(2) Ceramics—native (e.g., bone chips) or synthetic (e.g.,
Bioglass)
(3) Composites—combination of native and synthetic (e.g.,
hydroxyapatite-coated collagen fibers)
2. Manipulation
a. Design and grown human tissues outside the body for later
implantation to repair or replace diseased tissues
(1) Not necessarily patient specific
(2) Ideal for large-volume need such as skin grafts
b. Implantation of cell-containing or cell-free devices (with
appropriate signal molecules) that induce the regeneration of
functional human tissues; guided tissue regeneration, for
example, use of Perioglass combined with appropriate growth
factors in treatment of severe periodontal disease
c. Development of external or internal devices containing human
tissues designed to replace the function of diseased internal
tissues
(1) Involve use of stem cells or specific differentiated cells
from the patient
(2) Ideal for load-bearing tissues (e.g., bone, tendon)
C. Properties—physical, chemical, and mechanical properties should be
similar to those of natural tissues

Website Information And Resourc es

1130
Source Website Address Description
Clinicians Reports http://www.cliniciansreport.org Updates on dental materials and
devices

International Association for http://www.dentalresearch.org/DMG/ List of all dental materials sites and
Dental Research (IADR) dental materials manufacturer
Dental Materials Group websites
MEDLINE/PubMed http://www.ncbi.nlm.nih.gov/sites/entrez? Public access to National Library
db=pubmed of Medicine (NLM) abstract index
that includes all dental research
abstracts for published articles in
dental journals
The Dental Advisor http://www.dentaladvisor.com/ Evaluation of current dental
products
Dental Evaluation and http://www.airforcemedicine.af.mil/decs/ List of current reviews and
Consultation Service analyses of dental materials,
instruments, and devices;
evaluation of current dental
products

1131
1132
Suggested readings
Anusavice K.J., Phillips R.W. Phillip’s science of dental materials. ed
11 Philadelphia: Saunders; 2003.
Bayne S.C., Thomson J.Y. Biomaterials science [digital only]. Chapel
Hill, NC: Brightstar; 2004.
Powers J.M., Wataha J.C. Dental materials: properties and
manipulation. ed 10 St Louis: Elsevier-Mosby; 2013.
O’Brien W.J. Dental materials and their selection. ed 4 Philadelphia:
Quintessence; 2009.
Sakaguchi R.L., Powers J.M. Craig’s restorative dental materials. ed 13
St Louis: Elsevier-Mosby; 2012.

Chapter 13 review questions

Answers and rationales to chapter review questions are available on
this text’s accompanying Evolve site. See inside front cover for details.

1. Which mixing method is not used for dental materials?

a. Powder and liquid precapsulated and mixed in a triturator
b. Powder and liquid mixed on a mixing pad
c. Two liquids agitated together using a vibration
d. Powder and water mixed with a spatula in a mixing bowl
e. Two liquids mixed through a mixing nozzle
2. What of the following is the mixing time?
a. Elapsed time from the beginning of mixing until the beginning of
setting
b. Elapsed time from the beginning of the working interval until the
end of the setting interval
c. The setting interval
d. The time required by the operator to handle and place a dental
material
e. Elapsed time from the start of mixing until the end of mixing
3. Which of the following materials does not set by polymerization?
a. Hybrid glass ionomer cement
b. Dental stone

1133
 c. Polyvinyl siloxane impression material
d. Polysulfide impression material
e. Packable dental composite
4. Why is the linear coefficient of thermal expansion important for
restorative materials?
a. It predicts the loss in strength of a restorative material as the
temperature increases.
b. It indicates the insulating characteristics of a restorative material.
c. It indicates the resistance to thermal degradation of a material.
d. It indicates the amount of expansion/contraction on polymerization.
e. It predicts the mismatch in expansion/contraction at the interface of
restorative materials.
5. Which of the following materials involves imbibition problems?
a. Dental sealant
b. Dental composite
c. Dental cement
d. Alginate impression material
e. Gold restorations
6. Which of the following is a rapid thermal conductor?
a. Dentin
b. Dental amalgam
c. Dental composite
d. Zirconia all-ceramic inlays
e. Dental enamel
7. Which of the following undergoes crevice corrosion under plaque that
causes pitting?
a. Stainless steel restorations
b. Cast-gold restorations
c. PFM restorations
d. NiCr partial-denture alloys
e. All the above
8. Which of the following is BEST for pulpal insulation?
a. 1 mm of remaining dentin thickness
b. 3 mm of composite restoration

1134
 c. 5 mm of dental amalgam restoration
d. Surface sealant over restoration
e. 1 mm of calcium hydroxide liner
9. Which of the following terms is not important for color matching?
a. Ambient lighting conditions
b. Surface gloss
c. Translucency
d. Initiation
e. Hue and chroma
10. Which of the following is not associated with electrochemical
corrosion events?
a. Crevices
b. Stress
c. Passivation
d. Radiopacity
e. Plaque
11. Engineering stress is computed as:
a. Deformation divided by the volume of the object
b. Modulus multiplied by the plastic deformation
c. Difference between the total strain and plastic strain
d. Deformation divided by the original length
e. Applied load divided by original cross-sectional area
12. Engineering strain is computed as:
a. Area under the stress-strain curve
b. Load at yield divided by elastic deformation
c. Applied load divided by the total elastic deformation
d. Deformation divided by the original length of the object
e. Change between the initial and final strain divided by the time
13. What is another name for a material’s stiffness?
a. Elastic limit
b. Toughness
c. Fatigue resistance
d. Brittleness

1135
 e. Modulus
14. Loading of a restoration beyond the material’s elastic limit causes:
a. Only elastic deformation
b. Fatigue fracture
c. Elastic and plastic deformation
d. Stress relaxation
e. Only plastic deformation
15. At what point does loading produce both plastic and elastic strain at
the same time?
a. Toughness
b. Modulus
c. Endurance limit
d. Elastic limit
e. Fracture
16. What is the Mohs hardness value for enamel?
a. 2
b. 3 to 4
c. 5 to 6
d. 7
e. 9
17. Which phase in dental amalgam restorations is MOST likely to
corrode?
a. Ag-Sn
b. Ag-Sn-Cu
c. Sn-Hg
d. Cu-Sn
e. Ag-Hg
18. Which phase in dental amalgam is STRONGEST?
a. Ag-Cu
b. Cu-Sn
c. Ag-Hg
d. Ag-Sn
e. Sn-Hg

1136
19. Which method for amalgam is recommended to minimize mercury
vapor escape during mixing?
a. Friction-fit capsule
b. Precapsulated alloy and mercury
c. Covered mixing arm on the triturator
d. None of the above
e. Mortar and pestle
20. High-copper dental amalgam alloys involve what range of copper in
their composition?
a. 12% to 30%
b. 6% to 12%
c. 1% to 5%
d. 0.5% to 1%
e. 0.1% to 0.5%
21. What is the major advantage of high-copper over low-copper dental
amalgam restorations?
a. Lower coefficient of thermal expansion
b. Greater polishability
c. Lower corrosion tendency
d. Lower thermal conductivity
e. Better compressive strength
22. What is the OSHA limit for exposure to mercury vapor in air during
a 40-hour workweek?
a. 50 µg/m3
b. 42 µg/m3
c. 31 µg/m3
d. 20 µg/m3
e. 15 µg/m3
23. What is the melting temperature of the Ag-Hg matrix phase in a set
dental amalgam restoration?
a. 167°C
b. 157°C
c. 147°C
d. 137°C

1137
 e. 127°C
24. What is a major problem associated with polishing a dental
amalgam?
a. Burnishing of surface corrosion products into the amalgam
b. Production of grayish color
c. Localized melting of the amalgam with mercury smearing
d. Smearing amalgam onto enamel to cause staining
e. Creation of marginal ditching
25. What is the estimated incidence of hypersensitivity to mercury from
dental amalgam restorations in the general population?
a. 1 per 2000 patients
b. 1 per 50,000 patients
c. 1 per 3 million patients
d. 1 per 5 million patients
e. 1 per 100 million patients
26. What is the principal reason for the shift away from dental amalgam
use?
a. Environmental concerns about mercury
b. Much improved mechanical properties of other materials
c. Patient hypersensitivity problems to mercury released from
amalgams
d. Lower cost of procedures for alternative restorative materials
e. Toxicity of mercury to office personnel
27. What is the main reason for failure of a high-copper dental amalgam
restoration?
a. Occlusal marginal ditching
b. Creep
c. Wear facets
d. Interproximal caries
e. Black or green tarnish
28. Which restorative material is most often substituted for dental
amalgam in posterior restoration applications?
a. Dental composite
b. Hybrid glass ionomer

1138
 c. Direct gold
d. ART restorations
e. All-ceramic
29. Which of the following is TRUE about pit-and-fissure sealants?
a. Sealants should be filled to improve their mechanical properties.
b. Tinted sealants are more useful than colorless ones.
c. Sealant inspection is unnecessary after 2 years.
d. Partial sealing of pits and fissures is better than no sealing at all.
e. Uncured sealant along air-exposed surfaces will finish curing in 24
hours.
30. Which event does not alter the esthetics of existing composite
restorations?
a. Extensive tea exposure
b. APF application
c. Tobacco use
d. Gum chewing
e. Whitening techniques
31. Which of the following is likely to be deceptive in appearance in a
radiograph?
a. Dental composite restoration
b. Dental sealants
c. Temporary restorations
d. Glass ionomer restorations
e. Infiltrants
32. What is the most appropriate way to manage long-term wear or
discoloration of posterior dental composite restoration surfaces?
a. Replace the composite with a dental amalgam
b. Repair the worn areas with resin-modified glass ionomer
c. Resurface the old composite with new composite
d. Replace the restoration with a new, high-strength ceramic
e. Adjust the occlusion of the opponent tooth
33. Which procedure does not require phosphoric acid etching?
a. Ceramic orthodontic bracket attachment
b. Total-etch dentin bonding procedure

1139
 c. Self-etch dentin bonding procedure
d. Amalgam bonding procedure
e. Dental sealant
34. Which of the following is TRUE about the dentin smear layer?
a. Composed mostly of collagen and water
b. Dissolved by acid etching during bonding procedures
c. Easily removed with air/water spray
d. Effectively seals dentin
e. 50 to 100 µm–thick debris layer
35. What is required to produce good bond strength to dentin?
a. Drying of dentin
b. Preapplication of chlorhexidine
c. Postcuring materials with visible light
d. Hybrid layer formation
e. Long conditioning (etching) times
36. How do self-etching bonding systems work?
a. Acidic monomers replace need for phosphoric acid etching.
b. New monomers chemically adhere to hydroxyapatite.
c. Phophoric acid is mixed with other components of the bonding
system.
d. Chemical bonding to collagen replaces need for micromechanical
bonding.
e. Wetting agent helps adaptation and replaces need for
micromechanical bonding.
37. What products most likely contain water-miscible acrylic monomers?
a. Acidulated phosphate fluoride (APF)
b. Pit-and-fissure sealants
c. Dentin primers
d. Resin surface sealers
e. Polishing pastes
38. Which component of the dentin bonding system is most likely to
cause skin sensitization in dental personnel?
a. HEMA
b. Ethanol

1140
 c. UDMA
d. Bis-GMA
e. Phosphoric acid
39. What is the shorthand representation for a self-etching primer
adhesive?
a. E + PB
b. EP + B
c. EPB
d. E
e. E + P + B
40. Which of the following restorations requires surface protection with
petroleum jelly during APF applications?
a. Amalgams
b. Dental sealants
c. Cast gold
d. Orthodontic wire
e. Porcelain ceramics
41. Which of the following constituents may have a palliative action on
the dental pulp?
a. Calcium hydroxide
b. Bis-GMA
c. 4-META
d. Eugenol
e. HEMA
42. What is the primary filler component composite cement?
a. Potassium oxide
b. Silicon oxide
c. Zinc oxide
d. Calcium oxide
e. Aluminum oxide
43. Which of the following dental cements does not include polymer as
part of the matrix?
a. Polycarboxylate cement
b. Glass ionomer cement

1141
 c. Resin-modified glass ionomer cement
d. Composite cement
e. Zinc oxide–eugenol (ZOE) cement
44. What ions on tooth structure permit glass ionomer chemical
adhesion?
a. Calcium ions
b. Fluoride ions
c. Carboxylic acid ions
d. Hydrogen ions
e. Aluminum ions
45. Which of the following materials does not release fluoride?
a. Resin-modified glass ionomer
b. ART restorations
c. Provisional restorations
d. Compomer
e. Traditional glass ionomer
46. Which of the following MOST resembles a compomer?
a. Glass ionomer
b. Zinc phosphate cement
c. Polycarboxylate
d. Giomer
e. Composite
47. The fluoride release from glass ionomers follows what pattern?
a. Rapid decrease to low level after 24 hours
b. Rapid decrease over 7 to 14 days
c. Some decrease after 30 days
d. Some decrease after 6 months
e. Some decrease after 1 year
48. What is the effectiveness of recharging glass ionomer restorations?
a. Does not work
b. Increases fluoride release for a few days
c. Increases fluoride release for a few months
d. Increases fluoride release for 1 to 2 years

1142
 e. Permanently reestablished fluoride release from the material
49. Which of the following applications typically involves an ART
material?
a. Class II restorations
b. Class IV restorations in permanent teeth
c. Liner under composite restorations
d. Temporary restorations
e. Class III esthetic restorations
50. Which impression material is a hydrogel?
a. ZOE
b. Polysulfide
c. Polyether
d. Polyvinyl siloxane
e. Alginate
51. Which of the following features does not apply to polyvinyl siloxane
impression material?
a. Low shrinkage on setting
b. Dimensionally stable
c. Accurate
d. Contains no filler
e. Should not be poured immediately
52. Which application typically requires the STRONGEST gypsum
material?
a. Master cast
b. Repairing casts
c. Removable die
d. Denture fabrication
e. Orthodontic model
53. What is the chemical composition of set gypsum products?
a. Calcium sulfate dihydrate
b. Calcium sulfate monohydrate
c. Calcium sulfate unhydrated
d. Calcium sulfate hemihydrate

1143
 e. Calcium sulfate trihydrate
54. What is the chemical composition of gypsum powder that is to be
mixed with water to form models?
a. Calcium chloride
b. Calcium sulfate hemihydrate
c. Calcium carbonate
d. Calcium fluoride
e. Calcium phosphate
55. How much “water of reaction” is required for the actual setting of
100 g of calcium sulfate hemihydrate powder?
a. 12 mL
b. 18 mL
c. 24 mL
d. 32 mL
e. 50 mL
56. What is the major difference between plaster and stone powders?
a. Color
b. Crystal structure
c. Powder particle packing
d. Sterilization techniques
e. Hydration state
57. Why does diestone require less water for mixing than plaster?
a. Diestone undergoes a different reaction than stone.
b. Diestone powder particles are less porous and imbibe less water.
c. Diestone chemical reaction generates less heat and requires less
cooling.
d. Diestone contaminants are minimized by adding less water.
e. Diestone powder particles pack more efficiently.
58. Why should molten wax be applied slowly and in thin layers onto
dies?
a. To minimize porosity
b. To promote wetting onto the dies
c. To avoid distortion from thermal contraction during wax cooling
d. To avoid sag from wax’s low modulus

1144
 e. To avoid water absorption
59. What is the role of paraffin in most dental waxes?
a. Increase hardness
b. Increase thermal stability
c. Act as main low-melting component
d. Reduce thermal expansion
e. Increase tackiness
60. What is the main goal in the design of dental inlay waxes?
a. Low cost
b. Low melting temperature
c. Complete pyrolysis on heating to CO2 and H2O
d. Low coefficient of thermal expansion
e. High hardness
61. What are the primary constituents of an investment material?
a. Two fillers and a binder
b. Two liquid binders
c. Matrix, filler, and modifier
d. Two filled pastes that are mixed
e. Binder and accelerator
62. What is the principal advantage of phosphate-bonded investment
(PBI) over gypsum-bonded investment (GBI)?
a. Stronger
b. Less setting expansion
c. Faster reacting
d. Lower cost
e. More stability at higher temperatures
63. What is the karatage of an alloy that is 80% Au by weight?
a. 10 karat
b. 13 karat
c. 16 karat
d. 19 karat
e. 22 karat
64. In high-gold casting alloys, which element produces a temporary

1145
protective oxide on the molten alloy surface during the casting process?
a. Zn
b. Ag
c. Cu
d. Pd
e. Au
65. In high-gold casting alloys, which element is primarily responsible
for hardness?
a. Cu
b. Zn
c. Au
d. Pd
e. Ag
66. What element is responsible for producing the corrosion resistance of
stainless steel instruments?
a. Fe
b. C
c. Co
d. Ni
e. Cr
67. What level of chromium is required in steel alloys to produce
effective passivation?
a. 10%-14%
b. 14%-18%
c. 18%-28%
d. 28%-40%
e. > 40%
68. Which one of the following terms is not specifically related to
soldering?
a. Brazing
b. Joining
c. 600 to 650 fine
d. Precious metal content
e. Filler metal

1146
69. Which application does not use gold alloys?
a. Cast alloy bridge
b. Partial-denture framework
c. Cast post and core
d. Implant
e. Cast alloy crown
70. Which of the following dental materials cannot cause nickel
sensitivity?
a. Stainless steel crowns
b. Some PFM alloys
c. Some partial-denture framework alloys
d. Dental amalgam
e. Some orthodontic wires
71. What is the approximate incidence of nickel sensitivity for men?
a. 6%
b. 12%
c. 18%
d. 24%
e. 30%
72. What events contribute to a relatively high nickel sensitivity level in
women?
a. Contact dermatitis from nickel-based jewelry
b. Greater contact with stainless steel
c. Genetic differences
d. Less protective skin and hair during contact
e. Greater contact with metal coinage
73. What are the three principal components of dental porcelains?
a. Alumina, zinc oxide, calcium fluoride
b. Alumina, potassium oxide, calcium oxide
c. Calcium oxide, magnesium oxide, chromium oxide
d. Silica, alumina, potassium oxide
e. Silica, calcium oxide, alumina
74. What component of dental porcelain contributes primarily to

1147
esthetics?
a. Silica
b. Potassium oxide
c. Chromium oxide
d. Titanium oxide
e. Alumina
75. What component is involved with very-high-strength dental
ceramics?
a. Silicon carbide
b. Potassium oxide
c. Chromium oxide
d. Zirconia
e. Silica
76. Which statement is not true about feldspathic porcelain?
a. Relatively low coefficient of thermal expansion
b. Ductile
c. Used to veneer most dental porcelains
d. High hardness
e. Excellent translucency
77. Which one of the following dental materials is not a ceramic?
a. Silicon carbide
b. Corundum
c. Hydroxyapatite
d. Zirconium
e. Titanium dioxide
78. Which is TRUE of all traditional dental cements?
a. Endothermic reactions
b. Acid-base reactions
c. Good esthetics
d. High strength
e. Precapsulated
79. Which of the following dental cement compositions requires staged
additions of powder to the liquid during mixing on a chilled glass slab to

1148
control the reaction?
a. Polycarboxylate cement
b. Resin-modified glass ionomer cement
c. Zinc phosphate cement
d. Universal cement
e. Compomer cement
80. What is the primary monomer involved in denture base fabrication?
a. EMA
b. Bis-GMA
c. MMA
d. UDM
e. HEMA
81. Why are acrylic resin teeth popular for denture fabrication?
a. Excellent wear resistance
b. Ease of cleaning
c. Easily bonded to denture base
d. Lightweight
e. Best esthetics
82. What is the major problem for tissue conditioners over the first few
days?
a. Discoloration
b. Bad taste
c. Loss of bonding
d. Increased hardness
e. Fungal growth
83. Mouth protectors should be cleaned with:
a. Ultrasonic agitation in baking soda solutions
b. Dilute chlorine bleach in water
c. Denture-cleaning solutions
d. Cool soap-and-water solutions
e. Dilute chlorhexidine solutions
84. Mouth protectors are typically fabricated from what material?
a. Thermoplastic polymer

1149
 b. Impression material
c. Composite
d. Denture base resin
e. Guttapercha
85. Which of the following materials practically cannot be fabricated
using CAD/CAM procedures?
a. Dental porcelain
b. Gold alloys
c. Zirconia
d. Alumina
e. Dental composite
86. What process does not harm the protective titanium dioxide surface
of dental implants?
a. Scaling with metal instruments
b. Use of polishing agents
c. Abrasive dentifrices
d. Dental floss
e. APF application
87. Which one of the following dental materials fabrication processes
would be classified as “additive”?
a. CAD/CAM machining of zirconia
b. CAD/CAM machining of composite
c. Inkjet printing
d. Casting
e. All the above
88. What are the major requirements for tissue engineering?
a. Cells and bone
b. Cells and collagen
c. Collagen, hydroxyapatite, and signals
d. Cells and scaffolds
e. Cells, signals, and scaffolds
89. Which of the following biomaterials utilizes tissue from a cadaver?
a. Allograft

1150
 b. Xenograft
c. Synthetic tissue
d. Engineered tissue
e. Autograft
90. Which of the following is not a scaffold material for tissue
engineering?
a. Gold mesh
b. Polylactic acid (PLA)
c. Bioglass
d. Collagen
e. Bone chips

1151
C HAPT E R
14

1152
Periodontics
Denise M. Bowen

The vast majority of periodontal needs are related to the treatment of

gingivitis and early periodontitis, the prevention of periodontal disease,
and the maintenance of periodontal health after therapy. The demand for
these services, provided by dental hygienists, continues to grow. An
understanding of periodontics is critical to the process of dental hygiene
care.

1153
Basic features of the periodontium
A. The periodontium is composed of gingiva, periodontal ligament,
cementum, and alveolar bone (Fig. 14-1)

FIG 14-1 Anatomy of the periodontium.

B. The function of the periodontium is to attach the teeth to the alveolar

bone tissues of the mandible and the maxilla

Gingiva
Definition
A. Part of the oral masticatory mucosa that surrounds the cervical
portion of the teeth and covers the alveolar process of the jaws
B. Components
1. Marginal gingiva (unattached or free gingiva)
a. Unattached cuff-like tissue that surrounds all surfaces of the
teeth
b. Parts of marginal gingiva

1154
 (1) Gingival margin—most coronal portion; located at or
approximately 0.5 mm coronal to the cemento-enamel
junction (CEJ)
(2) Gingival groove—when present, it is located 1 to 1.5 mm
apical to the gingival margin at the base of the gingival
sulcus
(3) Gingival sulcus—space formed by the tooth and the
sulcular epithelium laterally and by the coronal end of the
junctional epithelium (base of the sulcus) apically; a
sulcular measurement of 1 to 2 mm facially and lingually
and 1 to 3 mm interproximally is considered normal
(4) Interdental gingiva—occupies the interdental space
coronal to the alveolar crest (clinically, it fills the embrasure
space beneath the area of tooth contact)
(a) Interdental gingiva—consists of two interdental
papillae (one facial and one lingual) that are connected
by the concave interdental col
(b) Col is absent when teeth are not in contact
2. Attached gingiva
a. Portion of the gingiva that is attached to the underlying
periosteum of the alveolar bone and to the cementum by
connective tissue fibers and the epithelial attachment
b. Boundaries
(1) Apically demarcated from the alveolar mucosa by the
mucogingival junction
(2) Coronally demarcated by the base of the gingival sulcus
c. Width varies from 1.8 to 4.5 mm
(1) Generally widest in the facial anterior maxillary areas and
narrowest in the mandibular premolar facial areas
(2) The width is not measured on the palate because it cannot
be clinically distinguished from the palatal mucosa
3. Changes in the width of attached gingiva result from changes at the
coronal end

Histologic Features1
See the sections on “Oral Histology,” “Oral Mucosa,” and “Dento-
Gingival Junction” in Chapter 2.
A. Epithelium
1. Sulcular (crevicular) epithelium—stratified squamous,
nonkeratinized epithelium that is continuous with the oral

1155
 epithelium; lines the peripheral surface of the sulcus, extending to
the coronal border of the junctional epithelium
2. Junctional epithelium—stratified squamous, nonkeratinized
epithelium that surrounds and attaches to the tooth on one side and
attaches on the other side to the gingival connective tissue; new cells
originate from the cells in the apical portion adjacent to the tooth
and from the cells in contact with the connective tissue; epithelial
cells are shed at the coronal end of the junctional epithelium, at the
base of the gingival sulcus
a. The junctional epithelium is more permeable the oral
epithelium
b. The junctional epithelium serves as the route for the passage of
fluid and cells from the connective tissue into the sulcus and for
the passage of bacteria and bacterial products from the sulcus
into the connective tissue
c. The junctional epithelium is easily penetrated by the
periodontal probe; penetration is increased in inflamed gingiva
d. The length of the junctional epithelium ranges from 0.25 to
1.35 mm
3. Epithelial attachment—basal lamina, hemidesmosomes, adhesion
proteins (laminins), and anchoring fibrils that connect the junctional
epithelium to the tooth surface at or slightly coronal to the CEJ
B. Connective tissue (or lamina propria)—composed of gingival fibers
(connective tissue fibers), intercellular ground substance, cells, and
vessels and nerves (see Chapter 2, Figs. 2-20 and 2-27)
1. Gingival fibers—composed of collagen fibers (60% of connective
tissue volume) and an elastic fiber system composed of oxytalan,
elaunin, and elastin fibers; fiber bundle groups provide support for
marginal gingiva, including the interdental papilla (see Chapter 2;
Fig. 2-28, B, and the section on “Periodontal Ligament” for gingival
fiber groups)
2. Intercellular ground substance (or matrix)—similar to connective
tissue in the periodontal ligament
3. Cells
a. Fibroblasts (predominant cells)
(1) Produce various types of fibers found in connective tissue
(2) Instrumental in synthesis of intercellular ground
substance
Wound healing or healing after therapy is regulated by
fibroblasts (see the section on “Regeneration and Wound
Healing” in Chapter 7)

1156
 b. Other connective tissue cellular components—host defense
cells
4. Vessels and nerves (see the section on “Blood Supply, Lymph, and
Innervation of the Periodontium”)

Normal Clinical Features (Fig. 14-2)

A. Color—in light-skinned individuals, pale or coral pink; in dark-
skinned individuals, coral pink to brown; color varies, depending on (1)
the degree of vascularity, (2) amount of melanin, (3) epithelial
keratinization, and (4) thickness of epithelium

FIG 14-2 Normal gingiva in a young adult. Note the demarcation, referred to as
the mucogingival line (arrows), between the attached gingival and the darker
alveolar mucosa. (From Newman MG, et al: Carranza’s clinical periodontology, ed 12, St
Louis, 2015, Elsevier.)

B. Texture
1. Gingival margin—dull, smooth surface
2. Attached—stippled, “orange peel” surface present on facial surfaces;
may not always be present in health
C. Consistency
1. Gingival margin—firm and resilient; resists displacement
2. Attached gingiva—firmly bound to the underlying alveolar bone and
cementum
D. Contour and shape
1. Papillary contour—pointed; papilla fills proximal embrasure space to

1157
 the contact point
2. Marginal contour—most coronal edge should form a knife-like edge
with a scalloped configuration mesiodistally (follows the CEJ)
3. The contour varies with the shape and alignment of teeth and with
the size and position of contacts

Periodontal Ligament
See the section on “Periodontal Ligament” and Fig. 2-27 in Chapter 2.

Functions
A. Physical—attachment of the tooth to the bone, transmission of
occlusal forces to the bone, absorption of the impact of occlusal forces,
and maintenance of the proper relationship of gingival tissues to teeth
B. Formative—participation in formation of cementum and bone and
remodeling of the periodontal ligament by activities of connective tissue
cells (cementoblasts, fibroblasts, osteoblasts)
C. Resorptive—by the activity of connective tissue cells (primarily
osteoclasts)
D. Nutritive—nutrients carried through blood vessels to cementum,
bone, and gingiva
E. Sensory—proprioceptive and tactile sensitivity provided by
innervation to the ligament

Clinical Considerations
A. Thickness varies from 0.05 to 0.25 mm (mean, 0.2 mm), depending on
the stage of eruption, the person’s age, and the function of a tooth; the
ligament is thickest in the apical area and is thicker in functioning than
in nonfunctioning teeth and thicker in areas of tension than in areas of
compression
B. Periodontal ligament cells that form collagen in ligament bundles can
also remodel the ligament through secretion of new collagen
(fibroblasts) and resorption of older collagen (fibroclasts), as well as
lateral resorption of adjacent bone (osteoclasts) when altered forces are
applied (e.g., orthodontics)
C. Accidentally exfoliated teeth can be reimplanted if handling of torn
ligament is minimized before reimplantation; heal by reattachment

Cementum

1158
See the section on “Cementum” in Chapter 2.

Clinical Considerations
A. Compensates for occlusal wear and continuous eruption by apical
deposition of cementum throughout life
B. Protects the root surface from resorption during tooth movement
C. Has a reparative function, which permits reestablishment of new
connective tissue attachment after certain types of periodontal therapies
D. When enamel and cementum do not meet, cervical hypersensitivity
and caries are more likely

Alveolar Process
See the section on “Alveolar Bone” and Fig. 2-26 in Chapter 2.

Shape, Thickness, and Location

A. The contour of the alveolar bone follows the contour of the CEJ and
the arrangement of the dentition
B. The shape of the alveolar crest is generally parallel to the CEJ of
adjacent teeth; is approximately 1.5 to 2 mm apical to the CEJ
C. Cortical plates generally are thicker in the mandible than in the
maxilla
D. Posterior areas—bone generally is thick, and cancellous bone
separates the cortical plate from the alveolar bone proper
E. Anterior areas—bone is thin, with little or no cancellous bone
separating the cortical plate from the alveolar bone proper
F. Dehiscence—situation in which the marginal alveolar bone is denuded,
forming a defect extending apical to the normal level, exposing an
abnormal amount of root surface
G. Fenestration—situation in which the margin of alveolar bone is intact;
an isolated lack of alveolar bone on the root surface leaves it covered only
by the periosteum and gingiva

Radiographic Features of the Normal Periodontium

(Fig. 14-3)
A. Alveolar crest—thin, radiopaque line continuous with the lamina
dura; the shape depends on the proximity of adjacent teeth and roots and
level of adjacent CEJs

1159
 FIG 14-3Crest of interdental septum, which is normally parallel to a line drawn
between the cemento-enamel junction of adjacent teeth (arrow). Note the
radiopaque lamina dura around the roots. (From Newman MG, et al: Carranza’s
clinical periodontology, ed 12, St Louis, 2015, Elsevier.)

B. Interdental septum—proximal alveolar bone bordered by the alveolar

crest
C. Lamina dura—radiographic image of the alveolar bone proper; may or
may not be present as a thin radiopaque line surrounding the bone
adjacent to the periodontal ligament
D. Periodontal ligament space—thin radiolucent line surrounding each
tooth between the root and adjacent alveolar bone
E. Supporting bone—radiopacity of the trabecular pattern varies,
depending on the amount, pattern, and presence of cancellous and
cortical bone
F. Limitations of radiographs—radiographs:
1. Do not show the relationships between soft and hard tissues
2. Do not show the initial signs of early bone loss
3. Do not show bone changes on facial or lingual surfaces; these bony
plates are obscured by teeth roots
4. Do not reveal current cellular activity; only reflect past events
5. Have their diagnostic value affected by variations in technique

Blood Supply, Lymph, and Innervation of the

1160
Periodontium 1,2
See the section on “Blood and Lymph” and “Nerve Tissue” in Chapter 2.
A. Blood supply originates from the inferior and superior alveolar
arteries
B. Lymph drains into larger lymph nodes and veins
C. The nerve supply is derived from the branches of the trigeminal nerve
and thus is sensory in nature; nerve branches terminate in the
periodontal ligament, on the surface of alveolar bone, and within gingival
connective tissue; receives stimuli for pain (nociceptors) and for position
and pressure (mechanoreceptors and proprioceptors)

1161
Diseases of the periodontium
Classification of Periodontal Diseases1,2
See the section on “Periodontal Diseases” in Chapter 9.
A. Importance of disease classification
1. Useful for dental hygiene diagnosis, prognosis, care plans, and legal
documentation
2. Classifications of periodontal diseases are changing as new
information about causes, pathogenicity, and host factors continues
to evolve
B. Current classifications of periodontal diseases
1. Gingival diseases
a. Dental plaque–induced gingival diseases—can occur on a
periodontium with no attachment loss or past attachment loss
that is not progressing; include dental plaque (biofilm)–
associated gingivitis and gingival diseases modified by systemic
factors such as hormonal disorders, blood dyscrasias,
medications, and malnutrition
b. Non–plaque-induced gingival lesions—include gingival diseases
of specific bacterial, viral, fungal, or genetic origin; gingival
manifestations of systemic conditions such as mucocutaneous
disorders and allergic reactions; and traumatic lesions, foreign
body reactions, and otherwise nonspecified gingival lesions
2. Chronic periodontitis—localized or generalized
3. Aggressive periodontitis—localized or generalized
4. Periodontitis as a manifestation of systemic diseases (hematologic or
genetic)
5. Necrotizing periodontal diseases
6. Abscesses of the periodontium
7. Periodontitis associated with endodontic lesions
8. Developmental or acquired deformities and conditions

Gingival Diseases1,2
A. Common characteristics
1. Signs and symptoms confined to the gingiva
2. Presence of bacterial biofilm, which initiates or exacerbates the
lesion
3. Clinical signs of inflammation
4. No loss of attachment or stable attachment levels; possible
precursor to attachment loss

1162
B. Dental plaque–induced gingivitis
1. Inflammation of the gingiva resulting from biofilm at the gingival
margin
2. Most common form of periodontal disease; prevalent in all age
groups
3. Change in gingival color and contour (redness, swelling,
enlargement); increased sulcular temperature and gingival exudate;
bleeding on provocation; reversible with biofilm removal
4. Sensitivity or tenderness can occur, although not present in all
clients
5. Absence of attachment loss and bone loss is characteristic; after
active periodontal treatment and resolution of inflammation in
periodontitis, tissue becomes healthy, but attachment loss remains;
dental plaque–induced (biofilm-induced) gingivitis on a reduced
periodontium can occur in these patients if gingival inflammation
arises without evidence of progressive attachment loss
C. Gingival diseases associated with endocrine changes or endogenous
sex hormones
1. Periodontal tissues are modulated by androgens, estrogens, and
progestin
2. Most information exists about sex hormone–induced effects in
women: menstruation, pregnancy, and puberty
3. Gingival response requires biofilm in conjunction with steroid
hormones
a. Puberty-associated gingivitis—occurs in adolescents during
puberty in both genders when the dramatic rise in hormone
levels has a transient effect on gingival inflammation; signs of
gingivitis exist in the presence of relatively sparse deposits
b. Menstrual cycle–associated gingivitis—significant and
observable inflammatory changes occur most frequently during
ovulation, often not present
c. Pregnancy-associated gingivitis—some of the most remarkable
endocrine changes occur during pregnancy because of increased
plasma hormone levels; features are similar to biofilm-induced
gingivitis, but little biofilm may be present; increased
prevalence and severity have been reported
d. Pregnancy-associated pyogenic granuloma (pregnancy tumor)—
pronounced response of gingiva to dental biofilm at gingival
margin in the form of a sessile or pedunculated protuberant
mass; most common interproximally; regresses after parturition
D. Gingival diseases associated with medications (drug-influenced

1163
gingival diseases)
1. Drug-influenced gingival enlargement— prevalence 5% to 50%;
overgrowth of the gingiva most often associated with:
a. Anticonvulsant agents (e.g., phenytoin)
b. Immunosuppressant agents (e.g., cyclosporine)
c. Calcium channel blockers (e.g., nifedipine, verapamil, diltiazem,
sodium valproate)
2. Occurs most frequently in the anterior gingiva, especially in
children; onset within 3 months of drug regimen
3. Changes in gingival contour, size, and color because of enlargement;
increased gingival exudate and bleeding on provocation can coexist;
first occurs interproximally
4. Found in the gingiva, with or without bone loss; not associated with
attachment loss
5. Biofilm control can limit the severity of the pronounced gingival
inflammatory response
6. Oral contraceptive–associated gingivitis—no longer considered a
significant risk3
E. Gingival diseases associated with systemic diseases
1. Diabetes mellitus–associated gingivitis—found in children with
poorly controlled type 1 diabetes mellitus
2. Leukemia-associated gingivitis (hematologic gingival disease)—
primarily found in persons with acute leukemia
3. Both diseases manifest with pronounced inflammatory response to
bacterial dental biofilm; changes in gingival color and contour;
increased bleeding on provocation
4. Dental biofilm control can limit severity
F. Gingival diseases associated with malnutrition
1. Malnutrition leads to compromised host response and defense
mechanisms
2. Increased susceptibility to infection may exacerbate gingival
response to dental biofilm
3. Scurvy can also result from ascorbic acid (vitamin C) deficiency; the
resultant gingival lesions are described as erythematous, bulbous,
hemorrhagic, swollen, and spongy
G. Non–plaque-induced gingival lesions2
1. Infectious gingivitis—includes specific bacteria (e.g., Neisseria
gonorrhoeae, Treponema pallidum), viruses (e.g., herpes simplex types 1
and 2, varicella-zoster, papillomavirus), fungi (e.g., Candida species),
or genetic conditions (e.g., hereditary gingival fibromatosis) (see the
section on “Periodontal Diseases” in Chapter 9); linear gingival

1164
 erythema occurs in individuals who have acquired
immunodeficiency syndrome (AIDS) or other
immunocompromising diseases
a. Clinical changes—distinct band of severe erythema on marginal
gingiva; can be localized or generalized; sometimes punctuated
red dots are also present on attached gingiva; no ulceration or
loss of attachment occurs
b. Radiographic changes—none; normal findings
c. Cause—immunosuppressed host response to biofilm
microorganisms
d. Treatment—scaling and debridement with povidone-iodine
irrigation for antimicrobial and topical anesthetic effect;
prescription of antifungal agents if candidiasis is also present;
critical importance of thorough self-care practices, including
mechanical removal of dental biofilm and twice-daily 0.12%
chlorhexidine rinses, 1-month reevaluation, and continued care
2. Dermatologic diseases, including lichen planus, pemphigoid,
pemphigus vulgaris, erythema multiforme, psoriasis, and lupus
erythematosus, also may present with gingival manifestations; the
diagnosis depends on clinical findings and biopsy specimens (see
the sections on “Major Aphthous Ulcers,” “Skin Diseases,” and
“White Lesions” in Chapter 8)
3. Allergic reactions in the oral mucosa are uncommon but can be
caused by dental restorations, dentifrices, mouthwashes, and food
allergens; signs and symptoms do not resolve when oral hygiene is
instituted
4. Foreign body reactions occur when ulceration of the gingival
epithelium allows entry of a substance into the gingival connective
tissue; most frequently is an amalgam tattoo
5. Mechanical trauma can be accidental, iatrogenic, or factitious; results
in gingival or tooth abrasion, recession, ulceration, inflammation, or
laceration

Chronic Periodontitis1–3
A. Slowly progressive; most common in adults; can also occur in children
and adolescents
B. The disease results from the inflammatory process originating in the
gingiva (gingivitis) and extending into the supporting periodontal
structures; may have periods of activity and remission; has slow to
moderate progression; may have periods of rapid progression

1165
 1. Can be further classified on the basis of extent and severity
a. Extent—number of sites involved
(1) Localized—30% of sites or less
(2) Generalized—more than 30% of sites
b. Severity—clinical attachment loss (CAL)
(1) Early—progression of gingival inflammation into the
alveolar bone crest, with slight bone loss; with normal
gingival contour, usual periodontal probing depth is 2 to
3 mm, with slight loss of connective tissue attachment and
alveolar bone; average 1 to 2 mm CAL
(2) Moderate—a more advanced state of the early condition,
with increased destruction of periodontal structures and
noticeable loss of bone support; average probing depth of 4
to 5 mm, with normal gingival contour; average 3 to 4 mm
CAL
(3) Advanced—further progression of periodontitis, with
major loss of alveolar bone support greater than 30%
usually accompanied by increased tooth mobility; furcation
involvement in multiple-rooted teeth is likely; recession is
common; average probing depth 6 mm or more, with
normal gingival contour; average 5 mm or greater CAL
2. Radiographic features (see later section on “Changes in the
Periodontium Associated with Disease”)
3. Cause—host response to dental biofilm; the amount of destruction
is consistent with the presence of local factors; subgingival calculus
is frequently seen; is associated with various microbial patterns; can
be associated with local predisposing factors; may be modified by
systemic diseases and other risk factors
4. Treatment—nonsurgical or surgical periodontal therapy, or both,
depending on extent and severity, followed by periodontal
maintenance procedures
C. Chronic periodontitis can be recurrent and refractory (nonresponsive);
not all cases of periodontitis have successful treatment outcomes

Aggressive Periodontitis1–3
A. Can occur at any age; may be localized or generalized
B. Common features
1. Occurs in persons otherwise healthy; most common in African
populations
2. Rapid attachment loss and bone loss, which may or may not be self-

1166
 arresting
3. Familial aggregation
4. Secondary features that are less universal include the following:
a. Bacterial biofilm inconsistent with the severity of periodontal
destruction
b. Elevated proportions of Aggregatibacter actinomycetemcomitans
and sometimes Porphyromonas gingivalis
c. Phagocyte abnormalities and poor antibody response
d. Progression of attachment loss and bone loss can be self-
arresting
C. Localized aggressive periodontitis
1. Onset around the age of puberty is most common
2. Localized incisor and first-molar onset with interproximal
attachment loss on two or more teeth (one first molar) and involving
no more than two teeth other than incisors and first molars
D. Generalized aggressive periodontitis
1. Most common before age 30, but may also occur in older persons
2. Pronounced episodic nature of bone loss and attachment loss
3. Generalized interproximal attachment loss affecting at least three
permanent teeth other than incisors and first molars
E. Treatment—same as for chronic periodontitis; systemic antibiotic
(combination metronidazole and amoxicillin therapy) and diligent
periodontal maintenance procedures

Periodontitis as a Manifestation of Systemic

Diseases1,2
A. Systemic factors modify all forms of periodontal disease, but some
systemic diseases cause periodontitis; the listing is categorized under
broad headings
B. Hematologic disorders (see the section on “Blood Dyscrasias” in
Chapter 8)
1. Neutrophil deficiencies cause severe destruction of periodontal
tissues; leukocyte activities such as chemotaxis, phagocytosis, and
killing or neutralization of ingested organisms or substances must
be integrated for adequate protection
2. Quantitative leukocyte disorders
a. Neutropenia—cyclic or chronic forms involve deep periodontal
pockets with extensive, generalized bone loss
b. Leukemia—most common in the acute form; symptoms include
generalized gingival enlargement, swelling caused by cellular

1167
 infiltrate, and uncontrolled bleeding related to associated
thrombocytopenia
C. Genetic disorders1 (see the section on “Genetics” in Chapter 7)
1. Genetic disorders usually manifest early in life and have similar
signs and symptoms as those of aggressive forms of periodontitis;
host genetic factors are believed to be important determinants in a
person’s susceptibility to periodontitis
2. Disorders associated with periodontitis include familial and cyclic
neutropenia, Down syndrome, leukocytic deficiency syndrome,
Papillon-Lefèvre syndrome, Chédiak-Higashi syndrome, histiocytosis
syndrome, glycogen storage disease, infantile genetic
agranulocytosis, Cohen syndrome, Ehlers-Danlos syndrome (types
IV and VIII), and hypophosphatasia; rare conditions such as
Papillon-Lefèvre syndrome, Chédiak-Higashi syndrome, and Ehlers-
Danlos syndrome have the strongest evidence linking genetic
mutations with periodontitis4

Necrotizing Periodontal Diseases2,3

A. Necrotizing ulcerative gingivitis (NUG)—inflammatory destructive
disease of the gingiva that has a sudden onset with periods of remission
and exacerbation; predisposing conditions may be preexisting (e.g.,
gingivitis, smoking, period of severe stress, deficient diet or sleep)
1. Clinical findings are characterized by crater-like depressions at the
crest of the interdental papilla that progress into the marginal
gingiva
a. Surface of the lesion(s) is covered by a gray, necrotized slough
surrounded by an obvious erythematous (red) zone;
interproximal necrosis
b. Bleeding may be spontaneous and will occur even when necrotic
tissue is removed gently
c. Initially, moderate pain increases as the disease advances
d. Strong fetid odor and increased salivation
e. Swelling and tenderness of regional lymph nodes (especially
submandibular nodes)
f. Fever and malaise may be present
2. Radiographic findings—normal, unless the disease has not been
treated and has led to the destruction of supporting structures
(necrotizing ulcerative periodontitis)
3. Causes—predisposing factors are present, with intermediate-sized
spirochetes (Treponema and Selemonas), Fusobacterium, and Prevotella

1168
 intermedia found within the tissue; the primary causative factor is
uncertain; also has been associated with immunosuppression
4. Treatment
a. Debridement for dental biofilm and debris removal—initially by
the clinician and then daily by the client (who may find it
difficult to do because of pain); ultrasonic debridement may be
beneficial
b. Reappoint in 24 to 48 hours to evaluate healing; after removal of
bacterial challenge, rapid response in individuals with normal
immune function; no response in the immunocompromised;
complete and thorough scaling, root planing, and periodontal
debridement performed at this appointment; pain is greatly
reduced if healing has begun
c. The recurrent nature of NUG and the critical role of self-care
practices and frequent continued-care visits must be stressed
d. Antibiotics may be prescribed for the treatment of systemic
symptoms (lymphadenopathy, fever)
e. Suggest soft nutritious diet and the avoidance of spicy foods,
alcohol, and tobacco
B. Necrotizing ulcerative periodontitis
1. Occurs in persons who have human immunodeficiency virus (HIV)
infection or AIDS, other immunocompromising diseases, or severe
malnutrition
2. Characterized by severe soft tissue necrosis and rapid destruction of
periodontal attachment and bone; may lead to the exposure of
alveolar bone and sequestration
3. Chief complaint may be “jaw pain” or “deep aching pain”
4. Can be localized or generalized
5. Treatment requires medical consultation and conventional
periodontal therapy with povidone-iodine irrigation and pain
control; rigorous self-care practices for mechanical biofilm removal
in conjunction with twice-daily 0.12% chlorhexidine mouth rinsing,
judicious use of systemic antibiotics, or both; adjunctive antifungal
therapy, if indicated; more frequent maintenance therapy than
indicated for persons with adult periodontitis

Abscesses of the Periodontium 1

A. Microbiology—Streptococcus viridans is the most common isolate;
similar to microbiota found in deep periodontal pockets
B. Factors associated with abscess formation

1169
 1. Occlusion of pocket orifices or incomplete calculus removal during
treatment of a 2. periodontal pocket
2. Furcation involvement
3. Systemic antibiotic treatment
4. Diabetes mellitus
C. Classification of abscesses of the periodontium
1. Gingival abscess—a localized purulent infection involving the
marginal gingiva or interdental papilla; may have bluish hue; does
not involve the underlying periodontium
2. Periodontal (or lateral) abscess—localized, purulent area of
inflammation within periodontal tissue
a. Clinical findings—the abscess may be:
(1) In the supporting periodontal tissues lateral to the root;
may result in a sinus (fistula) opening through the bone
extending out to the external surface
(2) In the soft tissue wall of a deep periodontal pocket,
adjacent to a periapical lesion, or after deep scaling or
periodontal debridement if incomplete
(3) Acute or chronic
(a) Acute—extreme pain, sensitivity, mobility, enlarged
lymph nodes; the gingival area is edematous, red, and
smooth with a shiny surface; exudate may be expressed
from the gingival margin on pressure
(b) Chronic—usually asymptomatic or episodes of dull
pain; elevation of the tooth; desire to grind on the tooth
(may have acute episodes)
b. Radiographic findings (many variations according to the
location, stage, and extent of the lesion)—typical appearance is
that of a discrete radiolucent area along the lateral aspect of the
root
c. Treatment—debridement with 0.12% chlorhexidine or povidone-
iodine irrigation; antibiotics if fever, swelling, or lymph node
involvement is present; combined periodontic-endodontic
therapy if related to periapical abscess
3. Pericoronal abscess—inflammation of the tissue flap (operculum)
surrounding the crown of a partially erupted tooth; also called
pericoronitis; most common in third-molar areas; may be acute,
subacute, or chronic
a. Clinical findings if acute
(1) An extremely red, swollen lesion with exudate is present
(2) The area is painful; may radiate to the ear, throat, and floor

1170
 of the mouth
(3) A foul taste is present in the mouth
(4) Inflammation may progress so that swelling, inability to
close the jaw, fever, and malaise occur; the symptoms are
less obvious when chronic
b. Cause—accumulation of food debris and bacterial growth
between the soft tissue flap and the tooth; inflammation may be
compounded by trauma from the opposing tooth
c. Treatment
(1) Antibiotics if fever, swelling, or lymphadenopathy is
present
(2) Cleansing of the area (lavage, debridement) and creation
of access for the drainage of the exudate
(3) Frequent rinsing with warm water and return for follow-up
care after 24 hours
(4) Extraction of the involved tooth or removal (excision) of
the soft tissue flap after the pain subsides and the infection
is controlled

Periodontitis Associated with Endodontic Lesions1

Combined periodontal–endodontic lesions—either a deep periodontal
pocket or an endodontic infection may be the cause or the result of the
other, or both may develop independently; require combined endodontic
and periodontic treatment

Developmental or Acquired Deformities and

Conditions1,3
A. Localized tooth-related factors that modify or predispose to dental
plaque–induced gingival diseases and periodontitis
1. Tooth anatomical factors—enamel pearls, furcation, tooth position,
root proximity, open contacts, root abnormalities
2. Dental restorations and appliances—marginal discrepancies,
overhangs
3. Root fractures—periodontal lesions usually accompany vertical root
fractures
4. Cervical root resorption and cementum tears
B. Mucogingival deformities and conditions around teeth; gingival
recession (or gingival atrophy)—exposure of the root surface caused by
an apical shift in the position of the gingiva

1171
 1. The severity of the recession is determined by the actual position of
the gingiva
2. The recession may be partially clinically visible and partially hidden
(covered by inflamed pocket wall)
3. The term recession refers only to the location of the gingiva, not to the
condition of the gingiva; recession of gingiva may be inflamed or
noninflamed
4. Causes—the following factors have been implicated as possible
causative factors:
a. Gingival inflammation
b. Faulty toothbrushing (gingival abrasion)
c. Tooth position
d. Location and amount of pull on margin of frenum attachment
e. Dehiscence
f. Advancing age
5. Clinical significance
a. Exposed roots are susceptible to dental caries and abrasion
b. Wearing away of cementum on the exposed surface exposes
dentin, which may be sensitive to mechanical, chemical, or
thermal stimuli
c. Interproximal recession creates space for the accumulation of
biofilm and debris
6. Treatment—nonsurgical or surgical
a. Removal of causative or risk factors
b. Daily thorough oral self-care practices and periodontal
maintenance
c. Root desensitization, if needed
d. Gingival graft, regenerative or periodontal flap surgery may be
performed
C. Mucogingival deformities or conditions on edentulous ridges—similar
to dentulous areas

Epidemiology of Periodontal Diseases and Related

Risks1,3,5
A. Basic terminology
1. Incidence—number of new cases in an identified population during
a specific period
2. Prevalence—percentage of affected people in an identified
population
3. Extent—number or percentage of teeth or sites affected by a disease

1172
 or condition
4. Severity—degree of severity or advancement of a given disease or
condition
5. Risk factor—environmental, behavioral, or systemic characteristic or
exposure that is associated strongly with a disease, without causality
established; usually confirmed through longitudinal studies
6. Risk indicator—a probable or putative risk factor that has been
associated with a given condition or disease through cross-sectional
studies; not confirmed in longitudinal studies
7. Risk predictor or marker—a factor that has been associated with
future development of a given disease or condition; considered
potentially predictive without established causality
8. Odds ratio—odds represent the ratio of the probability that an event
will occur to the probability that the event will not occur; an odds
ratio of 1.0 means that people exposed to a particular event or factor
are no more likely than a normal, healthy individual to develop that
disease or condition; greater than 1.0 is more likely
B. Natural history of periodontal disease
1. Landmark studies of the natural history of periodontal disease by
Löe and colleagues6 established important features of the disease
a. Severe disease tends to cluster in a small percentage of the
population
b. Pronounced differences in susceptibility to periodontal
destruction can be independent of the environment
2. These studies examined the course of periodontal disease during a
20-year period in two cohorts: Sri Lankan tea workers who were
generally healthy, but had never received dental care and did not
know of toothbrushing, and students and academicians from
Norway who had lifelong dental care and oral self-care education
3. Plaque, calculus, and gingivitis, which were common conditions in
both groups, led to a slow loss of periodontal attachment with
increasing age
4. Periodontal attachment loss progressed at a rate of 0.3 mm per year
in Sri Lanka and 0.1 mm per year in Norway; professional care and
self-care prevented or slowed the progression of disease
5. In the Sri Lankan group with no periodontal therapy, the disease
patterns identified were:
a. No progression beyond gingivitis (11%)
b. Moderate progression of 4-mm attachment loss (81%)
c. Rapid progression of 9-mm attachment loss (8%)
6. Periodontal diseases are most often slowly progressive; however,

1173
 whereas some individuals show no progression even without care,
others show rapid progression
7. Plaque, calculus, and gingival inflammation were present in both
cohorts; thus, studies have identified other risk factors associated
with periodontal disease
C. Current model of pathogenicity
1. All individuals are not equally susceptible to periodontal disease
2. Only a low percentage of sites with gingivitis will develop into
periodontitis
3. Periodontal disease is a highly complex disease, and variations in its
epidemiology can be attributed to both local (environmental) factors
and host susceptibility
D. Epidemiology of periodontal diseases1,3–5
See also the section on “Epidemiology of Oral Diseases and
Conditions” in Chapter 20.
1. Gingivitis
a. Prevalence—large-scale national studies in the United States
have estimated that 50% of adults have gingivitis; this may be
an underestimation because of study designs
(1) Gingival bleeding in at least one site was seen in 63% of
adults
(2) Gingivitis is more prevalent, severe, and extensive in
groups of participants with extensive dental deposits, low
socioeconomic status, limited access to health education
and dental care, less education, and low health literacy, as
well as in adolescents, underserved minorities, and
cognitively and developmentally challenged persons
b. Risk factors—may be environmental or systemic
(1) Systemic conditions that produce vascular changes,
including acute leukemia, hemophilia, Sturge-Weber
syndrome, and Wegener ’s granulomatosis)
(2) Systemic conditions that affect host response, including
diabetes mellitus, Addison’s disease, thrombocytopenia,
combined immunodeficiency diseases, and HIV infection
(3) Systemic conditions related to hormonal changes, such
as pregnancy and puberty
(4) Environmental factors or local factors such as plaque-
retentive factors (calculus, poorly fitting restorations),
tooth malalignment or crowding, and smoking
c. Causative factors—cause-and-effect studied
(1) Dental biofilm is causative in gingivitis—plaque-

1174
 retentive factors such as calculus, incorrect restorative
margins, prostheses, and orthodontics increase risk of
gingival inflammation; gingivitis is preventable in most
people with frequent and effective personal and
professional plaque control measures
(2) Prescription drugs can cause drug-influenced gingival
enlargement, resulting, in whole or in part, from systemic
drug use; these drugs can cause drug-influenced gingival
enlargement, or their effects can be exacerbated by
bacterial plaque
d. Possible influence of diet and nutrition
(1) No direct link has been established between nutrition
and periodontal disease except in the case of scurvy and
severe ascorbic acid (vitamin C) deficiency
(2) The relationship of diet and nutrition to disease
susceptibility, tissue integrity, and defense mechanisms
cannot be ignored
2. Chronic periodontitis1,3,5
a. Prevalence—varies significantly, depending on the population
being treated or untreated; greatest increases in mean CAL
found in untreated groups; U.S. surveys indicate as many as
one in three adults over 30 years of age may have
periodontitis, including only 7.3% moderate to severe forms;
severity is highest in older age groups
b. Risk factors with positive association
(1) Tobacco use—strongest environmental risk factor,
predicts future disease, and inhibits periodontal
treatment outcomes; smokers are more likely to have
periodontitis than nonsmokers; dose related:
development of severe disease increases with number of
cigarettes smoked per day and with years of smoking; all
forms of tobacco implicated; most likely related to effects
on host immune response; smoking has been found to
depress the number of helper lymphocytes, impair
vascularization, inhibit collagen production, increase
collagenase activity, and inhibit healing after periodontal
therapy; although the past effects of smoking on the
periodontium are not reversed, smoking cessation is
beneficial to periodontal health
(2) Diabetes mellitus—in persons with poor metabolic
control and children and teenagers with type 1 diabetes;

1175
 associated with more severe and rapid disease
progression and with poor treatment outcomes
(3) Immunosuppression—especially when HIV converts to
AIDS with CD4 counts below 200/µL and in severely
immunocompromised patients, including those with HIV
infection and AIDS, immunosuppression, leukemia,
hemophilia, neutropenias, uncontrolled diabetes
mellitus, agranulocytosis, Wegener ’s granulomatosis,
Addison’s disease, Sjögren syndrome, Crohn disease,
Sturge-Weber syndrome, Down syndrome, and others;
necrotizing periodontal diseases have been associated
with immunocompromised status
(4) Genetics—studies in twins have shown that genetic
factors contribute significantly to the risk of chronic
periodontitis
(5) Poor oral hygiene increases the risk for greater disease
progression and attachment loss; poor biofilm control
also is related to poor treatment outcomes
(6) Dental factors—sites previously affected by
periodontitis; increased probing depth and loss of clinical
attachment or multiple residual periodontal pockets after
active treatment increase the risk for continued CAL
c. Risk indicators
(1) Age—rate of progression is not related to age; however,
prevalence, severity, and extent are greater in older
groups of people, perhaps because of the cumulative
nature of the disease
(2) Gender—in developed nations, males tend to have a
higher prevalence of periodontal disease than do females
who have access to dental care
(3) Socioeconomic status (SES), education, and access to
dental care—negative association; lower SES, education,
and number of dental visits are related to more
periodontal destruction
(4) Osteoporosis—most likely related to common pathways
shared in the pathogenesis of periodontitis and
osteoporosis
(5) Psychological stress—weakly associated; believed to be
related to behavioral changes and immune system
effects, especially in those who have poor coping skills
(6) Obesity—has been associated with periodontitis; both

1176
 diseases also are associated with other chronic diseases,
such as diabetes and heart disease
(7) Local predisposing factors can be associated with
periodontal disease; tooth-related or iatrogenic factors,
missing teeth, mobile teeth, mouth breathing, and areas
of food impaction increase the risk of periodontal disease
3. Aggressive periodontitis
a. Prevalence—true prevalence and incidence are difficult to
determine because of few longitudinal, prospective, and even
careful retrospective studies, as well as variations in
diagnostic criteria and protocols in larger studies; frequency
of affected individuals increases between puberty and 25
years of age
b. Risk indicators
(1) Race—aggressive periodontitis seems to be more
prevalent among African populations and less prevalent
among Caucasians; however, it is difficult to isolate racial
differences from access to care and socioeconomic factors
(2) Genetics—familial aggregation is found in siblings and
offspring of those who have aggressive periodontitis; the
disease is consistently present in several genetic or
inherited disorders, such as leukocyte adhesion
deficiency, acatalasia, Chédiak-Higashi syndrome, Ehler-
Danlos syndrome, Papillion-Lefèvre syndrome,
hypophosphatasia, and prepubertal periodontitis (see the
section on “Genetics” in Chapter 7)

1177
Changes in the periodontium associated
with disease
See the section on “Inflammation” in Chapter 7.
A. Pathogenesis and stages of the periodontal lesion1,3
1. Pathogenesis—mode of origin or development of a disease; bacterial
virulence factors, constituents, or metabolites that are capable of
disrupting protective host mechanisms or causing disease initiation,
progression, or both are required for the occurrence of periodontal
disease
2. Stage I gingivitis, or initial lesion—2 to 4 days after biofilm
accumulation
a. Changes are not clinically visible; subclinical lesion
b. Histologic changes
(1) Brief vasoconstriction followed by “widening” of small
capillaries (vasodilation), margination, emigration, and
migration of polymorphonuclear neutrophils (PMNs)
(2) Increase in leukocytes, particularly PMNs (neutrophils)
and macrophages, in the connective tissue, junctional
epithelium, and gingival sulcus; neutrophils are the earliest
responders, or the first line of defense, in inflammation
(3) Host systems (e.g., complement and kinin systems and
arachidonic pathways)
(4) Increase in the flow of gingival crevicular fluid into the
sulcus
(5) Inflammatory infiltrate occupies 5% to 10% of the gingival
connective tissue where collagen has been lost
3. Stage II gingivitis or early lesion—begins 4 to 7 days after bacterial
plaque accumulation; may persist for 21 days or longer
a. Clinical signs of gingivitis appear (erythema, edema, and
bleeding on stimulation)
b. Histologic changes
(1) Persistence of inflammation from initial lesion
(2) The sulcular lining is ulcerated (allowing bleeding)
(3) Inflammatory infiltrate in the connective tissue dominated
by lymphocytes (75%); primarily T cells, with some
macrophages, plasma cells, and mast cells
(4) The junctional epithelium becomes densely infiltrated
with inflammatory cells and begins to proliferate into
connective tissue

1178
 (5) Destruction of collagen fibers (especially circular and
dento-gingival) in the infiltrated area; fibroblasts are altered
(6) Migration of leukocytes, macrophages, dendritic cells, and
lymphocytes into the junctional epithelium and the gingival
sulcus
(7) Gingival crevicular fluid peaks 6 to 12 days after clinical
signs of gingivitis
4. Stage III gingivitis or established (chronic) lesion—the period varies;
may persist for months or years without progressing to stage IV
(periodontitis)
a. Clinical changes
(1) Erythema (redness) of the gingiva resulting from
proliferation of capillaries, or a bluish hue superimposed
over the reddened gingiva as a result of congested blood
vessels, sluggish blood flow, or both
(2) Bleeding may occur on probing because of thinning of the
sulcular epithelium, ulceration of the sulcular epithelium,
or both
(3) Color changes begin in the gingival margin and papilla,
then spread to the attached gingiva
(4) Consistency may be soft and spongy or firm; depends on
whether destructive changes or reparative changes within
the gingiva are dominant
(5) Texture may be smooth and shiny (inflammation) or
stippled and nodular (reparative, fibrotic)
(6) Increase in size of gingiva (enlargement)
(7) Increase in depth of the gingival sulcus—may be caused by
enlargement of the gingival tissue only; creates a gingival
pocket or pseudopocket (Fig. 14-4)

1179
 FIG 14-4 Different types of periodontal pockets. A, Gingival
pocket. No destruction of the supporting periodontal tissues
is seen. B, Suprabony pocket. The base of the pocket is
coronal to the level of the underlying bone. Bone loss occurs
horizontally. C, Infrabony pocket. The base of the pocket is
apical to the level of the adjacent bone. Bone loss occurs
vertically. (From Newman MG, et al: Carranza’s clinical
periodontology, ed 12, St Louis, 2015, Elsevier.)

(a) Begins with papillary enlargement

(b) Extends into margins, producing rounded and
bulbous gingival margins
(8) Progression of inflammation orchestrated by the
progression of cytokines
(a) May remain only within gingival tissue (gingivitis)
(b) May extend into supporting periodontal tissue in
stage IV (periodontitis)
Note: Periodontitis must be preceded by gingivitis, but
gingivitis does not always progress to periodontitis
b. Histologic changes
(1) Vascular proliferation and increase in number of B cells
and plasma cells (produced by B lymphocytes) invade the
connective tissue; blood vessels are congested, and blood
flow is impaired
(2) Widened intercellular spaces in the junctional epithelium
contain lysosomes, lymphocytes, and monocytes; pathogens

1180
 such as Aggregatibacter actinomycetemcomitans and
Porphyromonas gingivalis invade host tissues
(3) Periodontal pathogens found in plaque biofilm, such as A.
actinomycetemcomitans, P. gingivalis, and Tannerella forsythia,
produce collagenase and elastinase, enzymes that destroy
connective tissue; A. actinomycetemcomitans, P. gingivalis,
and Treponema denticola also produce a trypsin enzyme that
kills lymphocytes; Prevotella intermedia, Capnocytophaga, and
P. gingivalis degrade antibodies
(4) The junctional epithelium continues to protrude into the
connective tissue; sulcular lining is ulcerated
(5) Collagenase and other enzymes actively break down
connective tissue, resulting in continued loss of collagen
(6) Simultaneous proliferation of collagen fibers and
epithelium (enlargement) occurs
(7) Bone loss has not occurred
5. Stage IV—pathway of inflammation from the gingiva to supporting
periodontal tissue (transition from gingivitis to periodontitis), or
advanced lesion
a. Characterized by loss of connective tissue attachment to teeth,
including gingival and periodontal ligament fibers and their
attachment to cementum, concurrent gingival inflammation,
resorption of alveolar bone, and apical migration of the
epithelial attachment along the root surface (i.e., CAL)
b. Generally follows the course of blood vessels through soft
tissues and into alveolar bone; the pattern of inflammatory
pathway affects the pattern of bone destruction
c. Initially, the inflammation penetrates and destroys gingival
fibers near the gingival fiber attachment to cementum and then
spreads
(1) Interproximally—into bone and the periodontal ligament
(2) Facially and lingually—from bone to the periodontal
ligament, from the gingiva to the periosteum and
periodontal ligament, and from the periosteum into bone
B. Formation of the periodontal pocket1
1. Persistent, chronic gingivitis may progress to periodontitis, which
results in loss of connective tissue attachment, bone destruction, and
periodontal pocket formation
2. Periodontal pocket—pathologic deepening of the gingival sulcus
produced by the destruction of supporting tissue and apical
migration of the junctional epithelium

1181
 3. Classification (see Fig. 14-4)
a. Suprabony pocket—base of the pocket is coronal to the alveolar
crest; also called supracrestal or supra-alveolar pocket
b. Infrabony pocket—base of the pocket is apical to the alveolar
crest; also called intrabony, intra-alveolar, or subcrestal pocket
4. Histopathology
a. The gingival epithelium may show evidence of inflammatory
changes
b. Connective tissue changes
(1) Inflammatory cells infiltrate the connective tissue and
proceed through it
(2) Degeneration of gingival connective tissue fibers; gingival
cells release inflammatory mediators or chemicals that
destroy bone
(3) Tissue invasion by periodontal pathogens
c. Changes within supporting bone as inflammatory process
progresses
(1) Cytokines and effector molecules (e.g., interleukins,
prostaglandin E2 [PGE2], matrix metalloproteinase) have
proinflammatory effects and stimulate osteoclasts that
degenerate mineral content of bone; PMNs, macrophages,
and mononuclear cells degenerate organic matrix of bone
by producing collagenase
(2) Bone marrow component (fatty tissue) is replaced by
inflammatory cell infiltrate, fibroblastic proliferation, and
deposition of collagen fibers
(3) The cortical plate of the interdental septum (crest) is the
first area to be involved
(4) Once this central breakthrough has occurred, supporting
bone is destroyed in a lateral direction; bone loss is
accompanied by both resorption and formation
(5) Periodontal pockets are constantly undergoing repair
C. Common clinical changes associated with periodontitis
1. Similar changes in the gingiva as seen in gingivitis, but usually more
chronic
2. Areas of gingival recession
3. Bleeding on probing
4. Periodontal attachment loss
5. True periodontal pockets
6. Loose, extruded, or migrated teeth; diastemas may develop
7. Exudate from the gingival margin in response to pressure;

1182
 suppuration (pus) is a sign of secondary infection
8. Symptoms—generally painless; client may complain of itching
gums, loose teeth, food impaction, and bad taste; relief is felt with
pressure applied to the gums
9. Furcation involvement
D. Radiographic changes associated with periodontitis (usually follow
this sequence)
1. Fuzziness and discontinuity off the crest of the interdental septum
in the proximal area
2. Wedge-shaped radiolucent area formed between the mesial or distal
aspects of the alveolar crest and the root surface of the involved
tooth; also called triangulation
3. Center of the crestal portion of the interdental septum also becomes
fuzzy, and faint cup-shaped areas of alveolar crest bone loss appear;
bony crater
4. Bone destruction patterns in periodontitis (Fig. 14-5 and 14-6)

FIG 14-5 One-, two-, and three-wall vertical defects on the right lateral
incisor. A, Three bony walls: 1, distal; 2, lingual; and 3, facial. B, Two-wall
defect: 1, distal, and 2, lingual. C, One-wall defect: 1, distal only. (From
Newman MG, et al: Carranza’s clinical periodontology, ed 12, St Louis, 2015, Elsevier.)

1183
 FIG 14-6Angular defects. A, Circumferential vertical defect in relation to
the maxillary canine and premolars. B, Infrabony pockets around the
molars. (From Newman MG, et al: Carranza’s clinical periodontiology, ed 12, St
Louis, 2015, Elsevier.)

a. Horizontal bone loss is most common; bone is reduced in height

but remains parallel to the CEJ of adjacent tooth surfaces
b. Osseous defects or bone deformities
(1) Vertical or angular defects occur in an oblique direction;
most frequently, infrabony pockets accompany vertical
defects
(2) Classified by number of walls; may have one, two, or three
walls
c. Osseous craters are concavities in the crest of interdental bone,
common in posterior segments
d. Bulbous bone or bony enlargements occur as adaptations to
excess function
e. Craters result from complete loss of interdental bone without
loss of radicular bone
5. Limitations of radiographs in the diagnosis of periodontitis
a. The radiograph does not reveal minor destructive changes in
bone
b. The involvement of facial and lingual surfaces cannot be seen
c. Angulation errors can affect radiographic image of alveolar
bone
d. The internal morphology of infrabony craters or defects cannot
be seen
e. As a general rule, bone loss is always greater than that revealed
by the radiograph
E. Periodontal disease activity
1. Refers to the stage(s) of periodontal disease characterized by loss of
alveolar bone and connective tissue attachment
2. Implies that the natural history of periodontal disease has periods of
active destruction and periods of relative inactivity, although chronic

1184
inflammation persists

1185
Bacterial dental biofilm1,3
See the sections on “Microbiology of the Oral Cavity” and “Bacterial
Plaque” in Chapter 9.
A. Definition—complex community of bacteria that forms on any surface
that is exposed to the fluids in the mouth; communication of bacteria
within the biofilm allows for production of byproducts; dense,
noncalcified, highly organized; firmly adherent to teeth or other hard
materials within the mouth; cannot be washed off by salivary or water
flow
1. Biofilms protect bacteria housed within them (sessile), offering
greater potential than freestanding (planktonic) bacteria
2. Microorganisms produce a matrix called glycocalyx and extracellular
proteins that encase and coat bacteria in the biofilm, providing
protection from the oral environment, retentive qualities essential to
being adherent to the tooth surfaces, and pathogenic byproducts
(e.g., dextrans and levans, uronic acid, and others); referred to as the
slime layer
3. The matrix, or slime layer, of a biofilm provides a barrier from
antimicrobial and antibiotic agents, making the biofilm resistant to
chemotherapy
4. The matrix or slime layer provides structure for the biofilm,
nutritional advantages required for growth and maturation of
bacteria within the biofilm, and strength against forces that attempt
to detach bacteria from tooth surfaces
B. Two categories of bacterial plaque—supragingival and subgingival
C. Stages in plaque formation
1. Acquired pellicle
2. Bacterial plaque biofilm
a. Complex microbial community forms, allowing for
communication of bacteria within the biofilm and providing
firm adherence to the tooth and other such surfaces
b. Rate of formation varies from person to person, from tooth to
tooth, and between areas on the same tooth; seen on teeth after
24 to 48 hours without oral hygiene
c. Growth of microcolonies within the matrix and co-aggregation
and adhesion of bacteria allow for increased thickness of the
biofilm; shifts in the types of microorganisms occur; bacteria
deep within the biofilm are more metabolically active and better
protected than those on the surface that can be more easily
dislodged

1186
D. Supragingival versus subgingival plaque biofilms
1. Supragingival plaque
a. As plaque ages, the percentage of gram-positive organisms
decreases
b. As plaque ages, aerobic bacteria decrease and anaerobic
bacteria increase
2. Subgingival plaque
a. Inflammatory changes in the gingival sulcus or periodontal
pocket resulting from supragingival plaque modify the
relationship between the gingival margin and the tooth surface,
creating a protected subgingival area
b. This environment allows subgingival bacteria to colonize and
adhere to other bacteria, the tooth, or the epithelial tissue
surrounding the sulcus or the pocket
c. Pathogenic anaerobic bacteria and spirochetes become well
established in the subgingival plaque biofilm
d. Subgingival plaque may be attached or loosely adherent
(epithelium associated)
(1) Attached subgingival plaque (also called tooth-associated
subgingival plaque)
(a) Similar to supragingival bacterial plaque; inner layers
are dominated by gram-positive rods and cocci and
facultative bacteria; species of the genera Streptococcus,
Veillonella, Prevotella, Neisseria, Gemella, and
Actinomyces
(b) Apical portions are dominated by gram-negative rods,
with some filaments present; secondary colonizers
such as P. intermedia, Capnocytophaga spp.,
Fusobacterium nucleatum, and P. gingivalis co-aggregate
(2) Loosely adherent or unattached subgingival plaque
(a) Extends from the gingival margin apical to the
junctional epithelium, adjacent to the gingival
epithelium or the pocket lumen
(b) Primarily gram-negative rods as well as motile
organisms, filaments, and spirochetes that are not
highly organized; predominance of species such as P.
gingivalis, A. actinomycetemcomitans, T. denticola, P.
intermedia, T. forsythia (formerly Bacteroides forsythus)
(pathogenic), and Capnocytophaga ochracea (beneficial)
e. Bacterial invasion of periodontal tissues
(1) Bacteria have been found within diseased periodontal

1187
 tissue in disease
(2) Widened intercellular spaces in the gingival epithelium or
the pocket lining may allow for the penetration of
organisms from subgingival bacterial plaque
(3) Bacterial invasion may occur, or the presence of bacteria
within the tissue may be a result of displacement or
manipulation rather than actual invasion
(4) Aggregatibacter actinomycetemcomitans and Porphyromonas
gingivalis are believed to be tissue-invading organisms
E. Bacterial specificity
1. Specific plaque hypothesis—suggests that specific combinations of
bacteria communicating with the biofilm cause various forms of
periodontal disease; only certain microorganisms are pathogenic
2. Research is further defining the bacterial causes and host response
effects of destructive periodontal disease
F. Dental calculus—bacterial plaque that has mineralized
1. Calculus plays a secondary role in the etiology of periodontal
diseases by serving as a plaque-retentive factor; not all plaque
necessarily calcifies; all calculus in humans is covered by bacterial
plaque
2. Earliest mineralization occurs along the inner surface of the plaque
or in attached subgingival plaque; calcium and phosphorus come
from the saliva for the mineralization of supragingival calculus and
from the gingival crevicular fluid (GCF) for the mineralization of
subgingival calculus
3. Its porosity serves as a reservoir for bacteria and endotoxins that are
destructive to the periodontium; impossible for the client to remove
4. Modes of attachment to teeth
a. By acquired pellicle
b. By direct attachment of the calculus to the tooth surface;
penetrates cementum
c. By mechanically locking into tooth surface irregularities
5. Effect on the periodontium—because bacterial plaque always covers
calculus, it is primarily a bacterial irritant (not mechanical); calculus
plays a significant role as a secondary, contributing factor in the
pathogenesis of periodontal disease; a plaque-retentive factor
G. Pathogenic effect on periodontium (see the sections on “Acute
Inflammation” and “Chronic Inflammation” in Chapter 7)
1. Bacterial plaque biofilm contributes to periodontal breakdown by
direct injury to tissue and by stimulating host-mediated responses
that result in tissue injury

1188
 2. Direct injury is caused by toxins and enzymes produced by bacteria
and proinflammatory metabolic byproducts of bacterial metabolism;
most significant pathologic effects during the early stages of disease
a. Exotoxins are proteins and other metabolic byproducts such as
hydrogen sulfide, uric acid, and fatty acids released by
organisms that cause direct injury to tissue
b. Endotoxins called lipopolysaccharides or cytotoxic agents are
cellular components of gram-negative bacteria that are toxic to
surrounding cells, contribute to the inflammatory process, and
induce bone resorption; endotoxins are released from the cell
wall on the death of gram-negative bacteria, initiating
inflammation and tissue destruction
c. Enzymes—mainly proteases, collagenase, hyaluronidase,
chondroitin sulfatase, fibrinolysin, and phospholipase A—
directly degrade surrounding tissue and penetrate by breaking
down structural barriers
3. Indirect toxicity results when subgingival bacteria act as antigens
and a resultant local immune reaction occurs; the host response
attempts to control the bacterial attack, and some destruction of
tissue results by a variety of immunopathologic reactions
H. Host response—protective (see Figs. 7-1 to 7-4 in Chapter 7); host-
mediated destructive processes play a role in the cause of inflammatory
periodontal infections once the protective elements of the periodontium
are overwhelmed
I. Host response—destructive
1. Cytokines, including interleukins and PGE2, participate in
periodontal pathologic changes; these low-molecular-weight (LMW)
proteins are produced by fibroblasts and inflammatory cells (e.g.,
monocytes, lymphocytes); lipopolysaccharide (LPS) stimulates
cytokines
2. Collagenase and lysosomal enzymes destroy connective tissue
3. Aspartate transaminase (AST, aspartate aminotransferase)—an
intracellular enzyme that indicates cell death or tissue destruction
when present extracellularly
4. Elevated levels of host-derived enzymes (e.g., collagenase, AST, β-
glucuronidase, elastase) in GCF can be used as markers for
periodontitis
5. Tumor necrosis factor alpha (TNF-α)—an inflammatory mediator
that contributes to bone resorption; shares properties with
interleukins
6. Matrix metalloproteinase (MMP)—produces collagenase

1189
contributing to CAL

1190
Clinical assessment of the periodontium1,4
A. Indices—system for documenting clinical observations to help clients
become aware of their current status, to demonstrate changes in the
client’s health over a certain period, and to survey large populations for
current status and trends in health (see Table 20-6 in Chapter 20)
B. Periodontal documentation
1. Used to document existing periodontal status; baseline for future
reference
2. Updated periodically to determine changes in periodontal health or
disease progression
3. Necessary for care planning
4. Serves as a guide for the clinician during treatment and evaluation
5. Serves as a legal document; a risk management technique to reduce
risks associated with failure to diagnose and treat periodontal
disease
C. Periodontal assessment—complete periodontal documentation should
be based on a thorough periodontal assessment, which includes the
following:
1. A description of gingival tissue—includes visual signs of
inflammation
2. Findings from examination of the periodontium with a periodontal
probe (see the section on “Instrumentation for Assessment” in
Chapter 17), which include the following:
a. Presence of bleeding—widely accepted as an indicator of
gingival inflammation; more sensitive than visual signs;
however, inflamed sites do not always bleed, and bleeding is a
poor predictor of attachment loss (only 30%), unless multiple
sites are found in conjunction with deep pockets, attachment
loss, or both; these combined conditions help make important
risk prediction for attachment loss
b. Probing depth (also called sulcus or pocket depth)—gives a
historical record of past periodontal disease activity; useful in
monitoring the success of periodontal therapy; important in
determining client’s ability to maintain health through plaque
biofilm control; the periodontal probe remains the best
diagnostic aid for detecting periodontal pockets and CAL
c. Clinical attachment level (CAL)—measures from the CEJ to the
attachment; determines the amount of apical migration of the
junctional epithelium or the amount of lost periodontal
connective tissue attachment to the tooth; most accurate

1191
 measure of severity of periodontal disease because the
measurement is not influenced by the position of the gingival
margin influenced by inflammation and recession, and because
CEJ is a static reference point when measuring CAL
(1) Because the gingival attachment is located slightly apical
to the CEJ in a fully erupted tooth, and the gingival margin
is slightly coronal to the CEJ in normal gingival contour,
probing depth will be slightly greater than CAL
(2) When gingival recession is present and the gingival margin
is apical to the CEJ, the probing depth will be less than
CAL; therefore, a normal sulcus depth can be present in an
area of connective tissue and bone loss
(3) If the gingival margin meets the CEJ, the probing depth
and CAL are equal
d. Recession—measured from the CEJ to the gingival margin;
indicates apical migration of the gingiva
e. Presence of purulent exudate (suppuration)—in response to
lateral digital pressure on the gingival margin or probing;
suggests advanced lesion of periodontitis and secondary
infection at site
f. Adequacy of width of attached gingiva—measured from
attachment to mucogingival junction; the amount varies,
depending on location; adequate zone necessary to withstand
stresses from mastication; if none is present, the gingival
margin will move with alveolar mucosa; if inadequate, a
mucogingival problem or defect exists
3. Alternatives to use of standard periodontal probe for periodontal
examination1 (see the section on “Periodontal Assessment” in
Chapter 15)
a. Periodontal screening and recording system (PSR)—provides
thorough screening and recording for all clients while saving
time in recording aspect of initial examination
b. Electronic periodontal probes—increase accuracy by reducing
the margin of error, standardizing pressure, or both; reduce
time required for probing and recording
4. Presence and distribution of bacterial plaque and calculus (may use
indices)
5. Condition of tooth proximal contacts—loose or open contacts permit
food impaction
6. Degree of pathologic tooth mobility (see “Periodontal Assessment”
in Chapter 15 for a specific classification system)

1192
 a. Pathologic tooth mobility is caused by loss of periodontal
support (bone loss), trauma from occlusion, inflammation
extending into the periodontal ligament from the gingiva or the
apex (abscesses), periodontal surgery (temporarily), hormonal
changes associated with pregnancy and sometimes
menstruation or use of hormonal contraceptives, and pathologic
processes of the jaws that destroy the bone or roots of teeth
(e.g., osteomyelitis, tumors)
b. Tooth mobility is usually assessed by using the blunt ends of
the handles of two dental instruments (single-ended); can be
measured electronically
7. Presence of furcation involvement (see “Periodontal Assessment” in
Chapter 15 for a specific classification system)
8. Presence of malocclusion or malposition of teeth
9. Presence and condition of dental restorations and prosthetic
appliances; missing teeth; dental implants
10. Presence of overhanging restorations (overhangs)—contributing
causative factor in periodontal disease from accumulation of
bacterial plaque and food impaction
11. Assessment of disease progression by longitudinal comparison of
probing depths, attachment levels, and interproximal bone height
(radiographic)
12. Interpretation of a satisfactory number of bitewing and periapical
radiographs of diagnostic quality (see the section on “Radiographic
Interpretation” in Chapter 6)
a. Level of alveolar crest in relation to the CEJ and interdental
bone
b. Furcation areas
c. Width of periodontal ligament space
d. Existing dental restorations and caries
e. Periapical disease
f. Length, shape, and position of roots
D. Documentation of oral habits
1. Bruxing (grinding) or clenching of teeth
2. Chewing on fingernails or foreign objects
3. Smoking or drinking (alcohol) habits
4. Temporomandibular joint (TMJ) trauma (evidenced by crepitus,
tenderness, or deviations)
E. Assessment of occlusion—includes:
1. Classification and anterior relationships
2. Excessive wear patterns (facets)

1193
 3. Defective prematurities—isolated occlusal contacts that cause
deflection in the pathway of physiologic mandibular movement
4. Teeth, restorations, or prosthetic appliances that may interfere with
the normal movements of the mandible
5. TMJ discomfort
6. Fremitus—vibration of root surfaces as the client “taps” teeth
together
7. Tooth sensitivity to pressure and to hot and cold substances
F. Classification of occlusal trauma1
1. Primary occlusal trauma—trauma results from excessive occlusal
forces when periodontal support is normal; result could be mobility,
excessive wear of a tooth or teeth, sensitivity of involved teeth, or
fremitus
2. Secondary occlusal trauma—the supporting periodontium is not
normal (some loss of supporting structures because of
periodontitis); one or more teeth are not able to withstand even
normal occlusal forces, and particularly excessive occlusal forces;
could result in mobility or sensitivity
G. Additional information obtained through client interview
1. Complete documentation of the client’s past and current health
status, including pharmacologic history and risk factors
2. Complete documentation of the client’s dental, fluoride, social, and
cultural histories
3. Client’s daily oral hygiene routine
4. Client’s knowledge level and attitude toward oral health
H. Supplemental diagnostic tests1
1. Traditional approach to periodontal diagnosis measures only the
results of periodontal inflammation and destruction; the goals for
developing newer diagnostic approaches include the ability to detect
the presence of disease early to predict destruction before it occurs;
prognostic devices or tests also are able to assess the risk of disease
2. Validity of a diagnostic test is determined by calculating its
sensitivity and specificity
a. Sensitivity—the probability of a test being positive when a
disease truly is present
b. Specificity—the probability of a test being negative when a
disease truly is not present
c. Predictive value—refers to the probability that a disease will be
present when the test is positive or not present when the test is
negative; influenced by the prevalence of disease in a particular
population

1194
3. Prognostic device or test—predicts the likelihood that a disease will
occur in the future
4. Supplemental diagnostic tests can be used for screening (to separate
the diseased from healthy individuals) or to detect sites or
individuals at high risk for progressive disease
5. General categories of supplemental diagnostic tests (microbiologic
monitoring)
a. DNA (deoxyribonucleic acid) probes—paper points are inserted
into specific site(s) and sent to a laboratory for analysis of
presence of eight known pathogens to provide general
information useful in antibiotic selection in refractory or
aggressive cases
(1) Culturing—plaque samples from specific sites are placed
in a vial containing transport medium and sent to a
laboratory for analysis; specific percentages of various
bacterial species are identified with specific
recommendations for antibiotic
(2) Enzyme-linked immunosorbent assay (ELISA)—matches
sample DNA and bacterial antigens to periodontal
pathogens; used in research rather than in clinical practice
b. Bacterial risk assessment test (BANA)—tests three anaerobes
typically associated with periodontal disease risk; based on
chairside incubation and testing of samples of subgingival
biofilm
c. Local measures of host response;1 host-derived enzymes in GCF,
which are produced by inflamed pocket wall and primarily
composed of inflammatory cells and serum proteins as well as
inflammatory mediators and tissue breakdown and bacterial
byproducts (e.g., collagenase, PGE2, AST)
d. Genetic testing—determines genotype status through an in-
office test for periodontal disease susceptibility (see the section
on “Genetics” in Chapter 7)
e. Automatic calculus detection systems
(1) Fiberoptic probe—lights up and sounds when subgingival
calculus is detected
(2) Periodontal endoscope—a specific type of endoscopy used
to explore and visualize the root surface, periodontal
pocket, and furcation areas
f. Risk assessment tool—Internet-based periodontal risk calculator
that assesses a person’s risk for periodontal disease on the basis
of nine weighted risk factors

1195
Systemic effects of periodontal disease1,3
A. Periodontal disease is a chronic inflammatory response to a given
stimulus (virulent bacteria in biofilm) that has been associated with
increased risk for conditions such as myocardial infarction, stroke,
cardiovascular disease, peripheral vascular disease, adverse pregnancy
outcomes, and pneumonia; a relationship between periodontal disease
and these diseases has been documented, although a cause-and-effect
connection has not been established
1. Periodontal infection presents a chronic inflammatory burden at the
systemic level
2. Bacterial pathogens released from biofilm in the periodontal pocket
enter tissues through ulcerations in the pocket epithelium and
colonize other body parts; systemic exposures to these gram-
negative pathogens and LPS trigger inflammatory mediator
expression in the affected tissues (i.e., release of proinflammatory
mediators and acute-phase proteins), contributing to systemic
inflammation, atherogenesis, and other pathology
3. Client-based clinical outcomes such as disease morbidity and
mortality and surrogate markers (e.g., serum inflammatory markers
such as cross-reactive protein) are used instead of traditional
markers or outcomes (e.g., bleeding, pocket depth)
B. Research into the associations between periodontal diseases and the
occurrence and severity of systemic diseases and conditions is ongoing.

1196
Treatment1,3,6
Initial Care Plan
See the section on “Planning” in Chapter 15.
A. Collection of data to assess the status of the periodontium (see the
previous section on “Clinical Assessment of the Periodontium”)
B. Formulation of initial care plan based on data collection and
assessment
1. Determination of all causative and contributing factors (risk factors
and risk indicators)
2. Removal or control of etiologic and risk factors in an organized,
logical sequence
a. Plaque removal and control and removal of any plaque-retentive
factors
b. Reduction, control, or elimination of risk factors
c. Elimination of inflammation; pocket reduction or elimination
3. Order of treatment will depend on:
a. Severity of the client’s periodontal condition and prognosis
b. General health status of the client
c. Client’s motivation, cooperation, needs, and desires
C. Contributing factors influencing the prognosis
1. Local factors
a. Degree of periodontal destruction (amount of attachment loss)
b. Rate of periodontal destruction (amount of attachment loss per
unit of time)
c. Presence of contributing local factors (e.g., malocclusion,
parafunctional habits, position of teeth in alveoli, malalignment,
root proximity, missing teeth)
d. Quality of restorations present
2. Risk factors—related to the client’s general health (presence or
absence of systemic disease), factors affecting host response, and
environmental factors (stress, smoking)

Preventive Therapy or Treatment of Biofilm-Induced

Gingivitis
A. Control biofilm—client co-involvement in daily self-care; remove
biofilm-retentive factors
1. Address risk factors
2. Oral prophylaxis (versus nonsurgical periodontal therapy for

1197
 periodontitis)
a. The objective is to prevent the initiation of gingivitis and, failing
that, to prevent the conversion of gingivitis to periodontitis;
therapeutic goal of oral prophylaxis is to establish gingival
health through the elimination of causative factors
b. Performed for clients with healthy periodontium or with
gingivitis; NSPT is performed for clients with loss of periodontal
support
c. Oral prophylaxis includes supragingival and subgingival
debridement to remove deposits; removal or correction of
biofilm-retentive factors; and coronal polishing, if necessary, for
stain removal or for client satisfaction
3. The term scaling refers to supragingival or subgingival calculus
removal without intentional removal of tooth surface
B. Nonsurgical periodontal therapy (NSPT); also called initial therapy or
phase I therapy);1,3,6 (see the section on “Concepts in Periodontal
Instrumentation” in Chapter 17)
1. Objective—to treat and manage established periodontal disease and
to create conditions conducive to health
2. Principles—elimination or suppression of pathogenic
microorganisms through the removal and control of biofilm and its
retentive factors (e.g., calculus, overhangs, food impaction, improper
contacts); control of the infection and prevention of reinfection;
resolution of inflammation
a. Oral hygiene self-care, including plaque biofilm removal and
control
b. Periodontal instrumentation—scaling, root planing, periodontal
debridement
c. Adjunctive use of antiplaque and antigingivitis agents, as
indicated (Table 14-1)

1198
 Table 14-1
Local Chemotherapy for Prevention and Control of Oral Diseases or Conditions

3. Consider and, if possible, control behavioral, systemic, and

environmental host risk factors
4. Restoration or maintenance of comfort, function, and esthetics
5. Decreasing the likelihood of disease progression
C. Components of NSPT
1. Dental biofilm control—client as co-therapist: self-care, goal setting,

1199
 long-term commitment; customized oral hygiene instruction,
correction of biofilm-retentive factors, and supragingival and
subgingival debridement; antimicrobial or antigingival agents or
devices may be used as adjuncts to mechanical self-care methods;
long-term success of NSPT depends on adequate biofilm control and
regular periodontal maintenance visits
2. Adequate periodontal instrumentation for removal and control of
biofilm and biofilm-retentive factors
a. Rationale—periodontal instrumentation and biofilm control
result in a significant reduction of gram-negative periodontal
pathogens and encourage repopulation with the gram-positive
microorganisms that are associated with health; a reduction in
inflammatory cytokines responsible for tissue damage occurs
after the bacterial composition is altered; calculus, overhanging
restorations, and other biofilm-retentive factors that harbor
bacterial plaque also are removed; all these components of
NSPT reduce inflammation, promote tissue regeneration, and
create a biologically acceptable root surface; control, alteration,
or elimination of risk factors (e.g., diabetes, smoking, stress,
medications) alters the host response to bacterial pathogens and
has the potential to slow periodontal disease progression
b. Supragingival and subgingival scaling, periodontal
debridement, root planing, or a combination of all is performed;
all these procedures are technically demanding; definitive
treatment procedures are designed to remove cementum or
surface dentin that is diseased, embedded with calculus, toxins,
or microorganisms; treatment often requires local anesthesia;
when performed thoroughly, some soft tissue removal, termed
incidental curettage, is unavoidable; in the case of root planing,
the need for extensive cementum removal to obtain a glassy,
smooth surface is debatable because of a lack of clarity about its
absolute necessity, the possibility of overtreatment, and
resultant hypersensitivity
(1) Complete removal of calculus from root surfaces is
unlikely, especially as pocket depth and inaccessibility
increase; complete removal of detectible calculus remains
the initial clinical end point because thorough
instrumentation remains paramount to the success of
therapy, whether nonsurgical or surgical
(2) The areas most susceptible to residual deposits after
treatment include furcations, line angles, root concavities,

1200
 and the CEJ
c. NSPT most often requires multiple appointments after
assessment for treatment (e.g., four appointments 1 week apart
for a quadrant therapy approach) to remove or correct all
detectible deposits and plaque-retentive factors; some evidence
suggests longer appointments within 24-hour and 48-hour
periods for complete mouth debridement, termed full-mouth
disinfection, are necessary to reduce cross-contamination from
untreated areas to treated areas
d. Hand-activated or mechanized instruments (sonic, ultrasonic)
may be effectively used for root planing and periodontal
debridement; ultrasonic instruments are advocated for
debridement and associated lavage
e. NSPT has been shown to be successful in treating early to
moderate periodontitis, especially for initial pocket depths of 4
to 6 mm; results are less predictable in periodontal pockets
more than 6 mm in depth, if tooth movement occurs, or when
furcation involvement is present; NSPT is the definitive
treatment for early to moderate periodontitis and an initial
therapy for those expected to require surgical therapy
f. Root planing in healthy sulcus areas or shallow crevices is
contraindicated; has been shown to cause a loss of attachment
in crevices less than 3 mm
g. Use of lasers in periodontics appears to be equally effective to
traditional instruments for scaling, root planing, and
periodontal debridement
3. Initial evaluation of NSPT—occurs during and on completion of
instrumentation by careful tactile exploration of tooth and root
surfaces; a clear field, adequate illumination, and use of air to
facilitate assessment are required
a. The term periodontal debridement refers to treatment of
periodontal disease through mechanical removal of tooth and
root surface irregularities (including biofilm, clinically
detectable calculus, and all biofilm-retentive factors) depending
on the health of adjacent soft tissue
b. The difference between periodontal debridement and root
planing, as used in the literature, is in the desired initial end
point and the extent of instrumentation; root planing is
performed until root smoothness is obtained with reasonable
time and effort, whereas debridement attempts to preserve
tooth surface by removing only enough deposits and biofilm-

1201
 retentive factors to achieve periodontal health; “periodontal
debridement” is used on national certification examinations for
dental hygienists
4. Ultimate evaluation of NSPT—tissue response (i.e., elimination of
inflammation and bleeding)
a. Thorough reevaluation 4 to 6 weeks after scaling, root planing,
or periodontal debridement to determine the need for
additional therapy (e.g., surgery, physician referrals,
antimicrobials, antibiotics) by means of a periodontal
examination; it is critical to determine if clinical judgment
regarding the extent of root planing and periodontal
debridement was adequate to achieve periodontal health; if
unsuccessful, retreatment is indicated; 4 to 6 weeks is
considered appropriate for the resolution of inflammation and
periodontal tissue healing; relevant findings of the reevaluation
are documented in the patient’s legal treatment record
b. Reevaluation includes:
(1) Evaluation and reinforcement of the client’s self-care
(2) Updated periodontal assessment, including bleeding
points, probing depths, and attachment levels
(3) Reassessment of the clinical health of tissues; if areas still
show signs of inflammation, the cause should be
determined
c. Bacterial plaque and calculus self-care should be reviewed;
perform scaling, debridement, or root planing as indicated if the
condition is localized; the need for rescheduling and
retreatment with active therapy should be determined if the
condition is generalized
(1) If no plaque, calculus, or inflammation is noted, the
client’s success is reinforced and the importance of
periodontal maintenance emphasized
(2) If the pocket depth is still moderate to severe, controlled
drug delivery and surgical procedures might be warranted;
the client must be referred for evaluation by a periodontist
(3) If inflammation and bleeding are still severe, unexplained,
or generalized, physical examination by a physician should
be considered, including differential blood counts and
complete physical examination for a possible previously
undetected or undiagnosed systemic host condition
D. Use of topical antimicrobial agents as adjuncts (see the section on
“Mouthrinses or Chemotherapeutics” in Chapter 16); also referred to as

1202
local chemotherapy; can be employed in preventive therapy, in initial or
nonsurgical therapy, during the healing stage following periodontal
surgery, or during continuing care for periodontal health maintenance
1. Indicated for control of supragingival biofilm and gingivitis;
effectiveness in periodontitis has not been documented; used to
augment oral self-care efforts that are only partially effective; also
recommended for extensive restorative cases and dental implants;
aids healing after periodontal surgery (see the sections on “Oral
Irrigation” and “Dental Implant Maintenance” in Chapter 16)
2. Antiplaque and antigingivitis agents (see Table 14-1)
a. Chlorhexidine gluconate
(1) Most effective antimicrobial agent for reducing plaque and
gingivitis in the long term (45% to 61%); the “gold
standard” for topical antimicrobial mouthrinses; 0.12%
concentration in the United States and 0.2% outside the
United States
(2) High substantivity—ability to adhere to soft and hard
tissues for a long duration while releasing active ingredient;
a cationic bisbiguanide that ruptures bacterial cell
membranes
(3) Adverse effects—staining, reversible desquamation, poor
taste or alteration of taste, increase in supragingival
calculus deposits; especially with long-term use
(4) Alcohol content 11.6%, or alcohol-free form available
(5) Twice-daily use promotes compliance; client should be
instructed to use 15 mL of rinse for 30 seconds; rinse should
be separate from fluoride dentifrice by 30 minutes for full
effectiveness
(6) Also recommended for wound healing after surgery or as
pre-rinse to reduce salivary bacterial load and aerosols
during periodontal therapy and mechanized
instrumentation
b. Phenolic compounds (essential oils)
(1) Antiseptic form is a safe and effective antimicrobial and
antigingivitis agent (e.g., Listerine Antiseptic)
(2) Long-term studies indicate approximately 30% to 45%
reduction in plaque and gingivitis
(3) Available antiseptic products have variable alcohol content
(21.6% to 26.9% alcohol); thymol, menthol, eucalyptol, and
methyl salicylate are active ingredients; act by bacterial cell
wall disruption and inhibition of bacterial enzymes

1203
 (4) Adverse effects—burning sensation and bitter taste; some
report soft tissue irritation; caution with significant
xerostomia and recovering alcoholic clients; some
formulations have high alcohol content; some are now
alcohol free; however, they are for reduction of halitosis
rather than as an antiseptic antigingivitis agent
(5) Twice-daily use promotes compliance; client should be
instructed to use 15 mL of rinse for 30 seconds after
brushing
(6) Also recommended as preprocedural rinse to reduce
salivary bacterial load and aerosols during periodontal
therapy and mechanized instrumentation
c. Triclosan
(1) Food and Drug Administration (FDA) approval as a safe
and effective antimicrobial and antigingivitis agent (e.g.,
Colgate Total)
(2) A bisphenol that has broad-spectrum antimicrobial
activity, especially when combined with zinc citrate or with
a co-polymer to increase substantivity and to provide some
anticalculus properties
(3) Dentifrice formulation promotes compliance; shown to
reduce biofilm formation and gingivitis by 30 to 45%; can be
combined with fluoride, unlike other antimicrobial agents,
which often are not compatible
2. Other agents used in periodontal therapy
a. Povidone-iodine
(1) An iodophor with polyvinyl-pyrrolidone added to iodine;
effective against many organisms, including bacteria,
viruses, and fungi
(2) Primarily used as a preprocedural rinse or during
mechanized instrumentation for antiseptic lavage or
irrigation; often recommended for use during treatment of
immunocompromised clients who might have multiple
organisms affecting their oral health; can be effective
antimicrobial and antigingivitis agent, but only with short-
term use
(3) Adverse effects—concern for iodine toxicity with
prolonged use; contraindicated in those with iodine
sensitivity or allergy, thyroid dysfunction and pregnant or
lactating women; temporary extrinsic tooth staining
b. Stannous fluoride

1204
 (1) Antimicrobial mechanism of action appears to be related
to the stannous (tin) ion rather than fluoride
(2) Long-term studies have shown significant reductions in
gingivitis without concurrent significant reductions in
biofilm and gingival inflammation
(3) Available in dentifrice; in gel form; or in rinses containing
0.63% concentrations; however, the dentifrice and gel forms
are most effective
(4) Stannous fluoride has low to moderate substantivity,
depending on concentration; twice-daily use promotes
compliance
(5) Adverse effects may include unpleasant taste in the mouth
and tooth staining after prolonged use (2 to 3 months) in
some individuals
(6) Stannous fluoride has the American Dental Association
(ADA) Seal of Acceptance for anticaries activity; the
dentifrice formulation has been approved for plaque-
reducing and gingivitis-reducing properties; dentifrice and
gels also approved for dentinal hypersensitivity reduction
c. Quaternary ammonium compounds (cetylpyridinium chloride)
(1) The most common formulation is cetylpyridinium chloride
used alone or with domiphen bromide; cationic surface
active agents rupture bacterial cell walls; the compound
binds to oral tissues but releases rapidly, which may limit
its substantivity and therefore effectiveness in the oral
cavity
(2) Six-month studies show 14% to 24% reduction in bacterial
biofilm and gingivitis; the therapeutic value of the product
is questionable
(3) Has benefit in reducing halitosis; often alcohol free
(4) Adverse reactions are minimal; may include possible
slight staining
d. Oxygenating agents—hydrogen peroxide: anti-inflammatory
properties decrease the clinical signs of inflammation, but
bacterial pathogens may not be reduced; studies do not support
long-term use of 100% hydrogen peroxide as oral rinse; ration
with water 1:1 recommended as maximum; safety issues such as
tissue injury and co-carcinogenicity have been raised with long-
term use of hydrogen peroxide
e. Oxidizing agents (chlorine dioxide, zinc)—have no therapeutic
value but are recommended for breath freshening and to reduce

1205
 halitosis; reduce volatile sulfur compounds (VSCs) that are
believed to be responsible for halitosis
3. Methods for topical delivery of antimicrobial agents
a. Mouthrinses, dentifrices, and gels deliver agents
supragingivally; subgingival penetration is 0 to 1 mm—most
common method
b. Oral irrigation can deliver agent subgingivally; complete plaque
removal is not achieved, but periodontal pathogens found in
loosely adherent plaque can be removed; recommended as an
adjunct to mechanical biofilm control; often used during the
maintenance of periodontal health after completion of active
periodontal therapy; pulsating oral irrigators may be used as
water flossers
c. Oral irrigation can be accomplished with water or antimicrobial
agents; both reduce bleeding and gingivitis, but antimicrobials
are more effective in removing bacterial plaque and making it
less pathogenic; effect on periodontitis is not well documented
d. Depth of penetration with oral irrigation is related to type of tip
used; standard jet tip is shallow; subgingival tip 6 mm or less;
cannula deepest but concern for patient safety
e. Oral irrigation can have value in conjunction with daily self-care
regimen for mechanical plaque biofilm removal in the treatment
of gingivitis or in periodontal maintenance therapy
f. Professionally administered oral irrigation, with and without
root planing and periodontal debridement, has been studied;
the main benefit is from mechanical debridement; a single
application of an antimicrobial irrigant has little value because
of low substantivity in the periodontal pocket
E. Sustained-release, local drug delivery systems (also called controlled
drug delivery)1
1. Systems are available for site-specific, sustained, local delivery of
antibiotics or antimicrobials to specific subgingival sites (e.g., gels,
chips, collagen film, bioabsorbable materials); the objective is to
eliminate periodontal pathogens; these methods of local delivery
provide the benefits of antibiotic or antimicrobial therapy with
greater safety and compliance; delivery mechanisms allow the
antibiotic or antimicrobial agent to be delivered for up to 14 days
(varies by product) after placement; controlled delivery releases the
material’s active ingredient over time, maintaining a constant and
sufficient release of the active ingredient
2. Controlled delivery offers the advantage of sustained release of a

1206
 high concentration of the active ingredient to the site of periodontal
infection without systemic involvement; can be used in conjunction
with scaling, debridement, and root planing during initial
periodontal therapy in pockets greater than 5 mm with bleeding on
probing, at reevaluation for recalcitrant sites, or during continuing
care for localized sites needing adjunctive therapy for the
maintenance of periodontal health; few use these systems as a
monotherapy
3. Contraindicated in the presence of allergy to the active ingredient or
to any component of the delivery system and during pregnancy or
lactation; not useful for treatment of generalized diseased sites
4. Studies have shown that these controlled delivery systems result in
improved clinical attachment levels or probing depths of 2 mm or
greater at 30% to 40% of sites treated in multiple-center, randomized
clinical trials, a level considered both statistically and clinically
significant
5. Examples of available sustained-release systems for subgingival
application used most often in conjunction with scaling and root
planing
a. Chlorhexidine chip—2.5-mg chlorhexidine gluconate in a
hydrolyzed gelatin biodegradable film; self-retentive on contact
with moisture, placed using cotton pliers
b. Minocycline hydrochloride microspheres (2%)—consist of
antibiotic minocycline hydrochloride in a bioabsorbable
polymer of poly-D, l-lactide-CO-glycolide; microspheres are
dispensed subgingivally from a capsule placed in a syringe; the
tip is inserted into the base of the pocket and then withdrawn
after the drug has been applied
c. Doxycycline hyclate gel (10%)—solidifying liquid, biodegradable
polymer that hardens after exposure to fluid in the periodontal
pocket; delivered by injection from a syringe with a blunt
cannula inserted into the pocket; common use is with scaling
and root planing
F. Use of systemic antibiotics1,3—drugs that target the bacterial load
1. Sometimes used in conjunction with periodontal therapy (surgical or
nonsurgical); however, no evidence that antibiotics alone arrest
periodontal disease exist; may be prescribed for clients who are
nonresponsive to periodontal therapy, acute periodontal infections
with systemic manifestations, for prophylaxis in medically
compromised clients, and in conjunction with surgical or
nonsurgical therapy when systemic health or classification of

1207
 periodontal disease warrants use after consideration of risks and
benefits
a. Generalized recurrent or refractory periodontal disease despite
appropriate treatment—often related to impaired host
resistance or persistent, superinfecting microorganisms
b. Aggressive forms of periodontitis—related to neutrophil
defects and tissue-invasive microorganisms (A.
actinomycetemcomitans and P. gingivalis)
c. Acute, severe infections (e.g., periodontal abscess, NUG)—
especially with fever, malaise, lymphadenopathy, or other
systemic signs and symptoms
d. Immunocompromised status—used with extreme caution to
avoid development of resistant strains
2. Not recommended for the routine treatment of gingivitis or chronic
periodontitis; problems such as adverse drug reactions, drug
hypersensitivity, development of antibiotic-resistant strains,
interactions with other prescribed medications taken by the client,
and client nonadherence limit widespread use; the Centers for
Disease Control and Prevention (CDC) recommends judicious use of
antibiotics because of growing concerns about overuse and
consequently the development of drug-resistant strains of bacteria,
which has led to a resurgence of diseases previously well controlled
by antibiotics (e.g., tuberculosis, staphylococcal infections,
diphtheria); particular concerns about use in pregnant or lactating
women do exist, and a higher risk of drug interactions is present
with long-term use of cardiovascular disease, asthma, seizures, and
diabetes medications
a. Common side effects include nausea, vomiting, diarrhea, rashes,
changes in vaginal or intestinal flora, and allergy; prolonged use
can be associated with bleeding problems
b. Specific reactions include the disulfiram (Antabuse) effect of
metronidazole taken with alcohol, discoloration or deformed
teeth with tetracycline use in children under 8 years of age, and
increased risk of pseudomembranous colitis with clindamycin
3. Restricted use and careful selection are indicated on the basis of
response to mechanical therapy, medical history analysis, possible
drug interactions, and risks; indiscriminate use is prohibited;
microbial analysis, antimicrobial sensitivity testing, or a
combination of both before prescribing systemic antibiotics for
periodontal therapy is recommended
4. Common agents include tetracylcines (doxycycline), nitroimidazoles

1208
 (metronidazole), lincomycins (clindamycin), quinolones
(ciprofloxacin), and macrolides (azithromycin but not erythromycin);
combination therapy includes metronidazole and amoxicillin or
metronidazole and ciprofloxacin; the combination is synergistic and
increases the spectrum of drug activity; penicillins and
cephalosporins are not considered drugs of choice
G. Use of host-modulating drugs;1,3 host response is the target
1. While studies of nonsteroidal anti-inflammatory drugs (NSAIDs),
bisphosphonates, and most recently, lipoxims and resovins have
shown proof of concept, only low-dose doxycycline has been FDA
approval for treatment of periodontal disease.
a. Subantimicrobial-dose doxycycline (SDD)—used systemically in
subantimicrobial doses to inhibit proteases and periodontal
disease progression; downregulates the activity of MMPs that
are active during periods of periodontal tissue breakdown and
thus play a major role in inflammation and the destruction of
collagen and bone
b. Has not been shown to substitute for meticulous home care and
periodontal maintenance
c. Administered 20 mg twice daily (instead of the 50-mg or 100-mg
dosage used as antibiotic) for 6 to 9 months or up to 12 months
concurrent with periodontal therapy; a low dose eliminates most
side effects, although SDD is contraindicated when known
allergy to tetracyclines is present
d. Research has shown slight but statistically significant gains in
clinical attachment and reductions in probing depths

Additional Clinical Interventions

A. Gingival curettage1,4—a procedure to remove the ulcerated, chronically
inflamed tissue lining a periodontal pocket; evidence fails to support the
efficacy of this procedure
1. Studies of gingival curettage have almost always combined this
technique with root planing; research indicates that gingival
curettage is ineffective and that root planing alone can, in most
cases, reduce inflammation, shrink tissue, and promote healing
2. In some states, gingival curettage is a legally permissible procedure
that can be performed by dental hygienists
3. If new connective tissue attachment is the goal of a particular
periodontal treatment plan, curettage has no justifiable application;
healing occurs by means of a longer junctional epithelium and tissue

1209
 shrinkage, as it does with root planing or periodontal debridement;
surgical intervention is the therapy of choice when new attachment
is the desired end point
B. Treatment of occlusal trauma1
1. Definitions
a. Occlusal trauma—injury to the periodontal attachment
apparatus resulting from occlusal forces when those forces
exceed the reparative and adaptive capacity of the attachment
apparatus
b. Primary occlusal trauma—injury to the periodontium as a result
of excessive occlusal forces when the periodontal attachment
apparatus and the attachment level are normal
c. Secondary occlusal trauma—injury to a compromised
periodontium with loss of attachment or bone loss resulting
from normal or excessive occlusal force
2. Clinical features and diagnosis
a. When injury to the periodontal ligament occurs, collagen is
destroyed, vascular elements are affected, and osteoclasts are
increased on the pressure side, all of which results in a widening
of the periodontal ligament space because of the lateral
resorption of the bony socket wall, especially in the crestal area
when the force is great enough to cause necrosis of the
ligament; when a back-and-forth motion, or “jiggling,” of the
tooth in the socket (fremitus) occurs from occlusal trauma,
changes are seen on both the tension and the pressure side,
resulting in a funnel-shaped widening of the periodontal
ligament and loss of bone; as such, mobility is the hallmark of
occlusal trauma, and radiographic findings reveal widening of
the ligament space, infrabony defects, or both; parafunctional
habits such as bruxism and clenching or iatrogenic factors
causing premature contacts (e.g., “high” restorations) most
frequently result in occlusal trauma; tissues can regenerate on
removal of the occlusal force that is causing destruction;
therefore, constant evaluation and reevaluation are indicated
b. Although necrosis of the ligament and loss of bone can occur
from occlusal trauma, it is important to note that attachment
loss characterized by apical migration of the periodontal
attachment, such as that caused by periodontitis, does not occur
solely from occlusal trauma; occlusal trauma can contribute to
advancing loss of attachment once attachment loss or bone loss
from periodontitis has weakened tooth support

1210
 c. Positive diagnosis is made on the basis of signs and symptoms
of injury (e.g., tooth mobility or migration; pain on percussion
or chewing; radiographic changes such as widened periodontal
ligament, crestal infrabony [angular] defects, and condensing
osteitis, or root resorption; TMJ dysfunction, severe wear facets;
crown or root fractures; or fremitus (a term used when tooth
movement or vibration occurs with the teeth occluded and
grinded in all functional positions); clinicians correlate clinical
findings with radiographic findings; pathologic occlusion shows
evidence of disease interfering with comfort, function, or
esthetics that can be attributed to occlusal forces
d. Pulp vitality testing, evaluation of parafunctional habits, clinical
assessment of occlusal discrepancies and bone, fremitus and
mobility, radiographic assessment of the periodontal ligament
and bone, and other adjunctive diagnostic procedures generally
are required for differential diagnosis
3. Once diagnosed, occlusal traumatism may be treated; however,
plaque-induced inflammation also must be eliminated

Surgical Interventions
A. Principles of periodontal surgery
1. Rationale
a. Eliminate active infection
b. Render the periodontium more cleansable by the client and
maintainable by the professional
(1) Improvement in the contours of hard and soft tissues
(2) Pocket elimination or reduction
c. Replace damaged or destroyed periodontium
(1) Soft tissue replacement (gingival grafts)
(2) Hard tissue replacement (osseous grafts)
d. Surgery is rarely performed solely to remove inflammation or
infection but, rather, in an attempt to:
(1) Eliminate both hard and soft defects created by disease
(2) Restore normal architecture and physiologic function
(3) Gain regeneration or new attachment of the supporting
structures
2. Case preparation (see the sections on “Implementation” and
“Evaluation” in Chapter 15)
a. Clients need to complete the initial therapy before entering the
surgical phase; initial care aims to remove the causative factors,

1211
 control active disease, and educate the client in the role as a co-
therapist
b. Completion of initial therapy prepares tissue for surgery by
reducing marginal inflammation and improving tissue tone,
which allows more predictable incisions and suturing and
reduces surgical bleeding
c. The prognosis is improved overall after initial preparation or
therapy
d. The client’s response to NSPT is assessed in relation to healing
response; motivation and supplemental self-care devices may be
needed for adequate healing
e. Completion of initial therapy can reduce the number of sites
requiring surgery or even eliminate the need for surgery in a
given sextant or quadrant
B. Types of surgical intervention
1. Resective periodontal surgery
a. Gingivectomy—surgical procedure for pocket reduction by
excision of the soft tissue pocket wall; indicated for gingival
pockets composted of fibrotic enlargement or to correct gingival
form; only involves the gingiva
b. Gingivoplasty—reshaping of the gingiva to obtain a physiologic
form similar to that characteristic of healthy tissue by using a
rotary instrument; frequently combined with gingivectomy
c. Periodontal flap procedures—may be used as a method of
surgical curettage (e.g., modified Widman flap) or for pocket
elimination by apically repositioning the soft tissue; most
common form of surgery; provides access for thorough scaling
and root planing when access is not possible through NSPT
(deep pockets, furcation areas, or other areas of complex
anatomy); can access bony deformities or craters
d. Osseous resective surgery or osseous resection
(1) Objectives—removal of alveolar bone to produce a more
physiologic architecture or contour; ultimately, pocket
reduction in one-walled infrabony or vertical defects; also
for lengthening the clinical crown for root restoration; the
goal is to remove a minimal amount of bone; may include
ostectomy, osteoplasty, or both
e. Root resection or hemisection—the objective is removal of the
crown, root, or both to eliminate the involved furcation when
osseous resection or regenerative surgery is not feasible;
resection is removal of one molar root when two roots are

1212
 involved to include class II or III furcations; also requires
endodontics and restorative dentistry; hemisection is converting
a two-rooted tooth into a single-rooted tooth by removing both
one root and a portion of the crown
2. Regenerative and reconstructive surgery
a. Bone grafts and regenerative surgery
(1) Objective—to promote regeneration of connective tissue,
periodontal ligament, cementum, and alveolar bone
(2) Indications—two-walled and three-walled vertical defects,
class II furcation defects, circumferential defects (Figs. 14-5
and 14-6)
b. Options available
(1) Guided tissue regeneration (GTR) and guided bone
regeneration (GBR)—involve using a semi-permeable
membrane between the epithelium and the underlying
ligament and bone to prevent rapid downgrowth of the
epithelium or connective tissue, which would interfere with
connective tissue regrowth after surgical debridement of
the defect; nonresorbable membranes most frequently used
(2) Bone grafts—involve placing bone-grafting material into a
debrided defect to the level of the uninvolved crest to
promote bone healing and regeneration; the graft
stimulates new bone formation and thus new attachment;
autografts are obtained from the same client, allografts are
transferred from genetically dissimilar individuals within
the same species (e.g., processed human cadaver bone that
is freeze-dried or demineralized); alloplastic grafts use
biologic fillers (e.g., bioactive glass ionomers,
biocompatible composite polymers) or organic materials
such as coral and bone; xenografts are obtained from
another species
(3) Biologic and biomimicry mediators—biologic agents such
as enamel matrix derivatives or synthetic biomimicry agents
such as platelet-derived growth factors, platelet-rich
plasma, and bone morphogenetic proteins are being
studied for their potential to enhance periodontal
regeneration
3. Periodontal plastic and reconstructive surgery
a. Includes mucogingival surgery to correct defects or deficiencies
in the shape, position, or amount of keratinized, attached
gingiva surrounding teeth; mucogingival therapy to correct

1213
 these types of defects in soft tissue and underlying bone;
periodontal plastic surgery to create morphology and
appearance that is acceptable to the client and the clinician,
including root coverage, crown lengthening, ridge preservation,
and augmentation; esthetic surgery around implants; and
exposure of teeth for orthodontics
b. Includes gingival augmentation to increase the width of the
attached gingiva, establish vestibular depth, arrest progressive
gingival recession, and facilitate self-care; frenectomy for the
elimination of abnormal frenum often in conjunction with a soft
tissue graft; alveolar ridge augmentation resulting from tooth
loss; esthetic crown lengthening when anterior teeth are shorter
than normal; papillary retention and reconstruction to correct
deficient interproximal height of papillary gingiva; or surgical
movement of impacted teeth for orthodontics

Healing Following Periodontal Therapy

See the section on “Regeneration and Wound Healing” in Chapter 7.
A. In health, periodontal tissue constantly undergoes renewal; the oral
epithelium maintains thickness by the mitotic activity of epithelial cells,
fibroblasts generate and regenerate connective tissue, and cementoblasts
form new cementum; periodontal ligament cells and bone are continually
remodeled by fibroblasts and osteoblasts
B. Basic healing processes after all forms of periodontal therapy are the
same
1. Regeneration—growth and differentiation of new cells and
intercellular substances to form or re-form tissues or parts of the
same type as the precursor; primary means of healing after NSPT,
creating a longer junctional epithelium
2. Repair—also referred to as healing by scar tissue or fibrosis; does not
necessarily restore the original architecture or function of the tissue
or part
3. Epithelial adaptation—close adaptation of the marginal gingival
epithelium without complete pocket elimination; occurs with
shrinkage of the gingiva after therapy; often occurs in conjunction
with the regeneration of a longer junctional epithelium
4. New attachment—embedding of new periodontal ligament fibers
into new cementum and formation of a new gingival attachment in
an area previously degenerated by disease rather than repair of the
periodontal attachment apparatus after an injury (reattachment)

1214
 a. Goal of periodontal surgery—the rapid downgrowth of the
epithelium must be prevented to allow the formation of
connective tissue and bone; this is the basis of using a barrier in
regenerative surgery
b. Requires adequate removal of local etiologic factors through
debridement; immobilization of mobile teeth and elimination of
occlusal stress in a weakened periodontium are necessary

Sutures
A. Objectives
1. Used to hold soft tissue in place until the healing process has
progressed to the point at which tissue placement can be self-
maintained
2. Stabilization of the soft tissue helps:
a. Maintain blood clotting around the wound
b. Protect the wound area during the healing process
B. Types of suture materials
1. Absorbable—surgical gut (from intestines of sheep); polyglactin and
polyglecaprone; absorb through proteolysis by enzymes in saliva in 7
to 10 days, thus eliminating the need for removal
2. Nonabsorbable—surgical silk most common; must be professionally
removed after 7 to 10 days
C. Procedure for suture removal
1. Grasp the knotted end of suture with cotton pliers, and gently pull it
away from the tissue
2. Insert the tip of scissors under the suture, and cut the suture
material that had been in the tissue
3. Gently pull the knotted end so that only the suture material that had
previously been incorporated within the tissue will pass through the
tissue during the removal process
4. Count and record the number of sutures removed, and compare this
number with the suture placement record
5. Gently cleanse the wound sites, and check for bleeding; control the
bleeding, as needed

Periodontal Dressings
A. The rationale for the use of periodontal dressing is to protect the
tissues after surgery; have no curative properties; wound healing
progresses at the same rate with or without dressings; sometimes used

1215
for client comfort or for protection of the wound area
B. Types—dressings using metallic oxide and fatty acids (noneugenol) are
most common; clear, translucent light-cured dressings are preferred by
some clinicians for esthetics
C. Removal of the periodontal dressing
1. Remove the dressing within 5 to 7 days; tease the edges of the
dressing away from teeth with a curette or cotton pliers; be sure that
sutures are not embedded in the dressing
2. After the pack has been removed, gently cleanse the area with warm
water or dampened cotton tips; remove sutures; assess tissue
healing, but do not probe sulcular areas

1216
Postoperative care
Client Instructions and Education
A. Discomfort—the client should:
1. Expect some discomfort after the local anesthesia wears off; use the
prescribed pain medication
2. Rest and limit physical activities during the first few days to prevent
excessive bleeding and promote healing
3. Use an ice pack to prevent swelling
4. Eliminate spicy, hot, cold, hard, or sticky foods and liquids and
tobacco use to limit tissue irritants and protect the dressing
B. Home care recommendations—provide the following instructions to
the client:
1. Do not rinse the mouth on the first day because this may disturb the
process of blood clotting that is necessary for wound healing
2. After the first day, rinse gently with lukewarm water or a small
amount of an antimicrobial rinse (e.g., chlorhexidine gluconate) to
help control bacterial biofilm; brush and floss nonsurgical areas as
usual but gently
3. Using a soft brush and water, very gently clean the surface of the
dressing
4. Slight seepage of blood during the first few hours is normal; any
unusual, persistent bleeding should be reported to the periodontist

Follow-up Care
A. Client returns approximately 7 days after surgery
B. Dressing and sutures are removed; new dressing may or may not be
applied
C. Dentinal hypersensitivity may be experienced; desensitization is
indicated for dentinal hypersensitivity; desensitization methods may be
prescribed (see the section on “Assessment of Dentinal Hypersensitivity”
in Chapter 16)
D. Home-care instructions are provided for biofilm control
E. Long-term postoperative care requires periodic evaluation (also known
as periodontal maintenance care, continued care, or recare)

Periodontal Maintenance
A. An extension of periodontal therapy; also called periodontal
maintenance

1217
 1. Initiated after completion of active periodontal treatment and
continued at various intervals for the life of the dentition or its
implant replacements
2. Periodontal maintenance is an extension of active therapy, whether
nonsurgical or surgical
B. The objectives of periodontal maintenance care is to:
1. Minimize any recurrence and progression of periodontal disease in
previously treated clients
2. Reduce tooth loss incidence by monitoring the client’s periodontal
status at regular intervals
3. Reevaluate results after active periodontal therapy (nonsurgical or
surgical) over the long term
4. Reinforce self-care instructions and encourage client’s long-term
protective oral health behaviors
5. Determine the need for additional treatment in a timely manner
C. Components of periodontal maintenance care
1. Need for the cooperation of client, dental hygienist, dentist, and
periodontist
2. Emphasis on scaling, root planing, and periodontal debridement;
extrinsic stain removal; and reinstruction of client in self-care to
maintain attachment levels
3. Optimization of protective factors; minimization and elimination of
risk factors
D. Periodic reevaluation and assessment
1. Review and update of client’s health, pharmacologic, and dental
histories; review and control of associated risk factors
2. Radiographic review
3. Examination of extraoral and intraoral soft tissues
4. Dental charting of caries, tooth mobility and fremitus, and other
tooth-related problems
5. Periodontal assessment and charting of gingival recession, probing
depths, bleeding on probing; levels of plaque and calculus, furcation
involvement, exudation, occlusal trauma, tooth mobility; and other
signs or symptoms of periodontal disease
6. Evaluation of client’s oral self-care behavior, attitude, values, and
skill
7. Examination of dental implants and peri-implant tissues
E. Treatment—based on assessment
1. Always encourage the client; provide oral self-care reinstruction, and
reinforce client’s compliance with recommended maintenance
intervals

1218
 2. Healthy periodontium—removal of supragingival deposits; no root
planing indicated
3. Presence of bleeding or inflammation of the gingiva—treatment
depends on the cause and pocket depths; removal of deposits and
contributing factors, as necessary; possible use of an antimicrobial
rinse (e.g., 0.12% chlorhexidine) or sustained-release, locally
delivered antibiotic or antimicrobial agent
4. Presence of periodontal pockets—scaling, periodontal debridement,
and root planing followed by reevaluation in 4 to 6 weeks to
determine the need for adjunctive therapy or possible periodontal
surgery
5. Determination of frequency of periodontal maintenance must be
individualized
a. The frequency increases when clients have less-than-optimal
oral self-care practices
b. Longer intervals are acceptable if clients can control bacterial
plaque (dental) biofilm, unless systemic disease or advanced
periodontitis exists
c. The goal is to control the clinical signs of inflammation and to
stabilize attachment levels
d. Frequent intervals (3 months or less) are generally necessary for
subgingival and supragingival plaque and calculus removal in
the presence of periodontitis
e. Generally, the shorter the interval, the greater the long-term
success, particularly during the healing phase (1 year) after
surgery
F. Indications for retreatment
1. Increase in probing depth or attachment loss of 2 mm or more
2. Bleeding on probing that does not respond to periodontal
maintenance procedures
3. Severity—to be considered in determining treatment regimens
(nonsurgical or surgical); retaining questionable teeth is not
recommended
4. Generalized deterioration—systemic complication might be
suspected
5. Dental implants with bone loss or mobility

1219
Dental implants
See the sections on “Dental Implants” in Chapter 13 and “Advanced
Instrumentation Techniques” in Chapter 17.
A. Definition—artificial replacements of teeth that are permanently
affixed into alveolar bone by a biomedical device and usually composed
of an inert metal or a metallic alloy
1. Implants offer an alternative to removable dentures for edentulous
or partially edentulous persons; single or multiple teeth can be
replaced
2. Implants provide a permanent anchor for artificial teeth by serving
as an abutment for fixed or removable prostheses
a. Implant—portion surgically placed within the bone
b. Abutment—metallic post attached to the implant so that a
restoration can be placed over it
c. Superstructure—prosthetic replacement (e.g., crown, bridge,
denture) that is affixed to the abutment or a removable
replacement tooth that the client can remove and clean
d. Implant-assisted prosthesis—removable tissue dentures
(overdentures) supported in the arch by endosseous dental
implants
B. Limiting factors
1. Systemic—age is a consideration only if the client’s jaws are still
growing because implants are contraindicated until full growth is
attained; any condition or disease that affects an individual’s ability
to fight infection should be carefully considered because implant
failure is often caused by infection; greater failure also occurs in
poor quality and density of bone, so conditions such as osteoporosis
also require careful consideration; cigarette smoking is a
documented risk factor for implant failure, so tobacco cessation is
essential before implant placement; factors affecting the client’s
ability to withstand surgery also are paramount (e.g., malnutrition,
recent cardiac arrest, bleeding problems)
2. Local—unfavorable ridge morphology or other bone quality and
density changes caused by resorption; sufficient bone and soft tissue
for implant positioning must be similar to that of a natural tooth
within the tissue and the alveolar ridge—orthodontics and surgical
augmentation or correction may be possible; severe malocclusion or
parafunctional habits that would cause excessive trauma would
contraindicate implants; uncontrolled periodontal disease is also a
contraindication; an immobile implant generally is not attached to a

1220
 natural tooth with periodontal ligament mobility
C. Implant design
1. Systems—either two stage (submerged) or one stage
(nonsubmerged)
a. Submerged—designed to protect the implant from occlusal
stress and bacterial exposure during the healing phase; the
implant is placed in two steps, allowing osseo-integration for 3
to 6 months before exposing the implant to the oral cavity for
abutment placement; a prosthetic device is later connected to
the implant
b. Nonsubmerged—the implant has a collar that extends through
tissue and attaches the prosthesis supragingivally or slightly
subgingivally at the time of placement; only one surgery is
involved for client comfort and convenience
c. Shape and size vary in either system; most common are screw-
shaped, root-shaped, or cylinder-shaped implants
2. Materials typically used for dental implants—must be biocompatible
a. Titanium—a metallic element; pure, plasma sprayed, or
titanium alloy
b. Hydroxyapatite—plasma sprayed
D. Types of implants most frequently used
1. Endosseous implants (inside bone)
a. The implant is placed directly into a socket, which has been
prepared through a process called trephining; uses a series of
specially prepared drills and burs
(1) Osseo-integration refers to the implant being in direct
contact with bone without intervening connective tissue
(i.e., no periodontal ligament or connective tissue
attachment); the implant is in effect “ankylosed” within
bone
(2) After initial loss of 1 to 2 mm of alveolar bone during the
first year, crestal bone should be stable with no more than
0.1 to 0.2 mm per year thereafter
b. After bone and soft tissue heal, the final bridge or denture is
placed
2. Transosteal implants—means “through the bone”; mandibular
denture anchors are placed all the way through the mandible from
under the border into the oral cavity
E. Implant-tissue interface
1. The implant-tissue interface is the basis of implant success.
2. The epithelial attachment to the implant may be similar to the

1221
 attachment to a natural tooth (i.e., basal lamina and
hemidesmosomes); no periodontal ligament; called perimucosal seal
3. Perimucosal seal, or biologic seal, is defined as the adaptation of
keratinized or nonkeratinized epithelium to the abutment cylinder
of an implant; critical to implant retention
4. Osseo-integration—contact established between normal and
remodeled bone and the implant surface without the interposition of
connective tissue
F. Criteria for successful treatment outcomes
1. Immobility of the implant
2. No peri-implant radiolucency on the radiograph
3. Width of implant
4. Width of attached gingiva
5. Medical conditions
6. Smoking
7. Absence of signs and symptoms such as pain, bleeding, infections,
paresthesias, or mandibular canal involvement
8. Minimum success rate of 85% at 5 years and 80% at 10 years of
observation
G. Implant management
1. Periodic evaluation of implants, surrounding tissue, and oral hygiene
essential to long-term success; considerations in periodic evaluation
include:
a. Extent of biofilm and dental calculus
b. Clinical appearance of peri-implant soft tissue
c. Radiographic appearance—no periodontal ligament space or
bone loss; no peri-implant radiolucency
d. Absence of occlusal interference or trauma; stability of implant
and prostheses—no mobility
e. Probing depths (if other signs of disease present)—gentle,
careful technique
f. Absence of bleeding or exudate
g. Adequacy of maintenance interval
h. Client comfort and function
2. Goals
a. Maintenance of the health of the implant and supporting tissue
b. Prevention of loss of perimucosal seal
c. Prevention of gingivitis and, failing that, prevention of
conversion of gingivitis to peri-implantitis, a periodontitis-like
disease process that can affect dental implants
(1) Infectious failure—failing implants with a primarily

1222
 infectious cause
(2) Traumatic failure—failing implants with a primarily
traumatic cause
d. Provision of preventive and maintenance therapies with
minimal damage, or surface scratching, to implants
e. Control of bacterial plaque biofilm
H. Preventive instrumentation (see the sections on “Dental Implant
Maintenance” in Chapter 16 and “Instrumentation of Dental Implants”
in Chapter 17)

Website Information And Resourc es

Source Website Address Description
American Academy of www.perio.org Position papers, parameters of care,
Periodontology scientific information, and related links in
periodontics as well as related information
for consumers
Cochrane Collaboration www.cochrane.org Evidence-based health care databases; site
search for “periodontal” provides excellent
related systematic reviews
European Federation of www.efp.org Publications, news, patient information
Periodontology
National Center for Dental www.usc.edu/hsc/dental/dhnet Current topics in dental hygiene and
Hygiene Research periodontics with links to related
government sites, product companies, and
professional associations
University of Minnesota www1.umn.edu/perio/tobacco/ Information on tobacco use cessation and
School of Dentistry, Division of related links
Periodontology

1223
References
1 Newman M.G., Takei H.H., Carranza F.A. Carranza’s clinical
periodontology. ed 11 St Louis: Saunders; 2012.
2 Armitage G.C. Periodontal diagnoses and classification of
periodontal diseases. Periodontology. 2004;34:9–21.
3 Dentino A., Lee S., Mailhott J., Hefti A.F. Principles of
periodontology. Periodontology. 2013;61:16–53.
4 Darby M.L., Walsh M.M. Dental hygiene theory and practice. ed 4 St
Louis: Elsevier; 2015.
5 Borrell L.N., Burt B.A., Taylor G.W. Prevalence and trends in
periodontitis in the USA: from the NHANES III to the NHANES,
1988 to 2000. J Dent Res. 2005;84:924–930.
6 Löe H., Anerud A., Boysen H., et al. Natural history of periodontal
disease in man: the rate of periodontal destruction after 40 years
of age. J Periodontol. 1978;49:607–620.

Chapter 14 review questions

Answers and rationales to chapter review questions are available on
this text’s accompanying Evolve site. See inside front cover for details.

1. Recession is noted in the mandibular anterior region, and the attached

gingiva measures 0.5 mm, requiring evaluation by a dentist or
periodontist. If periodontal surgery is indicated, a mucogingival surgery
would be performed to correct this condition.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
2. Smoking is a major risk factor for periodontal disease. Light,
moderate, and heavy smokers are all at equal risk for more severe
periodontal destruction than nonsmokers.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.

1224
3. Which of the following devices would be MOST effective for plaque
biofilm removal in the mandibular anterior region when recession has
resulted in open embrasure spaces?
a. Dental floss
b. Dental tape
c. Oral irrigation
d. Interproximal brush
4. Systemic antibiotics are recommended in treatment of aggressive
periodontitis. Locally-delivered, sustained-release antibiotics should be
considered in the care plan when generalized chronic periodontitis is
present.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
5. An oxygenating mouthrinse would be beneficial for a patient with
halitosis because these mouthrinses are the most effective in reducing
bacterial plaque biofilm.
a. Both the statement and the reason are correct and related.
b. Both the statement and the reason are correct but are NOT related.
c. The statement is correct, but the reason is NOT correct.
d. The statement is NOT correct, but the reason is correct.
e. NEITHER the statement NOR the reason is correct.
6. In addition to professional dental hygiene care and proper oral
hygiene measures, which of the following procedures or agents would
address a client’s chief concerns about “bad breath?”
a. Selective stain removal
b. Chlorine dioxide mouthrinse
c. Tooth whitening
d. Daily oral irrigation
e. Daily fluoride mouthrinse
7. Which of the following periodontal therapies would be BEST
recommended for a patient who presents with probing depths of 3 to
5 mm, slight bone loss detected on the radiographs, and a history of
infrequent dental hygiene care?

1225
 a. Regenerative periodontal surgery
b. Gingival curettage
c. Nonsurgical periodontal therapy
d. Oral prophylaxis
e. Periodontal maintenance therapy
8. Which of the following would be the BEST indicator of treatment
success at the reevaluation appointment 4 to 6 weeks after initial
periodontal therapy?
a. Relatively free of plaque biofilm
b. Stable periodontal probing depths
c. Absence of gingival inflammation and bleeding
d. No re-formed dental calculus deposits
9. What change in alveolar bone on a dental radiograph indicates early
loss of bone?
a. Fuzziness in the crest of the bone
b. Faint cup-shaped areas interproximally
c. Vertical or angular defects
d. Furcation involvement
10. After thorough periodontal debridement is performed, which is the
first inflammatory cell to respond to avoidable resultant irritation of the
gingiva?
a. B lymphocytes
b. Plasma cells
c. Neutrophils
d. T lymphocytes
e. Macrophages
11. Which of the following changes result in a false or pseudo
periodontal pocket?
a. Apical migration of the junctional epithelium
b. Apical migration of the gingival margin
c. Resorption of the alveolar bone
d. Swelling of the gingival margin without bone loss
12. Which of the following diagnostic procedures is MOST accurate for
determining severity of periodontal attachment loss?

1226
 a. Full-mouth digital radiographic survey
b. Microbial testing of plaque biofilm
c. Detection of pathologic tooth mobility or furcations
d. Periodontal probing of all sulcular areas
e. Determining presence or absence of bleeding on probing
13. In clients of periodontitis, what is the first area to be involved in
bone resorption?
a. Facial and lingual aspects of supporting bone
b. Cribriform plate or lamina dura
c. Cancellous portion of supporting bone
d. Cortical plate of the interdental septum
e. Bone surrounding the apical area of the tooth
14. Which one of the following bacteria are predominant in
supragingival plaque biofilm associated with gingivitis?
a. Chromogenic bacteria
b. Gram-negative anaerobic bacteria
c. Aerobic and facultative bacteria
d. Gram-positive Streptococcus spp.
15. Which of the following types of cells are responsible for resorption
of cementum and bone in periodontal destruction?
a. Cementoblasts
b. Fibroblasts
c. Osteoblasts
d. Cementoclasts
e. Osteoclasts
16. Which of the following histologic changes in inflamed gingiva results
in redness?
a. Vasodilation within the gingival connective tissue
b. Ulceration of the sulcular lining
c. Lymphoid cell accumulation
d. Collagenase destroying the lamina propria
e. Alteration of fibroblasts in the connective tissue
17. Tooth mobility and fremitus can be signs of occlusal trauma because
trauma can result in lateral resportion of bone.

1227
 a. Both the statement and the reason are correct and related.
b. Both the statement and the reason are correct but are NOT related.
c. The statement is correct, but the reason is NOT correct.
d. The statement is NOT correct, but the reason is correct.
e. NEITHER the statement NOR the reason is correct.
18. Which of the following conditions can be determined by
radiographic examination? Select all that apply.
a. Extent and severity of bone loss
b. Height of crestal bone
c. Widening of the periodontal ligament space
d. Presence of pseudopockets
e. Presence of dental calculus on lingual surfaces
19. Which radiographic findings will MOST LIKELY be seen in dental
plaque–induced gingivitis? Select all that apply.
a. A thin periodontal ligament space
b. Slight changes in the lamina dura
c. Condensing osteitis
d. Normal lamina dura and crestal bone
e. Slight fuzziness at the alveolar crest
20. Oral examination findings for a 56-year-old woman with good
general health status reports diabetes well controlled by medication and
diet and taking hormonal therapy for symptoms of menopause. Clinical
findings include localized 4-mm and 5-mm periodontal probing depths,
with radiographic bone loss visible on teeth #3, #14, #19, #30, and #31;
slight gingival inflammation in the mandibular anterior and molar
regions; fair oral hygiene with generalized light deposits; and no active
caries. On the basis of these findings, which of the following would be
the MOST accurate preliminary diagnosis?
a. Necrotizing ulcerative gingivitis
b. Chronic periodontitis
c. Dental plaque–induced gingivitis
d. Localized aggressive periodontitis
e. Hormone-associated gingivitis
21. Which of the following antimicrobial and antigingivitis agent is the
LEAST effective?

1228
 a. Essential oils
b. Chlorhexidine gluconate
c. Chlorine dioxide
d. Cetylpyridinium chloride
e. Stannous fluoride
22. Which of the following tissues consist(s) of nonkeratinized
epithelium? Select all that apply.
a. Crevicular epithelium
b. Attached gingiva
c. Interdental papilla
d. Junctional epithelium
e. Marginal gingiva
23. Which of the following microbes is associated with necrotizing
ulcerative gingivitis and periodontitis?
a. Actinomyces viscosus
b. Porphyromonas gingivalis
c. Prevotella intermedia
d. Treponema pallidum
e. Capnocytophaga ochracea
24. Which of the following types of drugs have been associated with
fibrotic gingival overgrowth? Select all that apply.
a. Oral contraceptives
b. Antidepressants
c. Calcium channel blockers
d. Antihistamines
e. Anticonvulsants
25. Which of the following conditions can cause periodontitis as a
manifestation of systemic disease? Select all that apply.
a. Diabetes mellitus
b. Chédiak-Higashi syndrome
c. Papillion-Lefèvre syndrome
d. Cardiovascular disease
e. Leukemia
26. Which of the following BEST describes the sulcular epithelium?

1229
 a. Keratinized epithelium
b. Basal cell epithelium
c. Squamous cell epithelium
d. Simple cuboidal epithelium
e. Parakeratinized epithelium
27. Which type of periodontal disease is characterized by gray, sloughing
tissue, pain, and spontaneous bleeding with rapid connective tissue loss
and exposed alveolar bone?
a. Pericoronitis
b. Periodontal abscess
c. Necrotizing ulcerative gingivitis
d. Aggressive periodontitis
e. Necrotizing ulcerative periodontitis
28. Which of the following indicates that periodontitis is present rather
than gingivitis? Select all that apply.
a. Widened periodontal ligament space on radiographs
b. Periodontal probing depth of 4 mm or greater
c. Clinical attachment loss
d. Apical migration of the alveolar bone
e. Bleeding on probing
29. Which condition should be suspected when a radiolucent area on a
radiograph occurs lateral to the root of a tooth with a 7-mm probing
depth?
a. Periodontal abscess
b. Pyogenic granuloma
c. Occlusal traumatism
d. Periapical abscess
e. Mucogingival problem
30. Which of the following are possible causes of gingival recession?
Select all that apply.
a. Faulty toothbrushing
b. Bacterial plaque biofilm
c. Tissue response to medication
d. Dental caries

1230
 e. Periodontal disease
31. All the following are risk factors associated with periodontal disease
EXCEPT one. Which one is the exception?
a. Genetics
b. Immunosuppression
c. Hormonal changes
d. Frequent fermentable carbohydrates in diet
e. Poor oral hygiene
32. At a reevaluation appointment with a client 4 weeks after completion
of nonsurgical periodontal therapy, the hygienist notes localized gingival
inflammation and bleeding in the proximal surfaces of the molars.
Periodontal probing depths of 5 mm remain unchanged, corresponding
to the localized inflammation, but are reduced to 2 to 4 mm in most
areas. Plaque control is acceptable. What is the MOST probable
explanation for these findings?
a. Residual dental calculus deposits are present.
b. Plaque removal was absent for the past 24 hours.
c. Systemic disease influencing host response is present.
d. Plaque removal was enhanced immediately before appointment.
33. Which of the following situations would be an indication for a
gingivectomy?
a. Edematous 5-mm pseudopocket
b. Severe drug-influenced gingival enlargement
c. Infrabony pocket of 6 mm on the distal aspect of tooth #30
d. Gingival recession that extends into the alveolar mucosa
e. Periodontal abscess
34. Which of the following is an objective of periodontal reconstructive
surgery?
a. Improve the esthetics of the client’s face
b. Create gingival contour and appearance acceptable to the client
c. Remove alveolar bone to improve contour and correct defects
d. Remove enlarged tissue to assist the client in daily plaque control
e. Promote regeneration of a new attachment
35. All the following are substances produced by the host response to
bacterial plaque biofilm EXCEPT:

1231
 a. Lipopolysaccharide (LPS)
b. Matrix metalloproteinase (MMP)
c. Cytokines
d. Interleukin-1 (IL-1)
e. Prostaglandin E2 (PGE2)
36. Which of the following are necessary for new attachment after
periodontal surgery? Select all that apply.
a. Thorough removal of bacterial irritants
b. Immobilization of mobile teeth
c. Shrinkage of the gingival margin
d. Regeneration or generation of new tissues or parts
e. Rapid apical growth of epithelium
37. All the following are advantages of controlled (sustained-release)
drug delivery over systemic drug administration in periodontal therapy
EXCEPT:
a. Less concern about client adherence throughout indicated time
frame
b. Site-specific antimicrobial action in periodontal pocket
c. High concentration delivered to the site of infection
d. Can be used when periodontal infection is generalized or severe
38. Periodontal dressings also minimize client discomfort. These
dressings make the placement of sutures unnecessary in some cases.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
39. A female patient, age 40, returns for periodontal maintenance
therapy every 3 months for 1 year after nonsurgical periodontal
treatment for chronic periodontitis. The inflammation has been
resolved, and periodontal probing depths have decreased from 5 or
6 mm to 4 mm or less in most treated areas, with the exception of the
distal surface of tooth #15, where the probing depth has increased from
4 to 6 mm. Radiographs reveal no change on tooth #15 distal. All the
following explain this finding EXCEPT:
a. Continuing clinical attachment loss

1232
 b. Error in periodontal probing technique
c. Calculus deposits affecting accuracy of initial reading
d. Inaccessibility and poor visibility in pocket areas
e. Increased inflammation of the gingival tissues
40. All the following factors could limit a recommendation for dental
implants EXCEPT:
a. Complete edentulism
b. Tobacco habit
c. Osteoporosis
d. Head and neck radiation therapy
41. Which of the following materials could be used in curettes for
maintaining dental implants? Select all that apply.
a. Stainless steel
b. Carbon steel
c. Plastic resin
d. Titanium
42. Which of the following findings would indicate a failed dental
implant?
a. Peri-implant inflammation
b. Bleeding on provocation
c. Alveolar bone loss
d. Loosening of the prosthetic crown
e. Mobility
43. Which of the following classifications of periodontal disease would
be characterized by clinical attachment loss in the first molars and
incisors in an adolescent patient with fair plaque control?
a. Hormone-influenced gingivitis
b. Localized chronic periodontitis
c. Localized aggressive periodontitis
d. Necrotizing ulcerative periodontitis
44. Which factors determine the severity of chronic periodontitis? Select
all that apply.
a. Extent of attachment loss
b. Immune response

1233
 c. Hormonal changes
d. Vitamin C deficiency
e. Frequency of periodontal maintenance therapy
45. How is clinical attachment loss measured with a periodontal probe?
a. From the margin of the gingiva to the epithelial attachment
b. From the cemento-enamel junction to the base of the pocket
c. From the margin of the gingiva to the cemento-enamel junction
d. From the cemento-enamel junction to the margin of the bone
46. In which area of the mouth would the width of the attached gingiva
be expected to be the narrowest?
a. Mandibular anterior area
b. Mandibular premolar areas
c. Maxillary molar areas
d. Lingual of the maxillary teeth
47. Where is the lamina propria located in the periodontium?
a. In the periodontal ligament
b. In the alveolar bone
c. At the cemento-enamel junction
d. In the gingival mucosa
48. Which of the following changes would result in pocket reduction
after periodontal debridement in an edematous pocket? Select all that
apply.
a. Reattachment
b. New attachment
c. Longer junctional epithelium
d. Shrinkage of the gingival margin
e. Downward growth of the junctional epithelium
49. Occlusal trauma causes clinical attachment loss and bone loss in
patients with gingivitis. Occlusal trauma can contribute to attachment
loss and bone loss surrounding teeth affected by periodontitis.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.

1234
50. Occlusal trauma can result in all the following EXCEPT:
a. Periodontal pockets
b. Attrition of the tooth
c. Temporomandibular joint discomfort
d. Fractured teeth and restorations
51. At a reevaluation appointment following thorough periodontal
debridement, what does generalized severe inflammation and bleeding
in the presence of localized plaque biofilm indicate?
a. A need for more frequent periodontal maintenance therapy
b. Poor self-care to control plaque biofilm
c. A possible undiagnosed systemic disease
d. Residual calculus present
52. What does bleeding on periodontal probing indicate?
a. Loss of crestal bone
b. An increase in gingival vasculature
c. Fibrosis in the connective tissue
d. Ulceration of crevicular epithelium
e. Apical migration of junctional epithelium

1235
C HAPT E R
15

1236
Dental Hygiene Process of Care
Laura Mueller-Joseph

The dental hygiene process of care is a systematic, problem-solving

approach to the provision of quality oral health care. This process
provides a framework for evidence-based decision making and sound
clinical judgment while identifying and resolving client needs within
dental hygiene practice.1 The dental hygiene process is a standard of
practice recognized by the American Dental Hygienists Association
(ADHA) and is an educational standard of the American Dental
Association (ADA) Commission on Dental Accreditation.2,3 This chapter
reviews components of the dental hygiene process of care: assessment,
diagnosis, planning, implementation, evaluation, and documentation,
including prognosis and legal-ethical considerations.

1237
Basic concepts
Dental Hygiene Paradigm 1
A. A paradigm is composed of major concepts selected for study by a
discipline
B. The paradigm for the discipline of dental hygiene includes four
concepts4:
1. Clients—recipients of dental hygiene care; include persons, families,
groups, and communities from all age, cultural, gender, and
economic groups
2. Environment—external factors that affect the client’s optimal oral
health; includes economic, psychological, cultural, physical, legal,
educational, ethical, and geographic dimensions
3. Health and oral health—status of the overall health and the oral
wellness or illness of the client
4. Dental hygiene actions—interventions that a dental hygienist
initiates to promote wellness, prevent and control oral disease, and
encourage active client participation and collaboration
C. Dental hygiene practice—based on a systematic process of care that
involves assessment, diagnosis, planning, implementation, and
evaluation (Fig. 15-1)

1238
 FIG 15-1 Dental hygiene process-of-care algorithm.

D. The dental hygiene process of care provides a logical system for

determining the health and disease status of a client and for selecting
appropriate interventions and measuring treatment outcomes
E. The dental hygiene process of care is integrated with a client’s
comprehensive dental hygiene diagnosis and care plan

Human Needs Theory and Assessment1,5–7

See the section on “Human Behavior Principles” in Chapter 16.
A. Most widely known model in the discipline of dental hygiene—human
needs conceptual model; requires assessment of each client’s human
needs as the framework for providing care
B. Based on the theory that human activity is dominated by behaviors
aimed at need fulfillment; an internal drive exists in all humans to satisfy
unmet needs; unmet needs motivate specific behaviors to eliminate the
perceived deficit; the model encourages establishing an environment
that is more client oriented than task oriented

1239
C. The human needs model uses eight needs relevant to oral health that
should be considered in the implementation of the dental hygiene
process of care (Fig. 15-2)

FIG 15-2 Eight human needs related to oral health and disease. (Modified from
Walsh MM, Darby ML: Human needs theory and dental hygiene care. In Darby ML, Walsh MM,
editors: Dental hygiene theory and practice, ed 4, St Louis, 2015, Saunders.)

D. During baseline assessment, deficits in eight human needs are

identified, and a dental hygiene diagnosis is made; planning,
implementation, and evaluation of dental hygiene care are carried out to
address the client’s unmet needs
E. Human needs assessment form—an instrument to assist in the
summation and organization of gathered assessment data; used to
provide a written record of unmet needs, dental hygiene diagnoses, client
goals, treatment and preventive care plans, and outcome evaluation of
dental hygiene care (Fig. 15-3)

1240
 FIG 15-3 American Dental Association (ADA) health history form. (Copyright 2011
American Dental Association. All rights reserved. Reprinted with permission.)

Assessment
A. Definition—comprehensive and systematic collection of data used to
identify a client’s needs, oral health status, and general health and well-
being
B. Assessment—first phase of dental hygiene process of care
C. Data collection—continuous process of collecting and documenting
subjective and objective client information
D. Data are continuously updated and documented during the dental
hygiene process of care
E. Data are collected by interview, questionnaire, observation,
measurement, and examination
F. Data recordings are discussed with the client and other health care

1241
professionals responsible for the client’s care
G. Data collection and documentation—includes comprehensive
personal, health, and dental histories; pharmacologic history;
identification of a client’s chief concerns and human needs; clinical
examination; periodontal examination and risk status; analysis of
diagnostic radiographs; microbiologic or other tests for assessing
periodontal status and risk levels related to dental caries8

1242
Health history evaluation
A. Health history—taken to identify and evaluate predisposing
conditions and risk factors that may affect dental hygiene interventions,
client management, potential for an emergency, and oral and general
health outcomes;9 such conditions and factors include, but are not
limited to, allergies, chronic diseases, human immunodeficiency virus
(HIV) infection, pregnancy, tobacco use, substance abuse, and
medications
B. Health history form—legal document containing past and present
information about a client’s health9
1. Provides baseline information about a client’s health status and
assists in medical and dental diagnoses
2. Information used to assess the overall physical and emotional health
of a client and allow identification of:
a. Needed precautions to ensure a client’s need for safety
b. Potential medical emergencies
c. Needed referrals to a physician or other health care provider
d. Diseases, conditions, or medications that contraindicate dental
or dental hygiene care
e. Previous history of reactions to medications or drugs
f. Infectious diseases that could endanger other individuals
g. Physiologic state of a client, including pregnancy, puberty,
menopause, and use of hormones
3. Health history questionnaire should be completed in ink, and
comprehensive information should be recorded on a questionnaire
form or a summary sheet; this may be a component of an electronic
client record
4. The health history should be reviewed by the client and dental
hygienist and updated at each dental hygiene appointment
5. The client should sign the written health history form at each
appointment to confirm its accuracy; if the client is a minor, a parent
or legal guardian must sign and date the health history form;
electronic signatures are used in the electronic health record
6. The dental hygienist should sign the health history form at each
appointment indicating medical and pharmacologic updates were
obtained and verified; electronic signatures are used in the
electronic health record
7. The health history form should be thorough and concise and legible,
using simple language to facilitate understanding

1243
Health History Questions (Fig. 15-4)
A. Personal, social, and cultural histories related to health and disease

FIG 15-4 Request for medical consultation.

B. Dental history information should include:

1. Main concern—why the client is seeking dental or dental hygiene
care
2. In the case of new clients, the date of the last dental or dental
hygiene visit
3. Areas of pain or discomfort identified during the health history
interview, but not associated with the client’s main concern
4. Nervousness or anxiety about treatment; history of an upsetting
experience; the client’s need for freedom from anxiety and stress
should be addressed

1244
 5. Pain, swelling, or gingival bleeding
6. The client’s satisfaction with his or her teeth and oral health
7. Past or current orthodontics, periodontal surgery, extractions,
temporomandibular joint (TMJ) problems, occlusal equilibration,
fixed and removable dentures
8. Oral habits such as clenching or grinding, biting lips or cheeks,
mouth breathing, and holding foreign objects between teeth
C. Radiographic history information (see Chapter 6)
1. Purpose—the radiation exposure history of the client should be
obtained to make safe decisions for radiographic prescriptions
2. Information should include:
a. Whether the client is regularly exposed to radiation in his or her
work environment
b. The dates and total number of dental and medical films exposed
during a 5-year period

Health History Information

See Chapters 7, 8, and 19 for more detailed discussions of health
conditions.
A. Screening questions are designed to assess risk factors or
undiagnosed diseases to enable a clinician to determine the need for a
physician consultation or referral before dental hygiene care (Table 15-1)

Table 15-1
Health History Screening Questions

Risk Factor
Sample Questions Significance of Finding
Category
Overall health How do you rate your general health? Hospitalization history can provide a
Has there been any change in your good record of past serious illnesses that
general health within the past year? may be significant to dental hygiene
Have you been under the care of a care
medical doctor during the past 2 years? Knowledge of why a client was
What is the date of your last physical hospitalized is used to evaluate the
examination? client’s ability to tolerate stress involved
Have you ever been hospitalized or had during treatment
a serious illness? Knowledge of any problems for which
the client required medical intervention
can increase the ability to evaluate the
patient’s condition before treatment
Weight Have you unintentionally lost or gained Unexpected weight changes may
fluctuation more than 10 pounds in the past year? indicate heart failure, hypothyroidism,
history Are you on a medically recommended hyperthyroidism, or uncontrolled

1245
 diet? diabetes
Information may identify an underlying
systemic problem, such as diabetes,
hyperthyroidism, or cancer
Cardiovascular When you walk up stairs or take a walk, Clients with cardiovascular disease are
disease do you ever have to stop because of pain more susceptible to physical or
in your chest or shortness of breath or emotional challenges during dental
because you are very tired? hygiene care
Do your ankles swell during the day? These signs may indicate possible
Do you require more than two pillows valvular disease, arrhythmia, or
to sleep, or do you have an elevated bed? congestive heart failure
Diabetes Are you on a medically recommended Determine family history or potential
diet? for diabetes; consultation with a
Do you have to urinate more than six physician may be indicated
times a day? Complications of diabetes include
Are you frequently thirsty? blindness, hypertension, kidney failure,
Does your mouth frequently become and delayed healing
dry?
If yes, what is the probable cause?
Tuberculosis Do you have a nonproductive persistent May indicate current or past history of
or other cough? tuberculosis
respiratory Do you have a productive persistent History of the disease must be defined,
diseases cough? and medical consultation may be
Do you have night sweats? indicated
Do you have difficulty breathing?
Hematologic Do you bruise easily? Need to determine whether a blood
disorder Do you have a tendency to bleed longer disorder is present; medical consultation
than normal? may be indicated
Have you ever had a blood transfusion? Concerns about delayed healing,
prolonged bleeding, and infection
Latex allergy Have you experienced a skin reaction Need to assess risk for reaction
(redness, rash, hives, or itching) to May need medical consultation to
adhesive tape, adhesive strips, kitchen determine risk of anaphylaxis
gloves, or rubber or latex products? Provide a latex-reduced environment
Have you experienced swelling of the
lips, tongue, or skin after dental
treatment, after blowing up a balloon, or
after contact with rubber or latex
products?
Have you experienced a runny nose,
itchy eyes, scratchy throat, or difficulty
breathing after contact with rubber or
latex products?
Do you have an allergy to bananas,
kiwis, potatoes, tomatoes, avocados,
chestnuts, or other foods?

B. Detailed questions are designed to identify diseases or conditions that

1246
a client previously had or currently has and to determine the need for
precautionary measures, physician consultation before dental hygiene
care, or need for antibiotic prophylaxis (Table 15-2)

Table 15-2
American Heart Association (AHA) and American Association of Orthopedic Surgeons (AAOS)
Antibiotic Premedication Guidelines for Professional Oral Health Care

1247
Modified from Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease: Prevention of infective endocarditis:
Guidelines from the American Heart Association, April 19, 2007, www.americanheart.org/presenter.jhtml?
identifier=3004539; and from American Academy of Orthopedic Surgeons, American Association of Orthopedic Surgeons:
Prevention of orthopedic implant infection in patients undergoing dental procedures: evidence-based guidelines and
evidence report, http://www.aaos.org/research/guidelines/PUDP/PUDP_guideline.pdf. Accessed July 20, 2015.
* Every attempt should be made to complete procedures and services in as few appointments as possible; follow-up
appointments should be scheduled at least 9 days apart if client is premedicated.
† Clinical judgment may indicate antibiotic use in selected circumstances that may cause significant bleeding.

1. When practitioner questions the client regarding his or her disease

status, specific information should include:
a. Type and onset of disease
b. Treatment received in the past
c. Severity of disease or extent of damage
d. Type of current medical care
e. Results of follow-up testing
f. Classification of the client’s risk for a medical emergency using
the American Society of Anesthesiologists (ASA) Physical
Status Classification System (Table 15-3)

1248
 Table 15-3
American Society of Anesthesiologists (ASA) Physical Status Classification
System* and Stress Reduction Protocols

Modified from American Society of Anesthesiologists: ASA Physical Status Classification System,
www.asahq.org/clinical/physicalstatus.htm; accessed August 20, 2015; and Malamed SF: Knowing your
patients, J Am Dent Assoc 141:3S-7S, 2010.
ARD, Acute renal disease; BMI, body mass index; CAD, coronary artery disease; COPD, chronic
obstructive pulmonary disease; CVA, cerebrovascular accident; DIC, disseminated intravascular
coagulation; ESRD, end-stage renal disease; MI, myocardial infarction; PCA, post-conceptual age; TIA,
transient ischemic attack.
* Note: Physical status 5 and 6 are used primarily in medical practice.

2. Questions regarding cardiovascular disease (CVD) are significant

because clients with various forms of CVD are especially vulnerable

1249
to physical or emotional challenges that may be encountered during
dental hygiene care; for most CVDs, the stress reduction protocol,
based on the ASA system, is necessary (see the sections on
“Vasoconstrictors” in Chapter 18; “Congenital Heart Disease,”
“Cardiac Arrhythmias and Dysrhythmias,” “Hypertensive Disease,”
“Ischemic Heart Disease,” “Cerebrovascular Accident,” and
“Congestive Heart Failure” in Chapter 19; and “Vital Signs” in
Chapter 21)
a. Hypertension can result in myocardial infarction (MI) and
stroke (cerebrovascular accident, CVA) and contribute to
arteriosclerosis, impaired kidney function, and cardiac
enlargement; hypertension guidelines must be followed during
professional care to reduce the risk of a medical emergency
(Table 15-4)

Table 15-4
Classification of Adult Blood Pressure (BP) and Precautionary Measures

Modified from Little JW, Miller C, Rhodus NL, Falace D: Dental management of the medically compromised
patient, St Louis, 2008, Mosby; and US Department of Health and Human Services, National Institutes of
Health, National Heart, Lung, and Blood Institute, National High Blood Pressure Education Program: JNC
7 Express, Seventh Report of the Joint National Commission on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure, Bethesda, Md, NIH Pub No 03-5233, 2004,
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm; accessed August 20, 2015.

b. When CVD is identified, it is important for the clinician to

conduct a thorough interview to assess the severity and level of
control of disease and to determine alterations in care (e.g.,
physician consultation, antibiotic prophylaxis, stress reduction
protocol)
c. Clients undergoing corrective surgery for congenital heart
disease and who have prosthetic material or a prosthetic device

1250
 are susceptible to transient bacteremia for up to 6 months and
must receive antibiotic prophylaxis; at 6 months after surgery,
antibiotic prophylaxis is not usually recommended (see Table
15-2)
d. When antibiotic prophylaxis is necessary, 9 to 10 days should be
scheduled between appointments to allow oral bacteria to
return to the original state; clients currently following an
antibiotic regimen must use an alternative regimen of antibiotic
therapy; if antibiotic medication is inadvertently missed,
administer within 2 hours after the procedure
3. Questions regarding diseases of the immune system and blood
disorders assess a client’s potential risk for infection in dental
hygiene care and his or her ability to handle stress through the
appointment; primary concerns include prolonged bleeding, delayed
healing, and secondary infections; physician consultation may be
required for more chronic or involved conditions
a. For clients with diabetes, concerns exist about a hypoglycemic
incident, susceptibility to oral infections (abscesses, periodontal
diseases), impaired wound healing, and impaired glycemic
control because of the presence of periodontal disease;
consultation with a physician is indicated in most cases, and
referral is based on health history, dialogue, and oral conditions
b. Oral assessment should be initiated to determine the presence
of infections and the extent of periodontal disease before
consultation with a client’s physician; glycated hemoglobin
values (A1c ) and blood glucose levels are requested from the
physician; the client should be asked to bring his or her
glucometer, or a glucometer should be available in the oral care
facility (Box 15-1)

Box 15-1
Glyc emic Management for Adults
(Nonpregnant) with Diabetes
Blood Glucose Level (mg/dL)

1251
Modified from American Diabetes Association: Standards of medical care in diabetes
2015, Clin Diabetes 33(2):97-111, 2015.
* 15 g = 3 glucose tablets, a tube of glucose gel, or 4 ounces of fruit juice.
† Postprandial glucose measurements should be made 1 to 2 hours after the beginning of
the meal.

c. In clients with well-controlled diabetes, no alteration of the care plan is

indicated unless complications of diabetes such as hypertension,
congestive heart failure (CHF), MI, angina, or renal failure are present
d. Clients with controlled diabetes should eat before appointments;
appointments should be scheduled no later than midmorning, and a
sugar source must be available in the oral care facility in case of an
episode of hypoglycemia or hyperinsulinism
4. Metabolic syndrome (MetS) is closely associated with insulin
resistance, in which the body cannot use insulin efficiently; patients with
MetS are at increased risk of coronary heart disease, stroke, peripheral
vascular disease, and type 2 diabetes
a. MetS is identified by the presence of three or more components:
obesity measured by waist circumference (men > 40 inches and women
> 35 inches), fasting blood triglycerides (> 150 mg/dL), blood high-density
lipoprotein (HDL) cholesterol (men < 40 mg/dL and women < 50 mg/dL),
blood pressure (> 130/ 85 mm Hg), and fasting glucose (> 100 mg/dL)
b. Physician referral, medical consultation, or both may be required for
clients who do not have regular medical care, to determine the presence
of associated conditions or the level of control of existing conditions
5. Questions regarding respiratory disease or chronic obstructive
pulmonary disease (COPD) assess the level of compromised respiratory
function; clinicians should use precautionary measures to avoid further
depression of respiration (see the section on “Chronic Obstructive
Pulmonary Disease” in Chapter 19)
6. Musculoskeletal system disorders may be associated with chronic use
of salicylates or nonsteroidal anti-inflammatory drugs (NSAIDs), which

1252
can alter blood clotting and corticosteroid therapy and increase the risk
of acute adrenal insufficiency
7. Neurologic and psychological disorders must to be identified and the
degree of control determined; medications used to control seizures can
cause drug-influenced gingival enlargement, and psychiatric drugs have
the potential to interact adversely with the vasoconstrictors in local
anesthetic agents
8. Other disorders, such as glaucoma, sexually transmitted infections
(STIs), herpes, chemical dependency, and tobacco use, have significant
implications for treatment; in clients with glaucoma, anticholinergics are
contraindicated because these agents increase intraocular pressure;
chemical dependency and tobacco use are risk factors for infectious
diseases, malignancies, CVD, pulmonary diseases, and periodontal
diseases; dental hygiene care for clients with active herpes or STIs should
be postponed until the disease is no longer active
9. The physiologic state of women identifies their status related to
pregnancy and endocrine changes
10. The identification of the risk of latex allergy is essential to reduce the
chances of an allergic reaction; types of reactions include irritant contact
dermatitis, allergic contact dermatitis (delayed hypersensitivity), and
latex allergy
a. Irritant contact dermatitis—the most common reaction; causes dry,
itchy areas of irritation on the skin
b. Allergic contact dermatitis (type IV hypersensitivity reaction)—results
from exposure to chemicals added to latex during harvesting of rubber,
processing, or manufacturing
c. Latex allergy, or immediate allergic urticaria (type I hypersensitivity
reaction)—results from certain proteins in latex rubber; symptoms range
from skin redness, rash, hives, or itching to runny nose, itchy eyes,
asthma, and anaphylaxis
d. Clients at risk for latex reaction should be treated in a latex-reduced
environment; physician consultation is indicated for clients with risk of
an anaphylactic reaction
11. Listing of current medications—used to determine medications taken
by the client and possible interactions with other medications; these
medications may be the only clue to the client’s existing condition
(Physicians’ Desk Reference or Mosby’s Dental Drug Reference can help with
the identification of adverse reactions, precautions, contraindications,
and dental considerations)
12. Identification of medication allergies informs health care
professionals of the client’s previous adverse reactions to medications

1253
13. Vital signs (see the section on “Vital Signs” in Chapter 21)
a. Vital signs are values given to measurements of blood pressure (BP),
respiration, pulse, and temperature; serve as a baseline in a medical
emergency
b. Abnormal or elevated BP values should be brought to the client’s
immediate attention; on the basis of the BP values, monitoring of BP at
every appointment or a physician consultation may be required before
initiation of dental hygiene care (see Table 15-4)
c. BP, respirations, and pulse are measured and recorded before the
administration of local anesthetic agents or nitrous oxide–oxygen (N2O-
O2) analgesia
14. Conditions being treated with medications—may influence or
contraindicate certain procedures; for example, anticoagulant therapy
may require a lower dose; antihypertensive drugs may alter the choice of
local anesthetic; antipsychotic medications may alter the choice of N2O-
O2 analgesia (see the sections on “Anticoagulants” in Chapter 11;
“Toxicity,” “Vasoconstrictors,” and “Conscious Sedation with Nitrous
Oxide–Oxygen” in Chapter 18; and Chapter 21)
15. Physician consultations—may be necessary, depending on the
information obtained from health history or physical examination;
written documentation from the physician is necessary (see Fig. 15-1)
a. Written informed consent is obtained from the client before
submitting the request for physician consultation
b. Medical consultation can be faxed or mailed to the physician’s office
C. Health history information is gathered through interviews, written
questionnaires, or a combination of both
1. The interview method allows the dental hygienist to develop client
rapport and ensures that the client understands the questions
2. The self-administered written questionnaire is the most common
format used to gather information pertaining to the client’s health
status
3. Use of both the interview and the written questionnaire is the best
approach to collect accurate and comprehensive health information

1254
Extraoral and intraoral assessment
A. Purpose—to assess and recognize deviations from normal conditions
significant to a client’s health
B. Establishment of an assessment sequence that is followed
systematically—skills used in performing extraoral and intraoral
examination include direct observation, palpation, auscultation, and
olfaction
1. Direct observation—visual inspection techniques used to examine a
client’s movement, body symmetry, color, texture, contour,
consistency, and form of skin and mucous membrane
2. Palpation—sense of touch used to examine for tenderness, texture,
masses, and variations in structure and temperature within the head
and neck region
a. Digital palpation—use of single (index) finger to move or press
against the tissue of the floor of the mouth or hard palate
b. Bidigital palpation—use of one or more fingers and thumb to
move or compress the tissue of lips, tongue, cheeks, and
vestibule
c. Bimanual palpation—simultaneous use of the index finger of
one hand and the fingers and thumb of the other hand to move
or compress the tissue of the floor of the mouth
d. Manual palpation—use of all the fingers of one hand to move
and compress tissue to assess cervical lymph nodes
e. Bilateral palpation—use of both hands simultaneously to move
or press the tissue on the contralateral sides of the head to
assess the submandibular nodes, TMJ, inferior border of
mandible, and temporalis and masseter muscles
f. Circular compression—use of fingers that move in a rotating,
circular motion while slight pressure is applied
3. Auscultation—listening to and detecting sounds made by the body,
such as clicking (crepitation) of the TMJ; speech disorders; and vocal
hoarseness
4. Olfaction—use of the olfactory sense to detect variations in breath
odors, such as alcohol breath, fruity ketosis (diabetic acidosis), and
halitosis associated with dental caries, periodontitis, and necrotizing
ulcerative gingivitis

Extraoral Examination Procedure

See also Chapter 4.

1255
A. Head, neck, and face—the overall appearance of client should be
assessed via visual inspection
B. The symmetry of skin, eyes, nose, and ears should be observed; areas
of unusual discoloration should be inspected
1. Skin (see the section on “Skin Diseases” in Chapter 8)
a. Normal texture is continuous, firm, and pigmented in relation
to normal variations associated with race and ethnicity
b. Abnormal textures or pigmentations should be recorded (e.g.,
scarring, swelling, moles, freckles, pallor, redness, severe acne,
tumors, jaundice)
c. Abnormal lesions should be measured and documented in
writing, with details about color, size, shape, and surface texture
2. Face
a. Face and head should be symmetrical and have normal function
b. Asymmetry or lack of function may be associated with injury,
Bell’s palsy, tumor, abnormal growth and development, difficulty
swallowing, Parkinson’s disease, Tourette syndrome, and abuse
c. Facial expression can indicate the client’s general frame of mind
(e.g., anxious, happy, sad, angry)
3. Eyes (see the section on “Visual Impairment” in Chapter 19)
a. Clarity of the sclera should be noted; a yellowing color may
indicate the presence of jaundice
b. Excessively dry or irritated eyes may be a result of medication
side effects
4. Nose
a. Breathing should be assessed; flared nostrils or ragged breath
could indicate difficulty breathing
b. An enlarged, bulbous, and red nose may be associated with an
overgrowth of sebaceous and sweat glands from alcohol abuse
(rhinophyma)
5. Ears (see the section on “Hearing Impairment” in Chapter 19)
C. The symmetry of bones, muscles, lymph nodes, and salivary glands
should be observed
1. The inferior border of the mandible should be assessed for
asymmetry by using bimanual palpation from the midline to the
posterior angle
2. The TMJ and the muscles of mastication should be inspected
a. The TMJ should be assessed for deviation, pain, crepitus,
grinding, and reduced range in opening or closing; evaluated
through client interview and bilateral palpation with index
fingers anterior to outer meatus; client is asked to open and

1256
 close the mouth slowly several times; any deviation or
symptomatology is recorded
b. Masseter and temporalis muscles are assessed for
overdevelopment, pain, swelling, and unusual hardness by
using bilateral circular compression; client is asked to clench the
teeth together while the muscles are palpated
3. The mentalis muscle is assessed for overdevelopment and
smoothness of contraction during the swallowing movement;
evaluated by digital palpation; tissue is moved over the mandible,
and client is asked to swallow
4. The larynx is assessed for unrestricted movement by bimanual
palpation; the larynx is gently moved from side to side to check
movement
5. Lymph node chains are assessed (Fig. 15-5)

1257
 A, Location of the thyroid gland and major muscle groups. B,
FIG 15-5
Lymph nodes of the head and neck region. (Modified from Ball JW, et al:
Seidel’s guide to physical examination, ed 8, St Louis, 2015, Elsevier.)

a. Occipital lymph nodes are assessed for pain, swelling,

enlargement, unusual hardness, or fixed position by using
bilateral palpation
b. Auricular and parotid lymph nodes are examined for pain,
swelling, enlargement, unusual hardness, or fixed position by
using bilateral palpation
c. Superficial cervical lymph nodes are assessed for pain,
enlargement, unusual hardness, and fixed position by placing
client’s head to one side with the chin slightly lowered and by
palpating with fingers along the sternocleidomastoid muscle
d. Deep cervical lymph nodes are examined for pain, enlargement,
unusual hardness, and fixed position by placing client’s head
upright and by palpating deep tissues along the

1258
 sternocleidomastoid muscles with the thumb and fingers
6. Submental and submandibular glands are examined for asymmetry,
noncontinuous borders, pain, tenderness, swelling, enlargement,
unusual hardness, or difficulty in swallowing by bilateral digital
palpation
7. The thyroid gland is assessed for asymmetry and enlargement by a
combination of bidigital palpation and circular compression; client
is asked to sit upright and to swallow (see Fig. 4-8 in Chapter 4)
8. Parotid glands are examined for pain, swelling, enlargement, and
hardness by using bilateral circular compression; salivary flow can
be observed at the opening of Stensen’s duct when the gland is
compressed

Intraoral Examination Procedure

A. Screen the client to detect lesions that may be pathologic, particularly
lesions that may be cancerous
B. Prevent the development of advanced, irreversible, or untreatable oral
disease through early recognition of initial lesions
C. Oral piercing is a popular form of body art
1. Inspect the tongue, lips, cheeks, frenum, and uvula for piercings
2. Barbells and rings are the most common types of jewelry
3. Complications from piercing include excessive hemorrhage;
transmission of communicable diseases; nerve damage; infection;
bacteremia; Ludwig’s angina; cracked, fractured, or abraded teeth;
recession; dehiscence; and aspiration or ingestion of jewelry10
4. Jewelry should be removed during the radiography procedure
D. The oral mucosa, lips, floor of the mouth, tongue, salivary ducts, hard
and soft palates, and oropharynx should be examined and evaluated (see
Table 5-1 and Figs. 5-1 to 5-8 in Chapter 5)
1. The lips are examined by visual inspection and palpation for:
a. Changes in size—may be caused by swelling or allergic reaction
b. Chapping—may be caused by mouth breathing or nutritional
deficiency
c. Blistering—may be associated with herpetic lesions
d. Cracking—may be associated with angular cheilosis,
candidiasis, or vitamin B deficiency (see the section on
“Vitamins” and Table 12-4 in Chapter 12)
e. Scar tissue or irritations—may be associated with habitual lip
biting or trauma; bruising at commissures may indicate binding
or gagging associated with physical abuse

1259
 f. Abnormal texture, lack of moistness or firmness—may be
associated with dehydration and excessive sun exposure
g. Limitations of opening; muscle elasticity, and muscle tone—may
be associated with stroke or TMJ dysfunction
2. Labial and alveolar mucosa and the gingiva are examined by using
bilateral and bidigital palpation
a. Signs of tissue trauma from biting, toothbrush abrasion, burns,
or physical abuse; lacerated or torn frenum (tissue tags) may
indicate binding, gagging, or forced feeding
b. Ulcerated lesions such as herpetic lesions or aphthous ulcers
c. Tight or low frenum attachments, which can cause gingival
defects such as recession and loss of attached gingiva
d. “Spit tobacco” lesion (leukoplakia), hyperkeratinized tissue;
white, sometimes corrugated in appearance; client should be
taught self-assessment techniques
e. Amalgam tattoo, blue-and-black coloration, size variations—can
be found on any area of soft tissue (see section on “Conditions
of Oral Soft Tissues” in Chapter 8)
f. Fordyce granules—ectopic sebaceous glands
3. The buccal mucosa is assessed by using bidigital palpation; the
mouth mirror is used to reflect light and to inspect the buccal
mucosa
a. The buccal mucosa is examined for color and texture
b. The parotid papilla and duct (Stensen’s duct) are evaluated; the
duct is palpated to assess salivary function
c. Atypical findings include traumatic lesions related to cheek
biting, linea alba adjacent to occlusal plane, ectopic sebaceous
glands (Fordyce granules)
4. Hard and soft palates and alveolar ridges are examined by visual
inspection; the mouth mirror is used to reflect light; digital
palpation is used on the hard palate and alveolar ridges; palpation is
not recommended for soft palate to avoid triggering the gag reflex
a. The hard palate, including the incisive papilla, rugae, and
palatine fovea, is examined and assessed for:
(1) Shape of the palate—low, high, narrow vault; alterations in
shape may require alteration in oral radiographic
techniques
(2) Petechiae, torus palatinus, trauma (food burns, denture
irritation), stomatitis (nicotine, ulcerative, necrotizing, and
denture), fistulas from draining abscesses, denture-related
candidiasis (see Chapter 8)

1260
 b. The soft palate is assessed for inflammation, petechiae, trauma,
stomatitis, and bifid uvula
c. Alveolar ridges are assessed for impacted third molars, scarring
from third-molar extractions, opercula, and exostosis
5. Oropharynx is assessed by visual inspection with a mouth mirror
a. Client is asked to say “ah” to relax and lower the posterior
portion of the tongue
b. Anterior and posterior pillars are assessed for inflammation,
petechiae, trauma, stomatitis, and enlarged tonsillar tissues
6. Floor of the mouth is examined by visual inspection and bimanual
palpation
a. Function of the submandibular gland is tested by wiping each
Wharton’s duct with gauze and compressing it with a gloved
finger to observe salivary flow
b. Entire floor of the mouth is palpated; the finger of one hand and
the finger and thumb of the other hand are placed under client’s
chin to palpate
c. Enlargement or masses, Wharton’s duct, sublingual caruncle,
and lingual frenum are assessed
d. Varicosities, tight frenum attachment (ankyloglossia), and
blocked salivary duct are inspected
e. Exostosis along lingual surface of mandible and mandibular tori
—significant if interfering with prosthetic appliances
7. The tongue is examined by visual inspection and digital palpation
a. The dorsal surface is inspected; the entire tongue is palpated,
and the lateral borders of the tongue are examined by using
gauze to gently hold the tongue
b. The ventral surface is examined by having client touch the
palate with the tongue
c. The tongue is assessed for:
(1) Coating on the dorsal surface and the condition of
papillae; the extent is assessed
(2) Size; macroglossia associated with Down syndrome or
cretinism (see the section on “Down Syndrome” in Chapter
19)
(3) Lingual frenum; tight frenum restricting movement
(ankyloglossia)
(4) Fissured tongue; deep grooves and crevices along the
lateral borders and the dorsal surface; the lateral borders
are common sites of oral cancer
(5) Geographic tongue—benign condition in which a sporadic

1261
 migration of dorsal papilla occurs; tenderness is assessed
(6) Nutritional deficiencies; burning or glossy tongue (see the
section on “Abnormalities Affecting the Tongue” in Chapter
8)
(7) Black hairy tongue related to proliferation of filiform
papillae; caused by irritants such as smoking, alcohol, and
rinsing with hydrogen peroxide (see the section on
“Abnormalities Affecting the Tongue” in Chapter 8)
(8) Hairy leukoplakia caused by extensions of keratin on the
lateral borders of the tongue; associated with HIV infection
(9) Atypical lesions, including aphthous ulcerations, trauma-
associated fibroma, hemangiomas, and white plaque

1262
Assessment of dentition
A. Purpose—to assess and document the position and condition of teeth,
restorations, and dental caries, noting normal and abnormal findings on
a detailed dentition chart
1. Used for care planning, communication with client, legal
documentation, forensic use, and financial audits
2. Components include study models, occlusion assessment, dentition
charting, pulp vitality testing, and strain assessment
B. Study models—impressions for study models taken to obtain visual
reproduction of teeth, gingiva, and adjacent intraoral structures and to
assist with dentition and periodontal charting
C. Occlusion assessment—presence of malocclusion or tooth position
determined; signs of parafunctional habits resulting in occlusal
traumatism noted (see the sections on “Intra-arch and Interarch
Relationships” in Chapter 5 and “Clinical Assessment of the
Periodontium” in Chapter 14)
D. Dentition charting—graphic representation of a client’s teeth at
assessment (see Table 15-5)

Table 15-5
Periodontal Assessment Symbols

1263
1264
1265
1. Includes developmental anomalies and defects, condition of teeth,

1266
 dental caries activity, restorative history, and other problems; a
combination of radiographs and direct visual inspection is used to
assist with accurate recording of tooth assessment (Box 15-2)

Box 15-2
Systematic Approac h for Dentition Charting
Sequenc e
Complete a general appraisal of teeth, and note developmental
anomalies and defects affecting tooth shape, number of teeth, tooth
size, and presence of partial or complete dentures (e.g., generalized
moderate fluorosis, amelogenesis imperfecta, peg laterals, number of
teeth present, mandibular partial denture)
Chart all missing or erupted supernumerary teeth before recording
specific tooth-by-tooth information
Using radiographs, chart all unerupted or impacted teeth
Chart teeth indicated for extraction
Chart existing restorations (amalgam, tooth-colored, and temporary
restorations; inlays, onlays, and gold foils; crowns, veneers, and
bridges)
Chart signs of tooth damage (dental caries, risk areas, attrition)
Chart areas of plaque-retentive factors and defective restorations needing
replacement (overhangs, deficient margins, unpolished amalgam
restorations, fractured restorations, improper anatomical contour,
occlusal surfaces indicated for pit-and-fissure sealants)
When treatment has been completed on teeth indicated for restorative or
supportive care, update the chart using a different color to quickly
identify teeth that were restored after original baseline charting
Update the dentition charting at each recare visit, and record any areas of
change

2. Office guides and professional organizations’ dentition charting

symbols may be adopted for use; the ADA’s National Board Dental
Examination (NBDE) provides a dental charting symbol key in each client
case used
3. Universal Numbering System—most widely used notation system;
permanent teeth numbered from 1 to 32 and primary teeth lettered from
A to T; 1 to 16 or A to J are located on the maxillary arch, moving right to
left; 17 to 32 or K to T are located on the mandibular arch, moving left to
right (from client’s perspective)

1267
4. Developmental anomalies that affect enamel and dentin,
developmental defects that affect tooth shape, number of teeth, and
tooth size are noted (see the section on “Abnormalities of Teeth” in
Chapter 8)
5. Tooth positions, eruption patterns, and missing teeth are recorded (see
the sections on “Eruption” and “Intra-arch and Interarch Relationships”
in Chapter 5)
6. Tooth damage that results in loss of integrity of tooth surface is
recorded; common forms of damage include attrition, abrasion, erosion,
fracture, and dental caries (see the section on “Abnormalities of Teeth” in
Chapter 8)
7. Dental caries is an infectious, transmittable, and multifactorial disease
of bacterial origin; carious lesions are classified by the type and location
of the lesion by using visual inspection with magnification, laser
fluorescence, light fluorescence, digital imaging, fiberoptic
transillumination, gentle probing, and radiographic examination with
standard bitewing or digitized view11
a. Classification for carious lesions includes rate, direction, and type of
disease progression; used to determine level of priority for restorative
therapy
(1) Rampant caries—a rapidly progressive decay process that affects the
smooth surfaces of numerous teeth and requires urgent intervention;
frequently found with early-childhood caries (formerly called nursing
bottle syndrome)
(2) Chronic caries—slow progressive decay process
(3) Arrested caries—carious lesion that has been reversed because of the
remineralization process
(4) Backward caries—lateral spread of decay at the dentino-enamel
junction through an undermining process; the surface lesion appears
small, but destruction is extensive underneath12
(5) Recurrent or secondary caries— new decay located around existing
restorations
b. Carious lesions described by specific location on tooth surface (see the
section on “Dental Caries” in Chapter 9)
(1) Pit-and-fissure caries—develop in the pits and grooves of the occlusal
surfaces of premolars and molars, lingual pits of maxillary incisors,
buccal grooves of mandibular molars, and lingual grooves of maxillary
molars; pit-and-fissure sealants are an effective preventive strategy to
protect tooth surfaces (see the sections on “Pit-and-Fissure Sealants” in
Chapter 13 and “Dental Sealants” in Chapter 16)
(2) Smooth surface caries—found on the facial, lingual, mesial, and distal

1268
surfaces of teeth
(3) Root caries—found on exposed root surfaces
c. G.V. Black’s classification of dental caries and restorations provides a
precise description of the types and location of caries and restorations
(1) Class I—pits and fissures on the occlusal, buccal, and lingual surfaces
of posterior teeth and the lingual surfaces of anterior teeth
(2) Class II—proximal surface of posterior teeth, usually involving the
occlusal surfaces
(3) Class III—proximal surfaces of incisors and canines, not including the
incisal edge
(4) Class IV—proximal surfaces of incisors and canines, including the
incisal edge
(5) Class V—gingival third of facial or lingual surfaces of any tooth
(6) Class VI—cusp tips of posterior teeth and the incisal edge of anterior
teeth
8. Charting of existing restorations, treatment procedures (endodontics,
apicoectomy), and tooth replacement methods (implants, crown, bridge)
completed by using accepted dental symbols
a. Restorations should be charted with G.V. Black’s classification system
and should reflect the actual restoration
b. The restoration morphology, margin quality and location, and
biocompatibility of restorative material with soft tissue are evaluated13
(1) The restoration and the surrounding tooth structure are assessed for
new or recurrent dental caries
(2) The marginal and structural integrity assessed for open margins or
signs of restorative material fatigue or fractures; the appropriate margin
is smooth to tactile evaluation and does not show any overhang
(3) The interproximal and occlusal contours and the proximal contact are
assessed; the appropriateness of faciolingual and occlusocervical
dimensions are determined; indication for amalgam polishing or
recontouring to improve restoration is assessed
(4) Surface finish is assessed to determine whether it meets the
functional and esthetic requirements of the client; indication for
amalgam polishing or finishing is assessed
c. Faulty restorations are usually in need of replacement because of the
presence of recurrent dental caries, fractures, or factors that encourage
microbial plaque biofilm retention and may contribute to the
development of secondary caries, periodontal disease, and dentinal
hypersensitivity
d. Overhangs on class II restorations should be assessed for removal
(margination procedures) to correct defective margins and to provide a

1269
smooth surface that will not harbor bacterial plaque biofilm13,14
(1) Type I overhang—less than one third of the interproximal space;
treated with margination procedure and repolishing of restoration; may
be detected radiographically
(2) Type II overhang—one third to one half of the interproximal
embrasure space; treated with margination procedure if the predicted
final result is good (prognosis for the tooth, complexity, and cost of
replacement are considered); usually radiographically and clinically
detectable
(3) Type III overhang—more than half of the interproximal embrasure
space; treated with replacement of restoration; clinically and
radiographically detectable
9. Implant identification (see the sections on “Dental Implants” in
Chapters 13 and 14)—to assess for peri-implantitis and the stability of
the implant
10. Prosthetic appliances—assessed for stability and functionality
E. Pulpal vitality testing—when applicable (see the section on “Pulpal
Vitality and Testing Devices” in Chapter 16)
F. Stain assessment (see the section on “Selective Stain Removal” in
Chapter 17)—to determine the extent and type of stain present
1. Stains are primarily factors related to esthetics; result from deposits
of chromogenic bacteria, foods, and chemicals
2. Heavy tobacco stains encourage bacterial plaque biofilm retention

1270
Periodontal assessment
See the section on “Clinical Assessment of the Periodontium” in Chapter
14.
A. Recognition of oral health, gingivitis, or periodontitis must occur
through systematic and comprehensive periodontal examination to
determine whether oral prophylaxis, nonsurgical periodontal therapy
(NSPT), periodontal maintenance (PM), or other periodontal therapy is
indicated and to what extent15 (Table 15-5)
B. During general periodontal examination, anatomical features such as
position, size, and shape of gingiva and interdental papillae and position
of frena must be recorded
1. The presence, location, and severity of gingival inflammation are
assessed—soft tissue description (color, texture, consistency,
marginal and papillary shape)
2. Mucogingival relationships are evaluated to identify the deficiencies
of keratinized tissue, abnormal frenum insertions, and other tissue
abnormalities, such as clinically significant gingival recession (e.g.,
recession, loss of attachment/clinical attachment level, attached
gingiva)
C. Periodontal probing is done to assess the probing depth and to
provide information on the health of subgingival areas, including the
presence of bleeding on probing (see the section on “Clinical
Assessment Using Periodontal Probes” in Chapter 17)
1. Probing depths are measured on six tooth sites (distofacial, facial,
mesiofacial, distolingual, lingual, mesiolingual) and recorded on the
periodontal chart
2. Clinical pocket depth measurements and loss of attachment
readings are used to determine the presence of pseudopockets (false
or gingival pockets) or periodontal pockets
D. Periodontal soft tissues, including peri-implant tissues, should be
examined
E. The presence of purulent exudates and gingival crevicular fluid (GCF)
should be determined; increased GCF and purulent exudate indicate
inflammatory changes within the pocket wall; these are considered risk
factors for disease progression and require further assessment to
determine cause and to plan interventions
F. The presence and amount of bleeding on probing is noted to assist in
the determination of disease severity
G. The presence and distribution of bacterial plaque biofilm and calculus
—location, extent, and tenacity of deposits are identified to assist with

1271
appropriate care planning and instrument selection (see the section on
“Clinical Assessment with Dental Explorers” in Chapter 17)
H. Degree of mobility of teeth and dental implants
1. Mobility—risk factor for periodontal disease progression; should be
measured when moderate to advanced disease is present
2. Measured by bidigital evaluation when teeth are not occluded and by
direct observation (fremitus) when teeth are occluded; classified by
degree of movement
a. Class 1 or I—slight mobility, greater than normal
b. Class 2 or II—moderate mobility, greater than 1 mm
c. Class 3 or III—severe mobility, tooth can move in all directions
and can be depressed into the socket
3. Contributing factors—trauma from occlusion, inflammation in
periodontal ligament, periodontal surgery, physiochemical changes
(pregnancy or hormonal changes) in periodontal tissues, and
pathologic conditions (tumors)16
I. The presence, location, and degree of clinical furcation involvement are
determined
1. Occurs when loss of attachment extends into bifurcation or
trifurcation of multi-rooted teeth; classified by degree of
involvement
a. Class I—exposure of furcation; but bone remains between roots
b. Class II—loss of some bone between roots; but not complete
communication from one surface to another
c. Class III—through-and-through involvement with complete loss
of bone between roots; opening covered by gingiva
d. Class IV—through-and-through involvement with complete loss
of bone between roots; entrance clearly visible
2. Furcation involvement—risk factor in predicting periodontal
breakdown; compromises the prognosis of a tooth; detection and
thorough periodontal debridement essential at the earliest point
J. Bacterial culturing, genetic testing, deoxyribonucleic acid (DNA) or
ribonucleic acid (RNA) probes, antibody and enzyme markers should be
used, when indicated (see the section on “Clinical Assessment of the
Periodontium” in Chapter 14)
1. Microbial assessments are not recommended routinely because tests
fail to identify specific diseases or predict disease progression;
however, microbiologic monitoring may be used in clients who
continue to experience disease progression despite regular NSPT,
surgical intervention, and effective oral self-care; those at high risk
for disease progression or medically compromised clients with

1272
 aggressive periodontitis may benefit from microbiologic monitoring
2. Commercially available genetic tests assess susceptibility to chronic
periodontitis and assist in risk assessment
3. Salivary diagnostic advances allow for identification of periodontal
bacteria and genetic testing; although use in clinical practice is
limited, this diagnostic assessment tool is expanding17

1273
Radiographic evaluation
See the sections on “Radiology Techniques: Intraoral and Extraoral” and
“Radiographic Interpretation” in Chapter 6.
A. A satisfactory number of diagnostic-quality periapical and bitewing
radiographs are exposed and interpreted during the assessment phase of
therapy
B. Depending on the diagnostic needs of the client, current radiographs
are used for the proper evaluation and interpretation of the status of the
dentition, periodontium, and dental implants
C. Any radiographic abnormalities are noted in the client’s chart, and
appropriate follow-up or referral is done
D. Digital subtraction radiology is used to detect and measure small
changes in living bone (progressive bone loss or bone fill) that would
otherwise go unnoticed with traditional technology

1274
Oral hygiene assessment
A. Oral hygiene assessment—review of current home care practices,
adherence levels, oral health and hygiene knowledge, skill levels, and
psychosocial factors that might influence behaviors and oral habits;
assists in the development of effective self-care educational sessions
during the implementation phase of care (see Chapter 16)
B. Indices—tools to measure and score periodontal assessment factors
such as plaque biofilm, calculus, and bleeding for the benefit of both the
clinician and the client (see the section on “Clinical Assessment of the
Periodontium” in Chapter 14 and Table 20-11 in Chapter 20)
C. Oral self-care methods—used by a client to remove or reduce bacterial
biofilm both supragingivally and subgingivally (1 to 3 mm); oral hygiene
measures, oral home care, plaque biofilm control, and mechanical plaque
biofilm removal are synonymous with oral self-care methods (see the
sections on “Dental Plaque Biofilm Detection,” “Mechanical Plaque
Biofilm Control on Facial, Lingual, and Occlusal Tooth Surfaces,”
“Interdental Plaque Biofilm Control,” and “Care of Fixed and Removable
Prostheses” in Chapter 16)
1. Determination of the use, frequency, and methods of plaque biofilm
removal devices, dentifrices, mouthrinses, and fluorides
2. Determination of the frequency of tobacco use, oral habits, and
sugar intake
3. Assessment of a client’s skill level for oral self-care
a. Skill deficiency—present if the client does not have the
knowledge and the psychomotor ability to perform mechanical
plaque biofilm removal
b. Management deficiency—present if the client possesses the
ability but does not perform plaque biofilm removal effectively
on a daily basis
4. Assessment of a client’s motivation and readiness for behavior
change
D. Evaluation of dietary risk factors for dental caries; recommendations
offered to reduce total sugar clearance time per day (see the section on
“Nutritional Assessment and Counseling” in Chapter 12)

1275
Risk factor assessments
A. Risk factors—factors that significantly increase the risk for the onset
or progression of a specific disease; include systemic disease,
oropharyngeal cancer, caries, and periodontal disease risk factors
B. Systemic disease—risk factor for periodontal disease, and in some
cases, periodontal disease is considered a contributing factor for
systemic conditions; CVD, diabetes mellitus, respiratory disease,
osteoporosis, and preterm low birth weight (see Chapter 14); when these
conditions are present, consider the following American Academy of
Periodontology recommendations18,19
1. Diagnose the periodontal condition, and inform the client of his or
her risk for systemic disease
2. Consultation with client’s physician may be indicated to advise the
physician about the client’s periodontal status and the proposed care
plan
3. Determine the level of control or the status of disease, such as
gestational period, medications used, and glycemic control
4. Provide self-care education regarding the relationship of periodontal
infection to systemic health and of systemic health to periodontal
disease
5. Provide adequate NSPT, and encourage the client to commit to
periodontal maintenance care
C. Oral and pharyngeal cancer risk—determined by evaluating risk
factors such as socioeconomic status, tobacco use, race, alcohol use, sun
exposure, gender, and age to formulate appropriate care plan and
intervention to reduce risk: use the ADHA’s tobacco cessation initiative
Ask, Advise, Refer based on U.S Department of Health and Human
Services Clinical Practice Guidelines20
D. Caries risk—determined by assessing protective and causative factors
(e.g., frequency of sugar intake, high cariogenic bacteria count, biofilm
removal ability, salivary dysfunction, biofilm-retentive factors, recare and
fluoride history) to formulate appropriate care plan to reduce the client’s
risk (Table 15-6)

1276
Table 15-6
Classification of Caries Risk

Modofied from American Academy of Pediatric Dentistry: Guideline on caries-risk management for infants, children, and
adolescents, Pediatr Dent 35(5):E157-E164, 2013; and American Dental Association, Councils on Dental Practice and
Scientific Affairs: Caries risk assessment form. http://gsa.ada.org/search?
as_sitesearch=www.ada.org/sections/professionalResources/docs&q=caries+risk&searchButton.x=0&searchButton.y=0&site=ADAor
8&ip=24.117.153.112&access=p&sort=date%3AD%3AL%3Ad1&entqr=3&oe=UTF-8&ud=1. Accessed August 20, 2015.
CFU/mL, Colony-forming units per milliliter.

1. Sugar intake assessment includes determining the form and

frequency of exposure and offering appropriate recommendations to
reduce exposure
2. Plaque-retentive factors (restoration overhangs, defective and poorly
fitting crown margins, dental caries, exposed root surfaces, excess
cement, xerostomia) should be identified and eliminated or
minimized

1277
 3. Use of topical fluoride or chemotherapeutic agents (e.g.,
antimicrobial mouthrinses and dentifrices, products with xylitol)
should be assessed and prescribed if not already being used by the
client
4. Recare regularity is evaluated and adjusted on the basis of the level
of caries risk
E. Periodontal risk—assessed by determining dental and host-
environmental risk factors and risk indicators (e.g., history of previous
aggressive disease, increased pocket probing depth, loss of clinical
attachment, infrequent dental visits, stress, poor oral hygiene, specific
bacterial pathogens, tobacco use, diabetes mellitus with poor glycemic
control, inherited risk) and by determining signs and symptoms of
disease to assist with the formulation of accurate diagnosis and plan of
care (see the section on “Changes in the Periodontium Associated with
Disease” in Chapter 14)

1278
Diagnosis
A. Definition—clinical diagnosis by licensed dental hygienist that
identifies actual or potential unmet human needs (deficits) related to
oral health or disease that a dental hygienist is educated and licensed to
treat or refer for care;7 the second phase in the dental hygiene process of
care (see Fig. 15-1)
B. Dental diagnosis identifies a specific oral disease, whereas dental
hygiene diagnosis identifies human needs deficits related to dental
hygiene care
C. Interpretation of collected data during assessment phase of care is
necessary to identify significant findings, recognize deviations from
normal, describe abnormalities, and analyze significance of the
abnormalities
1. Analysis of assessment data used to identify deviations from normal
values and to identify patterns or relationships within data
2. Synthesis combines elements from data to develop explanations for
symptoms
a. Inductive reasoning finds possible patterns in observations to
predict new information
b. Deductive reasoning begins with generalizations and proceeds
to discover specific facts
D. Identification of unmet human needs related to oral health or
systemic problems provides a unique focus for the provision of dental
hygiene care
E. Validation allows for the recognition of errors and discrepancies, the
need for additional information from the client or from other health care
professionals, or the reinterpretation of documented evidence
F. Diagnostic statements are formulated after data analysis and
validation; become framework for planning, implementation, and
evaluation phases of care; Fig. 15-6 shows three major components of
written diagnostic statements:

1279
 FIG 15-6 Dental hygiene diagnosis. (Modified from Darby ML, Walsh MM: Application of
the human needs conceptual model to dental hygiene practice, J Dent Hyg 74(3):233, 2000.)

1. Condition or problem, or potential problem, as identified by unmet

human needs (diagnosis) related to dental hygiene care; used to
formulate client goals
2. Identification of contributing or causative factors related to unmet
human needs; used to determine appropriate dental hygiene
interventions
3. Signs and symptoms (evidence) of unmet human needs that support
existence of problem; used to evaluate outcomes of dental hygiene
care

1280
Prognosis
A. Definition—prediction of duration, course, and termination of disease
and response to treatment; usually determined after diagnosis and
before care is planned
B. Overall prognosis considers both oral and systemic health and the
significance of factors present (e.g., type of periodontal disease, age,
socioeconomic status, systemic conditions, malocclusion, periodontal
status, complicated prosthesis, tobacco use, cooperation of client)
C. Prognosis for individual teeth made after overall prognosis is
determined and relates to mobility, periodontal pockets, adequacy of
attached gingiva, mucogingival involvement, furcation involvement,
tooth morphology, status of teeth serving as abutments, bone level
surrounding tooth, and extensive caries
D. Level of prognosis established through collaboration of the dental
hygienist and the dentist after comprehensive assessment21
1. Excellent prognosis—no bone loss, excellent gingival conditions, and
adequate client commitment to care
2. Good prognosis—adequate remaining bone support, adequate
possibilities to control causative and risk factors, and adequate client
commitment to care
3. Fair prognosis—less-than-adequate remaining bone support, some
tooth mobility, grade I furcation involvement, adequate maintenance
possible, and acceptable client commitment to care
4. Poor prognosis—moderate to advanced bone loss, tooth mobility,
grade I and II furcation involvement, difficult areas to maintain, and
doubtful client commitment to care
5. Questionable prognosis—advanced bone loss, grade II and III
furcation involvement, tooth mobility, and inaccessible areas
6. Hopeless prognosis—advanced bone loss, areas not maintainable,
and extraction or extractions indicated

1281
Evidence-based decision making22,23
A. Health care professionals must be able to assess the value of the
information available in scientific literature and to use current best
evidence when providing dental hygiene care
B. Evidence-based decision making integrates clinical expertise, client
values, and best evidence into the decision-making process to achieve
successful therapeutic outcomes
C. Evidence-based decision making begins during the process of care
when a client presents with a specific clinical question or when a
question arises during dental hygiene care; the four elements of an
evidence-based question (PICO) are:
1. Patient, or problem
2. Intervention, cause, or prognosis
3. Comparison, or control
4. Outcome, or outcomes
D. The hygienist develops a well-defined clinical question (PICO) related
to the diagnosis, therapy, prognosis, cause, or harm to answer the client-
related question (Table 15-7)

Table 15-7
Asking the Clinical Question: PICO Mnemonic

Element
Descriptive Question(s) to Ask Example
(PICO)
Patient, or How would I describe a group of clients similar to A client with generalized
problem mine? What are the most important characteristics marginal biofilm and
for this client? inflammation
Intervention, Which main intervention or prognostic factor am I A powered toothbrush
cause, or considering for this client?
prognosis
Comparison, What is the main alternative to compare with the Compared with a manual
or control intervention? toothbrush
Outcome, or What can I hope to accomplish, measure, or Decrease marginal biofilm
outcomes improve? and inflammation
Modified from Forest JL, Miller SA: Translating evidence-based decision making into practice: EBDM concepts and finding
the evidence, J Evid Based Dent Pract 9:(2):59-72, 2009.

E. A computerized literature search is conducted to answer the PICO

question—randomized controlled clinical trials (RCTs), systematic
reviews, or meta-analysis studies provide the best evidence for answering
the question
F. Evidence obtained from literature search is critically evaluated to
determine validity and clinical applicability—studies are reviewed to

1282
identify the results and determine whether they are valid and whether
they apply to the client
G. Evidence gathered from literature appraisal is applied to clinical
practice by discussing the findings with client and offering
recommendations for treatment
H. The process and the clinician’s performance are evaluated

1283
Planning
A. Definition—identification and prioritization of current and potential
dental and dental hygiene care needs, establishment of client goals, and
determination of interventions and outcomes to meet these needs
B. Clients are more likely to express their wants, needs, and desires and
to commit to a care plan if they are actively involved in the development
of goals, priorities, interventions, and appointment planning
C. Assessment data and diagnosis should be used to develop a logical
plan of therapy to eliminate disease, slow disease progression, and
maintain and promote health15
D. Four components to consider when completing written care plan:
1. Establish priorities for care that require a collaborative approach
among the client, the dental hygienist, and the dentist; address the
following:
a. Needs of the client based on conditions that pose the greatest
threat to comfort, life, health, and safety
b. Main concerns or preferences of the client (chief complaint)
c. Motivational level of the client
2. Set client-oriented goals and evaluation measures that reflect the
expected and desired outcomes of dental hygiene care
a. For each dental hygiene diagnosis, at least one goal and
intervention should be established; some diagnoses may require
multiple interventions
b. Goals should focus on the cognitive, affective, or psychomotor
domain and contain a subject, verb, measurement criteria, and
specific time element:
(1) Cognitive goals focus on increasing knowledge level
(2) Affective goals focus on changes in beliefs, attitudes, and
values
(3) Psychomotor goals focus on skill development when skill
deficiencies are present
c. Expected outcomes and evaluation measures are used to
determine whether goals are being met during care or after
completion of therapy; when indicated, modify the diagnosis or
care plan if goals are not being met; two forms of evaluation
should be considered when planning care:
(1) Evaluation that occurs throughout the implementation
phase of care
(2) Evaluation or reevaluation that occurs after the completion
of initial therapy

1284
3. Identify interventions as part of care planning that specifically
address the dental hygiene diagnosis (Table 15-8)

1285
Table 15-8
Components of Dental Hygiene Care

Component Elements
General assessment Medical and dental history
Chief concern
Clinical examination
Radiographic analysis
Microbiologic, genetic, and biochemical diagnostic tests
Extraoral and intraoral examinations
Periodontal and restorative Risk assessment
assessment Plaque or biofilm, calculus
Dental restorations
Caries assessment
Dental implants
Probing depth (bleeding and suppuration)
Clinical attachment level and gingival recession
Furcation status
Prosthetic appliances
Occlusion (mobility, occlusal discrepancy, fremitus)
Proximal contact relationships
Periodontal-systemic interrelationships
Self-care education Risk factors
Disease theory education
Skill enhancement
Behavior interventions (nutrition counseling, tobacco
cessation, medical referral)
Instrumentation and Pain and anxiety control methods
supportive therapy Plaque biofilm and calculus removal
Restoration overhang removal
Desensitization for dentinal hypersensitivity
Fluoride therapy
Sealant application
Local or systemic chemotherapeutic agents
Implant maintenance
Mouthguard fabrication
Selection of polishing Selective stain removal (polishing)
procedures Restoration enhancement (finishing, polishing)
Referrals Medical consultation
Restorative therapy
Periodontal surgery
Orthodontics
Endodontics
Oral surgery
Oral pathology diagnosis
Modified from American Academy of Periodontology: Statement on comprehensive periodontal therapy, 2010,
http://www.perio.org/resources-products/posppr3-4.html, accessed August 20, 2015.

1286
a. Traditional phases of dental care planning include24:
(1) Preliminary phase—focuses on treating periodontal or
dental emergency needs
(2) Phase I therapy—focuses on controlling the risk factors
responsible for disease; includes self-care education, diet
control, removal or correction of biofilm-retentive factors,
antimicrobial therapy, and dental caries management
(3) Phase II therapy—focuses on surgical care; includes
periodontal surgery, placement of implants, and endodontic
therapy
(4) Phase III therapy—focuses on prosthetic treatment and
final management of dental caries, along with periodontal
examination to reevaluate response to restorative
procedures
(5) Phase IV therapy—focuses on long-term periodontal
maintenance therapy; includes assessment, self-care
education, deposit removal, and evaluation of continued-
care (recare) interval
b. Common system of periodontal disease classification; includes
overall disease extent (localized and generalized), severity (case
type), and activity (chronic, aggressive, or necrotizing) (see the
section on “Diseases of the Periodontium” in Chapter 14)
c. Interventions for common forms of periodontal disease include:
(1) Therapy for gingivitis (case type I)—includes oral self-care
education, supragingival and subgingival debridement,
antimicrobial agents, and correction of plaque biofilm–
retentive factors completed during a 1-hour appointment;
may include reevaluation at another appointment if
extensive bleeding occurs on probing or pseudopockets are
present
(2) Therapy for mild periodontitis (case type II)—includes
elimination, modification, or control of systemic diseases
and other risk factors; oral self-care education; and
supragingival and subgingival debridement, including
scaling and root planing with a quadrant approach, during
four 60- to 90-minute appointments, and reevaluation
(3) Therapy for moderate periodontitis (case type III)—
includes elimination, alteration, or control of systemic
diseases and other risk factors; oral self-care education; and
supragingival and subgingival debridement, including
scaling and root planing with a sextant or quadrant

1287
 approach, during four to six 60- to 90-minute appointments,
and reevaluation for surgery
(4) Therapy for advanced periodontitis (case type IV)—
includes elimination, modification, or control of systemic
diseases and risk factors; oral self-care education;
debridement, including scaling and root planing;
subgingival microbial sampling; and extraction of teeth that
have a poor prognosis with a sextant approach during six
60- to 90-minute appointments, and reevaluation for surgery
(5) Therapy for refractory periodontitis—includes self-care
education, debridement, scaling and root planing, control
of risk factors, systemic antibiotics, locally delivered
antibiotics, microbial diagnostic testing, and antimicrobial
therapy, with a sextant or quadrant approach, based on
number of sites involved; reevaluation for surgery; and
periodontal maintenance therapy
4. Written care plan provides permanent documentation and becomes
a contract between the dental hygienist and a client; elements of care
plan include:
a. Procedure—course of action or procedures to be rendered;
associated risks and benefits
b. Alternative treatment options
c. Appointment sequence—order in which therapy will be given
d. Approximate time for each procedure and total time for each
appointment
e. Expected outcomes and limitations of care

1288
Case presentation
A. Definition—presentation of assessment data to include dental and
dental hygiene diagnosis and proposed care plan
B. Purpose—to satisfy legal and ethical responsibilities for care, reach
agreement for therapy, and obtain informed consent
C. A collaborative approach between client and clinician should be
encouraged
D. Case presentation should be accurate, direct, and concise; should
describe:
1. Existing oral conditions and related causative and contributing
factors presented in terms that are understandable to the client
2. Treatment procedures and how therapy may differ from previous
appointments (e.g., number of appointments, length, purpose of
each appointment, services to be incorporated, description of
services)
3. Desired outcomes of treatment and provisional prognosis
4. Risks and benefits of all treatment options involved
5. Consequences of rejecting treatment or not proceeding with all
components of care
6. Alternative approaches to care, if any exist (e.g., mechanized vs.
hand-activated instrumentation; NSPT vs. surgery when advanced
disease is present)
7. Client’s responsibility as a co-therapist (e.g., commitment to self-care
and continued-care recommendations)
8. Client’s right to decline care by providing an opportunity to initially
consent for care and to withdraw from treatment at any time
9. Time and cost involved in professional care

1289
Informed consent
A. Definition—process by which a client agrees to a proposed treatment
after a complete case presentation (see Chapter 22)
B. Includes use of a written informed consent form, signed by the client
or guardian, the clinician, and a witness, stating that all treatment
descriptions, risk, benefits, outcomes of treatment, alternative
treatments, and an opportunity for questions and answers were
provided; should be completed before implementation of care plan
C. An informed refusal form is completed when a client declines some or
all of the care plan; includes:
1. Proposed dental and dental hygiene care planned
2. Risks involved without treatment
3. List of procedures being refused
4. Date the informed refusal form was signed
5. Signature of the client, the dental hygienist or the dentist, and a
witness

1290
Implementation
See the section on “Preventive Therapy or Treatment of Biofilm-Induced
Gingivitis” in Chapter 14.
A. Definition—delivery of preventive and therapeutic procedures
identified in an individualized care plan to meet a client’s human needs
(see Table 15-8)
1. Activities—reduction or elimination of risk factors for disease,
health promotion, self-care education, mechanical and mechanized
instrumentation, pharmacotherapeutic interventions, pain control
strategies, selective polishing; supporting interventions include
overhang removal, desensitization, dietary assessment and
counseling, dental caries management, and occlusal therapy
2. Modifications to the initial care plan are made as new assessment
criteria become available during the implementation of care (i.e.,
improved self-care, increase in healing response time)
B. Self-care education—teaching disease control, health maintenance,
and health promotion strategies to target the client’s diagnosed
problems; should occur at each appointment before instrumentation
procedures; strategies are those implemented by the client at home (see
Chapter 16)
C. Pain and anxiety control should be used when indicated to prevent or
manage apprehension and pain and promote the client’s cooperation and
compliance; includes local anesthetic agents, N2O-O2 analgesia, topical
anesthetic agents, and psychosomatic methods (see Chapter 18)
D. Instrument selection—based on intraoral conditions discovered in the
assessment phase of care: periodontal pocket depth, furcation
involvement, root concavities, deposit size, configuration, mode of
attachment, and location (see Chapter 17)
1. Hand-activated instrumentation—use of sharp curets and files, with
fundamental instrumentation principles during scaling and
debridement
2. Mechanized instrumentation—ultrasonic and sonic scaling
equipment and techniques for scaling and debridement
E. Polishing procedures—use of abrasive agents, prophy angle, low-speed
handpiece, toothbrush, or air abrasion unit to remove bacterial plaque
biofilm and stain and to produce a smooth, lustrous tooth surface
1. Selective polishing—esthetic procedure accomplished with a rubber
cup and paste or air-polishing unit (air abrasion) to remove extrinsic
stain remaining after periodontal instrumentation (see the section
on “Selective Stain Removal” in Chapter 17)

1291
 2. Therapeutic polishing—prophylaxis pastes may include
supplemental ingredients for added benefits, including fluoride,
xylitol, and calcium phosphate compounds25
3. Polishing and finishing restorations prevent recurrent caries and
deterioration of restorations, maintain periodontal health, and
prevent occlusal problems
F. Maintenance therapy (formerly known as supportive therapy)—a term
used for interventions directed at sustaining oral health and controlling
disease progression (e.g., debridement for control of periodontal
diseases and maintenance of periodontal health, fluoride therapy, sealant
application, occlusal appliance fabrication, oral irrigation,
desensitization, local or systemic antibiotics, implant maintenance) (see
the section on “Periodontal Maintenance” in Chapter 14 and “Oral
Irrigation,” “Fluorides,” “Mouthrinses or Chemotherapeutics,” “Dental
Sealants,” “Care of Fixed and Removable Prostheses,” “Dental Implant
Maintenance,” “Tobacco Use Interventions,” and “Assessment of
Dentinal Hypersensitivity” in Chapter 16.
G. Ergonomics focuses on the prevention of exposure to injury within the
work environment; involves clinician and client positioning, tasks and
procedures performed, equipment design and use, and impact of these
actions on musculoskeletal health
1. Cumulative trauma disorders (also known as repetitive strain
disorders)—musculoskeletal and nerve impairments caused by
repetitive work activities, especially when performed aggressively, in
awkward positions, or both
2. Prevention of ergonomic hazards—involves daily application of
ergonomic principles while providing dental hygiene care (e.g.,
posture, grasp, properly fitted gloves, instrument and equipment
design, exercise for hand and body, positioning of equipment and
materials in the environment)

1292
Client management with effective
communication
A. Communication—giving or exchanging information, signals, or
messages through facial expression, behavior, talking, gestures, and
writing; effective communication is essential in creating an environment
conducive to modifying a client’s psychomotor skills, level of knowledge,
values, attitudes, and lifestyle
B. Intrapersonal communication—processing a message within oneself;
often affected by one’s personal life experiences, culture, beliefs, and
values
C. Interpersonal communication—messages between two or more
people; focuses on the interaction and interpretation of a conversation
with nonverbal behaviors and spoken words; effective interpersonal
communication may reduce the incidence of miscommunication and
client management problems and increase the client’s commitment to
care
1. Nonverbal behaviors—nonspoken messages, including body
orientation, posture, facial expressions, gestures, touch, distance,
voice tone, and hesitation in speech
2. Verbal behaviors—spoken messages, including language, active
listening, paraphrasing, and reflective responding
a. The language used in communication should be carefully
selected based on the client’s characteristics and presented in a
straightforward and nonthreatening manner
b. Active listening requires maintaining eye contact and
concentration and focusing on what the client is communicating
c. Paraphrasing is restatement or summary of what the client said;
provides the opportunity to correct any misunderstandings
d. Reflective responding addresses the actual feelings of the client;
response is presented in manner that restates, rewords, or
reflects what the client said
D. Enhancement of client–dental hygienist relationship through
confidence and trust requires:
1. Acceptance—accepting the client without judgment
2. Comfort—ability to deal with embarrassing or emotionally painful
topics related to an individual’s health
3. Concreteness—communicating in a clear and precise manner with
terms understandable to a client
4. Empathy—listening and understanding the emotions and feelings of

1293
 an individual
5. Genuineness—communicating in an open and honest manner
6. Respect—ability to convey honor and esteem for an individual
7. Responsiveness—ability to reply to messages at the very moment
they are sent
8. Self-disclosure—sharing personal experiences with a client
9. Warmth—displaying personal feelings and empathy

1294
Evaluation
See the sections on “Treatment” and “Periodontal Maintenance” in
Chapter 14.
A. Definition—measurement of extent to which client has achieved
specified goals in care plan and determination of success of
interventions; ensures that high-quality care has been provided
B. The quality of dental hygiene care is assessed by certain criteria and
standards
1. Criteria—qualities or characteristics by which the knowledge, skill,
or oral health status of a client is measured through descriptions of
acceptable levels of performance of client or dental hygienist (e.g.,
probing attachment levels are reduced by 1 to 2 mm and no sites
with bleeding on probing)
2. Standards—acceptable and expected levels of performance by the
dental hygienist or other health care professionals, established
through national consensus2
C. Measurement of outcomes of dental hygiene interventions involves
collecting evaluation data to determine whether the client’s goals
established during the planning phase of care have been met, partially
met, or not met
D. Supervised neglect occurs when the client needs further professional
care to achieve higher levels of oral wellness or to prevent or control oral
disease process, but has been discharged from care under the false
assumption that a healthy state was achieved
E. Two forms of evaluation:
1. Evaluation—occurs continually throughout implementation phase of
care; provides the mechanism for modifying the care plan as new
assessment criteria become available during treatment (e.g.,
improved client self-care, increase in healing response time)
2. Reevaluation—occurs 4 to 6 weeks after therapy is completed to
evaluate response to initial care and to recommend additional
therapy as needed (e.g., decrease in probing depths, elimination of
bleeding points)
F. Elements of reevaluation appointment include components of the
dental hygiene process of care: assessment, diagnosis, planning, and
implementation
1. Assessment
a. Reassessment of initial assessment data and periodontal status
to evaluate improvement, such as effective self-care methods,
reduction of 1 to 2 mm in probing measurements, no bleeding

1295
 on probing, and healthy-appearing gingival tissue
b. Determination of the presence of residual deposits, newly
accumulated deposits, or unresponsive areas indicated by
bleeding on probing or gingival inflammation
c. Reevaluation of the client’s self-care practices
2. Diagnosis—reevaluation of dental or dental hygiene diagnosis, if
indicated, based on assessment data
3. Planning—care plan developed on the basis of assessment findings;
includes, when indicated, modification to self-care practices,
localized debridement, chemotherapy, appropriate referrals, and
establishment of continued-care schedule or periodontal
maintenance therapy
4. Implementation—provision of self-care education; removal of
residual deposits and plaque biofilm–retentive factors; debridement
of nonresponsive areas; provision of indicated therapy, and
reassessment of continued-care schedule
G. The continued-care (recare) schedule is determined on the basis of
individual client needs, degree of risk for oral disease, and disease
progression; client is informed of the rationale for and the importance of
continued care24
1. Continued-care schedules with intervals of 1 to 3 months are
recommended to clients who display poor results after therapy, have
significant risk factors, have advanced or aggressive disease, have
poor self-care, have furcation involvement, or have complicated
prostheses
2. Intervals of 3 months are recommended to clients who complete
routine NSPT with uneventful healing and demonstrate moderate to
high risk for oral diseases and disease progression
3. Intervals of 3 to 4 months are recommended to clients who have
maintained generally good results for 1 year or longer after therapy
but display significant risk factors (e.g., inconsistent or poor oral
hygiene, heavy calculus formation, systemic disease or condition,
tobacco use, localized pockets, occlusal problems, complicated
prostheses, ongoing orthodontic therapy, dental caries activity,
localized teeth with less than 50% of alveolar bone support)
4. Intervals of 6 months to 1 year are recommended to clients who
maintain excellent results for 1 year or longer and have been able to
eliminate or control risk factors for oral disease (e.g., good oral
hygiene, minimal calculus, no occlusal problems, no complicated
prosthesis, no remaining pockets, no teeth with less than 50% of
alveolar bone remaining, low risk for dental caries)

1296
H. Documenting the outcomes of dental hygiene care aids in preventing
possible legal charges related to inadequate documentation and client
feeling inadequately informed about his or her oral health status; should
include:
1. Status and prognosis for the case, sites at risk for disease
progression, and sites with disease progression
2. Sites with plaque biofilm and calculus, bleeding, and areas of
inflammation
3. Need for restorative and periodontal treatment and for referral to a
specialist
4. Discussion that took place with the client regarding his or her health
or disease status
5. Past commitment of the client and recommendations suggested by
the clinician
6. Time interval required for the next appointment (continued-care
interval)
7. Acceptance or rejection of any further needed therapy

1297
Documentation
A. Definition—the process of accurately recording all aspects of the
process of care, including assessment data, diagnosis, care plan,
treatment rendered, client education, and evaluation findings, for the
purpose of establishing the client’s health record
B. Accurate documentation of all assessment findings is the legal
responsibility of all clinicians (see Table 15-8)
C. Assessment findings should be clearly recorded and dated using ink
on appropriate data collection forms: health history forms, extraoral and
intraoral examination forms, dentition and periodontal charting forms,
and radiographic interpretation forms
1. Documentation and monitoring of abnormal lesions must be
followed; if after 1 week to 10 days the lesion or abnormality
remains, procedures should be implemented to diagnose the
condition (e.g., excisional or incisional biopsy, brush biopsy) (see the
section on “Diagnostic Tools for Oral Cancer Detection” in Chapter
16)
2. Active disease or any deviations from normal should be documented
and monitored
D. Additional information that was assessed (e.g., risk factors) and
discussed with the client, but not charted, should be recorded on a
record-of-services form
E. Diagnostic report documentation includes clearly written statements
that connect assessment findings with possible causes that can be
prevented, reduced, or resolved by dental hygiene interventions
F. Care-planning documentation, as previously mentioned, should
outline all interventions needed to address client needs, including the
estimated number of appointments
G. Implementation documentation is the recording of all treatments and
educational interventions administered to the client, with the
appropriate date of service; must include the signature of the provider of
care
H. Documentation of evaluation includes the resulting outcomes of the
interventions provided as well as any updated information found during
the reassessment process; next steps are communicated to the client and
detailed in the client’s permanent record

1298
Ethical, legal, and safety issues
Provision of comprehensive, quality care by licensed dental hygienists
includes legal, ethical, and safety issues that require consideration.
A. Ethical issues that place hygienist at risk are:
1. Failure to refer to a medical professional or other dental specialist
when indicated
2. Failure to maintain client confidentiality
3. Failure to perform a thorough case presentation so that a client can
make an informed decision about the dental hygiene care
4. Failure to perform comprehensive assessment to detect oral diseases
and abnormalities and degree of client risk for disease or disease
progression
B. Legal issues that place hygienist at risk are:
1. Failure to comply with the Health Insurance Portability and
Accountability Act (HIPAA); the clinician must verify that clients
have read the HIPAA policy and obtain a written Acknowledgment
of Receipt of the Notice from the client
2. Failure to assess, diagnose, treat, or refer for disease; even when
under the supervision of a dentist, a licensed dental hygienist is
accountable and responsible for client care
3. Failure to obtain written informed consent before initiating care
4. Failure to provide necessary care on the basis of assessment
findings; constitutes “supervised neglect”
5. Failure to provide evidence-based care
6. Failure to document assessment, care plan, informed consent,
services rendered, and client response to care
C. Safety issues that place the dental hygienist and the client at risk are:
1. Failure to protect a client from harm during care
2. Failure to assess accurately the client’s health and pharmacologic
history and to make necessary physician referrals
3. Failure to allow time during appointment for the provision of
adequate care
4. Failure to evaluate therapy after completion of care or to recommend
an appropriate continued-care interval
5. Failure to follow established protocol that protects the clinician and
the client during therapy (e.g., standard precautions; see Chapter 10)
6. Failure to use instrumentation in effective and responsible manner
(e.g., not using sharp instruments, not selecting appropriate
instruments based on conditions present, and causing tissue
trauma)

1299
 7. Failure to follow the manufacturer ’s instructions in the use of
equipment, devices, and dental materials

Website Information and Resourc es

Source Website Address Description
Medline and PubMed www.ncbi.nlm.nih.gov/pubmed/ Used for evidence-based decision
making
Medline Plus www.nlm.nih.gov/medlineplus/ Patient information on health
topics and medication; medical
encyclopedia
National Center for Dental www.usc.edu/hsc/dental/dhnet/ Focus for many dental hygiene
Hygiene Research research-related topics and links
Healthfinder www.healthfinder.gov Patient information on health
topics, special population topics,
health care, directory
Dimensions of Dental Hygiene www.dimensionsofdentalhygiene.com/ Online journal with dental and
dental hygiene–related topics
National Institutes of Health www.nih.gov Health topics, funding, news,
events
American Academy of www.perio.org Association website; parameters
Periodontology of practice and position papers
related to the treatment of
periodontal diseases
National Institute of Dental and www.nidcr.nih.gov Oral health information,
Craniofacial Research educational resources and
research
National Guideline www.guideline.gov Evidence-based clinical practice
Clearinghouse guidelines
Centers for Disease Control and www.cdc.gov Health and safety topics,
Prevention publications, data and statistics
Occupational Safety and Health www.osha.gov Information on the health and
Administration safety of employees
RxList www.rxlist.com/script/main/hp.asp Information related to
prescription medications
Merck Manual www.merck.com Information related to medical
conditions
MyMedicineList www.safemedication.com Database containing important
medication information
Aetna InteliHealth (Harvard www.intelihealth.com Consumer information related to
Medical School-Intelihealth health and medicine
Partnership)
U.S. Department of Health and www.hhs.gov/ocr/privacy/ Health information privacy
Human Services

1300
References
1 Darby M.L., Walsh M.M., eds. Dental hygiene theory and practice. ed
4 St Louis: Saunders; 2015.
2 American Dental Hygienists Association. Standards for clinical
dental hygiene practice. Chicago: ADHA; 2008.
3 Commission on Dental Accreditation. Accreditation standards for
dental hygiene education programs. Chicago: American Dental
Association; 2013.
4 American Dental Hygienists Association. Policy manual: ADHA
framework for theory development—1. Chicago: ADHA; 2005.
5 Darby M.L., Walsh M.M. A proposed human needs conceptual
model for dental hygiene. Part I. J Dent Hyg. 1993;67(6):326–334.
6 Darby M.L., Walsh M.M. Application of the human needs
conceptual model of dental hygiene to the role of the clinician.
Part II. J Dent Hyg. 1993;67(6):335–346.
7 Darby M.L., Walsh M.M. Application of the human needs
conceptual model to dental hygiene practice. J Dent Hyg.
2000;74(3):230–237.
8 American Academy of Periodontology. Statement on comprehensive
periodontal therapy. 2010. http://www.perio.org/resouces-
products/posppr3-4 Accessed July 24, 2015.
9 Pickett A.F. Personal, dental and health histories. In: Darby M.L.,
Walsh M.M., eds. Dental hygiene theory and practice. ed 4 St Louis:
Saunders; 2015.
10 Pires I.L., Cota L.O., Oliveira A.C., Costa J.E. Association between
periodontal conditions and use of tongue piercing. J Clin
Periodontol. 2010;37(8):712–718.
11 Fontana M., Young D.A., Wolff M.S., et al. Defining dental caries
for 2010 and beyond. Dent Clin North Am. 2010;54(3):423–440.
12 Pimlott J.F., Leakey J.D. Assessment of the dentition. In: Darby
M.L., Walsh M.M., eds. Dental hygiene theory and practice. ed 4 St
Louis: Saunders; 2015.
13 Hinrichs J.E. The role of dental calculus and other predisposing
factors. In: Newman M.G., Takei H.H., Klokkevold P.R., Carranza
F.A., eds. Clinical periodontology. ed 12 St Louis: Saunders; 2015.
14 Chan D.C.N., Chung A.K.H. Management of idiopathic
subgingival amalgam hypertrophy: the common amalgam
overhang. Operat Dent. 2009;34(6):753–758.
15 American Academy of Periodontology. Guidelines for periodontal
therapy. J Periodontol. 2001;72:1624–1628.

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16 American Academy of Periodontology. Parameter on occlusal
traumatism in patients with chronic periodontitis. J Periodontol.
2000;71:873–875.
17 Giannobile W.V. Salivary diagnostics for periodontal diseases. J Am
Dent Assoc. 2012;143(10 Suppl):6–11.
18 Lockhart P., Bolger A., Papapanou P., et al. Periodontal disease and
atherosclerotic vascular disease: does the evidence support an
independent association? AHA Scientific Statement. Circulation.
2012;125:2520.
19 American Academy of Periodontology. Parameter on systemic
conditions affected by periodontal diseases. J Periodontol.
2000;71:880–883.
20 Fiore M.C., Bailey W.C., Cohen S.J., et al. Treating tobacco use and
dependence: clinical practice guideline. Rockville, Md: US
Department of Health and Human Services, Public Health
Service; 2000.
21 Novak K.F., Goodman S.F., Takei H.H. Determination of prognosis.
In: Newman M.G., Takei H.H., Klokkevold P.R., Carranza F.A.,
eds. Clinical periodontology. ed 12 St Louis: Saunders; 2015.
22 Forrest J.L. Introduction to the basics of evidence-based dentistry:
concepts and skills. J Evid Based Dent Pract. 2009;9(3):108–112.
23 Forrest J.L., Miller S.A. Translating evidence-based decision
making into practice: EBDM concepts and finding the evidence. J
Evid Based Dent Pract. 2009;9(2):59–72.
24 Merin R.L. Supportive periodontal treatment. In: Newman M.G.,
Takei H.H., Klokkevold P.R., Carranza F.A., eds. Clinical
periodontology. ed 12 St Louis: Saunders; 2015.
25 Pence S. Polishing particulars. Dimens Dent Hyg. 2013;11(6):24–28.

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Suggested readings
American Academy of Periodontology. Guidelines for the
management of patients with periodontal diseases. J Periodontol.
2006;77(9):1607–1611.
Beemsterboer P.L. Ethics and law in dental hygiene. ed 3 Philadelphia:
Saunders; 2010.
Featherstone J., Roth J.R. Curing the silent epidemic: caries
management in the 21st century and beyond. J Calif Dent Assoc.
2007;35(10):681–685.
Featherstone J., Young D.A., Domejean-Orliaguet S. Caries risk
assessment in practice for age 6 though adult. J Calif Dent Assoc.
2007;35(10):703–713.
Forrest J.L. Introduction to the basics of evidence-based dentistry:
concepts and skills. J Evid Based Dent Pract. 2009;9(3):108–112.
Forrest J.L., Miller S.A. Translating evidence-based decision making
into practice: EBDM concepts and finding the evidence. J Evid
Based Dent Pract. 2009;9(2):59–72.
Friedewald V.E., Kornman K.S., Beck J.D., et al. The American Journal
of Cardiology and Journal of Periodontology Editors’ Consensus:
Periodontitis and atherosclerotic cardiovascular disease. J
Periodontol. 2009;80:1021–1032.
Little J.W., Miller C., Rhodus N.L., Falace D. Dental management of
the medically compromised patient. ed 7 St Louis: Mosby; 2008.
Malamed S.F. Medical emergencies in the dental office. ed 6 St Louis:
Mosby; 2007.
Mealey B.L., Oates T.W. Diabetes mellitus and periodontal diseases.
J Periodontol. 2006;77:1289–1303.
Miller S.A., Forrest J.L. Translating evidence-based decision making
into practice: appraising and applying the evidence. J Evid Based
Dent Pract. 2009;9(4):164–182.
Ramos-Gomez F., Crall J., Gansky S., et al. Caries risk assessment
appropriate for the age 1 visit (infants and toddlers). J Calif Dent
Assoc. 2007;35(10):687–702.
Wartenberg D., Thompson W.D. Privacy versus public health: the
impact of current confidentiality rules. Am J Public Health.
2010;100(3):407–412.
Wun E., Dym H. How to implement a HIPAA compliance plan into
a practice. Dent Clin North Am. 2008;52(3):669–682.

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Chapter 15 review questions
Answers and rationales to chapter review questions are available on this
text’s accompanying Evolve site. See inside front cover for details.

Case A
A 44-year-old man presents as a new client for dental hygiene care. His
medical history reveals type 2 diabetes, high blood pressure (BP)
controlled with medication, and a hip replacement. He reports no blood
glucose monitoring and controls diabetes with diet and exercise. He had
a physical examination last year but is not sure of the examination
results. He assumes “everything is fine.” You record his BP reading at
150/102 mm Hg.

Use Case A to answer questions 1 to 4.

1. Which of the following should be considered before implementing
dental hygiene care for this client?
a. Dental hygiene care can be implemented immediately without any
considerations.
b. Dental hygiene care can be started immediately as long as the client
consents to treatment.
c. Consult with client’s physician to establish a definitive diagnosis of
diabetes and level of control for diabetes and hypertension before
initiating dental hygiene care.
d. Appointments should be longer than normal to reduce the number
of appointments needed and to reduce stress.
2. What is this client’s ASA physical status (PS) classification?
a. PS1
b. PS2
c. PS3
d. PS4
3. What is the BEST course of action for the dental hygienist related to
the BP reading?
a. Recheck BP in 5 minutes; if it is still elevated within that range,
dismiss the client and seek immediate consultation with physician

1304
 b. Recheck BP at each appointment; if it is still within range for three
consecutive appointments, refer to physician
c. Recheck BP in 5 minutes; if it is still elevated within that range,
continue with noninvasive care only and consult with physician before
dental hygiene therapy
d. Recheck BP in 5 minutes, and continue with dental hygiene care
4. Which human need should be considered during the dental hygiene
process of care?
a. Freedom from head and neck pain
b. Protection from health risks
c. Skin and mucous membrane integrity of head and neck
d. Wholesome facial image

Case B
A 25-year-old female presents for dental hygiene care. Her records
indicated that 10 months have lapsed since receiving dental hygiene
care, and she scheduled the appointment because her teeth are sensitive
when she eats candy and her “gums” hurt when she brushes her teeth.
She reports an arrhythmia but is not sure of the type or cause and
irregularly takes the prescribed medication for its treatment. Her vital
signs are within normal limits. During the dental and periodontal
assessment, you record generalized marginal gingival inflammation,
generalized moderate interproximal subgingival calculus deposits,
generalized bleeding on probing, with 2-mm to 4-mm probing depths.
Existing restorations include teeth #14-MO, #4-MOD, #13-MO, #18-MO,
and #19-B. Radiographs reveal no evidence of bone loss, proximal carious
lesions on #29 D, #30 M, and #19 M and restoration overhangs on #14 M
and #4 D. She brushes once a day and does not use an interproximal
cleaning aid.

Use Case B to answer questions 5 to 11.

5. Which of the following conditions represents the MOST accurate
periodontal disease classification?
a. Case type I—gingivitis
b. Case type II—mild periodontitis
c. Case type III—moderate periodontitis
d. Case type IV—advanced periodontitis

1305
6. All the following human need categories relate to the client’s
current conditions EXCEPT one. Which one is the exception?
a. Protection from health risks
b. Freedom from anxiety and stress
c. Skin and mucous membrane integrity of head and neck
d. Biologically sound and functional dentition
7. All the following are related to the overhanging restorations
EXCEPT:
a. Increase bacterial plaque biofilm retention
b. Restorations should be replaced
c. Restorations are risk factors for periodontal disease
d. Restorations are treated using margination procedures
8. Based on the oral assessment findings, what is the classification of
caries risk for this client?
a. Low risk
b. Moderate risk
c. High risk
d. Insufficient data to determine
9. The restoration on tooth #14 would be BEST classified as a:
a. Class I restoration
b. Class II restoration
c. Class III restoration
d. Class IV restoration
10. Based on the periodontal assessment, what is the BEST
reevaluation interval for this client?
a. 1 to 2 weeks
b. 4 to 6 weeks
c. 3 to 4 months
d. 6 months to 1 year
11. What is the overall prognosis for this client after phase I therapy?
a. Excellent
b. Good
c. Fair
d. Poor

1306
Case C
A heavy tea drinker just purchased over-the-counter whitening strips to
see if her discolored teeth could be whitened. She wants to know if using
whitening strips is better than using the professional custom tray
bleaching system at home. You want to provide an evidence-based
answer, based on a search of the research literature.

Use Case C to answer questions 12 and 13.

12. Which of the following would be an example of a well-developed
question to help narrow your research literature search?
a. For clients with discolored teeth, are whitening strips the best
method to increase whitening?
b. Are whitening strips the best method to increase whitening?
c. Are whitening strips more effective than custom tray bleaching
systems?
d. For clients with tooth discoloration from tea stain, are whitening
strips more effective in increasing teeth whitening compared with
professional at-home custom tray bleaching?
13. Which type of study will provide the BEST evidence to answer the
client’s question?
a. Case-control studies
b. Randomized controlled clinical trials
c. In vitro research
d. Case reports
14. A dental hygienist records a client’s blood pressure as 152/85 mm
Hg. What blood pressure category is represented?
a. Prehypertension
b. Stage I hypertension
c. Stage II hypertension
d. Stage III hypertension
15. What phase of dental care focuses on periodontal surgery?
a. Preliminary phase
b. Phase I
c. Phase II
d. Phase III
16. The written care plan includes all the following components

1307
EXCEPT:
a. Appointment sequence for therapy to be provided
b. Approximate time for each appointment
c. Cost of each presented procedure
d. Expected outcomes and limitations of care
17. When localized bleeding on probing is noted during a 4- to 6-week
reevaluation appointment, all following procedures are required
EXCEPT:
a. Determining presence of residual or new deposits
b. Establishment of continued-care (recare) interval
c. Evaluation of self-care practices
d. Referral to physician
18. Which is a CORRECT statement regarding the assessment phase of
care?
a. It includes the comprehensive collection, analysis, and permanent
documentation of client data.
b. It involves the collection of only subjective information.
c. Assessment data should be updated only during continued-care
(recare) appointments.
d. Data should not be discussed with the client or appropriate health
care providers.
19. When reviewing a health history, the client has indicated that he
has allergies to kiwis, avocados, and bananas. For what condition is
this client at risk?
a. Acute adrenal insufficiency
b. Asthma
c. Diabetes
d. Latex allergy
20. The American Academy of Periodontology (AAP) classification for
advanced periodontitis is:
a. Case type I
b. Case type II
c. Case type III
d. Case type IV
21. All the following factors are considered when providing dental

1308
hygiene care for diabetic clients EXCEPT:
a. Cardiovascular conditions
b. Continued-care (recare) interval
c. Susceptibility to oral infection
d. Rapid healing
22. Individuals with stable angina pectoris, COPD, and/or mild
congestive heart failure are in which ASA physical status (PS)
classification category?
a. PS1
b. PS2
c. PS3
d. PS4
23. What phase of the dental hygiene process of care immediately
follows diagnosis?
a. Assessment
b. Evaluation
c. Implementation
d. Planning
24. All the following are components of assessment EXCEPT:
a. Health history
b. Intraoral photographs
c. Periodontal probing
d. Self-care education
25. After a comprehensive assessment, findings show chronic
periodontitis with moderate bone loss, generalized pocket depths of 4
to 6 mm with bleeding, light subgingival biofilm and calculus on the
maxillary arch, and moderate to heavy subgingival biofilm and
tenacious calculus on the mandibular arch. Based on these findings,
what would be a realistic approach to nonsurgical periodontal therapy
(NSPT) for this client?
a. A 60-minute appointment consisting of oral self-care education and
supragingival and subgingival debridement
b. Two 60-minute appointments consisting of oral self-care education,
debridement, and scaling and root planing
c. Five 60- to 90-minute appointments consisting of oral self-care
education, debridement, scaling and root planing, and reevaluation

1309
d. Six 60- to 90-minute appointments consisting of oral self-care
education, debridement, scaling and root planing, and reevaluation
26. When client-oriented goals are developed during the planning
phase of care, to what do affective goals relate?
a. Increasing client’s knowledge level about bacterial biofilm
b. Influencing changes in beliefs and attitudes
c. Providing information related to bacterial biofilm
d. Modifying a toothbrushing method
27. When reviewing a health history, the client has indicated that she
urinates more than six times a day, she is frequently thirsty, and her
mouth is always dry. What condition manifests these characteristics?
a. Asthma
b. Diabetes mellitus
c. Hypertension
d. Thyroid disease
28. Which of the following conditions is indicated by yellow sclera of
the eye?
a. Difficulty breathing
b. Drug abuse
c. Jaundice
d. Medical emergency status
29. What is the G.V. Black classification of dental caries and
restoration located on the gingival buccal third of tooth #18?
a. Class II
b. Class III
c. Class IV
d. Class V
30. A client presents with a type III overhang on an amalgam
restoration. Which of the following statements related to this
overhang is CORRECT?
a. Covers less than one third of interproximal space
b. Restoration indicated for replacement
c. Indicated for a margination procedure
d. Clinically not detectable
31. All the following represent standard client assessment information

1310
that is necessary for planning comprehensive dental hygiene care
EXCEPT:
a. Extraoral assessment
b. Current self-care practices
c. Dentition evaluation
d. Fluoride varnish application
32. A 53-year-old client presents for a periodontal maintenance
appointment. When developing a dental hygiene care plan, which of
the following should be addressed first?
a. Chlorhexidine stain on teeth
b. Localized light plaque
c. Pain on tooth #28
d. Smoking habit
33. Which of the following is the BEST method for examining the
mentalis muscle?
a. Circular compression
b. Digital palpation
c. Indirect vision
d. Auscultation
34. Which of the following is LEAST significant when determining the
continued-care (recare) interval for periodontal maintenance therapy?
a. Presence of light plaque biofilm
b. Elimination of pocket depths
c. Bleeding on probing
d. Cost of care
35. Assessment findings reveal that an 11-year-old client has deep pits
and fissures, generalized areas of heavy plaque, marginal gingival
inflammation, and incipient carious lesions on teeth #3 and #14, #19,
and #30. Given these findings, what would be the degree of caries
risk?
a. Low
b. Moderate
c. High
d. No risk
36. A client cannot correctly demonstrate the use of the threader with

1311
floss. The discrepancy in performance is MOST likely the result of
which of the following?
a. Management deficiency
b. Motivation
c. Readiness to learn
d. Skills deficiency
37. To engage in effective verbal behaviors, which one of the following
skills is necessary?
a. Appropriate voice tone
b. Gestures
c. Paraphrasing
d. Posture
38. All the following are included in the case presentation EXCEPT:
a. Desired outcomes of treatment
b. Alternative approaches to care
c. Risks of all proposed therapeutic options
d. Treatment outcome guarantee
39. Which of the following BEST identifies the procedure that is
immediately followed after a client declines a component of the dental
hygiene care plan?
a. Alternative approaches to care are suggested.
b. Outcomes of therapy are explained.
c. Informed refusal form is completed.
d. Client’s right to decline care is clarified.
40. What would be a reasonable prognosis for a client with chronic
periodontitis and moderate bone loss with localized areas of grade II
furcation involvement, improvable oral self-care methods, and
irregular continued-care (recare) intervals?
a. Excellent
b. Good
c. Fair
d. Poor
41. Failure to refer a client to a medical professional when indicated
constitutes which one of the following?
a. Ethical issue

1312
b. Legal issue
c. Safety issue
d. Breach of contract
42. When implementing a tobacco cessation program into practice, the
second step is:
a. Ask
b. Advise
c. Assist
d. Arrange
43. When providing dental hygiene care, all the following relate to safe
practice issues EXCEPT:
a. Failure to obtain written informed consent
b. Failure to provide comprehensive care
c. Failure to follow infection control protocol
d. Failure to use proper instrumentation during the provision of dental
hygiene care
44. What is a grade III furcation involvement?
a. Exposure of furcation with bone remaining between roots
b. Complete loss of bone between roots
c. Loss of some bone between roots
d. Severe bone loss and furcation clearly visible
45. To determine a care plan that is BEST for a client, which of the
following actions should be addressed FIRST?
a. Periodontal debridement for the entire mouth
b. Consultation and treatment for areas of pain
c. Tobacco cessation counseling
d. Consultation for periodontal surgery
46. When reviewing the health history, the client indicates that he has
a persistent cough that is nonproductive, difficulty breathing, and
night sweats. What condition is manifested by these characteristics?
a. Acute adrenal insufficiency
b. Asthma
c. Tuberculosis
d. Common cold
47. Which of the following conditions is often related to a nutritional

1313
deficiency?
a. Black hairy tongue
b. Burning tongue
c. Geographic tongue
d. Macroglossia
48. The term prognosis refers specifically to which of the following?
a. Diagnosis
b. Care planning
c. Evaluation
d. Prediction
49. What recare interval is recommended for a client who has
maintained good results for the first year following routine
nonsurgical periodontal therapy, but displays localized pockets?
a. 1 to 2 months
b. 3 to 4 months
c. 4 to 6 months
d. 6 months
50. The submental glands are BEST examined using which type of
palpation?
a. Bilateral digital
b. Circular compression
c. Digital palpation
d. Auscultation
51. Which of the following conditions requires prophylactic antibiotic
premedication for dental hygiene care?
a. Rheumatic heart disease
b. Functional heart murmur
c. Prosthetic heart valve
d. Mitral valve prolapse with regurgitation

1314
C HAPT E R
16

1315
Strategies for Oral Health
Promotion and Disease Prevention
and Control
M. Anjum Shah*

The promotion of oral health and the prevention of oral diseases are
fundamental to dental hygiene practice and distinguish the profession
from other health disciplines. As a provider of preventive and
therapeutic services, a dental hygienist must use evidence-based
strategies and interventions that support prevention-oriented health
care. The success of a preventive oral health program depends on a
client’s self-care behaviors. Therefore, a dental hygienist must be
knowledgeable about behavior change theories and be able to employ
behavior change models designed to motivate client adherence to
appropriate self-care regimens. This chapter focuses on the dental
hygienist’s role in health promotion at the individual level.

1316
Preventive care planning
Basic Concepts
A. Initiation and progression of oral diseases depend on the interaction
of host, agent, and environmental factors; thus, prevention and control of
these diseases require attention to all primary and modifying factors in
each category.
B. Dental caries and inflammatory periodontal diseases are complex
disease states that involve colonization by specific pathogenic bacteria in
dental plaque biofilm; none will occur in the absence of pathogenic
bacteria in biofilm; thus the control of plaque biofilm is essential in any
oral disease prevention program
C. The discipline of dental hygiene is based on disease prevention,
halting disease progression, and maintenance of oral health
D. Effective preventive programs assess disease risk and identify active
disease; clients at high risk for dental caries, periodontal disease, and
oral lesions require multiple preventive strategies applied frequently and
aggressively (see the sections on “Epidemiology of Periodontal Diseases
and Related Risks” in Chapter 14 and “Risk Factor Assessments” and
Table 15-6 in Chapter 15)
E. The prevention of oral disease requires the participation of clients who
understand oral disease processes and personal level of risk; skills in
implementing oral self-care, health literacy, and the motivation to
practice preventive behaviors to decrease the level of risk also are key to
preventing oral disease
F. Many strategies can facilitate changes in the health behaviors of
clients; a grasp of the basic concepts underlying educational,
motivational, and behavioral theory is necessary to understand the
variables influencing a person’s oral health beliefs, attitudes, values, and
behaviors
G. Assisting clients in adopting effective oral care practices follows the
dental hygiene process-of-care model

1317
Behavior change theory1
Human Behavior Principles
A. Values
1. Values form the basis for behaviors
2. Clients come to the dental hygienist with existing values
3. Conflicts between clients’ existing values and those values that
support and enable preventive oral health care practices must be
recognized and resolved
4. Clients who have value systems that support preventive health
behaviors will adopt new behaviors that fit readily into their existing
value system
B. Motivation
1. Definition—a desire to fulfill an unmet human need (deficit); an
inner force that causes a person to act; motivation may be internally
or externally generated
a. Internally generated motivation focuses on one’s own perceived
needs; generally longer lasting
b. Externally generated motivation is based on offers of reward or
punishment; generally of shorter duration

Maslow’s Hierarchy of Needs2

A. Theory about human nature that is used to explain the motivational
process; Maslow suggested that inner forces (needs) drive a person to
action; he classified needs in a pyramid according to their importance to
the client, his or her ability to motivate self, and the importance placed
on the needs being satisfied; only when a client’s lower needs are met
will a client become concerned about higher-level needs; once the needs
have been met, they no longer function as motivators (Fig. 16-1)

1318
 FIG 16-1 Maslow’s hierarchy of needs. (From Darby ML, Walsh MM: Dental hygiene
theory and practice, ed 4, Philadelphia, 2014, Saunders. Modified from Potter PA, Perry AG:
Fundamentals of nursing, ed 8, St Louis, 2012, Mosby.)

B. Hierarchy of needs
1. Physiologic—survival needs are the most powerful and must be met
before any others; include the components necessary for body
homeostasis, such as food, water, oxygen, sleep, temperature
regulation, and sex
2. Security and safety—these needs are required for protection against
physical or psychological damage and are more cognitive than
physiologic in nature; include shelter, a job for economic self-
sufficiency, and a well-organized and stable environment
3. Social—once the physiologic and security needs have been met, then
the needs for love and social belonging become prime motivators;
include belonging to a group and having the chance to give and
receive friendship and love
4. Esteem or ego—of the two categories of needs that exist at this level,
one involves feelings of worth, such as competence, achievement,
mastery, and independence; the other involves gaining the esteem of
others and triggers learning and the desire to acquire status, power,

1319
 and higher-level skills
5. Self-actualization or self-realization—these needs drive the client to
reach the very top of his or her field; based on positive actions
toward development, growth, and self-enhancement
C. Application—assessment of a client’s level of needs may aid in the
identification of motivational factors that can be targeted for enhancing
behavior change

Health Belief Model3

A. Based on the concept that one’s beliefs direct behavior; the model is
used to explain and predict health behaviors and acceptance of health
recommendations; the emphasis is on the perceived world of a client,
which may differ from objective reality
B. Components
1. Susceptibility—clients must believe that they are susceptible to a
particular disease or condition
2. Severity—clients must believe that if they contract the particular
disease or condition, the consequences will be serious
3. Asymptomatic nature of disease—clients must believe that a disease
can be present without their being fully aware of it
4. Benefit of behavior change—clients must believe that effective
means of preventing or controlling the potential or current problem
exist, and that action on their part will produce positive results
C. Cues to action—once these beliefs have been accepted, the client will
act on them, when necessary; the stronger the beliefs, the greater the
potential that appropriate action will occur

Trans-Theoretical Model3,4
A. Conceptualizes behavior change through a series of steps; progression
through the steps depends on the balance of the advantages and
disadvantages of the decision
B. Provides a framework to determine and select appropriate
interventions to assist clients in improving their health behaviors
C. Stages of change include:
1. Precontemplation—the client has no intention of making a change
within the next 6 months
2. Contemplation—the client intends to make a change within the next
6 months
3. Preparation—the client intends to make a change within the next 30

1320
 days and has taken some behavioral steps in this direction
4. Action—the client has practiced changed behaviors for less than 6
months
5. Maintenance—the client has practiced changed behaviors for more
than 6 months

Motivation Theories3
A. Locus of control
1. Internal locus of control—clients believe that they have control over
their own outcomes and that their behavior will make a difference;
they are most likely to adopt preventive health behaviors
2. External locus of control—clients believe that the outcomes are out
of their control and that whatever they do will not affect the
outcomes; they are less likely to change behaviors and rely more on
the dental professional to take care of their problems
B. Attribution theory
1. Involves explanations given for performance; influences client’s
feelings about self
2. The success or failure at performing a behavior is influenced by the
client’s thoughts1
3. Self-efficacy—the client’s level of self-confidence affects his or her
belief in the success of performing a behavior

Motivational Interviewing: Evidenced-Based

Approach5–8
A. Motivational interviewing (MI)—form of collaborative conversation
for strengthening a person's motivation and commitment to change
1. Client-centered counseling style for addressing the common
problem of ambivalence about change
2. Designed to strengthen an individual's motivation for and
movement toward a specific goal by eliciting and exploring the
person's own reasons for change within an atmosphere of acceptance
and empathy
3. Shown to have positive effects on health behavior change related to
smoking, exercise and weight reduction, diabetes management,
medication adherence, condom use, and oral health
B. Using the guiding principles of MI, the dental hygienist asks open-
ended questions designed to elicit a client’s desire, ability, reasons, and
need for change (“change talk”);

1321
 1. Collaborative exploration accomplished through four key principles
of MI:
a. Resisting the righting reflex (refraining from trying to fix the
problem)
b. Understanding the client’s motivation
c. Listening to the client
d. Empowering the client
2. Identifying the client’s stages of change is also an important
component in the use of MI
3. Use of these principles enables the client to express his or her view
of the pros and cons associated with a particular behavior and to
determine what action, if any, to take
4. Ultimately, the decision to change resides within the client, not the
clinician; in this sense, the dental hygienist allows the client to have
complete autonomy in the decision-making process

Concepts of Effective Teaching

See Table 19-14 for dental management considerations for clients who
have special needs.
A. Effective teaching involves the facilitation of learning to help make
positive changes in a person’s behaviors
B. To maximize learning, these four principles apply to the design of an
educational plan:
1. Small step size—present only what person can assimilate in one
session; provide conceptual or factual information when the “need
to know” is evident
2. Active participation—provide time and opportunity for the person
to ask questions; offer suggestions and monitor the practicing of
new skills to enhance learning and retention
3. Immediate feedback—provide the learner with early and frequent
information regarding progress; make suggestions for improvement,
and use positive reinforcement to support and encourage learning
4. Self-pacing—recognize that each person will progress at a different
pace; recognize the learner ’s needs, and establish an instructional
pace tailored to each client
C. Visual aids enhance verbal instructions
1. Use of visual aids available in print or on the Internet can enhance
client comprehension of oral hygiene instructions
2. Demonstration of dental plaque biofilm control techniques on
models before intraoral demonstration may be helpful

1322
 3. Written instructions and illustrated pamphlets reinforce in-office
instructions
4. Use of an intraoral camera that projects images on a monitor enables
clients to see the conditions in their mouth

Factors Influencing Client Adherence to Preventive

Regimen
A. Client-clinician relationship
1. The quality of communication and the relationship between the
client and the hygienist is critical to achieving client adherence
2. Clients must be encouraged to share the responsibility for their oral
health
3. Authoritarian or autocratic verbal and nonverbal messages from the
dental hygienist will be less effective than messages that allow for
genuine client involvement and assumption of responsibility
4. The dental hygienist must recognize that established behaviors are
difficult to change because they generally satisfy needs; new
behaviors are adopted slowly
B. Health literacy9
1. The ability to comprehend health, medical, dental, and overall health
information
2. Clients who exhibit greater understanding of information provided
in the health care setting are more likely to be compliant in home
care instructions
3. Low dental health literacy is considered a barrier to good oral health
outcomes
4. Clinicians need to explain health related information in an easily
understandable vocabulary
5. Screening instruments are available to evaluate a client’s health
literacy
C. Client’s support systems
1. Client’s lifestyle and significant others influence the client’s
willingness and ability to carry out self-care regimens
2. Support systems are important, especially with children and clients
with disabilities, who must depend on caregivers to carry out home
care practices
D. Complexity of therapy
1. Clients must agree that time and effort required to practice
preventive behaviors are reasonable
2. Changes in basic lifestyle are more difficult to achieve than modest

1323
 modifications to existing behaviors
3. Product cost and availability affect adherence to oral self-care
regimens

Prevention Principles for Children

A. Proactive counseling of parents about anticipated developmental
changes in their children
B. Information provided to parents or caregivers in appropriate-sized
“bites” on the basis of the developmental milestone anticipated in their
children
C. Guidance is based on the rationale that people are ready to apply
information that is most relevant to them and their children
D. Box 16-1 provides suggestions for obtaining compliance from pediatric
clients

Box 16-1
Tips for Dental Hygienists Working with
Children
When a child visits your practice, your priority is to create a positive
dental experience. The child is more important than his or her teeth.
Incorporating the ideas from this fact sheet as you interact with children
will help them to become both comfortable and compliant.
Make the reception area a friendly, colorful place. Include toys, games,
and videos. Books about visiting a dental office and a doll dressed as
an oral health care provider will help children discuss any fears they
may have.
Each staff member should greet the child by name in a friendly and
welcoming manner. Bend down or squat so that you are at the level of
the child’s head, and listen to what the child has to say.
The treatment room should be decorated in a way that is visually
accessible and appealing to children. Show the child the instruments
you will be using, and explain how they are used. Make everything that
looks unfamiliar look friendly. For example, you might draw friendly
faces on masks used for demonstration, and some practitioners like to
call the suction “Mr. Thirsty.” Demonstrate the buttons on the chair
and how it moves up and down, but do not put the chair back if doing
so makes the child nervous.
Allow the parent into the treatment area if the child desires, especially
for the first visit. Both you and the room will look less frightening with

1324
 a familiar face present.
Explain exactly what you are going to do during the appointment. Use
age-appropriate terms to explain why it is so important that teeth be
kept healthy.
Turn the appointment into a game. For example, count eyes, ears, and
fingers before moving on to counting teeth. Always give the child a
choice of flavors. Write down preferences so that you will have all the
child’s favorites ready for the next visit. If the light shines in the child’s
eyes, produce a pair of sunglasses and say how cool he or she looks.
Use a new toothbrush presented during the brushing lesson. Apply
fluoride varnish. Let the child know that you are in control, with a fast
solution to every problem.
Praise the good, but don’t criticize the bad. A child may take “these teeth
don’t look so good” very personally and feel he or she has done
something wrong. Concentrate on teaching the proper way to take care
of teeth.
Don’t use tricks or lie; keep your promises. If you say, “Just let me do one
more thing,” do it and let the child go. If a child will not cooperate, try
again another day.
When the visit is over, let the child pick a treat from a “treasure box.”
Praise good behavior, and let the child give the parent the “good news”
about the child’s teeth.
Snap a picture of the child’s sparkling smile and create a gallery of
photos in the office. Seeing his or her own picture is something a child
can look forward to at the next appointment.
Modified from American Dental Hygienists’ Association: Tips for dental hygienists working with
kids [members-only section, requires registration and password].

1325
Dental plaque biofilm detection
General Considerations
A. Because dental plaque biofilm is relatively invisible and tooth surfaces
are not easily accessed, teaching clients dental disease-control skills can
be challenging
B. Agents that make biofilm visible supragingivally can enhance the
teaching-learning process by:
1. Demonstrating a relationship between the presence of plaque
biofilm and the clinical signs of disease
2. Guiding the development of skills that are applied before biofilm
removal
3. Allowing evaluation of the effectiveness of skills that are applied
after biofilm removal
4. Promoting self-evaluation of skills that are applied by the client at
home
C. The presence of subgingival plaque biofilm cannot be demonstrated
by using disclosing agents
D. The plan for disease control education should include establishing the
associations among the presence of plaque, clinical signs of disease such
as bleeding, the presence of risk factors, and possible links to systemic
disease
E. Subgingival biofilm detection by the client is best managed when the
client has an understanding of the gingival sulcus (or pocket) and of the
clinical changes that occur with ineffective plaque biofilm removal

Disclosing Agents
A. Erythrosin (FD&C Red No. 3 or No. 28)
1. A red dye available in tablet or solution form; most widely used
agent
2. Can be dissolved into a solution or chewed to dissolve in mouth
3. Tends to stain soft tissues, making postapplication evaluation of
gingiva difficult
B. Fluorescein dye (FD&C Yellow No. 8)
1. Plaque biofilm stained with sodium fluorescein; visible only with use
of an ultraviolet light source
2. More expensive to use but has the advantage of not interfering with
gingival assessment or leaving a visible stain on oral tissues
C. Two-tone dyes (FD&C Red No. 3 and Green No. 3)
1. Combination solution; has the advantage of differentiating mature

1326
 plaque biofilm (stains blue) from new plaque biofilm (stains red)
2. Discloses plaque biofilm but not gingival tissues
D. Precautions
1. Avoid staining restorative materials that may be susceptible to
permanent discoloration
2. Dispense the solution into a disposable cup; do not contaminate the
solution by introducing applicators into the storage container bottle
3. To avoid staining the lips, apply a light coat of nonpetroleum or
water-based lubricant (e.g., K-Y jelly)
4. Avoid using the agent before application of a dental sealant
5. Avoid any risk of staining clothing, that is, provide appropriate
protective drapes to the client, and use small amounts of the
solution

Plaque and Gingival Indices

Recording a plaque score at consecutive appointments enables the client
to see progress (see Table 20-11 for information on indices and
computing indices).

1327
Mechanical plaque biofilm control on
facial, lingual, and occlusal tooth surfaces
Basic Concepts
A. Microbial population of dental plaque biofilm contributes to the
initiation of dental caries and periodontal diseases
B. Mechanical disruption of organized plaque biofilm colonies, both
supragingivally and subgingivally, is effective and widely used to prevent
and control dental diseases
C. Toothbrushing—most widely used and effective means of controlling
plaque biofilm
D. Toothbrushes are available in many shapes, sizes, and textures
E. The selection of the type of toothbrush should be based on the client’s
needs, oral characteristics, and preferences
F. Special attention to subgingival plaque biofilm control in areas greater
than 3 mm is essential; toothbrushes are generally ineffective in depths
greater than 3 mm and in furcations; additional tools must be selected
G. Toothbrushes should be replaced after 2 to 3 months of use and when
filaments become bent or splayed
H. Clients who are immunosuppressed, debilitated, or diagnosed with a
known infection and those about to undergo surgery should disinfect
their toothbrushes or use disposable ones

Manual Toothbrushes
A. Description
1. Parts include the handle, head, and shank; the head, or the working
end, holds clusters of bristles (tufts) in a pattern
2. Design variables
a. Handle can be in the same plane with the head or offset at an
angle
b. The length varies, with adult brushes being longer than those
recommended for children
c. Tuft placement can be in two to four rows, with 5 to 12 tufts per
row; bristles may be of varying lengths
d. The brushing planes can be even, flat, or uneven
e. Many brushes have contoured or thick handles, angled shanks,
and flexible heads
3. Bristle characteristics
a. Nylon bristles, or filaments, are manufactured for uniformity in

1328
 texture, shape, and size; nonabsorbent nylon bristles are easily
cleaned, dry quickly, and are durable
b. Relative stiffness—the diameter and length of filaments
determine whether the brush will be ranked hard, medium, soft,
or extra-soft; variations exist among products from different
manufacturers
B. Desirable characteristics of toothbrushes
1. Conform to individual requirements in size, shape, and texture
2. Easily and efficiently manipulated
3. Readily cleaned and aerated
4. Impervious to moisture
5. Durable and inexpensive
6. Flexible and soft
7. Contain rounded-end filaments
C. Factors in toothbrush selection and recommendations
1. Oral health status
2. Recommended method of brushing
3. Periodontal status
4. Client’s age, dexterity, and ability to use the brush in an effective,
nontraumatic manner
5. Client’s preference and motivation
6. Unique, special needs of the client (e.g., arthritis, Parkinson’s
disease; see Chapter 19)
D. Soft brush head design is important for effective plaque removal and
minimal likelihood of trauma to soft and hard tissues4
E. Both angled and standard toothbrush designs have little impact on
plaque removal capacity; both designs prevent gingival recession as long
as soft-bristled toothbrush is used

Manual Toothbrushing Methods1

Although the Bass (sulcular) method is widely recognized as being the
most effective and most often recommended, it is helpful to know all the
major toothbrushing methods. The method selected should disrupt both
supragingival and subgingival plaque biofilm to the extent possible.
Although a horizontal scrub technique is often used, it is not
recommended because of potential trauma to hard and soft tissues.
In all the following methods, the handle is placed parallel to the
occlusal plane for posterior (facial and lingual) and anterior facial
surfaces and parallel to the long axis of the tooth (using the toe of the
brush) for anterior lingual surfaces. Occlusal surfaces are cleaned with a

1329
scrubbing motion.
A. Bass or sulcular brushing method
1. Technique—direct the bristles into the sulcus at a 45-degree angle to
the long axis of the tooth; vibrate the bristles in a short, back-and-
forth motion
2. Indications—plaque biofilm disruption at and under the gingival
margin; good gingival stimulation; widely recognized as an effective
control technique
B. Stillman’s method
1. Technique—position the bristles on the attached gingiva, and direct
them apically at a 45-degree angle to the long axis of the tooth; use
firm, gentle vibration, holding the bristles stationary
2. Indication—gingival stimulation
C. Roll method
1. Technique—place the sides of the bristles on the attached gingiva
and direct them apically; turn the wrist to roll or sweep the bristles
over the gingiva and the tooth
2. Indications—facial and lingual tooth surfaces; often combined with
the Bass, Charters’, or Stillman’s method
D. Charters’ method
1. Technique—position the bristle tips toward the occlusal surfaces at a
45-degree angle to the long axis of the tooth; move the bristles in a
short, back-and-forth motion
2. Indications—cleaning orthodontic appliances, fixed appliances; after
periodontal surgery when sulcular brushing must be avoided to
allow wound healing
E. Fones (circular) method
1. Technique—with upper and lower teeth together, place the bristles
perpendicular to the buccal tooth surfaces; use a wide circular
motion to cover the gingiva and tooth surfaces of both arches; on the
lingual surfaces, use smaller circles to brush each arch separately
2. Indications—when technique must be easy to learn and execute; can
be mastered by children
F. Combination methods
1. Modified-Bass method—combination of Bass and roll methods
2. Modified-Stillman’s method—combination of Stillman’s and roll
methods

Power Toothbrushes
A. General description

1330
 1. Brush heads contain bundles of bristles arranged on a variety of
brush head shapes; toothbrushes with different brush head shapes
are available on the market
2. The bristles can have flat, bilevel, or multi-level trims; designed for
occlusal and smooth surfaces or interdental proximal surface
cleaning
3. The handles are larger than those of manual brushes
4. Power toothbrushes move in directions and at speeds unattainable
by manual toothbrushes
5. Power toothbrushes have timers to ensure adequate brushing
duration and a pressure sensor to monitor the force applied on the
toothbrushes
B. Power source—electric rechargeable handle-base; replaceable,
rechargeable, and nonreplaceable batteries
C. Motion—distinctly different stroke movement from the motion of
manual toothbrushes; motions occur in one of the following directions:
1. Side-to-side, arcuate, or back-and-forth
2. Oscillating or rotating
3. Rotating or counter-rotating
4. High-frequency pulsating, combined with an oscillating or rotating
movement
5. Sonic vibratory motion from low-frequency acoustic energy
D. Indications for use—recommended for all clients because of the
effectiveness of power toothbrushes in removing plaque biofilm and
reducing gingivitis; especially valuable to those who:
1. Lack the manual dexterity, discipline, or motivation to master an
effective manual toothbrushing technique, especially children and
adolescents who are physically and mentally challenged
(recommended to the caregivers who may be doing the
toothbrushing for these children and adolescents)
2. Have orthodontic appliances or implants
3. Are prone to dental stain
4. Are aggressive brushers, or exhibit abrasion, erosion, abfraction, or
gingival recession
5. Have periodontal disease or are undergoing periodontal
maintenance therapy
E. Power toothbrushes, especially those with oscillating-rotating brushes
reduce gingival bleeding and inflammation10
F. Power toothbrushes reduce plaque biofilm and gingivitis better than
the manual toothbrush can, with or without floss10

1331
Single-Tufted Brushes
A. Design—flat or tapered
B. Suggested use—to remove plaque biofilm from surfaces not accessible
with larger brushes, including areas of crowded or malpositioned teeth,
distal surfaces of terminal molars, around pontics, in furcations, and on
lingual surfaces of molars; also used on type II or III embrasure
(depending on design) and fixed dental prosthesis1
C. Technique—tufts are positioned at or just under the gingival margin,
and a sulcular brushing stroke is used; placement of the tapered angled
side against teeth allows for the insertion of the bristles several
millimeters subgingivally

Factors in Toothbrushing Effectiveness

A. Sequence
1. A methodical, systematic approach enhances effectiveness
2. Suggested sequence—begin systematic, overlapping strokes at the
facial aspect of the maxillary right or left terminal tooth; continue
around the arch to the terminal tooth on the opposite side; switch to
the lingual aspect, and begin working back toward the starting side;
use the same pattern for the mandible, and then brush the occlusal
surfaces
B. Duration
1. Monitor the brushing time in an area by counting strokes or seconds
after each time the brush is moved
2. The total manual brushing time of 2 minutes is often recommended;
the average brushing time is 1 minute or less
C. Frequency
1. Thorough removal of plaque biofilm every day is the goal of client
self-care and for maintenance of oral health
2. Toothbrushing should be performed twice daily; however, the
frequency should be increased when gingival or periodontal
conditions warrant it or when caries risk is high
3. Thoroughness in daily brushing is more important than frequency
4. Emphasis should be placed on effective oral cleaning, not just
toothbrushing
D. Skill level
1. Careful attention should be given to evaluating skill development in
all components of toothbrush manipulation, including grasp,
placement, activation, wrist movement, and amount of pressure
applied

1332
 2. Control of toothbrush placement and motion is essential for
effectiveness

Improper Toothbrushing
A. Need to assess
1. Improper toothbrushing—may result from lack of education in
proper technique, incorrect application following instruction, or
long-established habits
2. The dental hygienist should evaluate the client’s toothbrushing
technique and monitor the conditions of hard and soft tissues at
each continued-care visit
3. Faulty placement, overly vigorous motion or pressure, and use of a
brush with frayed, splayed, or broken bristles can lead to unwanted
consequences
B. Acute consequences—soft tissue injuries such as denuded attached
gingiva, lesions that appear “punched out” and red, and clusters of small
ulcerations at the gingival margin
C. Chronic consequences
1. Soft tissue—loss of gingival tissue or change in contour;
malpositioned or prominent teeth and an inadequate band of
attached gingiva are predisposing factors
2. Hard tissue—loss of tooth structure and creation of a wedge-shaped
defect at the cervical third of tooth (noncarious cervical lesion)

Toothbrush Maintenance
A. Toothbrushes should be rinsed clean after each use and then allowed
to air-dry in the upright position
B. Toothbrushes should be replaced when the bristles splay or lose
resiliency; generally, should not be used longer than 2 to 3 months
C. Some toothbrushes have color-indicator bristles to alert the user about
replacement time
D. After an acute illness and an oral infection, toothbrushes should be
replaced or disinfected with 0.12% chlorhexidine gluconate; power
toothbrushes with a built-in sanitizer unit help control toothbrush
contamination1

1333
Interdental plaque biofilm control
Basic Concepts
A. Toothbrushes—effective in removing plaque biofilm from facial,
lingual, and occlusal surfaces of teeth; relatively ineffective on proximal
surfaces
B. Interdental cleaning devices—designed for access to interproximal
surfaces; essential for effective control of plaque biofilm
C. Interdental col area—protected area that harbors microorganisms that
can initiate disease
D. Anatomy of the interdental area—significant factor in both disease
initiation and disease control

Factors to Consider When Selecting Interdental

Cleaning Methods
A. The level of oral health or disease, teeth positioning, and condition of
the gingiva and attachment should be considered when recommending
interdental aids (Fig. 16-2); three types of embrasures1:

FIG 16-2 Interproximal embrasure types and corresponding interdental

cleansers. A, Type I—no gingival recession: dental floss. B, Type II—moderate
papillary recession: interdental brush. C, Type III—complete loss of papillae:
uni-tufted brush. (From Darby ML, Walsh MM: Dental hygiene theory and practice, ed 4, St
Louis, 2014, Saunders. Modified from Newman MG, et al: Carranza’s clinical periodontology,
ed 12, St Louis, 2015, Elsevier.)

1. Type I embrasures are occupied by interdental papillae

1334
 2. Type II embrasures have slight to moderate recession of interdental
papillae
3. Type III embrasures have extensive recession or complete loss of
interdental papillae
B. Client manual dexterity, adherence, skill development, and personal
preferences must be considered

Flosses
A. Dental floss—most frequently recommended device for interdental
cleaning of type I embrasures1 (Fig. 16-3)

FIG 16-3 Use of interdental plaque biofilm control devices. A, Dental floss. B,
Interdental brush. C, Toothpick in holder. (From Darby ML, Walsh MM: Dental hygiene
theory and practice, ed 4, St Louis, 2015, Saunders.)

1335
B. Flossing may precede or follow brushing in a home care regimen
C. As gingival recession increases, as in type II and type III embrasures,
the effectiveness of flossing decreases; other interdental plaque-control
aids should be selected
D. Agents to enhance color, taste, and therapeutic value have been
incorporated into the dental floss; evidence to confirm the effectiveness
of the addition of fluoride and whitening agents is limited
E. Floss type
1. Unwaxed—unbound filaments are spread on the tooth and have
more friction for cleaning; filaments hold plaque and debris for
easier removal; the floss slips through contacts more easily
2. Waxed—resists tearing and shredding on faulty restorations or when
moved through very tight contacts
3. Polytetrafluoroethylene (PTFE) floss—slides through contacts easily;
does not fray

Flossing Technique
A. Floss length—varies with holding technique; 10 to 15 inches when
forming a loop; 12 to 24 inches when wrapping around fingers
B. Holding technique
1. Ends may be tied together to form a loop, wrapped around middle
fingers, or tucked into the palm of the hand
2. With equal tension in both hands, grasp with both thumbs or with
the thumb and the forefinger for use on the maxilla or with both
forefingers for use on the mandible; leave 1-inch to 2-inch length
between fingers
C. Insertion
1. Approach the embrasure space obliquely, and ease the floss past the
contact with a back-and-forth motion
D. Adaptation and stroke
1. Position fingers such that the floss wraps securely against the
proximal surface and forms a C shape against the tooth
2. Slide beneath the gingival margin, and move in an apicocoronal
direction several times

Improper Flossing
A. Acute consequences—snapping through contacts, failure to curve the
floss against the proximal surfaces, and application of excessive pressure
can result in floss cuts of interdental papillae

1336
B. Chronic consequences
1. Soft tissue—excessive pressure applied submarginally can be
destructive to soft tissue
2. Hard tissue—repeated heavy sawing movements in a faciolingual
direction can abrade proximal tooth structure

Flossing Aids
A. Types of aids
1. Floss holders
a. General description—the floss is threaded through and held on
a double-pronged plastic device, forming a span between the
prongs
b. Technique—the prepared holder is positioned for insertion,
then adapted and activated in much the same manner as the
handheld floss; special care should be taken not to snap the
floss through the contacts
c. Indications for use—client’s lack of dexterity to floss properly
and client preference
2. Floss threaders
a. General description—firm, flexible, blunt-ended devices for
moving the floss through closed contacts or under pontics or
orthodontic wires; a variety of designs are available
b. Technique—position the floss in the threader with even lengths
on each side; pass the threader through the embrasure from the
buccal aspect to the lingual aspect, leaving sufficient length on
the buccal aspect; remove the threader and use the floss in the
normal manner; slide through the space to remove it

Interdental Brushes
A. General description
1. Soft nylon filaments are twisted onto a stainless steel wire to form a
tapered or a nontapered small brush; the wire may be plastic coated
for use around dental implants and for client comfort
2. Interdental brushes must be used with a special handle; some have
small handles, and some have contra-angled handles
3. Interdental brushes provide excellent access to root concavities,
furcation areas, and proximal surfaces where papillae do not fill the
interdental spaces, as in type II and type III embrasures (see Fig. 16-
3)

1337
 4. Interdental brushes come in a variety of sizes, with thin wires and a
tapered brush to remove interproximal plaque biofilm from all types
of embrasures
B. Technique
1. Choose a brush of appropriate size, insert interproximally, and use
an in-and-out motion from the buccal aspect to the lingual aspect,
and vice versa
2. Brushes may be used in furcation areas in a similar manner
3. Access into the interproximal pockets may be achieved with careful
vertical placement and movement
C. Precautions
1. Avoid forcing through tight, tissue-filled areas to prevent trauma
2. Do not aim the wire into tissue
3. Discard the tip when the filaments lose their original shape
4. Do not use a brush with a stainless steel wire on an implant; the
brush must have a plastic-coated wire to prevent damage to the
implant

Toothpicks1
A. Suggested use—for proximal surfaces and concavities and in exposed
furcation areas
B. Technique—round toothpicks can be used alone or inserted into
special holders; moisten the tip with saliva, and adapt it to the surface to
be cleaned; subgingivally, use a 45-degree angle to the tooth; move the
toothpick in and out several times for cleaning the interproximal
surfaces, and follow the tooth contour on the facial or lingual surfaces
C. Precautions—rigid pointed tips can cause injury if forced into tight
tissue areas; over time, papillae will abrade if toothpicks are used
improperly

Interdental Wedges1
A. Suggested use—for cleaning the proximal surfaces or just under the
gingival margin; triangular in cross section; should be used
interproximally only when adequate space for insertion is available (e.g.,
type II and III embrasures)
B. Technique—moisten the tip, position the flat base of the triangle at the
gingival border, insert with the tip angled slightly toward the occlusal
surface, and move the wedge in and out, with moderate pressure against
the surface

1338
C. Precautions—discard tips as soon as splaying occurs; repeated
insertion with the tip perpendicular to the long axis of the tooth may
cause blunting of interdental papillae

Interdental Tip
A. Suggested uses—for proximal surfaces, in exposed furcations, and
under gingival margins; conical or pyramidal, flexible rubber or plastic
tip; may be used to maintain interproximal gingival contours or to
recontour papillae following periodontal surgery; rubber tips are also
used for massaging the gingiva to improve blood circulation, increase
keratinization, and provide epithelial thickening1
B. Technique
1. Dental plaque biofilm removal—trace the gingival margin with the
tip aimed into the sulcus; move the tip in and out in a buccolingual
direction along the proximal tooth surface apical to contact areas
2. Contouring gingiva—place the tip, without forcing it, into the
interdental contour, being careful to follow the gingival form; press
the side of the tip against the gingiva, and use a firm rotary motion
to apply intermittent pressure
C. Precaution—avoid flattening interdental papillae; use of interdental
tips made from rubber should be avoided in clients with latex sensitivity

Power Interdental Cleaning Devices

A. Power flossing devices are available to make interdental cleaning
easier; include flossers, interdental brushes, and dental water jets
B. Technique—usually the unit comes with an attachment (similar to a
floss holder, interdental brush, or single-tufted or end-tufted brush); the
brush is activated by turning it on after attaching the brush handle;
requires only one hand to operate; the tip is aimed into the interproximal
space
C. Suggested use—alternative to the handheld floss; client preference

Dental Water Jet1

A. General description—motor-driven pulsating device with a reservoir
and specially designed tips to deliver the irrigant to the gingival pocket;
depending on the size of the tip selected, this device has the ability to
reach deep periodontal pockets; dental water jets produce a steady
stream of fluid
B. Technique—the reservoir is filled with water or an antimicrobial agent;

1339
after inserting the appropriate tip into the handle, the pressure gauge is
adjusted to the client’s comfort setting; starting with posterior teeth, the
tip is placed at a 90-degree angle to the long axis of the tooth, following
each tooth along the gingival margin
C. Indications for use—clients with fixed orthodontics, dental implants,
crowns, and bridges; those with gingivitis; and persons in periodontal
maintenance program; research suggests that the use of oral irrigation
does not reduce plaque biofilm; however, it does improve gingival health
compared with regular oral hygiene11
D. Precaution—each manufacturer ’s product differs; follow each model’s
instructions for use

1340
Dentifrices
Basic Concepts
A. Definition—toothpaste used with a toothbrush
B. Purposes
1. Cosmetic—tooth surfaces are cleaned and polished; breath is
freshened
2. Cosmetic and therapeutic—certain nontherapeutic substances
augment the efficiency of brushing in the removal of plaque biofilm,
debris, and stain
3. Therapeutic—vehicle for transporting biologically active ingredients
such as fluoride, which inhibits tooth demineralization and
promotes remineralization, to the tooth and its environment
C. Basic ingredients1
1. Detergents—lower surface tension to loosen debris and stain;
provide foaming characteristic; sodium lauryl sulfate, a common
foaming agent, has been implicated in causing aphthous ulcers in
susceptible clients
2. Cleaning and polishing agents—abrasives that help remove stain,
plaque biofilm, and debris from tooth surfaces and give a luster to
the tooth surface; should provide maximal cleaning benefit with
minimal abrasion; examples include calcium carbonate, silica,
calcium pyrophosphate, aluminum oxide, insoluble calcium
metaphosphate, magnesium carbonate, and bicarbonate
3. Humectants—retain moisture to ensure a chemically and physically
stable product; for example, glycerin, mannitol, sorbitol, synthetic
cellulose, vegetable oils, and propylene glycol
4. Binding agents—prevent separation by increasing the consistency of
a mixture of liquid and solid ingredients; for example, mineral
colloids, natural gums, and seaweed colloids
5. Flavoring and sweetening agents—provide a pleasant and refreshing
flavor and aftertaste, and cover unpleasant flavors; for example,
peppermint, cinnamon, wintergreen, and noncariogenic artificial
sweeteners such as glycerin, sorbitol, menthol, and xylitol
6. Coloring agents—contribute to the product’s attractiveness and
desirability; vegetable dyes and titanium dioxide
7. Preservatives—prevent bacterial growth and prolong shelf life of the
product; for example, alcohol, benzoates, and dichlorinated phenols

Therapeutic and Active Ingredients

1341
A. Definition—biologically active ingredients that produce a beneficial
effect on hard or soft tissue; dentifrices claiming therapeutic effects are
eligible for acceptance by the American Dental Association (ADA)
Council on Scientific Affairs; all products with the ADA Seal of
Acceptance are listed at www.ada.org
B. Remineralizing agents
1. Fluoride—substantial data exist to show that approved fluoride
dentifrices reduce the incidence of dental caries; fluorides currently
used in dentifrices are sodium fluoride (NaF), stannous fluoride
(SnF2), SnF2–sodium hexametaphosphate, and sodium
monofluorophosphate (Na2-PO3F)1
2. Amorphous calcium phosphate (ACP)—calcium and phosphate
were traditionally added to dentifrices as abrasives and lubricants
and now for caries control
3. Xylitol—a sugar substitute, which has anticaries and antiplaque
properties; Streptococcus mutans cannot metabolize xylitol, which
allows a less acidic environment for tooth demineralization1
C. Antimicrobial agents—triclosan is the primary agent used in the
United States; its antigingivitis and antiplaque efficacy has been
demonstrated
D. Desensitizing agents— desensitization agents work in one of two
ways; they either block dentinal tubules (high concentration of fluoride,
calcium phosphates, and oxalate salts) or block nerve repolarization
(potassium salts, including potassium nitrate and potassium citrate);
potassium nitrate is the primary agent used in desensitizing dentifrices1
E. Anticalculus agents—function by interfering with the calcium
phosphate bond in the calculus matrix; effective only against the
formation of supragingival calculus on enamel surfaces
1. Pyrophosphate system—pyrophosphate has a negative charge,
attracts positively charged calcium ions, and interferes with calculus
formation
2. Zinc system—zinc has a positive charge, attracts negatively charged
phosphate ions, and interferes with calculus formation
F. Whitening agents—several dentifrices are marketed for their ability to
remove or bleach stains; several whitening dentifrices have low abrasive
levels; may be effective for the maintenance of cosmetic restorations;
whitening agents include papain (Citroxain), silica, hydrogen peroxide,
and carbamide peroxide

Guidelines for Dentifrice Selection

1342
A. Products selected should carry the ADA Seal of Acceptance or the
Canadian Dental Association (CDA) Seal of Recognition; this ensures
that adequate evidence of safety and efficacy has been demonstrated in
controlled clinical trials, that advertising claims comply with ADA and
CDA standards for accuracy and truthfulness, and that the therapeutic
ingredient will be bioavailable when the dentifrice is used
B. All ADA-accepted and CDA-recognized dentifrices have safe levels of
abrasiveness
C. Dentifrices containing fluoride are granted acceptance on the basis of
their caries-reducing properties
D. Desensitizing dentifrices that carry ADA and CDA seals have gained
acceptance for their proven efficacy in the control of dentinal
hypersensitivity

Guidelines for Dentifrice Use

A. Daily use of fluoride dentifrice should be recommended to all clients,
regardless of caries risk, because these products promote tooth
remineralization
B. Young children (under age 6) should be supervised when using a
fluoride dentifrice—use of a small, pea-sized amount of a toothpaste
because children under 6 will most likely swallow the dentifrice

1343
Controlling oral malodor12
A. Identifying malodor
1. Oral malodor (bad breath, or halitosis)— common problem that
originates approximately 90% of the time from the mouth and from
the oropharynx region (tongue coating, gingivitis, periodontitis,
pharyngitis, and tonsillitis); systemic causes account for 10% of oral
malodor
2. Malodors are produced by microorganisms on the tongue and teeth;
proteolytic activity results in foul-smelling compounds or volatile
sulfur compounds (VSCs)
3. Oral dryness (xerostomia) exacerbates malodor; smoking,
medications, alcohol, and caffeine increase oral dehydration
4. Bad breath caused by high levels of VSCs is often associated with
periodontal infections and overnight denture wearing
5. Malodor can be measured by sensory or organoleptic (smell)
instruments such as gas chromatography (GC) that monitor VCSs
(hydrogen sulfide, methyl mercaptan, methyl sulfide)
B. Controlling malodor
1. Improve oral hygiene by including tongue cleaning in the process
2. Abstain from tobacco and alcohol use
3. Avoid caffeine
4. Stimulate salivary flow by chewing sugarless gum with xylitol
5. Use ADA-accepted or CDA-recognized antimicrobial mouthrinses
6. Use saline nasal sprays and humidifiers to control dryness of throat
and nasal passages
7. Use sugar-free (with xylitol) breath sprays, breath fresheners, or
drops

1344
Oral irrigation
Basic Concepts
Oral irrigation can be a valuable adjunct to maintaining oral cleanliness
and health. Oral irrigating devices force a steady or pulsating stream of
water over gingival tissue and teeth, with the goals of removing
unattached debris and reducing the concentration of microorganisms
and cellular end products that may be present; irrigators also are used to
deliver antimicrobial agents supragingivally and subgingivally.

Home Irrigation
A. Home uses
1. Before toothbrushing and flossing to remove debris or retained food
particles, or after toothbrushing to deliver antimicrobial agents
2. Debridement of recessed areas of fixed prosthetic or orthodontic
appliances; around dental implants
3. Flushing of periodontal pockets with a controlled, low-intensity,
pulsating stream of water
B. Types of irrigators
1. Hand syringes—blunt tip, side-port cannula; requires high level of
dexterity and motivation; not recommended for most clients
2. Power-driven device—unit with a water reservoir; plugs into an
electrical outlet to create a pulsating jet of water; water pressure is
regulated by an adjustable dial or sliding switch
3. Water pressure–driven device—attaches directly to a faucet to
deliver a constant stream of water; pressure is controlled by
regulating water flow from the faucet
4. Tips—standard jet tip or flexible subgingival tip; tips with a side-
port design or an end-port design show similar effectiveness
C. Use with antimicrobial agents1,13
1. Some studies have documented greater benefits with the addition of
antimicrobial agents
2. Since standard irrigation tips are unable to access periodontal
pockets completely, no significant benefits in treating periodontitis
is found; demonstrated benefits are limited to parameters such as
plaque and bleeding indices, gingivitis, and reduction of bleeding on
probing
3. The use of water alone is as effective as the use of chemotherapeutic
agents
D. Precautions—contraindications to use

1345
 1. Clients should be trained in the proper use of irrigating devices and
be monitored for adverse effects
2. Transient bacteremias may occur following oral irrigation,
particularly when untreated disease is present; persons at highest
risk for infective endocarditis can use irrigation as part of their oral
self-care
3. Use of low pressure prevents gingival tissue trauma and allows
better access to the base of the pocket
E. Antimicrobial agents
1. Stannous fluoride—1.64% SnF2; dispense equal parts of 3.28% SnF2
concentrated gel and distilled water; use a fresh mixture for each
client
2. Chlorhexidine digluconate—0.12% in the United States and 2% in
Europe; may be diluted to 0.06% concentration; may become less
effective in the presence of sodium laurel sulfate, fluoride, blood,
and protein
3. Essential oils mouthrinse; may be diluted with equal parts water for
use in a power irrigator, but most studies use it at full strength

1346
Care of fixed and removable prostheses
Dental prostheses are replacements for one or more teeth or other oral
structures, ranging from a single tooth to a complete denture. Clients
wearing fixed or removable dental prostheses have unique needs that
require specific procedures for maintaining the prosthesis as well as
retained natural teeth; relevant terminology follows1:
A. Appliance—in dentistry, a general term referring to a device used to
provide a functional or therapeutic effect
B. Abutment—tooth, root, or dental implant used for the support and
retention of a fixed or removable dental prosthesis
C. Clasp—retains and stabilizes the denture by attaching it to the
abutment teeth
D. Denture—artificial substitute for missing natural teeth and adjacent
tissues
E. Pontic—artificial tooth on a fixed, partial denture or isolated tooth on a
removable, partial denture that replaces lost natural tooth, restores its
function, and usually occupies space previously occupied by a natural
crown
F. Fixed prosthesis—dental prosthesis firmly attached to natural teeth,
roots, or dental implants usually by a cementing agent; cannot be
removed by client
G. Obturator—maxillofacial prosthesis that includes an intraoral
structure that replaces all or part of the palate or the maxilla; it may also
have a palatal lift that aids in speech or swallowing
H. Overdentures—dentures with retained natural teeth or dental
implants
I. Removable prosthesis—dental prosthesis that can readily be placed in
the mouth and removed by the wearer
J. Orthodontic bracket—a small metal attachment fixed to a band that
serves as a means of fastening the archwire to the band
K. Orthodontic band—a thin metal ring that secures orthodontic
attachments to a tooth
L. Orthodontic wire—a slender, pliable rod or thread of metal used as a
source of force to direct teeth to move in desired directions
M. Implant, or dental implant—a device surgically inserted into the
jawbone to be used as a prosthodontic abutment; may be used to support
complete dentures
N. Grills (“grillz,” fronts)—a decorative, jewel-encrusted encasement for
teeth in hip-hop culture; usually made of precious metals (e.g., gold,
platinum)

1347
Fixed-Prosthesis Maintenance
A. Fixed prostheses such as fixed bridges and orthodontic bands and
wires increase the potential for plaque biofilm and debris retention and
make access to the proximal surfaces more difficult
B. Home care armamentarium
1. Floss threaders—allow the floss to move beneath pontics and
between pontics and abutments
2. Interdental brushes—access interdental spaces apical to closed
contacts
3. Special brushes and toothpicks
a. Orthodontic bilevel toothbrushes—three rows wide, with
shorter middle row; moves into and around orthodontic
appliances; adapts to areas between the orthodontic appliance
and the gingival margin
b. Two-row brushes—for cleaning of sulci; adapt to narrow areas
between brackets and gingivae
c. Toothpick holders—for cleaning type II embrasures, furcations,
and margins of appliances, brackets, and sulci
d. Single-tuft or end-tuft brushes—for use in type III embrasure
areas, furcations, margins of appliances and brackets, and
single-teeth abutments
e. Oral irrigators—flushing action removes loose debris and food
material

Removable-Prosthesis Maintenance
A. Clients with removable appliances, including orthodontic appliances,
must be taught about the importance of conscientious home care
B. Debris, stain, plaque biofilm, and calculus will collect on removable
appliances, if the appliances are not cleaned regularly
C. Inadequate cleaning may contribute to the development of soft tissue
lesions underlying the appliance or of carious lesions on abutting tooth
surfaces; chronic Candida albicans infection also may result
D. Removable prostheses can be maintained by:
1. Brushing with dentifrice after each meal and before retiring to bed at
night
a. Special denture brushes have two different arrangements of
filaments to access both the inner curved surface and the outer
and occlusal surfaces
b. Special clasp brushes have a narrow, tapered cylindrical design
that can adapt to the inner clasp surface, a prime site for plaque

1348
 biofilm formation and retention
2. Immersion in a solvent that chemically loosens or removes stains
and deposits is recommended; the appliance should be brushed
after soaking it to remove residual debris and chemicals
3. Antifungal denture solutions help prevent candidiasis
E. Removable appliances should be taken out at night and stored in a
covered container with one of the solvents or denture solutions listed
above
F. Cleansing procedures
1. Hold the appliance securely to avoid dropping and breaking it
2. When brushing, hold the appliance over a sink partly filled with
water or lined with a cushioning material
3. Avoid overzealous brushing and use of strong abrasives; the plastic
resin material can be scratched or abraded to the extent of
compromising denture fit
4. If any denture adhesive material is used, it should be removed from
the appliance and the underlying mucosa several times a day
5. Brush the underlying mucosa at least once daily with a soft
toothbrush
6. Solutions used for cleansing or soaking a denture should be renewed
for each use
G. All removable appliances and prostheses, including fluoride carriers,
night guards, mouthguards, and bleaching trays should be cleaned on a
regular basis and appropriately stored after use1

Dental Implant Maintenance

See the sections on “Dental Implants” in Chapters 13 and 14 and
“Instrumentation of Dental Implants” in Chapter 17.
A. Osteo-integrated implants and superstructures require special home
maintenance, products, and techniques; clients must learn the
techniques for plaque biofilm control that prevent damage to the implant
material and superstructure
B. The home care armamentarium may include:
1. Soft-bristled, multi-tufted nylon toothbrushes
2. Interdental brushes with nylon coating over metal wire cores;
coating prevents scratching of the implant material (usually
titanium)
3. Flat and tapered end-tuft brushes
4. Dental floss
5. Implant flossing aids—braided nylon filaments with a hook leader

1349
 for insertion is recommended; flat cotton floss; or floss containing a
soft filament brush component
6. Rubber tip stimulator; wood sticks
7. Disclosing tablets or liquid; may be most useful during initial
education on plaque biofilm control
8. Antimicrobial mouthrinse; chlorhexidine used twice daily is the
rinse of choice after treatment; other antimicrobial mouthrinses may
be used for long-term treatment
9. Small amount of ADA-approved or CDA-recognized gel or fine-
abrasive, fluoridated toothpaste; abrasive toothpastes must be
avoided; anticalculus formulas are acceptable
10. Oral irrigators may be used on the lowest setting, with the tip
directed perpendicular to the long axis of the tooth or implant; water,
chlorhexidine 0.12%, phenol-based, or plant alkaloid mouthrinses
may be used
C. Skill development in plaque biofilm control
1. Clients must be shown how to control plaque biofilm on all areas of
the implant and the superstructure
2. Sufficient supervised practice will ensure adequate skill
development
3. Plaque biofilm control must be monitored at each continued-care
appointment and techniques modified, as indicated
4. Research indicates that tobacco use increases implant failure14

1350
Caries management
Caries Management by Risk Assessment 15
Caries management by risk assessment (CAMBRA) is an evidence-based
approach to the prevention or treatment of dental caries in the earliest
stages. The dental hygienist identifies a client’s level of risk by
determining the balance between pathologic and protective risk factors.
Once the clinician identifies a client’s caries risk (low, moderate, high or
extreme), a therapeutic and/or preventive plan is implemented. (See
Table 15-6 in Chapter 15.)
A. Caries disease indicators—uses acronym WREC to describe:
1. White spots lesions
2. Restorations placed within the past 3 years as a result of caries
3. Enamel proximal lesions
4. Cavitation of carious lesions penetrating into dentin
B. Pathologic factors
1. Medium or high level of streptococci and lactobacilli counts
2. Presence of heavy biofilm on teeth
3. Frequent snacking between meals
4. Deep pits and fissures
5. Recreational drug use
6. Inadequate salivary flow caused by medication, radiation, or
systemic diseases
7. Exposed roots
8. Orthodontic appliance
C. Protective factors—biologic or therapeutic factors related to the
client’s practice of oral hygiene that can counterbalance the challenge
presented by caries risk factors
1. Drinks fluoridated water on a regular basis
2. Uses a fluoride toothpaste once or more daily
3. Uses fluoride-containing mouthrinse daily
4. Has had fluoride varnish applied in the past 6 months
5. Has received an in-office topical fluoride treatment in the past 6
months
6. Has used prescription chlorhexidine daily for 1 week in each of the
past 6 months
7. Has used xylitol gum or lozenges four to five times daily in the past 6
months
8. Has used calcium and phosphate supplement during the past 6
months

1351
 9. Has adequate salivary flow

Fluorides16,17
See the sections on “Topical Fluorides and Fluoride Varnishes” in
Chapter 13 and “Preventing and Controlling Oral Diseases and
Conditions” in Chapter 20.

General Considerations
A. Most effective agent for the prevention and control of dental caries,
especially on smooth surfaces
B. A multi-therapeutic approach is most effective; three categories of
administration:
1. Systemic—community water supplies, institutional water supplies,
and dietary supplementation
2. Professional application—gels and varnishes
3. Self-applied—dentifrices, rinses, and gels
C. Safe when used in recommended amounts and concentrations; dental
hygienists must be alert to the potential for acute and chronic adverse
effects
1. Large quantities of fluoride products should not be stored in the
home
2. Institutions that have fluoride programs must handle and store
fluoride products safely
3. Parents and caregivers must be educated about supervising home
use of products containing fluoride by young children to prevent
acute toxic reactions or long-term effects (e.g., dental fluorosis)
4. Products intended for topical application should not be swallowed
5. If excessive amounts have been ingested, vomiting should be
induced immediately with ipecac or manually; calcium solution or
milk should be administered to slow the absorption rate; emergency
medical care should be obtained (see the section on “Drug-Related
Emergencies and Poisoning” in Chapter 21)
6. Fluoride therapy is based on the client’s risk assessment

Ingested Fluorides
A. Drinking optimally fluoridated water (0.7 ppm) during tooth
formation and then later as a topical fluoride from drinking the water
provides a significant decrease in the overall percentage of dental caries
in both children and adults

1352
B. Maximum benefits are obtained when fluoride is provided from the
onset of tooth development until tooth eruption is complete and then
used continuously for drinking
C. Fluoride works primarily and most effectively via topical (surface)
mechanisms (whether delivered in the drinking water, foods, beverages,
or products) to inhibit demineralization, enhance remineralization, and
inhibit plaque bacteria
D. The dental hygienist has a key role in educating parents, caregivers,
and children about the value of fluoride and its topical benefits

Fluoride Agents for Professional Application

A. Neutral sodium fluoride (NaF)
1. Characteristics—first fluoride used for topical application; available
in 2% concentration foam or gel and 5% concentration varnish
2. Application
a. Applications of 2% NaF at 6-month intervals as a substitute for
acidulated phosphate fluoride when porcelain or certain types
of composite restorations are present have not been
substantiated in the literature; 4-minute application
b. Fluoride varnish—contains a 5% NaF concentration, approved
by the U.S. Food and Drug Administration (FDA) for use as a
desensitizing agent and cavity liner; the varnish is used as a
topical fluoride treatment; painted on teeth; the varnish is
retained on the tooth surface for 3 to 4 hours
3. Advantages—safe for use in dentition with porcelain crowns and
composite restorations; varnish is easily applied on the teeth of
young children; research highly supports the efficacy of fluoride
varnish for caries prevention compared with other professional
fluoride methods16
B. Acidulated phosphate fluoride (APF)
1. Characteristics—available as foam, gels, and thixotropic gels; 1.23%
NaF with 1 molar (M) orthophosphoric acid concentration
2. Application intervals—every 6 months, or more frequently when
caries risk is high; 4-minute application
3. Advantages—high level of client acceptance; nonirritating to soft
tissues; does not discolor tooth structure; highest documented
efficacy; most common in-office treatment; 1-minute application not
supported by the research literature
4. Disadvantages and precautions—low pH of 3.5 for enhanced fluoride
uptake may cause etching of dental sealants and porcelain and some

1353
 composite restorations; sealants, porcelains, and composites should
be protected with a water-based lubricant, or use NaF as an
alternative

Indications for Professional Application

A. Topical fluoride therapy is an accepted part of the prevention-oriented
care plan
B. Assessment of client’s risk for dental caries will determine a client’s
fluoride therapy plan
C. Therapy regimen may include both professionally applied and self-
applied agents
D. Inclusion of topical fluoride in client’s care plan should be based on
the following criteria16:
1. For children and adults at moderate, high, or highest risk for dental
caries—fluoride varnish or fluoride gel is the treatment of choice at
continued-care intervals
2. Less than optimally fluoridated drinking water
3. Fair or poor oral hygiene
4. Decalcification, white spots, or incipient lesions are present;
secondary or recurrent caries; active caries
5. Following root instrumentation, dentin can be exposed and dentinal
tubules opened; hypersensitive root surfaces that often result can be
controlled by fluoride application
6. Fluoride application reduces incidence of root caries and dentinal
hypersensitivity associated with exposed root surfaces resulting
from gingival recession
7. Irregular professional dental visits
8. Inappropriate dietary practices (e.g., frequent sugar intake)
9. When xerostomia is present as a result of irradiation to the head and
neck, certain medications, or salivary gland dysfunction, resulting in
changes in quality and quantity of saliva; caries destruction occurs
rapidly and is generalized when salivary production is minimal;
multiple fluoride treatments are used to control high risk for dental
caries associated with xerostomia
10. Clients wearing orthodontic, prosthodontic, or any other oral
appliances

Application Principles—General Guidelines for

Client Preparation

1354
A. Explain the indication(s), the steps involved, and the time required for
the procedure, the need to control salivary flow and to avoid ingestion,
and postapplication instructions
B. Position the client to facilitate salivary control and reduce potential for
gagging
C. Calculus, extrinsic stains, materia alba, and heavy plaque biofilm
should be removed before the application of fluoride

Application Methods
Tray Systems
A. Designed for use with fluoride gels; trays cover all teeth in an arch,
come in a variety of materials, shapes, and sizes; tray systems are not
appropriate for solutions because they cannot be adequately retained
within tray boundaries
B. Tray examples—most frequently used
1. Disposable polystyrene (Styrofoam)—used for professional fluoride
application; ADA and CDA do not recommend the use of fluoride
foam because of lack of sufficient scientific evidence for its efficacy
in caries prevention; ADA and CDA recommend only 4-minute
fluoride gel application16
2. Custom-fitted polyvinyl—used by the client for self-application of
fluoride gel; provides excellent coverage; must be remade as the
dentition matures; relatively expensive
C. Application procedure
1. Assemble the armamentarium—trays, fluoride, a saliva ejection
device, gauze squares, and a timer or clock
2. Protect the dental sealants and the porcelain or composite
restorations with a water-based lubricant for APF application, or,
preferably, use neutral NaF
3. Thoroughly dry each arch; this prevents dilution of the material and
controls for a potential salivary barrier
4. Insert the tray(s); one or two trays can be inserted at once; tray type,
client variables, and clinician preference will influence the method
selected
5. Insert the saliva ejection device, which reduces the potential for
ingestion, nausea, and vomiting
6. Adapt the tray(s); the dental hygienist or the client can gently press
on the trays to close any small anterior gaps
7. Have the client apply gentle biting pressure to force the gel

1355
 interproximally
8. Remove the tray(s); if only one tray was inserted initially, insert the
second tray at this point; do not allow the client to rinse between
insertions
9. Clear any excess agent from the mouth; instruct the client to
expectorate and swab the tongue, teeth, and soft tissues with gauze
squares
10. Provide post-treatment instructions; clients are instructed not to
eat, rinse, or drink for at least 30 minutes; this increases the total
contact time of fluoride exposure

Self-Applied Fluorides
A. Frequent, low doses of fluoride exposure to tooth surfaces are
important for enamel remineralization and prevention of
demineralization
B. Rinses—available by prescription, except as noted
1. Daily use—low potency, high frequency
a. 0.044% APF rinse supplement
b. 0.05% NaF (available over the counter [OTC])
c. 0.1% SnF2 rinse (0.63% plus water)
2. Weekly use—high potency, low frequency
a. 0.2% NaF
b. Most common concentration used for school-based fluoride
rinse programs
3. Many commercially prepared fluoride rinses contain alcohol and
should not be recommended for persons with a history of alcoholism
or xerostomia; use alcohol-free rinses with children and clients who
need to avoid exposure to alcohol
4. Fluoride rinses are not recommended for children under 6 years old;
swallowing small doses of fluoride over a period may lead to dental
fluorosis
C. Gels—available OTC and by prescription
1. 0.4% SnF2 (brush-on or tray application)
2. 1.1% NaF (brush-on or tray application, also available in paste)
3. 0.05% APF (tray application)
D. Some studies indicate that SnF2 may have antiplaque,
antihypersensitivity, and anticaries effects

Amorphous Calcium Phosphate18,19

A. Amorphous calcium phosphate (ACP) contains the same minerals as

1356
the hydroxyapatite crystals of tooth enamel
B. Casein phosphopeptide–amorphous calcium phosphate (CPP-ACP), a
milk protein peptide, is usually added to stabilize and localize the
calcium and phosphate ions on the tooth surface, promoting
remineralization of enamel
C. Products that contain ACP should not be substituted for fluoride
therapy; ACP should be used in conjunction with fluoride to enhance
fluoride uptake
D. Several professionally applied and OTC self-applied products,
including dentifrices, tooth-whitening agents, prophylaxis paste, and
fluoride varnish, contain ACP

Xylitol for Dental Caries Prevention20,21

A. Xylitol is a noncariogenic artificial sweetener; Streptococcus mutans
cannot metabolize xylitol, which causes a decrease in S. mutans infections
B. Xylitol inhibits the attachment and transmission of S. mutans, reduces
plaque biofilm formation, and stimulates salivary secretion
C. Research does not support the effectiveness of xylitol in preventing
dental caries
D. Xylitol-containing salivary stimulants can be beneficial for people with
xerostomia and diabetes
E. Several products contain xylitol (e.g., chewing gum, lozenges, mints);
when used for therapeutic purposes, products must contain 1.55 g of
xylitol and must be used at least four or five times daily

1357
Mouthrinses or chemotherapeutics22,23
A. May have cosmetic and therapeutic value
B. Effectiveness of many mouthrinses is limited to dislodging gross
debris, temporarily reducing microorganisms, and providing a feeling of
freshness
C. One category of commercial mouthrinses is approved by the ADA
Council on Scientific Affairs: phenol-related essential oils compounds
gained acceptance for control of both plaque biofilm and gingivitis and
carry the ADA Seal of Acceptance
1. Chlorhexidine gluconate (Peridex, PerioGard, Pro Dentx, PerioRx)
a. Available by prescription only
b. 0.12% concentration in an aqueous solution containing 11.6%
alcohol, pH 5.5; also made without alcohol for persons who
cannot use alcohol (ask the pharmacist)
c. Clinical effects are comparable with 0.2% mouthrinse used for
many years outside the United States; extensive clinical research
has documented its efficacy
d. Review of numerous studies has established chlorhexidine’s
safety, stability, and substantivity, which make it effective in
preventing and controlling plaque biofilm and reducing and
inhibiting gingivitis
e. May cause brownish yellow stain and supragingival calculus
f. Unpleasant taste may hinder client acceptance
g. Recommended for short-term use only; one 2-ounce, 30-second
rinse, twice daily for 6 months
h. Available in alcohol-free formulation
2. Phenol-related essential oils (Listerine and many equivalent generic
store brands)
a. Available without a prescription
b. Contains thymol, menthol, eucalyptol, and methylsalicylate in a
hydroalcohol solution, 21.6% to 26.9% alcohol, pH 5.0
c. Low substantivity
d. Listerine’s efficacy in inhibiting bacterial plaque biofilm and
gingivitis has been documented
e. Various flavors available to enhance client acceptance and
adherence to manufacturer ’s recommendation for a 30-second
rinse twice daily
f. Essential oils mouthrinses, using basically the same formula as
Listerine, are marketed under many store brand names and are
also accepted by the ADA Council on Scientific Affairs as

1358
 having antiplaque and antigingivitis effects
g. Can be used as preprocedural mouthrinses before aerosol-
producing procedures; or as a preprocedural subgingival
irrigant
h. Anticalculus formulation of Listerine containing zinc chloride;
inhibits supragingival calculus accumulation; has the ADA Seal
of Acceptance
i. Available in alcohol-free formulation
D. Mouthrinses are recommended as adjuncts to, not replacements for,
mechanical plaque biofilm control
E. Effective on supragingival biofilm only, unless delivered subgingivally
with irrigators
F. Approved mouthrinses should be considered for clients with the
following conditions:
1. Inability to achieve acceptable mechanical plaque biofilm control
2. Fixed splinting, prostheses, dental implants, and overdentures
3. Orthodontic appliances
4. Postperiodontal or other oral surgery
5. Clients at high risk for dental caries
6. Medication-induced gingival enlargement
7. Immunosuppression
8. Preprocedural application to minimize bacteremia and disease
transmission
G. Commercially prepared mouthrinses may contain alcohol or may be
alcohol free; other ingredients are water, flavoring, coloring, sweetening
agents, and a variety of active ingredients such as:
1. Antimicrobials to reduce or inhibit biofilm activity (cetylpyridinium
chloride, chlorhexidine, sanguinarine, phenolic compounds,
triclosan)
2. Oxygenating agents to debride and release oxygen (hydrogen
peroxide)
3. Astringents to shrink tissue (citric acid, zinc chloride)
4. Anodynes to alleviate pain
5. Buffering agents to reduce acidity, dissolve mucinous films, and
relieve soft tissue pain
6. Deodorizing (sodium bicarbonate) and oxidizing (chlorine dioxide)
agents to neutralize odors and eliminate volatile sulfur compounds
7. Fluorides to decrease dental caries risk (see the previous section on
“Self-Applied Fluorides”)
8. Whitening agent such as hydrogen peroxide to reduce intrinsic
stains

1359
H. Inexpensive mouthrinses may be prepared by the client (not
recommended for clients on a low-salt or sodium-free diet) and used
following thorough periodontal debridement
1. Isotonic (normal) saline solution: 1/2 teaspoon salt in 8 ounces of
water
2. Hypertonic saline solution: 1/2 tsp salt in 4 oz water
3. Sodium bicarbonate solution: 1/2 tsp sodium bicarbonate (baking
soda) in 8 oz warm water
I. Mouthrinse use should be monitored by both the client and the dental
hygienist; any adverse effects indicate that use should be evaluated and
possibly discontinued
J. The dental hygienist should teach clients how to be wise consumers of
mouthrinses, helping clients to recognize the benefits, limitations, and
appropriate therapeutic regimens for mouthrinses

1360
Dental sealants
General Considerations
See the section on “Pit-and-Fissure Sealants” in Chapter 13.
A. Although systemic and topical fluorides provide increased resistance
to carious destruction, the pit-and-fissure surfaces do not benefit from
fluoride use to the same degree as do smooth surfaces
B. Sealants are a thin resin or glass ionomer coating placed in the pits
and fissures of teeth to act as a physical barrier to oral bacteria
1. Preventive sealant—placed in caries-free pits and fissures
2. Therapeutic sealant—placed in pits and fissures with incipient
carious lesions to halt caries process
C. Pits and fissures allow for the accumulation and stagnation of
fermentable substrates and serve as accumulation sites for acidogenic
microorganisms capable of demineralizing tooth tissue
D. The effectiveness of dental sealants in the prevention of pit-and-
fissure caries has been clearly demonstrated in research settings
E. Protection from caries approaches 100% when pits and fissures remain
completely sealed; numerous clinical trials have documented the efficacy
of sealants
F. Comprehensive prevention programs incorporate the complementary
use of sealants and fluorides
G. Sealants classified by method of polymerization
1. Auto-polymerizing—chemically cured or self-curing
2. Photo-polymerizing—cured by visible light
H. Sealants classified by filler content
1. Filled sealant—composite resin sealant containing particles of glass
and quartz
2. Unfilled sealants—composite resin sealant without particles; less
resistant to long-term wear
3. Glass ionomer—salivary control not a critical factor; ideal for teeth
when moisture control is an issue
4. Fluoride releasing—promotes remineralization
5. Calcium phosphate—promotes remineralization
I. Sealants classified by color—available in clear, tinted, and opaque
color; the color aids in detection and in monitoring retention

Indications for Application

A. Factors to consider
1. Dental caries activity, risk, and pattern

1361
 2. Depth of pits and fissures
3. Dietary patterns
4. Current and past fluoride exposure
5. Eruption status
6. Frequency of preventive services
B. Procedure for sealant placement1
1. Clients or guardians should be informed about sealants as a primary
preventive measure
2. Clients who can benefit from sealant application:
a. Children with newly erupted teeth with pits and fissures
b. Persons whose lifestyle, behavior patterns, physical or
emotional development, or lack of fluoride exposure put them at
high risk for dental caries
c. Children and adults whose teeth have deep pits and fissures
d. People with xerostomia or persons with orthodontic appliances
e. Other persons who desire sealants as a preventive measure to
protect pits and fissures
C. Teeth with questionable or incipient carious lesions should be sealed;
incipient lesions are arrested after sealant placement24

Contraindications to Sealant Application

A. Presence of frank carious lesion on occlusal surface
B. Presence of carious lesion on proximal surface that necessitates
preparation of occlusal surface
C. Previously restored tooth, except as noted in item C above
D. Life expectancy of the primary tooth predicted to be short

Application Guidelines1
A. Mechanical cleansing of enamel
1. Debride the pit-and-fissure surface of plaque biofilm and surface
debris
2. Cleansing agents include:
a. Toothbrush
b. Air polishing, rubber cup polishing
c. Dental explorer
B. Isolating
1. Salivary contamination of etched enamel surfaces is a major reason
for resin sealant failure
2. Isolation—using a rubber dam or cotton rolls and bibulous

1362
 (absorbent) pads is essential for consistent success
C. Drying
1. Dry isolated tooth thoroughly in preparation for the application of
conditioner or etchant
2. Avoid water contamination if using air/water syringe
D. Conditioning or etching
1. Acid conditioning etches enamel surface before the application of
resin or glass ionomer (sealant) material; etching removes a layer of
enamel and increases the total surface area by rendering the deeper
enamel regions porous; the sealant’s resin material fills the enamel
micropores, producing a mechanical “lock” when polymerized
2. Acid conditioning agents (30% to 50% phosphoric acid)—available in
solution or gel form
a. Apply the solution by gently dabbing the enamel surface with a
saturated cotton pellet or brush; avoid rubbing the surface
because it causes a breakdown of lattice-like micropores
b. Gels are applied with a special applicator, brush, cotton tip, or
cotton pellet
c. Whether using gel or solution, cover all susceptible surfaces and
cuspal inclines with the etchant
d. Contact between the etching agent and soft tissues should be
avoided
e. Etch the tooth surface for 10 to 20 seconds; check the
manufacturer ’s instructions for etching time
E. Rinsing the conditioned tooth
1. Thoroughly rinse the etched enamel surfaces by using a water
syringe and a high-speed evacuation system; do not allow the client
to swish; rinsing time may need to be increased to ensure complete
removal
2. Salivary contamination at this point results in substantial reduction
in resin sealant bond strength
a. Do not allow client to close the mouth, rinse, or touch the
conditioned surface with the tongue
b. When using cotton rolls or bibulous (absorbent) pads, change
them as needed, being careful to avoid salivary contamination
F. Drying the conditioned tooth
1. Prepare the tooth for resin sealant application by drying it
thoroughly with compressed air for at least 10 seconds; a completely
dry tooth surface is essential for effective application of the resin
sealant; it is not as critical when using glass ionomer sealants
2. Examine the conditioned surface; properly etched surfaces will

1363
 appear dull and chalky; re-etch the tooth surface when these changes
are not seen or salivary contamination occurs
G. Applying the sealant material—all susceptible pits and fissures,
including the buccal pits of mandibular molars and the lingual grooves
of maxillary molars, should be sealed, when possible
1. Visible light–cured sealants—the resin sealant is applied to the
etched surface; the tip of the light source is placed 2 mm from the
sealant (see the manufacturer ’s instructions)
a. Light must be delivered for polymerization to occur and for the
prevention of sealant failure
b. Once polymerization is complete, the sealant should be wiped
with a wet cotton roll or pellet to remove any air-inhibited layer
of nonpolymerized resin; failure to remove this layer will result
in an unpleasant taste
c. The sealant material is delivered in a variety of ways; unit dose
dispensers contain enough sealant for one quadrant; this
method reduces the risk of cross-contamination, when used
properly
2. Chemical or self-curing sealants—the catalyst and the sealant are
mixed and then placed immediately onto the prepared tooth surface
with a brush or a custom dispenser; working time from mixing to
setting is 1 to 3 minutes; it is important not to disturb the layer of
applied sealant during polymerization
3. The sealant material should be allowed to flow into all areas to
minimize entrapment of air bubbles
4. Applying excess sealant to the occlusal surface should be avoided
because this could alter the client’s occlusion
H. Evaluating the results
1. Examine the sealant to determine the adequacy of bond strength and
the absence of voids, underextensions, overextensions, or
undercuring
2. The sealed surface should feel completely smooth
3. Floss teeth to ensure that the sealant has not flowed into
interproximal spaces
4. For the filled-type sealant material, occlusion should be checked
with articulating paper; frank high spots should be reduced with a
finishing bur or fine stone; in the case of unfilled-type sealant
materials, high spots self-adjust after a few days
5. Evaluate sealant retention at each appointment; replace the material,
as needed
6. Most sealant failures result from “operator error,” for example, oil,

1364
 debris, or moisture contamination, or from not following
manufacturer ’s instructions
I. Document on client’s chart the type of sealant used and the teeth
sealed

1365
Tobacco use interventions
General Considerations25,26
A. The two types of tobacco are smoked tobacco and unsmoked tobacco
1. Examples of smoked tobacco include bidis, cigars, pipes, cigarettes,
water pipe (hookah), and clove cigarettes
2. Unsmoked tobacco is also known as spit tobacco, snuff, or smokeless
tobacco
B. Tobacco cessation is considered to have occurred when an individual
permanently discontinues the use of tobacco
C. Smoking is a primary risk factor for:
1. Lung cancer
2. Chronic obstructive lung disease
3. Heart disease
4. Head and neck, oropharyngeal, and other cancers
5. Periodontal disease
D. Oral effects of tobacco use: oral and pharyngeal cancer, failure of
periodontal therapy, failure of dental implants, dental caries, tobacco
abrasion, extrinsic stain, halitosis, attrition, delayed wound healing,
nicotine stomatitis, oral leukoplakia, and tooth loss
E. From a host response perspective, smoking has been found to
interfere with the normal function of helper lymphocytes critical to
antibody production, impair revascularization in both soft and hard
tissues, inhibit collagen production, and increase collagenase activity
F. Spit tobacco use is associated with oral, laryngeal, and pharyngeal
cancers
1. Oral mucosal lesions and gingival recession are mostly observed in
individuals using spit tobacco
2. Oral mucosal lesions often disappear after spit tobacco use is
discontinued
G. Dental hygienists must assume the responsibility for helping clients
abstain from tobacco use and to encourage and appreciate nonusers
H. Nicotine itself is not a carcinogen, but it is physiologically addictive;
clients trying to quit may experience withdrawal symptoms (e.g.,
insomnia, irritability, weight gain); embedded social and psychological
factors also contribute to the challenge
I. Dental hygienists should take an active role in the community and in
legislative efforts to reduce all tobacco use

Tobacco Cessation Interventions25–28

1366
A. Oral care and all other health care facilities should be tobacco free
B. Oral health care professionals should strive to quit all tobacco-related
habits and serve as positive role models
C. Tobacco use by all clients should be addressed, assessed, and
documented in clients’ permanent records
D. The Agency for Healthcare Research and Quality’s Clinical Practice
Guideline on Treating Tobacco Use and Dependence recommends five
components for successful client-provider interaction28:
1. Ask—at every visit of every client, identify and document tobacco
use status
2. Advise—a clear, strong, personalized message to refrain from all
tobacco use should be communicated to each client who uses
tobacco
3. Assess—determine if the client is willing to make an attempt to quit
4. Assist—if client is willing to make an attempt to quit, counseling
and pharmacotherapeutic agents should be used; FDA-approved
pharmacotherapeutic agents include:
a. Nicotine reduction therapy—nicotine transdermal patch, gum,
lozenge, nasal spray, and oral inhaler
b. Nonnicotine agents for managing nicotine addiction—
sustained-release bupropion hydrochloride (Zyban) tablets and
varenicline (Chantix)
5. Arrange—a follow-up contact should be scheduled within the first
week following the quit date
E. The American Dental Hygienists’ Association Smoking Cessation
Initiative (SCI) recommends three steps:
1. Ask—ask every client about his or her tobacco use at every visit; ask
if the client is a current, former, or never tobacco user
2. Advise—advise every tobacco user to quit; advise those who have
tried and not succeeded to try again; employ the teachable moment
by linking clinical findings with advice
3. Refer—refer the client to QUITLINES, websites, and local cessation
programs; find programs and assistance at www.smokefree.gov,
www.askadviserefer.org, or call 1-800-QUIT NOW (1-800-784-8669);
these websites and telephone numbers provide resources to use at
the chairside
F. Teenagers, preteens, and children should be considered potential users
of smoked and spit tobacco products; interventions include:
1. Questioning them about tobacco use (e.g., cigarettes, cigars, pipes,
water pipes [hookahs], chewing tobacco, snuff)
2. Educating them about the health risks of tobacco use27

1367
 3. Educating them about the negative effects of tobacco on their
physical appearance and athletic prowess
4. Encouraging them to resist peer pressure and media messages to
start using tobacco
G. Tobacco-use assessment should be part of history taking; assessment
should include:
1. Form of tobacco used
2. Amount used
3. Duration of habit
4. Previous quit attempts
5. Reasons for quitting or abstaining from tobacco use
H. Client readiness for cessation—clients should be asked if they are
ready to quit; the trans-theoretical model can be used to assess stages of
readiness to quit; clients should set their own quit date27 (see Table 20-16
in Chapter 20)
I. Typically, smokers try to stop multiple times before they succeed

1368
Periodontal disease risk assessment29
A. Periodontal risk assessment
1. Involves the identification of clients and populations at risk of
developing periodontal disease
2. Purpose of risk assessment
a. Reduce the need for complex periodontal therapy
b. Improve client outcome
c. Reduce risk of chronic systemic diseases
3. Identification of risk factors and taking steps that can reduce the risk
will help prevent periodontal disease; identification of risk factors
does not imply cause and effect
B. Common risk factors for periodontal disease
1. Tobacco use
a. Heat from smoking enhances attachment loss and increases
calculus formation, which in turn creates favorable environment
for plaque biofilm retention
b. Nicotine negatively affects collagen synthesis, protein secretion,
and bone formation, leading to impaired bone healing
c. Use of tobacco products increases production of cytokines
because of lower oxygen levels, which cause breakdown
periodontal tissues
d. Tobacco history is assessed during health and social histories
2. Systemic diseases
a. Have been associated with oral diseases (e.g., periodontal
disease, dental caries, salivary gland dysfunction and
xerostomia, burning mouth syndrome) and increased
susceptibility to oral infections
b. Evidence shows a high chronic systemic inflammatory response
in clients with metabolic syndrome
3. Genetic factors
a. Interleukin-1 (IL-1) polymorphism studies have indicated that
IL-1 genotype–positive clients have greater chance of
periodontal disease than IL-1 genotype–negative clients
b. Oral disease and tooth loss in the family are assessed during the
health history
4. Poor oral hygiene—lack of plaque biofilm removal encourages an
environment conducive to the survival of periodontal disease
pathogens
5. Metabolic syndrome29,30
a. Group of disorders that increase the risk of heart disease,

1369
 stroke, and diabetes, including high blood pressure, elevated
plasma glucose, excess body fat around the waist and abdominal
area, and high cholesterol level
b. Studies show link between periodontal disease and metabolic
syndrome

1370
Oral cancer risk assessment
Many oral cancers, unfortunately, are not detected until they have
invaded deep tissues and require radical surgery, extensive
chemotherapy, irradiation, or all three interventions. Early detection and
early treatment are the best ways to manage oral cancer; self-examination
can supplement a thorough in-office head and neck, extraoral, and
intraoral examination. Clients can potentially benefit from self-
examination skills. It is especially important to educate high-risk
persons.
A. Clients need to be taught mutable and nonmutable risk factors for
oral cancer
1. Mutable risk factor—can be changed or eliminated (e.g., smoking,
sun exposure, or drinking behavior)
2. Nonmutable risk factor—cannot be changed or eliminated (e.g.,
genetic makeup, gender)
B. Strategies for reducing risk factors should be part of the dental
hygiene care plan

High-Risk Factors31,32
A. Tobacco use
1. Clients who smoke are estimated to be at greater risk than
nonsmokers
2. Clients who use snuff and spit tobacco are prone to squamous cell
carcinomas at or near the site where the tobacco is held
B. Alcohol use—the combination of smoking and alcohol use is
responsible for the majority of head and neck cancers1
C. Virus—certain viruses, such as human immunodeficiency virus (HIV)
and human papillomavirus (HPV), are linked to the development of
cancers of the nasopharynx, cervix, and lymphatic system
D. Sun exposure—clients who work outdoors, especially those with a fair
complexion, are at higher risk for basal cell tumors of the skin
(predominating around the face and lips)

Examination Technique
Materials Needed
A. Large mirror and adequate light source are essential for self-
examination procedures
B. A flashlight, mouth-sized mirror, and gauze or tissue squares help to

1371
access and visualize intraoral structures

Systematic Approach
A. Face and neck
1. Symmetry—one-sided irregularities should be further investigated;
right and left sides should have the same outline and shape; lesions
that fail to heal within 2 weeks should be suspect
2. Skin—have the client remove eyeglasses; check for sores, bumps,
and discoloration
3. Neck—palpate lymph chains for lumps or tender areas
B. Visually examine and palpate lips and gums
1. Have the client remove full or partial dentures
2. Retract the lips; look for sores or color changes
C. Cheek
1. Retract the right side and then the left side to visualize the inner
surface; look for red, white, brown, or speckled patches
2. Palpate for lumps or tenderness
3. Run a finger over the inside surface to check for rough or raised
places
D. Roof of mouth
1. Tilt the head back and use a flashlight for better visualization
2. Look for sores or color changes; feel for lumps or areas of tenderness
E. Tongue
1. Have the client extend the tongue, and look at the dorsum
2. Grasp the tongue with a gauze square; pull and roll the tongue to the
right side and then to the left side
3. Look for sores, color changes, and irregularities
4. Feel for lumps, areas of tenderness, or roughened surfaces
F. Floor of mouth
1. Have the client place the tip of the tongue against the roof of the
mouth
2. Look for any asymmetry, sores, or color changes
3. Place the fingers of one hand under the client’s jaw, and use the
index finger of the other hand to compress structures
4. Check for lumps, tenderness, or irregularities
G. Provide the client with an assessment of his or her mutable and
nonmutable risk factors; help the client to reduce the risks for oral cancer
H. Provide the criteria for determining significant deviations from
normal
1. Sores that fail to heal within 2 weeks

1372
 2. Appearance of white, red, or dark-colored patches
3. Presence of swellings, lumps, bumps, or growths
I. Define the oral health professional’s role in interpreting findings; the
client should report unusual findings, but should not self-diagnose
J. Establish the concept that self-examination is not meant to be a
substitute for periodic regular professional evaluation

1373
Diagnostic tools for oral cancer detection
General Considerations
A. The combination of visual examination and palpation is the main
approach to detecting epithelial changes in the oral mucosa
B. Routine examination for the detection of oral cancer should be
completed for each client (see the section on “Extraoral and Intraoral
Assessment” in Chapter 15)
C. Routine oral cancer screenings can reduce oral cancer incidence and
mortality rate30
D. The diagnosis of a suspicious lesion is established by traditional
biopsy

Brush Biopsy
Definition
A. Transepithelial oral biopsy—samples the superficial, intermediate,
and basal epithelial layers to detect oral cancer at its earliest stages (Fig.
16-4); indicated for small, innocuous-appearing lesions

FIG 16-4 Brush biopsy technique being used in evaluation of a suspect intraoral
lesion. (Photo courtesy of Oral CDx, Suffern, New York.)

B. The dental hygienist’s role is to identify red, white, or mixed lesions as

1374
well as ulcerated, thickened, traumatized, or irritated oral epithelium to
be evaluated using brush biopsy
C. Dental hygienists should consult their state regulatory board or state
statutes to determine whether they are legally permitted to perform
brush biopsies
D. Accurate detection of precancerous or cancerous areas requires
scalpel biopsy

Advantages
A. Easy, chairside test to evaluate epithelial changes and lesions that may
have received only a clinical follow-up before this test became available
B. Rapid results, generally within 3 days to detect dysplasia or carcinoma
C. Minimally invasive
D. Each specimen is evaluated by both computer-assisted analysis and a
pathologist

Disadvantages
A. Costs for both obtaining and analyzing the specimen are incurred by
the client
B. As with any biopsy method, false-negative results are possible
C. Brush biopsies with negative results require careful follow-up

Procedure
A. Armamentarium (see www.oralcdx.com)
1. Sterile brush instrument for biopsy
2. Microscope specimen slide
3. Fixative
4. Laboratory forms
B. Obtaining and preparing the sample
1. Using the client’s saliva, moisten the biopsy brush
2. Firmly press the biopsy brush against the lesion
3. While pressing, rotate the brush over the surface of the lesion until
pink tissue or pinpoint areas of bleeding occur; number of rotations
will vary, depending on the thickness of the lesion
4. Use of topical anesthesia is contraindicated because it may distort
the sample
5. To prepare the glass slide, transfer as much of the cellular sample as
possible by rotating and dragging brush lengthwise on the slide
6. Apply the fixative to cover the slide thoroughly; allow drying for 15

1375
 minutes
7. Package the sample and send it to the laboratory for evaluation

Laboratory Findings for Brush Biopsy

A. Classification categories
1. Unsatisfactory—specimen is not adequate for diagnosis
2. Class I: Normal—only normal cells are present
3. Class II: Atypical—some cellular changes may be present; no
suggestion of malignancy is present
4. Class III: Intermediate—changes may suggest malignancy, but
findings are not clear; biopsy is recommended
5. Class IV: Suggestive of cancer—cells with malignant characteristics
are present; biopsy is mandatory
6. Class V: Positive for cancer—cells are obviously malignant; scalpel
biopsy is mandatory
B. Follow-up needs
1. Unsatisfactory—the client should be scheduled for another smear or
brush biopsy
2. Class I or II findings—the client should be monitored for healing of
lesion or reevaluated if the lesion fails to resolve; as with all biopsy
methods, false-negative reports are possible; a healed lesion is the
best reassurance for reports in categories I and II
3. Class III, IV, or V findings—the client should be referred for scalpel
biopsy

ViziLite
A. Definition—an FDA-approved technology that screens for oral
abnormalities potentially indicative of oral cancer
1. This tool helps oral health care professionals identify lesions before
they appear on oral tissue surfaces
2. ViziLite illumination cannot distinguish keratotic, inflammatory,
malignant, or possibly malignant lesions; clinical judgment, and
scalpel biopsy are essential for proper patient care33
B. Procedure
1. The client rinses with a solution
2. The oral health care professional activates a patented light stick
intraorally
3. The light stick illuminates any suboral lesions during the oral cancer
screening examination (www.vizilite.com)

1376
C. Studies have shown inconsistent results with the use of ViziLite

VELscope
A. Definition—an FDA-approved handheld device that uses oral
fluorescence technology to identify precancerous and cancerous lesions
in the oral cavity33
1. The fluorescence technology shows healthy tissue as green and
potentially cancerous lesions as dark magenta, brown, or black
2. Changes in tissue can be detected while the change is still
subepithelial and otherwise not visualized during conventional oral
examination
3. Surgical margins can be determined, which will help guide complete
removal of oral cancers in the operatory
B. This device should be used as an adjunct to clinical screening; clinical
judgment and scalpel biopsy are essential for the diagnosis of oral cancer
lesions
C. There is higher risk of false-positive results; VELscope does not
provide a definitive diagnosis

Other Devices and Oral Examination

A. Other oral cancer detection devices are available, such as Identafi;
however, these devices are unable to provide definitive diagnosis
B. Routine oral cancer visual and tactile examination is still the “gold
standard” for identification of oral cancer lesions33

1377
Assessment of dentinal hypersensitivity
A. Definition—abnormal condition that occurs when vital dentin is
exposed to the environment of the oral cavity; the result is painful stimuli
that can reach the pulp and cause pain
1. Thermal, evaporative, tactile, osmotic, or chemical stimuli can cause
fluid movement within the dentinal tubule, exciting the nerve and
signaling the pulp to respond
2. Gingival recession and loss of enamel should be minimized to avoid
dentinal hypersensitivity
3. Treatment of dentinal hypersensitivity is a valuable client service;
symptoms cause considerable discomfort to the client and may
interfere with both control of plaque biofilm and professional
treatment
B. Characteristics
1. Rapid onset
2. Sharp pain
3. Short duration
4. Response to stimuli

1378
Etiology
A. Primary causes of hypersensitivity are exposed dentin and open
dentinal tubules
B. Dentin exposure occurs:
1. In 10% of all teeth; during development, enamel and cementum do
not join
2. When enamel or cementum is lost through abrasion, erosion,
abfraction, dental caries, or overinstrumentation
3. When soft tissue is lost because of gingival recession, periodontal
surgery, or an aggressive toothbrushing technique
4. When diet exposes the dentin to foods and beverages with a low pH;
soft drinks, sport drinks, coffee, and fruit juices/drinks; citrus fruits;
yogurt; and some alcoholic beverages; plaque biofilm acids
C. Loss of hard and soft tissues is believed to be accelerated from the
combined use of mechanical brushing and a dentifrice applied
immediately after exposure to acidic food or drink

Pain Mechanism
A. Hydrodynamic theory—the most widely accepted
B. Explains the following:
1. Dentinal tubules are exposed
2. Pain-producing stimuli are present
3. Pain-producing stimuli initiate the flow of lymphatic fluid within
dental tubules
4. Odontoblasts and their processes act as receptors and transmitters
of sensory stimuli
5. The movement of tubular fluids causes nerve endings at the pulpal
wall to be stimulated and produce pain

Pain Stimuli
A. Thermal or evaporative stimuli—foods and liquids at extreme
temperatures, cold air, and too-rapid drying of a tooth surface; cause a
concurrent rapid drop in tooth temperature; are more problematic than
hot-air changes
B. Mechanical stimuli—instrumentation, home care devices, eating
utensils, and friction from removable prosthetic or orthodontic devices
C. Chemical stimuli—foods high in acid or sugars; some topical
medications; plaque acids

1379
Desensitizing Agents
A. Modes of action—desensitizers:
1. Seal dentinal tubules by surface precipitation of ions, subsurface
incorporation of ions, or stimulation of secondary dentin
2. Decrease the excitability of sensory nerves, thereby making the
nerve less sensitive to stimuli
B. Optimal characteristics—professionally applied desensitizing agents
should act rapidly and should be nontoxic, easy to apply, and have
consistent outcomes and long-term effects

Types of Desensitizing Treatments

A. No single desensitizing agent or form of treatment is effective for all
persons
B. Numerous agents have varying degrees of success, including:
1. Solutions, gels, or pastes of fluoride in varying compounds and
percentages, stannous fluoride, calcium hydroxide, strontium
chloride, potassium nitrate, sodium citrate, formaldehyde,
glutaraldehyde, arginine and insoluble calcium, casein
phosphopeptide–amorphous calcium phosphate complex, or
potassium or ferric oxalate
2. Adhesive, varnish, or bonding materials
3. Polymerizing agents1
a. Glass ionomer cements (GICs)—used in cervical abrasion and
abfraction; the sensitive area is etched with 50% citric acid,
rinsed with water, and dried before application of GIC
b. Adhesive resin primers—reduces dentin permeability by
occluding open tubules; the material is rubbed on the sensitive
area for approximately 30 seconds and air-dried
4. Iontophoretic devices—technique sensitive
a. Iontophoresis is the application of an electrical current to
impregnate tissues with ions from dissolved salts
b. Fluoride iontophoresis is thought to result in the increased
uptake and penetration of fluoride ions into dentin
5. Laser therapy—one-time treatment that reduces or eliminates dentin
sensitivity by sealing dentinal tubules; sensitive dentin treated with
laser is found to be harder than untreated dentin
6. Restorations—restoration may be placed on the surface where
dentin is exposed to help reduce sensitivity

1380
Desensitization Methods
A. Self-care regimens
1. Effective plaque biofilm control strategies are important in gaining
and maintaining control of hypersensitivity; modifications to
minimize aggressive brushing are critical
2. Specially formulated toothpastes containing 5% potassium nitrate to
desensitize the nerve are often combined with fluoride, which
promotes remineralization
3. Daily use of a fluoride gel or rinse is advisable when the problem is
generalized or recurrent
B. Professionally delivered regimens should support and enable self-care
regimens
1. General guidelines
a. Remove all deposits; involved surfaces must be free of barriers
to the agent
b. Local anesthesia is appropriate when instrumentation
procedure or application of the agent is too painful
c. Isolate the sensitive tooth and control saliva
d. Dry the affected tooth with cotton pellets or gauze; avoid using
an air syringe
e. Apply the agent according to the manufacturer ’s instructions
for method and time required
(1) Pastes are usually burnished in with a wooden point,
whereas solutions, gels, or varnishes are painted or bathed
on
(2) Some clients may experience an acute pain reaction to the
agent; immediately remove the agent, wait a few minutes,
and then attempt reapplication
f. Remove any excess agent to avoid ingestion by the client
g. Test for change in pain reaction; this will not be possible with
anesthetized areas
h. Plan for future reapplication if desensitization has not occurred
2. Precaution—some agents have very high concentrations of fluoride;
to prevent nausea, use proper application and techniques to control
salivary flow

1381
Pulpal vitality and testing devices
Basic Concepts
A. Teeth may become nonvital from bacterial invasion of the pulp
associated with caries or periodontal disease or from injuries such as
mechanical or thermal trauma
B. Any tooth suspected of being nonvital should be tested for pulpal
vitality
C. The preferred method of testing provides a qualitative assessment
D. Tests should correlate with or mimic the client’s chief complaint
E. Palpation, percussion, and radiographic findings (e.g., widened
periodontal ligament) are other sources of data for pulpal assessment

Laser Doppler Flowmetry34

A. Noninvasive, painless, semi-quantitative method; measures pulpal
blood flow through assessment of the vascular supply by the passage of
light through a tooth; monitors blood flow in response to pressure
changes and administration of local anesthesia
B. Useful in young children whose responses are usually unreliable
C. Studies have shown that blood circulation is the most accurate
determinant in assessing pulp vitality34
D. Laser Doppler flowmetry is more reliable at identifying vital and
nonvital teeth earlier than other pulp vitality tests

Traditional Electrical Testing Devices

A. The electrical pulp tester (also known as a vitalometer) and the digital
pulp tester use gradations of electrical current to excite a response in
pulpal tissue and thus assess response to stimulus
1. Pulp testers have either a portable battery or a plug-in electrical
power source
2. All testers have rheostats, with a scale (e.g., 1 to 10 or 1 to 50) that
indicates the relative amount of current being applied; digital pulp
testers provide a digital reading
3. Electrical pulp testers can be used safely on clients with implanted
cardiac devices
B. Procedure
1. Armamentarium
a. Testing device
b. Cotton rolls

1382
 c. Toothpaste or other conducting medium
2. Client preparation
a. Explain the procedure to the client; use the minimal stimulation
necessary to evoke a response
b. Instruct the client to raise a hand when the slightest warmth or
tingling sensation is felt
3. Obtaining a reading
a. Isolate and dry the teeth to be tested; this prevents the
conduction of current into the soft tissue
b. Apply a small amount of toothpaste, or an alternative
conductor, to the tester tip
c. Place the tip on sound tooth structure, within the middle third
of the crown for a single-rooted tooth and within the middle
third of each cusp for a multi-rooted tooth; a clip resting on the
client’s lip and attached to the handpiece is necessary to create a
closed electrical circuit and to activate the tester
d. Avoid any contact with restorations and soft tissue
e. Slowly advance the rheostat from zero to increasingly higher
numbers until a sensation is felt by the client; the rheostat
should not be moved above that point for that tooth
4. Documentation
a. Two readings should be taken for each tooth tested and the
readings averaged
b. For all teeth tested, record the lowest average reading, the type
of testing device and conductor used, and any client actions or
reactions that may have affected the results
C. Variables affecting results
1. Pulpal conditions may vary from early inflammation to complete
necrosis; client responses vary with each condition; the pulp of the
tooth that is tested is considered to be degenerating when,
compared with a control, much more current is required to gain a
response
2. Metallic restorations conduct electrical charges more rapidly than
tooth structure and can produce false readings
3. Teeth with splints, bridges, or proximal restorations may produce
false-positive reactions because the circuit can be transferred from
adjacent vital teeth
4. Multi-rooted teeth may have some combination of vital and nonvital
canals and may give false-positive results
5. Pain reactions are influenced by the client’s attitude, age, gender,
anxiety, emotions, fatigue, culture, and medications

1383
Thermal Testing
A. Employs a hot or cold stimulus to test for pulpal response
B. The cold test is used most often
C. The heat test is useful when an unidentified tooth is heat sensitive

1384
Ethical, legal, and safety issues
A. Dental hygienists must have knowledge of evidence-based preventive
products and strategies to provide optimal care
B. A combination of frequent review of the literature; focus on
information from controlled clinical trials and systematic review articles;
the practitioner ’s knowledge, clinical experience, and judgment; and
client preferences leads to appropriate evidence-based decision making
and best practices
C. Thorough, accurate, and confidential chart documentation is essential;
adherence to the regulations of the Health Insurance Portability and
Accountability Act (HIPAA) is mandatory
D. The client’s progress with regard to self-care should be documented in
the client record and should include the client’s response, knowledge,
adherence, involvement, skills, and measurable oral changes
E. The dental hygienist should discuss all the procedures with clients on
an appropriate level for comprehension, obtain informed consent, and
encourage client participation in the dental hygiene care plan
F. Dental hygiene interventions are offered within the scope of dental
hygiene practice and within the legal jurisdiction of the employment
setting
G. Clients have the right to accept or reject the dental care plan and still
retain the respect of the dental hygienist
H. Clients have the right to receive individualized, cutting-edge,
evidence-based recommendations and care

Website Information and Resourc es

Source Website Address Description
National Center for Dental Hygiene http://www.usc.edu/hsc/dental/dhnet/ Dental hygienists’
Research resources and links
American Academy of http://www.perio.org Periodontics resources
Periodontology and position papers
Campaign for Tobacco Free Kids http://www.tobaccofreekids.org/index.php Information and
initiatives to keep kids
tobacco free
ADHA Ask. Advise. Refer. Campaign http://www.askadviserefer.org Information about
smoking cessation
American Lung Association— http://www.lungusa.org/ Information about lung
Freedom from Smoking diseases and tobacco
cessation

1385
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education: theory, research, and practice. ed 4 San Francisco: Jossey-
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4 Hollister M.C., Anema M.G. Health behavior models and oral
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19 Azarpazhooh A., Limeback H. Clinical efficacy of casein
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20 Fontana M., Gonzalez-Cabezas C. Xylitol lozenges were not
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30 Halpern A., Mancini M.C., Magalhães M.E., et al. Metabolic
syndrome, dyslipidemia, hypertension and type 2 diabetes in
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34 Vaghela D., Sinha A. Pulse oximetry and laser Doppler flowmetry
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Suggested readings
Harris N.O., Garcia-Godoy F. Primary preventive dentistry. ed 8
Upper Saddle River, NJ: Pearson Prentice Hall; 2013.
Kenneth M. A new treatment alternative for sensitive teeth: a
desensitizing oral rinse. J Dentistry. 2013;41(1):S1–S11.
Pockey J.R., Song E., Sutfin E.L., et al. The need for tobacco
cessation in a free clinic population. Addict Behav.
2012;37(12):1299–1302.
Schmidt B.L. Current topics in oral cancer research and oral cancer
screening. J Dent Hygiene. February 2012;86:7–8.
Wilkins E.M. Clinical practice of the dental hygienist. ed 11
Philadelphia: Lippincott Williams & Wilkins; 2013.
Yasuhiro N., Katsura S., Yuuji K., et al. Examination of denture-
cleaning methods based on the quantity of microorganisms
adhering to a denture. Gerodontology. 2012;29(2):e259–e266.

Chapter 16 review questions

Answers and rationales to chapter review questions are available on
this text’s accompanying Evolve site. See inside front cover for details.

1. Which behavior change theory stresses the importance of patient

autonomy in decision-making?
a. Human Needs Model
b. Trans-theoretical Model
c. Health Belief Model
d. Motivational Interviewing
2. Which of the following theory states that the client’s basic needs must
be met before they can be motivated to achieve higher-level needs, such
as purchase of a power toothbrush?
a. Health Belief
b. Maslow’s hierarchy of needs
c. Motivation theory
d. Trans-theoretical model
3. Ms. Murphy, 30 years old, presents to clinic with a chief complaint of

1389
bleeding gums when brushing. On probing, the dental hygienist notices
generalized calculus with 5-mm to 6-mm pocket depths. The dental
hygienist plans to perform four-quadrant scaling and root planing.
Performing scaling and root planing falls under which of the following
steps of the dental hygiene process of care?
a. Assessment
b. Planning
c. Implementation
d. Documentation
4. Which of the following products would you recommend for plaque
removal under a pontic to a client with severe rheumatoid arthritis?
a. End-tuft brush
b. Super-floss
c. Proxy brush
d. Waxed floss
5. All the following are risk factors for oral cancer EXCEPT one. Which
one is the exception?
a. HPV
b. Tobacco use
c. Alcohol use
d. Periodontitis
6. All the following interventions are aimed at the prevention of oral
cancer EXCEPT:
a. Oral cancer screening at each visit
b. Tobacco cessation counseling
c. Biofilm removal education
d. Nutritional counseling
7. A client with periodontal disease can benefit from using all the
following products EXCEPT:
a. Antimicrobial mouthrinse
b. Power toothbrush
c. Dentifrices with potassium nitrate
d. Interdental brush
8. For proper oral care, a toothbrush should be regularly disinfected and

1390
replaced every 3 months of use. Toothbrushes should be changed after a
cold, the flu, a mouth infection, or a sore throat.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
9. Which of the following ingredients in oral products helps in the
remineralization of a tooth surface?
a. Amorphous calcium phosphate
b. Casein phosphopeptide–amorphous calcium phosphate
c. Fluoride
d. All the above
10. All the following are TRUE statements about 5% fluoride varnish
EXCEPT:
a. Approved for caries control
b. Can be applied to teeth in both children and adults
c. Recommended for clients with high caries risk
d. Available over the counter for caries prevention
11. All the following mouthrinses can be recommended to clients with
periodontal disease EXCEPT:
a. 0.12% chlorhexidine gluconate
b. 0.05% sodium fluoride
c. Essential oils
d. Cetylpyridinium chloride
12. One of the main causes of oral malodor is plaque biofilm
accumulation on the dorsal surface of the tongue. Clients struggling to
control oral malodor should seek professional oral health care combined
with daily interdental cleaning, tongue brushing, and use of
antimicrobial mouthrinse.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
13. Which of the following is NOT a risk factor for root caries?

1391
 a. Dental recession
b. Xerostomia
c. Plaque biofilm
d. Diastema
14. Triclosan as an added ingredient to dentifrices falls under which of
the following categories?
a. Therapeutics
b. Humectants
c. Preservatives
d. Binding agents
15. All the following are risk factors for dental implants failure EXCEPT:
a. Tobacco use
b. Heavy plaque biofilm
c. Periodontal disease
d. Dental calculus
16. An individual can be in the “high-risk” or “low-risk” category for
development of dental caries. All the following factors are low-risk
factors in the development of dental caries for adults EXCEPT:
a. Normal salivary flow
b. Use of fluoride mouthrinse
c. Sealants in pits and fissures
d. Poor manual dexterity
17. Which of the following clients would be an ideal candidate for dental
sealants?
a. Client with periodontal disease
b. Client who uses fluoride
c. Client with incipient carious lesions
d. Client with habitual bruxism
18. Stimuli causes fluid movement within the dentinal tubule, exciting
the nerve and signaling the pulp to respond as dentin hypersensitivity.
Pain stimuli can only be thermal, such as hot or cold foods and liquids.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.

1392
 d. The first statement is FALSE; the second statement is TRUE.

Case A
Ms. McDonald, age 59, is a regular patient at the dental office. She has
been recently diagnosed with breast cancer and is scheduled to have
double mastectomy in 1 month. She takes valsartan (Diovan HCT) for
hypertension and naproxen for rheumatoid arthritis. She experiences dry
mouth and reports brushing twice daily with a soft toothbrush. She
states she knows she should floss more often, but only flosses
occasionally. Ms. McDonald has moderate levels of interproximal plaque
biofilm. She is missing teeth #1, #3, #14, #16, #17, and #32. She has
occlusal amalgam restorations on teeth #2, #29 and #3.

Use Case A to answer questions 19 to 23.

19. According to the Trans-theoretical model, what stage of change is
Ms. McDonald in with regard to flossing?
a. Precontemplation
b. Contemplation
c. Preparation
d. Action
20. How would you categorize Ms. McDonald’s caries risk assessment
after radiation therapy?
a. Low caries risk
b. Moderate caries
c. High caries risk
d. Severe caries risk
21. What American Society of Anesthesiologists (ASA) Physical Status
Classification is applicable to Ms. McDonald?
a. ASA I
b. ASA II
c. ASA III
d. ASA IV
22. What interdental device would the dental hygienist recommend to
Ms. McDonald?
a. Dental floss

1393
 b. Floss threader
c. Interdental brush
d. Toothbrush
23. Which of the following over-the-counter products can the dental
hygienist recommend to Ms. McDonald for remineralization of her
teeth?
a. Fluoride mouthrinse
b. Essential oil mouthrinse
c. 5% fluoride varnish
d. Dentifrices with triclosan
24. A client with high caries risk would manifest all the following
EXCEPT:
a. Moderate plaque biofilm
b. Xerostomia
c. Generalized restorations
d. Fluorosis
25. In addition to proper toothbrushing technique, daily use of all the
following may help a client with calculus prevention EXCEPT:
a. Dental floss
b. Dentifrice with triclosan
c. Fluoride mouthrinse
d. Antimicrobial mouthrinse
26. Clients with all the following conditions can benefit from daily use
of oral irrigation EXCEPT those with:
a. Osteoarthritis
b. Hypertension
c. Parkinson’s disease
d. Periodontal disease

Case B
Ms. Thompson, age 35, is a new patient who presents to clinic today. Her
health history reveals she is taking metformin for type 2 diabetes and
the anticonvulsant phenytoin for prevention of seizers. She smokes one-
half pack of cigarettes daily. Intraoral assessment reveals a coated
tongue; a white, asymptomatic, 3-mm lesion on the left lateral border of

1394
the tongue; generalized brown extrinsic stains covering most of the
lingual surfaces; moderate gingival hyperplasia; and light calculus
around the cervical third of premolars. Periodontal assessment reveals
generalized 6-mm probing depths with no recession. When asked about
the lesion on her tongue, Ms. Thompson states, “It has been there for at
least a month.”

Use Case B to answer questions 27 to 37.

27. Which of the following is contributing to Ms. Thompson’s gingival
hyperplasia?
a. Phenytoin
b. Plaque biofilm
c. Smoking
d. Both a and b
28. Which of the following may be signs of periodontal disease?
a. Bleeding on probing
b. Gram-negative anaerobic bacteria
c. Probing depths
d. All the above
29. Which of the following clinical examination methods should the
dental hygienist use when examining Ms Thompson’s tongue?
a. Probing and transillumination
b. Observation and palpation
c. Radiographs and exploration
d. Transillumination and palpation
30. What is MOST likely contributing to Ms. Thompson’s white spot
lesion on the tongue?
a. Phenytoin
b. Smoking
c. Plaque biofilm
d. Diabetes
31. State statutes do not permit the dental hygienist to perform biopsies.
How best can the dental hygienist deal with Ms. Thompson’s tongue
lesion?
a. Refer to oral pathologist for definite diagnosis

1395
 b. Leave the lesion alone, since it is asymptomatic
c. Use ViziLite for immediate diagnosis
d. Perform scalpel biopsy
32. Which of the following dentifrices can Ms. Thompson use for
whitening her teeth?
a. Dentifrice containing triclosan
b. Dentifrice with sodium fluoride
c. Dentifrice with potassium nitrate
d. Dentifrice with hydrogen peroxide
33. Ms. Thompson can benefit from all the following measures to
control her gingival hyperplasia EXCEPT:
a. Floss threader
b. Dentifrice with triclosan
c. Antimicrobial mouthrinse
d. Daily oral irrigation
34. When discussing maintenance of Ms. Thompson’s white smile, the
dental hygienist should include all the following EXCEPT:
a. Smoking cessation
b. Tooth-whitening methods
c. White spot lesion on the tongue
d. Desensitizing treatments
35. How best can the dental hygienist document 6 mm probing depths
using the American Academy of Periodontology (AAP) classification
system?
a. AAP Case Type I
b. AAP Case Type II
c. AAP Case Type III
d. AAP Case Type IV
36. Dental stains are classified as exogenous/endogenous and
extrinsic/intrinsic. Tobacco stains on Ms. Thompson’s teeth are
considered to be endogenous and intrinsic.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.

1396
 d. The first statement is FALSE; the second statement is TRUE.
37. Which of the following educational pamphlets will the dental
hygienist recommend to Ms. Thompson for prevention of oral cancer?
a. Risk of tobacco use
b. Oral self-examination
c. Management of nicotine addiction
d. All the above
38. Which of the following antimicrobial and antigingivitis agents is
known for its high substantivity?
a. Essential oils
b. Chlorhexidine gluconate
c. Cetylpyridinium chloride
d. Stannous fluoride
39. When evaluating gingival characteristics, how would the clinician
describe an enlarged gingival margin with the formation of a life saver–
like gingival prominence?
a. Coral pink
b. Festooned
c. Stippled
d. Firm
40. Both mutable and nonmutable risk factors for oral cancer can be
changed. Examples of mutable risk factor include smoking, sun
exposure, and high alcohol intake.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
41. Which of the following mouthrinses is available only as a
prescription?
a. 0.12% Chlorhexidine gluconate
b. 0.05% Sodium fluoride
c. Essential oils
d. Cetylpyridinium chloride
42. In which of the following toothbrushing methods are the toothbrush

1397
bristles placed on the attached gingiva and directed apically at 45-degree
angle to the long axis of the tooth?
a. Bass method
b. Charters’ method
c. Stillman’s method
d. Fones method
43. All the following are desirable characteristics of toothbrushes
EXCEPT:
a. Durable
b. Impervious to moisture
c. Flexible and soft
d. All the above
44. Clients with removable appliances should be educated on the proper
cleaning and storage of the oral appliance. Inadequate cleaning of oral
appliances can contribute to which of the following oral conditions?
a. Candida albicans infection
b. Amelogenesis imperfecta
c. Dental fluorosis
d. Fordyce granules
45. Which of the following is NOT a removable oral appliance?
a. Obturator
b. Partial denture
c. Dental implant
d. Mouthguard
46. Which of the following is a GOOD characteristic of professional
desensitizing agents?
a. Fast acting
b. Easy application
c. Nontoxic
d. All the above
47. What is the number-one reason for the failure of resin-based pit-and-
fissure dental sealants?
a. Incomplete dry tooth surface
b. Conditioning or etching

1398
 c. Glass ionomer cements
d. Photo-polymerization
48. All the following are therapeutic ingredients in dentifrices EXCEPT:
a. Amorphous calcium phosphate
b. Triclosan
c. Sodium fluoride
d. Sodium laurel sulfate
49. All the following dentifrice ingredients would help control calculus
formation EXCEPT:
a. Zinc citrate
b. Pyrophosphate
c. Triclosan
d. Potassium citrate
50. All the following types of dentifrices will be beneficial for a client
with generalized demineralization EXCEPT:
a. Stannous fluoride
b. Carbamide peroxide
c. Amorphous calcium phosphate
d. Sodium fluoride
51. Which one of the following statements is FALSE when
recommending the use of oral irrigation systems?
a. Improves gingival bleeding
b. Reduces pocket depths
c. Replaces dental floss
d. Removes loose biofilm

*M. Anjum Shah and the publisher acknowledge the past contributions of Catherine
Mary Dean and Jacquelyn L. Fried to this chapter.

1399
C HAPT E R
17

1400
Periodontal Instrumentation for
Assessment and Care
Jill S. Gehrig; Rebecca A. Sroda

This chapter focuses on the use of periodontal instruments for

assessment and nonsurgical periodontal instrumentation. The primary
objective of nonsurgical periodontal instrumentation is to restore
periodontal tissue to health by removing plaque biofilm, its byproducts,
and biofilm-retentive factors from tooth surfaces and from within the
tooth pocket space. Successful professional care depends on reducing
biofilm to a level that is acceptable to the tissue; therefore, instructing
and supervising the client’s daily self-care precedes, continues with, and
follows instrumentation by the dental hygiene practitioner.

1401
Instrument design
Parts of an Instrument
A. Handle—the part of a periodontal instrument that the clinician holds;
various shapes, weights, sizes, and surface serrations (smooth, ribbed, or
knurled) exist
1. Types
a. Single-ended—one working end
b. Double-ended—two working ends; working ends may be
unpaired (dissimilar working ends) or paired (mirror-image
working ends)
2. Handle design characteristics
a. Small-diameter ( -inch) handles, with smooth or flat texture,
decrease the user ’s control and increase muscle fatigue
b. Large-diameter (⅜-inch) handles that are lightweight and have
bumpy texturing maximize the user ’s control and reduce muscle
fatigue
B. Shank—connects the working end with the handle; usually bent in one
or more places to facilitate placement of the working end against the
tooth surface
1. Functional shank—the part of the shank that allows the working end
to be adapted to the tooth surface; begins below the working end
and extends to the last bend in the shank nearest the handle
a. Instruments with short functional shanks are used on teeth
crowns
b. Instruments with long functional shanks are used on both the
crown and the root (Fig. 17-1)

1402
 FIG 17-1 Functional shank and lower (terminal) shank. (From Nield-
Gehrig JS: Fundamentals of periodontal instrumentation and advanced root
instrumentation, ed 6, Philadelphia, 2013, Lippincott Williams & Wilkins.)

2. Lower (terminal) shank—the bent portion of the functional shank

nearest to the working end (Fig. 17-1)
3. Extended lower shank—3 mm longer than a standard lower shank;
provides additional leverage, acting as a fulcrum, and is ideal for
working in deep periodontal pockets
4. Simple shank—bent in one plane (front to back); used primarily on
anterior teeth; also called a straight shank
5. Complex shank—bent in two planes (front to back and side to side)
to facilitate instrumentation of posterior teeth; this design is
necessary to reach around the crown and onto the root surface; also
called an angled shank or curved shank
C. Working end—the part of the dental instrument that contacts the
tooth (explorer, curet) or soft tissue (probe) to perform the work of the

1403
instrument; begins where the instrument shank ends; an instrument may
have one or two working ends
1. Parts of the working end—identified as the face, back, lateral
surfaces, toe, and tip; on a hand-activated periodontal instrument, a
cutting edge is formed by the union of a lateral surface and the face
of the working end
2. Application of the working end—the tooth surfaces or areas of the
mouth on which an instrument can be used
a. Anterior use—one single-ended instrument (e.g., anterior sickle
scaler, such as a Jacquette 33) can be used to perform
procedures on the facial, lingual, mesial, and distal surfaces of
anterior teeth
b. Posterior use—one double-ended instrument (e.g., posterior
sickle scaler, such as a Jacquette 34/35) can be used to perform
procedures on the facial, lingual, mesial, and distal surfaces of
posterior teeth
c. Universal use—one double-ended instrument (e.g., universal
curet, such as a Columbia 13/14) can be used to perform
procedures on both anterior and posterior teeth
d. Area-specific use—an instrument that can be applied only to
specific surfaces and areas of the mouth; a set of area-specific
instruments (e.g., area-specific curets, such as the Gracey series)
is needed for procedures on the entire dentition
3. Function of the working end
a. Assessment of teeth, soft tissue, or both
b. Instrumentation of tooth surfaces (the removal or disruption of
calculus deposits and plaque biofilm)

Design Characteristics
A. Instrument balance—a balanced instrument has working ends that
are aligned with the long axis of the handle
1. During a work stroke—for example, in calculus removal; balance
ensures that finger pressure applied against the handle is
transferred to the working end, which results in pressure against the
tooth
2. An instrument that is not balanced is more difficult to use and
increases stress on the muscles of the user ’s hand and arm
B. Instrument identification—the unique design name and number that
identify each periodontal instrument
1. Design name—identifies the school or individual responsible for the

1404
 original design or development of an instrument or group of
instruments (e.g., ODU 11/12 periodontal explorer, in which the
ODU stands for Old Dominion University; and the TU-17, in which
TU stands for Tufts University School of Dental Medicine)
2. Design number—the number designation of the working end that,
when combined with the design name, provides the exact
identification of the working end (e.g., Gracey 11, in which Gracey is
the design name, and 11 is the design number)
3. Identification of the working ends of a double-ended instrument—a
double-ended instrument will have two design numbers, one
number for each working end of the instrument
a. If the design name and number are stamped along the length of
the handle, each working end is identified by the number
closest to it
b. If the design name and number are stamped across the handle,
the first number identifies the working end at the top of the
handle, and the second number identifies the working end at
the bottom

1405
Hand-activated instruments
Classifications
A. Hand-activated nonsurgical periodontal instruments are classified as
periodontal probes, explorers, sickle scalers, periodontal files, universal
curets (or curettes), and area-specific curets (Table 17-1); hoes and chisels
are rarely used because their functions have been largely replaced by
ultrasonic and sonic devices

Table 17-1
Use of Hand-Activated Instruments

Classification Purpose
Calibrated Measurement of pocket depths, clinical attachment level, width of attached
probe gingiva, gingival recession, and intraoral lesions; evaluation of gingival tissue for
consistency and presence of bleeding or exudate
Furcation Detection of furcation involvement in multi-rooted teeth
probe
Explorer Detection of calculus deposits, tooth surface irregularities, defective margins on
restorations
Sickle scaler Removal of medium-sized to large-sized calculus deposits from enamel surfaces;
provides good access to the proximal surfaces on anterior crowns and the enamel
surfaces apical to the contact areas of posterior teeth; should NOT be used on
cementum
Periodontal Used to crush large calculus deposits and prepare burnished calculus before
file removal with another instrument; should NOT be used directly on cemental
surfaces
Universal Instrumentation of crown and root surfaces; removal of light to medium-sized
curet supragingival and subgingival calculus deposits; some designs have long functional
shanks that allow access to the cervical and middle thirds of root surfaces
Area-specific Instrumentation of crown and root surfaces; removal of light supragingival and
curet subgingival calculus deposits; some designs have extended shanks that allow
access to the middle and apical thirds of root surfaces
From Nield-Gehrig JS: Fundamentals of periodontal instrumentation and advanced root instrumentation, ed 6,
Philadelphia, 2013, Lippincott Williams & Wilkins.

B. Periodontal instruments are divided into classifications based on the

specific design characteristics of the working end
1. Design of the cutting edges, back, lateral surfaces, and shank
2. Cross section of the working end
3. Relationship of the face to the lower shank
C. In selecting an instrument for a specific task, one of the most
important considerations is the classification of the working end

1406
Dental Mirror
A. Characteristics
1. The working end has a reflecting (mirrored) surface
2. Types
a. Front surface—the reflecting surface is on the front surface of
the glass; produces a clear mirror image with no distortion
b. Concave—the reflecting surface is on the front surface of the
mirror lens; produces a magnified but slightly distorted image
c. Plane—the reflecting surface is on the back surface of the mirror
lens; this type of surface is less easily scratched than a front
surface mirror and produces a double or “ghost” image
B. Uses
1. Indirect vision—the mirror ’s reflecting surface provides a view of the
tooth surface or intraoral structure that cannot be seen directly
2. Retraction—using the mirror to hold the client’s cheek or tongue to
view tooth surfaces or other structures that are otherwise hidden by
the cheeks or tongue
3. Indirect illumination—reflecting light from the mirrored surface
into a dark area of the mouth
4. Transillumination—reflecting light from the mirrored surface
through anterior teeth

Probe
A. Characteristics
1. Assessment instrument that is used to evaluate the health of
periodontal tissue
2. Two types: calibrated and furcation probes
B. Types
1. Calibrated probe (e.g., Williams, PSR screening probe) has a slender,
rod-shaped, blunt working end marked in millimeter increments;
can be used as a miniature ruler for making intraoral measurements,
such as for measuring sulcus and pocket depths, clinical attachment
levels, width of attached gingiva, or the size of oral lesions; also used
to assess for the presence of bleeding or purulent exudate (pus)
2. Furcation probe (e.g., Nabers 1 N) is a curved, blunt-tipped
instrument used to detect and assess bone loss in the furcation areas
of bifurcated and trifurcated teeth
C. Calibrations—millimeter marks at intervals that are specific for each
probe design
1. Calibrated probes

1407
 a. Probe designs may differ in millimeter markings (Table 17-2);
only certain millimeter increments may be indicated on the
probe (e.g., 1—2—3—5—7—8—9—10 mm), or each millimeter
may be indicated (e.g., 1—2—3—4—5—6—7—8—9—10—11—12
—13—14—15 mm)

Table 17-2
Examples of Probe Markings

Type Marking Pattern Increments (mm)

UNC15 All mm marked 1 to 15
Glickman 26G No mark at 6 mm 1–2–3–5–7–8–9–10
Goldman Fox No mark at 6 mm 1–2–3–5–7–8–9–10
Merritt No mark at 6 mm 1–2–3–5–7–8–9–10
Williams No mark at 6 mm 1–2–3–5–7–8–9–10
Maryland No mark at 6 mm; ball-end 1–2–3–5–7–8–9–10
Moffitt
Michigan “O” Marks at 3, 6, and 8 mm 3–6–8
PSR Colored band from 3.5–5.5; marks at 8.5 and 3.5–5.5–8.5–11.5
Screening 11.5 mm; ball end
CP-18 Colored bands from 3–5 and 8–10 3–5–8–10
CP-11 Colored bands from 3–6 and 8–11 3–6–8–11
CP-12 Colored bands from 3–6 and 9–12 3–6–9–12
Hu-Friedy Right-angled probe; available in a wide variety Available in various
Novatech of designs increments
From Nield-Gehrig JS: Fundamentals of periodontal instrumentation and advanced root instrumentation,
ed 6, Philadelphia, 2013, Lippincott Williams & Wilkins.

b. Color-coded probes are marked in bands (often black), with

each band being several millimeters in width (e.g., 3 to 5 mm
and 8 to 10 mm)
2. Furcation probes
a. Most furcation probes do not have millimeter markings
b. Some furcation probes are marked in bands (usually black),
with each band being several millimeters in width (e.g., 3 to
6 mm and 6 to 9 mm); these probes usually are used in research
investigations to facilitate investigators’ calibration

Explorer
A. Characteristics
1. Assessment instrument with a fine, flexible wire-like working end
2. Provides the best tactile information to the clinician’s fingers; used
to locate calculus deposits, tooth surface irregularities, and defective
margins on restorations

1408
B. Design (Fig. 17-2)

FIG 17-2 Design characteristics of a dental explorer. (From Nield-Gehrig JS:

Fundamentals of periodontal instrumentation and advanced root instrumentation, ed 6,
Philadelphia, 2013, Lippincott Williams & Wilkins.)

1. The working end is 1 to 2 mm in length and is referred to as the tip;

the side of the tip, rather than the actual point, is used for detecting
calculus
2. Circular in cross section, the explorer may have paired or unpaired
working ends
C. Types—available in a variety of design types; not all design types are
well suited to subgingival use; therefore, the clinician must be
knowledgeable about the recommended use of each design type
1. Shepherd hook (e.g., #23 and #54 explorers)—an unpaired explorer
with a short, highly curved shank and a sharp point; used for

1409
 supragingival examinations to detect irregular margins of
restorations; not recommended for calculus detection because
subgingival use could result in tissue trauma
2. Straight explorer (e.g., 6, 6A, 6 L, 6XL)—an unpaired explorer with a
short lower shank and a sharp point; used for examinations to detect
irregular margins of restorations; not recommended for subgingival
calculus detection
3. Curved explorer (e.g., 3, 3A)—an unpaired explorer with a curved
shank and a sharp point; limited for use in examining normal sulci
or shallow pockets; may be used for calculus detection; however, care
must be taken not to injure the junctional epithelium when the
working end is used subgingivally
4. Orban-type explorer (e.g., TU-17, Orban 20)—an unpaired explorer
with a straight lower shank that can be used in deep pockets with
only slight tissue displacement (stretching of the tissue wall away
from the tooth); the explorer tip is bent at a 90-degree angle to the
terminal shank, which allows the back of the tip (instead of the
point) to be directed toward the junctional epithelium; useful for
detecting subgingival calculus on anterior teeth or on the facial and
lingual surfaces of posterior teeth; however, the straight lower shank
makes it difficult to adapt to the line angles and proximal surfaces of
posterior teeth
5. Pigtail or cowhorn explorer (e.g., 3MI, 3CH, 2A)—a paired universal
explorer with a short, broadly curved lower shank and a sharp point;
the curved lower shank causes considerable tissue displacement;
useful for detecting calculus in normal sulci or shallow pockets
extending no deeper than the cervical third of the root
6. The 11/12-type explorer (e.g., ODU 11/12, 11/12 AF)—a paired
universal explorer with an extended lower shank and a tip that is
bent at a 90-degree angle to the terminal shank; the tip design allows
the back of the tip to be applied to the pocket base without
lacerating the junctional epithelium; this effective explorer design
adapts well to all surfaces throughout the mouth and is equally
useful when exploring a shallow sulcus or a deep periodontal pocket

Sickle Scaler
A. Characteristics
1. Calculus removal instrument; limited for use on enamel surfaces
2. Anterior and posterior designs
B. Design (Fig. 17-3)

1410
 FIG 17-3 Design characteristics of a sickle scaler, consisting of two-level
cutting edges that meet in a point and an instrument face that is at a 90-degree
angle to the lower shank. (From Nield-Gehrig JS: Fundamentals of periodontal
instrumentation and advanced root instrumentation, ed 6, Philadelphia, 2013, Lippincott
Williams & Wilkins.)

1. Cutting edges—two cutting edges that meet in a point

2. Back—sharp, pointed back; some types of scalers are made with
flattened backs
3. Cross section—triangular; lateral surfaces meet the instrument face
at an internal angle between 70 and 80 degrees
4. Face—perpendicular to the lower shank so that the cutting edges are
level with each other; level cutting edges require that the lower
shank be tilted slightly toward the tooth surface to establish correct
angulation
5. The anterior sickle scaler has an unpaired working end and a simple
shank; primarily used on anterior teeth (e.g., Jacquette 33)
6. The posterior sickle scaler has paired working ends, with complex
shanks; primarily used on posterior teeth but may be used on
anterior teeth (e.g., Jacquette 34/35)
C. Uses
1. Removal of medium-sized to large calculus deposits from enamel
tooth surfaces
2. Provides good access to the proximal surfaces on anterior crowns
and to the enamel surfaces apical to the contact areas of posterior
teeth
D. Limitations
1. The pointed tip and the straight cutting edges do not adapt well to

1411
 rounded root surfaces and concavities
2. The pointed back is not suited to subgingival use (may injure the
junctional epithelium)

Periodontal File
A. Characteristics
1. Calculus removal instrument used to prepare calculus deposits
before removal with another instrument
2. Anterior and posterior designs
B. Design
1. Cutting edges—multiple cutting edges at a 90- to 105-degree angle to
the lower shank
2. Working end—thin in width with a large circumference at the base;
the base may be round, oval, or rectangular in shape
3. Area-specific application—each working end is designed for use on a
single surface (four working ends are needed for procedures on all
tooth surfaces); files with simple shanks work best on anterior teeth;
those with complex shanks work best on posterior teeth
C. Uses
1. Preparation of burnished calculus deposit (a deposit with a smooth
outer surface) before definitive removal of the deposit with a curet; a
file is used to scratch the surface of a burnished deposit so that it
can be removed with another instrument
2. Crushing of a large calculus deposit; once a deposit has been
crushed with a file, it is easier to remove with a curet
3. Smoothing overextended or rough amalgam restoration in sites
where the file can be effectively adapted
D. Limitations
1. Limited to use on enamel surfaces or to applications on the outer
surface of a calculus deposit; gouging could result if a file is used on
root surfaces
2. The working ends have straight cutting edges on a flat base; do not
adapt well to curved tooth surfaces

Universal Curet
A. Characteristics
1. One of the most frequently used and versatile of all the instruments
for calculus removal
2. Used both supragingivally and subgingivally; two curets usually are

1412
 paired on a double-ended instrument (the paired working ends are
mirror images of each other)
B. Design (Fig. 17-4)

FIG 17-4 Design characteristics of a universal curet, consisting of two-level

cutting edges and an instrument face that is at a 90-degree angle to the lower
shank. (From Nield-Gehrig JS: Fundamentals of periodontal instrumentation and advanced
root instrumentation, ed 6, Philadelphia, 2013, Lippincott Williams & Wilkins.)

1. Cutting edges—two cutting edges that converge in a rounded toe

2. Back—the rounded back is ideal for subgingival use
3. Cross section—semi-circular; lateral surfaces meet the instrument
face at an internal angle between 70 and 80 degrees
4. Face—perpendicular to the lower shank so that the cutting edges are
level with each other; the level cutting edges require that the lower
shank be tilted slightly toward the tooth surface to establish correct
angulation
5. Universal use—one double-ended instrument can be applied to all
tooth surfaces in the anterior and posterior regions of the mouth
C. Uses
1. Calculus removal from crown and root surfaces
2. Removal of small to medium-sized calculus deposits
D. Limitations
1. The toe is wider than a pointed tip and therefore may be more
difficult to adapt for use beneath the contact areas of anterior teeth
2. The level cutting edges require that the lower shank be tilted slightly
toward the tooth for correct angulation

1413
Area-Specific Curet
A. Characteristics
1. Calculus removal instrument with one cutting edge (only one cutting
edge per working end is used for procedures); a set of curets is
needed to perform procedures throughout the mouth
2. The curet is used supragingivally and subgingivally; especially well
suited for instrumentation of roots within periodontal pockets
3. Designs include area-specific curets with flexible and rigid shanks
B. Design (Fig. 17-5)

FIG 17-5 Design characteristics of an area-specific curet, consisting of one

cutting edge, an instrument face at a 70-degree angle to the lower shank, and
one cutting edge positioned lower than the other, nonworking cutting edge.
(From Nield-Gehrig JS: Fundamentals of periodontal instrumentation and advanced root
instrumentation, ed 6, Philadelphia, 2013, Lippincott Williams & Wilkins.)

1. Cutting edge—one working cutting edge per working end; only the
lower, longer cutting edge is used
2. Back—rounded back; ideal for subgingival use
3. Cross section—semi-circular; the lateral surfaces meet the
instrument face at an internal angle between 70 and 80 degrees
4. Face—tilted at a 60- to 70-degree angle in relation to the lower shank,
making one cutting edge (the working cutting edge) lower than the
other; this tilted relationship makes the working cutting edge “self-
angulated”; that is, when the lower shank is parallel to the tooth
surface, the cutting edge is at the correct angulation
5. Area-specific use—each working end is limited to use only on

1414
 certain teeth and on certain surfaces
C. Uses
1. Instrumentation of crown and root surfaces
2. Removal of small deposits of calculus and biofilm
D. Limitations
1. The toe is wider than a pointed tip and is therefore more difficult to
adapt to the proximal surfaces of anterior crowns
2. A single working cutting edge per working end means exchanging
instruments more frequently

Advanced Root Instrumentation

A. Characteristics
1. The treatment of clients with periodontitis requires specialized
instruments with longer shank lengths and miniature working ends
for instrumentation of root concavities and furcation areas
2. Designs include area-specific curets with miniature working ends,
extended shanks, flexible and rigid shanks, and diamond-coated
working ends
B. Examples of advanced periodontal instruments—a variety of
periodontal instruments have been developed to increase treatment
effectiveness on root surfaces within deep periodontal pockets
1. The 11/12-type periodontal explorer—an 11/12 AF (After Five)
explorer has an extended shank and is ideal for use in deep
periodontal pockets
2. Advanced curet designs—several curets are ideal for
instrumentation within deep periodontal pockets
a. Vision Curvette curet series—have a working end that is
shortened to half the length of a standard Gracey curet, a curved
working end, and an extended lower shank
b. Modified Gracey curets
(1) Several varieties of modified Gracey curets—include
modified Gracey curets with extended shanks, miniature
Gracey curets, and micro Gracey curets
(2) Design features for modified Gracey curets—include
extended lower shank length, thinner working ends, and
working ends that are shorter in length than in a standard
Gracey curet
c. Quétin (kee′-tan) furcation curets—specialized instruments that
are used to debride furcation areas and root concavities; each
miniature working end has a single, straight cutting edge with

1415
 rounded corners; the working ends are available in either 0.9-
mm or 1.3-mm size
d. O’Hehir debridement curets—area-specific curets that are
designed to remove light residual calculus deposits and
bacterial contaminants from root surfaces
(1) The working end of an O’Hehir curet is a tiny circular disc;
the entire working end is a cutting edge; the working end
curves into the tooth for easy adaptation in furcation areas
and developmental grooves
(2) These curets have extended lower shanks
e. Instruments with diamond-coated working ends
(1) The working ends of these instruments do not have cutting
edges; instead, they are coated with a very fine diamond
grit; for example, a version of the Nabers furcation probes
is diamond coated
(2) Diamond-coated instruments can be used to remove light,
residual calculus deposits
(3) Because of the abrasive nature of their working ends, these
instruments should be used with light, even pressure
against the root surface to avoid gouging or grooving

1416
Principles of instrumentation
Position of the Clinician
A. Neutral, seated position (Fig. 17-6)

FIG 17-6 Neutral seated position for the clinician. (From Nield-Gehrig JS:
Fundamentals of periodontal instrumentation and advanced root instrumentation, ed 6,
Philadelphia, 2013, Lippincott Williams & Wilkins.)

1. Head—tilt of 0 to 15 degrees
2. Shoulders—in a horizontal line
3. Back—straight or leaning forward slightly from the waist or hips
4. Thighs—hips slightly higher than the knees
5. Upper arms—parallel to the long axis of the torso
6. Elbows—at waist level; held slightly away from body
7. Forearms—parallel to the floor; raised or lowered, if necessary, by

1417
 pivoting at the elbow joint rather than by raising the elbows
8. Feet—seat height should be positioned low enough so that the heels
of the feet can rest on the floor
B. Relationship to the client and the dental unit
1. The client’s chair should be positioned such that the tip of the
client’s nose is at a level slightly lower than clinician’s elbows;
clinician should not have to raise the elbows above his or her waist
level to reach the client’s mouth; lower arms should be in a
horizontal position or raised slightly so that the angle formed
between the lower and upper arm is slightly less than 90 degrees
2. All instruments and equipment should be positioned within easy
reach of the clinician

Stabilization During Instrumentation

A. Modified pen grasp—the recommended grasp for holding a
periodontal instrument that allows precise control of the working end;
precise placement of the fingers in the modified pen grasp is important
to be successful in instrumentation technique
1. Finger placement and function (Fig. 17-7)

1418
 FIG 17-7 Finger placement in the modified pen grasp. The index finger
and the thumb hold the instrument handle. The middle finger rests on the
instrument shank. The ring finger acts as a support for the hand and
instrument. (From Nield-Gehrig JS: Fundamentals of periodontal instrumentation
and advanced root instrumentation, ed 6, Philadelphia, 2013, Lippincott Williams &
Wilkins.)

a. Index finger and thumb—finger pads hold the instrument

handle
b. Middle finger—the side of the finger pad rests on the
instrument’s shank; the clinician’s fingers should be able to feel
the vibrations in the instrument’s shank as the working end
encounters roughness on the tooth surface
c. Ring finger—fingertip rests on a stable surface, usually the
occlusal or incisal tooth surface, which stabilizes the hand for
control and strength
2. Technique
a. A light grasp is needed for increased tactile sensitivity during

1419
 assessment procedures (e.g., subgingival use of explorer or
probe)
b. A firm grasp is used with hand-activated instruments during
calculus removal
3. Glove fit—proper fit of sterile gloves is important in avoiding muscle
strain during instrumentation
a. Select right-hand and left-hand fitted gloves rather than
ambidextrous gloves
b. Select gloves that come in a range of numbered sizes (e.g., 5½, 6,
6½) rather than those marked in size ranges of small, medium,
and large
B. Fulcrum and finger rest
1. Definitions
a. Fulcrum—the point of support on which the clinician rests the
hand; used to stabilize the clinician’s hand during
instrumentation; the pad of the ring finger serves as the fulcrum
finger during instrumentation to control stroke pressure and
length
b. Finger rest—the place where the fulcrum finger rests during
instrumentation
2. Types of fulcrums
a. Basic intraoral fulcrum
(1) The finger rest is placed on a tooth, close to the tooth
being worked on; should not be positioned in the line of the
instrument’s stroke to prevent instrument stick
(2) The intraoral fulcrum is considered the most desirable
because it provides the greatest stability and strength for
calculus removal
b. Basic extraoral fulcrum—placed outside the client’s mouth,
usually on the chin or cheek
c. Advanced fulcrums—variations of the basic fulcrum that may be
required for access to posterior teeth or root surfaces within
periodontal pockets; advanced fulcrums require greater skill and
stroke control than the basic intraoral fulcrum
3. Advanced fulcrum techniques
a. Piggybacked—intraoral fulcrum in which the middle finger is
stacked on top of the ring finger
b. Cross-arch—intraoral fulcrum in which the finger rests on the
side of the mouth opposite the treatment area (treatment area is
mandibular right quadrant, finger rest on mandibular left
quadrant)

1420
 c. Opposite arch—intraoral fulcrum in which the finger rests on
the arch opposite to the treatment area (treatment area on
mandibular arch, finger rest on maxillary arch)
d. Finger-on-finger—intraoral fulcrum in which the finger of the
nondominant hand serves as the resting point for the ring finger
of the dominant hand
e. Stabilized—intraoral or extraoral fulcrum in which a finger of
the nondominant hand is used to concentrate lateral pressure
against the tooth surface and to help control the instrument
stroke

Adaptation
A. Definition—positioning the first 1 or 2 mm of the lateral surface of the
instrument’s working end in contact with the tooth surface
B. Characteristics
1. Explorer—the first few millimeters of the tip (not the point) are
adapted to the tooth surface for calculus detection
2. Probe—the side of the probe tip is maintained against the tooth
surface, with the length of the probe almost parallel to the tooth
surface being probed
3. Sickles and curets—the leading one third of the cutting edge is
positioned to conform to the tooth surface

Angulation
A. Definition—the relationship between the instrument face and the
tooth surface to which the working end is applied
B. Principles
1. For insertion beneath the gingival margin—the face-to-tooth surface
angulation is between 0 and 40 degrees
2. For calculus removal—the face-to-tooth surface angulation is
between 45 and 90 degrees; a 60-degree angulation works well for
biofilm removal, whereas a 70- to 80-degree angulation is ideal for
calculus removal (Fig. 17-8)

1421
 FIG 17-8 Angulation for calculus removal should be between 45 and 90
degrees. An angulation between 60 and 80 degrees is ideal for calculus
removal. (From Nield-Gehrig JS: Fundamentals of periodontal instrumentation and
advanced root instrumentation, ed 6, Philadelphia, 2013, Lippincott Williams &
Wilkins.)

Activation
A. Definition—moving an instrument to produce a stroke; it is the action
of an instrument in the performance of the task for which it was designed
B. Types
1. Hand-forearm activation
a. Made by rotating the hand and forearm as a unit to provide the
power for the instrumentation stroke; similar to the action of
turning a doorknob
b. Uses the power of the hand and arm to move the instrument;
recommended for calculus removal with hand-activated
instruments
2. Digital (finger) activation
a. Created by flexing the thumb, index, and middle fingers to
move the instrument
b. Used whenever physical strength is not required during a task,
such as when using ultrasonic or sonic instruments, probes, and
explorers
C. Stabilization and lateral pressure
1. Definitions

1422
 a. Stabilization—preparing for an instrument’s stroke by locking
the joints of the ring finger and pressing the fingertip against
the tooth surface to provide control for the stroke
b. Lateral pressure—applying pressure equally with the index
finger and the thumb inward against the instrument’s handle to
engage the working end apical to a calculus deposit before and
throughout a calculus removal or assessment stroke
2. Stroke pressure
a. Pressure during stroke activation—stroke pressure is applied in
a coronal direction; the pressure ranges from light to firm,
depending on the amount of pressure needed for the particular
task (e.g., assessment, calculus removal)
b. Pressure between strokes—finger muscles should be relaxed as
the working end is repositioned, using light stroke pressure
D. Maintaining adaptation during stroke production
1. Hand pivot—turning the hand and arm slightly while resting on the
fulcrum to maintain adaptation; used when moving around line
angles and onto proximal surfaces
2. Handle roll—rolling the instrument handle slightly between the
thumb and the index finger to maintain adaptation as the
instrumentation strokes advance around the tooth surface; either the
thumb or the index finger is used to roll the instrument
E. Neutral wrist position—correct wrist position is important to avoid
muscle discomfort and injury during the procedure; the wrist should be
aligned with the long axis of the forearm; bending the wrist up, down, or
to the side should be avoided

Instrumentation Strokes
A. Types of strokes
1. Assessment strokes—used to evaluate a subgingival root surface or
the health of periodontal tissue
a. Used with probes, explorers, curets
b. Angulation—50 to 70 degrees
c. Lateral pressure—in contact with the tooth surface; light
pressure
d. Character—fluid strokes of moderate length
e. Number—many strokes used to cover the entire root surface
2. Work strokes for calculus removal
a. Used with hand-activated sickle scalers, curets, and files
b. Angulation—70 to 80 degrees

1423
 c. Lateral pressure—moderate to firm
d. Character—powerful strokes; short in length
e. Number—the number of strokes should be limited to the areas
where needed
3. Work strokes for removal of residual calculus deposits and biofilm
removal
a. Used with hand-activated curets
b. Angulation—60 to 70 degrees
c. Lateral pressure—light to moderate
d. Character—lighter strokes of moderate length
e. Number—many strokes used to cover the entire root surface
B. Stroke direction
1. Vertical—parallel to the long axis of the tooth; used on facial, lingual,
and proximal surfaces of anterior teeth and on the mesial and distal
surfaces of posterior teeth
2. Oblique—diagonal to the long axis of the tooth; used most often on
facial and lingual surfaces
3. Horizontal—perpendicular to the long axis of the tooth; used at the
line angles of posterior teeth, furcation crotch areas, and within
pockets that are too narrow to allow vertical or oblique strokes
4. Multi-directional—a combination of vertical, oblique, and horizontal
strokes, one by one, used in succession on of a subgingival tooth
surface
C. Stroke characteristics
1. Length—short, powerful stroke for calculus removal; longer, lighter
stroke for removal of residual calculus deposits and biofilm
2. Overlap—strokes should overlap to ensure complete coverage; long
ridges of calculus are treated in sections, in overlapping scaling
zones
3. Pattern
a. Large calculus deposits should be removed in sections with a
series of short, firm strokes
(1) A calculus deposit should not be removed in layers
because removing the outermost layer will leave the deposit
with a smooth surface (burnished surface)
(2) A burnished calculus deposit may be indistinguishable
(when explored) from the tooth surface
b. For subgingival instrumentation, it is helpful to imagine that
the root surface is divided into a series of narrow, diagonal
instrumentation zones
(1) Each instrumentation zone is only as wide as the toe-third

1424
 of the cutting edge
(2) Deposits are removed in each zone, from the junctional
epithelium to the gingival margin, before progressing to the
next zone

1425
Steps for calculus removal with hand-
activated instruments
A. Position the dental mirror, and establish a finger rest
B. Grasp the instrument in a modified pen grasp
C. Establish a finger rest
1. Locate the finger rest near the site of instrumentation in the dental
arch; precise control of the instrument’s stroke becomes more
difficult as the finger rest is moved farther away from the site of the
procedure
2. Select the correct working end of the instrument
D. Adjust the hand-wrist-forearm as a unit
1. Position the thumb and the index finger across from each other on
the instrument handle, near the junction of the handle and shank
2. Lightly rest one side of the middle finger pad on the instrument
shank
3. Place the other side of the middle finger pad against the ring finger
to allow the hand to function as a unit during the production of the
stroke
4. Balance the tip of the ring finger on an occlusal or an incisal surface
to support the weight of the hand and instrument
5. Position the wrist in a neutral position so that it is aligned with the
long axis of the forearm (Fig. 17-9)

FIG 17-9 Neutral wrist position. The wrist should be aligned with the long
axis of the forearm. (From Nield-Gehrig JS: Fundamentals of periodontal
instrumentation and advanced root instrumentation, ed 6, Philadelphia, 2013,
Lippincott Williams & Wilkins.)

E. Adapt the cutting edge

1426
 1. If working subgingivally, close the face of the working end toward
the tooth, and slide the working end to the junctional epithelium;
use a light grasp while positioning the working end
2. Adapt the toe-third of the cutting edge to the tooth surface just
apical to the deposit
3. Establish the instrument face-to-tooth surface angulation of 70 and
80 degrees
4. Fine-tune the grasp and the wrist position
F. Stabilize the grasp, and apply lateral pressure
1. Press down with the ring finger against the finger rest
2. Apply pressure against the instrument handle with the index finger
and the thumb
G. Activate a pulling stroke away from the junctional epithelium
1. Use hand-forearm activation for strength and control
2. Activate instrumentation strokes in a coronal direction to prevent
particles of calculus from being pushed into soft tissue
3. Use vertical and oblique strokes in most areas; supplement these
strokes with horizontal strokes, as needed
4. Use short, powerful strokes for calculus removal and longer, lighter
strokes for removal of residual calculus deposits and biofilm
5. Use overlapping strokes to ensure complete coverage of the entire
root surface
H. Pause briefly at the end of a stroke
1. Relax the grasp, the finger rest, and the lateral pressure
2. Use a relaxed grasp to reposition the working end of the instrument
for the next stroke
I. Check the instrumentation area frequently with an explorer

1427
Instrumentation for assessment
Basic Concepts
A. Thorough assessment involves examining all aspects of the
periodontium and teeth
B. Client preparation, based on information from the personal,
comprehensive health and dental histories, is essential for safe
instrumentation
C. Successful treatment depends on well-developed assessment skills,
before instrumentation for dental hygiene care planning and during and
after instrumentation for evaluating treatment outcomes

Assessments with Periodontal Probes

A. Purposes of the periodontal examination
1. Aid in planning dental hygiene care by determining gingival
characteristics, probing depth, level of attachment, and presence of
bone loss
2. Determine the extent of inflammation in conjunction with the
probing depth and attachment level; bleeding resulting from
probing is an early clinical sign of inflammation (Fig. 17-10)

1428
 FIG 17-10 Assessment for the presence of bleeding. Bleeding on probing
is an early clinical sign of inflammation. (From Nield-Gehrig JS: Fundamentals
of periodontal instrumentation and advanced root instrumentation, ed 6, Philadelphia,
2013, Lippincott Williams & Wilkins.)

3. Evaluation of treatment outcomes according to:

a. Tissue response to the client’s self-care and nonsurgical
periodontal therapy
b. Evidence of health determined by the probe
(1) No bleeding on gentle probing
(2) Clinical attachment levels remain the same or decrease in
depth
B. Factors that may affect probing accuracy
1. Probe design
a. Calibration—the probe must be clearly and accurately marked
and easy to read; the clinician must be knowledgeable about the
calibration pattern
b. Thickness—a thinner probe causes less distention of the sulcus
or the pocket wall; use a probe no larger than 0.5 mm in
diameter
2. Influence of tissue health and related factors
a. Tissue resistance—with light pressure, the probe is inserted
until it meets the physical resistance of the base of the sulcus or
the periodontal pocket
(1) Normal tissue—the junctional epithelium offers more
resistance; probing is stopped by the coronal portion of the

1429
 junctional epithelium
(2) Gingivitis and early periodontitis—the junctional
epithelium offers less resistance; the probe tip passes
farther into the junctional epithelium
(3) Advanced periodontitis—the junctional epithelium offers
little or no resistance; the probe tip may penetrate the
junctional epithelium to reach the attached connective
tissue fibers
b. Dental calculus—large calculus deposits can hinder the
placement of the probe
3. Concepts of probing technique
a. Adaptation—place the side of the probe tip against the tooth
surface, with the length of the probe positioned as parallel as
possible to the tooth surface; to assess the col region, tilt the
probe so that the tip reaches under the contact area
b. Stroke technique—strokes must be close to each other as the
probe is “walked” along the entire circumference of the
junctional epithelium
c. Pressure—a light pressure of 10 to 20 g should be sufficient

Probing Technique
A. Parallelism—the probe is positioned as parallel as possible to the
tooth surface being probed
B. Adaptation—the side of the probe tip is maintained in contact with
the tooth at all times
C. Activation—digital (finger) activation may be used with the probe
because only light pressure is used when probing
D. Walking strokes—a series of bobbing strokes made within the sulcus
or the pocket while keeping the probe tip against the tooth
1. The junctional epithelium is continuous around a tooth, and the
probing depth may vary considerably on different surfaces; for
complete evaluation, the entire circumference of the sulcus or the
pocket base should be assessed with a series of probing strokes
2. The probe is gently inserted under the gingival margin, holding the
side of the tip against the tooth with a light lateral pressure; the
probe tip is moved gently in an apical direction along the tooth
surface until it encounters the resistance of the junctional
epithelium
3. The tip is moved up and down in short bobbing strokes of 1 to 2 mm
while progressing forward in small, 1-mm to 2-mm steps around the

1430
 circumference of the tooth; with each downward stroke, the probe
tip returns to gently touch the junctional epithelium
4. The base of the sulcus or pocket will feel soft and resilient; if the
resistance on the probe feels hard, the probe tip has encountered a
large calculus deposit before reaching the junctional epithelium
5. The probe should not be removed from the sulcus or the pocket after
each instrumentation stroke; repeated insertion and removal is
unnecessary and can cause trauma to the free gingival margin
E. Proximal surface probing—the probe is walked across the proximal
surface until it touches the contact area; the probe is slanted slightly so
that the tip reaches under the contact area; with the probe in this
position, it is gently pressed downward to touch the junctional
epithelium to take a reading
F. Sequence of steps for probing by quadrants
1. Insert the probe at the distal line angle of the posterior-most tooth
in the quadrant; walk the probe in a distal direction, adapting the
probe around the line angle and across the distal surface, slightly
past the midline of the distal surface (because this is the distal-most
tooth in the quadrant, no contact area is present to contend with)
2. Reinsert the probe at the distal line angle, and proceed in a mesial
direction, across the distal surface, around the line angle, and across
the mesial surface, slanting under the mesial contact area, as needed
3. Remove the probe from the sulcus or the pocket, and reinsert at the
distal line angle of the next tooth in the quadrant; assess each tooth
in the quadrant in a similar manner, ending with the mesial surface
of the central incisor
4. After probing the facial aspect of the quadrant, assess the lingual
aspect of the same quadrant
G. Calculus—when a large calculus deposit is encountered, the probe
should be moved outward from the tooth and around the deposit and
guided back to the tooth, proceeding in an apical direction
H. Recording probing depths—for the purpose of documentation, each
tooth is divided into six areas (three on the facial aspect and three on the
lingual aspect)
1. The six areas are:
a. Distofacial line angle to the midline of the distal surface
b. Facial surface
c. Mesiofacial line angle to the midline of the mesial surface
d. Distolingual line angle to the midline of the distal surface
e. Lingual surface
f. Mesiolingual line angle to the midline of the mesial surface

1431
 2. Only one reading per area is recorded—if the probing depths vary
within an area, the deepest reading obtained in that area is recorded
(e.g., when readings for an area range from 3 to 6 mm, only the 6-mm
reading is entered on the chart for that area)
3. Depths are recorded in millimeters and rounded up (e.g., a reading
of 4.5 mm is recorded as a 5-mm reading)

Clinical Assessment Using Periodontal Probes

A. Bleeding on probing
1. Rationale
a. Bleeding on probing is a significant clinical indicator of
inflammation and is an earlier clinical sign of disease than
marginal redness
b. Bleeding on probing correlates with an increase in motile
bacterial organisms, especially spirochetes, in the pocket
c. Bleeding may indicate an area nonresponsive to nonsurgical
periodontal treatment
d. No bleeding on probing is a criterion for healthy tissue
2. Technique
a. Insert the probe a few millimeters into the pocket (tip should
not be in contact with the junctional epithelium)
b. Make horizontal sweeping strokes along the pocket wall, using
light pressure with the side of the probe
c. Spongy tissue of a pocket wall will usually bleed near the
gingival margin; firm chronic pocket linings usually do not
bleed until sweeping strokes are made in the deep part of the
pocket (bleeding may not be evident for a few seconds)
d. Bleeding on probing usually is recorded on the periodontal
chart; often indicated by a red dot on the chart
B. Measurement of recession of the gingival margin
1. Definition and rationale
a. Gingival recession is the movement of the gingival margin from
its normal position, slightly coronal to the cemento-enamel
junction (CEJ), leading to exposure of a portion of the root
surface to the oral cavity
b. Gingival recession indicates the apical migration of the
junctional epithelium
2. Procedure
a. Position a calibrated probe parallel to the tooth surface with the
toe of the probe touching the gingival margin

1432
 b. Measure the extent of recession in millimeters from the CEJ to
the gingival margin with a calibrated periodontal probe
C. Measuring probing depths
1. Definition—the distance in millimeters from the gingival margin to
the base of the sulcus or the pocket, as measured with a calibrated
probe
2. Rationale
a. Used in mathematically calculating clinical attachment levels
b. Useful in prescribing client self-care regimens and in educating
clients
3. Limitations—in the presence of gingival recession, probing depth
measurements are not an accurate indication of loss of attachment
or level of bone support to the tooth
4. Technique
a. With the probe in a vertical position and in contact with the
attached tissue, record the distance from the gingival margin to
the base of the sulcus or the pocket
b. When the gingival margin contacts the probe between the
millimeter marks, use the higher number for the final reading
D. Measuring clinical attachment levels (CALs)
1. Definition—the position of the attached tissue at the base of the
sulcus or the pocket, as measured from a fixed point, usually the CEJ
2. Rationale
a. Probing depths are not reliable indicators of the position of the
junctional epithelium because the measurement is made from
the gingival margin; the position of the gingival margin changes
with recession and edema
b. Measurements are taken from a fixed point on the tooth; the
CEJ usually is used because it provides a more reliable
indication of the level of the attached tissue
c. When evaluating treatment outcomes, measurements taken
from a fixed point provide a better way of monitoring whether
the level of the attached tissue has remained the same,
decreased, or increased in depth
3. General concepts
a. Two measurements are made and then used to calculate the
clinical attachment; the measurements include:
(1) The probing depth
(2) The distance from the CEJ to the gingival margin
b. Three possible relationships exist between the CEJ and the
gingival margin; the clinician must understand how to calculate

1433
 the CAL for each of these relationships
(1) Visible gingival recession (gingival margin is apical to the
CEJ) (Fig. 17-11)

FIG 17-11 Comparison of the probing depth and the clinical

attachment level (CAL) when the gingival margin is apical to
the cemento-enamel junction (CEJ). The CAL provides an
accurate estimation of the level of the attached tissues.
(From Nield-Gehrig JS: Foundations of periodontics for the dental
hygienist, ed 3, Philadelphia, 2010, Lippincott Williams & Wilkins.)

(2) Gingival margin is coronal to the CEJ

(3) Gingival margin is approximately level with the CEJ
4. Calculation technique in areas of visible gingival recession
a. Measure and record the probing depth (distance from the
gingival margin to the base of the pocket)
b. Measure and record the amount of gingival recession (distance

1434
 from the CEJ to the gingival margin)
c. Calculate the CAL by adding the probing depth and the
measurement of gingival recession
5. Calculation technique in areas where gingival margin is coronal to
the CEJ
a. Measure and record the probing depth
b. Apply the probe, and determine the location of the CEJ by
tactile sensitivity; measure the distance from the gingival
margin to the CEJ
c. Calculate the CAL by subtracting the distance from the gingival
margin to the CEJ from the probing depth
6. Calculation technique in areas where the gingival margin is level
with the CEJ—when the gingival margin is within 0.5 mm apical or
coronal to the CEJ, the probing depth and the CAL are the same
measurement
E. Mucogingival examination
1. Rationale—to determine the width of the attached gingiva
2. Procedure for determining the amount of attached gingiva
a. On the external (outer) surface of the gingiva, measure the
distance in millimeters from the gingival margin to the
mucogingival junction; this is the total width of the gingiva (free
and attached gingiva)
b. Measure the probing depth
c. Calculate the width of the attached gingiva by subtracting the
probing depth from the total width of the gingiva
3. Significance of finding
a. If the probing depth is equal to or greater than the width of the
total gingiva, no attached gingiva (NAG) exists
b. If the probe tip passes the mucogingival junction, mucogingival
involvement exists in this area
F. Furcation involvement
1. Definition—furcation involvement occurs when periodontal
infection invades the area between and around the roots of a
bifurcated or trifurcated tooth, and the bone level is apical to the
furcation crotch area
2. Classification—furcation involvement is classified according to the
extent of bone loss
a. Class I—early, or incipient, involvement; the anatomy of the root
surfaces can be felt by moving the probe from side to side,
passing over the root into the concavity of the furcation area,
and up the opposite side to the adjacent root

1435
 b. Class II—moderate involvement; bone has been destroyed to an
extent that allows the probe to partially enter the furcation,
which extends approximately one-third the width of the tooth
between the roots
c. Class III—severe, or advanced, involvement; in mandibular
molars, the probe can pass between the roots, through the
entire furcation; in maxillary molars, the probe can pass
between the mesiobuccal and distobuccal roots to touch the
palatal root
d. Class IV—same as class III; also, the furca is visible clinically
because of the presence of tissue recession
3. Access to furcation area
a. Bifurcated roots (two roots)
(1) Mandibular molars—to examine between the mesial and
distal roots, probe midfacial and midlingual aspects (Fig.
17-12)

FIG 17-12 Furcation morphology on a mandibular molar

(mesial and distal roots). The furcation can be examined
from the facial and lingual aspects. (From Nield-Gehrig JS:
Fundamentals of periodontal instrumentation and advanced root
instrumentation, ed 6, Philadelphia, 2013, Lippincott Williams &
Wilkins.)

(2) Maxillary first premolars—to examine between the buccal

and palatal roots, probe from the mesial and distal aspects,
apical to the contact area
b. Trifurcated roots (three roots)—maxillary molars; to examine

1436
 around the palatal root and the two facial roots, probe from the
midfacial, mesial, and distal aspects (Fig. 17-13)

Furcation morphology on a maxillary molar

FIG 17-13
(mesiobuccal, distobuccal, and palatal roots). The furcation can
be examined from the facial, mesial, and distal aspects. (From
Nield-Gehrig JS: Fundamentals of periodontal instrumentation and advanced
root instrumentation, ed 6, Philadelphia, 2013, Lippincott Williams & Wilkins.)

G. Evaluation of oral deviations—a calibrated periodontal probe is used

to determine the size of an oral lesion or deviation; when documenting
measurements, anatomical terminology such as anteroposterior or
superoinferior, is used, rather than terms such as length or width

Clinical Assessment with Dental Explorers

A. Purposes and uses
1. Dental explorers detect, by tactile response, the texture and
character of tooth surfaces before, during, and after treatment, to
assess the progress and thoroughness of instrumentation
2. Dental explorers examine tooth surfaces for:
a. Dental calculus
b. Cemental changes that may have resulted from pocket
formation
c. Anomalies
d. Anatomical features such as grooves, curvatures, and furcation
areas

1437
 3. Dental explorers define the extent of instrumentation for treatment
procedures of the tooth surface, including:
a. Removal of calculus deposits and biofilm
b. Removal of overhanging restorations
c. Sealant placement
B. Dental calculus (see the sections on “Bacterial Plaque” in Chapter 9
and “Bacterial Dental Biofilm” in Chapter 14)
1. Definition
a. Calcified or mineralized plaque biofilm is a hard, tenacious
mass that forms on tooth surfaces and on dental prostheses
b. The surface of calculus is rough and is covered by a layer of
plaque biofilm
2. Types, distribution, and shape
a. Supragingival (supramarginal) calculus
(1) Located coronal to (above) the gingival margin
(2) Distribution—localized, usually not generalized
throughout the mouth
(3) Most common locations include the lingual surfaces of
mandibular anterior teeth, facial surfaces of maxillary
molars, teeth out of occlusion, or overlapping teeth
b. Subgingival (submarginal) calculus
(1) Located apical to (beneath) the gingival margin
(2) Distribution—may be localized or generalized; heaviest on
proximal surfaces
(3) Extends along the root surface almost to the base of the
pocket; the newest, less calcified calculus is at the most
apical area, near the soft tissue attachment
(4) Shape—flattened to conform to pressure from the gingival
pocket wall; forms may include combinations of the
following:
(a) Nodular deposits (spicules)
(b) Ledge-like or ring-like formations
(c) Thin, smooth veneers
(d) Finger-like and fern-like formations
3. Modes of attachment—calculus is more easily removed from some
tooth surfaces than from others; the difficulty in removal usually is
related to the manner in which the calculus is attached to the tooth;
on any one tooth, more than one mode of attachment can occur
a. Attachment to acquired pellicle (thin acellular layer on tooth
surface)—most common mode of calculus attachment to
enamel; calculus may be removed readily because no

1438
 interlocking of calculus to the tooth exists
b. Attachment by “locking” into minute irregularities in the tooth
surface
c. Attachment of the calcified calculus matrix to the tooth surface
by interlocking of inorganic crystals of the tooth with the
mineralizing plaque biofilm
C. Calculus detection
1. Supragingival assessment—unnecessary supragingival exploration
should be avoided; adequate light combined with the use of a dental
mirror and compressed air will reveal most supragingival deposits
2. Subgingival assessment and adaptation
a. Instrument grasp and lateral pressure—a relaxed grasp and
light lateral pressure are used to enhance tactile sensitivity;
pressure with the middle finger against the instrument shank
should be avoided, because this reduces tactile sensitivity
b. Activation—a combination of hand-forearm and digital
activation
c. Strokes—many, overlapping, fluid strokes are used to
thoroughly cover the entire root surface
D. Carious lesions
1. Historically, the use of tactile examination of a tooth surface, with
firm application of a sharp tip of an explorer into a suspected site of
caries, was a common method of carious lesion detection, but this
approach is no longer recommended
2. Research has shown this technique to be unreliable for carious
lesion detection and to be potentially harmful
3. Firm application of a sharp explorer tip into a carious pit or fissure
on a tooth surface may actually cause additional damage to the tooth
surface and interfere with subsequent attempts at remineralization
of the caries lesion (see Chapter 16)

1439
Concepts in periodontal instrumentation
Instrumentation Terminology
A. Instrumenting—using a periodontal instrument for a task
B. Biofilm management—the disruption or removal of subgingival plaque
biofilm and its byproducts from cemental surfaces and the pocket spaces
C. Tactile sensitivity—the ability to feel vibrations transferred from the
instrument’s working end, shank, and handle to the clinician’s fingers
D. Assessment—examination of a tooth and periodontium to determine
anatomy and detect biofilm-retentive factors, and oral disease status
E. Nonsurgical periodontal instrumentation—removal of hard and soft
deposits from the tooth crown, root surfaces, and pocket space to the
extent needed to reestablish periodontal health and restore a balance
between the bacterial flora and the host’s immune responses
F. Overhang removal—recontouring procedures that correct defective
margins of restorations to provide a smooth surface that will deter
bacterial accumulation
G. Supragingival—located coronal to (above) the gingival margin
H. Subgingival—located apical to (beneath) the gingival margin
I. Biofilm-retentive factors—conditions that foster the establishment and
growth of biofilm, such as calculus deposits and overhanging
restorations

Rationale for Nonsurgical Periodontal

Instrumentation
A. Arrests the progress of disease
B. Induces positive changes in the subgingival bacterial flora (count and
content)
C. Creates an environment that permits the gingival tissue to heal,
thereby eliminating inflammation
1. Converts the pocket from an area experiencing increased loss of
attachment to one in which the CAL remains the same or decreases
2. Eliminates bleeding
3. Improves integrity of tissue attachment
D. Increases the effectiveness of client self-care
E. Permits reevaluation of periodontal health status; surgery may then be
unnecessary, lessened in extent, or confined to specific areas
F. Prevents recurrence of disease through frequent periodontal
maintenance therapy

1440
Rationale for Removal of Overhangs
A. Eliminates irregular surfaces where biofilm can collect
B. Induces positive changes in the microflora of the pocket when the
overhang extends subgingivally
C. Encourages resolution of inflammation
D. Facilitates interdental biofilm removal and control by the client

End Point of Instrumentation

A. The goal of instrumentation is to render the root surface and pocket
space acceptable to tissue so that healing occurs
B. Tissue healing occurs slowly, and it is not possible to assess tissue
response for at least 1 month after completion of instrumentation
1. The client’s appointment for reevaluation should be scheduled 4 to 6
weeks after completion of instrumentation
2. During reevaluation, a periodontal assessment should be completed
that includes probing depths, CALs, and bleeding on probing
3. Nonresponsive sites are those that show continued loss of
attachment and may exhibit clinical signs of inflammation or
bleeding, or both, on probing; nonresponsive sites may require:
a. Removal of new or residual calculus deposits; or other biofilm-
retentive factors
b. Thorough subgingival biofilm removal, preferably with an
ultrasonic instrument or glycine-powder air polishing with a
specially designed subgingival nozzle tip
4. Consideration should be given to other risk factors that might be
contributing to the disease process (host response, systemic, and
local factors)

Steps for the Preparation for Instrumentation

A. Protect client safety
1. Review the client’s personal and health histories for indications of
special needs; prepare for a possible emergency
2. Assess vital signs
3. Observe the client for signs of stress
B. Use standard precautions (see Chapter 10)
1. Postpone treatment for a client with a communicable disease or an
open oral lesion
2. Provide the means for lowering the bacterial count of the client’s oral
surfaces

1441
a. Provide the client with a preprocedural antimicrobial
mouthrinse or antimicrobial irrigation to lower the count of oral
microorganisms
b. Discuss oral self-care with client (e.g., plaque control) before
any instrumentation

1442
Sharpening of Hand-Activated
Instruments
A. Sharp cutting edges are vital to achieve efficient periodontal
instrumentation with minimal tissue trauma
B. Sharp cutting edges help provide more efficient treatment because of
easier calculus removal, fewer strokes, improved stroke control,
increased client comfort, and reduced clinician fatigue
C. To sharpen instruments correctly, the clinician must understand the
design of the working end
1. A sharp cutting edge is a line without width; a dull cutting edge is a
rounded surface
2. The internal angle formed between the face and lateral surface of a
sickle scaler or curet is between 70 and 80 degrees
3. Most sickle scalers have pointed tips and backs; curets have rounded
toes and backs
4. Sickle scalers and universal curets have two working cutting edges
per working end; area-specific curets have one working cutting edge
per working end
D. Instruments should be sharpened at the first sign of dullness—the
cutting edge of the instrument dulls at various rates because of:
1. Number of working strokes used
2. Amount of lateral pressure used
3. Hardness and tenacity of the deposit
4. Composition of the metal of the instrument
E. Equipment
1. A stable, well-lighted work surface
2. Heat-sterilized rectangular sharpening stone or sharpening tool and
plastic sharpening test stick (Table 17-3)

1443
 Table 17-3
Sharpening Stones and Tools

Modified with permission from Nield-Gehrig JS: Fundamentals of periodontal instrumentation and advanced root
instrumentation, ed 6, Philadelphia, 2013, Lippincott Williams & Wilkins.
* Includes autoclave, dry heat, or chemical sterilization.

† Natural stones become brittle over time with heat exposure.

3. Water or oil to lubricate the stone (depending on the type of stone)

4. Protective eyewear, facemask, and household gloves (when
sharpening contaminated instruments)

1444
Ultrasonic and sonic instrumentation
A. Description
1. Powered ultrasonic and sonic devices use rapid vibrations of a fluid-
cooled instrument tip to fracture and dislodge supragingival and
subgingival calculus deposits from the teeth and to cleanse the
environment within the periodontal pocket
2. Ultrasonic devices (magnetostrictive and piezoelectric)
a. High-frequency electrical energy is converted into mechanical
energy in the form of ultrasonic vibrations; instrument tip
vibrations range from 25,000 to 50,000 cycles per second (cps,
hertz [Hz])
b. Heat that is produced must be dissipated by a constant flow of
water through the handpiece; antimicrobial solutions may be
used instead of water in certain units
c. Ultrasonic instruments provide efficient removal of all types of
calculus deposits (old, new, supragingival and subgingival, light
and heavy deposits)
3. Sonic instruments
a. Air pressure also is used to create rapid mechanical vibrations;
sonic instrument tip vibrations range from 3000 to 8000 cycles
per second (Hertz)
b. No heat is generated; although water cooling is not necessary, a
water coolant is indicated to obtain the benefits of water lavage
c. Because of the lower frequency of vibration, sonic instruments
are less efficient in removing calculus deposits and have a
limited ability to remove tenacious deposits; they function well
for the removal of newly formed and light deposits
B. Definitions
1. Fluid lavage—the fluid stream within the periodontal pocket,
produced by the constant flow of fluid through the handpiece, near
the instrument’s tip; when the fluid strikes the vibrating instrument
tip, it creates a spray composed of millions of tiny bubbles
2. Cavitation—the energy release that occurs when the tiny bubbles in
the fluid spray collapse, producing shock waves that may alter or
destroy bacteria by tearing the bacterial cell walls
3. Stroke—the maximum distance the powered instrument tip moves
during one cycle of vibration
C. Instrument tip design
1. Working ends of ultrasonic/sonic instruments have no cutting edges
to cut or tear tissue; less tissue trauma can result in faster healing

1445
 rates for sites treated with ultrasonic or sonic instruments
2. The entire length of the working end is active; therefore, adaptation
is not limited to a single region on the working end
3. Tip selection
a. Ultrasonic tip selection varies, depending on the manufacturer;
the availability of a full range of tip designs is an important
criterion when purchasing a mechanized device
b. Tips may range in size from large, broad tips (standard size), to
medium-sized tips to slim-diameter slender tips
c. Standard tips (ultrasonic and sonic designs)
(1) Broad, large tips are used to remove heavy, supragingival
deposits
(2) Medium-sized tips are used to remove medium and light
deposits; some may be used subgingivally if the tissue
permits easy insertion of the tip
d. Slim-diameter ultrasonic tips
(1) Similar in diameter to periodontal probes, and
significantly smaller in size than the working end of a curet
(2) Approximately 40% thinner than a standard-sized
ultrasonic tip
(3) Available in straight, right-paired, and left-paired styles
(4) Used for biofilm and light calculus removal; provide
excellent access to deep pockets and furcation areas
4. Energy dispersion—ultrasonic instrument tips are active on all
surfaces; by adapting the appropriate tip surface, the clinician can
control energy dispersion and client sensitivity during the procedure
a. Point—generates the most energy; should not be used directly
against the tooth surface
b. Face (concave surface)—second most powerful surface
(generates less energy than the point); usually not
recommended for use against the tooth surface
c. Back (convex surface)—generates less energy than the face;
follow the manufacturer ’s recommendations regarding direct
use on the tooth surface
d. Lateral surfaces (sides)—generate the least amount of energy;
may be used directly against the tooth surface; adaptation of a
lateral surface is recommended for calculus removal and
deplaquing
5. Fluid delivery—ultrasonic instruments require a constant stream of
fluid running through the handpiece, which disperses in a fine spray
at or near the instrument tip to prevent overheating of the vibrating

1446
 instrument tip
a. Fluid delivery to the tip
(1) The external flow tube is adjacent to the instrument’s
shank
(2) In the internal fluid flow system, the fluid flows directly
through the instrument tip
b. Water is the most common fluid used; some ultrasonic units
have an independent fluid reservoir that can deliver distilled
water or other fluid solutions (e.g., sterile saline, stannous
fluoride, chemotherapeutic agents) to the instrument tip
6. Tip frequency—the number of times per second that the tip moves
back and forth during one cycle
a. Active tip area—the portion of the tip that is capable of doing
work; ranges from 2 to 4 mm in length (Fig. 17-14)

FIG 17-14 Active tip area of a mechanized instrument. The active

tip area ranges in length from 2 to 3 mm and is the portion of the
instrument tip that is capable of doing the work. (From Nield-Gehrig
JS: Fundamentals of periodontal instrumentation and advanced root
instrumentation, ed 6, Philadelphia, 2013, Lippincott Williams & Wilkins.)

b. Manual ultrasonic units allow the clinician to adjust the tip

frequency by turning an adjustment knob on the unit; automatic
ultrasonic units control the tip frequency automatically; sonic
instruments have a preset frequency that cannot be controlled
by the clinician
D. Several factors influence the force produced by the powered
instrument tip
1. Exposure time—sufficient time must be allowed for the tip to do its
work (e.g., ultrasonic instruments are effective, but even they do not

1447
 instantaneously remove calculus); powered instrument tips work by
creating microfractures in a calculus deposit; the tip should be
moved back and forth repeatedly over the deposit to allow time for
the microfractures to develop
2. Angle of adaptation—an angle of between 0 and 15 degrees is
recommended for direct adaptation to tooth surfaces
3. Sharp or dull tip—only dull tips are recommended; sharpened tips
emit high energy levels that could damage the tooth
4. Lateral pressure—tips function most effectively with light lateral
pressure against the tooth or calculus deposit; moderate or firm
lateral pressure decreases or even stops the vibrations of the tip
E. Uses of modern ultrasonic instruments
1. Removal of attached and unattached plaque biofilm from root
surface and pocket space
2. Removal of supragingival and subgingival calculus
3. Removal of toxins from root surfaces
4. Smoothing down overextended or rough amalgam restorations,
removing extrinsic stains for esthetic considerations, and removing
orthodontic cement (using standard tips)
F. Contraindications
1. Client with a communicable disease that can be disseminated by
aerosols
2. Immunocompromised client with high susceptibility to an infection
who could be exposed to microorganisms in contaminated water or
aerosols or by other means (e.g., debilitated clients, those with
uncontrolled diabetes, immunosuppressed clients)
3. Client with respiratory disease or difficulty breathing (e.g., history of
emphysema, cystic fibrosis, asthma); the client is at increased risk of
respiratory infection if septic material or oral microorganisms are
aspirated
4. Client who has difficulty swallowing or is prone to gagging (e.g.,
multiple sclerosis, amyotrophic lateral sclerosis, muscular dystrophy,
paralysis)
5. Client with a cardiac pacemaker; the dental clinician should check
with the client’s cardiologist if the device is shielded or unshielded
6. Client with primary or newly erupted teeth—danger of heat being
conducted to large pulp chambers
7. Direct contact between the instrument tip and porcelain jacket
crowns, composite resin restorations that could be damaged by the
vibration or the tip, and demineralized enamel surfaces
(conservation of demineralized enamel surfaces is indicated) should

1448
 be avoided
8. Direct contact with titanium implant surface should be avoided,
unless the instrument tip is covered with a specially designed plastic
sleeve
G. Precautions
1. The handpiece and the working end of ultrasonic instruments must
be cooled with constant flow of water to dissipate heat
2. Aerosols produced may be contaminated with pathogens; use of
barriers, surface disinfectants, protective clothing, and laminar
airflow systems is recommended
3. The client may experience sensitivity
4. Shifts in hearing sensitivity have been reported; the effect of
ultrasonic and sonic equipment on the hearing of clinicians who
frequently use these instruments has not been studied well
H. Preparation
1. Employ universal precautions, and ensure that protective attire is
worn by the clinician, the assistant, and the client
2. Have the client use a preprocedural antimicrobial mouthrinse, or
irrigate the treatment area to reduce the number of airborne
microorganisms in aerosols created by water spray
3. Monitor the condition of the equipment
4. Replace the instrument tip as soon as it shows signs of wear or
damage
a. Tip wear—1 mm of wear results in approximately 25% loss of
efficiency; tips should be discarded at 2 mm of wear; some
manufacturers offer wear guides that make it easy to determine
tip wear; precision-thin tips must be replaced more frequently
than standard tips
b. Metal stacks of magnetostrictive insert—replace if the stacks are
bent or separated, or if the insert does not slide easily into the
ultrasonic handpiece
5. Instrument tips and handpieces should be sterilized according to
manufacturer ’s instructions; use surface disinfectant and barriers on
an ultrasonic unit
I. Technique
1. Biofilm control in water tubing—flush the water tubing of stagnant
water for 2 minutes at the start of the day, and for 30 seconds
between clients; use units with an independent fluid reservoir or
waterline point-of-use filter, or both
2. Tip selection—select the appropriate instrument tip for the task at
hand

1449
 a. Broad, standard tips for removal of heavy and medium-sized
supragingival calculus
b. Medium-sized standard tips for moderate and light
supragingival use; also may be used subgingivally if the tissue
permits easy insertion of the tip
c. Slim-diameter tips for removal of light deposits and deplaquing
3. Power setting—use standard instrument tips at medium-power or
low-power setting, and slim-diameter tips at low-power setting; high-
power setting is no more effective than medium power and is not
recommended
4. Grasp—use light, relaxed grasp, even during calculus removal
5. Finger rest—use an intraoral or extraoral rest; advanced fulcrum
techniques may be helpful for gaining access to posterior pockets
6. Lateral pressure—use light stroke pressure for effective calculus
removal
7. Activation—use digital activation as recommended
8. Fluid adjustment and containment
a. Adjust the water spray around the instrument tip to create a
light mist or halo effect, with no excess dripping of water;
insufficient water flow over an ultrasonic tip can result in
trauma to the pulp; a warm handpiece is a sign of inadequate
fluid flow through the handpiece
b. Use high-volume suction or a saliva ejector for fluid control;
position the suction tip at the corner of the mouth where the
fluid will pool; deactivate the instrument tip occasionally to
prevent large amounts of fluid accumulation
c. Use the client’s lips and cheeks as barriers to deflect fluid back
into the client’s mouth
9. Tip adaptation
a. Adaptation to the tooth surface—position the tip with the point
directed toward the junctional epithelium and the length of the
tip at a 0- to 15-degree angle to the tooth surface; never apply
the point of the tip directly to the tooth surface
b. Adaptation to a calculus deposit—place the tip directly against
the uppermost or outermost edge of the calculus deposit; the
lateral surface of a tip may also be adapted to a calculus deposit
10. Instrumentation strokes
a. Motion—use a tapping motion against large-sized calculus
deposits and a sweeping, eraser-like motion against small
deposits and for biofilm removal from root surfaces
b. Pressure—use light pressure; firm pressure decreases

1450
 effectiveness
c. Direction—use overlapping vertical, oblique, and horizontal
strokes; subgingival strokes should cover the entire root surface
for calculus removal and deplaquing
11. Calculus removal
a. Sequence—work in a coronal-to-apical direction, beginning at
the gingival margin and working toward the junctional
epithelium (this is the reverse of the sequence for calculus
removal with a curet)
b. Technique for removing stubborn deposits
(1) Use an adequate number of strokes—move the tip
repeatedly over the deposit or tap against the deposit; keep
the tip in constant motion
(2) Select the proper tip for the type of calculus; for example,
do not use slim-diameter tips for medium-sized or large
deposits
(3) Approach the deposit from different aspects (e.g.,
approach an interproximal deposit from both the facial and
the lingual aspect)
(4) Do not apply firm stroke pressure; use of light pressure is
most effective
(5) Increase the frequency on a manually calibrated unit
(6) Increase the power setting from low to medium

1451
Advanced instrumentation techniques
Instrumentation of Dental Implants
A. Definition—dental implant: a nonbiologic device surgically inserted
into or onto the jawbone to replace a missing tooth or to provide support
for an implant superstructure (e.g., a fixed bridge or denture)
B. General guidelines
1. Special instruments are recommended for assessment and
instrumentation of implants; plastic instruments are used most
often because the plastic material is softer than the implant material
2. Metal instruments (e.g., stainless steel, carbon steel, and metal
ultrasonic instruments) may leave scratches on the surface of the
implant
a. Scratches or surface roughness on an implant may promote
accumulation of biofilm
b. Surface coating of an implant may be disturbed, thereby
reducing the biocompatibility of the implant with the
surrounding tissues
3. Some plastic instruments may be sterilized by autoclaving; follow
the manufacturer ’s instructions for sterilization and reuse
C. Design of the working end of plastic instruments
1. Wrench-shaped, crescent-shaped, and hoe-shaped working ends—
useful for instrumentation of an implant’s superstructure
2. Working ends that are similar in design to conventional metal
probes, sickle scalers, and curets—useful for the assessment and
instrumentation of the implant abutment
D. Use of plastic, calibrated probe for assessing peri-implant tissues (soft
tissues that surround the dental implant)
1. Peri-implant probing depths are related to the thickness of the
mucosa around the implant; deeper probing depths are found in
conjunction with a thicker mucosa
2. Probing depths and CALs are important parameters for the
longitudinal monitoring of peri-implant tissue stability
3. Considerations
a. Probing may be invasive because the probe may penetrate the
weakly adherent biologic seal and could introduce bacteria into
peri-implant tissue
b. Accurate probing depths may be difficult to obtain because of
the constricted “cervical” area of some implants
c. Radiographs are more accurate than probing depths for

1452
 detecting the absence or presence of bone loss around implants
E. Instrumentation for calculus removal
1. Calculus is removed easily from implants because no interlocking or
penetration of the deposit exists within the implant surface
2. Light lateral pressure with a plastic scaler or curet is recommended;
care must be taken not to scratch the surface of the implant
3. Instrumentation should be restricted to supragingival deposit
removal

1453
Selective stain removal
A. Definitions
1. Intrinsic—stains that occur within the tooth substance; the process
of removal is performed by a dentist using bleaching techniques or
prosthetic coverage with a crown
2. Extrinsic—stains that occur on the external surface of the tooth;
removed by client self-care and professional procedures such as
scaling and rubber cup and brush scaling, rubber cup/brush, and
conventional air polishing
B. Significance of dental stains
1. No detrimental effects have been shown to result from the presence
of dental stains; research shows that stains do not directly contribute
to periodontal disease, dental caries, or any oral disease; however,
stains may contribute to biofilm retention
2. Removal of unsightly dental stains on anterior teeth may benefit the
client’s appearance and self-esteem
C. Rationale for selective stain removal
1. Polishing is viewed as a cosmetic procedure with limited application;
stain removal provides no therapeutic benefit to the client and has
numerous detrimental effects on teeth and soft tissue
2. Decision to include stain removal in a client’s care plan can best be
made after client self- care education and after complete periodontal
instrumentation because much of the stain may be removed along
with calculus deposits
D. Contraindications to polishing
1. Dental contraindications
a. Tooth surfaces that have no extrinsic stains or have stains that
are not visible when client smiles or engages in conversation
b. Areas of dentinal hypersensitivity—application of fluoride is
one treatment for tooth sensitivity; protective fluoride must be
left undisturbed (see the section on “Assessment of Dentinal
Hypersensitivity” in Chapter 16)
c. Restored tooth surfaces—gold and other restorative materials
may be scratched by the abrasive agent
d. Titanium implants—polishing could scratch the titanium
abutment
e. Areas of demineralization—conservation of demineralized
enamel surfaces is indicated
f. Gingiva that is enlarged, soft, spongy, or bleeds easily—
polishing is not recommended because paste can enter the

1454
 tissue, and the action of the rotating cup can further traumatize
the tissue
2. Systemic contraindications
a. Client with a communicable disease that could be spread by
aerosols
b. Client with a high susceptibility to infection who could inhale
contaminated aerosols (e.g., client with respiratory or
pulmonary disease, debilitated client)
c. Client who has a history of renal insufficiency, Addison’s
disease, Cushing syndrome, or metabolic alkalosis; is taking
mineralocorticosteroids, antidiuretics, or potassium
supplements; air polisher use should be avoided
d. Client who has a history of hypertension or a sodium-restricted
diet; air polishing using a sodium-containing powder is
contraindicated; air polishing can be used with one of the newer,
sodium-free polishing powder products, such as those
composed of aluminum trihydroxide or calcium carbonate
E. Adverse effects of polishing
1. Aerosol production and spatter from power-driven polisher
a. Contaminated aerosols present a hazard to the clinician, other
dental personnel, and other clients in the oral health care
environment; polishing splatter is composed of polishing paste,
microorganisms, and saliva
b. Components of commercial prophylaxis pastes may include
various chemicals that can cause a severe inflammatory
response in the eye
2. Iatrogenic damage to tooth surfaces
a. Enamel surfaces—stain removal with an abrasive agent removes
the surface layer of tooth structure where the fluoride content is
greatest and most protective; polishing the teeth for 3 minutes
with pumice removes 3 to 4 micrometers (µm) of enamel; over
time, the loss of enamel can be significant
b. Cemental surfaces—exposed surface near the CEJ has a thin
cementum or dentin surface that can be abraded or removed
with an abrasive agent
c. Heat production—care must be taken to use a wet polishing
agent with minimal pressure and low speed to prevent
overheating of a tooth, particularly the pulp tissues of small
children; primary teeth have large pulp chambers, which make
them particularly vulnerable to heat generated by power-driven
handpieces

1455
 3. Tissue trauma—during polishing, abrasive paste is forced into the
gingival sulcus and even into the tissue itself; some individuals
experience a negative tissue response to abrasive particles or
chemicals in the paste, which can delay tissue healing
F. Power-driven polisher (rubber cup polishing)
1. Description
a. Handpiece—connects to the dental unit’s low-speed handpiece
line
b. Prophylaxis angle—attaches to the handpiece; holds polishing
cups and bristle brushes
c. Attachments
(1) Polishing cups—used for stain removal from tooth
surfaces and for polishing restorations
(2) Bristle brushes—used for stain removal from occlusal
surfaces; not for use near the gingival margin or on
cementum or dentin, where the brush could denude the
epithelium or remove cementum
2. Technique considerations
a. Application of polishing agent—apply agent only to individual
teeth requiring stain removal for esthetic purposes
b. Use the lowest possible handpiece speed
c. Apply the cup to the tooth with a light, intermittent pressure
(1) The edges of the cup should just barely flare from the
tooth surface
(2) Use of continuous motion—avoid holding the cup on a
single spot for too long to prevent buildup of frictional heat
G. Conventional supragingival air polishing
1. Definition—an air-powered device using air and water pressure to
deliver a controlled slurry of powder to the tooth surface
2. Technique
a. Wear protective attire
(1) Client—provide a plastic apron, hair cover, eye protection,
and lip lubrication
(2) Clinician and assistant—wear a paper or cloth long-sleeved
garment, facemask, hair cover, eye protection, and gloves
b. Administer a preprocedural mouthrinse to lessen contaminated
aerosols; have the client rinse with an antibacterial mouthrinse
c. Direct the powder spray away from the gingival tissue, never
direct the spray into the sulcus or pocket space; establish the
recommended angulation of the tip to the tooth surface
(1) Facial and lingual surfaces—position the nozzle tip at a 60-

1456
 to 80-degree angle to the tooth
(2) Occlusal surfaces—position the nozzle at a 90-degree angle
to the surface of the tooth
d. Direct the spray in constant motion for only 3 to 5 seconds at
any area on the enamel surface
H. Postoperative procedures for mechanical and air polishing
1. Remove particles of abrasive at the contact areas with dental floss
2. Loosen and remove particles in sulci or pockets by irrigation and
aspiration with central suction

1457
Ethical, legal, and safety issues
A. Provision of quality care by licensed dental hygienists includes ethical,
legal, and safety issues
B. A comprehensive review of the client’s medical health and
pharmacologic histories is essential to assess the degree of client risk for
dental procedures and to make necessary physician or specialty referrals
C. Adherence to the Health Insurance Portability and Accountability Act
(HIPAA) is necessary; thorough, accurate, and confidential chart
documentation is essential
D. A comprehensive client assessment is essential to detect oral diseases
and abnormalities and determine the degree of client risk for caries,
periodontal disease, or disease progression
E. Failure to provide necessary care based on assessment findings
constitutes supervised neglect; the licensed dental hygienist is
accountable and responsible for client care
F. A thorough case presentation is essential so that the client can make an
informed decision about recommended dental hygiene care; written
informed consent should be obtained before beginning care; discussion
of all procedures with clients, using everyday language the client can
understand, and encouragement of client participation are essential
G. The dental hygienist has an obligation to provide evidence-based care
H. The dental hygienist has an obligation to protect the client from harm
during care
I. The dental hygienist has an obligation to follow established protocol
that protects the clinician and the client during treatment
J. It is essential to allow sufficient time during appointments for
provision of adequate care
K. Nonsurgical periodontal instrumentation should be performed in an
effective and responsible manner; use of sharp instruments and selection
of appropriate instruments for the task are essential
L. It is important to evaluate the success of nonsurgical periodontal
instrumentation at appropriate continued-care intervals
M. The dental hygienist has a legal obligation to document thoroughly
and accurately the assessment, care plan, informed consent, services
provided, and the client’s response to care

Website Information and Resourc es

Source Website Address Description

1458
Source Website Address Description
American Academy http://www.perio.org Parameters of care, position papers, scientific information,

of Periodontology related links

Cochrane http://www.cochrane.org Evidence-based health care database
Collaboration
National Center for https://dent- Current topics in dental hygiene; links
Dental Hygiene web10.usc.edu/dhnet
Research
Hu-Friedy http://www.hu- Online catalogue of periodontal instruments; ultrasonic and
friedy.com air-polishing devices; white papers, material safety data
sheets (MSDS), instrument care, articles
Premier Dental http://www.premusa.com Online catalogue of periodontal instruments; fluoride;
continuing education seminar information
Deldent Ltd. Air http://www.deldent.com Information about the products marketed by Deldent
Polishers
Dentsply http://www.dentsply.com News articles, career and legal information, and information
Ultrasonic Units about Dentsply products
KaVo America http://www.kavousa.com Information about KaVo dental products
Parkell Ultrasonic http://www.parkell.com Information about Parkell dental products
Scalers

1459
Suggested readings
Darby M.L., Walsh M.M. Instruments and instrumentation theory.
In: Darby M.L., Walsh M.M., eds. Dental hygiene theory and
practice. ed 3 Philadelphia: Saunders; 2010.
Nield-Gehrig J.S. Fundamentals of periodontal instrumentation and
advanced root instrumentation. ed 7 Philadelphia: Lippincott
Williams & Wilkins; 2013.

Chapter 17 review questions

Answers and rationales to the review questions are available on this
text’s accompanying Evolve site. See inside front cover for details.

Case A
Synopsis of Patient History
Age: 57
Sex: M
Height: 6′3″
Weight: 220 lb

Vital Signs
Blood pressure: 150/95
Pulse: 76 bpm
Respiration: 15 rpm

Medical History
History of hypertension diagnosed 5 years ago

Dental History
Missing with no replacement: #1, #2, #13, #16, #17, #31, #32
Several large amalgams and tooth-colored anterior restorations
Recurrent caries apical to class V amalgam on F #19
Pocket depth range 3-6 mm with class II furcation involvement on F #3
and #18

1460
6-mm pocket depth on M #14, which has drifted mesially
6-mm pocket depth on D #15
Significant recession on F #19, D and F #14
Heavy tobacco stain
Fibrotic gingival tissues with generalized slight bleeding on probing

Social History
Real estate agent
Deacon at his church

Chief Complaint
Wants teeth to look whiter and wants to replace the “gap” on the upper
left

Current Oral Hygiene Status

Generalized subgingival calculus deposits in anterior and posterior
sextants
Heavy generalized plaque biofilm on gingival thirds of teeth
Radiographs confirm bone loss and furcation involvement in posterior
sextants

Use Case A to answer questions 1 to 10.

1. The best way to remove tobacco stain is to use:
a. The toe of a universal curet
b. An air polisher with coarse, abrasive sodium bicarbonate slurry
c. A Nabers diamond-coated file (similar to Nabers furcation probe
with diamond coating)
d. A standard ultrasonic tip
2. Which of the following instruments would be the BEST choice to
initiate removal of the moderate calculus deposits?
a. Standard ultrasonic tip
b. Ultrasonic slim-diameter tip with a straight working end
c. Set of rigid Gracey curets 1/2, 11/12, and 13/14
d. Quétin furcation curet
3. Tooth #3 has class II furcation involvement on the facial aspect. Which
of the following instruments would be the BEST choice for light calculus
removal and deplaquing of the furcation area?

1461
 a. Slim-diameter ultrasonic tip with a curved working end
b. Periodontal file
c. Standard Gracey curet 1/2
d. Universal curet with an extended lower shank
4. You are working on the mesial of tooth #14, which has drifted
mesially, and having difficulty keeping the instrument’s lower shank
parallel to the long axis of the tooth. You are using an After Five (AF)
Gracey 11/12 with a miniature working end with a standard intraoral
finger rest. Which of the following would MOST LIKELY improve
access on this mesial surface?
a. Switch to an advanced fulcrum
b. Use a straight, slim-diameter ultrasonic tip
c. Use a universal curet with an extended shank
d. Use a rigid Gracey curet instead
5. Which instrument would be BEST to detect furcation involvement on
multi-rooted teeth?
a. Furcation probe, such as a Nabers probe
b. Periodontal file
c. Miniature Gracey curet
d. Calibrated periodontal probe
6. All the following statements are TRUE about ultrasonic
instrumentation EXCEPT:
a. The side of the tip should maintain contact with the tooth at all
times.
b. Cavitation creates tiny bubbles that collapse and kill bacteria.
c. You should never use digital motion.
d. There are no cutting edges on the ultrasonic tip.
7. To determine the deepest pocket depth on the distal surface of the
facial aspect of tooth #15, the clinician should:
a. Place the probe tip at the distofacial line angle, slide it down to the
base of the pocket, take a reading, and record this as the probing depth
for the facial aspect distal surface
b. Insert the probe to the base of the pocket, use a series of walking
strokes from the distofacial line angle to the midline of the distal
surface, and record the deepest reading as the probing depth for the

1462
 facial aspect of the distal surface
c. Use the probe to measure the point where the col would be if tooth
#16 were still present and record this depth
d. Slant the probe so that the tip crosses the midline of the distal
surface, insert the probe, and take and record this reading for the facial
aspect of the distal surface
8. On a tooth with class III furcation involvement, which of the
following instruments would you use from the facial aspect to
instrument the distal half of the mesial root?
a. Universal curet
b. ODU 11/12 explorer
c. Miniature Gracey 11/12 curet
d. Miniature Gracey 13/14 curet
9. Tooth #19 has significant recession of the gingival margin. If there
were light tobacco stain on the root surface, what would be the BEST
way to remove it?
a. Use a straight, slim-diameter ultrasonic tip with light overlapping
strokes
b. Do not remove the stain, because it is not visible when the patient
smiles, and stain does not contribute to periodontal disease or dental
caries
c. Use a rigid Gracey 11/12 curet with light pressure
d. Use a motor-driven polisher with fine pumice
10. A periodontal probe can be used to assess all the following EXCEPT:
a. Width of attached gingiva
b. Clinical attachment level
c. Degree of recession
d. Extent of carious lesions

Case B
Synopsis of Patient History
Age: 27
Sex: F
Height: 5′4″
Weight: 120 lb

1463
Vital Signs
Blood pressure: 118/74
Pulse: 70 bpm
Respiration: 16 rpm

1. Under the care of a physician: x YES ____ NO

2. Hospitalized within the last 5 years: x YES ____ NO
(childbirth)
3. Has or had the following condition:
Asthma
4. Current medications:
Prenatal vitamins
5. Smokes or uses tobacco products: x YES ____ NO
6. Is pregnant: x YES ____ NO
(5 months)

Medical History
Pregnant with second child
Asthma controlled with albuterol inhaler; last attack about a year ago
and has not used it since becoming pregnant

Dental History
All third molars have been surgically extracted
Tooth-colored filling on occlusal #31 and lingual of #7
Gingival tissues red and slightly enlarged on maxillary and mandibular
anterior teeth

Social History
Academic advisor at nearby university

Chief Complaint
Wants teeth cleaned

Current Oral Hygiene Status

Light calculus on proximal and lingual surfaces of #22 to #17 and facial
surfaces of #3 and #14
Generalized moderate plaque biofilm

Use Case B to answer questions 11 to 19.

11. Access to the light subgingival calculus deposits on the proximal

1464
surfaces of the anterior teeth is difficult because of papillary
enlargement of the gingival tissues. Which of the following is the BEST
approach for thorough subgingival calculus removal from the proximal
surfaces?
a. Use a universal curet
b. Try to remove the deposit with an explorer since the working end is
so tiny
c. Apply a topical anesthetic, then use a calculus removal stroke
subgingivally with an anterior sickle
d. Use an ultrasonic slim-diameter tip and approach the deposit from
both facial and lingual aspects
12. Clinical examination shows that the gingival tissues are red and
slightly enlarged on maxillary and mandibular anterior teeth. Which of
the following should the hygienist consider as an etiologic factor(s) in
the tissue inflammation and enlargement?
a. Moderate plaque biofilm is present.
b. The patient is pregnant.
c. The patient is asthmatic.
d. Both a and b
13. Which of the following instruments would be the MOST effective in
removing a small subgingival calculus deposit on the lingual aspect of
tooth #24?
a. Gracey 1/2 curet with a miniature working end and an extended
lower shank
b. Anterior sickle scaler
c. Periodontal file designed for use on the lingual aspect
d. Standard Gracey 1/2 curet
14. Calculus assessment reveals light calculus deposits on the
mandibular anterior teeth and maxillary first molars and generalized
plaque biofilm. Of the following instruments, which would you be most
likely NOT to use in treating this client?
a. Universal curet
b. Anterior sickle scaler
c. ODU 11/12 explorer
d. Standard Gracey curet
15. While removing the light calculus on the lingual surfaces of lower

1465
anterior teeth, you would be using your mirror for all the following
purposes EXCEPT:
a. Retraction
b. Direct vision
c. Indirect illumination
d. Indirect vision
16. Which of the following is TRUE regarding use of a universal curet
for this client’s treatment?
a. It can be used in the anterior and posterior sextants for removal of
supragingival and subgingival calculus deposits.
b. It is the most efficient instrument for removing small calculus
deposits just below the contact areas of the mandibular anterior teeth.
c. The pointed tip is effective in removing calculus interproximally.
d. If used in areas of gingival inflammation, the curet will cause undue
discomfort for the patient.
17. When removing calculus deposits on the facial aspect of a maxillary
posterior sextant, where would you place your fulcrum for best
stability?
a. On the facial surface of a tooth near the tooth being instrumented
b. On the opposite arch (mandibular arch)
c. On the occlusal surface of a tooth near the one being instrumented
d. On the occlusofacial or occlusolingual line angle of a tooth near the
tooth being instrumented
18. What is the correct sequence in steps for executing a calculus removal
stroke?
a. Adjust instrument grasp, establish a finger rest, position the mirror,
adapt the cutting edge to the tooth
b. Position the mirror, establish a finger rest, adjust instrument grasp,
adapt the cutting edge to the tooth
c. Establish a finger rest, adjust instrument grasp, position mirror,
adapt cutting edge to the tooth
d. Position the mirror, establish a finger rest, adapt the cutting edge to
the tooth, adjust instrument grasp
19. The facial surface of tooth #3 is coated with a thin layer of
supragingival calculus. All the following instruments will remove this
calculus deposit efficiently EXCEPT a:

1466
 a. Posterior sickle scaler
b. Gracey curet
c. Universal curet
d. Standard ultrasonic tip

Case C
Synopsis of Patient History
Age: 87
Sex: M
Height: 5′9″
Weight: 188 lb

Vital Signs
Blood pressure: 122/86
Pulse: 59 bpm
Respiration: 14 rpm

Medical History
Sees a physician every 3 months for monitoring of cardiac condition and
cholesterol levels
Is compliant in taking medication and monitors fat intake
Client reports that it is typical for his blood pressure to “run a little high”

Dental History
Missing all third molars and #14 and #18
Two Maryland bridges on 6/7 and 10/11 replace congenitally missing
laterals
Gold onlay on #3 and gold inlays on #13 and #20
Large class II amalgams on #30 and #19 with overhangs on both M and D
of both teeth
Gingival tissues are inflamed and bleed easily on probing; moderate
bleeding interproximally in all posteriors
Tissue in mandibular anterior and premolar teeth is thin and tears easily

Social History
Retired pilot for United Airlines
Had a second career for 10 years as a salesman for sheet metal

1467
Chief Complaint
Has noticed bleeding when brushing and was told by his friend at the
retirement community he should have his teeth cleaned
Reports mouth has become very dry

Current Oral Hygiene Status

Moderate generalized interproximal calculus
Moderate plaque biofilm at gingival third
Probing depths range 4-7 mm with deepest readings in mandibular left
and maxillary right
Clinical attachment levels confirm generalized bone loss

Use Case C to answer questions 20 to 29.

20. While checking for subgingival calculus deposits on the mandibular
anterior teeth with an ODU 11/12 explorer, the clinician finds it difficult
to insert the explorer without unduly distending the tissue. Which of the
following techniques might cause less tissue distention?
a. Switch to an Orban-type explorer
b. Aim the point of the ODU 11/12 explorer toward the base of the
sulcus so that less of the working end is inserted in the sulcus
c. Switch to a pigtail explorer
d. Use a calibrated periodontal probe to locate calculus deposits
21. One of the client’s chief complaints is that his medication makes his
mouth dry. All the following are useful suggestions for the client to
minimize effects of xerostomia EXCEPT:
a. Increase intake of caffeine beverages to stimulate saliva production
b. Use toothpastes and mouthrinses specially designed for individuals
with xerostomia
c. Chew sugarless gum to increase the flow of saliva
d. Replace lost saliva with saliva substitutes
22. You are using hand instruments to remove the calculus deposits from
the client’s teeth. After 30 minutes, your hand muscles are noticeably
fatigued. Potentially, all the following can cause hand fatigue EXCEPT:
a. Glove fit is too big
b. Instrument handles are of small diameter
c. Instrument is not balanced

1468
 d. Using finger motion instead of wrist motion activation
23. A large piece of burnished calculus is present on the distal aspect of
tooth #2. Which instrument would be MOST effective in preparing the
burnished deposit for eventual removal with another periodontal
instrument?
a. Beavertail ultrasonic tip
b. Rigid Gracey 13/14
c. Periodontal file
d. Miniature Gracey 13/14 curet with an extended shank
24. The client has defective margins (overhangs) on the amalgam
restorations on two posterior teeth, reducing his ability to keep the area
clean with floss and resulting in chronic inflammation. What can you do
to help mitigate the circumstance?
a. Use a standard Gracey to pop off the extra amalgam
b. Use a sturdy posterior sickle apical to the overhang to try and
remove it
c. Use an ultrasonic tip designed to smooth defective margins on
restorations
d. Use a Quétin curet to smooth the extra amalgam
25. The client is missing teeth #14 and #16. What might be challenging
when trying to remove subgingival calculus deposits from the mesial
surface of tooth #15?
a. Keeping the instrument’s functional shank parallel to the long axis of
the tooth
b. Finding a secure intraoral fulcrum
c. Establishing 0-degree insertion with an area-specific curet
d. Probing the col
26. The client has two bridges to replace congenitally missing maxillary
lateral incisors. All the following statements are TRUE regarding patient
treatment EXCEPT:
a. There is no reason to probe around teeth #7 and #10
b. Since calculus does not form on pontics, there is no need to check
the pontics for calculus deposits
c. Avoid using the motor-driven polisher so as not to scratch the
restoration
d. Instrumentation of the abutment teeth is necessary to remove all

1469
 calculus deposits
27. Tooth #15 has supererupted, causing an exposed root surface. Which
of the following instruments is the BEST choice for removal of light
calculus deposits from the facial surface of the root?
a. Universal curet
b. Posterior sickle scaler
c. Gracey 11/12 curet
d. Periodontal file
28. After working for 15 minutes on the distal of tooth #3, the calculus
deposit remains. You decide to take a minute to assess your
instrumentation technique. Ensuring all the following steps will help
you effectively remove the deposit EXCEPT:
a. The instrument working end angulation is 70 to 80 degrees.
b. Only the toe-third of the working end is adapted to the tooth.
c. The instrument’s lower shank is parallel to the long axis of the tooth.
d. Your middle finger is on top of the handle to allow for greater
pressure against the tooth.
29. The client has dark-coral, friable tissue in the mandibular anterior
area. After instrumentation of the lower mandibular anterior teeth, there
is evidence of tissue trauma. All the following practices may cause tissue
trauma EXCEPT:
a. Using a standard versus miniature area specific curet
b. Using a cowhorn explorer instead of an Orban-type explorer
c. Repeatedly removing the working end from the sulcus or pocket
space and reinserting it again beneath the gingival margin after each
stroke
d. Adapting the anterior third of the working end

Case D
Michael is a precocious, 15-year-old high school senior with type 1
diabetes mellitus who struggles to keep his blood glucose levels stable.
His doctor has advised him to lose 30 pounds, but his weight has
plateaued at 250 pounds for his 5-foot, 8-inch frame. He presents for his
appointment with generalized marginal gingivitis, moderate bleeding on
probing, light calculus, and heavy plaque biofilm. Dental examination
revealed four new class V carious lesions on the facial of mandibular

1470
molars. He admits to drinking four cans of soda (Mountain Dew) a day.

Use Case D to answer questions 30 to 33.

30. In addition to controlling local oral factors—biofilm and calculus
deposits—the dental team should consider the all the following to assist
Michael in improving his oral health EXCEPT:
a. Consultation with Michael’s primary care or endocrinologist
b. Explain the connection between poor glycemic control and poor oral
health
c. Recommend a gingivectomy to control the marginal gingivitis
d. Brainstorm with Michael about alternative methods of biofilm
control that he would be more likely to use on a daily basis, such as a
water flosser instead of dental floss
31. The client’s mandibular anterior teeth are crowded and in
linguoversion, making it challenging to remove calculus deposits from
the lingual surfaces. Which of the following patient-positioning
suggestions is BEST to ensure an ergonomic instrumentation technique?
a. Ask the client to lower his chin (chin-down position)
b. Lower the back of the chair until it is parallel to the floor
c. Ask the client to keep his chin in an upward position (chin-up
position)
d. Put the chair in an upright position so the clinician can work from a
standing position
32. Before calculus removal, an explorer is used to determine the type,
amount, and location of calculus deposits. Which of the following
explorers is NOT recommended for calculus detection?
a. ODU 11/12
b. Shepherd’s hook
c. Orban type
d. Pigtail or cowhorn
33. During instrumentation for calculus removal using hand
instruments, your hand becomes fatigued. Self-assessment indicates you
have been using finger motion. Digital activation is acceptable for all the
following situations EXCEPT:
a. Using an ultrasonic for debridement
b. Using a calibrated probe to measure pocket depth

1471
 c. Looking for calculus using an ODU 11/12 explorer
d. Using a universal curet for calculus removal

Case E
Stacy accepts a new position as dental hygienist for a large dental
conglomerate, replacing an employee who held the position for the
previous 12 years. On her first day, Stacy notices that almost all the
instruments in her cassettes are dull and that a few have broken tips.
The instrument handles are narrower in diameter than the large-
diameter handles she previously used. In addition, the selection of
instruments in each cassette is limited to one anterior sickle, a standard
Gracey 11/12, and a standard Gracey 13/24.

Use Case E to answer questions 34 and 35.

34. Using a dull instrument inhibits efficient patient treatment. All the
following statements are TRUE about the importance of using a sharp
versus a dull instrument EXCEPT:
a. Calculus is more easily removed.
b. Heavier lateral pressure is applied.
c. Fewer strokes are necessary.
d. Stroke control is much improved.
35. At the end of the workday, Stacy notices muscle fatigue in her
dominant hand. All the following may cause muscle fatigue EXCEPT:
a. Narrow-diameter handles cause the clinician to use more grip
pressure, thus causing muscle fatigue.
b. A limited selection of instruments forces the clinician to use an
instrument that is not appropriate for the task at hand, such as using a
Gracey 11/12 to remove a heavy calculus deposit.
c. Dull instruments are not effective in removing calculus deposits.
d. Relaxing the fingers in the grasp after each calculus removal stroke
is inefficient and stresses the hand muscles.

Case F
Candy is a healthy 4-year old preschooler who presents at your office for
her 6-month recare appointment. Her mother assists with daily
toothbrushing and states that the family uses Colgate toothpaste and
ACT mouthwash. On examination, you do not identify any new carious

1472
lesions. There are no visible calculus deposits, but there is light plaque
along the gingival margins. The lingual surfaces of the teeth have light
stain from the fruit juice that Candy drinks daily.

Use Case F to answer questions 36 to 38.

36. All the following instruments can be used during treatment of a
pediatric patient EXCEPT:
a. Anterior sickle
b. Pigtail explorer
c. Universal curet
d. Ultrasonic instrumentation
37. Which of the following approaches to biofilm removal is likely to be
of MOST benefit to the patient’s ongoing oral health?
a. Guiding the child as she removes the biofilm herself during the
appointment
b. Using a universal curet to remove the biofilm
c. Using a rubber cup and prophy paste to remove the biofilm
d. Using a toothpick holder (Perio-Aide) to remove the biofilm
38. All the following are TRUE about power-driven polishing (rubber
cup polishing) EXCEPT:
a. Using a dry polishing agent with high speed can heat up the large
pulp chambers in primary teeth.
b. Only teeth requiring stain removal for esthetic purposes should be
polished with polishing agent.
c. Bacteremia can be induced during rubber cup polishing.
d. All teeth in the dentition should be polished with a rubber cup
polisher until all surfaces are shining.

Case G
Shirley, age 92, suffers from dementia. Her husband, also 92, drove her to
the appointment and sits in a corner of the treatment room to assist in
explaining the procedures to his wife. Shirley does not seem aware of her
surroundings, and although she has been your patient for the past 3
years, she does not know who you are or what you are doing. She
presents with generalized posterior recession of the gingival margin and
bone loss and moderate subgingival calculus.

1473
 Use Case G to answer questions 39 to 41.
39. You decide to use ultrasonic instrumentation for calculus removal.
Which of the following statements is TRUE about the correct technique
with ultrasonic instrumentation?
a. Keep the tip stationary and on top of a calculus deposit until you feel
or see it release.
b. Use moderate to firm pressure against a calculus deposit for more
effective removal.
c. Move the tip repeatedly over a calculus deposit, using light stroke
pressure, for efficient calculus removal.
d. Always set the power level to the highest setting for use with all
ultrasonic tips, because the high power setting is much more effective
than a medium power setting.
40. The client’s medical history presents a few challenges, so a thorough
assessment must be conducted. At what stage of treatment should you
assess the client for signs of anxiety?
a. After instrumentation of a few teeth
b. After reviewing the medical history and before beginning
instrumentation
c. While explaining what to expect during ultrasonic instrumentation
d. Before taking radiographs
41. All the following are ethical and legal concerns when treating this
client EXCEPT:
a. Obligation to protect the client from harm or injury during care
b. Following standard of care protocol for her treatment
c. Assessing for physician or specialty referrals
d. Having the patient’s daughter present at all times during treatment
42. Which of the following instruments would be BEST to remove
moderate to heavy calculus on the distal of tooth #29?
a. Rigid Gracey 13/14 curet
b. Posterior sickle
c. Quétin curet
d. Universal curet

1474
43. Removing the medium-sized subgingival calculus deposits from the
mandibular anterior teeth would be BEST accomplished using:
a. Straight ultrasonic tip
b. Anterior sickle
c. Standard Gracey 1/2
d. Universal curet

1475
44. Tooth #32 has drifted into the open space with a tilt, making it
challenging to assess the mesial surface accurately. When detecting
calculus with an ODU 11/12 explorer, it is important to take all the
following steps to ensure accuracy EXCEPT:
a. Maintain the explorer ’s lower shank parallel to mesial tooth surface
b. Use a fulcrum for stability
c. Instead of using the working-end normally used on a mesial surface,
switch to the opposite working-end for easier access
d. Use overlapping strokes to assess carefully the entire mesial surface
with the explorer

1476
45. The calculus deposit on the distal of tooth #18 has been burnished.
Which of the following hand instruments would be your FIRST choice
when beginning calculus removal?
a. Periodontal file
b. Standard Gracey 13/14
c. Posterior sickle
d. Universal curet

1477
46. Which of the following instruments is BEST for calculus removal
from a dental implant?
a. Plastic curet
b. Plastic periodontal probe
c. Standard Gracey curet
d. Miniature Gracey curet

1478
47. The patient’s periodontal diagnosis is chronic generalized
periodontitis. Teeth #28 and #29 have heavy calculus deposits. Which of
the following is NOT recommended for removing these calculus
deposits?
a. Begin calculus removal using a powered tip of a sonic device
b. Begin with a standard ultrasonic tip, approach the deposits from
both the facial and the lingual aspect of the sextant
c. Assess the amount, type, and location of the calculus deposits with a
periodontal explorer, such as an ODU 11/12
d. Once the heavy and medium-sized deposits have been removed, use
a slim-diameter ultrasonic tip to complete calculus removal

1479
48. Which instrument would be most efficient in removing supragingival
interproximal calculus deposits from the anterior teeth that exhibit
crowding?
a. Universal curet
b. Anterior sickle scaler
c. Gracey miniature 1/2 curet
d. Beavertail ultrasonic tip

1480
49. The client has multiple teeth restored with porcelain-fused-to-metal
crowns, many of which have defective margins. Which of the
instruments would you use FIRST to begin removal of the moderate
calculus deposits?
a. Thin ultrasonic tip
b. Gracey miniature 11/12 and 13/14 curets
c. Posterior sickle scaler
d. A universal curet

1481
50. The distal of tooth #18 has a large piece of calculus. When probing,
what is the BEST way to obtain accurate probing depth?
a. Insert the probe until it is obstructed by the calculus deposit; record
this measurement as the probing depth
b. To obtain an initial reading, move the probe over and around the
deposit and insert the probe to the base of the sulcus or pocket; record
this as an initial depth
c. Once the calculus deposit has been removed, use the probe to obtain
an accurate probing depth
d. Answers b and c would obtain the most accurate reading

1482
C HAPT E R
18

1483
Management of Pain and Anxiety*
Gwen L. Hlava; Todd N. Junge Subject Matter Consultants: Margaret J. Fehrenbach, Demetra
Daskalos Logothetis

As clinicians, dental hygienists must be able to manage the client’s pain

and anxiety. This requires mastery of head and neck anatomy, physiology,
pharmacology, medical emergencies, and clinical technique. Local
anesthetic administration is within the legal scope of dental hygiene
practice in most jurisdictions in the United States. This chapter reviews
four methods to relieve and manage pain and anxiety: (1) local anesthesia
with standard syringe, (2) topical anesthesia, (3) computer-controlled
local anesthesia delivery device, and (4) nitrous oxide–oxygen conscious
sedation.

1484
Characteristics and physiology of pain
A. Definitions
1. Pain—sensation of discomfort resulting from the stimulation of
specialized nerve endings called nociceptors (free nerve endings)
2. Pain perception—process whereby the sensation of pain is
transmitted from the periphery to the central nervous system
3. Pain reaction—result of pain perception; what a person will do about
the perceived pain
4. Pain-reaction threshold—amount of pain one must experience
before exhibiting a reaction
B. Pain reactions and pain-reaction thresholds vary from individual to
individual and within the same individual from day to day
C. Pain perception
1. Functional unit—neuron, or nerve cell
2. Types of nerve cells
a. Unipolar
b. Bipolar—transmits dental pain perception
c. Multi-polar
3. Sensory neuron characteristics (Fig. 18-1)

FIG 18-1 Sensory neuron showing the direction of impulse travel (red
arrow). (From Patton KT, Thibodeau GA: Anatomy and physiology, ed 8, St Louis,
2013, Mosby.)

a. Cell body

1485
 b. Nucleus
c. Axons (fibers, processors)
d. Free nerve endings (nociceptors)
4. Fiber diameter—varies; determines speed of impulse conduction
and type of pain perceived
a. A fibers—3 to 20 micrometers (µm, microns)
(1) Myelinated
(2) Rapid conduction (rate of 100 meters per second [m/s])
b. C fibers—0.5 to 1 µm
(1) Nonmyelinated
(2) Slow conduction (rate of 0.5 to 2 m/s)
5. Nerve trunk versus ganglia—a nerve trunk is an extremely large
bundle of nerve fibers or axons; a ganglion is the site where cell
bodies are bundled
D. Resting nerve cell membrane
1. Membrane potential—the difference in the electrical charges across
the nerve membrane
2. Membrane potential maintained by:
a. The sodium-potassium pump
b. The permeability of the cell membrane
3. Ions essential to nerve conduction
a. Potassium (K+) ions (predominately intracellular)
b. Sodium (Na+) ions (predominently extracellular)
4. Sodium-potassium pump; resting state polarized (unstimulated)

5. Permeability of the cell membrane—impermeable to sodium (at rest)

E. Minimal threshold stimulus
1. Stimulus—an environmental change that can be chemical, thermal,
mechanical, or electrical in nature
2. Minimal threshold stimulus—the magnitude of the stimulus
required to initiate a nerve impulse
3. “All-or-none” law—either the nerve fires as strongly as possible or it

1486
 does not fire at all
F. Excitation
1. When a minimal threshold stimulus excites the nerve:
a. The permeability of the cell membrane changes
(1) Influx—Na+ enters the cell
(2) Efflux—K+ diffuses to the outside of the cell
b. Reversed polarity

2. Depolarization—the time interval that exists while ionic concentrations

are reversing
3. Reversed polarity—the result of a reversal in ionic charges
4. Repolarization—occurs after reversed polarity; the membrane becomes
hyperpermeable to K+ and impermeable to Na+; polarity is reestablished
5. Action potential—rapid sequence of changes in the membrane
potential (negative to positive, and positive back to negative); the stages
are:
a. Depolarization—resulting in reversed polarity
b. Repolarization
6. Absolute refractory period—the period during depolarization and
reversed polarity when the cell membrane cannot be reexcited
7. Relative refractory period—during repolarization, the nerve cell
membrane can be reexcited, but it requires a greater stimulus than the
stimulus required for excitation from the resting state
G. Pain intensity determined by:
1. Number of fibers stimulated—depends on:
a. Anatomy of the area
b. Dimensions of the area being stimulated
2. Frequency of excitation—depends on duration of the stimulus
H. Pain reaction—determined by a person’s pain-reaction threshold
1. High pain-reaction threshold produces hyporeactive behavior
2. Low pain-reaction threshold produces hyperreactive behavior
3. Factors affecting the pain-reaction threshold

1487
a. Emotional state—most consistently reported, variable; greater
anxiety and negativity results in lower pain-reaction threshold
b. Fatigue—greater fatigue results in lower pain-reaction
threshold
c. Age—younger people experience a lower pain-reaction
threshold
d. Gender—variable

1488
Local Anesthesia Armamentarium
A. Definition—all items essential for the administration of a local
anesthetic agent
B. Armamentarium categories
1. Needle
a. Components (Fig. 18-2)

FIG 18-2 Components of a hypodermic needle. A, Shaft or shank,

the working end of the needle. B, Bevel, or angulation, of the tip. C,
Lumen, the hollow interior of the shaft. D, The hub holds the shaft
and is threaded onto the adapter of the syringe. E, The syringe end
enters the anesthetic cartridge. F, The protective shield sleeve
(colored end) covers the needle shaft. G, The protective shield
guard (clear or white) covers the syringe end of the needle. H, The
security seal holds the protective shield sleeve and guard together
until the hub is assembled and attached to the syringe.

b. Composition—stainless steel
c. Gauge (ga)—the diameter of the lumen is indicated by a number
(1) The larger the gauge number, the smaller the lumen
diameter
(2) The 25-, 27-, and 30-ga needles are the most common in
dentistry
d. Length—measured from hub to the point of bevel
(1) Short = 1 inch
(2) Long = 1⅝ inches
e. Method of sterilization—disposable needles come presterilized,

1489
 with a security seal
2. Anesthetic cartridge
a. Components (Fig. 18-3)

FIG 18-3 Components of the glass cartridge for the dental local
anesthetic. (Modified from Malamed SF: Handb ook of local anesthesia, ed 6,
St Louis, 2013, Mosby.)

(1) Metal cap end is directed toward the needle when the
cartridge is loaded into the syringe
(2) Round rubber diaphragm—the syringe end of the needle
penetrates this diaphragm and enters the cartridge
(3) Cylinder—glass tube containing the anesthetic solution
(4) Inscription—legally required information on the cartridge,
which includes:
(a) Volume—1.8 mL
(b) Anesthetic agent—generic and brand names
(c) Percentage of drug
(d) Vasoconstrictor
(e) Concentration ratio of vasoconstrictor
(f) Manufacturer
(g) Lot number
(h) Expiration date
(5) Rubber stopper—seals the opposite end of cartridge; it is
the movable component of the cartridge
b. Ingredients in the anesthetic solution
(1) Anesthetic drug
(2) Vasoconstrictor

1490
 (3) Preservative (sodium bisulfite)
(4) Sodium chloride—makes the solution isotonic
(5) Distilled water—inert ingredient
c. Method of storage—away from direct sunlight and ultraviolet
light, and maintained at room temperature (68 °F to 77 °F; 20 °C
to 25 °C) or slightly cooler
3. Anesthetic syringe (Fig. 18-4)

FIG 18-4A, Assembled breech-loading, metallic, cartridge-type syringe.

B, Disassembled local anesthetic syringe. (Modified from Malamed SF:
Handb ook of local anesthesia, ed 6, St Louis, 2013, Mosby.)

a. Components
(1) Adapter—the hub of the needle is threaded onto this part
of the syringe
(2) Barrel—holds the anesthetic cartridge

1491
 (3) Harpoon—the fishhook-shaped tip is forced into the
rubber stopper
(4) Piston rod—connects the harpoon to the thumb ring; can
be advanced to expel the solution or retracted to aspirate
(5) Large window—faces the operator during injection; rubber
stopper speed, positive aspirations, and volume are
observable
(6) Small window—aids in removing the used cartridge
(7) Spool finger grip—place of rest for the index and middle
fingers
(8) Thumb ring—enables the operator to aspirate or express
fluid from the cartridge
b. Method of syringe sterilization—the bioburden is removed; the
syringe is dried, packaged, and sterilized
c. Auxiliary materials—hemostat or cotton pliers; used if the
needle breaks
C. Record keeping and documentation in client dental record
1. Documentation requirements vary by state law
2. Documentation includes:
a. Time of administration
b. Type and percentage of drug administered
c. Type and ratio of vasoconstrictor
d. Amount of drug administered in milligrams
e. Name of injection(s) administered and the region of the mouth
in which the injection(s) is administered
f. Reactions to drug (if any)
g. The American Dental Association (ADA) Code D9215 for health
insurance reimbursement

1492
Local anesthetic agents (Table 18-1)
Chemical Structure

Table 18-1
Comparison of Frequently Used Local Anesthetic Agents in Dentistry

1493
* Reference value = Lidocaine@100%
A. Chemical components
1. Aromatic lipophilic group—for diffusion into the lipid nerve
membrane
2. Intermediate chain—determines if the agent is an ester or an amide;
also determines the potential for any allergic reaction
3. Hydrophilic group—required for diffusion into water-soluble tissues
B. Allergies related to chemical structure
1. A considerable amount of documentation on allergic reactions to
esters is available; because of their potential for causing allergic
reactions, esters are no longer used
2. Cross-reactivity occurs with esters; thus, if a client is allergic to one
ester, an allergic reaction will occur with all other ester derivatives
3. No substantiated cases, to date, of allergic reactions to amides
4. Cross-reactive allergic reactions do not occur among amides
5. In cases where the agent cannot be identified, the client should be
referred to an allergist for testing

Mechanism of Action
A. Physiologic effect—local anesthetics prevent cell membrane
permeability to sodium

1494
B. Properties of local anesthetics
1. Salt
a. Water soluble (hydrophillic)
b. Acidic
c. Charged, cation RNH+ (ionized)
d. Active form at site of action
e. Form present in dental cartridge (pH 3.3-6.0)
2. Free Base
a. Fat soluble (lipophillic)
b. Unstable
c. Alkaline
d. Uncharged, anion RN, nonionized
e. Penetrates nerve tissue
f. Form present in tissue (pH 7.4)
C. Dissociation—the ability of a drug to separate or part
1. Solution in cartridge is predominately acidic pH 3.3-6
2. Once injected into basic tissue pH 7.4 dissociation (loss of H+
molecule) of cation RNH+ (acid) to anion RN (base) occurs to
penetrate the nerve
3. Once in axoplasm molecules regain a H+ ion and revert back to
active RNH+ (ionized) form to block nerve conduction
D. Effects of inflammation—decreased anesthetic effect in areas of
inflammation; caused by three factors:
1. Decreased pH of tissues—causes dissociation to occur more slowly
or not at all
2. Edema—dilutes concentration of local anesthetic
3. Increased vascularity—facilitates rapid removal of drug from area
E. Nerve fiber susceptibility
1. Smaller, nonmyelinated fibers (C fibers) are the first to be blocked;
however, sensation is regained last in these fibers
2. Large, myelinated fibers (A fibers) are the last to be blocked;
however, sensation is regained first in these fibers

Potency
A. Definition—lowest concentration of drug needed to consistently
produce adequate anesthesia
1. Potency is related directly to lipid solubility
2. If a local anesthetic drug is highly potent, lower concentrations are
effective in achieving adequate anesthesia
3. Greater potency also equals greater chance of systemic toxicity (see

1495
 Table 18-1)

Toxicity
A. Definition—the amount of drug capable of causing adverse systemic
reactions in normal persons; adverse reactions occur when the rate of
drug absorbed is greater than the rate of biotransformation, the body’s
ability to metabolize the drug
B. True toxic reactions occur immediately—the most profound effects of
toxic reaction are on the central nervous system (CNS) and the
cardiovascular system
1. CNS effects
a. CNS stimulation phase—the person becomes extremely
talkative, restless, and anxious
b. CNS depression phase—convulsions may occur, in extreme
cases, unconsciousness may result
2. Cardiovascular effects
a. During the stimulation phase—the person’s blood pressure and
pulse rise rapidly
b. During the depression phase—the person’s blood pressure and
pulse drop significantly
3. Respiratory failure is the primary cause of death
4. Vital functions must be supported until the drug is eliminated by
biotransformation

Biotransformation (Metabolism)
A. Definition—process whereby the drug is broken down, changed, or
combined with other substances to render it physiologically inactive
B. Biotransformation (according to chemical group)
1. Esters—metabolized in plasma through the process of hydrolysis;
inactivated by plasma cholinesterase (an enzyme)
2. Amides—metabolized in the liver; history of cirrhosis, alcoholism,
liver disease or liver transplantation, and jaundice may affect the
rate of biotransformation
a. Lidocaine, mepivacaine, and bupivacaine are metabolized in the
liver
b. Prilocaine is metabolized in the liver and lungs
c. Articaine is metabolized 95% in the plasma and 5% in the liver

Topical Anesthetic

1496
A. Purpose—reduces the discomfort associated with the initial
penetration of the needle through the mucosa
B. Controversy exists with regard to widespread use
1. Dosage control—impossible to standardize because of variability in
factors such as operator, client, and area of operation
2. The concentration of the topical anesthetic used exceeds that which
is administered by injection (e.g., 5%, 10%, 20% topical anesthetic vs.
2%, 3%, or 4% local anesthetic)
3. Except for 5% lidocaine (Xylocaine), all other topical anesthetics are
esters
4. Lidocaine and prilocaine periodontal gel (Oraqix) is an amide; used
in adults who require limited pain control during root debridement
in periodontal pockets
5. Cetacaine—a combination of benzocaine, butamben, and tetracaine
hydrochloride—is an ester topical indicated in adults who require
preinjection, deep scaling, and suture removal anesthesia (available
in spray, liquid, or gel form)
C. Esters have a greater incidence of allergic reactions and cross-
reactivity than amides
D. Topical agents have indications and contraindications; can interact
with other medications; clinicians must always assess for potential
allergies, side effects, and adverse effects and take appropriate
precautions

Calculation of Maximum Recommended Dose for

Local Anesthetics
A. Maximum recommended dose (MRD)—maximum amount of drug
administered that does not produce a toxic reaction and is based upon
mg per pound or mg per kilogram
B. Maximum recommended doses of local anesthetic agents per
appointment for healthy patients
1. Lidocaine: 3.2 mg/lb, 7.0 mg/kg, 500 mg max
2. Mepivacaine: 3.0 mg/lb, 6.6 mg/kg, 400 mg max
3. Prilocaine: 4.0 mg/lb, 8.8 mg/kg, 600 mg max
4. Articaine: 3.2 mg/lb, 7.0 mg/kg, no max listed
5. Bupivacaine: 0.9 mg/lb, 2.0 mg/kg, (based on Canadian
recommendations, no US weight based recommendations), 90 mg
max
C. Steps to calculating maximum recommended dose and maximum
cartridges

1497
Step 1: Obtain necessary patient information
Step2: Calculate number of mg of anesthetic in one cartridge
Take the percentage of solution and multiply by 10.
Take the answer and multiply by 1.8 (mL in one cartridge) = mg of
anesthetic per cartridge.
(2% lidocaine: 20 × 1.8 = 36 mg/cartridge)
Step 3: Convert pounds to kilograms if using this unit of measurement
lb ÷ 2.2 = kg.
Multiply kilograms by mg/kg or pounds by mg/lb
120 ÷ 2.2 = 54.5 kg × 7 (mg/kg) = 381.5 mg (MRD)
or
120 lb ÷ 3.2 (mg/lb) = 384 mg (MRD)
This number may be different for each anesthetic and provides the
maximum recommended dose (MRD) in mg for the patient, based on
his/her weight.
Step 4: Divide the MRD (Step 3) by the number of mg of the selected
anesthetic per cartridge (Step 2) = maximum number of cartridges.
384 mg ÷ 36 = 10.6 cartridges
D. Calculating milligrams of anesthetic administered
1. Multiply number of cartridges administered by the number of mg of
anesthetic in each cartridge.
Administered 2.5 cartridges of 4% articaine: 2.5 × 72 (mg of articaine
in one cartridge) = 180 mg administered

Vasoconstrictors (Table 18-2)

A. Vasoconstrictors are combined with local anesthetics to counteract the
vasodilating properties of local anesthetics.

Table 18-2
Vasoconstrictors Available in the United States

B. Description—all vasoconstrictors can be referred to as adrenergic drugs

or sympathomimetic amines

1498
 1. Adrenergic drug—capable of producing the same effects as those of
adrenalin
2. Sympathomimetic amine—mimics the sympathetic nervous system
and contains an amine group within its chemical structure, which is
characteristic of vasoconstrictors
3. All vasoconstrictors can be produced synthetically; two naturally
occurring vasoconstrictors, epinephrine and norepinephrine, are
produced in the adrenal medulla and the sympathetic
postganglionic nerve fibers
4. There are two vasoconstrictors that are added to local anesthetic
drugs available in the US, epinephrine and levonordefrin.
C. Benefits of Vasoconstrictor:
1. Reduce systemic absorption of the local anesthetic agent
2. Decrease risk of systemic toxicity
3. Reduce blood flow through the area (hemostasis)
4. Increase duration of action of the anesthetic
5. Increase in the effectiveness of the local anesthetic by decrease in
diffusion
6. Lower dose of the local anesthetic agents required
D. Mode of action—stimulate α-adrenergic receptors located in the walls
of arterioles
1. α-Adrenergic receptors—responsible for arterial constriction
2. β-Adrenergic receptors—responsible for dilation
3. Each type of vasoconstrictor possesses varying degrees of response
of both α- and β-adrenergic activity (see Table 18-2); although
epinephrine exhibits the most β-adrenergic activity, to achieve the
same amount of vasoconstriction as epinephrine, the concentration
of all other vasoconstrictors must be increased
E. Termination of action—Once absorbed, the action of epinephrine is
terminated primarily by the reuptake action of adrenergic nerves, any
epinephrine that escapes the reuptake action is inactivated by enzymes
catechol-O-methyltransferase (COMT), and monoamine oxidase (MAO)
in the blood.
F. Pressor potency—the ability of a drug to produce vasoconstriction
1. Epinephrine—the most potent vasoconstrictor; pressor potency
value = 1
2. Levonordefrin—another type of adrenergic vasoconstrictor; pressor
potency value = ⅙
3. Concentrations of all vasoconstrictors must be increased to obtain
the same vasoconstrictive potency as that of epinephrine
G. Vasoconstrictors in solution—unstable; preservative (e.g., sodium

1499
bisulfite) is added to prevent oxidation
H. Toxicity—toxicity resulting from vasoconstrictor overdose is caused by
constriction of blood vessels, which raises blood pressure and cardiac
rate from β-adrenergic receptor stimulation
1. Symptoms
a. Increased blood pressure
b. Increased heart rate (tachycardia > 150 beats/min)
c. Talkativeness
d. Restlessness
e. Palpitations or irregular heartbeat
f. Headache
2. Prevention of cardiac emergencies—strict adherence to MRD in the
case of persons with cardiac disease (see Chapter 21)
I. Maximum recommended dose for vasoconstrictor drugs
1. Based on recommendations from the American Heart Association
and the New York Heart Association.
a. Based on “healthy” or “compromised” individuals, and not
weight dependent
b. See Table 18-2 for “healthy” and “cardiac” doses
J. Steps to calculating vasoconstrictor drug doses (using 1:100,000
epinephrine as the example)
Step 1: Obtain necessary patient information
Step 2: Calculate mg of vasoconstrictor in one cartridge of anesthetic
Example 1:100,000
1 g = 1000 mg/100,000 mL of solution = 0.01 mg vasoconstrictor/1 mL of
solution
To obtain amount in 1 cartridge multiply 0.01 × 1.8 mL (mL in one
cartridge) = 0.018 mg in one cartridge
Step 3: Convert MRD of vasoconstrictor to cartridges
Divide MRD by number of mg of vasoconstrictor per cartridge of
anesthetic (Step 2)
Healthy MRD = 0.2 mg ÷ 0.018 = 11.1 cart
Cardiac MRD = 0.04 mg ÷ 0.018 = 2.2 cart
K. Limiting drug (see Table 18-1)
1. When determining the safety of administering a specific quantity of
a particular anesthetic solution, you must calculate both the MRD of
the anesthetic drug and the MRD of the vasoconstrictor
2. In any local anesthetic solution containing a vasoconstrictor, either
the anesthetic drug or the vasoconstrictor drug will reach its MRD
first; when you have determined which of the drugs limits the total
amount of solution to be administered, you have determined the

1500
 limiting drug
3. Example: 150 pound healthy patient for 2% lidocaine 1:100,000
For the local anesthetic (lidocaine)
2% = 20 mg/mL × 1.8 mL = 36 mg (in one cartridge of lidocaine)
150 × 3.2 mg/lb = 480 mg MRD
480 mg ÷ 36 mg = 13.3 cartridges of lidocaine maximum
For the vasoconstrictor (epinephrine) calculation
1:100,000 = 1 mg/100 mL = 0.01 mg/1 mL × 1.8 mL = 0.018 mg (in one
cartridge of 1:100,000 epinephrine dilution)
0.2 mg (MRD of vasoconstrictor for healthy patient) ÷ 0.018 mg = 11.1
cartridges maximum
Because 11.1 is lower than 13.3, epinephrine is the limiting drug in
this example.

1501
Local anesthesia injections
Basic Injection Procedure
A. Steps to providing a successful injection
1. Preanesthetic patient assessment and consultation
2. Select anesthetic and dosage based upon preanesthetic patient
assessment
3. Confirm care plan
4. Obtain informed consent
5. Select injection(s) based upon the areas needing to be anesthetized,
presence of infection, and the need for hemostatis
6. Prepare and check equipment
7. Position patient in a supine position
8. Apply topical anesthetic
9. Dry tissue and visualize or palpate the penetration site to determine
any needle access problems
10. Establish a fulcrum
11. Make tissue taut
12. Keep syringe out of patient’s sight
13. Gently insert needle and slowly move toward target
14. Aspirate, if negative, slowly deposit anesthetic at a rate of 1 mL of
solution per minute
15. Observe the patient
16. Document the procedure

Injection Types
A. Supraperiosteal injection or local infiltration—anesthetizes small area,
usually one or two teeth and associated structures by injection near
apices
1. Can be administered on any tooth of either dental arch
2. Increased clinical effectiveness in maxillary arch more than
mandibular arch and mandibular anterior teeth than mandibular
posterior teeth
3. Target area—superior (or inferior) to apex (apices) near terminal
nerve endings
4. Injection site—needle should be inserted parallel to long axis of
tooth usually the height (or depth) of mucobuccal fold or lingual
tissue with bevel orientation of needle toward alveolar process
B. Nerve block (see next sections for Maxillary Nerve Blocks and
Mandibular Nerve Blocks, see Tables 18-3 and 18-4)—usually affects

1502
larger area of anesthesia than supraperiosteal injection and thus
additional teeth
1. Increased level of clinical effectiveness when compared to
supraperiosteal injection and can be administered at a distance away
from localized inflammation or infection
2. Fewer injections and lesser amounts of agent can be used for
anesthesia within a quadrant
3. Target area—Near larger nerve trunks

1503
Trigeminal nerve: maxillary nerve, second
division (V2)
See the section on “The Nervous System” in Chapter 4.

Maxillary Nerve Innervation

A. V2 branches within pterygopalatine fossa
1. Zygomatic nerve—fibers for lacrimal gland via lacrimal nerve
a. Zygomaticofacial nerve
b. Zygomaticotemporal nerve
2. Pterygopalatine nerves
a. Orbital branches
b. Nasal branches—including nasopalatine (NP) nerve (relevant
branch for local anesthesia)—both right and left nerves via
incisive foramen (with incisive papilla)
c. Palatine branches—communication between nerves at junctions
of distribution
(1) Greater palatine (GP) nerve (relevant branch for local
anesthesia)—via GP foramen
(2) Lesser palatine nerve—via LP foramen; possible gag reflex
by default when soft palate anesthetized with GP nerve
d. Pharyngeal branch
3. Posterior superior alveolar (PSA) nerve (relevant branch for local
anesthesia)—via superior dental plexus; join with IO nerve or
maxillary nerve
a. External branch—innervation of maxillary molars
b. Internal branch—via PSA foramina
4. Infraorbital (IO) nerve (relevant branch for local anesthesia)—
largest contributor via IO foramen; joins PSA nerve or maxillary
nerve directly
a. Anterior superior alveolar (ASA) nerve—via superior dental
plexus; possibly involved in crossover-innervation; joins with IO
nerve in IO canal
b. Middle superior alveolar (MSA) nerve—via superior dental
plexus in only 28% of cases; joins with IO nerve in IO canal
c. Lateral nasal nerve
d. Superior labial nerve
e. Inferior palpebral nerve

1504
Maxillary Nerve Blocks (See Table 18-3 and Fig. 18-5)

Table 18-3
Maxillary Nerve Blocks

Data from Logothetis DD: Local anesthesia for the dental hygienist, ed 2, St Louis, 2017,
Mosby.
ASA, Anterior superior alveolar; MSA, middle superior alveolar; IO, infraorbital; PSA,
posterior superior alveolar; GP, greater palantine; NP, nasopalantine.

1505
Trigeminal nerve: mandibular nerve, third
division (V3)
See the section on “The Nervous System” in Chapter 4.

Mandibular Nerve Innervation

A. V3 branches from undivided main nerve trunk within infratemporal
fossa
1. Meningeal branches (sensory)
2. Medial pterygoid nerve (motor)
B. V3 branches from divided nerve trunk
1. Anterior trunk
a. Lateral pterygoid nerve (motor)
b. Masseter nerve (motor)
c. Anterior deep temporal nerve (motor)
d. Posterior deep temporal nerve (motor)
e. (Long) buccal nerve (sensory)—relevant branch for local
anesthesia—does not serve buccinator muscle
2. Posterior trunk

1506
 FIG 18-5 Local anesthetic nerve blocks with the related structures that
are anesthetized. Note that the anterior middle superior alveolar, the
mental, and the Gow-Gates or Vazirani-Akinosi mandibular blocks are
not included (see also Table 18-3 and Table 18-4). (From Fehrenbach MJ,
Herring SW: Illustrated anatomy of the head and neck, ed 5, St Louis, 2017, Elsevier.)

a. Auriculotemporal nerve (sensory) (relevant brand for local

anesthesia)—can get anesthetized with IA nerve
b. Lingual nerve (sensory) (relevant branch for local anesthesia)—
can get damaged with oral surgery and local anesthesia
c. Inferior alveolar nerve (mixed) (relevant branch for local
anesthesia)—travels in mandibular canal; via mandibular
foramen; can be bifid with two mandibular foramina
(1) Mylohyoid nerve (motor but may provide accessory
sensory innervation for mandibular first molar)
(2) Mental nerve (sensory) (relevant branch for local
anesthesia)—via mental foramen
(3) Incisive nerve (sensory) (relevant branch for local
anesthesia)—travels in mandibular incisive canal; via
mental foramen; possibly involved in crossover-innervation

1507
Mandibular Nerve Blocks (Table 18-4)

Table 18-4
Mandibular Nerve Blocks

1508
Data from Logothetis DD: Local anesthesia for the dental hygienist, ed 2, St Louis, 2017,
Mosby.
IA, inferior alveolar nerve block; B, buccal nerve block; M, mental nerve block; I, incisive
block; G-G, Gow-Gates mandibular block; V-A, Vazirani-Akinosi mandibular block.

1509
Computer-controlled Local Anesthesia
Delivery Device (CCLADD)
CCLADD System Components
A. Three main components (Table 18-5):

Table 18-5
Comparison of Standard Syringe to Computer-Controlled Local Anesthesia Delivery Device
(CCLADD)

Standard CCLADD
Grasp and Palm grasp Pen grasp
needle Relies on large muscles of wrist, Control is transferred to small muscles of
control forearm, and shoulder fingers and thumb
Weighs 80 grams Weighs few grams
Held 9 inches from insertion site Held within 2 inches of insertion site
Fluid Thumb is used to start and stop flow Uses a foot control to deliver flow of agent
delivery of agent
Fluid Pressure and volume cannot be Maintains constant pressure and controlled
metering separated; thus is operator dependent volume
Aspiration Relies on operator control Automatic (on demand) by releasing foot
control
Needles Threaded hub in most cases; luer-lok Luer-Lok hub
in fewer cases Smaller gauge and length preferred
25-gauge, long and short 30-gauge
27-gauge, long and short 30-gauge, short
27-gauge, long
Path of Linear insertion (straight push Bi-rotational insertion (180°) between the
insertion through tissues, possibly causing thumb and index finger to overcome needle
needle deflection) deflection

1. Drive unit
2. Disposable plastic handpiece and tubing
3. Foot control that activates the unit and controls the two slow/fast
flow rates
a. Slow flow rate:
(1) Delivers 1 drop every 2 seconds
(2) 1.8 mL of anesthetic is delivered in 2 minutes
b. Rapid flow rate:
(1) Delivers a steady stream (30-gauge) or rapid drip (27-
gauge)
(2) Takes 1 minute to deliver the contents of cartridge

1510
Basic CCLADD Procedure
A. Decreases main causes of pain associated with dental injections that
include:
1. Initial tissue puncture
2. Depositing volume of fluid too rapidly into a confined space
B. Advantages of CCLADD (Table 18-5)
1. Eliminates initial pain from needle penetration by establishing
anesthetic pathway
2. Eliminates pressure pain by constant pressure and controlled
volume
C. Anesthetic pathway—anesthetic drip precedes the path of the needle
and can be used for any injection
D. Prepuncture technique used for palatal injections to increase comfort
1. Place bevel of needle against the tissue
2. Use cotton-tipped applicator on the top to seal bevel to tissue
surface
3. Initiate a rate of anesthetic for 2 to 3 seconds to force anesthetic
through surface epithelium before actual tissue penetration of
palatal tissue
E. Complications—postinjection pain, swelling, necrosis when
administered too rapidly and with too much agent

Computer-Controlled Local Anesthesia Delivery

Device (CCLADD) Injections
(Note: GP nerve block and NP nerve block can also use this device
effectively as well as other nerve blocks)
A. Anterior middle superior alveolar (AMSA) nerve block—palatal
approach
1. Teeth anesthetized—maxillary anterior teeth and premolars within
one maxillary quadrant; covering area served by ASA, MSA, GP, NP
blocks
2. Other structures anesthetized—facial periodontium and gingiva of
anesthetized teeth to midline; hard palate and palatal periodontium
and gingiva of the ipsilateral maxillary posterior teeth and maxillary
anterior teeth bilaterally; no regional soft tissue anesthesia of upper
lip and face but will need to administer PSA nerve block to complete
maxillary quadrant
3. Not as effective anesthesia for nonsurgical periodontal therapy due
to multi-tooth and pulpal anesthesia delivered from a single

1511
 injection increased deposition time, variable anesthesia, reduced
hemostatic control but with no numbness of lips and of muscles of
facial expression so used in cosmetic dentistry
4. Target area—pores in maxilla of hard palate allowing diffusion of
agent
5. Injection site—area on palate superior to apices of maxillary
premolars and midway between palatal gingival margin and median
palatal raphe (suture)
6. Amount—approximately 1.4 to 1.8 mL until blanching of tissue
7. Flow rate—slow flow rate
8. Needle—30-gauge extra-short or short
B. Palatal–anterior superior alveolar (P-ASA) nerve block
1. Teeth anesthetized—maxillary central incisors, lateral incisors, and
canines (lesser degree) in maxillary anterior sextant; covering area
served by bilateral ASA and NP blocks
2. Associated labial as well as palatal periodontium and gingiva
bilaterally
3. Not as effective anesthesia for nonsurgical periodontal therapy due
to multi-tooth and pulpal anesthesia delivered from single injection
with increased deposition time, variable anesthesia, reduced
hemostatic control but with no numbness of lips and facial muscles
of facial expression so used in cosmetic dentistry
4. Target area—anterior part of superior dental plexus and NP nerve
5. Injection site
a. Contralateral to incisive papilla
b. Needle should be reoriented to gain access to incisive canal
(and advance needle to bony wall and aspirate)
6. Amount—1.4 to 1.8 mL
7. Aspiration—required
8. Duration—60 to 90 minutes
9. Flow rate—slow flow rate
10. Needle—30-gauge extra-short or short
C. Periodontal ligament (PDL) injection
1. Teeth anesthetized—single tooth
2. Other structures anesthetized—associated periodontium and
gingiva of selected tooth
3. Pulpal anesthesia for single tooth or supplemental injection to block
or supraperiosteal injection or local infiltration
4. Target area—nearby terminal nerve endings at apex (or apices) so
agent can also flow into marrow spaces of alveolar bone proper
5. Injection site—maxillary and mandibular teeth

1512
 a. Long axis of tooth either mesial or distal with single-rooted
tooth; mesial or distal to each root for multirooted tooth
b. Into depth of gingival sulcus and then into alveolar bone proper
6. Aspiration—not necessary
7. Duration—1 hour
8. Flow rate—slow flow rate
9. Needle
a. 27-gauge extra-short or short for premolars and molars
b. 30-gauge extra-short or short for incisors
D. Intraseptal injection
1. Structures anesthetized—interdental periodontium and gingiva of
two adjacent teeth
2. Target area—terminal nerve endings within marrow of interdental
bone of alveolar process associated with adjacent periodontium and
gingiva of two or more teeth
3. Injection site—inject few drops and then use pressure to push
needle into interdental bone center of interdental papilla adjacent to
selected teeth
4. Aspiration—required
5. Duration—variable
6. Flow rate—slow flow rate
7. Needle—27-gauge short

1513
Local Anesthesia Complications
See Table 18-6

Table 18-6
Local Complications Associated with the Administration of Local
Anesthetics

1514
1515
From: Logothetis DD, Local anesthesia for the dental hygienist, ed 2, St Louis, 2017,
Mosby.

1516
Conscious sedation with nitrous oxide–
oxygen
A. Synonymous terms
1. Conscious sedation
a. The client is always awake and able to respond to verbal
commands
b. Protective reflexes are intact, including the ability to maintain
an open airway, breathe automatically, and cough, to avoid
aspiration
2. Inhalation sedation—nitrous oxide and oxygen gases are inhaled
through the nose
3. Nitrous oxide psychosedation—acts on the CNS in such a way that
pain impulses are not relayed to the cerebral cortex, or the
interpretation of pain impulses is altered
4. Relative analgesia
a. Refers to the state of sedation produced
b. Alters the mood and increases the pain reaction threshold but
does not totally block pain sensations
B. Chemistry
1. Nitrous oxide (N2O) properties
a. Stored as a liquid at 650 to 900 pounds per square inch (psi) in a
blue cylinder and delivered as a gas
b. The contents of the N2O cylinder cannot be determined by the
pressure gauge until it is almost empty
c. Colorless
d. Tasteless
e. Sweet smelling
f. Nonexplosive
g. Supports combustion
2. Oxygen (O2)
a. Stored as a gas in a green cylinder and delivered as a gas
b. Contents of the O2 cylinder can be determined by reading the
pressure gauge (full = 2100 psi)
3. Blood-gas solubility coefficient
a. The blood-gas solubility coefficient of N2O is 0.47, which means
that 100 mL of blood dissolves 47 mL of N2O
b. This blood-gas solubility coefficient accounts for the rapid onset
and recovery from the effects of the analgesic

1517
 c. N2O is 15 times more soluble in the blood than nitrogen; N2O
displaces nitrogen in blood
d. N2O does not compete with O2 and carbon dioxide (CO2) in
combining with the hemoglobin molecule
C. Pharmacology
1. N2O has no effect on heart rate, blood pressure, and the liver or the
kidneys, as long as an adequate amount of O2 is delivered
simultaneously
2. N2O affects all sensations (e.g., hearing, touch, pain, warmth)
3. N2O reduces the gag reflex but does not eliminate it
D. Physiology
1. N2O works by depressing the CNS
2. The exact mechanism of action is unknown; however, the effect
either alters the relay of nerve impulses to the cerebral cortex or
causes them to be interpreted differently
3. The client experiences reduced anxiety and increased tolerance to
pain
4. Pain perception is not blocked
5. N2O does not combine with any body tissues; it is the only
anesthetic that is not metabolized
6. The N2O molecule enters the bloodstream through the lungs, where
it displaces nitrogen and is eventually exhaled, unchanged, through
the lungs
7. Toxic reaction associated with too much N2O is hypoxia (lack of O2 to
the tissues), characterized by headache and nausea
E. Stages of anesthesia
1. Stage I: Analgesia stage—client feels pain but is not bothered by it;
this stage has three planes; the first two planes are appropriate for
dental hygiene care
2. Stage II: Delirium or excitement stage—hyperresponsiveness to
stimuli; exaggerated inhalations and loss of consciousness
3. Stage III: Surgical anesthesia—used in oral and maxillofacial
surgery; this stage has four planes
4. Stage IV: Respiratory paralysis—the patient is no longer breathing
independently
F. Indications for use
1. Mild apprehension
2. Refusal of local and general anesthesia
3. Allergy to local anesthesia

1518
 4. Hypersensitive gag reflex
5. Intolerance for long appointments
6. Cardiac conditions
7. Hypertension
8. Asthma
9. Cerebral palsy
10. Intellectual and developmental disabilities
G. Relative contraindications to use
1. Pregnancy
2. Communication difficulties
3. Nasal obstruction
4. Emphysema
5. Multiple sclerosis
6. Emotional instability
7. Epilepsy
8. Negative response to past experience
H. Advantages and disadvantages of use
1. Advantages
a. History of cardiovascular disease—O2 enrichment coupled with
stress reduction
b. Simple, relatively safe procedure to perform
c. Minimal equipment
d. No restraining straps or pharyngeal airways
e. The client is awake and responsive
f. Rapid onset of and recovery from the effects of the anesthetic
g. No need for the client to be accompanied by someone to the
appointment
h. No preoperative tests or food intake restrictions required
i. No need for the patient to spend time in a recovery room
2. Disadvantages
a. Oversedation causes vertigo, nausea, or vomiting
b. Difficult behavioral problems cannot always be managed
c. Instrumentation in the maxillary anterior region difficult
because of the presence of the mask over the nose of the client
I. Signs and symptoms of N2O-O2 sedation
1. Objective signs—directly observed by the clinician in the client
a. Being awake
b. Lessened pain reaction
c. Drowsy, relaxed appearance
d. Normal eye reaction and pupil size

1519
 e. Normal respiration
f. Normal blood pressure and pulse
g. Minimal movement of limbs
h. Flushing of skin
i. Perspiration
j. Lacrimation
k. Little or no gagging or coughing
l. Speech infrequent and slow
2. Subjective symptoms—reported by the client
a. Mental and physical relaxation
b. Indifference to surroundings and passage of time
c. Lessened pain awareness
d. Floating sensation
e. Drowsiness
f. Warmth
g. Tingling or numbness
h. Sounds seeming distant
J. Equipment
1. Cylinders—blue indicates N2O; green indicates O2
2. Gas machine
a. Yokes
b. Flowmeter
c. Pressure gauge
d. Reservoir bag
e. Gas hose
3. Mask
a. Only masks with two-hose scavenging systems reduce the N2O
exhaled into the air and breathed in by the operator
b. Scavenging systems reduce environmental N2O contamination
from 900 to 30 parts per million (ppm)
c. Maximum allowable contamination in health care environments
is 50 ppm
K. Safety measures
1. Color-coded tanks—blue (N2O) versus green (O2)
2. Pin Index System—ensures that the N2O cylinder does not fit into
the yoke that holds the O2 cylinder, and vice versa
3. Diameter Index System—the diameter of the hole at the top of the
cylinder (O2 or N2O) fits only with corresponding cylinder head
4. Audible alarm system—emitted when O2 runs out
5. Automatic turnoff—occurs when O2 is depleted

1520
 6. Oxygen maintained at 2 to 3 L at all times in most units
7. Oxygen flush—fills the reservoir bag with 100% O2
L. Record keeping and documentation in the client’s dental record
1. Documentation will vary according to the laws of the state or the
legal jurisdiction
2. Documentation includes:
a. Tidal volume (TV) in liters (L)
b. Amount of N2O in liters or percentage
c. Amount of O2 in liters or percentage
d. Duration of sedation
e. Oxygenation period (5 minutes O2/15 minutes N2O delivered)
f. Client’s response
g. ADA Code D9230 for health insurance reimbursement

Website Information and Resourc es

Source Website Address Description
Essential https://itunes.apple.com/us/app/essential- Study bony landmarks, nerves, and muscles
Skeleton 4 skeleton-4/id623811668?mt=8 pertaining to the administration of local
anesthesia
Dental—Head https://play.google.com/store/apps/details? Same as above
and Neck id=com.jass.refapp8
Anatomy

1521
Suggested readings
American Dental Association (ADA): Glossary of dental clinical and
administrative terms CDT 2011–2012, Chicago, IL.
Fehrenbach MJ, Herring SW: Illustrated anatomy of the head and neck,
ed 5, St. Philadelphia, 2017, Saunders/Elsevier.
Logothetis DD: Local anesthesia for the dental hygienist, ed 2, St
Louis, 2017, Elsevier.
Malamed S.F. Handbook of local anesthesia. ed 6 St Louis: Mosby;
2013.
Walsh M.M. Nitrous oxide-oxygen analgesia. In: Darby M.L., Walsh
M.M., eds. Dental hygiene theory and practice. ed 4 Philadelphia:
Saunders; 2015.
Walsh M.M., Darby M.L. Local anesthesia. In: Darby M.L., Walsh
M.M., eds. Dental hygiene theory and practice. ed 4 Philadelphia:
Saunders; 2015.

Chapter 18 review questions

Answers and rationales to review questions are available on this text’s
accompanying Evolve site. See inside front cover for details.

1. The potency of an anesthetic agent is primarily a result of its:

a. Water solubility
b. Protein solubility
c. Lipid solubility
d. Carbohydrate solubility
2. The nerve that travels the mental foramen is a branch of the:
a. Inferior alveolar nerve
b. Middle superior alveolar nerve
c. Lingual nerve
d. Posterior superior alveolar nerve
3. Sodium bisulfite is added to a cartridge of anesthetic to increase the
stability of the:
a. Distilled water
b. Vasoconstrictor

1522
 c. Hydrochloride salt
d. Plasma cholinesterase
4. Which of the following explains why the administration of a local
anesthetic into an area of inflammation has a decreased effect?
a. Inflamed tissue has a high pH.
b. The local anesthetic remains in the salt form (ionized).
c. Vascularity is decreased in the area of the inflammation.
d. The local anesthetic is converted to the free base (un-ionized).
5. All the following statements are TRUE about lidocaine EXCEPT:
a. It is an amide-linked compound.
b. It is used in 2% concentrations.
c. It forms a salt with a strong acid that is water soluble.
d. Its lipophilic portion is ester-linked to the amino group.
6. Which of the following gauge numbers indicates the needle with the
smallest lumen?
a. 30
b. 27
c. 5
d. 23
7. The maxillary division of the trigeminal nerve is:
a. Sensory only
b. Motor only
c. Sensory and motor simultaneously
d. Mostly sensory and minimally motor
8. The type and size of a nerve plays an important part in the
development of adequate anesthesia. All the following are TRUE about
nerves and anesthesia EXCEPT:
a. Myelinated nerves require a greater concentration to be blocked.
b. Myelinated nerves require less time to be blocked.
c. Smaller nerve fibers are the last to regain sensation.
d. Smaller nerve fibers are blocked before the larger ones.
9. Anesthetics decrease or limit the sensation of pain by:
a. Decreasing the firing threshold

1523
 b. Preventing depolarization
c. Repolarizing the nerve membrane
d. Causing hyperpolarization
10. Saltatory conduction refers to:
a. Rapid transmission of nerve impulses along a myelinated nerve fiber
b. Diffusion of sodium into the nerve cell during impulse conduction
c. Conduction of an impulse along a nonmyelinated nerve fiber at the
nodes of Ranvier
d. None of the above
11. The sensory receptors responsible for the initiation of pain perception
are:
a. Meissner ’s corpuscles
b. Ruffine’s end organs
c. Free nerve endings
d. Pacini’s corpuscles
12. When does depolarization of a nerve fiber occur?
a. During the resting state of the fiber
b. Because of the sodium pump
c. During the relative refractory period
d. Between the polarization stage and reverse polarity
13. An environmental change capable of initiating a nerve impulse is
termed:
a. Minimal threshold stimulus
b. Initiation stimulus
c. Firing mechanism
d. The “all or none” law
14. The anesthetic solutions injected into the tissues are:
a. Acidic salts
b. Strong acids
c. Weak bases
d. Alkaloids
15. The lipophilic portion of an anesthetic molecule allows the anesthetic
solution to:

1524
 a. Diffuse through the nerve tissue
b. Diffuse through osseous tissue
c. Diffuse through the interstitial tissues
d. Be absorbed by the blood supply
16. Which acid is most often combined with a local anesthetic drug?
a. Sodium bisulfite
b. Sodium chloride
c. Acetic acid
d. Hydrochloric acid
17. The patient’s medical history indicates past liver damage. Why is the
amount of amide-based anesthetic solution a relative contraindication?
a. Amides increase the risk of an allergic reaction.
b. Amides undergo biotransformation in the liver.
c. Without action by the liver, amides will be reabsorbed.
d. Amides are absorbed much slower at the injection site.
18. All the following ingredients are contained within an anesthetic
solution EXCEPT:
a. Sodium chloride
b. Sodium bisulfate
c. Water
d. Vasoconstrictor
19. Local anesthetic drugs are bases; the local anesthetic solution injected
into the tissues are weak bases.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement if FALSE; the second statement is TRUE.
20. The lipophilic portion of an anesthetic molecule allows the anesthetic
solution to diffuse through the interstitial tissues; the hydrophilic
portion allows the solution to diffuse through the nerve membrane.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.

1525
21. Vasoconstrictors are added to local anesthetic agents to increase
duration and:
a. Reduce toxicity by increasing the efficiency of the heart
b. Reduce toxicity by slowing absorption
c. Extend the overall shelf life
d. Help speed up the detoxification process
22. Where are vasoconstrictors metabolized?
a. Liver
b. Plasma
c. Bloodstream
d. Kidneys
23. For what purpose is epinephrine added to either prilocaine or
lidocaine local anesthetic agent?
a. Prolongation of anesthesia
b. Reduction of hemorrhage in field of operation
c. Constriction of blood vessels in area of injection
d. Prevention of toxic effects from too-rapid absorption
e. All the above
24. Which of the following vasoconstrictor agents is used with
mepivacaine (Carbocaine) 3%?
a. Neo-Cobefrin
b. Epinephrine
c. Levophed
d. Benzocaine
e. None of the above
25. After starting the root-plaing procedure, you encounter considerable
bleeding from the client's sulcular tissues. After consulting with the
dentist, it is decided to administer a local anesthetic for hemostasis.
Which component of the local anesthetic will help to achieve hemostasis?
a. Anesthetic salt
b. Vasoconstrictor
c. Sodium bisulfite
d. Distilled water
26. What is the pressure in a FULL tank of oxygen (O2)?

1526
 a. 700-800 psi
b. 900-1100 psi
c. 1400-1600 psi
d. 1800-2100 psi
27. What is the pressure in a FULL tank of nitrous oxide (N2O)?
a. 650-900 psi
b. 900-1100 psi
c. 1400-1600 psi
d. 1800-2100 psi
28. What is the pressure of a HALF-FULL tank of O2?
a. 700-800 psi
b. 900-1100 psi
c. 1400-1600 psi
d. 1800-2100 psi
29. What is the pressure in a HALF-FULL tank of N2O?
a. 650-900 psi
b. 900-1100 psi
c. 1400-1600 psi
d. 1800-2100 psi
30. Which of the following is TRUE concerning N2O?
a. A full tank would read approximately 2100 psi.
b. It exists as a gas in the tank and is delivered as a gas.
c. It can be administered and monitored by dental hygienists in all
states.
d. It may induce nerve damage if used chronically.
31. The use of a scavenging system with N2O sedation equipment is
desirable because it:
a. Removes the odor of nitrous from the room
b. Assists the patient’s respiration
c. Removes any potentially toxic waste gas from the environment
d. Allows the patient to inhale room air through the nosepiece
32. Which of the following patients would NOT be a good candidate for
the use of N2O?

1527
 a. “Gagger ”
b. Pediatric patient
c. Patient with heart disease or a heart attack
d. Patient with chronic obstructive pulmonary disease
33. In monitoring the use of N2O, the patient should be in which stage of
general anesthesia?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
34. The ideal concentration range of N2O is:
a. 10% to 25%
b. 30% to 50%
c. 50% to 60%
d. 60% to 70%
35. The dental hygienist administered 2.4 cartridges of 3% mepivacaine.
How many milligrams were administered?
a. 129.6 mg
b. 135.7 mg
c. 138.4 mg
d. 125.2 mg
36. How many cartridges of lidocaine 2% 1:100,000 epinephrine
anesthetic agent can be safely administered to a 120-lb patient taking
tricyclic antidepressants?
a. 1.1 cartridges
b. 2.2 cartridges
c. 3.3 cartridges
d. 4.4 cartridges
37. How many cartridges of prilocaine 4% anesthetic agent can a healthy
130-lb patient receive?
a. 6.8 cartridges
b. 7.2 cartridges
c. 7.8 cartridges
d. 8.3 cartridges

1528
38. What is the target area for the inferior alveolar nerve block?
a. Mandibular foramen
b. Lateral surface of mandibular ramus
c. Anteromedial border of neck of mandibular condyle
d. Retromolar pad or triangle
39. What is the injection site for the posterior superior alveolar nerve
block?
a. Retromolar pad or triangle
b. Maxillary tuberosity
c. Pterygopalatine fossa
d. Superior to maxillary canines
40. How can you determine a positive aspiration with the computer-
controlled local anesthetic delivery device?
a. Blood will be noticed in the glass cartridge.
b. Blood will be noticed in the plastic tubing only.
c. Blood will be noticed at the needle hub.
d. The unit will beep rapidly if aspiration is positive.

Case A
Synopsis of patient history
Age:40
Sex: F
Height: 5′6″
Weight: 160 lb

Vital Signs
Blood pressure: 125/82 mm Hg
Pulse: 75 bpm
Respiration: 16 rpm
1. Under the care of a physician: x YES ___NO
2. Hospitalized within the last 5 years: x YES ___ NO
Reason: _________________________________________________
3. Has or had the following conditions:
_______________________________________
_______________________________________

1529
4. Current medications:
Occasional aspirin
Daily OTC multi-vitamin
5. Smokes or uses tobacco products: x YES ___ NO
6. Is pregnant: ___ YES x NO

Medical History
Client has a history of smoking ½ pack of cigarettes for the past 20 years.

Dental History
Client’s oral hygiene is fair.
AAP classification = III

Social History
Client is a single divorced mother who works two jobs and has three
young children.

Chief Complaint
Client recently acquired dental insurance and wants teeth cleaned and
an examination.

Current Oral Hygiene Status

1. Client brushes 1-2 times a day
2. Never flosses
3. Interproximal bleeding generalized

Supplemental Oral Examination Findings

1. Previously extracted teeth #1, #16, #17, and #32
2. Mandibular anterior teeth have crowding
3. Attrition on anterior teeth with moderate supragingival calculus
4. Moderate to slight interproximal subgingival deposits throughout

Use Case A to answer questions 41 to 50.

41. Which nerve is involved when anesthetizing the palatal gingiva of the
maxillary lateral incisor?
a. Middle superior alveolar nerve
b. Nasopalatine nerve
c. Infraorbital nerve
d. Anterior superior alveolar nerve

1530
 e. Inferior alveolar nerve
42. After administering a posterior superior alveolar nerve block, the
maxillary first molar remains sensitive, but the maxillary second and
third molars are anesthetized. Which of the following would be the BEST
explanation?
a. Anesthetic agent was deposited too high
b. Not enough anesthetic agent was deposited
c. Mesiobuccal root is normally not anesthetized by posterior superior
alveolar nerve block
d. Anesthetic agent was deposited too low
43. Which nerve is involved when anesthetizing the facial gingiva of the
maxillary canine?
a. Middle superior alveolar nerve
b. Nasopalatine nerve
c. Infraorbital nerve
d. Anterior superior alveolar nerve
e. Inferior alveolar nerve
44. When lingual nerve is anesthetized, which of the following tissue will
NOT be affected?
a. Anterior two-thirds of the tongue
b. Floor of the mouth
c. Lingual gingiva
d. Palatal periodontium
e. Lower lip
45. The soft tissue of alveolar process of the mandible is innervated by:
a. Buccal and lingual nerves only
b. Buccal and mental nerves only
c. Buccal, lingual, and mental nerves
d. Buccal and inferior alveolar nerves only
46. Which injection anesthetizes the palatal gingiva and palatal mucosa
of tooth #14?
a. Middle superior alveolar nerve block
b. Posterior superior alveolar nerve block
c. Anterior middle superior alveolar nerve block (palatal approach)

1531
 d. Greater palatine nerve block
47. Which nerve is involved when anesthetizing the mandibular first
premolar?
a. Middle superior alveolar nerve
b. Nasopalatine nerve
c. Infraorbital nerve
d. Anterior superior alveolar nerve
e. Inferior alveolar nerve
48. To prepare the maxillary right premolars for nonsurgical periodontal
therapy, which of the following nerves need to be anesthetized?
a. Right buccal nerve only
b. Right MSA and greater palatine nerves
c. Right ASA only
d. Right PSA only
49. When anesthetizing the mental nerve, which of the following tissues
will be affected?
a. Facial gingiva of mandibular molars and mandibular second
premolar
b. Floor of the mouth as well as lower lip
c. Lingual gingiva of mandibular teeth
d. Facial gingiva of mandibular anterior teeth and mandibular first
premolar
e. Skin of upper cheek as well as lower chin
50. Following the administration of local anesthesia to anesthetize teeth
numbers 1 - 3 you notice a faint bluish discoloration on her cheek. You
check introrally and find the same discoloration near the injection site
along with swelling. What is the most probable cause of this mark?
a. The anesthetic cartridge was contaminated with alcohol
b. The needle created a tear in the blood vessel
c. The hygienist used a needle of too fine a gauge
d. The hygienist injected too rapidly

*Gwen L. Hlava, Todd N. Junge, and the publisher acknowledge the past contributions
of Danielle Leigh Ryan to this chapter.

1532
C HAPT E R
19

1533
Dental Hygiene Care for Clients
with Special Care Needs
Susan Lynn Tolle

Every person has unique abilities and needs. Two of every five clients
treated in the oral health care environment may require a modified care
plan because of special care needs. These special care needs may be
transient, such as pregnancy or a broken foot, or may be lifelong, such as
end-stage renal disease or intellectual and developmental disabilities.
With ongoing health care reforms and improved access to care for
underserved populations, dental hygienists will be serving increased
numbers of persons with special care needs in a variety of settings. The
National Institute of Dental and Craniofacial Research describes persons
requiring special care as those with genetic or systemic disorders that
affect oral, dental, or craniofacial health; whose medical treatments cause
oral problems; or whose intellectual or physical disabilities complicate
oral hygiene or dental treatment.

1534
General considerations
Life Span Approach to Care
A. Principles of growth, development, and maturation
1. Growth includes physical and functional maturation
2. Growth is generally a continuous and orderly process but can be
modified by numerous factors (e.g., nutritional deficiencies)
3. Different parts of the body grow and mature at different rates
4. Critical periods exist in growth and development
5. Hormonal changes can alter:
a. Physical stature and function
b. Mental state and mood
c. Oral status
d. Immunity and host response
6. During growth and maturation, a person’s perception of self and of
self in relation to others changes
7. Health status generally progresses from acute illness to chronic
illness
8. Transition from one life stage to another is gradual and not
necessarily based on chronologic age
9. Biologic age is not synonymous with chronologic age
10. Signs of aging can appear at any age
B. The U.S. health care system (see the section on “Provision of Oral
Health Care” in Chapter 20)
1. The current system is categorical, with many gaps in services
2. A continuum of services through people’s life stages must ensure:
a. Universal access
b. Continuity of care
c. A comprehensive philosophy of care
d. A system of planned change
3. Health care providers should consider:
a. Heterogeneity of persons bearing the same label
b. Individualized approach to care
4. Oral health needs and approaches to care can differ throughout a
person’s life cycle (Table 19-1)

1535
 Table 19-1
Life-Span Approach to Oral Health Care

Usual Oral
Life Stage General Care Concerns
Concerns
Early Teaching parents and caregivers oral care skills Oral infections
childhood Preventing early occurrence of caries or trauma (protecting Dental caries
developing teeth) Dental
Controlling risk factors development
Preventing vertical and horizontal disease transmission
Childhood Developing positive dental attitudes and behaviors Dental caries
Teaching self-care skills Dental
Controlling risk factors development
Preventing vertical and horizontal disease transmission Gingivitis
Adolescence Motivating toward self-responsibility for seeking and Dental caries
receiving care Periodontal
Controlling risk factors for disease diseases
Preventing oral injuries Dental
Tobacco use cessation development
Young adult Decreasing barriers and integrating oral health care into Periodontal
daily schedule diseases
Tobacco use cessation
Midlife Maintaining status and preventing deterioration
Controlling risk factors
Tobacco use cessation
Older adult Motivating to continue preventive care and accept new Periodontal
theories and interventions diseases
Decreasing barriers to care Dental caries
Controlling risk factors Oral cancer
Tobacco use cessation
Elderly Maintaining status and function and preventing infections Periodontal
adult and tooth loss diseases
Controlling risk factors Dental caries
Tobacco use cessation Oral cancer
Fractures, tooth
loss
Oral infections

Incidence and Prevalence of Individuals with Special

Needs
A. National statistics on incidence and prevalence figures are difficult to
compile because of:
1. Unreliable reporting systems
2. Variable and changing definitions of conditions

1536
 3. Differences between acute conditions versus chronic conditions
4. Overlap in data when dealing with multiple conditions
B. More than 60 million persons (1 in 5 persons) are considered
“disabled” as defined by the Americans with Disabilities Act; of these,
approximately 1 million are children younger than 6 years
C. In the United States, 38.3 million persons are considered to have a
severe disability
D. Table 19-2 identifies the most common chronic conditions in the older
adult population

Table 19-2
Leading Chronic Conditions in the Older-Adult Population

Noninstitutionalized Older Adults Nursing Home Residents

Arthritis Arthritis
Hypertension Heart disease
Hearing impairments Mental illness
Heart disease Paralysis

E. The most common disabilities in the United States are caused by

cardiovascular disease, stroke (CVA), obesity, arthritis, cancer, and
diabetes
F. The prevalence of disability increases with age
1. Of persons in the United States age 5 to 15, 6% are disabled
2. Of persons in the United States age 16 to 64, 12% are disabled
3. Of persons in the United States age 65 and older, 41% are disabled
G. Of individuals with developmental disabilities, 80% live in
community-based residences or at home with families

The Dental Hygienist and Individuals with Special

Needs
A. Recognize physical, mental, medical, social, and oral needs
B. Communicate with clients and caregivers in a positive, appropriate,
nondiscriminatory manner
C. Communicate with other professionals and team members to facilitate
planning, implementation, and coordination of care
D. Plan, implement, and evaluate community-based and office-based
programs
E. Adapt dental hygiene care plans, interventions, and evaluations to
meet clients’ special needs, considering:
1. Barriers to care

1537
 2. Resources
3. Personal skills and abilities
4. Cultural values and beliefs
F. Identify and eliminate potential barriers to care
G. Assess one’s own attitudes, values, and commitment to provision of
oral health services to these clients
H. Evaluate local, state, regional, and national trends for their potential
impact on the provision of oral health care
I. Advocate oral health promotion and disease-prevention programs, full
use of dental hygienists, and development of sound research so that
evidenced-based care is provided in oral health care programs

General Definitions
These definitions tend to change frequently and often overlap.
A. Labeling—the process of classifying persons for educational, medical,
or financial reasons
B. Barrier-free environment—facilities that are physically accessible to
everyone
C. Normalization—making available patterns and conditions of everyday
life that are as close as possible to the norms and patterns of mainstream
society
D. Mainstreaming—integration of persons with special needs into
community-based programs and services
E. Access to oral health care—opportunity for each individual to enter
into the oral health care system and use needed services

Goals of Normalization for Persons with Special Care

Needs
A. Ensure the same legal and civil rights as others
B. Guarantee appropriate education for continued learning
C. Increase or maintain social skills and problem-solving abilities
D. Increase employment options and decrease employer discrimination
E. Ensure comprehensive network of community resources

Potential Barriers to Oral Health Care

A. Accessibility
1. Financial
a. One fourth of the older adult population has an inadequate

1538
 income level; percentages are higher for women, ethnic
minorities, and single heads of household
b. Between 65% and 85% of disabled persons live near the poverty
level
c. Medicaid coverage for oral health care is extremely variable
across states and often does not cover older-adult care
d. Medical and pharmaceutical expenses for many persons with
disabilities consume a major portion of their income
e. Many individuals with special needs who have limited incomes
cannot afford standard private practice fees for dental care, have
no health insurance, or are underinsured
2. Transportation and geography
a. More than 50% of the disabled and older adult population live
in urban settings; the remainder live in small rural communities
or on farms
b. Public transportation is often unreliable, confusing,
unaffordable, or nonexistent
c. Clients with special care needs often rely on others for
transportation to dental appointments, which increases their
dependence and makes scheduling and compliance difficult
d. Homebound, hospitalized, or institutionalized clients
frequently cannot be transported for care in the community
3. Physical facilities
a. Minimum standards for accessibility must be met by dentists
according to the Americans with Disabilities Act of 1993
b. External barriers include parking lots and spaces, walkways,
curbs, stairs, narrow doors and entryways, heavy or pressurized
doors, and small-print signs
c. Internal barriers include narrow passageways or doors, cluttered
rooms or hallways, loose rugs or heavy shag carpets, abrupt
changes in floor textures, and bathrooms without grab-bars or
other modifications
B. Psychosocial concerns
1. More than 50% of persons in the United States express positive
attitudes toward older adults and persons with disabilities, and yet
most really perceive these populations as “different” and “inferior ”
2. Society perceives disabilities, differences, and disease states before
recognizing similarities
3. Feelings of guilt, anxiety, apathy, inadequacy, embarrassment,
depression, anger, and resentment about special needs interfere
with attempts to seek care

1539
 4. Fear of or inability to comprehend dental procedures, antisocial or
atypical behavior, or dependency on oral health care providers
interferes with provision of care
5. Basic daily needs and activities are often overwhelming and can
lower the priorities for oral health care
6. Perception of self-image and worth can affect care planning
C. Provider philosophy and provision of care
1. The Americans with Disabilities Act requires that public and private
dental offices serve persons with disabilities, that treatment is
provided on the same basis as for nondisabled persons, and that
dentists make reasonable modifications to facilitate access
2. Despite the Americans with Disabilities Act, surveys indicate some
dentists are unwilling to treat persons who are physically or
mentally challenged
3. Reasons given for not treating individuals with special needs
include:
a. Inadequate facilities and equipment
b. Inadequate training (knowledge and competencies)
c. Not wanting to expose “normal” clients to “special” clients
d. Inability to collect adequate fees
e. Additional effort and time required
f. Personal discomfort about perceived “differences” of special
clients
g. Treatment of medically complex persons increases insurance
premiums
D. Communication and cultural concerns
1. Sensory impairments (hearing, visual) limit the client’s ability to
transmit and receive communications when scheduling or
undergoing oral care or participating in oral health care education
2. The use of technical terminology or inappropriate language level
may interfere with understanding
3. Differences in communication styles (eye contact, physical proximity
and contact, formal vs. informal speech, cultural variations, use of
nonverbal cues and verbal language) can impair effective
communication
4. Use of condescending voice tones or language levels closes off
communication lines
5. Foreign language barrier may deter a client from seeking care or
reduce effectiveness of care
6. Inadequate numbers of health care providers possess cross-cultural
competence

1540
E. Medical concerns
1. Situations compromising the provider or client
a. Inadequate infection control procedures
b. Inadequate or inaccurate health histories
c. Inadequate precautions for potential emergencies
d. Inadequate knowledge of systemic conditions and their
treatments
F. Mobility and stability concerns
1. Impaired ambulation or use of assistive devices may hinder access to
care
2. Uncontrolled or sudden movements may interfere with home care or
dental hygiene interventions
3. Uncontrolled or aggressive behavior may endanger the care
providers and the client
4. Spatial disorientation may interfere with client relaxation in the
dental chair or with oral care procedures

1541
Specific conditions
See Chapters 8 and 9.

Developmental and Cognitive Challenges

A. Definition
1. Subaverage intellectual functioning originating during the
developmental period and associated with impairment in adaptive
behavior (formerly known as “mental retardation”)
2. Not the same as mental illness
3. Label represents a highly heterogeneous group of persons
4. Most common developmental disability
B. Incidence—2% to 3% of the U.S. population (57.7 million total),
depending on criteria
C. Levels of intellectual disabilities—intelligence quotient (IQ)
1. Mild—approximate IQ 50 to 70 (89%)
2. Moderate—approximate IQ 40 to 55 (6%)
3. Severe—approximate IQ 25 to 40 (3.5%)
4. Profound—IQ below 20 (1.5%)
D. Etiology—acquired (12%), inherited (13%), unknown (75%)
1. Viral infections and toxemias (rubella, meningitis, lead poisoning)
2. Trauma and physical or chemical agents (child abuse; fetal alcohol
syndrome)
3. Disorders of metabolism or nutrition (phenylketonuria, PKU)
4. Gross brain disease (atrophy or neoplasms)
5. Genetics
6. Gestational disorders (Rh incompatibility, anoxia, prematurity)
7. Environmental (lack of stimulation)
E. Signs, symptoms, and clinical manifestations
1. Variable, depending on etiology and individual circumstances
2. Unusual difficulty in learning and applying what is learned to issues
of daily living
3. Skull or other craniofacial anomalies may exist
a. Microcephaly—small cranium that restricts brain growth
b. Hydrocephaly—expansion of the cranium from excessive
accumulation of cerebrospinal fluid
c. Malformation or asymmetry of growth
4. General developmental delays
5. Other possible manifestations include motor incoordination, mental
deficiencies, visual or hearing disorders, specific learning

1542
 disabilities, maladaptive behaviors, emotional disturbances, medical
disabilities, and self-injurious behaviors
F. Oral manifestations
1. Most oral health problems are not inherent to the disability but are
related to extrinsic factors (e.g., neglect by caregivers or lack of
coordination leading to poor oral disease control)
2. Decayed-missing-filled surfaces (DMFS) scores comparable with
those of the general population, but the “decayed” component may
be higher because of lack of professional treatment (Fig. 19-1)

FIG 19-1 High incidence of dental caries is common and most likely
related to neglect. (From National Oral Health Information Clearinghouse, National
Institute of Dental and Craniofacial Research: Oral conditions in children with special
needs: a guide for health care providers, March 2011.)

3. Higher prevalence of periodontal conditions, probably related to

poor oral hygiene and lack of regular care
4. Higher incidence of malocclusion and deviations in tooth eruption is
associated with craniofacial syndromes and growth abnormalities
(Figs. 19-2 and 19-3)

1543
 FIG 19-2 Delayed tooth eruption is a common oral condition in children
with developmental disabilities. (From National Oral Health Information
Clearinghouse, National Institute of Dental and Craniofacial Research: Oral conditions
in children with special needs: a guide for health care providers, March 2011.)

FIG 19-3 Malocclusion is a common oral finding in children with

developmental disabilities. (From National Oral Health Information
Clearinghouse, National Institute of Dental and Craniofacial Research: Oral conditions
in children with special needs: a guide for health care providers, March 2011.)

1544
 5. Some cases of enamel dysplasia more frequently seen in those with
severe mental deficiency resulting from prenatal or perinatal defect
or insult
6. Thick flaccid lips, microglossia, bruxism, tooth anomalies such as
microdontia and abnormal eruption patterns

Fetal Alcohol Spectrum Disorders (FASD)

A. Definition
1. An umbrella term describing a pattern of malformations caused by
maternal alcohol consumption during pregnancy
2. Characterized by prenatal and postnatal growth deficiency,
dysmorphic facial features, and central nervous system (CNS)
dysfunction
3. FASD include fetal alcohol syndrome (FAS), alcohol-related
neurodevelopmental disorders (ARND), and partial fetal alcohol
syndrome (PFAS)
B. Incidence and prevalence
1. Incidence of FASD is 0.3 to 1.5 per 1000 live births
2. Leading known preventable cause of mental impairments and birth
defects in the United States
C. Etiology
1. Severity of fetal alcohol effects is dose dependent
2. No safe amount of alcohol known during pregnancy
3. Effects related to differences in blood alcohol content and
differences in tissue susceptibility
4. Alcohol affects the cell membrane and cell migration, thus altering
the organization of embryonic tissue
5. The fetal brain is most susceptible during the third trimester
6. Metabolic disturbances can impair fetal cell division and growth
D. Signs, symptoms, and clinical manifestations can range from mild to
severe
1. Premature or postnatal (or both) growth retardation—results in
short stature, slight build, small head, low body weight
2. Craniofacial dysmorphia—short eye openings, short upturned nose,
smooth philtrum, flat midface, thin upper lip
3. Nonspecific abnormalities in any organ system, depending on the
time of alcohol insult
4. Wide IQ range, many within the developmental/cognitive-challenged
range
5. Limited ability to read and write, but with minimal comprehension;

1545
 also language problems
6. Poor social judgment and socialization skills
7. Hyperactivity and short attention span
8. Problems with heart, kidneys, and bones
9. Skeletal and ear disorders
E. Oral manifestations
1. The majority of children with developmental and cognitive
challenges have oral problems related to tooth eruption,
malformations, or malpositioning of teeth (usually class II or III
malocclusion) (Fig. 19-4)

FIG 19-4 Tooth anomalies showing variations in eruption patterns and

size and shape of the teeth. (From National Oral Health Information
Clearinghouse, National Institute of Dental and Craniofacial Research: Oral conditions
in children with special needs: a guide for health care providers, March 2011.)

2. Some may have V-shaped or cleft palate

3. Moderate to severe gingivitis is seen

Down Syndrome
A. Definition and etiology
1. Mental or intellectual disorder

1546
 2. Associated with an anomaly of chromosome 21 (trisomy 21) in all or
some body cells
B. Incidence—most common chromosomal abnormality (1 in 691 live
births; but varies with maternal age); approximately 400,000 individuals
in the United States affected
C. Signs, symptoms, and clinical manifestations
1. Mild to profound developmental and cognitive challenges
2. Poor muscular development, with hyperflexibility and hypotonia
during childhood
3. Short stature, with delay in skeletal maturation
4. Short neck; extremities with broad stubby fingers
5. High incidence of congenital heart defects (30% to 50%); language,
vision (60%), and hearing problems (75%); risk of leukemia (less
than 1%), thyroid problems, and immunologic defects
6. Abnormal craniofacial features
a. Small brachycephalic skull
b. Round flat facies
c. Small nasomaxillary complex
d. Ocular hypotelorism (eyes closer together than normal)
e. Epicanthal folds
f. Strabismus (convergent eyes)
g. Simian crease (single transverse palmar crease)
h. More susceptible to infection because of poor immune response
D. Oral manifestations (Fig. 19-5)

1547
 FIG 19-5 Common facial characteristics shown in a person with Down
syndrome. (From Regezi JA, Sciubba JA, Jordan CK: Oral pathology: clinical pathologic
correlations, ed 7, St Louis, 2017, Elsevier.)

1. Relative mandibular prognathism as a result of a small

nasomaxillary complex
2. Dry skin and thick, dry, fissured lips
3. Open-mouth posture, with a protrusive, fissured tongue
4. Hyperplasia of the adenoids and tonsils
5. Altered salivary gland mechanism (decreased flow)
6. Increased susceptibility to severe periodontal disease of early onset,
especially in anterior areas; may be related to host immune defects
(e.g., periodontitis as manifestation of systemic disease)
7. Delayed eruption of teeth and abnormal tooth development
8. Higher incidence of congenitally missing teeth
9. Small tooth crowns with short crown/root ratio
10. Enamel dysplasia (Fig. 19-6)

1548
 Discoloration and enamel dysplasia associated with
FIG 19-6
developmental defects. (From Regezi JA, Sciubba JA, Jordan CK: Oral pathology:
clinical pathologic correlations, ed 7, St Louis, 2017, Elsevier.)

11. Malocclusion—anterior open bite or cross-bite, posterior cross-bite,

malocclusion common
12. Attrition
13. High palatal vault (Fig. 19-7)

FIG 19-7 High-arched palate with decreased width and length. (From
Regezi JA, Sciubba JA, Jordan CK: Oral pathology: clinical pathologic correlations, ed
7, St Louis, 2017, Elsevier.)

E. Risk of associated conditions—increased risk for congenital heart

defects, leukemia, respiratory conditions, and Alzheimer ’s disease

1549
Autism Spectrum Disorders (ASD)
A. Definition
1. A group of developmental disorders that affect the functioning of
the brain, resulting in specific behavioral and communicative
difficulties; speech, language and communication, social interaction,
sensory impairments, play, and repetition of behaviors are key areas
affected
2. Wide range of symptoms and behaviors with considerable individual
variation
B. Incidence and prevalence
1. Incidence not completely known; prevalence rate of autism is
increasing 10% to 17% annually
2. Unclear if the increase is real or reflects better diagnostic practices
3. Occurs in as many as 1 in 68 children
4. Five times more common in boys (1 in 42 vs. 1 in 189 girls)
5. Appears during the first 3 years of life
C. Etiology—different theories
1. Psychogenic theories
2. Genetic theories
3. Biochemical deficit theories
4. Neurophysiologic theories
D. Signs, symptoms, and clinical manifestations
1. Great variability in expression; no standard type
2. Extreme aloneness; failure to develop eye contact, to cuddle as
infants normally do, to develop social relationships, or to perceive
others’ feelings
3. Language disturbances—repetitious speech, pronoun reversals, lack
of ability to use gestures; failure to develop functional speech in 50%
4. Comprehension problems, especially with verbal directions
5. Obsessive about maintaining routines and sameness of the
environment (resistance to change)
6. Abnormal response to stimuli; may not respond to pain; or may have
constant movement and repetitious activity
7. Sensitivities to sight, hearing, touch, smell, and taste
8. May be aggressive or self-abusive
E. Oral manifestations
1. None directly associated with the syndrome; difficult behaviors,
feeding problems, and poor cooperation are challenges to dental
care
2. Oral care may be neglected because of issues with communication,

1550
 physical limitations, sensory stimulation, and socialization

Attention Deficit Hyperactivity Disorder (ADHD)

A. Definition
1. Developmental and behavioral disorder affecting specific areas of
learning or impulse control that can cause problems in acquiring
new skills
2. Relates primarily to vision, hearing, language, attention, and touch
B. Incidence and prevalence
1. Much controversy over diagnosis and treatment
2. One of most common neurobehavioral disorders of childhood and
occurs in 11% of school-age children 4 to 7 years old
3. More than 6.4 million persons have been diagnosed with ADHD
4. More common in boys at 13.2 % than girls at 5.6%
5. Affects up to 60% of adults who had ADHD in childhood
C. Etiology—unknown, but may be related to:
1. Neurologic deficits or neurochemical imbalances
2. Emotional factors
3. Environmental toxins
4. Genetic factors
D. Categories—areas of CNS function affected
1. Input—receiving, recognizing, and decoding messages (e.g.,
auditory-perceptual or visual-perceptual problems)
2. Organization—information storage, integration with other
information, and prompt retrieval (e.g., short-term memory
problem)
3. Output—management of movement or utterances (e.g.,
hyperactivity, apraxia)
E. Signs, symptoms, and clinical manifestations
1. Hyperactivity and inattentiveness
2. Irritability, impulsiveness, and need for immediate satisfaction
3. Problems with concentration and memory
4. Immaturity, clumsiness
5. Lack of sense of direction, position, or time
6. Problems in reading, writing, or math
F. Oral manifestations—none directly associated

Emotional Disturbance and Mental Illness

A. Definition

1551
 1. Any disease or condition affecting the brain that impairs thinking,
feeling, behavior, or all of these functions
2. Leading cause of disability in the United States
3. Many suffer from more than one mental disability at any given time
B. Incidence and prevalence
1. Approximately 57.7 million persons in the United States over age 18
affected (26.2% of population)
2. At some point in life, 10% of all adults will need or benefit from
some form of mental health intervention
3. Major depression, bipolar disorder, schizophrenia, and obsessive-
compulsive disorder are among top 10 leading causes of disability
C. Etiology—depends on the type of disturbance
1. Heredity (genetics)
2. Environmental stressors (e.g., death, divorce, financial problems,
dysfunctional family life)
3. Biology (dysfunctional neurotransmitters and neurologic chemical
imbalances)
4. Psychological trauma
D. Classification—three common classes:
1. Psychoneuroses—anxiety, depressive, obsessive, or conversion
reactions
2. Personality disorders—situational or adjustment reactions
3. Psychoses—schizophrenia
E. Signs, symptoms, and clinical manifestations—depend on the type of
disorder
1. Inner tensions create anxiety, frustration, fears, and impulsive
behavior
2. Examples of behavior
a. Translation of fears or anxieties into physical symptoms
b. Regression to earlier forms of behavior
c. Displays of hostility or aggression
d. Withdrawal into fantasy (e.g., daydreaming)
e. Fear of failure and criticism
f. Development of substitute fears, phobias, or compulsions
F. Oral manifestations
1. None directly associated
2. May see intraoral trauma resulting from unusual habits or
aggressive behavior
3. May have xerostomia as a side effect of medications
4. With compulsive behavior, may have immaculate oral hygiene

1552
Disorders of Eating
See signs and symptoms of disordered eating in the section on “Energy
Balances and Weight Control” in Chapter 12.
A. Definitions
1. Anorexia nervosa
a. Psychophysiologic condition characterized by suppression and
denial of sensation of hunger
b. Person may be socially isolated and relatively asexual
c. Consumption of only 300 to 600 calories per day is common
d. Often come from middle-class to upper-class families with high
parental or societal expectations
e. Perfectionists, competitive, and overachievers
f. Deny their emaciated appearance
g. Diagnosis based on person’s refusal to maintain normal body
weight for height and age; intense fear of becoming fat despite
being underweight; denial of the seriousness of the starvation
and a distorted body image
2. Anorexia bulimia
a. Syndrome involving episodic binge eating and purging
b. Purging involves self-induced vomiting and use of laxatives,
diuretics, or enemas
c. Often occurs after failed attempts to lose weight through dieting
d. May be of normal weight
e. Usually outgoing and sexually active
f. Calories consumed during bingeing range from 3500 to 20,000
g. Vomiting episodes may last from 5 to 30 minutes
h. Diagnosis of bulimia if there are at least two bulimic episodes
per week for 3 months
B. Incidence and prevalence
1. About 90% are female; 1.1% to 4.5% of the U.S. population have
eating disorder in their lifetime; rate is increasing yearly
2. Occurs in 1 in 200 white adolescent females
3. Occurs in 3% to 20% of college students
4. Most common age group is 12 to 35 years; also occurs in older adults
5. From 27% to 42% of persons with anorexia indulge in bulimia
6. Mortality rate of 9%
C. Etiology—multiple interactive causes
1. Depressive illnesses
2. Fear of obesity
3. Endocrine changes at puberty

1553
 4. Feelings of low self-esteem and poor body image
D. Signs and symptoms
1. Anorexia nervosa
a. Intense fear of becoming obese; refusal to maintain normal
weight
b. Disturbance of body image
c. Weight loss of at least 25% of original body weight, not caused
by physical illness
d. Downy growth of body hair (lanugo)
e. Periods of overactivity
f. Dry, flaky skin
g. Lowered blood pressure, body temperature, and pulse
h. Episodes of bulimia
i. Complications include cardiac arrhythmia from reduced heart
muscle mass and electrolyte imbalance from dehydration
2. Anorexia bulimia
a. Awareness that eating pattern is abnormal
b. Depression and self-deprecating thoughts
c. Repeated attempts to lose weight
d. Recurrent bingeing (rapid intake of food in a short period),
usually high-calorie, easily ingested food
e. Inconspicuous eating
f. Termination of episodes by purging with self-induced vomiting,
laxatives, diuretics, and enemas
g. Weight fluctuation more than 10 pounds
h. Dehydration
i. Electrolyte imbalance
E. Oral manifestations
1. Esophageal lacerations and chronic sore throat from repeated
vomiting
2. Parotid gland swelling and xerostomia
3. Burning sensation in the tongue
4. Perimyolysis (dental erosion), dentinal hypersensitivity, and
margination of amalgams from acid erosion of vomiting; lingual
surfaces of maxillary incisors most often affected
5. Rampant caries from high consumption of sucrose, xerostomia, and
dehydration
6. Irritated soft tissues from vomiting, dehydration, and vitamin
deficiencies
7. Dentinal hypersensitivity and vitamin deficiencies

1554
Alzheimer’s disease
A. Definition
1. Progressive irreversible brain disorder characterized by intellectual
and cognitive disturbance, behavioral changes, and eventually a
state of complete dependence
2. Three types:
a. Early onset—diagnosis before age 65
b. Late onset—occurs after age 65
c. Familial—entirely inherited; onset often in the 40s
B. Incidence and prevalence
1. Estimated 5.2 million cases in the United States
2. About 1 in 9 older Americans has Alzheimer ’s disease
3. Estimated 130% increase expected by 2050
C. Signs, symptoms, and clinical manifestations—different parts of the
brain affected in varying degrees but reflect neuronal degeneration
1. Early
a. Memory loss and inability to concentrate
b. Anxiety, irritability, withdrawal, petulance
c. Abnormal sleep patterns
d. Motor abnormalities, including exaggerated reflexes and gait
disturbances
2. Later
a. Apathy, depression
b. Disorientation, lack of judgment and understanding
c. Incontinence
D. Risk factors
1. Age—greatest risk factor
2. Family history
3. Mild cognitive impairment
E. Oral manifestations
1. None specific to the condition
2. Disease states usually are a result of neglect, the aging process, or
any accompanying chronic illnesses

Seizure Disorders
See the section on “Seizures and Convulsive Disorders” in Chapter 21.
A. Definitions
1. Not a disease; the term seizure disorders is used to describe
symptoms of recurrent or chronic brain dysfunction
2. Characterized by discrete, recurring behavioral manifestations that

1555
 include disturbances of balance, sensation, behavior, perception, or
consciousness
3. Should not be confused with one-time seizures that result from drug
overdoses, brain tumors, or other problems
4. Seizure—an episode of cerebral dysfunction produced by abnormal
excessive neuronal discharge; not necessarily a recurring condition
5. Convulsion—a broad range of behavioral manifestations, including
seizure activity
6. Aura—a specific sensation preceding a seizure, lasting from one to
several seconds and manifested as:
a. Numbness, tingling
b. Unusual smell perception
c. Peculiar sound perception
d. Feeling of nausea or fear
7. Status epilepticus
a. Continuous convulsion lasting longer than 5 minutes
b. May lead to death from heart failure, kidney failure, or both
c. Constitutes a medical emergency
B. Incidence and prevalence
1. Affect almost 3 million people in the United States
2. About 200,000 new cases of seizure and epilepsy are diagnosed in
the United States each year
3. Prevalence is highest among children, with occurrence of 5.2 to 7.3
per 1000 school-age children
4. About 10% of Americans will have at least one seizure in their
lifetime
C. Etiology
1. Prenatal
a. Maternal infections
b. Fetal growth abnormalities or prematurity
c. Chromosomal disorders
d. Toxicity or damage from drugs or radiation
e. Genetic influences
2. Perinatal
a. Delivery problems
b. Anoxia
3. Postnatal
a. Degenerative brain disease
b. Injury
c. Tumors
d. Prolonged high fever

1556
 e. Parasitic infections
f. Toxic agents (including alcohol and drugs)
4. Unknown
D. Types—can be classified by the origin of the seizure, the cause, or the
type of seizure activity
E. Signs, symptoms, and clinical manifestations
1. Generalized tonic-clonic (grand mal)
a. May experience an aura
b. Loss of consciousness
c. Tonic movements (voluntary muscles experience continuous
contractions)
d. Clonic movements (intermittent muscular contraction and
relaxation)
e. Interruption of respiration and dilation of pupils
f. Loss of bladder or bowel control
g. Seizure activity usually lasts 1 to 3 minutes
h. Lethargy and disorientation follow the return of consciousness
i. May occur any time during the day or only during sleep
2. Generalized absence (petit mal)
a. Transient loss of consciousness
b. May have minor motor movements of the eyes, head, or
extremities
c. Lasts 5 to 30 seconds
d. Person may not be aware of having had a seizure
3. Complex partial (psychomotor)
a. May be preceded by an aura
b. Transient clouding of the consciousness
c. Behavioral alterations
d. Purposeless, repetitive, and stereotypical movements or actions
e. Changes in affect or perception
f. May become antisocial
g. Person usually does not remember the incident
4. Atonic
a. Type of seizure that consist of a brief lapse in muscle tone
b. Caused by temporary alterations in brain function
c. Seizures are brief, usually less than 15 seconds
d. Originate in childhood and may persist into adulthood
F. Oral manifestations
1. Orofacial trauma—lips, tongue, buccal mucosa, teeth, facial bones,
or jawbone
2. Drug-induced gingival enlargement from phenytoin (Fig. 19-8)

1557
 FIG 19-8 Drug-induced gingival enlargement associated with medication
taken to control seizures. (From Regezi JA, Sciubba JA, Jordan CK: Oral
pathology: clinical pathologic correlations, ed 7, St Louis, 2017, Elsevier.)

a. More marked in anterior regions and facial surfaces

b. Does not occur in edentulous areas
c. Correlated with poor oral hygiene
d. Characteristically pale, pink, and fibrous
e. Aesthetic concerns caused by gingival enlargement
f. Severe gingival enlargement may displace teeth, create
malocclusion, and compromise esthetics
g. Superimposed inflammation occurs from food retention or
mouth breathing
h. Can sometimes be alleviated through meticulous oral hygiene,
surgery, or pressure appliances

Visual Impairment
A. Definitions
1. Visual impairment—when visual acuity in the best eye is no better
than 20/200 after correction, or if central or peripheral vision
impairment is present
2. Legally blind—visual acuity of less than 20/200 with correction
B. Incidence and prevalence
1. Approximately 0.6 in 1000 persons in the United States is legally or
totally blind
2. Visual impairments occur in 12.2 in 1000 persons under age 18

1558
 3. About 5 million persons in the United States over age 65 have severe
visual impairment
4. Leading cause of vision loss in those 25 to 74 years old is diabetic
retinopathy
C. Etiology—congenital, perinatal, postnatal, aging
1. Trauma
2. Disease (infections, inflammation, toxicity)
3. Structural or developmental defects
a. Nearsighted
b. Farsighted
c. Astigmatism
4. Retrolental fibroplasia—high concentration of oxygen in the
incubators of premature infants causes hemorrhage of retinal blood
vessels, scarring, and retinal detachment
5. Macular degeneration (loss of central vision)
6. Retinitis pigmentosa—night blindness and loss of peripheral vision
7. Diabetic retinopathy—retinal hemorrhages
8. Glaucoma—failure of liquid in the eye to drain, resulting in
increased pressure, pain, and destruction of the optic nerve
9. Cataracts—clouding and opacity of the lens blocking light
perception (mainly associated with aging or congenital problems)
D. Signs, symptoms, and clinical manifestations
1. Wears glasses or contact lenses
2. Awkward ambulation or bumping into objects
3. Eye pain
4. Constant tearing
5. Unusual squinting or blinking
6. Use of a guide dog or cane
7. Deliberate, slow actions
8. Attention to details and orderliness
9. Cloudy or fuzzy vision
10. Problems with glare
11. Double vision (diplopia)
E. Oral manifestations
1. No particular dental problems
2. Gingivitis, if the person cannot see the gingiva to monitor gingival
health
3. Trauma to the orofacial area if the person experiences frequent
accidents or falls

1559
Hearing Impairment
A. Definitions
1. Hearing impairment—defective but functional hearing
2. Deaf—unable to understand speech, even with the use of an aid
3. Frequency—length of the sound wave (vibrations per second, or
cycles per second [cps, hertz]; human range is 16,000 to 30,000
cps/Hz)
4. Intensity—measured in decibels (dB); human range is 1 to 100 dB
B. Incidence and prevalence
1. Approximately 31.5 million deaf and hearing-impaired persons in
the United States (10% of population); 66% of those affected are age
65 or older; 1 in 6 persons age 41 to 59 have a hearing impairment
2. Two to three cases of congenital hearing loss in 1000 live births
3. Hearing loss is associated with a number of other disabling
conditions
a. Cleft palate (90%)
b. Cerebral palsy (20%)
c. Down syndrome (70%)
4. Environmental causes are increasing
C. Classifications—usually by severity of loss, as measured in decibel
loss (Table 19-3)

Table 19-3
Hearing Loss and Probable Outcomes

D. Types of hearing loss (Table 19-4)

1560
Table 19-4
Description of Hearing Problems

Condition Characteristics
Acoustic Benign tumor of the auditory nerve; causes gradual hearing loss, tinnitus, and
neurinoma dizziness

Mastoiditis Inflammation of the air cells of the mastoid

Ménière’s Condition of the inner ear characterized by hearing loss, tinnitus, and vertigo
disease
Otitis media Inflammation of the middle ear caused by infection
Otosclerosis Disease characterized by formation of spongy bone in bone surrounding the inner
ear; results in gradual loss of hearing
Presbycusis Progressive hearing loss that occurs with age
Tinnitus Sensation of sound in the head (e.g., roaring, hissing, buzzing)
Transient Temporary hearing shifts associated with noise exposure

1. Conductive hearing loss

a. Injury or disease interferes with organs that conduct sound
waves through the outer or middle ear
b. Usually consistent over the entire range of sound
c. The person benefits most from the use of a hearing aid (sound
conducted by bone)
d. Speech is soft and low; the person hears own voice louder than
that of others
e. Usually caused by obstruction of the ear canal by cerumen or a
foreign object, perforated eardrum, otitis media, otosclerosis, or
congenital malformations of the ear
2. Sensorineural hearing loss
a. Malfunction of organs that perceive sound (sensory hair cells of
inner ear, auditory nerve, auditory center in brain)
b. Most common causes—aging process (presbycusis), hereditary
disease, noise damage, childhood viral infections, skull
fractures, intracranial tumors, oxytoxic drugs, and Rh
incompatibility
c. Involves loss of sensitivity and acuity in one or more frequencies
(usually higher frequencies and consonants)
d. If the individual wears a hearing aid, sound is conducted by air
e. Speech is loud; the person cannot hear own voice
E. Etiology
1. Prenatal or congenital
a. Genetic defects
b. Infections (rubella accounts for 20% of congenital types),

1561
 influenza, and syphilis
c. Rh incompatibility
d. Certain drugs, including thalidomide, streptomycin, aspirin,
erythromycin, kanamycin, neomycin, indomethacin, furosemide
(Lasix)
e. Unknown causes (10% to 20% of cases)
f. Environmental noise (more than 30% of cases)
2. Acquired
a. Infections (e.g., mumps, measles, poliomyelitis, chronic serous
otitis media)
b. Hereditary conditions
c. Trauma
d. Chronic use of certain drugs (e.g., aspirin, streptomycin)
e. Noise exposure
f. Pathology (e.g., brain tumor, stroke)
F. Signs, symptoms, and clinical manifestations
1. May lip-read or focus attention on other facial or nonverbal
expressions (speech reading); but can generally only understand 26%
to 40% of what is said
2. Speech may be characterized by aberrant modulations,
pronunciations, or grammatical structures
3. May use sign language—American Sign Language (ASL) or finger
spelling (American or manual alphabet)
4. May turn the head to one side if the loss is unilateral
5. May frequently ask others to repeat phrases, or may provide an
unrelated response to a question or comment
6. May not acknowledge having hearing loss
G. Oral manifestations
1. Not generally seen with hearing impairments unless associated with
a syndrome (e.g., rubella syndrome)
2. Prematurity or rubella may result in enamel dysplasia
3. Bruxism may be evident

Cleft Lip or Palate

A. Definition—disturbances in embryologic formation resulting in
incomplete closure of the lip, the palatal area, or both
B. Incidence and prevalence
1. About 2650 babies are born with a cleft palate and 4440 with a cleft
lip with or without a cleft palate
2. Occurs in 1 in 1000 Caucasian live births in the United States; twice

1562
 as common in Asian Americans; half as common in African
Americans
3. One of the most common congenital malformations of the face and
mouth
4. Cleft lip more common in males; cleft palate more common in
females
5. One in 2000 babies born with cleft palate, but without cleft lip
C. Classifications of cleft involvement
1. Tip of the uvula
2. Bifid uvula
3. Soft palate
4. Soft and hard palates
5. Unilateral lip and palate (Fig. 19-9)

FIG 19-9 Cleft lip. (From Regezi JA, Sciubba JA, Jordan CK: Oral pathology: clinical
pathologic correlations, ed 7, St Louis, 2017, Elsevier.)

6. Bilateral lip and palate

D. Etiology
1. Genetic in most cases
2. Other risk factors include maternal nutritional deficiencies, alcohol
use, infectious diseases, and smoking during pregnancy
3. Cleft lip occurs during gestational weeks 4 to 7

1563
 4. Cleft palate occurs during gestational weeks 8 to 12
5. Folic acid supplementation for the mother during pregnancy may
reduce risk
E. Signs, symptoms, and associated problems
1. Orofacial deformities
2. Ear disease with resultant hearing loss
3. Speech difficulties are a major disability caused by:
a. Palatal insufficiency
b. Missing or malpositioned teeth
c. Hearing loss
4. Feeding problems
5. Predisposition to upper respiratory tract infections
F. Oral manifestations
1. High incidence of missing or maldeveloped teeth in the line of the
cleft, usually affects lateral incisors
2. High incidence of malocclusion resulting from structural defects
3. Oral-motor dysfunction
4. Scar tissue from surgery

Cerebral Palsy
A. Definition—static, nonprogressive neuromuscular condition
comprising a series of syndromes that result from damage to the brain
B. Incidence
1. Approximately 764,000 persons in the United States have some
degree of cerebral palsy
2. About 10,000 babies born each year will develop cerebral palsy; 40%
to 50% of children born with cerebral palsy are premature, low birth
weight, or both
C. Etiology
1. Prenatal—genetic or congenitally acquired (e.g., anoxia, infections,
alcohol or drug abuse, Rh incompatibility, metabolic disturbances,
lack of folic acid)
2. Natal—anoxia, hemorrhage
3. Postnatal—head injury, infections, neoplasms, anoxia
D. Classification
1. Motor disorders
a. Spasticity (50% to 75%)—slight stimulus causes exaggerated
muscle contraction; stiff and jerky movements
b. Athetosis (15% to 25%)—muscles contract involuntarily;
difficulty bringing the body to the upright position

1564
 c. Ataxia (10%)—muscles respond to a stimulus but cannot
complete a contraction; low muscle tone and poor coordination
d. Hypotonia (less than 10%)—unable to respond to a volitional
stimulus
e. Rigidity (less than 10%)—increased initial muscle resistance;
gives way with minimal force
f. Mixed (5% to 20%)—two or more types appearing in the same
person
2. Limbs involved
a. Monoplegic—one limb
b. Hemiplegic—both limbs on the same side of the body
c. Paraplegic—lower limbs
d. Diplegic—like parts on either side of the body (e.g., both lower
limbs, both upper limbs)
e. Quadriplegic—all four limbs
f. Triplegic—three limbs
E. Signs, symptoms, and clinical manifestations (Fig. 19-10)

1565
 FIG 19-10 Person with spastic-type cerebral palsy, in which limbs are in a
severely flexed posture. (From Porter SR et al: Medicine and surgery for dentistry,
Philadelphia, 1999, Churchill Livingstone.)

1. Characterized by paralysis, weakness, muscle spasms,

incoordination, or other aberrations of motor function, especially
involving voluntary muscles
2. Joint immobility and contractures increase with age
3. Retained primitive reflexes (e.g., asymmetrical or symmetrical tonic
neck reflex)
4. Other associated conditions
a. Speech and language disorders (60%)
b. Hearing disorders (20%)
c. Visual defects (40%)
d. Developmental and cognitive challenges (40%)
e. Seizures (40%)
5. Wide range of limitations, from mild to totally dependent

1566
F. Oral manifestations—marked variation among individuals
1. Higher incidence of bruxism (Fig. 19-11), dental caries, enamel
dysplasia, malocclusion, and periodontal diseases

FIG 19-11 Example of extreme bruxism in a child with a developmental

disability. (From National Oral Health Information Clearinghouse, National Institute of
Dental and Craniofacial Research: Oral conditions in children with special needs: a
guide for health care providers, March 2011.)

2. Drug-induced gingival enlargement if phenytoin is used

3. Oral-motor dysfunction (e.g., impaired swallowing), mouth
breathing
4. Temporomandibular joint (TMJ) disorders
5. Increased gag reflex
6. Drooling
7. Trauma resulting from incoordination and frequent falls (Fig. 19-12)

1567
 FIG 19-12 Example of oral trauma. (From National Oral Health Information
Clearinghouse, National Institute of Dental and Craniofacial Research: Oral conditions
in children with special needs: a guide for health care providers, March 2011.)

8. Attrition and possible TMJ disturbances from mouth sticks

9. Increased dental caries as a result of surgery to control saliva and
drooling

Bell’s Palsy
A. Definition—paralysis of facial muscles that are innervated by cranial
nerve VII (facial nerve)
B. Incidence and prevalence
1. About 40,000 persons in the United States are affected annually
2. After age 50; more common in males
C. Etiology
1. Unknown
2. Associated with bacterial and viral infections (herpes simplex),
trauma from oral extractions, or surgery on the parotid gland
D. Signs, symptoms, and clinical manifestations (Fig. 19-13)

1568
 FIG 19-13 Person with Bell’s palsy, in whom the left side of the face is
paralyzed. (From Trend P, Swash M, Kennard C: Neurology: color guide, Edinburgh, 1998,
Churchill Livingstone.)

1. Abrupt paralysis without preceding pain

2. Occurs unilaterally
3. Corner of the mouth droops, causing drooling
4. Eyelids will not close; lower eyelid droops; predisposes the eyes to
infections
5. Speech and chewing are difficult
6. Spontaneous remission may occur in 2 to 8 weeks, or permanent
paralysis
E. Oral manifestations—ora-–motor difficulties can cause food retention
and the potential for increased caries or gingivitis

Myasthenia Gravis
A. Definition—autoimmune neuromuscular disease characterized by
variable weakness or fatigue of striated, voluntary muscles
B. Incidence and prevalence

1569
 1. Most often affects women younger than 40
2. If late onset after 60, men affected more often
3. Affects approximately 2 in 100,000 persons
C. Etiology—autoimmune mechanism causing a defect in nerve impulse
transmission at the neuromuscular junction
D. Signs, symptoms, and clinical manifestations
1. First symptoms usually affect muscles of the eyes (blurred or double
vision, drooping of one or both eyelids, weakness of muscles
affecting the eyeball, facial expression, mastication, and swallowing)
2. Breathing and speech are disturbed (weak, muffled voice)
3. Fatigue and weakness of muscles vary widely but tend to be worse at
the end of the day
4. Myasthenic crisis—weakness affects muscles that control breathing;
usually transient but life threatening
a. Precipitated by:
(1) Emotional excitement, stress
(2) Surgical procedures
(3) Fatigue or loss of sleep
(4) Infections
b. Symptoms
(1) Unable to clear secretions from the throat
(2) Impaired breathing; assisted ventilation may be needed
(3) Double vision
E. Medications that may cause muscle weakness and must therefore be
avoided:
1. β-Adrenergic blockers
2. d-Penicillamine
3. Interferon-α
4. Calcium channel blockers
F. Oral manifestations
1. Oral-motor dysfunction
2. Retention of food increases susceptibility to dental caries and
periodontal problems
3. Weakness of masticatory muscles causes the mouth to continuously
hang open
4. Chewing and swallowing difficulties
5. Furrowed and flaccid appearance of the tongue

Parkinson’s Disease
A. Definition—progressive disorder of the CNS causing loss of postural

1570
reflexes, slowness of spontaneous movement, tremors, and muscle
rigidity
B. Incidence and prevalence
1. Develops between ages 40 and 60
2. At age 60 or older, 1 in 100 persons affected
3. Higher incidence in men than in women (2:1)
4. Approximately 1.5 million persons in the United States affected; 7 to
10 million worldwide
C. Etiology
1. Cause unknown
2. Imbalance of dopamine and acetylcholine
D. Signs, symptoms, and clinical manifestations
1. Mild, diffuse muscular pain
2. Tremors of the extremities, occurring mainly at rest
3. Shuffling, slow gait, with arms held to the side
4. Slurred, indistinct speech
5. Staring, mask-like facial expression
6. Excessive salivation or dryness of mouth (side effects of medications)
7. Intellect not usually affected
8. Tremors in the lips, tongue, or neck; difficulty swallowing; can lead
to aspiration
9. Feelings of stiffness and rigidity (particularly of the large joints)
10. Sensitivity to heat
E. Oral manifestations
1. Impaired oral-motor functions and home care skills may increase the
incidence of dental caries, periodontal disease, and perioral skin
irritation
2. Side effects of medications (e.g., xerostomia) may increase the
incidence of dental caries and periodontal disease and negatively
affect dental prosthesis retention
3. Rigidity and tremors can induce orofacial pain, TMJ discomfort, and
trauma to soft and hard tissues

Arthritis
A. Definition
1. Term used to describe more than 100 disorders that cause pain in the
joints and connective tissue
2. Joint inflammation
3. The term polyarthritis refers to the involvement of many joints
B. Major types (Table 19-5)

1571
Table 19-5
Characteristics of Arthritis

TMJ, Temporomandibular joint.

1. Osteoarthritis (affects 21 million U.S. adults)

2. Rheumatoid (adult type) (affects three million adults)
3. Rheumatoid (juvenile type)
4. Others include gout, fibromyalgia, ankylosing spondylitis, lupus
C. Incidence and prevalence: common in all age groups
1. More than one in five U.S. adults is affected
2. Affects more than 22% of the U.S. population
3. Affects 55% of the population age 65 or older
4. More common in women than men
D. Etiology (see Table 19-5)—cause unknown
E. Signs, symptoms, and clinical manifestations—these affect various
sites in different ways; most are chronic (see Table 19-5)
F. Oral manifestations
1. Bruxism and occlusal imbalances
2. TMJ pain and limited ability to open the mouth
3. Masking of inflammation by prolonged steroid therapy
4. Delayed healing and excess bleeding with long-term aspirin therapy
5. Mucosal ulcerations or secondary oral infections (especially of the
gingiva) if gold salts are administered
6. Monitor need for antibiotic premedication

Fibromyalgia Syndrome (FMS)

A. Definition—neurosensory disorder characterized by widespread
musculoskeletal pain
1. Pain accompanied by persistent fatigue, sleep disturbances, and
memory and mood issues
2. Most common cause of chronic pain in the United States
B. Incidence and prevalence
1. FMS can affect any person regardless of age, gender, or ethnicity;
however 75% to 90% of those diagnosed are women

1572
 2. Prevalence of fibromyalgia is higher at middle age (30 to 50 years) or
over age 50
3. Worldwide incidence of FMS is 6.88 per 1000 males and 11.28 per
1000 females
C. Etiology
1. This complex syndrome is linked to a multifactorial etiology
2. Suspected causes of FMS include abnormalities in pain pathways,
neuroendocrine system, and autonomic nervous system, as well as
genetic and environmental factors such as physical trauma and
psychosocial factors such as abuse
D. Signs, symptoms, and clinical manifestations
1. Widespread pain—exacerbated by physical or emotional stress,
nonrestorative sleep, strenuous activity, and changes in weather
2. Sleep disturbances, including nonrestorative sleep, insomnia, and
poor-quality sleep
3. Fatigue, cognitive deficiency, tenderness on mild palpation
4. Can result in severe disability and loss of function, making daily
tasks, including oral self-care, difficult or unmanageable
E. Oral manifestations
1. Severe pain when opening; limited opening
2. TMJ disorder
3. Burning tongue
4. Difficulty discerning pain from oral disease from FMS pain
5. Taste distortion
6. Xerostomia

Scleroderma
A. Definition
1. Group of chronic connective tissue disorders
2. Autoimmune rheumatic condition with excessive collagen
deposition and vascular hyperreactivity and dysfunction
B. Incidence and prevalence
1. Mainly affects women, 4:1 over men, with onset between ages 30 and
50
2. Approximately 20 per 1 million individuals affected
C. Etiology—unknown, but presents with vascular dysfunction that
manifests as injury to the endothelial cells; immunologic activation of T
cells, cytokines, inflammation; and fibrosis
D. Signs and symptoms
1. Localized scleroderma affects only the skin—areas of the skin

1573
 become thickened, hard, and discolored, with hair loss over affected
areas
2. Diffuse scleroderma also harms structures beyond the skin, such as
blood vessels, internal organs, and digestive tract
a. Skin eventually binds with underlying structures, and painful
ulcerations occur at the joints
b. Esophageal dysmotility, renal disease, cardiac dysfunction, and
pulmonary disease manifest
c. Caused from chronic hardening and sclerosis of the connective
tissue within these organ systems, with life-threatening
consequences
E. Oral manifestations
1. Limited mouth opening
2. Fibrosis at the hard and soft palate
3. Widening of the periodontal ligament space
4. Mandibular resorption
5. Trigeminal neuropathy
6. Increased risk for periodontal disease and caries disease

Multiple Sclerosis
A. Definition—chronic degenerative disease of the CNS
1. Myelin is destroyed through the formation of sclerotic tissue called
plaque
2. Nerve impulses to the brain are disrupted or not transmitted
3. Scattered plaque accumulation causes inflammation and widespread
and varied symptoms with periods of exacerbation and remission
B. Incidence and prevalence
1. Approximately 500,000 persons affected in the United States; more
than 2.5 million worldwide
2. Varies geographically; more common in northern regions
3. Two to three times more common in women than men
4. Onset occurs at any age, but usually between 20 and 50
C. Etiology
1. Unknown, although genetic markers have been found
2. Possibly an autoimmune reaction or associated with viral infections
D. Signs and symptoms
1. Result from the location of lesions (Table 19-6)

1574
 Table 19-6
Symptoms Associated with Lesions in the Central Nervous System

Location of Lesions Possible Symptoms

Spinal cord Numbness
Loss of sensitivity in appendages
Sensitivity to heat
Unsteady gait; muscle stiffness
Loss of strength in the legs
Impaired eye-hand coordination resulting
in difficulty in fine motor movements
Brainstem Blurred vision, double vision, or both
Difficulty in swallowing or chewing
Diminished gag reflex
Slurred speech
Cerebrum (lesions in the cerebrum usually Disruptions in thinking
occur in the later stages of the disease process) Euphoria
Depression
Disruptions in behavior
From Lange BM, Enwistle BM, Lipson LF: Dental management of the handicapped: Approaches for dental
auxiliaries, Philadelphia, 1983, Lea & Febiger.

2. Precipitating factors
a. Infections
b. Stress and emotional trauma
c. Injury
d. Heavy exercise and fatigue
e. Pregnancy
f. Heat
3. Periods of remission in some; chronic progression in others
4. Death is usually the result of an infection
E. Oral manifestations
1. Most are the result of poor oral hygiene or the side effects of drugs
a. Ulcerations
b. Xerostomia
c. Drug-induced gingival enlargement (phenytoin administered for
pain)
2. Facial pain and TMJ dysfunction and pain

Muscular Dystrophies
A. Definition—group of progressive chronic diseases of the skeletal
(striated) muscles characterized by the degeneration of muscle cells with
replacement by fat or fibrous tissue
B. Incidence and prevalence

1575
 1. Affects approximately 220,000 persons in the United States
2. Two thirds of cases are children; 400 to 600 males are born with this
disease each year in the United States
C. Etiology—inherited; defective gene leading to a protein abnormality
D. Types (Table 19-7)

Table 19-7
Types and Characteristics of Muscular Dystrophies

E. Signs, symptoms, and clinical manifestations—vary by site and type

(see Table 19-7)
F. Oral manifestations
1. Weakness in masticatory muscles leads to decreased maxillary biting
force
2. Higher incidence of mouth breathing, open bite, and overexpansion
of the maxilla
3. In facio-scapulo-humeral type, the lips appear thick because of
involvement of the orbicularis oris muscle
4. Increase in dental disease if oral hygiene has been neglected

Spinal Cord Injuries

A. Definition
1. Fracture, dislocation, hyperextension, compression, or severance of
components of the spinal column
2. Occurs most often in the cervical and lumbar curves

1576
 3. Cord damage can occur above or below the level of bone injury
B. Incidence and prevalence
1. Affects approximately 450,000 persons in the United States
2. Annually, 15 to 40 new cases per 1 million population
3. About 82% of cases are males age 16 to 30
C. Etiology—acquired injury from accidents
1. Automobile or motorcycle crashes cause 50% of injuries
2. Occupational accidents cause 25% of injuries
3. Sporting accidents cause 18% of injuries
4. Falls, gunshot wounds, or other trauma cause 7% of injuries
D. Signs, symptoms, and clinical manifestations
1. Depend on severity and level of injury
2. Prognosis
a. First-aid measures performed at the site of the accident
b. Type and level of injury to the spinal cord
c. Survival is increasing with advances in emergency care and
rehabilitation
d. Restoration of function still very limited
3. Paraplegia refers to an injury below the cervical level that results in
paralysis of the lower portion of the body
4. Quadriplegia refers to an injury occurring in the cervical region that
results in paralysis of all four limbs and the trunk
5. Most frequent cause of death is kidney stones or infection
6. Functional limitations and specific manifestations depend on the
level of the lesion (Tables 19-8 and 19-9)

1577
Table 19-8
Clinical Manifestations of Spinal Cord Injuries

Area
Clinical Manifestations
Affected
Muscles Innervation and perception of pain and touch disturbed; leads to muscle
(limb and atrophy
trunk) Concerns for safety around varying temperatures
Formation of decubitus ulcers (pressure sores) caused by breakdown of tissue
from immobilization, bruises, or braces
Decreased or absent self-care skills
Spasticity and tremors
Adaptive equipment required, especially for:
—Wrist stability
—Pencil grasp
—Arm movements
Respiration Intercostal muscles may be paralyzed, resulting in need for diaphragmatic

breathing or tracheostomy and total or partial dependence on a respirator

Bowel and Limited innervation, resulting in incontinence and encopresis or retention
bladder Can lead to infections, particularly of kidneys
Autonomic hyperreflexia can occur (medical emergency)
Caused by sudden constriction of blood vessels
Symptoms—rapid increase in blood pressure (e.g., 280/80 mm Hg), low pulse,
pounding headache, skin blotching and sweating above site of injury, cold
goose bumps below site of injury
Bones and Contractures from spasticity and immobilization
joints Heterotopic ossifications (bony accumulations) may develop around joints
Metabolism Regulation of body temperature impaired
Social and Problems associated with coping with a debilitating acquired injury
emotional May experience stages of shock, denial, anger, depression, mobilization, and
status coping

1578
 Table 19-9
Functional Significance of Cervical, Thoracic, and Lumbar Lesion Levels

From Schubert MM, Snow M, Stiefel DJ: Dental management of patients with CNS and neurologic impairment:
spinal cord injury. DECOD series, Seattle, 1989, University of Washington.

Spina Bifida
A. Definition
1. Neural tube defect of the spinal column
2. Vertebrae fail to close completely around the spinal cord
B. Incidence and prevalence
1. Affects 166,000 persons in the United States in some form
2. Each year, about 1500 babies are born with spina bifida
3. A major cause of paraplegia in children
C. Etiology—specific cause unknown; but multiple factors, including
genetic and environmental factors, are suspected; folic acid supplements
taken during pregnancy can prevent this
D. Types (Fig. 19-14)

1579
 FIG 19-14 Types of spina bifida.

1. Spina bifida occulta

a. Small defect in a vertebra not involving the spinal cord
b. Often undetected
2. Meningocele—bony defect that allows meninges and cerebrospinal
fluid (CSF) to form a sac that protrudes from the vertebral column
3. Meningomyelocele (also myelomeningocele)—severe defect in which
the spinal cord also protrudes into the sac
E. Signs, symptoms, and clinical manifestations
1. Potential exposure of the nervous system to the external
environment results in an increased chance for further damage from
trauma or infection
2. Loss of motor function in the lower half of the body
a. Differential involvement of muscle groups causes muscle
imbalance, leading to spinal and limb deformities
b. Loss of sensation to pain, touch, and temperature creates safety
hazards and pressure sores
c. Loss of bladder and bowel control
d. Ambulation may be affected, creating a need for orthopedic
devices or a wheelchair
3. Deformity of the brain
a. Most have normal intelligence but experience learning
disabilities, especially visual-perceptual problems
b. Some develop seizure disorders
c. In about 80–90% of spina bifida cases, there is a cyst with parts
of the spinal cord and spinal wall present. This is called a
myelomeningocele. This type of spina bifida can happen in a
relatively high or low position on one's back. It often causes
problems with bladder and bowel functioning, and sometimes
paralysis or limb weaknesses.

1580
 (1) CSF accumulates in the ventricles of the brain
(2) Pressure expands the brain and skull
4. Latex allergy is common in this population
F. Oral manifestations
1. None directly associated
2. Evaluate for premedication if person has a ventriculoatrial shunt
(Fig. 19-15)

FIG 19-15 Types of shunts.

Cystic Fibrosis
A. Definition—inherited disorder of the exocrine glands
B. Incidence and prevalence
1. Occurs in 1 in 3000 live births in the United States
2. Between 2% and 5% of the population are carriers
3. Affects approximately 30,000 persons in the United States; 10 million
or more are carriers of the gene for cystic fibrosis
4. Most common cause of chronic lung disease in Caucasian children
5. Mean survival about 37.4 years
C. Etiology—autosomal recessive disorder; defect in gene on
chromosome 7 that results in phenylalanine deletion and problem with
chloride ion transport
D. Signs, symptoms, and clinical manifestations—include increased
viscosity of mucus (obstructs the pancreatic ducts, leading to cyst
formation, impaired metabolism, and progressive deterioration)
1. Accumulation of mucus in the lungs interferes with oxygen
exchange

1581
 a. Interferes especially with exhalation, causing a barrel-chested
appearance
b. Air sacs collapse and infections occur, often leading to
suppurative bronchitis, pneumonia, and obstructive
emphysema
c. Clubbing of fingers and toes
d. Chronic cough
2. Sweat glands affected, leading to high levels of sodium in the sweat
(“salty sweat”)
3. Salivary glands also affected
4. Other findings and complications include a small gallbladder,
cirrhosis of the liver, and sterility in men
5. Delayed linear growth and bone development
6. Insufficient pancreatic function can lead to diabetes
7. Death usually occurs in early adulthood
E. Oral manifestations
1. Lower dental caries rate and plaque accumulation with increased
calculus deposits; probably a result of alterations in saliva and long-
term use of antibiotics
2. Enlargement of the salivary glands
3. Intrinsic staining of the teeth, if tetracycline is administered during
the formative years
4. Mouth breathing, if sinuses are occluded

Chronic Obstructive Pulmonary Disease (COPD)

A. Definitions
1. General term for pulmonary disorders characterized by obstruction
of airflow during respiration
2. Consists of two or more disease processes that may coexist
3. Bronchitis—obstruction caused by narrowing or loss of airways
4. Emphysema—loss of elasticity and collapse of overinflated air sacs;
loss of gas exchange surface area; causes obstruction during
expiration
B. Incidence, prevalence, and etiology
1. Chronic bronchitis affects 10% to 25% of U.S. adults
2. More common in males and in persons age 60 or older
3. Most important risk factor is smoking, accounting for 80% to 90% of
persons with COPD
4. Can be a hereditary defect in pulmonary tissue; may be caused by
severe respiratory illnesses during childhood

1582
C. Signs, symptoms, and clinical manifestations
1. Dyspnea and wheezing on exertion or at rest; orthopnea
2. Chronic cough, mucus, respiratory infections, and cyanosis in
bronchitis
3. Use of accessory muscles of respiration
4. Chest pain
5. Advanced complications are heart failure and pulmonary failure
D. Oral manifestations—no associated oral manifestations unless a side
effect of the medications

Bronchial Asthma
See the section on “Asthma” in Chapter 21.
A. Definition
1. Chronic clinical state of hyperreactivity of the tracheobronchial tree
characterized by recurrent paroxysms of dyspnea and wheezing
2. Results from bronchospasm, bronchial wall edema, inflammation,
and hypersecretion by mucous glands
3. Status asthmaticus—persistent exacerbation of asthma despite drug
therapy (life threatening); causes excessive strain on the circulatory
and respiratory systems
B. Incidence and prevalence
1. Affects approximately 25.9 million persons in the United States
2. Initial symptoms usually occur in the first 5 years of life
3. Approximately 50% of affected children become asymptomatic
before adulthood
4. From 75% to 85% also have allergies
C. Etiology—unknown, but precipitating factors and their effects are
known
1. Extrinsic factors—smoking, dust, mold, pollen, smoke, animal
dander, household sprays, wool, certain foods, air pollutants,
sulfiting agents
2. Other factors—respiratory tract infections, aspirin and other anti-
inflammatory drugs, overexertion
D. Signs, symptoms, and clinical manifestations
1. Wheezing, dyspnea, coughing, chest pain, sneezing, sputum
production, fatigue, anxiety
2. Expiratory phase of breathing is slower and more pronounced
3. Facial (sinus) pain, conjunctivitis, otitis media
4. More severe symptoms—syncope, respiratory failure, cyanosis,
hyperexpansion of the chest

1583
E. Oral manifestations
1. β-Adrenergic agonists may impair salivary secretions, increasing
caries risk
2. Mouth breathing
3. Candida infections from inhalant use

Congenital Heart Disease

A. Definition
1. Anomalies of heart structure
2. Usually develops during the first 9 weeks in utero
B. Incidence and prevalence
1. Occurs in 8 to 10 of 1000 births in the United States
2. Affects approximately 500,000 adults
C. Etiology
1. Generally unknown
2. Genetic (e.g., Down syndrome)
3. Environmental (maternal)
a. Fetal hypoxia, endocarditis, or immunologic abnormalities
b. Rubella infection (German measles) or other viruses
c. Nutritional deficiencies (especially vitamin deficiencies)
d. Drugs (e.g., lithium, alcohol, cocaine)
e. Radiation
f. Metabolic disorders (PKU or diabetes)
D. Types of malformations
1. Cause initial left-to-right shunting of blood (e.g., atrial septal defect,
ventricular septal defect, patent ductus arteriosus)
2. Initial right-to-left shunting (e.g., tetralogy of Fallot)—causes
significant cyanosis
3. Malformations that obstruct blood flow (e.g., pulmonary stenosis)
E. Signs, symptoms, and clinical manifestations
1. Dyspnea, fatigue, weakness (most common symptoms)
2. Cyanosis, dizziness, syncope, or ruddy color, leading to congestive
heart failure
3. Clubbing of fingers or toes
4. Heart murmurs
5. Delayed growth and development
6. Complications—brain abscess, bacterial endocarditis, congestive
heart failure, acute pulmonary edema, bleeding problems
F. Oral manifestations
1. Bluish mucosa, if cyanotic; ruddy color, if person has polycythemia

1584
 2. Developmental defects of teeth sometimes seen
3. Slight hemorrhage secondary to trauma, if bleeding problems are
present
4. May have decreased ability to fight oral infections

Cardiac Arrhythmias and Dysrhythmias

A. Definition
1. Irregular heartbeat manifested as abnormal pulse rates or rhythms
2. Produces alterations in the normal sequence of contractions, leading
to inadequate blood flow, and produces aberrant electrical
depolarization
3. Adversely affects the ventricular rate
B. Types
1. Bradycardias—slowed heart rate (less than 60 beats/min)
2. Tachycardias—increased heart rate (more than 100 beats/min)
3. Isolated ectopic beats—premature impulses resulting in premature
atrial beats
4. Preexcitation syndrome
5. Cardiac arrest
C. Signs, symptoms, and clinical manifestations (may also be
asymptomatic)
1. Abnormal pulse
2. Palpitations
3. Breathlessness, pallor, fatigue
4. Syncope or dizziness
5. Cyanosis
6. Pain
7. Cardiac failure
8. Cardioversion through defibrillation
D. Oral manifestations—may have side effects from medications, such as
xerostomia, taste changes, or cyanotic oral tissues

Hypertensive Disease
See the section on “Vital Signs” in Chapter 21.
A. Definitions
1. Hypertension—abnormal elevation of arterial blood pressure when
constricted blood vessels increase resistance to blood flow, causing
an increase in pressure against blood vessel walls
2. Hypertensive heart disease—sustained elevation of the blood

1585
 pressure, creating an increased workload for the heart, resulting in
left ventricular hypertrophy and in late-stage kidney disease
3. Four hypertension categories (see Table 15-5 in Chapter 15; see the
section on “Cardiac Emergencies” in Chapter 21)
a. Normal—less than 120/80 mm Hg
b. Prehypertension—120/80 to 139/89 mm Hg
c. Stage 1—140/90 to 159/99 mm Hg
d. Stage 2—160/100 mm Hg or higher in either number
e. Hypertensive crisis—higher than 180/110 mm Hg in either
number
B. Incidence and prevalence
1. Incidence is increasing, with hypertension affecting approximately 1
in 3 (or 74.5 million) persons in the United States; more remain
undiagnosed
2. Prevalence increases with age and is greater in men before age 55
and in women after age 55
C. Etiology
1. Most cases are of unknown cause (essential hypertension)
2. From 5% to 10% are secondary to other conditions, such as renal
disease and endocrine disorders
3. Risk factors include prehypertension, race (African American), age,
stress, smoking, overweight and obesity, oral contraceptives, and
excess salt and fat in the diet
4. Chronic hypertension causes cardiac enlargement and eventual
congestive heart failure
D. Signs, symptoms, and clinical manifestations
1. Early—occipital headache, dizziness, tingling of the extremities,
vision changes, tinnitus, dyspnea
2. Advanced—cardiac enlargement, ischemic heart disease, congestive
heart failure, renal failure, stroke
E. Oral manifestations
1. Generally no direct oral manifestations
2. Facial palsy from some drugs
3. Oral lesions, taste changes or xerostomia from drugs
4. Many side effects and precautions associated with drugs; some
calcium channel blockers cause drug-induced gingival enlargement

Ischemic Heart Disease (Coronary Heart Disease)

A. Definition—coronary atherosclerotic heart disease that is
symptomatic

1586
B. Incidence and prevalence
1. Affects 17.6 million persons in the United States
2. Leading cause of death after age 40
3. Incidence and severity increase with age; more than 50% who die
suddenly have no previous evidence of disease
C. Etiology
1. Risk factors are the same as for hypertensive disease
2. Periodontitis may be a significant risk factor related to elevated
levels of cross-reactive protein and growth acceleration of lipids in
blood vessels because of increased inflammatory mediators
associated with periodontal gram-negative bacteria
3. Accumulation of atherosclerotic plaque inside blood vessels impairs
blood flow and thus the oxygen supply to the heart
D. Signs, symptoms, and clinical manifestations
1. Angina pectoris—transient and reversible oxygen deficiency;
classified as stable or unstable
a. Pain—crushing or paroxysmal, usually less than 10 minutes;
often mistaken for indigestion
b. Sweating, anxiety, pallor, difficulty breathing
c. Relieved by administration of nitroglycerin or rest
2. Myocardial infarction (MI)—an infarct or ischemic necrosis caused
by a sudden reduction or arrest of blood flow
a. Pain in the sternum, radiating to the left arm; lasts longer than
angina
b. Not relieved by nitroglycerin
c. Same symptoms as angina, with nausea and vomiting,
palpitations, and lowered blood pressure
d. Often leads to sudden death from ventricular fibrillation
e. Symptoms vary between males and females
E. Oral manifestations
1. None directly associated
2. Oral lesions or xerostomia may result as a drug side effect
3. Pain may be radiated to the mandible, palate, or tongue
4. Drug-induced gingival enlargement may result as a side effect of
some calcium channel blockers

Congestive Heart Failure (CHF)

A. Definition
1. Represents a symptom complex that involves the failure of one or
both ventricles (usually the left ventricle)

1587
 2. Imbalance between the demand placed on the heart and its ability to
respond
3. Results in an inadequate supply of blood and oxygen throughout the
body and in congestion of blood within the vascular system
B. Incidence and prevalence
1. Most common cause of death in the United States
2. Prevalence is 5.1 million persons; incidence is 400,000 cases each
year; incidence of 5% occurs in persons under age 40
C. Etiology
1. Underlying causes
a. Heart valve damage; ventricular failure; overload of blood in the
ventricles
b. Obstructive lung disease
c. Damage to the walls of the heart muscle
2. Precipitating causes that place an additional demand on the heart
a. Hypertensive crises
b. Pulmonary embolism
c. Arrhythmia
D. Signs, symptoms, and clinical manifestations
1. Dyspnea, irregular breathing pattern, coughing, weakness; the
person cannot breathe unless sitting up
2. Swollen ankles late in the day, pitting edema, ascites
3. Cyanosis, anxiety, fear
4. Paleness, sweating, cold skin
5. Decreased urine output
6. Frothy pink or white sputum
7. Weak pulse
8. Confusion from decreased cardiac output, thus decreased oxygen to
the brain
E. Oral manifestations—infections, gingival bleeding, and petechiae if
displaying polycythemia

Cerebrovascular Accident (CVA, Stroke)

A. Definition—sudden loss of brain function resulting from interference
with the blood supply to a portion of the brain
B. Incidence and prevalence
1. Affects 4.6 million persons in the United States, 75% in persons age
66 or older
2. Third leading cause of death in the United States; leading cause of
serious disability

1588
 3. African Americans are at greater risk than Caucasians
4. Men are at greater risk than women
5. Likelihood of having a stroke increases with age
C. Etiology
1. Intracranial hemorrhage
2. Blockage of vessels by thrombi or emboli (most common cause)
3. Vascular insufficiency
4. Predisposing conditions and risk factors
a. Cerebral arteriosclerosis
b. Dehydration
c. Trauma
d. Hypertension
e. Diabetes
f. Cigarette smoking
g. Periodontitis
D. Signs, symptoms, and clinical manifestations—depend on the area of
the brain involved and the extent of damage (Table 19-10)

Table 19-10
Functional Limitations in Stroke (CVA) Victims

Right Hemiplegia (L-CVA*) Left Hemiplegia (R-CVA)

Language problems Spatial-perceptual task difficulties—inability to judge
Decreased auditory memory distance, size, position, rate of movement, form, and relation
(cannot remember a long series of of parts to a whole
instructions) Often thought to be unimpaired because able to speak and
Vocabulary problems understand
Slow, cautious, disorganized Visual field cuts; angles, etc. cannot be perceived
Anxious Cannot use mirrors
Cannot sequence tasks, such as toothbrushing
Decreased visual memory (loses place when reading)
Cannot monitor self (keeps talking even though answered
questions already)
May neglect left side
Tendency to be impulsive and unaware of deficits; spatial-
perceptual difficulties are easy to miss
From Schubert MM, Snow M, Stiefel DJ: Dental management of patients with CNS and neurologic impairment: spinal cord
injury. DECOD series, Seattle, 1989, University of Washington.
CVA, Cerebrovascular accident.

1. Immediate
a. Syncope, headache, chills, convulsions, nausea, and vomiting
b. Changes in level of consciousness
c. Transient paresthesias
d. Mood swing

1589
 2. Residual or chronic
a. Paralysis—hemiparesis or localized paralysis
b. Speech problems and aphasia (reduced capacity for
interpretation and formulation of language)
c. Alterations in reflexes, especially the oral-motor reflexes
d. Functional disorders of the bladder or bowel
e. Visual impairments
f. Seizures
E. Oral manifestations
1. Oral-motor dysfunction
2. Increased incidence of dental caries or periodontal disease caused by
oral-motor problems and poor oral hygiene
3. Anticoagulant therapy to prevent clot formation creates bleeding
issues and physician consults required

Sickle Cell Disease

A. Definitions
1. Defect of hemoglobin that causes red blood cells to become sickle
shaped
2. Sickle cell trait—individual shows no symptoms unless experiencing
abnormally low concentration of oxygen
3. Sickle cell disease—progressively deteriorating and complex disease
with multiple symptoms
B. Incidence and prevalence
1. Found in African Americans and other nonwhite persons; occurs in
both genders
2. Two million persons in the United States are carriers of the sickle cell
trait
3. Approximately 80,000 persons in the United States have full-blown
sickle cell anemia
4. About 1 in 1400 Hispanic American children born with sickle cell
anemia
5. Babies do not show symptoms until age 6 months
C. Etiology
1. Mutation in the globin gene of hemoglobin
2. Sickle cell trait—the person has half normal hemoglobin and half
sickled hemoglobin
3. Sickle cell anemia—the person receives a sickle hemoglobin gene
from both parents; sickle cell anemia is autosomal recessive
D. Signs, symptoms, and clinical manifestations

1590
 1. Young children
a. Can develop enlarged spleen, septicemia, and meningitis
b. Swelling of the feet and hands, anemia, pallor, tiredness, fever,
pneumonia
c. Severe pain crises affecting the extremities
d. Stroke occurs in 10% of those affected
2. Children and adolescents
a. Can develop gallstones, enlarged hearts, and lung infarctions
b. Bones degenerate as a result of repeated sickling
c. Delayed growth and late puberty
d. Increased chance for stroke, impaired kidney and liver function
with jaundice, and arthritis
e. Continued pain crises
3. Adulthood
a. Hemorrhage in the eye, detached retina
b. Pain crises—variable in each person
c. Lung and kidney damage, gallstones
d. Leg ulcers and bone changes
e. Infection is a major cause of death and also precipitates crises
E. Oral manifestations
1. Sore, painful, red tongue
2. Loss of taste sensation
3. Osteoporosis
4. Decreased radiodensity (ground-glass appearance) with coarse
trabecular bone pattern and large marrow spaces
5. Mucosal pallor
6. Delayed eruption of teeth
7. Hypoplastic enamel—pain in the mandible
8. Bone loss can be significant in children

Cancer
A. Definition—cells that multiply at an abnormally rapid rate, invading
and destroying healthy tissue
1. Metastasis—spread of cancer to distant sites
2. Invasion—spread of cancer to local sites
B. Incidence and prevalence
1. Estimated 1,248,900 new cases of oral cancer per year; less than 50%
alive after 5 years
2. About 201 in 100,000 persons will die of cancer each year in the
United States

1591
 3. Approximately 75% of all head and neck cancers begin in the oral
cavity
4. The tongue is the most common intraoral location (30%) (Fig. 19-16)

FIG 19-16 Squamous cell carcinoma on the lateral border of the tongue.
(From Regezi JA, Sciubba JA, Jordan CK: Oral pathology: clinical pathologic
correlations, ed 7, St Louis, 2017, Elsevier.)

C. Etiology of oral cancer

1. Tobacco
2. Alcohol
3. Human papillomavirus (HPV)
4. Ultraviolet light
5. Genetics
D. Warning signs of oral cancer
1. Unexplained swelling, lump, or growth with or without pain
2. White scaly patches or red areas
3. Any sore that does not heal in 2 weeks
4. Unexplained numbness or tingling
5. Difficulty opening mouth or swallowing
6. Prolonged hoarseness
E. Oral manifestations—side effects of treatment and depend on type of
cancer and treatment
1. Oral ulcerations and mucositis
2. Candidiasis
3. Anemia
4. Xerostomia

1592
5. Radiation caries (Fig. 19-17)

FIG 19-17 A and B, Radiation-associated cervical caries. (From Regezi JA,

Sciubba JA, Jordan CK: Oral pathology: clinical pathologic correlations, ed 7, St Louis,
2017, Elsevier.)

6. Loss of taste
7. Osteoradionecrosis (Fig. 19-18)

1593
 FIG 19-18 Osteoradionecrosis of the lingual mandible. (From Regezi JA,
Sciubba JA, Jordan CK: Oral pathology: clinical pathologic correlations, ed 7, St Louis,
2017, Elsevier.)

8. Tooth sensitivity
9. Muscular dysfunction and trismus
10. Spontaneous gingival bleeding
11. Cosmetic disfigurement

Leukemia
A. Definition
1. Progressive malignant neoplasms characterized by an
overproduction of abnormal leukocytes
2. Abnormal leukocytes displace hematopoietic tissue in the bone
marrow, leading to decreased production of platelets, erythrocytes,
and normal leukocytes
B. Classification—chronicity
1. Acute form (A)—large numbers of immature nonspecific leukocytes
are produced; accounts for 25% more cases than the chronic form
2. Chronic form (C)—leukocytes are well differentiated and able to
mature; but immunologic capacity is decreased
C. Incidence and prevalence
1. Estimated 44,790 new cases each year in the United States
2. About 33% of cancers in children are leukemia
3. Seventh leading cause of cancer death in adults; leading cause of
cancer death in children

1594
 4. Five-year survival rate is approximately 46%
D. Etiology
1. Specific cause unknown
2. Predisposing factors—genetic factors, ionizing radiation, chemical
agents, exposure to human T cell lymphotrophic virus type I
E. Signs, symptoms, and clinical manifestations
1. Acute form appears suddenly and severely; chronic form is insidious
2. Fatigue, weakness, pallor, weight loss
3. Ecchymosed skin and nosebleeds
4. Fever
5. Headache, nausea, and vomiting
F. Oral manifestations (Fig. 19-19)

FIG 19-19 Gingival conditions associated with monocytic leukemia. (From Regezi
JA, Sciubba JA, Jordan CK: Oral pathology: clinical pathologic correlations, ed 7, St Louis,
2017, Elsevier.)

1. Initial
a. Leukemic infiltrate of the pulp and gingiva
(1) Causes pain in teeth
(2) Enlarged, bluish red, spongy, blunted papilla
(3) Ulceration and necrosis
b. Mucositis, mucosal atrophy, and mucosal pallor
c. Areas of spontaneous hemorrhage (intermittent oozing) and
petechiae
d. Loss of lamina dura, resorption of alveolar bone, cancellous
bone destruction

1595
 2. Secondary
a. Mucosal infections (e.g., Candida, Pseudomonas) and periapical
infections
b. Necrotizing ulcerative gingivitis
c. Viral infections
d. Osteomyelitis
3. Tertiary (treatment effects)
a. Painful oral ulcerations
b. Stomatitis
c. Xerostomia and dental caries
d. Jaw pain with Bell’s palsy
e. Secondary infections

Congenital Disorders of Coagulation: Hemophilias

See the section on “Hemophilia” in Chapter 8.
A. Definition—congenital disorder of the blood-clotting mechanism
B. Incidence and prevalence
1. More than 18,000 persons in the United States have hemophilia; 400
births yearly
2. Hemophilia A accounts for 80% to 85%; hemophilia B for 10% to 15%
3. About 90% of patients are under age 25
4. Vast majority of those affected are men
C. Classification
1. Type
a. Hemophilia A (factor VIII deficiency)—1.9 in 10 persons with
hemophilia have type A
b. Hemophilia B (factor IX deficiency)—Christmas disease
c. Von Willebrand’s disease (lack of plasma)—von Willebrand’s
factor is required for primary hemostasis
2. Severity—level of clotting factor (normal level is 50% to 100%)
a. Severe—have less than 1% of clotting factor; may bleed
spontaneously or from minor trauma
b. Moderate—have 5% to 25% of clotting factor; hemorrhage only
with trauma
c. Mild—have 25% to 50% of clotting factor; bleed only after severe
injury or surgery
D. Etiology
1. Hemophilia A and B
a. Sex-linked recessive mode of inheritance (female carrier and
manifested in males)

1596
 b. High mutation rate
2. Von Willebrand’s disease—transmission by dominant autosomal
gene; occurs with equal frequency in both genders
E. Signs, symptoms, and clinical manifestations
1. Bleeding and bruising from minor cuts or pressure
a. Ecchymoses and hematomas
b. Oozing
c. Intramuscular bleeding causes pain
2. Hemarthroses—bleeding into the soft tissues of joints, leading to
pain, swelling, and permanent joint contractures
3. Renal function is impaired; exposure to hepatitis during transfusions
4. Intracranial hemorrhages can cause seizures or other neurologic
disorders
F. Oral manifestations
1. Ecchymoses, hematomas, and gingival oozing can be problems
2. Oral trauma is more evident and can be serious

Diabetes Mellitus
See the section on “Diabetes Mellitus” in Chapter 21.
A. Definition—hereditary disease of metabolism with:
1. Inadequate production and action of insulin from the pancreas
2. Disorders in carbohydrate, protein, and fat metabolism
3. Body cells unable to use glucose, leading to hyperglycemia
4. Alternating extremes of hypoglycemia and hyperglycemia found in
the person with “brittle” (very poorly controlled) diabetes
B. Incidence and prevalence
1. Diabetes mellitus affects 23.6 million persons in the United States,
with approximately 8 million undiagnosed
2. Third leading cause of death in the United States
3. Much higher in Hispanic Americans and Native Americans
4. Approximately 800,000 new cases diagnosed yearly
C. Major types (Table 19-11)

1597
Table 19-11
Comparison of Type 1 and Type 2 Diabetes Mellitus

Characteristic Type 1 Type 2

Age of onset Young, usually before or during puberty, but may Adult, usually after 30
appear later years, but may occur at
younger age
Body weight Normal or thin Obesity is most important

risk factor
Ethnicity More common in Caucasians More common in African
Americans, Asian
Americans, Hispanic
Americans, and Native
Americans
Hereditary Yes, but less frequent occurrence in families than type Much more frequent
2 occurrence in families
Lifestyle Restrictions very difficult for young persons More frequent in
sedentary individuals with
high-fat diets
Onset of Rapid, abrupt symptoms of hyperglycemia Slow, insidious
symptoms progression over years
Symptoms Weight loss; weakness; polyuria; polydipsia; Any type 1 symptom;
polyphagia; blurred vision; mimic flu; kidney/cardiovascular
frequent/recurrent infections; slow healing; problems
tingling/numb extremities; fatigue;
eye/kidney/cardiovascular problems
Severity Severe, life-threatening Early mild but
progressively serious
Complications Acute hypoglycemic or hyperglycemic emergencies Acute complications rare;
and chronic long-term complications common chronic long-term
complications common
Stability Unstable, difficult and much effort to control More stable, easier to
manage
Exogenous All Some
insulin
required
Chronic Uncommon before 20 years; prevalent and severe by Develop slowly at later
manifestations 30 years ages
Ketoacidosis Common Rare
Prevention None (because of multiple factors) Prevent or delay with
lifestyle changes
Modified from Wilkins EM: Clinical practice of the dental hygienist, ed 10, Philadelphia, 2009, Lippincott Williams &
Wilkins.

1. Type 1—insulin dependent

2. Type 2—non–insulin dependent (92% of cases)
3. Prediabetes—impaired glucose tolerance; higher than normal levels

1598
 but not yet diagnostic for diabetes; at risk for atherosclerotic disease
4. Gestational diabetes—occurs in 2% of pregnant women during the
second or third trimester; the condition returns to normal after
delivery in most cases, but 30% to 40% may develop type 2 diabetes
later in life
D. Etiology
1. Genetic disorder
2. Destruction of the insulin-producing cells of the pancreas resulting
from inflammation, viruses, cancer, or surgery
3. Secondary to endocrine disorders (e.g., hyperthyroidism)
4. Iatrogenic disease after administration of steroids
5. Obesity
E. Signs, symptoms, and clinical manifestations (Table 19-12)

Table 19-12
Clinical Manifestations of Diabetes Mellitus

Hyperglycemia Hypoglycemia
Polydipsia Early stage
Polyphagia —Diminished cerebral function
Polyuria —Changes in mood
Loss of weight —Decreased spontaneity
Fatigue —Hunger
Headache —Nausea
Blurred vision More severe stage
Nausea and vomiting —Sweating
Tachycardia —Tachycardia
Florid appearance —Piloerection
Hot and dry skin —Increased anxiety
Kussmaul respiration —Bizarre behavior patterns
Mental stupor —Belligerence
Loss of consciousness —Poor judgment
—Uncooperativeness
Later severe stage
—Unconsciousness
—Seizure activity
—Hypotension
—Hypothermia
Modified from Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2013, Mosby.

1. Cardinal symptoms are those associated with hyperglycemia

2. An overdose of insulin or inadequate glucose intake to balance the
insulin intake can result in insulin shock (hypoglycemia)
3. Chronic complications include:
a. Atherosclerosis and other cardiovascular problems

1599
 b. Renal failure
c. Motor, sensory, and autonomic neuropathies
d. Glaucoma and cataracts leading to blindness
e. Associated with increased incidence of large babies, stillbirths,
miscarriages, neonatal deaths, and congenital defects
F. Treatment—no known cure
1. Management of acute symptoms
2. Exercise and diet plan (food exchange system)
G. Oral manifestations
1. Seen more often in persons with uncontrolled diabetes
2. Delayed wound healing and inability to manage oral infections (e.g.,
Candida), periodontal abscesses
3. Decreased salivary flow may lead to increased caries; may have
parotid gland enlargement
4. Predisposition to aggressive periodontal disease in both types of
diabetes, even in children and adolescents; magenta hue with
edematous glassy tissue, enlarged papilla, mobility, alveolar bone
loss (Fig. 19-20)

FIG 19-20 Gingival tissues exhibiting spontaneous bleeding,

inflammation, and edema in an adult client with diabetes. (From Newman
MG, et al: Carranza’s clinical periodontology, ed 12, St Louis, 2015, Elsevier.)

5. Periodontitis can make blood glucose levels more difficult to control

6. Poor blood glucose control greatly increases risk for periodontal
breakdown, bone loss, and loss of attachment
7. Children with diabetes may have accelerated tooth eruption and

1600
 enamel hypoplasia

Thyroid Disease
A. Definitions
1. Hyperthyroidism (thyrotoxicosis)—excess of thyroid hormones in
the bloodstream
2. Graves disease—type of hyperthyroidism; toxic goiter
3. Hypothyroidism—inadequate thyroid hormones in the bloodstream
a. Cretinism—childhood onset (congenital)
b. Myxedema—adult onset (acquired)
B. Incidence and prevalence
1. Thyroid disease affects 28 million persons in the United States, with
up to one half undiagnosed
2. Hyperthyroidism—disease is seven times more common in women;
especially manifested during puberty, pregnancy, or menopause
3. Hypothyroidism
a. Rare
b. Myxedema is five times more common in females; most
common between ages 30 and 60
c. Permanent congenital hypothyroidism occurs in 1 in 3500 to
4500 births
C. Etiology
1. Hyperthyroidism (Graves disease)
a. Cause is unknown
b. Autoimmune cause or familial tendency is postulated
2. Hypothyroidism
a. Disease of the thyroid gland
b. Myxedema may follow thyroid gland or pituitary gland failure
resulting from irradiation, surgery, or excessive antithyroid drug
therapy
D. Signs, symptoms, and clinical manifestations—results of
underproduction or overproduction of thyroid hormone (Table 19-13)

1601
Table 19-13
Clinical Features of Thyroid Disease

E. Oral manifestations—primarily delayed or accelerated dental

development or deterioration of alveolar bone (Fig. 19-21 and Table 19-13)

1602
 FIG 19-21 A, Radiograph of mandibular radiolucencies associated with
hyperparathyroidism. B, Radiograph of loss of lamina dura associated with
hyperparathyroidism. (From Regezi JA, Sciubba JA, Jordan CK: Oral pathology: clinical
pathologic correlations, ed 7, St Louis, 2017, Elsevier.)

Chemical Dependency
See the section on “Substance Abuse” in Chapter 11.
A. Definitions
1. State of psychological or physical dependence (or both) after
administration of a drug on a periodic or continuous basis
2. Drug use—when the effects of a drug can be realized with minimal
hazard
3. Drug misuse—when the drug or amount taken makes it more
dangerous than necessary to produce the desired effect
4. Drug abuse—continual misuse of a drug, loss of control over its use,
or disruption of family, social, or job responsibilities

1603
 5. Tolerance—use of larger doses of a drug to experience the same
effects over time
6. Recovery—overcoming physical and psychological dependence;
commitment to drug-free life
B. Incidence and prevalence
1. Several drugs or drug categories cause the most concern: cocaine,
heroin and other opiates, marijuana, stimulants, barbiturates and
other depressants, hallucinogens (psychedelics), tranquilizers,
volatile solvents, and other inhalants
2. Alcohol is a major problem (see next section); 70% of persons in the
United States drink at least on a social basis
3. Nitrous oxide and prescription drug abuse is of most concern to
dental professionals
4. Routes of administration—oral ingestion, inhalation, injection,
snorting, buccal, suppositories
5. In the United States, 41.7% of those over age 12 have used illegal
drugs at least once
C. Etiology
1. Stressful social, psychological, or economic environment
2. Peer pressure
3. Gateway drugs—alcohol, tobacco, marijuana
D. Signs and symptoms—vary with the agent involved and route of
administration
1. Affect autonomic, central, and peripheral nervous systems
2. Drug interactions have additive, inhibitory, and synergistic effects
3. Duration of effects ranges from 1 hour to many days
4. Withdrawal symptoms reported for all drug categories except
hallucinogens
5. Possible effects of some drug categories
a. Narcotics—euphoria, drowsiness, respiratory depression,
constricted pupils, nausea
b. Depressants—slurred speech, disorientation, intoxicated
behavior
c. Stimulants—alertness, excitation, euphoria, increased pulse rate
and blood pressure, insomnia, loss of appetite
d. Hallucinogens—illusions and hallucinations, poor perception of
time and distance
e. Marijuana—euphoria, relaxed inhibitions, increased appetite,
disoriented behavior
E. Oral manifestations
1. Oral trauma—if the person engages in aggressive behavior or fights

1604
 or has accidents
2. Xerostomia—if dehydrated
3. Mucosal lesions and leukoplakia from irritants smoked or used
orally
4. Increased caries typically seen at the cervical area; periodontal
disease prevalent if oral hygiene is neglected or the person
consumes high-carbohydrate diet
5. Advanced cervical caries associated with heavy methamphetamine
use
6. Tooth abrasion
7. Increased risk for oral and esophageal cancers
8. Reduced tolerance to pain
9. Bruxism

Chronic Alcohol Abuse and Dependence

A. Definition and etiology
1. Chronic impairment in physical, mental, or social functioning
caused by frequent ingestion (more than two drinks per day) of
alcohol
2. Can become dependent on alcohol ingestion and develop a tolerance
to increasing amounts
3. Genetically transmitted susceptibility to alcoholism
4. Often induced by a psychiatric disorder or stress
B. Incidence and prevalence
1. Estimated 5.1 million persons in United States suffer from alcohol
abuse
2. About 1 in 13 U.S. adults abuses alcohol or is an alcoholic (7.42% of
persons age 18 and older)
3. Alcohol problems are higher among young adults age 18 to 29
4. Normal activities are maintained by 90%
5. Approximately 80% are heavy smokers
C. Signs, symptoms, and clinical manifestations
1. Alcoholic breath
2. Unexplained tremors
3. Nausea and vomiting, gastrointestinal problems, ulcers
4. Cutaneous lesions (redness, acne, spider angiomas)
5. Edema of the eyelids and other parts of the body
6. Nutritional deficiencies (vitamin B, protein, calcium)
D. Long-term complications
1. Hypertension and other types of heart disease

1605
 2. Increased risk for various types of cancers
3. Hepatitis, cirrhosis, and hypoglycemia
4. Interference with secretion of pancreatic enzymes
5. Bleeding tendencies
6. Altered enzyme functioning and malabsorptive syndromes of the
small intestine
7. Irritation of the gastric mucosa leading to bleeding, inflammation,
and ulceration
8. Fetal alcohol syndrome (pregnant women)
E. Oral manifestations—increased incidence of:
1. Caries caused by nausea and vomiting, neglected oral hygiene, and
xerostomia
2. Periodontal disease caused by an impaired immune system and the
effects on white blood cells
3. Glossitis and angular cheilitis from nutritional deficiencies
4. Leukoplakia and oropharyngeal cancer (use of alcohol and tobacco
products increases risk of oropharyngeal cancer)
5. Swelling of the parotid glands leads to decreased salivation and
increased caries incidence
6. Trauma during inebriated states (accidents or fights)
7. Attrition secondary to bruxism

End-Stage Renal Disease

A. Definition
1. Progressive bilateral deterioration of renal function, resulting in
uremia and eventual death
2. Uremia is the toxic condition produced by retention of urinary
constituents in the blood
B. Incidence and prevalence
1. Chronic kidney disease affects approximately 20 million persons in
the United States, or 1 in 9 adults; over 5-year period, the number of
patients with kidney failure averaged about 90,000 annually
2. More than 485,000 persons in the United States are being treated for
end-stage renal disease; of these, more than 341,000 are patients
receiving dialysis and 140,000 have undergone kidney
transplantation
3. More common in Caucasians (61%), followed by African Americans
(31.7%), Hispanic (14%), Asians (4.5%), Native Americans (1.3%),
and other (1.5%)
C. Etiology

1606
 1. Infectious diseases (e.g., nephritis, viral and fungal infections)
2. Hypersensitivity states (e.g., glomerulonephritis)
3. Developmental defects of the kidneys
4. Circulatory disturbances (e.g., hypertension, hemorrhages)
5. Metabolic diseases (e.g., diabetes)
6. About 10% of new cases may result from analgesic misuse
D. Signs, symptoms, and clinical manifestations
1. Mental slowness or depression
2. Swelling and edema
3. Muscular hyperactivity
4. Hyperpigmentation of the skin (brownish yellow)
5. Anorexia, vomiting, and diarrhea
6. Anemia
7. Possible functional defect in factor VIII protein, leading to
hemorrhagic episodes
8. Hypertension, congestive heart failure
a. Blood runs from the artery to the dialysis machine, is filtered,
and then is returned to the vein
b. Heparin is added to prevent blood clotting
c. Patient is at risk for acquiring hepatitis B, hepatitis C, and
hepatitis D viruses from commercial blood products
9. Kidney transplantation—problems with graft rejection and infection;
use steroids, antibiotics, and immunosuppressives such as
cyclosporine
E. Oral manifestations
1. Painful oral ulcerations and stomatitis from drugs
2. Candidiasis or herpetic lesions from immunosuppression
3. Increased calculus deposits
4. Anemic mucosa
5. Oral petechiae and hemorrhage
6. Ground-glass appearance of alveolar bone caused by leaching of
calcium (uremic bone disease)
7. Bad taste and halitosis from urea in saliva
8. Enamel hypoplasia
9. Immunosuppressed patient who has received a transplant may have
increased risk for cancer
10. Drug-influenced gingival enlargement from cyclosporine (an
immunosuppressant) or nifedipine (a calcium-channel blocker)
11. Delayed eruption in primary teeth
12. Monitor for premedication needs with physician
13. Schedule appointment 24 hours after dialysis

1607
Older Adults
A. Definition
1. Age 55 and older
2. Older/elderly adults age 68 and older
B. Incidence and prevalence
1. Approximately 13% of the U.S. population age 66 or older; fastest-
growing segment of population
2. It is estimated that 20% of U.S. population will be age 65 or older by
2030
3. About 47% of older adults live in nursing home
a. 1% of persons age 65 to 74
b. 20% of persons age 85 or older
C. Systemic manifestations
1. Disease response—increased severity, longer course, and slower
healing
2. Decreased metabolism
3. Reduced elasticity of tissues, diminished reparative ability
4. Thin, dry, wrinkled skin; delayed healing
5. Special senses
a. 13% of persons age 70 to 74 and 31% of persons age 85 or older
have a visual impairment
b. 26% of persons age 70 to 74 and 49% of persons age 85 or older
have a hearing impairment
6. Musculoskeletal changes
a. Osteopenia and osteoporosis
b. Osteoarthritis
c. Loss of muscle function and tone
7. Increase in cardiovascular diseases
a. High blood pressure
b. Coronary heart disease
c. Valvular disease
D. Common chronic conditions
1. Arthritis
2. Hypertension
3. Cardiovascular disease
4. Diabetes
E. Oral manifestations
1. Soft tissues
a. Dry, purse-string lips with opening difficulties; angular cheilitis
(Fig.19-22)

1608
 FIG 19-22Angular cheilitis is a common oral finding in older adults
because of nutritional deficiencies. (From Ibsen OAC, Phelan JA: Oral
pathology for the dental hygienist, ed 6, St Louis, 2014, Elsevier.)

b. Capillary fragility, hyperkeratosis of oral mucosa

c. Fissures, sublingual varicosities, reduced taste from loss of taste
buds of tongue
d. Increased incidence of oral cancer
2. Hard tissues
a. Abrasion, attrition, dark color of teeth
b. Root caries
c. Decreased tooth sensitivity
d. Decreased pulp chamber size

1609
1610
Overall dental management
considerations for special care clients
A. Personal and professional prerequisites (Table 19-14)

Table 19-14
Dental Management Considerations for Clients with Special Needs

1611
1612
1613
1614
1615
1616
1617
1618
1619
ADA, American Dental Association; CDA, Canadian Dental Association; NSAIDs, nonsteroidal anti-inflammatory drugs;
TMJ, temporomandibular joint; TMD, temporomandibular disorder; INR, international normalized ratio.
* Standard precautions for infection control are used at each appointment.

1. Interview the client in a sensitive manner to gather accurate data;

initiate dental hygiene process
2. Analyze and summarize data in oral or written formats
3. Use problem-solving skills to develop alternative strategies to
manage problems
4. Evaluate client and professional goals and progress for
appropriateness and effectiveness
5. Remain current of new conditions, new protocols for medical
management, and advances in dental and dental hygiene care
6. Apply new knowledge or techniques from other areas to dental
management of special clients
7. Apply research principles and techniques to acquire clinical data
that serve as the basis for care planning and decision making
B. Office management issues
1. Stress a team concept, with cooperation among members and
coordination of information and activities; dental hygiene

1620
 procedures may require the help of a dental assistant
2. Identify and anticipate client needs and problems before initiation
of care; use of a previsit questionnaire is helpful (Fig. 19-23)

FIG 19-23 Previsit questionnaire for gathering preliminary data about

individuals with special needs.

3. Obtain informed consent for treatment from the client or an

appropriate representative
4. Explain office policies, procedures, and philosophy to the client or
guardian before or at the first appointment
5. Determine financial limitations that may affect care planning or
payment procedures
a. Assess additional resources available from other sources (e.g.,
community organizations)
b. Attempt to provide flexible payment alternatives

1621
 6. If the client is unable to receive care in the office because of physical
limitations or geographic distance, determine if care can be provided
in the home or community setting with portable equipment
7. If office facilities do not comply with accessibility guidelines, discuss
ways to:
a. Make them physically accessible
b. Accommodate client needs, or refer the client to a provider who
can provide access
8. Ensure that office layout and environment are not safety hazards or
health hazards for some clients
9. Keep scheduling somewhat flexible to allow for transportation or
other problems; block appointments are helpful when dealing with
groups
10. Be prepared to implement wheelchair transfers
C. Medical issues
1. Obtain a health history from the client or caregiver, with
supplemental information from other professionals or agency
records
2. Update the health history at each visit
3. Because many standard health history forms are inadequate for the
multiple conditions and problems of some clients, ask supplemental
questions
4. Obtain specifics regarding medical treatment regimens or other
therapies that may affect scheduling or treatment
5. Obtain names, addresses, and phone numbers for all the client’s
physicians who might provide helpful data (e.g., generalist,
cardiologist, orthopedist, endocrinologist) with permission to
release information
6. Be particularly alert to the client’s physical status during initial
assessment
7. Monitor vital signs, as indicated
8. Record all medication information; update at each visit
9. Note any indications or contraindications to treatment or
premedication
10. Maintain records of all medical advice, prescriptions, or drugs given
11. If clients refuse to disclose medical information or do not follow
recommended standard procedures for their own protection (e.g.,
antibiotic premedication), have them sign a statement to that effect
for the records
D. Treatment adaptations
1. Demonstrate understanding and acceptance of conditions or

1622
 problems to the client and to caregivers or family
2. Determine which special needs require provider adaptations versus
client adaptations
3. Demonstrate empathy, not sympathy
4. Discuss before implementation:
a. Behavioral expectations
b. Overview of the entire care plan
c. Procedures that will be performed at the appointment
d. Approximate time required
e. Communication techniques to be used during the appointment
5. Introduce clients to the oral health care setting gradually by using
desensitization, modeling, “show-tell-do,” or other methods
6. Ensure client comfort in the dental chair through frequent
assurance, positioning, and supportive measures as needed (e.g.,
pillows)
7. Explain carefully any need for client body restraint or stabilization
for behavioral or stability purposes to ensure the clinician’s safety
and the client’s safety while in the chair; Velcro® straps similar to
safety belts are helpful for stability (Fig. 19-24); ensure the following:

1623
 FIG 19-24 The Rainbow® Stabilizing System. A, Adult on large hinged
board. B, Child with elbow and knee stabilizers that prohibit movement of
joints. C, Head stabilizer. D, Safety belts for securing the client safely in
the dental chair. (Used with permission from Specialized Care, Hampton, NH.)

a. Obtain informed consent to use these aids

b. Ensure least restrictive restraint is used
c. Clearly document restraint used
d. Check state regulations to ensure proper compliance
8. Pharmacologic restraints such as oral, intramuscular, intravenous, or
inhalation sedation may be needed; general anesthesia is sometimes
necessary when a client is not easily stimulated or has partial or
complete loss of protective reflexes
9. Be aware that adaptations for specific procedures require problem
solving and experimentation among the provider, client, and
caregiver, if appropriate; Fig. 19-25 displays a variety of mouth props

1624
 FIG 19-25 A, Clinician shown using the OpenWide® Disposable Mouth
Prop on an adult. B, Clinician shown using the OpenWide® Re-Usable
Mouth Prop that allows for a saliva ejector to be kept in place with the
bite block. (Used with permission from Specialized Care, Hampton, NH.)

10. Discuss the mechanisms for wheelchair transfers with each client;
preferences and techniques vary
11. Protect the client’s airway through use of a rubber dam, adequate
suctioning, and other means; this is of paramount importance
because of the frequency of impaired oral reflexes
12. Some pediatric clients’ behavior may improve if they bring comfort
items such as a stuffed animal or a blanket; asking the caregiver to
sit nearby or hold the child’s hand may be helpful as well
13. For the most part, keep appointments short and positive
14. Fluoride therapies (varnishes) and antimicrobial rinses are
important preventive measures
15. Stress the importance of good oral health being part of good
general health
E. Preventive measures

1625
1. Identify risk factors for oral disease to plan preventive programs
that:
a. Maximize positive health behaviors
b. Eliminate risk factors
c. Eliminate existing disease
2. Common risk factors
a. Inappropriate nursing and feeding habits
b. Transfer of oral pathogens from mother or caregiver to infant
(vertical transmission); usually from sharing food and eating
utensils; can also occur among siblings or playmates (horizontal
transmission)
c. Nutritionally inadequate diet
d. Frequent intake of cariogenic foods
e. Suboptimal fluoride supplementation
f. Oral-motor dysfunction (e.g., hyperactive gag reflex or impaired
tongue control)
g. General motor dysfunction interfering with oral hygiene care
h. Crisis orientation to care
i. Preoccupation with one’s disability; depression
j. Previous negative experience with health care
k. Limited income and education
l. Different cultural values and beliefs
3. Develop individualized programs to reduce or eliminate the risk
factors and increase the protective factors
4. Consider the client’s limitations when recommending home care
procedures
a. Problems with fluoride or antimicrobial rinses or disclosing
tablets if the client has oral-motor problems
b. Problems performing the sequence of toothbrushing strokes if
the client has memory or general motor impairment; Fig. 19-26
displays a modified toothbrush for easier accessibility

1626
 FIG 19-26 The Surround® Toothbrush has a unique head that
surrounds the tooth to clean all surfaces at the same time; ideal
aid for caregiver brushing another person’s teeth. (Used with
permission from Specialized Care, Hampton, NH.)

c. Problems picking up and using a toothbrush and toothpaste if

the client has paralysis or control problems
d. Power toothbrushing and flossing devices can work well, but
some patients may respond poorly since they can be frightened
by the noise
5. Provide anticipatory guidance to parents on milestones and
preventive measures at each developmental stage
6. Schedule frequent maintenance care appointments
7. Coordinate preventive efforts in the home, school, day care,
workplace, or oral health care settings
8. Encourage the establishment of a dental home

Website Information and Resourc es

Source Website Address Description

1627
Source Website Address Description
American Academy of http://www.aapd.org Information, education, policies,
Pediatric Dentistry and guidelines on working with
all children, including those with
special care needs
National Maternal and http://www.mchoralhealth.org/default.html Information on working with
Child Oral Health Resource children with disabilities
Center
National Institute of Dental http://www.nidcr.nih.gov Information, education, and
and Craniofacial Research strategies on providing care to
patients with special care needs
National Institute of http://www.ninds.nih.gov Health information and resources
Neurological Disorders and for patients and professionals
Stroke related to a wide variety of
neurologic disorders
National Institute on http://www.ed.gov/programs/nidrr Support related to rehabilitation
Disability and of individuals with disabilities
Rehabilitation Research
University of Washington; http://dental.washington.edu/oral- Health and dental information for
School of Dentistry; Patients medicine/special-needs/patients-with- caregivers and professionals
with Special Needs special-needs/ related to patients with special
care needs

1628
Suggested Readings
American Dental Education Association: Oral health for independent
older adults.
http://www.adea.org/publications/Documents/CurriculumResourceGuide.
Accessed Oct 20, 2014.
Cawson R.A., Odell E.W. Oral pathology: clinical pathologic
correlations. ed 6 Philadelphia: Elsevier; 2012.
Darby M., Walsh M. Dental hygiene theory and practice. ed 4
Philadelphia: Elsevier; 2015.
Faulks D., Freedman L., Thompson S., et al. The value of education
in special care dentistry as a means of reducing inequalities in
oral health. Eur J Dent Educ. 2012;16(4):195–201.
Fikleman M., Stark P., Tao W., Morgoa J. Relationship between
duration of treatment in oral health in adults with intellectual
and developmental disabilities. Spec Care Dent. 2014;34(4):171–
175.
Little J.W., Falace D.A. Dental management of the medically
compromised patient. ed 8 St Louis: Elsevier; 2013.
Mayo Clinic Website: Diseases and conditions.
www.mayoclinic.com/invoke.cfm. Accessed Oct 24, 2014.
National Oral Health Information Clearinghouse: Practical oral care
for people with developmental disabilities, Making a difference series,
NIH Pub No 04-5193.
Simmer-Beck M. Providing care to individuals with special
healthcare needs. Dimens Dent Hygiene. 2010;8(5):64–67.

Chapter 19 review questions

46. What G.V. Black classification of caries is found on the mesial of tooth
#8?
a. Class I
b. Class II
c. Class III
d. Class IV
47. On the radiographs, the arrow is pointing to what radiopaque
structure on the maxillary left molar image?
a. Internal oblique ridge
b. Floor of the maxillary sinus

1629
 c. Coronoid process
d. Nutrient canal
48. As you are working on the patient, she displays a blank, staring look
and is nonresponsive for about 30 seconds, but quickly returns to
normal. What type of seizure is she experiencing?
a. Generalized tonic-clonic
b. Myoclonic
c. Generalized absence
d. Simple motor partial
49. The radiopaque area in the mandibular anterior image apical to teeth
#23 and #24 is:
a. Sclerotic bone
b. Tori
c. Genial tubercles
d. Nutrient foramen
50. What is the technique error associated with the left premolar
periapical radiograph?
a. Beam-indicating device alignment
b. Incorrect placement of film-holding device
c. Incorrect horizontal angulation
d. Incorrect vertical angulation
51. All following are acceptable approaches for teaching this patient oral
self-care EXCEPT:
a. “Show-tell-do” approach
b. Explanation of bone loss using radiographs
c. Demonstration of proper use of disclosing tablets
d. Use of powered toothbrushing techniques
52. Which of the following oral rinses would the patient MOST benefit
from?
a. Chlorhexidine
b. Phenolic-related essential oils
c. Cetylpyridinium chloridc
d. Chlorine dioxide

1630
 Use Case B and Figs. 19-33 through 19-38 to answer questions 46 to 52.
35. In which blood pressure category would this patient’s reading today
be placed?
a. Normal
b. Prehypertension
c. Stage 1
d. Stage 2
36. The apices of the roots are not present on the maxillary right molar
view? What is the most likely cause of this error?
a. Incorrect placement of film-holding device
b. Too much horizontal angulation
c. Too little vertical angulation

1631
 d. Too little horizontal angulation
37. All the following teeth have radiographic signs of subgingival
calculus EXCEPT:
a. #2
b. #12
c. #28
d. #30
38. Which of the following medications is the patient taking to help
manage the symptoms of fibromyalgia?
a. Symbicort
b. Lyrica
c. Glucophage
d. Zocar
39. The patient’s chief complaint of having jaw-opening problems is most
likely related to which of her medical conditions?
a. Diabetes type 2
b. Hyperlipidemia
c. Fibromyalgia syndrome
d. Asthma
40. Which of the following medical emergencies is most likely to occur
with this patient?
a. Seizure
b. Hyperglycemia
c. Angina
d. Anaphylaxis
41. Which American Society of Anesthesiologists (ASA) Physical Status
(PS) Classification would be most appropriately assigned to this patient?
a. PS1
b. PS2
c. PS3
d. PS4
42. All the following treatment modifications may be warranted for this
patient EXCEPT:
a. More upright chair position

1632
 b. Cervical neck pillow
c. Back and leg supports
d. Longer appointments
43. The patent reports an HbA1c value of 7%. This means that the level of
diabetes control is rated as:
a. Well controlled
b. Moderately controlled
c. Uncontrolled
d. Life threatening
44. What is the clinical attachment loss on the facial of tooth #24?
a. 4 mm
b. 5 mm
c. 6 mm
d. 8 mm
45. Which of the following oral hygiene aids would be BEST
recommended for cleaning the area between teeth #8 and #9?
a. Floss
b. Balsa wooden wedge
c. Interproximal brush
d. End tuft brush

1633
Use Case A and Figs. 19-27 through 19-32 to answer questions 35 to 45.

1634
FIG 19-27 Case A: anterior teeth.

FIG 19-28 Full mouth radiographs.

1635
 FIG 19-29 Lingual teeth.

FIG 19-30 Right lateral teeth.

1636
FIG 19-31 Maxillary lingual teeth.

FIG 19-32 Left lateral teeth.

1637
FIG 19-33 Case B: full-mouth series.

FIG 19-34 Maxillary anterior teeth.

1638
 FIG 19-35 Left lateral teeth.

FIG 19-36 Mandibular lingual teeth.

1639
 FIG 19-37 Right lateral teeth.

FIG 19-38 Maxillary lingual teeth.

1. The seizure type characterized by continuous intermittent contractions

and relaxation of voluntary muscles and loss of consciousness is termed:
a. Complex partial
b. Generalized absence
c. Generalized tonic-clonic
d. Atonic

1640
2. All the following are common clinical manifestations found with Down
syndrome EXCEPT one. Which one is the exception?
a. Long neck with thin, long fingers
b. Tranverse palmar hand crease
c. Eyes closer together than normal
d. Microcephaly of the head
3. Which of the following is the leading cause of preventable mental
impairments in the United States?
a. Nutritional deficiencies
b. Alcohol consumption
c. Exposure to toxic waste
d. Sensorineural malfunctioning
4. Which trimester of pregnancy is considered the safest for routine
dental care?
a. First
b. Second
c. Third
d. None
5. Which of the following is the progressive hearing loss that occurs with
age?
a. Otitis media
b. Presbycusis
c. Mastoiditis
d. Acoustic neurinoma
6. Which of the following is a nonprogressive neuromuscular condition
caused by damage to the immature brain and affecting the ability to
control posture and movement?
a. Parkinson’s disease
b. Scleroderma
c. Trigeminal neuralgia
d. Cerebral palsy
7. All the following are common oral findings associated with bulimia
EXCEPT:
a. Esophageal lacerations

1641
 b. Submandibular gland swelling
c. Enamel erosion
d. Burning tongue
8. Drug-influenced gingival enlargement is often associated with which
of the following antiseizure medications?
a. Carbamazepine (Tegretol)
b. Valproic acid (Depakote)
c. Topiramate (Topamax)
d. Phenytoin (Dilantin)
9. Which of the following is a chronic degenerative disease of the central
nervous system that destroys myelin?
a. Myasthenia gravis
b. Spina bifida
c. Fibromyalgia
d. Multiple sclerosis
10. Which of the common manifestations of Down syndrome is an
indication for antibiotic premedication prior to dental hygiene care?
a. Hearing impairment
b. Shunt
c. Congenital heart defect
d. Thyroid problem
11. Which of the following is an internal barrier to physical facilities for
the person with a disabling condition?
a. Armless chairs with wheels
b. Bathroom with grab bars by the commode
c. 36-inch-wide doorways
d. Nonslip floors
12. Which of the following is a common oral manifestation in the client
with Down syndrome?
a. Early eruption patterns
b. Large tooth crowns with long crown/root ratio
c. Enamel dysplasia
d. Low palatal vault
13. In which of the following conditions is retention of food common,

1642
causing increased susceptibility to oral disease?
a. Fibromyalgia
b. Myasthenia gravis
c. Spina bifida
d. Bronchial asthma
14. Body stability maintenance during dental hygiene care is of great
concerns for patients with:
a. Scleroderma
b. Sjögren syndrome
c. Addison’s disease
d. Cerebral palsy
15. In which of the following conditions would oral paralysis be found?
a. Cystic fibrosis
b. Bell’s palsy
c. Pemphigus vulgaris
d. Multiple sclerosis
16. Latex allergy is common in patient with:
a. Spina bifida
b. Parkinson’s disease
c. Congenital heart disease
d. Hyperthyroidism
17. Powered scaling devices would be contraindicated for use in patients
with all the following conditions EXCEPT:
a. Myasthenia gravis
b. Cystic fibrosis
c. Emphysema
d. Pernicious anemia
18. A dental hygienist should expect physical mobility limitations in
patients with all these disabling conditions EXCEPT:
a. Parkinson’s disease
b. Muscular dystrophy
c. Epilepsy
d. Cerebral palsy

1643
19. A stroke survivor should postpose elective dental hygiene treatment
for:
a. 2 months
b. 3 months
c. 4 months
d. 6 months
20. When being escorted, an adult blind patient holds the arm of the
dental hygienist just below the wrist. The blind patient then walks beside
and slightly behind the hygienist.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
21. Which of the following is an appropriate action for the dental
hygienist when a blind patient brings a guide dog to the appointment?
a. Pet the dog to make “friends”
b. Have “dog treats” ready to ensure the dog will behave
c. Ask the patient to leave the dog in the waiting room
d. Ignore dog, since it is working
22. Which is the most common chronic illness found in the elderly
population?
a. Renal dysfunction
b. Arthritis
c. Visual disturbances
d. Diabetes
23. Which is the most serious complication of radiation therapy to the
head and neck area?
a. Xerostomia
b. Radiation caries
c. Osteoradionecrosis
d. Increased severity of periodontal disease
24. Which of the following conditions represents a medical emergency
for someone with a: spinal injury?
a. Incontinence

1644
 b. Tremors
c. Deficit in acetylcholine
d. Autonomic dysreflexia
25. In which of the following conditions would mouth opening be a
potential problem for oral hygiene implementation?
a. Cystic fibrosis
b. Multiple sclerosis
c. Scleroderma
d. Myelomeningocele
26. Antibiotic premedication would be indicated before dental hygiene
treatment for the client with which of the following conditions?
a. Artificial heart valve
b. Generalized tonic-clonic seizure
c. Chronic obstructive pulmonary disease
d. Angioplasty and stent placement
27. Use of local anesthetic with epinephrine is contraindicated in patients
with coronary heart disease, since the epinephrine in limited amounts
can precipitate a myocardial infarction.
a. Both parts of the statement are TRUE.
b. Both parts of the statement are FALSE.
c. The first part of the statement is TRUE, but the second part is
FALSE.
d. The first part of the statement is FALSE, but the second part is
TRUE.
28. Which of the following functional limitations is common in patients
who have experienced a right CVA (cerebrovascular accident)?
a. Disorganization
b. Inability to use mirrors
c. Inability to see angles
d. Inability to judge distance
29. Patients with all the following conditions should see a dentist
immediately after diagnosis to help manage their oral disease and
condition EXCEPT those with:
a. Alzheimer ’s disease

1645
 b. Diabetes
c. Sickle cell disease
d. Oral cancer
30. Which of the following drugs is contraindicated to control dental pain
in a patient who is pregnant?
a. Acetaminophen
b. Naproxen
c. Codeine
d. Morphine
31. A renal transplant patient should have routine dental care postponed
for 6 months after the transplant, since the organ transplant is still being
monitored for signs of rejection.
a. Both parts of the statement are TRUE.
b. Both parts of the statement are FALSE.
c. The first part of the statement is TRUE, but the second part is
FALSE.
d. The first part of the statement is FALSE, but the second part is
TRUE.
32. All the following conditions may complicate the patient’s ability to
perform oral self-care EXCEPT:
a. Scleroderma
b. Parkinson’s disease
c. Arthritis
d. Hypothyroidism
33. A ground-glass appearance of the alveolar bone would be seen on
radiographs in the patient with which condition?
a. End-stage renal disease
b. Ischemic heart disease
c. Myasthenia gravis
d. Lichen planus
34. An alcoholic patient may have delayed healing after scaling and root
debridement because of:
a. Chronic swelling of glands
b. Deceased endocrine hormones

1646
 c. Decreased white blood cell count
d. Increased platelet count
Answers and rationales to review questions are available on this text’s
accompanying Evolve site. See inside front cover for details.

1647
C HAPT E R
20

1648
Community Oral Health Planning
and Practice
Christine French Beatty; Connie E. Beatty; Charlene B. Dickinson

Assessment, diagnosis, planning, implementation, and evaluation—the

dental hygiene process of care—are used in community oral health
practice, program development, and outcomes assessment. Community
health extends the role of the dental hygienist from a traditional health
care setting to the community as a whole. In a sense, the community can
be viewed as the client and the oral care environment as the
neighborhood health center, extended care facility, hospital, school,
agency, or country. One of the characteristics of community health is the
use of a team approach. Concerns for the oral health of the population
has renewed an interest in expanding the roles and responsibilities of
dental hygienists in order to increase access to oral health care for
underinsured and underserved patients. Expanding roles in community-
based care settings require that the dental hygienist possess the
knowledge and skills for developing public health programs, research
and epidemiologic methods, prevention and control of oral diseases,
provision and financing of oral health care, and the adaptation of care
and programs to diverse populations.

1649
Basic concepts
A. Health—community health practice requires a broad view of health
that includes the following:
1. Complete physical, mental, and social well-being; not just the
absence of disease or infirmity
2. Anatomical, physiologic, and psychological integrity
3. Ability to perform personally valued family, work, and community
roles to achieve individual and society goals
4. Ability to deal with physical, biologic, psychological, and social
stress
5. Freedom from the risk of disease and untimely death
6. Extent to which an individual or a group is able to realize aspirations
and satisfy needs and to change or cope with the environment
7. Emphasis on social and personal resources as well as physical
capabilities
B. Oral health—status of the oral cavity, encompassing all features,
normal and abnormal, of the oral, dental, and craniofacial complex
C. Wellness—high-level wellness is described as a dynamic process in
which the individual is actively engaged in moving toward fulfillment of
his or her human needs and potential; it reflects the following:
1. A change in the perceptions of health and wellness from the medical
model of health care that is treatment oriented
2. A prevention preference that examines the relationships among the
host, agent, environment, and preventive strategies
3. A health promotion orientation aimed at creating an environment
that enables individuals to increase control over and improve
current and future health status
D. Determinants of health—consist of social and economic factors, the
physical environment, and the person’s individual characteristics and
behaviors
1. Many determinants are nonmodifiable
2. Risk factors are modifiable determinants that can be changed
through education, preventive therapies, public health policies, and
modifications in the structure of health care delivery
E. Public health—the combination of sciences, skills, and beliefs directed
at maintaining and improving the health of all persons by preventing
disease, improving the quality of life, and promoting physical and mental
health through collective or social actions in the community;
characteristics include a collaborative approach, preventing rather than
curing disease, dealing with population health rather than individual

1650
health, social responsibility for oral health, use of epidemiology and a
multifactorial approach to controlling and preventing disease, and
application of biostatistics
1. Aggregate health of a group, community, state, nation, or group of
nations
2. Public health seen as people’s health
3. Concerned with four broad areas:
a. Lifestyle, behavior, and culture
b. Environment
c. Human biology
d. Organization of health programs and systems
F. Dental public health—science and art of preventing and controlling
oral diseases and promoting oral health through organized community
efforts; the form of dental practice that serves the community as a client
rather than the individual; concerned with the oral health education of
the public, applied dental research, and administration of group oral
health care programs, as well as the prevention and control of oral
diseases on a community basis; the application of public health and all
its characteristics to oral health
G. Community—any group with common traits, shared features, or
communal experiences; not strictly defined by traditional geographic
boundaries; as broad as a region or a state or as focused as a specific
institution or agency, such as a nursing home community, including
administrators, staff, residents, and caregivers
H. Community health—generally synonymous with public health; full
range of health services, environmental and personal, including major
activities such as health education of the public and the social context of
life as it affects the community; efforts that are organized to promote and
restore the health and quality of life of the people; uses a population-
based approach for identifying and addressing community-based
problems
I. Community oral health—services directed toward developing,
reinforcing, and enhancing the oral health status of people, either as
individuals or as groups and communities for the purpose of enhancing
the oral health of the population; Table 20-1 presents a comparison of
private health care practice to community health care practice

1651
Table 20-1
Comparison of Private Dental Practice and Community Oral Health Practice*

Private Dental Practice Community Oral Health Practice

Assessment of client’s dental, health, Survey of community oral health status; situation analysis
pharmacologic, and sociocultural including assessment of population demographics,
history and oral health status culture, mobility, economic resources, and infrastructure
(community profile)
Diagnosis of client’s oral health needs Analysis of survey data to determine the oral health needs
of the population
Treatment plan based on diagnosis, Program plan based on data analysis, community
professional judgment, client’s needs, priorities, and resources available
and priorities
Treatment plan initiated; primary Program operation implemented by varied, sometimes
dentist may coordinate treatment interdisciplinary, personnel
with other providers (e.g., dental
hygienists, specialists)
Payment methods determined Financing throughout process; funds may be from a
combination of government (local, state, and federal),
philanthropic and/or community agencies
Evaluation during treatment, at Ongoing and varied evaluation and appraisal conducted in
specific intervals, on completion of terms of effectiveness, efficiency, appropriateness, and
treatment, or at all these times adequacy
* Education occurs at all levels to facilitate anticipated outcomes.

J. Access—an individual’s or group’s ability to obtain appropriate health

care services
K. Prevention—primary focus of community oral health is prevention;
the wellness model focuses educational and behavioral efforts and
programs toward prevention of disease and maintenance of an optimum
state of well-being; three levels of prevention:
1. Primary—prevention of disease before it occurs; for example,
placement of dental sealants
2. Secondary—early disease control, including early identification and
prompt treatment before the individual is aware of a problem; for
example, restoration of caries identified through a routine dental
examination
3. Tertiary—provision of services that prevent further disability; for
example, restoration of a fractured tooth caused by severe caries
L. Comparison of private health care practice to community health care
practice—steps are presented in Table 20-1; the focus of public health is
on the population rather than on any individual patient, yet similarities
exist in the process of care
M. Criteria for identifying a public health problem

1652
 1. A condition, practice, or situation is widespread and an actual or
potential cause of morbidity (disease) or mortality (death)
2. The public, nongovernmental agency, government, or public health
personnel perceive the condition is a public health problem and
direct efforts at a solution
3. Public health solution—a solution to a public health problem that is
directed to the community at large; preventive strategies possess as
many characteristics of an ideal public health solution as possible
(Box 20-1)

Box 20-1
Charac teristic s of an Ideal Public Health
Solution
1. Safe; not hazardous to life or function
2. Effective in reducing or preventing a targeted disease, condition, or
practice
3. Easily and efficiently implemented
4. Potency maintained for a substantial time period
5. Attainable regardless of socioeconomic status (SES), education, or
income
6. Effective immediately on application
7. Affordable, cost-effective, and within the means of a community

N. Core functions of public health—nationally identified; form the

foundation of all community health activities
1. Assessment—regular and systematic collection, assembling, and
analysis of data related to the health of the population and making
the data available for use by various agencies; for example, oral
disease data collected through the National Oral Health Surveillance
System
2. Policy development—development of comprehensive public health
policies based on scientific evidence; for example, adoption of
Healthy People 2020 objectives and Centers for Disease Control and
Prevention (CDC) recommendations for water fluoridation
3. Assurance—provision of services necessary to achieve agreed-on
health goals related to improving the health of the public; for
example, provision of services and programs that are publicly
funded
O. Governmental levels of public health—each level provides various

1653
services, meets different needs of the population, and supports the
functions of other levels; for example, the federal departments support
state agencies, and local programs are often funded by grants or
contracts from the state or federal levels
1. Local—responsible for direct administration of educational
resources, preventive care, and patient care programs
2. State—consultation to the local level and other agencies; channels
federal and state funds such as Medicaid and Children’s Health
Insurance Program (CHIP); coordinates programs throughout the
state; conducts programs in rural areas that do not have local public
health agencies
3. Federal—numerous national public health government agencies are
involved in public health issues of national significance; Box 20-2
describes significant agencies and organizations that act as a
resource for community programming

Box 20-2
Federal Governmental Agenc ies of Interest in
Community Oral Health
Public Health Service (PHS)—the primary operating division of the U.S.
Department of Health and Human Services (DHHS), responsible for
the protection and advancement of the American population’s physical
and mental well-being. Various agencies and programs (e.g., CDC,
NIH, IHS, FDA) accomplish the goals of coordinating and
implementing national health policy on the state and local levels;
conducting medical and biomedical research; addressing issues related
to access, quality, and cost of health care; and enforcing laws to ensure
the safety of drugs and medical devices and to protect the public
against impure foods and cosmetics. Goals are carried out by the
Commissioned Core of health officers led by the Surgeon General, who
also staff federal clinics (e.g., in federal prisons, Indian Health Service
programs, and some armed services) and respond to national crises.
National Institutes of Health (NIH)—conducts epidemiologic research,
provides science transfer, and publishes and distributes educational
materials. Several institutes are relevant to oral health, such as
National Institute of Dental and Craniofacial Research (NIDCR),
National Cancer Institute (NCI), and National Institute on Aging
(NIA) (e.g., tobacco cessation); and provides surveillance data (e.g.,
water fluoridation).

1654
Indian Health Service (IHS)—provides direct patient care and community
health programming for Native American populations.
Centers for Disease Control and Prevention (CDC)—provides expertise,
information, tools, and community collaboration to assist agencies
with community programming; formulates recommendations for
evidence-based practice (e.g., infection control and use of fluoride
varnish); develops educational programs for local implementation.
Department of Defense (DoD) and Veterans Administration (VA)—provide
direct care for specific armed services populations.
Centers for Medicare and Medicaid Services(CMS)—manages the federal
Medicare and Medicaid programs to assist citizens with health care.
Administration for Children and Families (ACF)—involved in programs
that promote the economic and social well-being of families, children,
individuals, and communities; manages the Head Start program.
Data from Beatty CF: Community oral health practice for the dental hygienist, ed 4, St Louis, 2017,
Elsevier Saunders.

4. International—the World Health Organization (WHO) is the best-

known and largest international health agency; primarily serves
developing countries but also monitors health conditions and establishes
programs to coordinate health care throughout the world; the Pan-
American Health Organization (PAHO) is the regional office of WHO for
the Americas
P. Key national documents relevant to community oral health
programming—classic documents continue to provide a basis to
prioritize programs and target specific population groups; newer
documents update the vision and strategies for implementation with a
broader focus within the medical community; the documents
complement each other as they categorize population oral health needs,
priorities, and strategies and stress the importance of improving access
to oral health care and reducing oral health disparities in the population;
based on the three core public health functions of assessment, policy
development, and assurance
1. Oral Health in America: a Report of the Surgeon General, 2000—the key
points are:
a. Oral health is more than just healthy teeth
b. Oral health is integral to general health for all Americans
c. General health factors (e.g., tobacco use, poor diet, obesity,
diabetes) affect oral and craniofacial health
d. Oral health can be achieved by all Americans

1655
 e. Disparities exist in the oral health of Americans
2. A National Call to Action to Promote Oral Health—developed by a
broad collaboration of private and public health agencies and
organizations led by the Surgeon General’s office; includes five
principles and implementation strategies designed to result in
programs that will more effectively contribute to the goal of
optimum oral public health:
a. Change perceptions about oral health
b. Build the science and accelerate the transfer of the science
c. Increase collaborations (partnerships, coalitions)
d. Increase workforce diversity, capacity, and flexibility
e. Overcome barriers by replicating effective programs
3. Healthy People (HP) 2020—a comprehensive list of approximately
1200 disease prevention and health promotion objectives in 42
health topic areas
a. Developed by a federal interagency workgroup led by the U.S.
Department of Health and Human Services (DHHS) with input
from various health organizations
b. Includes developmental objectives that as yet have no baseline
data source; objectives are revised each decade based on
outcomes from previous decade
c. Current objectives establish the health agenda for the United
States and provide priorities for community programming for
the current decade
d. Oral health is one of the topic areas; there are 17 Oral Health
objectives (Table 20-2); objectives that relate to oral health are
also contained in other HP topic areas, such as cancer, diabetes,
older adults, and tobacco use

Table 20-2
Healthy People (HP) 2020 Objectives and Targets, with Outcomes in Last Decade

1656
1657
 Data from Department of Health and Human Services: Healthy people 2020,
http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx; and National Center for Health
Statistics: Healthy people 2010 final review: overview and selected findings, PHS Pub No 2012-1038,
Hyattsville, Md, 2012, http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf.
1 Target setting method was 10% improvement for most HP 2020 goals (OH-11 and OH-16 were
exceptions).

2 = Moved away from target; = Moved toward target; * = Met or exceeded target.

3 DNA = Data not available. These are new goals for 2020.

4 This goal for 2010 was for ages 35 to 44 years rather than the current age range of 45 to 64 years in the
2020 goal.
5 N/A = Not applicable: baseline data and targets are not set for developmental goals.

6 HP 2010 goal existed for this subgoal without other subgoals of the 2020 goal.

4. Advancing Oral Health in America—developed by the Institute of

Medicine (IOM); established the following new recommendations,
called a New Oral Health Initiative, to build and enhance the current
systems that are in place:
a. Establish high-level accountability
b. Emphasize disease prevention and oral health promotion
c. Improve oral health literacy and cultural competence
d. Reduce oral health disparities
e. Explore new models for payment and delivery of care
f. Enhance the role of nondental health care professionals
g. Expand oral health research and improve data collection

1658
 h. Promote collaboration among private and public stakeholders
i. Measure progress toward short-term and long-term goals and
objectives
j. Advance the goals and objectives of HP 2020
5. Improving Access to Oral Health Care for Vulnerable and Underserved
Populations—report of IOM focused on integrating oral health into
overall health care, including emphasis on changes needed in laws
and regulations such as scope of practice laws, improving dental
education in relation to treating diverse populations in various
settings, reducing financial and administrative barriers, and
expanding capacity
Q. Roles of the dental hygienist reflect various activities in public health;
all should be based on sound scientific information (evidence-based
practice):
1. Clinician—provides direct client care
2. Educator—uses valid educational theories to present scientific
information to individuals and groups to prevent disease and
promote oral health
3. Advocate—promotes change and advances the health of the public
through legislation and public policy
4. Researcher—determines which procedure, products, and programs
most effectively promote oral health and prevent disease, and
communicates those findings
5. Administrator/manager—administers and manages programs aimed
at promoting oral health

1659
Epidemiology
A. Definitions
1. Epidemiology—study of health-related conditions and diseases in
human populations and how these states are influenced by the
environment and ways of living, including the nature, cause, control,
and determinants of health and disease as well as related factors;
concerned with factors and conditions that determine the occurrence
and distribution of health, disease, defects, disability, and deaths
among individuals and groups; characterized by the use of statistical
and research methods to focus on comparisons between groups or
defined populations (Box 20-3)

Box 20-3
Definition of Epidemiology
Epidemiology is derived from three Greek root words:
• epi: upon or among—“upon the body; among the people”
• demos: people or district—“demographics”
• logos: study, word or discourse—“the study of ”
1. A branch of medical science that deals with the incidence, distribution,
and control of disease in a population
2. The sum of the factors controlling the presence or absence of a disease
or pathogen
3. The study of the distribution and determinants of disease frequency
Data from http://www.merriam-webster.com/dictionary/epidemiology; and What is epidemiology?
http://www.helsinki.fi/science/bgs/epidemiology.pdf.

2. Applied epidemiology—the application or practice of epidemiology to

address public health issues
B. Uses of epidemiology (Box 20-4)

Box 20-4
Uses of Epidemiology
1. To study
• Describe normal biologic processes
• Establish a history of disease in a population
• Measure the distribution of diseases in populations; detect patterns
of disease among groups
• Analyze trends in chronic disease and social epidemiology

1660
 • Identify nondisease entities such as accidents, suicide, or injury
• Recognize syndromes and precursors
2. To assess
• Collect data to describe and measure disease or health conditions
within a community
• Identify current public health policies, activities, and health services
that relate to disease in the community
3. To identify:
• Identify risk factors, risk indicators, risk markers, and other
determinants of disease such as health literacy
• Estimate risk of diseases among population groups
• Detect cause-and-effect relationships of diseases and various factors
to help in the diagnostic processes of disease identification, as well
as planning of preventive strategies
4. To control
• Limit causes of diseases, conditions, injury, disability, or death for
prevention and/or elimination
• Contain diseases within the population
5. To plan
• Develop appropriate health services and public health programs
• Design mechanisms to evaluate effectiveness of services and
programs
6. To evaluate
• Calculate how well public health policies, intervention and
preventive strategies, and programs control disease and improve the
health status of the population
• Appraise the appropriateness and utility of health services
7. To research
• Test hypotheses for the effectiveness of measures to prevent and
control disease
• Determine the success of disease prevention and control measures in
populations

C. Characteristics of epidemiology
1. Groups rather than individuals are studied
2. A multifactorial approach is used to study disease (multiple
causation); modifiable risk factors are controlled to control the
disease or condition
3. Determinants—risk factors or events that are capable of bringing
about a change in health; the various factors that make up the
multifactorial approach to a disease or health condition

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 4. Epidemiologic triad (epidemiologic triangle)—the traditional model
of infection or disease causation used to study the occurrence and
distribution of disease; includes a susceptible host, an external agent
(etiologic agent), and an environment that brings the host and agent
together so that disease occurs, as well as the time dimension
required for disease to occur; the ongoing interaction among these
factors affects disease or health status (Fig. 20-1)

FIG 20-1 Epidemiologic triangle. (Data from Centers for Disease Control and
Prevention: Lesson 1, Understanding the epidemiologic triangle through infectious
disease. http://www.cdc.gov/bam/teachers/documents/epi_1_triangle.pdf.)

5. Burden of disease—cumulative effect of a broad range of harmful

disease consequences on a community; includes the full scope of the
health, social, and economic effects of disease
6. Preventive intervention—a strategy to eliminate risk factors and
reduce the occurrence of disease
D. General epidemiology concepts—ideas that must be grasped to
comprehend epidemiology (Table 20-3)

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Table 20-3
General Epidemiologic Concepts

Term Definition

Acute disease Beginning abruptly with marked intensity, and then subsiding after a relatively
short period; often treatable
Chronic Developing slowly and persisting for a long period, often for the remainder of the
disease lifetime of the individual
Cluster Aggregate of cases of a disease or other health-related conditions, particularly
cancer or birth defect, closely grouped in time or space
Endemic Continuing problem involving normal disease prevalence; the expected number
of cases native to a population or geographic area
Epidemic A disease of significantly greater prevalence than normal (more than the expected
frequency); rapid spread of a disease through a population
Pandemic An epidemic that crosses international borders to affect a large proportion of the
geographic population of a continent, people, or the world
Population at Includes persons in the same community or population group who can acquire a
risk disease or condition
Mortality Death from a disease or condition
Morbidity Presence or extent of disease, injury, or disability in a defined population
Status Current state of a disease or health related condition in the population
Trend Long-term changes or movements in disease patterns and health-related
conditions in the population determined by examining surveillance data
Eradication The elimination of the infectious disease agent through surveillance and
containment
Socioeconomic Includes education, income, occupation, attitudes, and values and how SES
status (SES) relates to health-associated characteristics in the population

E. Concepts related to measurement of disease and its distribution

1. General measurement concepts (Table 20-4)

Table 20-4
Measurement Concepts in Epidemiology

Term Definition
Basic Rapid assessment accomplished in a short time by visual detection and
screening providing information about gross dental and oral lesions; accomplished
with a tongue blade, dental mirror, and appropriate lighting
Epidemiologic Detailed visual tactile assessment; accomplished with dental instruments and
examination a light source, provides more detailed information than basic screening;
differs from a clinical examination in that is does not involve a clinical
diagnosis that results in a treatment plan
Count The actual number of cases of a disease or condition occurring in a
population; simplest measure of a disease or condition; for example, the
number of children with a toothache
Rate Expression of disease in a population using a standardized denominator and

1663
 including a time dimension; allows for valid comparisons; for example, the
percentage of people diagnosed with cancer during a specific year, or the
percentage of children with caries in 2014
Incidence Rate of new cases of a disease (number of new cases/population at risk)
during or over a specific period; measures how fast a disease is spreading; for
example, the number of children with new carious lesions out of the entire
school population during the school year
Prevalence Rate of the total number of all existing cases of a disease or health condition
in a population measured at a given time, in relation to the number of
individuals in the population; expressed as a proportion; can be expressed as
a percentage; does not include a time period as incidence does; for example,
the percentage of children with untreated caries at the time of a survey
Occurrence General term of frequency of disease; does not distinguish between
incidence and prevalence
Ratio Expression of the magnitude of one occurrence of disease exposure in
relation to another with a fraction, obtained by dividing one quantity by the
other; often compares two rates; for example, if 4% of male and 2% of
female infants were born with cleft palate, the ratio of cleft palate in male
versus female infants would be 2:1
Prospective Observations of disease or disease related factors made forward in time (into
the future)
Longitudinal Observations of disease progression made over a long period (length of time
depends on condition being studied)
Retrospective Disease related data collected in the past; ex post facto, causal comparative,
or case control
Validity The accuracy of a measure; produced by measuring what is supposed to be
measured
Sensitivity The ability of a test to accurately identify the presence of a disease or
condition when disease is, in fact, present
Specificity The ability of a test to accurately identify the absence of a disease or
condition
Predictive The ability of a diagnostic test to accurately measure both the presence and
value the absence of disease
Reversal; A change of diagnosis in an illogical direction over a period, in contrast to a
negative positive reversal, which is a change of the measurement made in error in a
reversal logical direction
Reliability Consistency or reproducibility of a measurement over time
Inter- Agreement among two or more examiners as they apply an index or
examiner instrument to measure a disease or condition
(rater)
reliability
Intra- Consistency of a single examiner in applying an index or instrument over
examiner time to measure a disease or condition
(rater)
reliability
Calibration Standardization of examiners to increase reliability as they apply
epidemiologic measurements

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2. Surveillance/monitoring
a. Surveillance—ongoing, constant, systematic observation; use of
repeated surveys to analyze and evaluate health data to monitor
changes in populations related to disease, conditions, injuries,
disabilities, or death trends, for the purpose of program
planning; essential feature of epidemiology
b. National Oral Health Surveillance System (NOHSS)—a
collaborative effort between the CDC Division of Oral Health
and the Association of State and Territorial Dental Directors
(ASTDD) to track oral health indicators on a state and national
level using a variety of clinical and nonclinical methods (e.g.,
NHANES)
c. Oral health indicators are routinely assessed, based on the
Healthy People objectives (see Table 20-2); 26 of the hundreds of
HP 2020 objectives are deemed the leading health indicators,
considered to be the most critical to the health of the
population; two of the 26 leading HP 2020 health indicators
relate to oral health:
(1) Increase dental utilization (Oral Health topic objective)
(2) Reduce adult and adolescent cigarette smoking (Tobacco
Use topic objective)
d. National Health and Nutrition Examination Survey (NHANES)
—routinely conducted national health surveys carried out by the
National Center for Health Statistics of the CDC to monitor the
health and nutritional status of U.S. adults and children of all
ages; conducted through interviewing and direct physical and
dental examinations
(1) Began in the 1960s and has evolved to the current periodic
program that focuses on a variety of health and nutrition
measurements used to determine the health status of the
population and assess progress on Healthy People objectives
(2) Survey examines a nationally representative sample of
about 5000 persons each year, located in counties across the
United States; oral health is one of the areas of diseases and
health indictors monitored by NHANES

1665
Epidemiology and research
A. Evidence-based practice (EBP)
1. Involves the conscientious, explicit, and judicious use of current
evidence to inform decisions during the care of individual clients in
relation to their oral and medical conditions
2. Evidence alone is not sufficient to make decisions; the clinical
expertise of the professional and client preferences and values are
combined with the best available external clinical evidence from a
body of rigorous research findings to make EBP decisions (Fig. 20-2)

FIG 20-2 Evidence-based practice (EBP). (Data from American Dental

Association, Center for Evidence-Based Dentistry: Critical summaries and plain
language summaries, April 2014.
http://ebd.ada.org/~/media/EBD/Files/WEBSITE_Operations_Manual_April%202014.ashx;
and Forrest JL, Miller SA: Evidence-based decision making. In Darby ML, Walsh MM:
Dental hygiene theory and practice, ed 4, St Louis, 2015, Elsevier Saunders.)

3. Evidence is ranked according to the design of the research study

(Fig. 20-3)

1666
 FIG 20-3 Ranking of evidence for EBP. (Data from Icahn School of Medicine at
Mount Sinai, Levy Library: Evidence-based medicine tutorial, 2013.
http://libguides.mssm.edu/hierarchy; Oxford Centre for Evidence-Based Medicine:
OCEBM 2011 levels of evidence. http://www.cebm.net/wp-
content/uploads/2014/06/CEBM-Levels-of-Evidence-2.1.pdf.)

4. EBP relates to the practice of a dental hygienist in all roles and

settings, not just clinical; has implications for all aspects of
community oral health practice
5. All oral health care must be informed by evidence; lifelong learning
and access to quality research findings are critical to EBP
B. Research—continual search for new knowledge using the scientific
method; systematic and objective inquiry through laboratory, field, and
clinical investigations that lead to discovery or revision of knowledge,
resulting in improvements in health and health care delivery
C. Scientific method—methods used in any type of research that increase
the likelihood that information gathered will be relevant, reliable, and
unbiased (Fig. 20-4)

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 FIG 20-4 Steps of the scientific method.

D. Categories of community oral health research

1. Epidemiologic research to determine the presence and distribution
of disease in the population and factors that relate to the occurrence
of disease within the population
2. Clinical trials and tests of techniques and products to prevent and
control disease
3. Research in educational techniques and the behavioral sciences
related to oral health education
4. Evaluation of community oral health programs
E. Risk versus causality
1. Risk identifies attributes that are associated with a disease, from
case-control and cohort studies (Table 20-5); causality identifies
factors that have been demonstrated to be causally related, from
randomized controlled clinical trials (RCTs))

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 Table 20-5
Types of Risk Attributes

2. Risk is established with analytic studies; causality is established with

experimental studies; causality can be inferred with high-quality
longitudinal analytic studies
F. Three classifications of epidemiologic research (Table 20-6)

Table 20-6
Classifications of Epidemiologic Research

Data from Beatty CF: Oral epidemiology. In Nathe CN: Dental pub lic health and research, ed 4, Upper Saddle River, NJ,
2015, Pearson.

G. Experimental research
1. Requirements for an experimental study
a. Use of a control group
b. Control of extraneous variables
c. Randomization (random assignment to groups)
d. Control of errors in measurement to increase validity and
reliability
e. Manipulation of the independent variable
f. Measurement of the dependent variable

1669
 g. Occurrence of the independent variable before the dependent
variable in the design
2. A representative sample is required to allow for generalization (also
called inference); replication studies (repeated studies with different
samples) are frequently conducted to compensate for the poor
generalizability (low external validity) resulting from the use of
small convenience samples; multiple-site studies broaden the
representation of the population and improve the generalizability of
findings
3. Experimental study designs
a. Pretest/posttest—the dependent variable is measured before
and after introducing the independent variable; provides a
baseline measure for comparison
b. Posttest only—the dependent variable is measured only after
introducing the independent variable; controls any possible
effect of the pretest procedure on the dependent variable
c. Split-mouth—procedure unique to oral health research in which
each side of the mouth receives a different intervention; controls
subject-related variables (variables that can change from one
research participant to another)
d. Crossover—each group receives a different intervention or
control and, after a period, is switched over to the opposite
treatment, with an intervening washout period during which no
treatment is given, to eliminate the possibility of the first
treatment affecting the second one; controls subject-related
variables
e. Time-series (repeated measures)—design in which the
dependent variable is measured several times over a specific
period, to determine whether the effect of the independent
variable on the dependent variable holds over time
f. Blind (or masking)—this refers to examiners measuring the
dependent variable without knowing the group assignment, to
eliminate bias; if both examiners and participants are unaware of
the group assignments, it is called double-blind
g. Designs can be combined; for example, a study can combine
double-blind, pretest/posttest, split-mouth, and repeated-
measures designs to test the effectiveness of an antimicrobial to
reduce or control periodontal pocket depths over a long period
4. Comparison of clinical trials and epidemiologic surveys (Table 20-7)

1670
 Table 20-7

Comparison of Clinical Trials and Epidemiologic Surveys

Clinical Trial Epidemiologic Survey

Populations Experimental and control groups are Naturally occurring samples of
specially constituted as representative target populations are usually
samples from appropriate populations studied
Sample Sample sizes are often small, particularly Fairly large sample sizes are used
size when “treatments” are more
complicated
Time frame Trials are conducted over a period, Surveys are usually cross-sectional in
usually varying from 1 week to 6 months design, measuring only one time;
to several years (e.g., dental caries longitudinal designs are used
research), depending on treatment occasionally
involved and disease or condition
measured, to compare treatment
outcomes
Methods Although assessment methods may Indices are used for assessment, to
include indices, biomedical instruments, establish the disease level of selected
or physiologic measures, methods have populations, and to compare data
validity, reliability, and clinical from different populations
significance
Data Data generated from clinical trials are Data generated from surveys are
applicable to specific hypothesis testing used to establish underlying etiologic
factors and derive possible
preventive methods, leading to the
development of hypotheses to be
tested by controlled clinical trials

H. Hypothesis—a predictive statement of the expected outcome or

relationship among variables; answers the research question in a manner
that is observable and measurable; hypotheses can exist for all types of
studies, not just experimental
1. Null hypothesis—negative statement of the hypothesis that assumes
the absence of statistically significant differences between the
sample groups; for example, statement that no difference exists in
the effectiveness of the two treatments (experimental), or two
variables are not associated (nonexperimental); this is the hypothesis
that is statistically tested
2. Research hypothesis—also called the positive or alternative hypothesis;
positive statement of the hypothesis is in terms that express the
opinion or prediction of the researcher; for example, a statement that
a difference exists in the effectiveness of the two treatments
(experimental), or two variables are associated (nonexperimental)
I. Variable—a state, condition, concept, construct, or event whose value is

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free to vary (e.g., height, dental caries rate, IQ, creativity); must be
measurable
1. Independent variable—in an experimental study, the treatment or
intervention under study; condition that is manipulated or
controlled by the investigator; the experimental variable; the
experimental treatment
2. Dependent variable—in an experimental study, the dependent
variable is a measure of the outcome of manipulating the
independent variable; it is measured to observe the effect of the
independent variable
3. Nonexperimental studies measure variables as well; in analytic
studies, an attempt is made to determine the association or
relationship of these variables, also called factors
4. Extraneous variables—uncontrolled variables that may influence the
dependent variable and influence (or confound) the outcome, thus
interfering with accurate interpretation and producing invalid
research results; can be present in all types of research studies
J. Sampling (Table 20-8)

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Table 20-8
Sampling and Group Assignment

Type of
Sample or
Definition Result
Group
Assignment
Random Study participants are chosen Increases external validity by
sample independently of each other, with known controlling differences in study
opportunity or probability for inclusion; participants; yields a representative
table of random numbers can be used sample with a homogeneous
population; allows for valid
generalization of results to the
population (reduced bias)
Stratified Study participants are randomly selected Results in the sample proportionately
random from an existing, known subdivided and accurately representing the
sample population; most representative sample subgroups in the population; yields the
for a heterogeneous population most representative sample for a
heterogeneous population
Systematic Selection of every nth member of the Not strictly a random sample; it is
random population from a list or file of the total considered to be random when the first
sample population; the n depends on the size of member of the sample is selected
the sample desired in relation to the randomly and the list or file is in
population; for example, 10% is every random order
tenth member of the population

Convenience Study participants are chosen on the basis Introduces bias, which reduces validity
sample of availability; used when access to the of the sample and limits the
total population is not feasible for random generalizability of study results
sample selection
Judgmental Study participants are chosen by the Introduces bias, which reduces validity
or purposive researcher or someone else who has of the sample and limits the
sample knowledge of the population; used when generalizability of study results
participants are needed that require
specific disease levels and/or
characteristics
Experimental Sample group in an experimental study Randomization (also called randomized
group who is exposed to the experimental group assignment) results in equivalent
variable being studied (receives the groups to control differences in groups;
independent variable) controls validity of study
Control Sample group in an experimental study Provides a comparison group for a
group who does not receive the experimental stronger study design; randomization
treatment (independent variable); receives (also called randomized group
a placebo, traditional or standard assignment) results in equivalent
treatment, or no treatment groups to control differences in groups;
controls validity of study

1. Target or priority population—portion of the population to whom

1673
 the researcher wants to generalize findings; all members of a specific
group who possess a clearly defined set of characteristics
2. Sample—a portion of a specific population that, if properly selected,
can provide meaningful information about the entire population; a
sample is examined when the researcher cannot study an entire
population or does not have the resources; a sample may be random
or nonrandom and may be representative or nonrepresentative
3. Sample size
a. Large sample, if selected properly:
(1) Accurately represents a defined population
(2) Increases the validity and reliability of collected data
(3) Reduces the standard error of the sample mean
b. Small sample
(1) May be necessary, depending on the purpose of the
research; for example, a pilot study
(2) Results from a small study may not be generalized to
target population and lead to inaccurate conclusions when
inappropriate for the type of research
(3) Small samples require specialized statistics
(nonparametrics)
K. Group assignment—experimental and control groups are formed in an
experimental study (Table 20-8); randomization of groups is best way to
form groups to increase validity of the study
L. Pilot study—a study conducted with a small sample; often used as a
trial run to test research design and methodology before initiating a full-
scale study; can be conducted with any type of research

1674
Epidemiology of oral diseases and
conditions
A. Role of Healthy People 2020 objectives
1. Targets for various oral health diseases and conditions and the
strategies to address them have been set in the HP 2020 objectives
for the U.S. population (see Table 20-2); these targets will drive
community oral health programming for the decade 2010 to 2020
2. Analysis of outcomes in relation to the HP 2010 initiative indicated
that significant progress was made in meeting oral health goals;
most objectives moved toward, met, or exceeded their target;
significant exceptions were the objectives to reduce dental caries and
untreated dental caries in children, increase early detection of oral
and pharyngeal cancer, and increase dental utilization (see Table 20-
2)
3. Even though progress was made, disparities in oral health still exist;
community programs and interventions aimed at reducing oral
health disparities remain a high priority
B. Dental caries
1. Occurrence in the population
a. Dental caries is the most common chronic childhood disease;
among 5- to 17-year-olds, it is five times more common than
asthma, seven times more common than hay fever; one of the
major reasons for hospitalization of children, and costly to treat
b. The most commonly occurring type of caries is pit-and-fissure
caries, followed by smooth-surface coronal caries and root
caries; first and second molars are the most frequently affected
teeth
c. During the last half of the twentieth century, a substantially
declining caries rates in all age groups was observed in the
United States, including lower cumulative caries rates, less
severe caries, substantially fewer carious lesions in anterior
teeth, and fewer teeth lost as a result of caries
d. However, dental caries is still widespread, affects all age groups,
and increased during the 2000 to 2010 in preschool-age (early
childhood caries, or ECC; Table 20-9) and school-age children
(see Table 20-2) in the United States; Fig. 20-5 provides a
summary of current dental caries in these age groups

1675
Table 20-9
Categorizing Early Childhood Caries* (ECC) and Severe Early Childhood Caries
(S-ECC)

Age
ECC S-ECC
(years)
Younger 1 or more DMFS †
than 6 (cavitated or noncavitated)
Younger Any sign of smooth-surface caries
than 3
Age 3 1 or more cavitated DMFS in maxillary
anterior teeth OR 4 or more DMFS
Age 4 1 or more cavitated DMFS in maxillary
anterior teeth OR 5 or more DMFS
Age 5 1 or more cavitated DMFS in maxillary
anterior teeth OR 6 or more DMFS
Data from American Academy of Pediatric Dentistry (AAPD): Policy on early childhood caries (ECC):
classifications, consequences, and preventive strategies, Chicago, 2014. http://www.aapd.org/policies/.
* The term early childhood caries replaces previously used terms such as b ab y-b ottle tooth decay,
nursing caries, b ab y-b ottle mouth, and b ab y-b ottle caries.
† DMFS, Decayed, missing, and/or filled primary tooth surfaces.

1676
 FIG 20-5 Ratio of dental caries to untreated dental caries in
children and adolescents. (Data from National Institute of Dental and
Craniofacial Research: Dental caries (tooth decay) in children (age 2 to 11),
May 28, 2014.
http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/; and
National Institute of Dental and Craniofacial Research: Dental caries (tooth
decay) in adolescents (age 12 to 19), March 7, 2014.
http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesAdolescents12to19.htm

e. These recent rates of dental caries are accompanied by increases

in untreated caries for preschool-age and school-age children
(see Table 20-2 and Fig. 20-5), the association between low dental
utilization and higher caries rates in a population group is a
significant concern
f. Increases in early childhood dental caries (ECC) and untreated
caries in preschool-age children have raised concerns about the
potential for a trend of increasing caries in older age groups in
the future
g. Root surface caries rates have increased as a result of the aging

1677
 population and because older adults are retaining their natural
teeth; there is a new Healthy People objective for 2020 related to
root surface caries (see Table 20-2)
2. Factors that have contributed to the general trend of lower caries
rates
a. Use of fluorides, including water fluoridation, fluoride
dentifrices, and other fluoride modalities is the most significant
factor in the long term, primarily reducing smooth-surface
caries; widespread use of fluorides has decreased state and
regional differences in caries rates
b. More recently, dental sealants have contributed to reductions in
pit-and-fissure caries
c. Greater emphasis on preventive care and increased dental
utilization also contribute
3. Distribution varies for both coronal and root surface caries and
untreated caries in different groups in the population (Table 20-10);
this has implications for community programming

Table 20-10
Oral Disease Disparities by Age, Ethnicity, Socioeconomic Status (SES), and Dental
Attendance*

1678
Data from National Center for Health Statistics (NCHS): Healthy people 2010 final review: overview and selected
findings, PHS Pub No 2012-1038, Hyattsville, Md, 2012, NCHS,
http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf; Department of Health and Human Services:
Surgeon General report on oral health, Magnitude of the problem, updated April 3, 2014,
http://www.nidcr.nih.gov/datastatistics/surgeongeneral/sgr/chap4.htm; Centers for Disease Control and
Prevention: Disparities in oral health, July 10, 2013, http://www.cdc.gov/OralHealth/oral_health_disparities/; Li Y,
Lee S, Hujoel P, et al: Prevalence and severity of gingivitis in American adults, Am J Dent,23(1):9-13, 2010,
http://www.ncbi.nlm.nih.gov/pubmed/20437720; American Academy of Periodontology, CDC: Half of American
adults have periodontal disease, 2014: Available at http://www.perio.org/consumer/cdc-study.htm; Eke PI, Dye BA,
Wei L, et al: Prevalence of periodontitis in adults in the United States: 2009 and 2010, J Dent Res 91(10):914-920,
2012, https://www.scribd.com/doc/132397066/Prevalence-of-Periodontitis-in-Adults-in-the-United-States-2009-
and-2010-Full-Text-Available; Thornton-Evans G, Eke P, Wei L, et al: Periodontitis among adults aged ≥ 30 years—
United States, 2009–2010, MMWR 62(3 Suppl):129-135, November 22, 2013,

1679
 http://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a21.htm; National Cancer Institute, Surveillance,
Epidemiology, and End Results (SEER) Program: SEER stat fact sheets: oral cavity and pharynx cancer, 2011,
http://seer.cancer.gov/statfacts/html/oralcav.html; Agarwal MSS, Chopra SS, Jayan B, Verma MM: Epidemiology in
orthodontics: a literature review, Orthod Cyb er J, September 2013, http://orthocj.com/2013/09/epidemiology-in-
orthodontics-a-literature-review/; National Institute of Dental and Craniofacial Research: TMJ (temporomandibular
joint and muscle disorders), July 10, 2014, http://www.nidcr.nih.gov/oralhealth/topics/tmj/; and Centers for Disease
Control and Prevention: Facts about cleft lip and cleft palate, April 23, 2014,
http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html.
ND, No differences documented; DMFT, decayed-missing-filled teeth; ECC, early childhood caries, CAL, clinical
attachment loss.
* Health literacy is an underlying factor in disparities in the distribution of all oral diseases.

† In general, people who are non-Hispanic black, Hispanic, and American Indian and Alaska Native generally
have the poorest oral health of any racial and ethnic groups in the United States.
‡ In general, populations of low SES have much greater oral health disparities than higher-SES populations; low
SES is the strongest predictor of poor oral health.

4. Risk and associated factors vary in the population and form the
foundation of public health programs (see Chapters 13 and 16 for
further discussion of risk factors for caries)
a. Caries is a multifactorial, infectious, transmissible disease
b. Low socioeconomic status (SES) of the family is the most
powerful predictor of caries in young children; caries control
programs should be targeted especially to low-SES populations
c. Lack of access to water fluoridation is a critical risk factor
d. Health education and health promotion efforts should be
directed to preventive measures to reduce the risk factors
(1) Reduce bacteria with good oral hygiene and antimicrobials
(2) Reduce the amount and frequency of fermentable
carbohydrates and other acidic foods and drinks in the diet
(3) Routinely use fluorides and other chemotherapeutic
measures to increase the resistance of the enamel to acid
attack and enhance the protective nature of saliva
(4) Place dental sealants to increase the caries resistance of
pit-and-fissure surfaces
(5) Eliminate carious lesions and restore cavitated teeth to
eliminate bacteria and improve the individual’s ability to
remove plaque biofilm
5. Additional risk factors for ECC should be addressed in community
programs focused on maternal and child health, especially in lower-
SES populations
a. Transmission of cariogenic bacteria from the caregiver to the
young child; parental risk-related behaviors for ECC include
infant feeding practices, whether the infant is breastfed or
bottle-fed; delayed weaning from bottle feeding or
breastfeeding; allowing a baby to fall asleep with a bottle
b. High-cariogenic diet, including sugar drinks in the bottle or

1680
 sippy cup and high sugar levels in other components of the diet
c. ECC is also more common in situations where child care is
provided by individuals with low oral health literacy or poor
understanding of oral disease prevention
6. Other risk and associated factors for root caries to be considered in
public health programs
a. Root caries increases with age because of a greater likelihood of
exposed cementum and other risk factors
b. The increasing age of the population and decreasing tooth loss
result in more available root surfaces to become carious
c. Older adults exhibit greater use of medications that cause
xerostomia, in which case saliva loses its protective capacity;
multiple medications are especially a major risk factor for this
d. Increased sugar intake as sense of taste diminishes and eating
habits change with age creates a greater risk of caries for older
individuals
e. History of coronal caries and smoking are risk factors for root
caries
f. Diminished manual dexterity may limit oral self-care
C. Dental sealants
1. Rates of sealed first and second molars have improved; further
increase of these rates is an important Healthy People objective for
2020 (see Table 20-2)
2. Disparities occur in the rates of sealants in children (see Table 20-10)
3. Permanent molar teeth are most frequently sealed and are targeted
in community-based sealant programs because of their greater
susceptibility to caries; a new Healthy People objective for 2020 is to
increase dental sealant application on primary teeth (see Table 20-2)
because of the increase in dental caries in children over the past
decade
4. Sealants are targeted at children; placement is recommended as
soon as possible after tooth eruption
D. Periodontal diseases
1. Periodontal diseases manifest as different clinical entities,
depending on aggressiveness, severity, rate of progression, systemic
diseases present, hormonal influences, genetics, and other factors
2. Prevalence of periodontal diseases
a. The presence of periodontal diseases, either gingivitis or
periodontitis or both, is almost universal, with over 70% of
adults in all countries affected
(1) Worldwide data indicate prevalence of severe periodontitis

1681
 in the range of 5% to 15% in almost all populations,
regardless of economic development, oral hygiene, or
dental care available
(2) Increased levels of prevalence and severity of periodontal
diseases are found in areas of the world where generalized
malnutrition is common
(3) Differences in periodontal disease levels between peoples
of developed countries and developing countries are
attributed to differences in oral hygiene levels
b. Variations in data related to the prevalence of periodontal
diseases can be attributed to differences in study designs and
measurement
c. Prevalence of moderate to severe destructive periodontitis in the
United States in people age 45 to 74 is approximately 13% and
has decreased over the previous decade (see Table 20-2);
periodontitis is observed even in well-treated patients because
of the influence of genetics and immune response
d. Milder forms of periodontitis are more common; over 90% of
persons age 13 or older show signs of some clinical attachment
loss (CAL) while still maintaining a functioning dentition
e. Although gingivitis has declined in recent years because of
greater attention to oral hygiene, it is still present in the
majority of the population
3. The distribution of periodontal diseases varies in the U.S. population
according to demographic characteristics (see Table 20-10)
4. Risk and associated factors (see the section on “Epidemiology of
Periodontal Diseases and Related Risks” in Chapter 14)
5. Tooth retention and tooth loss
a. Rate of complete tooth loss as a result of dental caries or
periodontal disease in adults age 65 to 74 is 24%; approximately
three fourths of adults age 45 to 64 have had no permanent
tooth loss (see Table 20-2)
b. Rates are decreasing despite the aging U.S. population because
of increased emphasis on preventive dentistry, greater use of
fluorides, improved success with periodontal therapy, and
higher dental care utilization rates, especially for preventive
strategies
c. Smoking, early tooth loss, poor health, and low level of health
literacy are risk factors for edentulism
d. Disparities exist in both edentulism and partial tooth loss (see
Table 20-10)

1682
6. Denture use
a. Current specific data on denture use are unavailable
b. Despite reductions in tooth loss, the number of denture wearers
will remain significant because of the aging population; the
need will continue for denture fabrication and related patient
education and community oral health promotion programs with
older adults
7. Oral and pharyngeal cancers
a. Occurrence
(1) In the United States, in 2011 an estimated 281,591 people
were living with oral and pharyngeal cancers (cancers of the
lips, tongue, buccal mucosa, floor of the mouth, and
pharynx); estimates for 2014 are 42,440 cases of new
oropharyngeal cancer diagnoses and 8390 deaths1
(2) Occurrence and site distribution within the mouth vary
widely in different parts of the world
(3) Oral and pharyngeal cancers account for 2.5% of all
cancers in the United States and 1.4% of all cancer deaths1
(4) The survival rate 5 years after diagnosis is 62.7%; the
mortality rate varies according to the stage at diagnosis;
those diagnosed in the earliest stage have an 82.7% 5-year
survival rate versus 37.3% for those diagnosed in the latest
stage;1 the proportion of these cancers diagnosed at the
earliest stage has decreased in the past decade (see Table
20-2)
(5) Disparities exist in the distribution of these cancers among
different groups (see Table 20-10)
8. Causal and risk factors
a. Evidence is sufficient to infer a causal relationship between the
use of tobacco and oropharyngeal cancers; a dose-response
relationship exists between cigarette smoking and cancers of the
lung, larynx, oral cavity, and urinary bladder in women
b. The major risk factors for oropharyngeal cancers include heavy
alcohol consumption, tobacco use, combined alcohol and
tobacco use (increases the risk two to four times compared with
either factor alone), older age, and high levels of ultraviolet (UV)
light exposure (i.e., sun exposure)
c. Other determinants include chronic inflammation, viral
infections such as human papillomavirus (particularly HPV-16
and HPV-18), immunodeficiency, poor nutrition, occupational
exposures, and genetics

1683
 9. Healthy People 2020 goals directed at improving oropharyngeal
cancer morbidity and mortality rates include increased screening by
dentists and dental hygienists, increased detection in the early stage,
and increased tobacco cessation counseling by dentists and dental
hygienists; progress was made from 2000 to 2010 on increased
screening, but ground was lost on early detection; no data were
available for the frequency of tobacco counseling (see Table 20-2)
E. Cleft lip and palate
1. The CDC estimates that about 2650 babies are born with cleft palate
and 4440 are born with cleft lip in the United States each year;2 oral
clefts are the most common class of congenital malformations in the
United States; cleft lip is more common than cleft palate
2. Risk factors are important in relation to education for prevention;
clefts are associated with maternal diabetes and thyroid disease,
smoking, drug consumption (e.g., certain medications to treat
epilepsy), nutritional deficiencies (e.g., folic acid deficiency), alcohol
consumption, use of teratogenic agents (e.g., corticosteroids, drugs
of abuse) during the early stages of pregnancy, and premature birth
status
3. In the United States, 33 states have a system for recording and
referring infants and children with cleft lips and cleft palates to
craniofacial anomaly rehabilitative teams;3 an HP 2020 objective is to
increase this number (see Table 20-2)
4. Disparities exist for clefts in different population groups (see Table
20-10)
F. Malocclusion and orthodontic treatment
1. Although current epidemiologic data are not available for the United
States, adequate basic information is available to demonstrate the
prevalence of malocclusion and the need for orthodontic care; in
general, the prevalence of malocclusion is considered to be
increasing worldwide4
2. Malocclusions can occur from congenital or acquired crowding of the
teeth or jaws; prolonged bottle feeding, thumb sucking, and other
behaviors during development are attributed, which indicates a need
for public health education programs for young mothers regarding
feeding practices and the habits of young children in order to
prevent malocclusion
3. No data are available on differences in distribution of malocclusion
among population groups, but differences occur in frequency of
orthodontic treatment (see Table 20-10)
G. Craniofacial injuries and tooth trauma

1684
 1. Crown fractures are the most common type of dental injury to the
permanent dentition, and subluxation and avulsion are the most
common injury to the primary dentition5
2. There is no single risk factor for dental trauma; causes of head and
face injuries include accidental falls, assaults, sports-related and
recreational activities, bicycle and automobile collisions, and work-
related tasks and projects around the house; sports accidents
account for 10% to 29% of all dental injuries in children6
3. One third of traumatic dental injuries could be prevented, according
to treating dentists;5 prevention depends on an understanding of the
risk factors
4. Use of mouthguards, face guards, and helmets is recommended to
prevent injuries during high risk contact sports,6 but few sports have
regulations that require their use; health promotion efforts
regarding prevention of orofacial injuries should target parents;
children, youth, college students, and adults involved in organized
sports; coaches; and staff of school and sports organizations that
influence policy decisions
5. Most injuries are treated in emergency rooms; education of medical
personnel will increase the success of treatment of dental-related
injuries; an HP 2020 objective is to increase the number of states that
have an oral and craniofacial health surveillance system (see Table
20-2)
H. Temporomandibular joint (TMJ) disease
1. It is estimated that 10 million Americans are affected by TMJ
disorders7
2. Possible symptoms include pain in the jaw joint and muscles of
mastication, jaw muscle stiffness, limited movement or locking of
the jaw, painful clicking or crepitus in the TMJ, and a change in the
occlusion; symptoms can be present even when individuals do not
perceive a problem
3. Symptoms can be alleviated by eating soft foods, applying ice packs,
avoiding extreme jaw movements such as wide yawning and gum
chewing, short-term use of over-the-counter (OTC) or prescription
pain medicines, and learning techniques to reduce stress; symptoms
usually clear with minimal or no treatment; aggressive treatment is
rarely recommended
4. Variations in distribution occur according to demographic
characteristics (see Table 20-10)
I. Dental fluorosis
1. Description—chronic endemic form of enamel hypoplasia caused by

1685
 ingesting excessive fluoride during the time of tooth formation in
the late secretory to early maturation stage of enamel development;
starts for central incisors as early as age 22 months, usually occurs at
24 months, and may occur as late as age 4 years; characterized by
retention of enamel proteins and change in enamel matrix structure;
defective calcification produces a white, chalky appearance of the
enamel that may undergo brown discoloration and change of surface
texture in more severe classifications
2. Dean’s classification of dental fluorosis (see “Fluorosis Indices” in
Table 20-11)—provides a description of fluorosis for survey
purposes; other fluorosis indices, such as the Tooth Surface Index of
Fluorosis and the Thylstrup-Fejerskov Fluorosis Index, are based on
Dean’s classification and are more sensitive for research purposes

Table 20-11
Common Dental Indices Used in Community Oral Health and Oral Health Research

1686
1687
1688
1689
 Data from Carranza FA, Forrest JL, Kenney EB, Klokkevold PR: Carranza’s clinical periodontology, ed 12, St Louis,
2014, Elsevier Saunders; Hiremath SS: Textb ook of preventive and community dentistry, ed 2, New Delhi, India,
2011, Elsevier India; Wilkins EM: Clinical practice of the dental hygienist, ed 11, Philadelphia, 2012, Lippincott,
Williams & Wilkins; and World Health Organization: Oral health/periodontal/country profiles, 2014.
http://www.who.int/oral_health/databases/niigata/en/.

3. Prevalence of dental fluorosis

a. Less than one fourth of the population exhibit fluorosis, with
the vast majority in the classifications “very mild” and “mild”;
the prevalence is higher in younger groups, and the prevalence
of fluorosis in young children may be increasing in the very
mild to mild categories as a result of widespread use of
fluorides
b. Even children born and raised in optimally fluoridated
communities can exhibit mild forms of fluorosis because of
excess fluoride consumption from other sources
c. Occurs in many parts of the world; considered a public health
problem in East Africa, India, and Eastern Europe because of
the severity; not considered a major public health problem in
the United States at this time and is being addressed by the
careful use of fluorides and the downward adjustment of the
Public Health Service (PHS) recommended level of fluoride for
water fluoridation
d. Differences occur in the distribution of fluorosis in different
groups (see Table 20-10)

1690
4. Causes
a. Ingesting water with naturally occurring excessive fluoride
(1) 1 to 2 parts per million fluoride (ppm F) results in mild
fluorosis; 2 to 4 ppm F results in moderate to severe
fluorosis
(2) The Environmental Protection Agency (EPA), which is
responsible for the safety and quality of water, has set the
maximum allowable limit for fluoride at 4 ppm F and a
secondary limit at 2 ppm F (defluoridation is required at
4 ppm F and recommended at 2 ppm F)
(3) Some communities do not have a community water supply;
some members of the population depend on well water;
fluoride levels of well water vary
b. Children swallowing excessive amounts of fluoride-containing
dentifrices—swallowing or overenthusiastic use of fluoridated
toothpaste by young children is a concern; prudent use is
“smear ” or “rice-size” amount of toothpaste on the brush for
children younger than age 3 years and a “pea-size” amount for
children age 3 to 6 years; it is also recommended that toothpaste
be placed on the toothbrush by an adult
c. Inappropriate supplementation with fluoride tablets or fluoride-
containing vitamins in children—mild to moderate fluorosis is
associated with the use of fluoride supplements by children; use
tends to be higher in children from higher-SES families
d. Halo effect of secondary fluoride exposures to fluoride in
processed foods and beverages, especially those that vary by
water source, can occur even in nonfluoridated areas
(1) Infant formula, especially soybean-based formulas, should
be used in moderation in fluoridated communities
(2) Fruit juices and drinks with moderate to high
concentrations of fluoride consumed by children may
contribute to fluorosis; in the United States; water and
processed beverages can provide approximately 75% of a
person’s fluoride intake
(3) Some bottled water manufactured in the United States
contains an optimal concentration of fluoride; most contain
less than 0.3 ppm fluoride
e. Consumption of fluoridated water in combination with other
significant dietary sources of fluoride
(1) Combining systemic fluorides will increase the fluoride
level above the optimum and cause fluorosis in children

1691
 who are still in the stages of enamel development (up to age
8 years); education is needed to inform the public of the
need to control early consumption of fluoride
(2) Care must be taken to control young children
inadvertently swallowing other sources of fluoride, such as
toothpaste and mouthrinse
5. Prevention of dental fluorosis
a. The CDC has issued recommendations to reduce the risk of
fluorosis (Box 20-5)

Box 20-5
Rec ommendations to Reduc e the Risk of
Fluorosis
1. Counsel parents and caregivers regarding the use of fluoride
toothpaste by young children, especially those younger than 2 years
2. Encourage parents to supervise the use of fluoride toothpaste among
children younger than 6 years to reduce swallowing it
3. Promote the use of a small amount of toothpaste by young children
4. For children younger than 2 years, weigh the risk and benefits of
recommending fluoride products, taking into consideration the
fluoride level in the community drinking water, other sources of
fluoride, and factors likely to affect susceptibility to tooth decay
5. Target mouth rinsing and application of high-concentration fluoride
products to persons at high risk for dental caries
6. Target and judiciously prescribe fluoride supplements
7. Know the fluoride concentration in the primary source of drinking
water in order to make appropriate recommendations
8. Use an alternative source of water for children age 8 and younger
whose primary drinking water contains more than 2 parts per million
fluoride (ppm F)
9. Label the fluoride concentration of bottled water
10. Collaborate with professional health care organizations, public
health agencies, and suppliers of oral care products to educate
health care professionals and the public
11. Identify effective strategies to promote adoption of
recommendations for using fluoride
Data from Centers for Disease Control and Prevention: Community water fluoridation; Dental
fluorosis, July 10, 2013. http://www.cdc.gov/fluoridation/faqs/dental_fluorosis/#a10.

1692
b. Because of concerns about the increase in fluorosis in children, DHHS
recently recommended reducing the optimal amount of fluoride per liter
of water to reduce the possibility of children receiving too much fluoride,
since there are now multiple other sources of fluoride; this updated
recommendation is based on EPA and DHHS scientific assessments in
2011, which will also guide the EPA in determining whether to lower the
maximum amount of fluoride allowed in drinking water; this currently
recommended optimal level is 0.7 mg F per liter of water (0.7 ppm F)
c. Prior to promoting a fluoride modality or combination of modalities,
one must consider the group’s risk for dental caries, fluoride history,
current fluoride sources, and potential for dental fluorosis
d. Actions and recommendations related to the optimal level of fluoride
in drinking water and judicious use of other fluorides are in response to
the need to control fluorosis; future assessment will determine the
results of current measures to prevent fluorosis

1693
Measurement of diseases and conditions
in oral epidemiology
A. Dental index—abbreviated measurement tool used for data collection;
measures the presence or degree of intensity of a disease or condition in
a population; graduated numerical scale with defined upper and lower
limits designed to facilitate summarizing or describing a disease or
condition in the population, or for comparisons among populations; a
higher number on the scale indicates more severe disease or condition;
measured by clinical observation with an epidemiologic examination
B. Attributes of an ideal dental index
1. Validity—accuracy of measuring what is intended to be measured
2. Reliability—measures consistently at different times; reproducibility,
stability of measurement
3. Utility—clear, simple, and objective
4. Sensitive to shifts in disease in either direction
5. Acceptable to the individuals being measured
6. Quantifiable; amenable to statistical analysis
7. Clinically significant and meaningful
C. The index may assess disease that is a reversible condition, an
irreversible condition, or a combination; therefore, indices are classified
as:
1. Reversible index—measures conditions that can be reversed (e.g.,
gingivitis, plaque biofilm, calculus)
2. Irreversible index—measures cumulative conditions that cannot be
reversed (e.g., dental caries, bone loss, fluorosis)
D. Some common dental indices are used in community oral health and
oral health research (Table 20-11)
E. Index selection is determined by:
1. Type of condition to be assessed, specific to the information of
interest or the needs of the client or community
2. Age of the population
3. Purpose of the assessment (e.g., survey or clinical trial)
F. Other approaches to measurement in a population
1. A disaggregated approach rather than an index is currently used on
the NHANES and other surveys to assess periodontal conditions;
gingival bleeding, recession, pocket depth, CAL, and calculus as a
contributing risk factor are measured
2. Basic Screening Survey (BSS) for surveillance
a. A simple screening method currently used with adults, school-

1694
 age children, and preschool-age children in national surveys
b. Includes oral screening and an optional questionnaire
c. Screeners may be nondental personnel to improve access to the
population and reduce cost
d. Assesses a variety of oral health conditions consistent with the
Healthy People oral health objectives to monitor the success of
these objectives and compare population groups
e. Efficiently assesses dental caries using dichotomous measures
(e.g., yes or no) to assess the absence or presence of untreated
dental caries and dental caries experience (at least one decayed,
restored, or missing tooth) on a per-person basis, as opposed to
use of more complex indices
f. Regardless of condition being measured, results are reported as
the following categories to assess need and referral for dental
care:
(1) None—no obvious oral health problem; routine care
recommended
(2) Early—observable oral health problem; early dental care
(within several weeks) recommended
(3) Urgent—signs or symptoms present (e.g., pain, infection,
swelling, soft tissue ulceration) of longer than 2 weeks’
duration; emergency dental care (within 24 hours)
recommended
g. Results will underestimate disease prevalence
G. Examiners or raters should use calibrated or standardized
observational criteria in their use of an index or the BSS criteria; examiner
reliability requires training on the use and interpretation of evaluative
criteria and repeated use of the index
1. Intra-rater (intra-examiner) reliability—each examiner repeats the
scoring process using a data collection instrument; extent to which a
rater remains consistent within himself or herself
2. Inter-rater (inter-examiner) reliability—consistency exists between
or among examiners; degree to which different raters obtain the
same results when using the same data collection instrument
H. Potential errors in assessing disease
1. Errors in sampling technique—use of nonrandomized samples, use
of incorrect or inconsistent sampling technique, sample bias and
too-small sample size can result in a nonrepresentative sample,
particularly for subgroups of interest
2. Errors in collecting and recording data—variation in assessment;
lack of calibration; inconsistent or inaccurate data collection by the

1695
 examiners; known or unknown bias; intended or unintended
misleading or untruthful responses; lack of compliance of
participants; incorrect documenting of data by recorders; and
inaccurate data entry into the computer
3. Errors in analyzing data—incorrect computation, incorrect selection
of statistical tests, incomplete analysis, and invalid interpretation

1696
Preventing and controlling oral diseases
and conditions
Public Health Measures
A. Population-focused strategies to alleviate, reduce, or eliminate a
health problem or issue that is an actual or potential cause of morbidity
or mortality
B. Selection of strategy is based on the seven characteristics of an
effective public health solution (see earlier section on “Basic Concepts”);
several strategies may be implemented depending on the issue to be
addressed
C. Examples of public health measures include vaccination, water
purification, and water fluoridation (Box 20-6)

Box 20-6
Ten Great Public Health Ac hievements—
United States, Twentieth Century
1. Immunizations
2. Motor vehicle safety
3. Workplace safety
4. Control of infectious diseases
5. Decline in deaths from heart disease and stroke
6. Safer and healthier foods
7. Healthier mothers and babies
8. Family planning
9. Fluoridation of drinking water
10. Tobacco as a health hazard
Data from Centers for Disease Control and Prevention: Ten great public health achievements in the
20th century, 1900–1999, April 26, 2013. http://www.cdc.gov/about/history/tengpha.htm.

Measures for Preventing and Controlling Dental

Caries
Refer to the sections on “Topical Fluorides and Fluoride Varnishes” and
“Dentifrices and Prophylactic Pastes” in Chapter 13 and “Caries
Management” in Chapter 16.
A. Water fluoridation (Table 20-12)

Table 20-12

1697
Overview of Fluoride Delivery Modalities

1698
Data from American Dental Association: Fluoride and fluoridation, 2014, http://www.ada.org/en/public-
programs/advocating-for-the-public/fluoride-and-fluoridation; Fluoride supplements, http://www.ada.org/en/member-
center/oral-health-topics/fluoride-supplements; Fluoridation facts, 2005,
http://www.ada.org/~/media/ADA/Member%20Center/FIles/fluoridation_facts.ashx; Centers for Disease Control and
Prevention: Community water fluoridation, July 10, 2013, http://www.cdc.gov/fluoridation/; Guidelines and
recommendations, April 14, 2014, http://www.cdc.gov/fluoridation/guidelines/index.htm/; and Texas Department of State
Health Services: Happy child, b right smile: fluoride varnish manual, Pub No E08-13077, March 2009, http://www.dshs.
state.tx.us/dental/default.shtm.
APF, Acidulated phosphate fluoride; NaF, sodium fluoride; SnF, stannous fluoride; OTC, over-the-counter; sodium
monofluorophosphate

1. Adjustment of the natural fluoride (F) concentration to optimal level

a. 0.7 ppm F (same as 1 mg F/L water) was recommended by the
DHHS in 2011 (see earlier discussion of dental fluorosis for the
reason)
b. This suggested level of fluoride is a nonenforceable

1699
 recommendation from the PHS
c. Some states have community fluoridation laws that are
enforceable
d. Partial exposure (lower than the recommended fluoride level)
provides partial protection
e. Level must be maintained to continue maximum benefits of
fluoridation; benefits are lost when fluoridation is discontinued
2. Fluoridation is one of the 10 most effective public health measures
of the twentieth century (see Box 20-6); meets the requirements of a
public health solution (see Box 20-1)
3. Fluoridation does not have specific targets; it has the potential to
reduce disparities by reaching everyone in the community
4. Fluoridation is the most practical form of preventing caries in
communities with established community water systems
5. Fluoridation effectively prevents and controls dental caries in
children and adults
a. Is attributed with 20% to 40% caries reduction in the mixed
dentition of children (8 to 12 years of age), 15% to 35% caries
reduction in the permanent dentition of adolescents (14 to 17
years of age), and 20% to 40% reduction of coronal caries in
adults
b. Benefits both primary and permanent teeth
c. Primarily benefits smooth surface caries; as DMFS (decayed,
missing, and filled permanent surfaces) rates in a population
are reduced by fluoride, the proportion of pit-and-fissure caries
increases, even though the absolute number is reduced
d. Controls both coronal and root caries in older adults
e. Helps to control caries resulting from reduced salivary flow
caused by medications
f. Has no known prenatal benefits
g. Benefits of fluoride accumulate; combination of water
fluoridation with topical fluoride provides additional benefits
(systemic programs should not be combined to avoid increase in
fluorosis in the population)
h. Fluoride is the most effective means to prevent and control
dental caries; a common misconception is that oral hygiene is
the most effective means
6. Indirect benefits of fluoride include fewer missing teeth resulting in
improved self-image, less complicated restorative procedures, pain
reduction, decreased malocclusion, and decreased periodontal
problems related to tooth loss, all of which lead to improved quality

1700
 of life for the public; indirect benefits also include positive influence
on the practice of dentistry and dental hygiene
7. Posteruption benefits—primary benefit of fluoridated water occurs
after tooth eruption as a result of topical effects; preeruption effects
are minor
a. Critical period for benefits in children is immediately after tooth
eruption so that immature enamel of newly erupted teeth can
uptake the fluoride (ages 6 months to 13 years)
b. Posteruption benefits rely on the fluoride being available in
solution (via saliva) at the surface of the tooth; systemic fluoride
is released into saliva and is available in saliva and plaque
biofilm fluids
c. Fluoride inhibits demineralization by adsorbing to the
carbonated hydroxyapatite crystals, protecting the enamel
surface from dissolution by acids
d. Fluoride enhances remineralization of incipient caries by
adsorbing during the continual demineralization-
remineralization process; this is the primary action of fluoride
for control of dental caries
e. When fluoridated water is consumed, saliva has a constant
fluoride level, making it continually available for uptake by the
enamel
f. Bound fluoride in plaque biofilm is released in response to the
lowered pH level and taken up more readily by the
demineralized enamel
8. Preeruption benefits—once thought to be the primary action, this is
now understood to be a minor effect compared with the posteruptive
action; fluoride is incorporated into the mineralized tooth structure
during tooth development by the replacement of hydroxyapatite
with fluorapatite during enamel formation
9. Most cost-effective and efficient method of bringing fluoride
benefits to a community
a. A Healthy People 2020 Oral Health objective calls for 79.6% of the
U.S. population served by community water systems to have
optimally fluoridated water; 72.4% of the population currently
has fluoridated water (see Table 20-2)
b. Cost of fluoridation varies with the size of the community, water
system, labor costs, and chemicals used; smaller communities
experience higher costs because equipment and supplies
required for smaller water systems are more costly
c. The approximate annual per-person cost of water fluoridation is

1701
 50 cents for communities of more than 20,000 residents, $1 for
communities of 10,000 to 20,000 residents, and $3 for
communities of less than 5000
d. Annual per-person savings of dental treatment costs range from
$16 in small communities to $19 in large communities; every $1
invested yields $38 in savings of dental treatment costs; the
approximate cost of providing fluoridation to an individual for a
lifetime is equivalent to the national average cost to restore one
carious lesion
e. Fluoridation is compatible with other water treatment
processes; quality assurance protocol, including recommended
annual training of personnel to prevent spills, is necessary;
equipment or machinery used for community water fluoridation
resembles that used to add other agents to water systems,
facilitating training of water treatment personnel
10. Compounds used for water fluoridation
a. Any compound that forms fluoride ions in aqueous solution can
be used; the selection depends on the number and accessibility
of water sources and water quality
b. Most popular compounds used in fluoridation of water supplies
include:
(1) Sodium silicofluoride (solid)
(2) Sodium fluoride (solid)—most commonly used and least
expensive; byproduct of fertilizer manufacturing, which
results in the claim of those opposed to fluoridation that it
is a ploy to use waste
(3) Hydrofluorosilicic acid (liquid)—most expensive
11. Extensive research has demonstrated the safety of fluoridation
a. It is noncarcinogenic (opponents claim it is carcinogenic)
b. Kidney failure is the only condition that requires consideration;
kidney dialysis requires the use of mineral-free water
c. No valid research results have linked optimal levels of fluoride
to any health problems
d. It is safe to the fetus; the U.S. Food and Drug Administration
(FDA) does not recommend the use of fluoride during
pregnancy because no known benefits exist, not because it is
considered unsafe
12. Role of government agencies
a. PHS provides funding through block grants and consultation to
states
b. CDC provides education to public and water operators and

1702
 monitors water fluoridation as part of the NOHSS
c. State oral health departments provide consultation and
assistance to counties and cities attempting to fluoridate,
training and monitoring for water system operators, and
monitoring of water fluoridation within the state
d. Local governments without state-mandated fluoridation decide
whether or not to fluoridate, implement water fluoridation, and
pay the ongoing costs of equipment and supplies
13. Legality of fluoridation—courts have upheld the constitutionality of
water fluoridation
14. Promotion of water fluoridation
a. Oral health care professionals are effective advocates for
promoting water fluoridation within a community (Box 20-7)

Box 20-7
Strategies to Inc rease Water Fluoridation in
the United States
The 2012 Water Fluoridation Statistics indicated 74.6% of the U.S.
population on public water systems received optimally fluoridated water.
Healthy People 2020 has set a goal that 79.6% of the population on public
water systems should receive optimally fluoridated water by 2020.
• Develop and implement a plan of action to maintain the efficacy of
water fluoridation as a proven public health measure
• Organize and enlist the support of other state and federal
organizations that have an influence in guiding the development of
health policies bringing about social change
• Effectively translate fluoridation information into the languages of all
racial and ethnic groups
• Develop new and innovative strategies to meet the challenge of
fluoridation opponents, past and present
• Develop a national clearinghouse for fluoridation materials
• Develop a national surveillance system to collect, analyze, and evaluate
risk factor data related to fluorides
• Support legislation to fund community water fluoridation
Data from Centers for Disease Control and Prevention: Community water fluoridation, July 10,
2013, http://www.cdc.gov/fluoridation/; 2012 Water fluoridation statistics, November 22, 2013,
http://www.cdc.gov/fluoridation/statistics/2012stats.htm; and Healthy people 2020, 2010,
http://www.healthypeople.gov/2020/.

b. Ongoing education of individuals is required to encourage their

1703
continual support of fluoridation; fluoridation continues to be an issue
with regard to wider public acceptance; individuals should be aware of
their community fluoride water levels (information is available at My
Water ’s Fluoride at http://apps.nccd.cdc.gov/MWF/Index.asp) and of the
ways they have benefited from fluoridation in their communities
c. Three methods of implementing fluoridation:
(1) Administrative decision—a community leader introduces the idea of
community water fluoridation through appropriate government
channels, and the idea is approved by the appropriate governing body
(i.e., water board, public services director, mayor, city council)
(2) Initiative petition or referendum—allows members of the community
to vote for or against fluoridation of the water supply; the referendum
should be a last resort to avoid a politically charged situation
(3) Legislative action—mandate passed by state legislators that requires
specified public water supplies to be fluoridated or allows health
departments to order public water supplies to be fluoridated under
certain conditions; it is generally recommended that the decision to
fluoridate be made at the local level, although some states have
mandatory fluoridation laws
d. Public attitudes toward water fluoridation are both positive and
negative—only 20% of population opposed to fluoridation; the majority
of Americans support fluoridation; the lack of organization and passivity
on the part of the supporters of fluoridation make it easier for well-
organized anti-fluoridationists to block its implementation or adoption
e. Opponents’ arguments and tactics appeal to emotions and use of scare
tactics
(1) Suggest that water fluoridation is unconstitutional and violates
individual freedom of choice
(2) Create suspicion of government programs, officials, or both
(3) Allege that fluoridation is overregulation by the government
(4) Associate fluoridation with concerns about poor health, disease, and
aging, based on anecdotal evidence and poorly designed research studies
(5) Imply that water fluoridation is poisonous and causes health hazards
(6) Claims that it causes fluorosis when nonfluoridated communities
have lower levels of fluorosis than fluoridated communities
(7) Tied it to environmental issues, such as addition of unnecessary
chemicals to the water
(8) Asserting that adults do not benefit from fluoridation, making it
inappropriate for tax dollars appropriation
f. Strategies used to support water fluoridation
(1) Outcomes from rigorous studies that provide the evidence base for

1704
fluoridation
(2) Knowledge of the community (e.g., past efforts to introduce water
fluoridation or discontinue water fluoridation)
(3) Working with all community leaders, organizations, stakeholders, and
members of the community having influence, such as newspaper editors
or radio/television personalities; collaboration with other health care
professionals
(4) Creating awareness of the methods, tactics, and nonscientific
materials used by fluoridation opponents; recognition of the impact of
incorrect information presented in print and electronic media
g. Steps to implement a fluoridation campaign (Box 20-8)

Box 20-8
Steps to Implement Water Fluoridation in a
Loc al Community to Avoid a Referendum
1. Form a citizen’s community such as “Citizens for Healthy Teeth”;
consider hiring a consultant or arrange for consultation from the state
dental public health department
2. Know the facts: scientific basis for fluoridation, physiology,
effectiveness, safety, cost of fluoridating community, anti-
fluoridationists’ tactics, charges and answers, legality of fluoridation,
and history of local fluoridation
3. Identify and contact key community leaders to educate them and
receive support for the issue
4. Gather endorsements from key community leaders to document
support when meeting with the city council
5. Form a broad base of support beyond the dental and medical
professions through the committee and endorsements
6. Educate the city council members on the issue, one-on-one, before the
issue is brought before council meetings
7. Bring the issue formally before the city council only after support has
been received from community leaders and individual council
members
8. Attend council meetings to show support of the issue
9. Be prepared to testify at the city council meetings

B. Dietary fluoride supplements (Table 20-12)

1. Dosage and age recommendations are available (Table 20-13); other
available fluoride and related factors, such as risk, cooperation, age,

1705
 and ability of the child, should also be considered

Table 20-13
Dietary Fluoride Supplementation Schedule (in mg F/day*)

Data from American Academy of Pediatric Dentistry (AAPD): Guideline on fluoride therapy, 2014.
http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy.pdf.
* 2.2 mg sodium fluoride (NaF) contains 1 mg fluoride ion; ppm, parts per million; 1.0 ppm, 1 mg/L.

2. School-based fluoride supplement programs

a. Yielded 30% reduction in dental caries
b. Were cost-effective and efficient
c. Required parental consent and ongoing cooperation of highly
motivated staff and parents made implementation cumbersome
3. Current public health recommendation to prevent fluorosis is to use
fluoride supplements only with children age 6 years and older and
only when fluoridated water is not being consumed; this targeted
approach is based on the availability of multiple other sources of
fluoride and balances caries reduction benefits of fluoride for high-
risk children and its potential to cause fluorosis
4. At-home use has the disadvantage of dependence on adherence;
increased client adherence may be achieved with combined fluoride-
vitamin supplements
5. Controlled daily at-home use results in caries reduction similar to
water fluoridation
6. Dietary supplements are not recommended for infants who are
breast-fed; breast milk contains 0.0004 ppm F
7. Prenatal supplementation with fluoride is not recommended,
although it is not harmful to the fetus; even though it crosses the
placental barrier and enters the fetal circulation, benefits are minor,
since mineralization of enamel is not advanced until after birth, and

1706
 primary benefit of fluoride occurs after tooth eruption
8. Varnish programs (see Table 20-12)
a. Studies show 45% caries reduction with public health programs
b. Fluoride varnish programs have numerous advantages
compared to other fluoride modalities (Box 20-9)

Box 20-9
Advantages of Public Health Fluoride Varnish
Programs
• No special dental equipment required
• Professional dental cleaning not required before application
• Ease of application
• Dries immediately on contact with saliva
• Safety
• Well tolerated by all; especially convenient for use on infants, young
children, and individuals with special needs
• Inexpensive
• Minimal training required for placement; nondental personnel can be
trained
• Allows the ability to eat or drink immediately after application
• Prevents and reverses decay
• Shows caries reduction up to 45% compared with 30% to 35% for other
fluoride systems
Data adapted from Texas Department of State Health Services: Happy child, bright smile; fluoride
varnish manual, Pub No E08-13077, March 2009, http://www.dshs. state.tx.us/dental/default.shtm;
and Centers for Disease Control and Prevention: Other fluoride products, July 10, 2013,
http://www.cdc.gov/fluoridation/fluoride_products/.

c. Child positioning for examination and fluoride varnish application

(1) Knee to knee – infants are held by parents in their laps, with the
child’s head on the parent’s knees and the child’s legs around the parent’s
waist, and the operator is knee to knee with the parent, treating the
infant from behind; an alternate is to place the infant on an examination
table and work from behind
(2) Face to face—young children are seated in small school chairs, and
the operator is seated directly facing the child, tilting the child’s head
back for good visibility; alternative positions are the child standing in
front of the seated operator or the operator standing behind the seated
larger child and working from above
d. Varnish should be reapplied every 3 months in high-risk children and

1707
every 6 months in moderate-risk children
e. CDC recommends programs with preschool-age children such as Head
Start
f. Educational program with parents and children should be included to
increase adherence and address other aspects of caries prevention and
control
C. School water fluoridation (see Table 20-12)
1. Still in use in some communities with suboptimal fluoride levels,
particularly rural areas where community water fluoridation is
impossible; the extent of current practice is unknown; no longer
recommended by the CDC because of the disadvantages
2. This program reduced caries among schoolchildren by
approximately 40%
3. Disadvantages—children do not receive benefits until they begin
school; exposure occurs only during the school year and on school
days; benefits only schoolchildren; equipment for these small water
systems have logistical problems and greater risk of spills
4. To compensate for children drinking this water only when school is
in session, it is fluoridated at 4.5 times the optimum concentration
D. Fluoridated salt (see Table 20-12)
1. Addition of fluoride to table salt is a feasible way to deliver fluoride
in countries lacking widespread municipal water systems (not the
United States or Canada)
2. Reduction in caries parallels rates found with water fluoridation
3. Used in some other countries; WHO criteria include the inability to
implement water fluoridation, low levels of fluoride in the diet and
environment, lack of political will to introduce water fluoridation,
centralized salt production, and appropriate package labeling
E. Fluoridated milk (see Table 20-12)
1. The addition of fluoride to milk consumed in schools has been
studied in several European countries (not the United States or
Canada)
2. Outcomes have shown protection from caries comparable with water
fluoridation at the same concentration
3. Disadvantages—only provides a single fluoride exposure on school
days, requires refrigeration, and milk consumption declines with
increasing age of child
F. Professionally applied topical fluoride (see Table 20-12 and the sections
on “Topical Fluorides and Fluoride Varnishes” in Chapter 13 and
“Fluorides” in Chapter 16)
1. Professional application of topical F is the least cost-effective public

1708
 health fluoride measure
2. Sodium fluoride (NaF), stannous fluoride (SnF2), and acidulated
phosphate fluoride (APF) in gel, foam, and mouthrinse forms are no
longer recommended by the CDC as a population-based strategy,
although they may be indicated in high-risk populations in targeted
clinical programs such as institutions for high-risk, special-needs
groups
G. Fluoride mouthrinses in school-based public programs (see Table 20-
12)
1. Widely used at one time; still used in some areas, especially in
developing countries
2. Studies indicated a 20% to 35% reduction in caries; not cost-effective
in combination with systemic fluoride
3. Although highly successful, their use is limited today in the United
States because of expansion of water fluoridation and availability of
other sources of fluoride
4. Disadvantages—required level of parental compliance and
dependence on teachers and school nurses to administer the
program
H. Fluoride dentifrices (see Table 20-12)
1. Fluoride dentifrices are the most important fluoride vehicle on a
global scale, providing 15% to 30% caries reduction in children over
a 3-year period without water fluoridation; they are cost-effective and
add to the effectiveness of water fluoridation and other sources of
fluoride
2. Their use is institutionalized in the United States, Canada, and other
developed countries, accounting for over 90% of the market; this
makes distribution as a public health measure unnecessary; public
health distribution has value in developing countries where the
population does not have access to F dentifrices
I. Other chemical therapies
1. Xylitol
a. Used in food and snack items as a noncariogenic sweetener; its
use may reduce the incidence of dental caries in people with
moderate or higher risk; additional research is needed
b. Some studies have shown that xylitol is superior to other
chemical therapies to interrupt the vertical transmission of
dental caries from parent or caregiver to infants and the
horizontal transmission among siblings; this use is no longer
standard practice, and additional research is needed
c. Recommended to be used in combination with topical fluoride

1709
2. Chlorhexidine gluconate
a. Effective against Streptococcus mutans
b. Recommended for individuals who are at high or extreme risk
for caries
c. CAMBRA (Caries Management by Risk Assessment)
recommended regimen for caries control is 0.12% chlorhexidine
gluconate rinsed for 1 minute daily for 1 week each month;
additional research is needed
d. Loses effectiveness in the presence of lauryl sulfate or fluoride;
rinse should be used about 30 minutes after toothbrushing with
dentifrices that contain either compound
e. The American Dental Association recommends use of
chlorhexidine-thymol combination varnish for control of root
caries
3. Amorphous calcium phosphate (ACP)
a. Calcium and phosphate ions in ACP will prevent caries
progression by enhancing enamel remineralization, occluding
dentinal tubules, and increasing fluoride uptake in areas of
demineralization; also reduces sensitivity
b. Should be used in combination with fluoride therapy
c. Recommended for use by individuals who are at high risk for
caries
d. Contained in dentifrices and sensitivity relief products as well
as professional-use products such as polishing paste and
sealants
4. Casein phosphopeptides–amorphous calcium phosphate (CPP-ACP)
—also known by the name Recaldent
a. Enhances the effects of fluoride and provides a supersaturated
environment of calcium and phosphate for remineralization;
also reduces sensitivity
b. Recommended to be used in combination with fluoride therapy
c. Recommended for use by individuals who are at high risk for
caries
d. Some studies suggest long-term caries prevention effects;
additional research is needed
e. Contained in chewing gum and pastes for professional
application
5. Sodium bicarbonate
a. Claims are that it neutralizes acids produced by acidogenic
bacteria and has antibacterial properties; recommended for
individuals with xerostomia

1710
 b. Contained in chewing gum and dentifrice; can be rinsed by
mixing 2 teaspoons baking soda with 8 ounces water
c. Aggressive use of fluoride therapy should be continued by
individuals with xerostomia or other conditions that produce
high oral acidity
6. Calcium sodium phosphosilicate (NovaMin)
a. Delivers calcium phosphorus, sodium, and silica to replace
minerals lost to demineralization; should be used in
combination with fluoride
b. Contained in dentifrices, mints, and chewing gums
c. Additional research is needed
7. Tricalcium phosphate
a. Protects calcium ions and frees phosphate ions to prohibit
calcium from reacting prematurely with fluoride
b. Ingredient in Clinpro 5000 dentifrice
8. Probiotics
a. Noncariogenic bacteria replace and displace cariogenic bacteria
b. Promising results but additional research needed
J. Dental sealant programs (see the sections on “Pit-and-Fissure
Sealants” in Chapter 13 and “Dental Sealants” in Chapter 16)
1. Sealants prevent caries in sound and noncavitated pits and fissures
and reduce the rate of incipient carious lesions that progress to
cavitation
2. Sealants reduce bacteria levels in cavitated lesions 100-fold and
reduce lesions with any viable bacteria by 50%
3. Sealants are recommended in both fluoridated and nonfluoridated
communities
4. The use of fluorides in conjunction with sealants is recommended so
that both smooth surfaces and pit-and-fissure surfaces benefit
5. Sealant and fluoride programs are the most beneficial community-
based dental disease-prevention programs; sealants are a critical
component of disease prevention programs
6. Based on epidemiologic evidence, community-based sealant
programs are justified for children, adolescents, and young adults,
but not for other age groups
7. Sealant program settings may include schools, clinics, day care
facilities, and community centers; a team approach is necessary for
screening and treatment, including necessary support and
cooperation from administrators, staff, teachers, parents, caregivers,
and volunteers
8. Targeting school-based sealant programs

1711
 a. Schools are targeted that have high rates of children from low-
SES groups who are at high risk of dental caries, as determined
by the percentage of students eligible for free or subsidized
lunch programs
b. Limited resources require that sealant programs use criteria
that include risk of dental caries, availability of care, grade level
of the targeted group (e.g., second and sixth grades), and teeth
with deep pits and fissures
c. Teeth should be sealed within 6 months of eruption of first and
second molars
9. The cost-effectiveness of community-based sealant programs is a
result of the pattern of dental caries; the vast majority of dental
caries in schoolchildren currently occurs in pits and fissures
10. Retention rates are:
a. Comparable for various oral health professionals who place
sealants; cost-effectiveness depends on the use of nondentists to
place sealants
b. Higher with four-handed technique; parent and staff volunteers
can be trained to assist
11. Most third-party insurance payers cover sealants
12. An educational component is critical for parents and children of
the targeted population to increase adherence to other aspects of
caries prevention and control
13. CDC provides clinical guidelines for sealant use and
recommendations for school-based sealant programs (Box 20-10)

Box 20-10
CDC Rec ommendations for Sealant Use in
Community Oral Health
Clinical Recommendations
1. Sealants should be placed on pits and fissures of children’s primary
teeth when it is determined that the tooth, or the patient, is at risk of
experiencing caries.
2. Sealants should be placed on pits and fissures of children’s,
adolescents’, and adults’ permanent teeth when it is determined that
the tooth, or the patient, is at risk of experiencing caries.
3. Pit-and-fissure sealants should be placed on early (noncavitated)
carious lesions in children, adolescents, young adults, and adults to

1712
 reduce the percentage of lesions that progress.
4. Conditions that favor the placement of resin-based versus glass
ionomer cement; resin-based sealants are the first choice of material
for dental sealants.
5. Use of a bonding agent between the previously acid-etched enamel
surface and the sealant material may enhance sealant retention.
6. Use of a bonding agent that excludes acid etching is not recommended.
7. Routine mechanical preparation of enamel before acid etching is not
recommended.
8. When possible, a four-handed technique should be used for placement
of sealants.
9. The oral health care professional should monitor and reapply sealants
as needed to maximize effectiveness.
10. The manufacturer ’s instructions for sealant placement should be
followed.

Recommendations for School-Based Sealant Programs

1. Seal pit-and-fissure tooth surfaces that are sound or have noncavitated
lesions, prioritizing first and second permanent molars.
2. Unaided visual assessment is adequate prior to sealant placement to
differentiate surfaces with the earliest signs of tooth decay from more
advanced lesions.
3. Prior to assessment, dry the teeth with a cotton roll, gauze, or, when
available, compressed air.
4. An explorer may be used to gently confirm cavitations; do not use a
sharp explorer under force.
5. X-ray films are not needed solely for sealant placement.
6. A toothbrush can be used to help clean the tooth surface before acid
etching; more complex cleaning methods are not recommended.
7. Use a four-handed technique with an assistant to increase retention.
8. Provide sealants to children even if follow-up examinations for every
child cannot be guaranteed.
9. Evaluate sealant retention within 1 year.
Data from Beauchamp J, Caufield PW, Crall JJ, et al: Evidence-based clinical recommendations for
the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific
Affairs, J Am Dent Assoc 139:257-268, 2008; Centers for Disease Control and Prevention (CDC):
School-based dental sealant programs; and Gooch BF, Griffin SO, Gray SV, et.al: Preventing dental
caries through school-based sealant programs: updated recommendations and reviews of evidence,
J Am Dent Assoc 140:1356-1365, 2009. http://www.cdc.gov/oralhealth/dental_sealant_program/.

K. Caries management by risk assessment

1713
 1. CAMBRA is the process of dealing with dental caries as an infectious
disease by risk assessment and planned interventions or treatment
based on that risk (see Chapter 15)
2. Risk is based on the balance of pathologic factors and protective
factors; the level of risk is determined by professional judgment of
this balance
3. Targeting community-based programs should be done according to
the level of risk
a. Parent or caregiver of a child belonging to a low-SES group
automatically results in high risk for the child
b. Current or recent caries experience places any-age individual at
a high-risk level
c. Xerostomia and special-needs status automatically result in an
extreme-risk category

Measures for Preventing and Controlling Periodontal

Diseases
A. No parallel to water fluoridation and other fluoride modalities exists
for the prevention of periodontal diseases
B. A combination of meticulous self-care by individuals on a regular
basis, elimination of high risk behaviors such as smoking, control of
systemic diseases and conditions, and periodic periodontal maintenance
therapy leads to improved gingival health, decreased attachment loss,
and maintenance of natural dentition
1. Various mechanical and chemical interventions prevent and control
some periodontal diseases
2. Gingivitis is controllable with mechanical oral prophylaxis and
adequate oral hygiene to reduce or disrupt dental plaque biofilm
3. Personal oral hygiene practices such as regular toothbrushing and
interdental cleaning can be supplemented by OTC and prescription
antimicrobial mouthrinses
4. Tobacco cessation aids in periodontal disease prevention, control,
and progression
5. Health education informs persons about the relationship of systemic
diseases (diabetes, heart disease, stroke, osteoporosis, stress,
respiratory disease) and pregnancy to periodontal health
6. Addressing periodontal disease at the population level is
complicated by role of genetic factors in destructive periodontal
disease
C. Community activities could include:

1714
 1. Public education to increase health literacy; for example, personal
oral hygiene, control of behaviors that increase risk, regular
professional oral care, and linking systemic and oral health
2. Tobacco cessation programs and efforts
3. Support of funding for and promotion of population-based research

Measures for Preventing and Controlling Other Oral

Diseases and Anomalies
A. Oropharyngeal cancers
1. A primary prevention technique for human papillomavirus–related
oropharyngeal cancers is the HPV vaccine. Primary prevention for
most oral and pharyngeal cancers is not available; avoiding known
risk factors such as alcohol and tobacco is recommended
2. Although overall cigarette use in the United States has declined over
the last decade, tobacco prevention and cessation initiatives are still
necessary because the use of smokeless tobacco, cigars, e-cigarettes,
and hookahs has increased
3. Advocating for regular oral cancer screening and examinations
4. School-based prevention programs are important
a. The rate of cigarette use among high school students has
decreased steadily each year since 1997, but approximately 15%
of high school students reported smoking in 2013; the use of
cigar smoking and smokeless tobacco among high school
students have remained unchanged8
b. Recommendations for education of students—for example,
programs and information from the CDC and the American
Dental Hygienists Association (ADHA) Smoking Cessation
Initiative Project
(1) Focus on restricting social influences and environments
that lead to tobacco use
(2) Develop and enforce a school policy on tobacco use
prevention, control, and cessation
(3) Provide instruction on the short-term and long-term
negative physiologic and social influences of tobacco, peer
norms regarding tobacco use, and refusal skills
(4) Deliver tobacco-use prevention education in kindergarten
through twelfth grade; this instruction should begin no
later than fifth grade, should be especially intensive in
middle school, and reinforced in high school
(5) Offer program-specific training and dialogue scripts to

1715
 teachers and school nurses
(6) Involve parents and families in support of school-based
programs to prevent tobacco use
(7) Support cessation efforts among students and all school
staff who use tobacco; involve other associations and
organizations such as parent-teacher associations (PTAs),
American Association of Retired Persons (AARP),
employers, and health insurers
(8) Evaluate outcomes of tobacco-use prevention program at
regular intervals
5. Tobacco cessation as a preventive intervention
a. A Healthy People 2020 objective is to provide tobacco cessation
counseling by dentists and dental hygienists (see Table 20-2)
b. Some health insurance policies provide tobacco cessation
coverage
6. Secondary prevention consists of early detection (screening) and
treatment
a. Mass screening for oral cancers is costly
b. Professionals should include oral cancer examinations as part of
their assessment and teach self-examination techniques to
clients; progress was made in the last decade (see Table 20-2)
7. Other recommended strategies
a. Focus on populations at risk for use of smokeless tobacco (e.g.,
little league teams)
b. Emphasize health warnings on posters, brochures, websites,
products, and public service announcements that warn of
hazards
c. Urge people to regularly visit a professional oral health care
provider for examination, advice, and assistance with quitting
tobacco use
d. Provide public education regarding signs and symptoms of oral
cancer; promote regular self-examination
e. Encourage use of QUIT phone lines
f. Promote use of online smoking cessation assistance
g. Support population-based research efforts and lobbying
strategies
h. Keep abreast of new information on tobacco cessation, such as
from ADHA and CDC
i. Advocate for policies related to controlling the sale and use of
tobacco products
B. Craniofacial birth defects

1716
 1. Cleft palate and cleft lip are among the most frequent birth defects
2. Public health programs should emphasize awareness of risk and
protective factors during pregnancy
a. Prenatal care
b. Good nutrition
c. Tobacco use
d. Alcohol consumption
e. Drug abuse
f. Teratogenic prescription drugs (e.g., drugs used to treat acne)
g. Many occurrences cannot be linked to a direct behavioral link or
cause
3. Advocacy for policies related to improvement of surveillance and
referral
C. Facial injury or trauma (see the section on “Mouth Protectors [Athletic
Mouthguards]” in Chapter 13)
1. Oral health education that focuses on preventive behaviors
2. Increased public attention to the importance of head and facial
protection
a. Headgear and athletic mouth protectors during contact-sports
activities
b. Safety restraints in automobiles
c. Helmets for bicycling, skateboarding, in-line skating (roller
blading), and motorcycle use
d. Measures to prevent injuries from falls in the home, including
good lighting, nonskid flooring materials, and handrails
3. Emphasis on education of parents, coaches, caregivers and policy
makers
D. Tooth loss
1. Oral health education focused on the value of keeping natural teeth
and importance of early treatment of caries and periodontal diseases
2. Advocacy for and policies that improve access to care for
underserved populations
E. Problems related to denture use
1. Oral health education focused on importance of and techniques used
for denture cleanliness
2. Policies related to denture identification during fabrication
3. Health promotion programs for caregivers and staff of nursing
homes to encourage assistance with oral hygiene and denture care
for older-adult denture wearers who need assistance
F. Fluorosis
1. Monitoring of safe water fluoridation practices; training of water

1717
 treatment personnel
2. Promotion of policies related to removing excess fluoride from
community water supplies
3. Oral health education of the public and other health professionals
related to the safe use of fluorides

1718
1719
Community intervention
A. Steps of dental hygiene process of care (ADPIE) are similar to those
used in community programming in a circular approach continually to
improve programs: assessment, determination of priorities (problem
identification), planning, implementation, and evaluation (Fig. 20-6)

FIG 20-6 Use of ADPIE in community programming.

Assessment, Determination of priorities (problem identification), (Data from Nathe
CN: Dental pub lic health and research, ed 4, Upper Saddle River, NJ, 2015, Pearson.)

B. Community groups vary—programming principles can be applied to

all groups and types of programs, although programs may need to be
adapted for various priority populations based on culture and other
demographic factors
C. Factors to consider in community programming—current health care
system, workforce issues, resources, funding, geography, sociocultural
background, SES, cultural and political climates, and oral health literacy
D. Community programming uses various strategies
1. Surveillance at national and state levels that:
a. Provides information necessary for public health decision
making
b. Collects data on health outcomes, risk factors, and intervention
strategies
c. Can link current databases and address identified data gaps
d. Identifies public health issues requiring immediate action
e. Measures and monitors trends in the burden of disease
f. Guides planning, implementation, and evaluation of programs
g. May influence public policy and allocation of funds
h. Includes important qualities of surveillance: simplicity,

1720
 flexibility, data quality, representativeness, and timeliness
2. Survey
a. A description of the defined population at a point in time
b. Can be part of a needs assessment
3. Needs assessment that identifies:
a. Extent and types of assets and challenges in a community
b. Current system of services and programs available
c. Extent of needs and resource utilization
E. Roles of dental hygienists in community health planning and practice
1. Program planner or initiator
2. Consultant and resource person
3. Service provider
4. Administrator or manager of a particular program or division
5. Researcher, including data collection
6. Educator and oral health promotion professional
7. Consumer advocate
8. Politician
9. Trainer—training others to provide a service is a more efficient use
of resources
F. Several program planning models are used; elements common to
community oral health initiatives include education, financing, and
formative evaluation
1. Identify priority population
2. Assess the priority population
3. Collect, organize, and analyze data
4. Determine priorities
5. Develop a program plan
6. Implement the plan
7. Evaluate the program

Assessment and Problem Identification

A. Definition—multifaceted, organized, and systematic approach to
identify a target group and define the extent and severity of the oral
health care needs that are present
1. Priority group—group of individuals who are the focus of a
particular oral health care service or program; may be identified by
health professional or by group themselves
2. Use of a community-oriented primary care (COPC) philosophy of
health planning—this is the community being involved in
identifying its perceived needs and assigning priorities; also referred

1721
 to as community-based participation
B. Data collection
1. Important to complete as part of the needs assessment before
planning the intervention
2. Develop a community profile of the area where the target population
is located if adequate needs assessment is not available
3. Identify ongoing types of programs or projects
a. Purpose is to provide oral health services, education, disease
prevention, research, or combination
b. Community individuals and groups responsible for programs
and success
c. Locations or facilities where oral health care activities can occur
d. Individuals, special equipment (e.g., mobile vans or portable
equipment), facilities, coalitions, funding opportunities, and
other resources to meet the oral health care needs of the target
population
4. Assess current oral health status and needs
a. Used to identify the extent and severity of need and in
determining project aims and objectives
b. Three basic approaches to documenting oral health status and
needs:
(1) Identify and use an assessment method to obtain specific
data related to the proposed project or program
(2) Coordinate assessment with an agency or group such as an
academic center or community-based agency that is seeking
similar data about the target population
(3) Secondary data—research and collect secondary data from
records of state or local health care agencies, dental or
medical programs, and public health or related agencies
5. Various data collection methods can be used (Table 20-14)

1722
Table 20-14
Data Collection Methods and Applications

Data from Beatty CF: Community oral health practice for the dental hygienist, ed 4, St Louis, 2017, Elsevier
Saunders.

a. Method used is influenced by the type of information or data

1723
 needed
b. Types of data collected for assessment affects assessment
methods used
(1) Baseline data—data collected before program
implementation; used for problem identification, planning,
and evaluating a program; it is compared to outcomes data
to evaluate success of program; baseline data is also called
pretest data in research
(2) Primary data—new data collected by various techniques
(e.g., questionnaire, interview, direct observation, indices,
records, documents)
(3) Secondary data—existing data previously collected by
federal or state agencies, public policy organizations or
other sources (e.g., Census Bureau, Gallup polls, Oral
Health America)
(4) Qualitative data—nonnumerical descriptive data such as
observations, perceptions, attitudes, and comments made
c. Multiple data collection methods can be used together based on
program goals
d. Surveys—method used to assess knowledge, oral health status,
oral health behavior, interests, values, and attitudes; can be
done by use of questionnaire or interview
e. Oral health surveys—type of survey method used to collect
information about oral health, disease status, and treatment
needs for planning or monitoring oral health care needs
(1) Can be accomplished with a clinical examination (primary
data) or review of dental records (secondary data)
(2) Existing survey data may be available for comparisons of
target group to comparable groups or different geographic
regions
(a) National data from federal agencies responsible for
monitoring health and oral health status, such as CDC
and NOHSS
(b) State-level surveillance data available from the CDC,
NOHSS, or some state health departments
(3) ASTDD and WHO are resources for guidelines for
conducing and reporting results of an oral health survey
(4) Four types of examinations and inspections are used in
oral health surveys to measure dental caries (Table 20-15);
the type used varies according to the index or measurement
approach (see Table 20-11)

1724
 Table 20-15
Types of Caries Examinations and Inspections

* Type III and Type IV are the most common methods used in dental public health.

f. Special considerations are needed in planning oral health

surveys
(1) Cumulative nature of some diseases
(2) Disease is age related
(3) A significant percentage of the population is affected
(4) Irreversible nature of some oral diseases
(5) Trends in disease prevalence exist
(6) Common oral diseases exist in all populations; prevalence
may be higher in underinsured and uninsured, low-SES,
and nonwhite and Hispanic populations
(7) Standard measurements are used to assess many oral
diseases (dental indices); subjectivity and potential for error
are inherent in use of many dental indices
(8) Surveying requires planning, calibration of examiners, and
possibly pilot testing before implementation
C. Development of a community profile
1. Community profile—provides information essential in planning a
community health program; the rationale is to understand the
environment in which the target population is located
2. Not always necessary and depends on the scope of the proposed
intervention; the comprehensive nature depends on resources and
goals
3. Size, location, and type of community dictate the type, amount, and
comprehensiveness of information necessary for a community
profile
4. General areas for inclusion can consist of:
a. Community overview
(1) Number of individuals in the population and distribution
by income, age, education, employment rate, public
assistance, health and dental insurance rates, and

1725
 percentage of population receiving Medicare, Medicaid, or
CHIP
(2) Geographic location and boundaries, population setting
and density (urban or rural), standard of living,
homelessness
(3) Ethnic background, cultural heritage, languages, customs,
behaviors, beliefs
(4) Diet, nutritional levels, nutrition programs
(5) Amount, types, and influence of public services and
utilities, including transportation schedules, routes, fares,
and reliability
(6) Informed-consent procedures and confidentiality of health
records
(7) Distribution of public and private schools and religious or
faith-based organizations
(8) Extent and type of community fluoride and sealant
programs; fluoridation history
(9) State and local statutes, public health codes, and related
administrative rules and regulations
b. Community leadership and organization; political atmosphere
(1) Community, financial, and religious leaders, liaisons, and
councils
(2) Community power base for policy formulation
(3) Governance structure (e.g., health council, city
government, advisory board, school board, union); political
environment
(4) Grassroots individuals with political influence
(5) Educational institutions providing professional education,
resources, and support
(6) Attitudes of all these entities toward oral health, acquired
through interviews or surveys, is important in terms of
whether they will be assets or barriers to the community
programming process
c. Financing and funding of health services
(1) Local and state budget allocation procedures for oral
health care programs
(2) Funding sources (e.g., federal, state, or local funding;
individual or third-party payment; private funds;
foundations; grants; endowments)
(3) Mechanism for requesting the necessary funding; the
importance of the need for collaborative partners to

1726
 successfully obtain funding must be determined
d. Facilities, resources, and workforce
(1) Location of space and facilities in the community or
institution; U.S. Department of Labor Occupational Safety
and Health Administration (OSHA) standard compliance
(2) Availability and adequacy of equipment
(3) Location of medical and health science centers, clinics,
community health centers, and dental laboratories; ease of
access
(4) Number of licensed practicing dentists, dental hygienists,
midlevel dental providers, dental assistants, laboratory
technicians, medical personnel, or others experienced in
working with target population
(5) Consortia of health professionals, facilities, and resources
(collaboration is important)
(6) Barriers that limit access of the population to oral health
care (e.g., cost, transportation, political climate of
community, attitudes of leaders about oral health)
e. Sometimes a community assessment is accomplished for overall
community planning before identifying any specific group to
target; in this case, population groups previously identified as
being at high risk for oral health needs should be included in
the community assessment
(1) Preschool-age and school-age children
(2) Intellectually, developmentally, and physically challenged
persons
(3) Chronically ill and medically compromised persons
(4) Older adults
(5) Pregnant women and infants
(6) Low-income and minority groups
(7) Residents of inner-city and rural communities
D. Analysis of data
1. Analysis includes organizing, evaluating, and interpreting data
2. Data analysis can range from simple to complex, using simple
descriptive tabulations or advanced statistical tests
a. Planner alone can analyze the data
b. Statisticians and epidemiologists can be involved
c. Computers
d. Analysis of qualitative data requires special skills
e. Economic analysis of existing programs, including a cost/benefit
ratio

1727
 3. After analysis, population needs and priorities can be identified
a. Formal and informal input is sought through meetings, focus
groups, and social media
b. Input is sought from various stakeholder groups
c. Community representatives, partners, and advisory groups are
consulted
d. Consumers; political, religious, and financial leaders; and health
care professionals may be included
4. An opportunity for dialogue is important to gain support

Program Planning
A. Definition—organized response to reduce or eliminate one or more
problems; organized effort that includes the objective of reducing or
eliminating one or more problems, performance of one or more
activities, and use of resources
B. Elements of a program plan
1. Identification of program goals and objectives
2. Strategies and specific activities to meet objectives, including
sequence and individuals responsible
3. Resources required—facilities, equipment, materials, personnel
(employed and volunteer), with consideration of appropriateness,
adequacy, effectiveness, and efficiency
4. Timetables and deadlines clearly outlined, with some flexibility
5. Projected budget and budget justification
6. Program promotion and marketing
7. Identification of strengths, weaknesses/challenges, opportunities,
and threats (SWOT/SCOT analysis)
C. Goals and objectives
1. For each need prioritized, a goal with related objectives must be
determined
a. Goal—broadly based statement of what changes will occur as a
result of the program; provides direction
b. Objectives—specific statements that describe, in a measurable
manner, the desired outcomes from program activities
c. Most activities may deal with immediate goals, but intermediate
and long-term goals must also be considered
d. Objectives are stated in specific, measurable terms; SMART
formula for developing objectives provides the necessary
components of what, who, where, when, and how much
(1) Specific: clearly states the objectives

1728
 (2) Measurable: objectives can be evaluated
(3) Appropriate: taking the identified needs of target
population into consideration
(4) Realistic or related: objectives that are achievable and
related to anticipated outcomes
(5) Time-bound: establishment of a timeline
D. Program activities
1. The dynamic, energy-using procedures carried out to achieve
program objectives
2. Can be preventive, educational, treatment oriented, or research
oriented
E. Promotion or marketing of program
1. Necessary for participation, recognition, and success of project
2. Varied promotion techniques
a. Advisory committee composed of stakeholders (those who have
a stake in the outcome of the program) and key leaders from the
community
b. Liaison with related groups
c. Mass media (television and radio), printed media, banners,
billboards, Web-based and special-interest publications and
programs
d. Smaller programs may use posters, flyers, invitations,
newsletter announcements, and email
F. Implementation strategy development—the steps for implementing
the program are outlined before beginning the implementation process
G. Evaluation plan—the evaluation plan should be in place before
implementing the program to ensure its successful execution throughout
and on completion of the program

Implementation
A. Implementation is the process of operationalizing the plan; the
implementation strategy is employed to conduct the program
B. During implementation of the program, it is important to monitor the
program activities, personnel, equipment, resources, and supplies to
ensure smooth program operation
C. Ongoing formative evaluation throughout the program
implementation provides opportunity to make program adjustments as
needed; feedback mechanisms from personnel and participants are
critical components of this formative evaluation

1729
Health Education and Health Promotion
See also the sections on “Oral Health Education” and “Prevention-
Oriented Health Models” in Chapter 16.
A. Related concepts
1. Health promotion—a broad concept referring to the process of
enabling people and communities to increase their control over
determinants of health and therefore improve their own health;
includes wide range of strategies that may include policies that
prohibit sale of tobacco products to young people, product labeling
to indicate the amount of sugar in a product, strategies to increase
access to care, and educational interventions
2. Health education—the process in which the client is encouraged to
become responsible for personal oral health and is informed of
scientifically based methods for preventing dental disease
3. Health continuum—conceptualization of health status as perceived
on a continuous scale from optimal health through illness and death
4. Prevention—health education is one means of primary prevention
for both individuals and groups
5. Theories of health education and health promotion (Table 20-16)

Table 20-16
Health Education and Promotion Theories

1730
1731
 Data from Isman B: Health promotion and health communication. In Beatty CF: Community oral health practice for
the dental hygienist, ed 4, St Louis, 2017, Elsevier Saunders; and Hollister MC: Health education and promotion
theories. In Harris NO, Garcia-Godoy F, Nathe CN, editors: Primary preventive dentistry, ed 8, Upper Saddle River,
NJ, 2014, Pearson.
ADPIE, Assessment, determination of priorities (problem identification), planning, implementation, and
evaluation; CAMBRA, caries management by risk assessment.

a. Approaches to health promotion and health education

strategies and interventions should be based on sound theories
in order to result in desired changes in oral health status of
individuals and communities
b. No single theory applies to all situations; theories can be
combined to meet the needs of the situation; multi-dimensional
approaches may be more effective for conditions with multiple
social, behavioral, and biologic risk factors
c. These theories can help the professional move individuals
through the stages of the learning ladder (progression of
learning): unawareness, awareness, self-interest, involvement,
action, and habit
d. Individual models should be used to design community oral
health education programs; community models should be used
to develop oral health promotion strategies that may include
health education
6. Communication skills are critical to the effective implementation of
health promotion and health education programs (see the section on
“Client Management with Effective Communication” in Chapter 15)
7. Health education and health promotion programs must demonstrate
cultural sensitivity to meet the needs of varied groups within the

1732
 population; programs should be adapted to the culture of the target
population
8. The health literacy of the target population must be considered for
successful outcomes; almost two thirds of the U.S. population have
less-than-adequate health literacy (Table 20-17)

Table 20-17
Health Literacy

Data from Centers for Disease Control and Prevention: Health literacy, August 11, 2014,
http://www.cdc.gov/healthliteracy/; and US Department of Health and Human Services, Office of Disease
Prevention and Health Promotion: Quick guide to health literacy fact sheet,
http://www.health.gov/communication/literacy/quickguide/factsbasic.htm.

B. Goals of health education

1. Improve knowledge of health topics
2. Foster motivation for changes in health behaviors
3. Result in outcomes of changed health behaviors
4. Ultimately to improve health status
C. Both direct and indirect processes impact oral health education
1. Formal activities include the deliberate provision of oral health
education designed to elicit specific health promotion or disease
prevention behaviors
2. Informal activities and environmental influences can impact the
indirect or vicarious acquisition of oral health–related information
and motivation that may lead to specific health promotion or disease

1733
 prevention behaviors
D. Health education and health promotion are often integral parts of
community activities; may be directed to:
1. Other health care professionals
2. Preschool, elementary, secondary, and college students
3. Educators
4. Special population groups and caregivers
5. Adult and older-adult groups
6. Institutionalized populations
7. Diverse population groups recently settled in the community
E. Health education topics cannot be limited to oral hygiene instruction;
topics might include:
1. Preventive measures, such as appropriate use of fluorides, sealants,
and xylitol
2. Oral diseases and conditions (e.g., periodontal diseases,
malocclusion, oropharyngeal cancers) and risk factors such as diet,
systemic diseases, poor oral self-care behaviors, and infant-feeding
practices
3. Importance of routine assessment, prevention, and treatment
4. Self-examination techniques
5. Dental safety and dental emergencies (e.g., use of mouth protectors,
procedures for avulsed tooth)
6. Roles of various health professionals and their interrelationships
7. Care of the oral cavity and dental prostheses
8. Careers in dentistry and dental hygiene
9. Becoming a discriminating dental consumer; oral health care
products
10. Effects of tobacco use on oral and systemic health
11. Environmental factors affecting oral health (e.g., occupation-related
concerns)
12. Prenatal and postnatal oral health issues and recommendations;
early childhood caries
13. How to provide oral health care to those unable to care for
themselves
14. Oral and systemic disease links
15. Topics reflected in current Healthy People objectives (see Table 20-2);
Healthy People 2020 website provides resources in the Tools
Resources tab; ADHA, CDC, and other professional organizations
also provide resources

1734
Methods of Oral Health Education
A. Instructional methods
1. Lecture—informative talk, prepared beforehand and given to a
group; useful to introduce new topics, arouse interest in a subject, or
review concepts
a. Advantages
(1) Can present many facts and ideas in a short period
(2) Can convey information to large numbers of individuals
(3) Preparation takes place before presentation
(4) Allows instructor to determine aims, content,
organization, pace, and direction of presentation
(5) Integrates diverse materials and highlights various ideas
and concepts in an orderly way
(6) Can use media
(7) Builds on foundational knowledge in subsequent
presentations; allows for gradual development of complex
or difficult concepts and theories
b. Disadvantages
(1) No active participation by the learner; encourages one-way
communication; stifles creativity
(2) Instructor must have effective writing, speaking, and
modeling skills; poor presentation technique is a barrier to
learning
(3) Difficult to monitor student learning; requires a
considerable amount of unguided student time outside the
classroom
2. Lecture-demonstration—informative talk that presents information
supplemented by a demonstration to reinforce learning; can be used
to introduce information and to demonstrate skills or techniques to
supplement information
a. Advantages
(1) Illustrates information visually
(2) Sets forth information in a complete format
(3) Allows for concentration of attention and economical use
of time
(4) Useful for reinforcing material
(5) May use models, computer-generated presentation, slides,
videotapes, or other teaching tools; technology may allow
larger number of participants to view a demonstration (e.g.,
viewing computer monitors)

1735
 b. Disadvantages
(1) Difficult for large groups to see a demonstration unless
appropriate technology is used
(2) Requires careful preparation for success; requires adequate
equipment and facilities
3. Discussion—group activity in which the student and teacher define a
problem and seek a solution; an interaction between teachers and
students to promote divergent thinking where closure is not
expected; promotes understanding and clarification of concepts,
ideas, and feelings; includes use of questions by the leader to
stimulate interaction
a. Advantages
(1) Allows interaction among participants
(2) Provides two-way communication between the group
leader and members
(3) Encourages individuals to contribute to the discussion
(4) Engages participants in problem solving (higher-order
learning)
(5) Encourages teamwork, tolerance of divergent opinion, and
development of interpersonal skills
(6) Assists leader in directing the discussion
(7) Can be focused on both cognitive and affective learning
b. Disadvantages
(1) Strong personalities can influence a group
(2) Poor discussion leader may contribute to failure of the
discussion
(3) Nothing may be achieved; discussion may go in many
directions without closure
(4) May not be profitable if group members do not have
appropriate background
4. Discovery learning—uses a less direct questioning format to prod
the learner into using logic or common sense to discover ideas or
concepts; useful to build on foundational knowledge and introduce
new concepts
a. Advantages
(1) Requires learner involvement
(2) Requires application of knowledge (higher-level learning)
(3) Promotes critical thinking; motivates student to discover
the “right answer ”; several answers may be plausible
b. Disadvantages
(1) May be interpreted as guessing

1736
 (2) Need to guide learner so that correct information is
concluded
5. Brainstorming—free sharing of ideas generated by unstructured
group interaction; may have a well-defined, clearly stated problem to
address; ideas recorded for future discussion but never analyzed for
merit during session; useful for group identification of an issue or
problem
a. Advantages
(1) Useful for youth and adult groups
(2) Encourages creativity
(3) Encourages application of knowledge
(4) Encourages contribution by all participants with no fear of
a “wrong answer ”
(5) Encourages people to build on others’ ideas
b. Disadvantages
(1) Group dynamic may be influenced by stronger
personalities
(2) Needs to be carefully managed so the purpose is not lost
(3) Not useful for actual sharing of information, just for
problem identification or issue clarification
6. Web-based learning—uses a computer to present information in a
method that can be interactive; includes use of the monitor to
present photos, animation, video, print, and sound for lecture-
demonstration and cases, discussion groups, online testing, and
other online teaching methods
a. Advantages
(1) Provides an alternative medium to present information
(2) Accessible at all times if learner has access to a computer
(3) Can be updated
(4) Provides enhanced printed material
(5) Provides ready access to wealth of resources on the
Internet
b. Disadvantages
(1) Some older adults and institutionalized persons may not
have computer skills or access to appropriate technology
(2) Cost of equipment and linkages
7. Cooperative and collaborative learning activities—occur both inside
and outside the classroom or learning environment, such as group
activities and projects
8. Additional options
a. Field trips; virtual field trips

1737
 b. Panel discussions and debates
c. Problem-solving assignment
d. Symposium reporting
e. Distance learning
f. Computer simulations and modeling
g. Library research
h. Independent study
9. General principles for selection of oral health instructional methods
a. Oral health education should be focused on education and
intervention, stressing skill acquisition and adoption of risk-
reducing behaviors (evidence based)
b. Oral health education is more successful when characterized by
active involvement of participants
c. A combination of teaching techniques should be used for best
results to meet the needs of various learning styles and keep the
interest of the audience
d. Various techniques are more suitable for different topics and for
different age groups
B. Selection of media—vehicles of communication
1. Criteria for selection of media for instruction
a. Some priority populations may not have access to specific
equipment, computers, or the Internet
b. Mass media can be used to create awareness
c. Material must be presented at a convenient time for the majority
of participants
d. Media must be directed at participants’ level of understanding
e. Size of participant group may affect the appropriateness of
different types of media
f. Availability and familiarity with the operation of the educational
technology are necessary
g. Environments vary in their conduciveness to the use of media
and technology
2. Educational aids
a. Printed materials (e.g., pamphlets, books)
b. Photos, overheads, charts, posters, models, puppets, mobiles
c. Electronic, computer-generated presentations, slides,
videotapes, CD-ROMs, DVDs
d. Boards—story, flannel, bulletin, magnetic
e. Science experiments
f. Computer-generated media
g. Mass media—useful to increase awareness; not as useful to

1738
 motivate change of health behaviors
h. Radio and television (including cable)
i. Newspaper and magazine
j. Billboards
k. Advertisements
l. Distance education technologies (e.g., Internet, computerized
instruction, Web-based tutorials, telecommunications,
teleconferencing, iPods, discussion boards)
m. Social media
3. General principles for evaluation and selection of media
a. Specific purpose—arouse interest, provide information, develop
attitudes, change behavior
b. Accuracy and relevancy
c. Based on scientific principles and rigorous research (evidence
informed)
d. Target audience—appropriateness (reading level, use of
pictures), attractiveness, audience appeal, gender and racially
inclusive, culturally sensitive
e. Complexity of information and readability
f. Physical properties—illustrations, color, continuity, and style

Characteristics of Different Types of Learners

A. Groups of learners share commonalities; all groups are made up of
individuals, so care must be taken not to generalize indiscriminately
B. Characteristics of adult learners
1. Goal orientation and relevancy orientation; need to know the reason
to learn something
2. Driven by intrinsic motivation to learn
3. Interested in the immediacy of its application
4. Bring knowledge and experience to the learning situation
5. Come to the learning situation ready to learn
6. Possibly shy and apprehensive; do not respond as quickly as children
do
7. Used to an authority system and can take direction
8. Enjoy a fun, warm, friendly and humorous learning environment
9. Respond well to personal attention, compliments, and reinforcement
10. Value being treated as equals; are put off if “talked down to,”
embarrassed, humiliated, or kept waiting
11. Are social; like to share stories and get to know each other
12. Prefer hands-on, practical, tangible, orderly, and predictable

1739
 activities that include active involvement
13. Need a focus on transference of information (ability to use
information in a new setting)
C. Suggestions for oral health education programs for low-literacy
learners
1. Assess level of knowledge
2. Provide new information, building on and relating to what is already
known
3. Have meaningful interactions; ask questions related to responses
4. Provide information through familiar and uncomplicated modes; use
television, DVDs, radio, personal experience, demonstration, and
oral explanation
5. Provide explicit information that is relevant to current needs
6. Limit the amount of information taught at one time
7. Limit written materials; use basic terminology; maintain a fifth-
grade level, especially for written materials
D. Characteristics of young children as learners
1. Have undeveloped intrinsic motivation; respond to reinforcement
and behavior modification
2. Have limited attention and concentration spans; a variety of
activities are required to maintain attention
3. Have undeveloped problem-solving skills
4. Have a weak memory; repetition is required
5. Have limited life and learning experience; tend to accept information
being presented at face value
6. Use concrete reasoning; are unable to understand abstract concepts;
learning is better with hands-on and visual activities related to the
tangible, such as demonstration and practice
7. Very young children are unable to read and write; lessons must use
pictures
8. Have varied interests at different ages, based on their physical and
emotional development and life experiences
9. Motivations are current interests and needs (e.g., young children’s
need for approval by teacher; adolescents’ need for peer acceptance)
10. Respond well to oral health education geared to current level of
development (e.g., tooth eruption, orthodontic treatment)
11. Do not possess fine motor coordination skills; recommended oral
hygiene methods must be age appropriate (e.g., method of brushing,
flossing)
12. Possess a social nature and interest in sharing stories when asked
questions

1740
 13. Show lack of self-control; classroom management is required to
control behavior

Oral Health Education Plan Development

A. Health education plan (lesson plan)—organization of topics, goals,
objectives, learning experiences, and evaluation plan in relation to a
central theme or problem; provides educators with an organized
approach, which is vital in dynamic teaching for both student and
teacher; includes all the elements of a program plan previously described
B. Assessment of needs—learner needs, oral health status, interests, and
developmental level; teaching environment; availability of media;
resources available to support the lesson; previous oral health learning
experiences and current oral health knowledge and behavior
C. Prioritization of the learning needs of the audience to determine the
purpose, aim, and rationale of the lesson
D. Planning the lesson
1. Goals—one or two recommended; general, broad statements of
direction for the lesson
2. Instructional objectives—statement that describes the intended
outcome, aim, or product of instruction; what a successful learner is
able to do at the end of instruction; expected behavior; should be
precise and measurable; useful for guiding instruction and
evaluation; components of an effective, precise instructional
objective include:
a. Performance—what a learner is expected to be able to do or
demonstrate when the instructional event ends, using a verb
that denotes an observable behavior or action; for example, “The
client will demonstrate the modified Bass toothbrushing
technique”
b. Conditions—the important conditions (if any) under which the
performance is to occur; for example, “Given a soft-bristled
toothbrush, the client will demonstrate the modified Bass
toothbrushing technique on all tooth surfaces and on the
tongue”
c. Criterion—the criterion of acceptable performance; a
description of how well the learner must perform to be
considered acceptable; for example, “Given a soft-bristled
toothbrush, the client will demonstrate the modified Bass
toothbrushing technique and remove all clinically visible plaque
biofilm, as measured by the Plaque Index”

1741
 3. Identifying teaching strategies and learning experiences—should be
based on the objectives and on the principles of learning and
strategy selection previously explained
4. Identifying materials and media needed based on criteria described
earlier; identifying resources for materials; allowing preparation
time
5. Identifying and arranging for equipment required to present lesson
6. Planning follow-up activities and materials, such as handouts to
send home to parents or caregivers
E. Implementing the lesson
1. Introduction, main activity or activities, closure or conclusion, and
follow-up activities
2. Considering the learning needs of the audience during presentation
3. Preparing and practicing beforehand to control anxiety
4. Flexibility and adjustment of plans as needed
F. Evaluation of learning outcomes—should relate to objectives and to
pretest and assessment procedures to provide basis for comparison; used
for changes in future lessons and self-development as an educator

Health Education and Promotion Programs in the

School Setting
A. The program should focus on a combination of strategies and efforts
to reach parents, students, school personnel, and the community
B. The programs in school settings have the potential to reach significant
numbers of participants
C. The school environment supports learning and reinforcement, ideally
through an integrated curriculum, not isolated instances
D. The school program should be comprehensive, including efforts
directed to improving the environment, providing education, and
providing or promoting services (e.g., referrals, school-based sealant and
fluoride programs)
E. Teachers can serve as role models
F. Success is enhanced by identifying responsible individual(s) (decision
makers); involving parents for reinforcement at home; using community
resources and personnel (e.g., agencies, other oral health care
professionals); and evaluating and revising the program, when
appropriate
G. The primary role of the dental hygienist is to be a resource, train
teachers, work with the various groups to enhance the overall program,
and manage and support the program, not to provide all the classroom

1742
instruction

1743
Program evaluation
General Principles
A. Program evaluation is a key element of community oral health
programs; should take place at all stages; consists of both formative and
summative evaluation
1. Formative evaluation—ongoing evaluation during the program to
assess processes; can lead to revisions to improve program success
2. Summative evaluation—evaluation of outcomes based on program
objectives; provides comparison to needs assessment (baseline) data
to determine success of the program
B. Program evaluation is applied research; research methods are used
(see the earlier sections “Epidemiology and Research” and
“Measurement of Diseases and Conditions in Oral Epidemiology”)
C. Points to evaluate
1. Quality of program and personnel (formative)
2. Progress and effectiveness of activities—identify problems and
solutions to assist in revisions and modifications to meet goals and
objectives (formative)
3. Perceptions, attitudes, and participation of recipients of program
(formative)
4. Systematic and regular evaluation of goals and objectives by using
specific measurement instruments; outcomes assessment
(summative)
5. Health status indicators of recipients of program (summative)

Use of Statistics
A. Data—numbers collected from measurements or counts
1. Continuous data—numerical data capable of being any value along a
continuum (e.g., periodontal probe readings, blood pressure, time,
temperature); can be expressed meaningfully as a fraction
2. Discrete data—numerical variables or data that are counted only in
terms of whole numbers; for example, number of clients examined,
number of children who had teeth sealed, and number of children
with caries experience
3. Categorical data—division of data into categories with no numeric
representation (e.g., SES, ethnic group membership, gender, school
attended, grade in school)
4. Dichotomous data—categorical variable with only two groups (e.g.,
male/female, yes/no, bleeding/no bleeding, pass/fail)

1744
B. Scales of measurement—data fall in one of four scales:
1. Nominal scale—observations belong to mutually exclusive classes or
categories; for example, Republicans/Democrats,
smokers/nonsmokers, normal/abnormal, place of residence, gender,
and ethnic group membership
2. Ordinal scale—classes or categories that have ranking of
characteristics in some empirical order; for example, class rankings
of high school graduates; Likert scales such as strongly disagree,
disagree, agree, and strongly agree for patient satisfaction and other
measures; most dental indices; periodontal classification; and SES
3. Interval scale—measurement scale characterized by equal intervals
along the scale; has no absolute zero, such as a Fahrenheit
thermometer; not useful in oral health research
4. Ratio scale—measurement scale characterized by equal intervals
along the scale and the presence of an absolute zero, such as age,
weight, height, DMF, number of sealants, and test scores; most
dental indices are treated as ratio data
C. Statistics—science that describes, summarizes, analyzes, and
interprets numerical data
1. Statistic—numerical characteristic of a sample derived from the data
collected
2. Parameter—numerical characteristic of a population
D. Descriptive statistics—statistics used numerically to describe and
summarize data collected (Box 20-11)

Box 20-11
Common Statistic s in Community Oral Health
Descriptive Statistics
Descriptive statistics are used to describe data.
Mean—the arithmetic average; the sum of the values divided by the
number of items
• Incorporates the value of each score
• Affected by extreme scores
• Used with interval or ratio data
Median—midpoint of a distribution, with 50% of the scores falling above
it and 50% below it; scores of distribution are arranged in either
ascending or descending order to locate the midpoint
• When the total number of scores is odd, the median is the middle score
• When the total number of scores is even, the two middle scores are

1745
 added, then divided by 2
• Median can be a decimal
• Not affected by extreme scores
• Can be used with ordinal data; can be used with ratio data to avoid
effect of extreme scores
Mode—the most frequently occurring score in a distribution
• Distribution may be unimodal, bimodal, multi-modal, or have no mode
• Can be used with nominal data
Range—the spread between the highest and the lowest scores in a
distribution
• Easily determined
• Somewhat unreliable because it is determined by only two scores of the
distribution
• Can be used with ordinal and higher data
Standard deviation (SD)—the positive square root of the variance
• The greater the dispersion or spread of scores around the mean of the
distribution, the higher is the value of the SD and variance
• A small SD indicates that the distribution of scores is clustered closely
around the mean; a large SD indicates that scores are dispersed widely
around the mean

Correlation Statistics
Correlation statistics are used to associate variables and determine risk
in analytic studies; correlation does not demonstrate causality.
• Correlation coefficient, r, ranging from + 1.0 to − 1.0; the sign indicates
the direction of the correlation, and the number indicates the strength
of the correlation
• Interpretation of correlation coefficient
1. Direction of relationship
• Positive—value of one variable increases as the value of the second
also increases (e.g., presence of plaque biofilm and gingivitis);
expressed as a positive number
• Negative—inverse relationship between two variables; as the value
of one increases, the other decreases, and vice versa (e.g., fluoride
exposure and dental caries); expressed as a negative number
2. Strength, regardless of direction of relationship
• Very high: r = 0.9 to 1.0 (+ or −)
• High: r = 0.70 to 0.89 (+ or −)
• Moderate: r = 0.50 to 0.69 (+ or −)
• Weak: r = 0.26 to 0.49 (+ or −)
• Little if any: r = 0 to 0.25 (+ or −)

1746
Inferential Statistics
Inferential statistics are used to test hypotheses, make inferences, and
demonstrate causality.

Parametric Inferential Statistics

• The t test—determines if a statistically significant difference exists
between two mean scores
• The t test for independent samples—data are from two sample groups
drawn independently from a population (two independent groups);
commonly known as Student’s t test
• The t test for dependent samples—data are from two samples that are
related (two groups that are matched for relevant variables or pretest
and posttest from one group); also known as t test for correlated samples
and paired t test; more sensitive than the t test for independent samples
because groups are paired, eliminating a possible source of variance
• Analysis of variance (ANOVA)—used to analyze differences among
three or more mean scores; used to examine the effects of two or more
independent variables simultaneously within the same research design
and to determine interactions among the variables in multiple sample
groups
F ratio—value that results when ANOVA is computed
Result communicates if a difference exists somewhere among the
mean scores; follow-up statistics are used to determine exactly where
the difference lies
Variations of ANOVA include ANCOVA (analysis of covariance) to
control for extraneous variables in a study design and MANOVA
(multi-variate analysis of variance), which is used when multiple
dependent variables are measured

Nonparametric Inferential Statistics

Chi-square test—used to determine if a statistically significant difference
exists between frequencies of data (versus comparing mean scores as is
done with parametrics); used with nominal data from two or more
distributions with more than 5 scores in each one; has different
versions for special applications
• One version is used with a single distribution of data to determine
whether or not a significant difference exists between the observed
number of cases within designated categories and the expected
number of cases within designated categories according to the
hypothesis (goodness of fit)

1747
 • Another version is used with two data sets to test the differences in
the distributions of data (versus the differences in the mean scores)
• Another version is used to test the statistical significance of a
correlation coefficient result
Other similar nonparametric statistics exist to test differences of data
distributions that represent ordinal data, come from groups with more
than 5 in each one, come from more than two groups, or a combination
Data from Beatty CF, Beatty CE: Biostatistics. In Nathe CN: Dental public health and research, ed 4,
Upper Saddle River, NJ, 2015, Pearson.

1. Measures of central tendency—used to describe what is typical (the

midpoint) in the sample group based on the data gathered (e.g., mean,
median, and mode)
2. Measures of dispersion—used to describe variability of scores in a
distribution (e.g., range and standard deviation)
E. Correlation statistics—statistical measure for determining the strength
of the linear relationship between two or more variables; used to
associate variables and determine risk in analytic studies; correlation
does not demonstrate causality (Box 20-11)
F. Summary presentation of descriptive and correlation statistics
1. Frequency distribution table—table that summarizes the frequencies
of data in the distribution; data are entered into a frequency
distribution table before creating a graph
2. Bar graph (or bar chart)—two-dimensional diagram used pictorially
to display data that are discrete in nature, regardless of scale of
measurement; bars do not touch
3. Histogram—type of bar graph used to represent interval-scaled or
ratio-scaled variables that are continuous in nature; bars touch each
other
4. Frequency polygon—line graph used to represent data that are
continuous in nature; a histogram and a frequency polygon can be
used to represent the same data; a frequency polygon can be easier
to read than a histogram when more than one distribution is
presented for comparison
5. Polygon—a line graph that does not represent frequency data; for
example, a line graph showing the progression of a Plaque Index
score over time in a repeated-measures experimental study (this
would also be called a time series graph)
6. Pie graph (or pie chart)—used to display parts of a whole
7. Scattergram (or scatter plot)—a graph in which scores are plotted to

1748
 show the relationship or association of two variables; visually shows
the relationship represented by a correlation statistic
8. Advantages of tables and graphs—they provide a neat and organized
way to present data, facilitate understanding and analysis of data at a
glance, expedite review of data, enable comparisons, and ease recall
of data
G. Distributions of data (Fig. 20-7)

FIG 20-7 Distribution curves. (From Beatty CF: Community oral health practice for the
dental hygienist, ed 4, St Louis, 2017, Elsevier Saunders.)

1. Normal (bell) curve—symmetrical distribution of scores in which

the mean, median, and mode have the same value, and the scores fall
within a standard relationship to the mean (standard deviation, SD)
a. 68% of the scores fall between + 1 and − 1 SD of the mean
b. 95% of the scores fall between + 2 and − 2 SD of the mean

1749
 c. 99% of the scores fall between + 3 and − 3 SD of the mean
2. Skewed distribution—one in which the distribution is asymmetrical
a. Positive skew—mean has a higher value than the median and
mode; the bulk of the scores are at the lower end of the
distribution, and the tail of the curve is at the higher end
b. Negative skew—mean has a lower value than the median and
mode; the bulk of the scores are at the higher end of the
distribution, and the tail of the curve is at the lower end
H. Inferential statistics—that branch of statistics used to infer research
findings from the sample to the general population from whom the
sample was taken; used to test hypotheses, generalize results to a larger
population of interest, and provide evidence of causality (see Box 20-11)
1. Parametric statistics—inferential statistical procedures that require
the following assumptions about the population parameters:
a. Data are interval or ratio scaled; dental indices are treated as
ratio scaled even though many are ordinal scaled
b. Population from which the data are taken is normally
distributed (bell curve)
c. Sample is large (i.e., n ≥ 30) and randomized
2. Nonparametric statistics—inferential statistical procedures used
when the population parameters do not meet the assumptions
required for parametric statistics
a. Required if data are nominal or ordinal in nature
b. Population from whom the sample is drawn does not have a
normal distribution (has a skewed curve), or distribution is
unknown
c. Required with continuous data if sample size is small or skewed
I. Hypothesis testing
1. Definition—a formal decision-making process of testing a
hypothesis using statistical significance and inference, followed by
interpreting the statistical results
2. Null hypothesis is tested statistically to make the statistical decision
a. Retaining the null hypothesis is equivalent to rejecting the
research or alternative hypothesis
b. Rejection of the null hypothesis is equivalent to the acceptance
of the research or alternative hypothesis
c. Failure to accept (rejecting) the null hypothesis implies
accepting the research or alternative hypothesis
3. Statistical significance—according to the probability established by
the level of significance, the obtained result is less likely to be a
chance occurrence and more likely the result of the independent

1750
 variable
4. Probability level (p value)—researcher ’s acceptable odds for
determining the operation of chance factors in producing the
obtained research result; the cutoff point used to reject or accept the
null hypothesis; also known as significance level and alpha value
a. Small p values indicate rare chance occurrences that lead to the
rejection of the null hypothesis and provide more confidence
that the statistical decision is correct
b. Large p values indicate that chance occurrences are more likely
to account for the result
c. Maximum p value to reject the null hypothesis in oral health
research is typically 0.05; p values of 0.01 and 0.001 indicate
greater statistical significance
(1) If the probability is 0.05 or less, the results obtained are
reported as statistically significant
(2) A probability result of greater than 0.05 (p > 0.05) indicates
results are not statistically significant
5. Inferential statistics are used to test the hypothesis
6. Test statistics used to make the statistical decision depend on the
size of the sample, the number of samples, the type of data, and
other factors (see assumptions in the previous discussion of
inferential statistics and Box 20-11)
7. Because statistical decision making is based on probability (chance),
errors may occur (Fig. 20-8)

FIG 20-8 Type I and type II statistical errors.

a. Type I error—based on statistical results, the researcher rejects

the null hypothesis and concludes that a statistically significant
difference exists when, in fact, no true difference is present;
rejecting a null hypothesis that is true
b. Type II error—the researcher concludes that no statistically
significant difference exists and accepts the null hypothesis
when, in fact, a significant difference does exist; accepting a null

1751
 hypothesis that is false
c. The p value is set to control the acceptable rate of error, which
depends on the clinical importance or significance of the
question being researched
(1) Type I errors lead to unwarranted change; for example, a
client could receive ineffective treatment
(2) Type II errors maintain status quo; for example, a client
could miss out on treatment that could have been helpful or
even lifesaving
d. The potential for error is the reason why multiple studies are
critical for evidence-based decision making
J. Clinical significance
1. Statistical decision making is not the sole means by which research
findings are interpreted and applied; findings may have statistical
significance without having clinical significance
2. Practical implications of research may or may not be inherent in
research results; statistical significance does not necessarily indicate
that results are important or meaningful; for example, the free
gingival margin may have a statistically significant resorption of
1.0 mm, while the pocket depth is still 6.0 mm, so the resorption may
not be meaningful in the overall periodontal outcome

Evaluating Professional Literature

A. Professional responsibility includes keeping current with new
developments for evidence-informed decision making
B. Reviewing the professional literature is important for the
contemporary dental hygienist in all roles
1. It is necessary to review and study the literature before and during
community programming
2. It provides an impetus and evidence base for various types of
community activities
3. Journal articles, particularly randomized clinical trials, systematic
reviews, and meta-analyses, serve as a source of current information
for evidence-informed decision making
C. Reviewing the professional literature is a valuable means of
continuing education
D. Scientific writing should be comprehensible for the average reader
who is knowledgeable about the general area
E. Professional literature should be evaluated to ascertain the validity of
results (Box 20-12)

1752
Box 20-12
Criteria for Evaluating the Professional
Literature
1. Overall description of the article
• Concise and descriptive title
• Descriptive abstract
2. Reputable and refereed journal
• Editorial review board in place
• Peer review of articles before publication
• Affiliation with a learned society, professional group, specialty group,
or reputable scientific publisher
• Not a “popular ” magazine sponsored by a cause or published by a
commercial firm
• Concisely written articles, using a scientific style
3. Currency of data published
• Represents current knowledge, not outdated by more recent research
• General guide of 5 years
4. Qualified author
• Appropriate credentials to have knowledge of the topic
• Expertise in a particular area supported by current or past position
• Satisfactory reputation for well-conducted research
• No affiliation with a commercial firm if the report is of product
research
5. Funding of research
• Evidence of finances and facilities to support the research if the
article reports research results
• No conflict of interest represented
6. References
• Comprehensive, accurate, and reputable
• Appropriate number of current references, according to the topic
(older references may be indicated for historical purposes or because
they are considered classic)
7. Clear, accurate, and complete description of the research problem
• Clear purposes of the study
• Inclusion of a thorough review of the literature
• Adequate operational definitions of important terms and concepts
• Adequate and clear statement of the hypotheses or objectives that
follow directly from the problem statement

Methods

1753
1. Adequate description of the research design
2. Appropriate for the type of study (descriptive, analytic, and
experimental studies require different methods)
3. Adequate description of the characteristics of the population sampled
and an outline of the allocation of groups if a clinical trial
4. Adequate description of the sampling techniques
5. Lack of bias in the selection or assignment of objects or persons in the
sample
6. Control of variables that might influence the results
7. Evidence of comparability of experimental and control groups
8. Evidence of control of bias
9. Discussion of the limitations of the design
10. Use of tests and instruments that reasonably measure the factors
under study
• Use of valid and reliable measures (evidence of reliability is
provided)
• Control of conditions in which measurements are made
• Control and reporting of the reliability of the examiners
• Appropriate duration of the study
11. Data analysis
• Inclusion of all the factors needed to test the hypotheses or achieve
the objectives
• Use of appropriate statistical tests
• Description of general-purpose computer programs used for data
analysis
• Presentation of statistical results of hypotheses testing
• Clear presentation of findings
• Clear, easy-to-understand, and titled data tables and figures
• Straightforward presentation of data
12. Discussion to highlight significant issues from the research
• Interpretation of results
• Clear discussion of the importance or clinical significance of the
findings
• Explanation of the strengths and limitations of the study
• Report of any treatment or study complications and adverse effects
• Discussion of the relationship of the results to previous studies
• Discussion of the implications for practice or the profession
13. Conclusions
• Clear
• Supported by methods and findings

1754
Data from Beatty CF: Community oral health practice for the dental hygienist, ed 4, St Louis, 2017,
Elsevier Saunders; and Nathe CN: Dental public health and research, ed 4, Upper Saddle River, NJ,
2015, Pearson.

1755
Provision of oral health care
Diverse Modes of Dental Practice in the United
States
A. Dental care is delivered via a complex, fragmented system of care that
consists of diverse modes of dental practice and multiple sources of
funding (Table 20-18)

Table 20-18
Modes of Dental Practice

1756
1757
B. Healthy People 2020 objectives (see Table 20-2) address the need for
changes to the public health infrastructure to increase utilization

Oral Health Care Personnel Workforce

A. Types—dentist, dental assistant, dental hygienist, expanded-function
dental hygienists and assistants, dental laboratory technician, denturist,
other emerging midlevel practitioners in some states such as the dental
therapist or dental therapist/hygienist
B. Supply and distribution of dentists
1. Supply is traditionally measured with a dentist-to-population ratio—
not always an accurate reflection of supply because of location,
population involved, community need, demand for dental services,
and trends in use of other oral health care personnel to provide
dental treatment services
2. The number of active dentists began to decline in 2000, has
continued, and is projected to continue through 2020, influenced by
retirement patterns and smaller annual number of graduates9
3. The American Dental Association (ADA) estimates that the national
supply of dental services will increase as a result of a significant

1758
 growth in dental productivity because of increased employment of
allied dental professionals9
4. The dental profession has recognized the need to develop programs
to resolve the problem of uneven distribution of dentists, which
exists for various reasons:
a. Dentists have freedom to choose their practice location and tend
to locate their practices in areas of economic opportunity, high
demand for services, and desirable environments; most are
drawn to suburban areas rather than rural and urban areas
b. Location of dental schools provides an abundant number of
dentists in some areas and few in other areas; not all states have
a dental school
c. Portability of license from state to state is needed to be able to
relocate easily in response to geographic population shifts that
result in changes in areas of high demand; a national dental
licensing examination would provide greater portability
5. Inadequate supply and maldistribution of dental personnel results
in dental health professions shortage areas (DHPSAs, or DHSAs), as
defined by the federal government
a. Based on provider-to-population ratio (dentist/population ratio
of 1:5,000);10access to care according to distance, time, and
incomes at poverty level are also considered
b. In 2014, more than 49 million people were living in
approximately 4900 DHPSAs, and the number of practitioners
needed to achieve the recommended dentist/population ratio
was over 7300;10 number of DHPSAs, number of people living in
DHPSAs, and number of dentists required to remedy the
shortage areas have increased steadily over the past decade;11
federal incentives are available to attract dentists and dental
hygienists to these areas
6. The dental profession has recognized the need to increase
underrepresented minorities in the oral health care professions
a. Women are underrepresented in the profession; the number of
women graduating from dental schools has gradually increased;
currently approximately 50% of dental school students are
female;12 there is a need to evaluate the effect of this increasing
shift of gender on the values, caring quality, patient orientation,
and practice models of dentistry, as well as the number and
distribution needed to meet the needs of the population
b. A continuing need exists to increase the diversity of the dental
profession

1759
c. Fig. 20-9 depicts current racial/ethnic distribution of dentists in
the United States

FIG 20-9 Racial/ethnic representation of dentists in the United

States, 2010: actual and projected to 2050. (Data from American
Dental Education Association: Dean’s briefing book, 2013.
http://www.adea.org/uploadedFiles/ADEA/Content_Conversion_Final/deansbriefing/ADEA_Deans_BB_20

d. Although Healthy People 2010 targets were exceeded for

representation of the Asian or Pacific Islander population in
dentistry, representation for the black non-Hispanic population
moved away from the target, and targets were not met for other
minority groups in the dental profession3
e. The Indian Health Service (IHS) and the Health Resources and
Services Administration (HRSA) programs support
diversification of the health care professions workforce through
scholarships, repayment programs, and other incentives

1760
 f. The goal is to have diversity of oral health care personnel that is
proportionate to the diversity of the population; projected data
indicate movement toward this goal (Fig. 20-9)
C. Dental school enrollment
1. At 65 U.S. dental schools, located in 38 states, the Commonwealth of
Puerto Rico, and the District of Columbia, representing a very slight
increase over the past 10 years13
2. With 12,001 dental school applicants in 2010; current trend is an
increase in the number of applicants12 and the opening of new dental
schools14
D. Supply of dental hygiene personnel
1. About 192,800 dental hygienists were employed in 2012, with a
projected increase of 33% for 2012 to 202215
2. About 335 accredited dental hygiene programs in the United States
in 2014 offered a certificate, associate’s or bachelor ’s degree,
reflecting a 65.8% increase in number of programs since 1990; 7097
dental hygienists graduated in 2012; there are 55 degree completion
programs and 22 dental hygiene master ’s programs16,17
3. More dental hygienists than dentists have graduated every year since
1991, and the difference has increased each year; projections are that
this trend will continue17
4. States will continue to expand the scope of dental hygiene practice;
practice settings will grow and less supervision will be required in
order to meet the increasing demand for greater access to dental
care at a more affordable cost
5. As an organized profession, dental hygiene has sought to help meet
the oral health care needs of the population and improve access to
care by:
a. Promoting higher levels of education within dental hygiene,
such as baccalaureate, master ’s, and doctoral degree preparation
b. Establishing the dental hygienist as a primary care provider
c. Seeking direct reimbursement of dental hygienists and midlevel
practitioners; in 2013, 15 states recognized and reimbursed
dental hygienists as Medicaid providers16
d. Developing and supporting the advancement of new,
nontraditional practice models, such as collaborative and
independent practice as well as dental hygiene–based midlevel
providers, to improve access to care for underserved
populations and better meet the needs of community oral
health care practice
e. Creating and developing the advanced dental hygiene

1761
practitioner model
(1) The concept of midlevel providers in dentistry has become
a reality in the United States, possibly marking the
beginning of a new era in dentistry in which high-quality,
cost-effective dental care can be provided for currently
underserved groups in the population18 (Table 20-19)

Table 20-19
Nontraditional Oral Health Care Personnel and Midlevel Providers

Data from Academy of General Dentistry: Definitions of mid-level oral health care providers,
http://www.agd.org/files/webuser/website/advocacy/definitionsmidlevelproviders.pdf; American
Dental Association (ADA): About community dental health coordinators, 2014,
http://www.ada.org/en/public-programs/action-for-dental-health/community-dental-health-
coordinators; American Dental Hygienists Association: ADHA supports increased access to care,
use of dental hygienists and midlevel providers to help deliver dental services, July 1, 2014,
http://www.adha.org/resources-
docs/ADHA_Supports_Increased_Access_to_Care_Use_of_Dental_Hygienists_and_Mid_level_Providers.pdf
ADHA: Direct access states, June 2014, https://www.adha.org/resources-
docs/7513_Direct_Access_to_Care_from_DH.pdf; ADHA: The benefits of dental hygiene-based
oral health provider models, July 2014, http://www.adha.org/resources-
docs/75112_Hygiene_Based_Workforce_Models.pdf; American Student Dental Association:
Midlevel providers, 2014, http://www.asdanet.org/midlevel-providers.aspx; Emmerling H, Standley
E: The mid-level, RDH, June 1, 2011, http://www.rdhmag.com/articles/print/volume-31/issue-
6/features/the-mid-level.html; and Minnesota Board of Dentistry: Advanced dental therapist scope of
practice.
http://www.dentalboard.state.mn.us/Portals/3/Licensing/Dental%20Therapist/ADTSCOPE.pdf;
Dental therapists, 2014,

1762
 http://www.dentalboard.state.mn.us/Licensing/ProcessingandApplications/DentalTherapistAdvDentalTherapist/t
University of Minnesota School of Dentistry: Dental therapy—a new profession, February 2014,
http://www.dentistry.umn.edu/programs-admissions/dental-therapy/index.htm; University of
Washington School of Medicine: Dentex dental health aide therapist program,
http://depts.washington.edu/dentexak/; and Wides C, Bates T, Mertz E: Registered dental hygienists
in alternative practice in California, 2009 descriptive report, Center for the Health Professions,
University of California San Francisco, December 2011.
http://www.futurehealth.ucsf.edu/Content/11660/2011_12_Registered_Dental_Hygienists_In_Alternative_Practic
BS, Bachelor of science; MS, master of science.
* Dentistry based dental therapist/midlevel provider.

† Dental hygiene based dental therapist/midlevel provider.

(2) Three states have now authorized dental therapists who

function as midlevel providers;18 in 2013, eight additional
states considered a variety of related proposals,16 and 15
states are currently considering legislation to allow
midlevel providers18
f. Currently, 37 states in the United States allow dental hygienists
to provide direct care to patients in at least one practice setting
in the community without a dentist present, many of whom
were authorized within the last 10 years; many of these states
have collaborative dental hygiene practice models under various
names that allow for unsupervised practice of dental hygiene19
(Table 20-19)
g. Midlevel providers and other alternative practice models are
able to increase access to care cost-effectively for population
groups who do not have access to the traditional dental office, as
well as expand access to dental care in DHSAs, especially in
rural areas18
h. Some midlevel providers are dentistry based, whereas others
are dental hygiene based; ADHA promotes the value of the
dental hygiene–based model to build on the foundation of
dental hygiene education and practice experience20
i. More than 50 countries, including Canada, New Zealand,
Australia, and the United Kingdom, use dental therapists16
j. Workforce issues should continue to be analyzed and
adjustments made on the basis of retirement patterns of
practicing dentists, availability of oral health care personnel,
productivity improvement, population and economic growth,
demand for and financing of dental care, and new models of
midlevel oral health care practitioners
E. Gender and racial–ethnic group representation among dental
hygienists
1. Primarily women—95.8% of students in 2012 were female17
2. Inadequate racial-ethnic group representation in the dental hygiene

1763
profession; 72.5% enrolled in 2012 were non-Hispanic white17

1764
Financing oral health care
A. Oral health care financing in the United States is complex because of
the dual involvement of the corporate sector and the public sector, as
well as the presence of varied and multiple mechanisms of payment,
sources of payment, types of insurance plans, and providers of insurance
plans
B. This pluralistic system results in greater emphasis on individual
responsibility for oral health care
C. The Patient Protection and Affordable Care Act (ACA) expanded
dental coverage for children through Medicaid and state exchanges; some
believe that the new benefits may not be sufficiently comprehensive or
affordable21
D. Overall spending for dental services and out-of-pocket spending have
continued to increase22 and are forecasted to increase even more over the
next 10 years23

Mechanisms of Payment for Dental Care

A. Payment by the individual or fee-for-service—two-party system
(provider and client); less common today as third-party payment
increases
B. Third-party payment—also called insurance
1. Payment for health care services by some agency other than the
beneficiary (client or patient) of those services (e.g., insurance
company, employer, government agency); designed to improve
access to care and increase use of care
2. The dentist and the client are the first and second parties; the
administrator of the finances is the third party (also known as the
carrier, insurer, underwriter, or administrative agent) and may collect
premiums, assume the financial risk, pay claims, and provide
administrative services
3. Third-party plans can be private (a private insurance company or
employer) or public (government program such as Medicaid,
Medicare, or CHIP)
4. The purchaser of a private plan can be an organized private group
such as a union or employer or a government agency
5. Reimbursement for insurance plans is done by a variety of
mechanisms (Table 20-20)

1765
 Table 20-20
Mechanisms of Payment for Oral Health Care

6. Mechanisms are used by third-party carriers to control costs by

discouraging overuse and protecting the third-party payer ’s ability to
continue in business (Table 20-20)
C. Different types of insurance (benefits) plans
1. Although frequently referred to as “dental insurance,” benefits plan
is a more accurate term because, unlike medical insurance, it does
not truly represent the concept of insurance; specific types of dental
benefits plans fall into the two categories, fee-for-service and
managed care (Table 20-21)

1766
 Table 20-21
Dental Insurance (Benefits) Plans

Data from American Dental Association: The advantages of offering a dental benefits plan, 2014.
http://www.ada.org/en/public-programs/dental-benefit-information-for-employers/insurance-and-financing.

2. Fee-for-service—traditional system that provides freedom-of-choice

arrangements under which clients are not limited in their selection
of providers (called open panel), control of treatment decisions are
maintained by the provider and beneficiary, and the provider is paid
for each service rendered according to the fees established by the
provider24
3. Managed care—cost-containment systems that restrict the type,
level, and frequency of treatment; limit the client’s freedom of choice
to select a provider with financial benefits to use only certain
providers; and control the level of reimbursement for services24

1767
 a. Characterized by a comprehensive set of health care services,
selected providers (called closed panel), and financial incentives
to use selected providers
b. Typified by internal programs to monitor the amount and
quality of services provided (i.e., quality assurance)
c. Providers receive compensation in a predetermined form, such
as fixed amount per program member or fixed amount per
service
d. Results from increased costs of health care, the need to control
costs, and the need to improve access to care for a large segment
of the population without traditional dental insurance (benefits)
e. Views on managed care vary
(1) Managed dental care has not yet evolved to the extent of
managed medical care; dental professional groups have
expressed concern about closed-panel third-party
approaches because clients are denied freedom of choice of
dentists24
(2) An argument against the closed-panel approach relates to
the quality of care provided, although charges of poor
quality have not been substantiated
(3) Publically funded insurance is often administered through
managed care programs (Table 20-21)
(4) Managed care is expected to increase because of the need
to control the cost of dental care nationwide and greater
governmental involvement in financing dental care; dental
hygienists may contribute significantly in a managed care
model because of the emphasis on prevention and on cost
savings

Providers of Dental Benefits Plans

A. The variety of providers of dental benefits plans adds to the
complexity of the pluralistic system of payment for dental care in the
United States
B. The providers that offer different types of plans are explained in Table
20-21

Public Financing of Dental Care

A. Primarily addresses the needs of poor persons
1. The percentage of persons living in poverty in 2013 was 14.5%, down

1768
 slightly for the first time in 7 years; the poverty rate of children
under age 18 years is considerably higher than other age groups;
there is less poverty among the non-Hispanic white population, and
rates vary by geographic region and metropolitan status25
2. The significance of poverty rates in the population is the that low-
SES groups experience a greater number of factors that are
associated with poor health (determinants of health) and generally
have poorer oral health status
B. Problems with public financing
1. Fragmented; difficult to find and utilize resources
2. Medicaid has been plagued by changing eligibility requirements,
limitation of services, low allowable fees paid, delays in payment for
services, and dentists’ refusal to treat Medicaid clients
3. Poor enrollment of dentists as providers—reasons given include low
reimbursement rates, missed appointments by Medicaid clients,
difficult treatment issues, too much bureaucratic paperwork,
reluctance to have patients from low-SES groups in the reception
room with other patients, and preference to provide charity care
rather than Medicaid services
4. Many children who qualify are not enrolled in Medicaid/CHIP
5. Large numbers of additional adults and children will be insured
with pubic insurance as a result of the ACA;26 overall quality of care
provided may be affected by the limitations of public insurance and
the increased burden placed on providers accepting publically
funded insurance programs
C. Strategies to address problems with public financing
1. Recent increases in the services allowed and fees reimbursed by
Medicaid
2. Recent public health department initiatives to increase the number
of Medicaid/CHIP dental providers
3. Development of midlevel providers to make available a workforce
who can provide care at a lower cost to society
D. Medicaid/CHIP—most public expenditures for dental care are from
Medicaid or CHIP (Table 20-22)

1769
Table 20-22
Public Funding of Oral Health Programs

1. In 2013, more than 28 million children were enrolled in Medicaid

and 5.7 million in CHIP, representing a reduction in the rate of
uninsured children; even so, over 7 million children remain
uninsured27

1770
 2. The number of Medicaid recipients is expected to grow as a result of
the ACA;27 access to dental coverage for Medicaid-eligible adults is
expected to decline because only about half of states offer dental
benefits to adults, and capacity will be compromised by the increase
in demand to serve children
3. Many children enrolled in the Medicaid/CHIP program do not
receive dental services, which is related to the need to improve
health literacy
E. Federal and state programs (Table 20-22)
F. Local programs
1. Funded through a variety of sources, including local health
department funds; federally funded programs; national, state, and
local foundations; faith-based organizations; and other local sources
of funding (Table 20-22)
2. Collaboration must occur among public health agencies,
nongovernmental organizations (NGOs), dental and dental hygiene
associations and educational programs, community agencies, and
volunteer groups to fund local community oral health care programs
G. Involvement of the federal government in health care financing has
increased steadily, especially since 1965
1. Dental care has continued to be a small part, at best
2. Demand for services for the low-income population has increased at
a time when available services are declining
3. The emergence of alternative health care plans as a result of the
ACA provide future promise of more public funding of dental care
4. It is expected that future oral health care financing will continue the
current varied and complex financing systems and pubic coverage
for a large proportion of the population, primarily poor persons

1771
Need for, demand for, and utilization of
dental services
A. Definition of terms (Table 20-23)

Table 20-23
Terminology Related to Utilization

Term Definition/Description
Demand Volume and types of health care services that an individual or population desires to
consume at some price level; measured by self-report surveys
Effective demand—desire for care and ability to obtain care (client or community has
access to care)
Potential demand—desire for care and inability to obtain care (client or community
lacks access to care)
Need Normative need—usually professional judgment about the amount and types of health
care services or medical care services required by an individual or community to attain
or maintain some standard level of health; normative need defined as professionally
determined; expressed in terms of a population or individual; includes specific needs
identified through individual or community-based clinical assessment procedures
Perceived need or felt need—defined as determined by the client or the community; can
differ from normative need; clinically, perceived need can be referred to as a chief
concern; measured with self-report surveys and interviews; health education is
required to help a client or community to adjust perceived need to match normative
need
Utilization Proportion of the population who use dental services over a period; volume and types
of services actually consumed; typically measured by dental attendance rates during
the year

B. Current dental care utilization

1. Measured as the proportion of persons who visit a health care
provider during a given year
2. Less than half of the population visit the dental office each year, and
this rate has remained relatively unchanged in the past decade (see
Table 20-2)
3. Two Healthy People 2020 objectives address the goal to increase
utilization:
a. Increase the use of the oral health care system by persons age 2
years and older
b. Increase the receipt of preventive dental services by low-income
children and adolescents
C. Dental public health officials support the inclusion of an oral health
indicator to increase the proportion of children, adolescents, and adults
who use the oral health care system each year28

1772
D. Emergency department use as a safety net for preventable dental
conditions has increased and is costly to hospitals and society29
E. Patterns of dental care utilization in this decade
1. Gender—females continue to have more dental visits than males3
2. Age—higher utilization in children than adults and older adults;
slight increase in utilization for children and older adults and a
decrease in adults30
3. Race and ethnicity—utilization varies for racial and ethnic groups,
mostly as a function of SES and culture; overall utilization is highest
for the non-Hispanic white population, but disparities are less for
utilization of preventive dental services by low-income children and
adolescents, who are more likely to have dental benefits than other
age groups3
a. Culture and SES are associated with health literacy, which
affects health decisions
b. Hispanic Americans and African Americans have lower
utilization rates than non-Hispanic whites3
c. Native Americans residing on reservations receive care
primarily through the IHS; traditionally, utilization has not been
high but varies by location
4. Geographic location—utilization of dental care is lower in rural
communities (both farm and nonfarm) than urban areas; suburban
populations are the most frequent users
5. Region—utilization rates differ among states

Factors That Influence Dental Care Utilization and

Oral Health Behaviors
A. Increase in public awareness of health and oral health, influenced by:
1. New technologies such as telehealth, bioinformatics, and virtual
reality
2. Databases specifying the human, animal, and microbial genomes
3. Strong emphasis on evidence-informed approaches to health care
delivery
B. A person’s level of adopting the wellness paradigm versus the health-
disease paradigm
C. Compliance with recommendations varies as a result of:
1. Beliefs—trust placed in a provider, health custom, or system of
health care because of acceptance that something is true; personal or
cultural beliefs about illness and wellness may then influence health
behaviors

1773
 2. Attitudes—patterns of mental views based on judgments of likes
and dislikes (about health care systems, providers, or utilization);
established because of prior experience
3. Values—the importance or worth placed on health care and health
practices; beliefs, attitudes, and values are all interrelated and affect
each other; although difficult, beliefs, attitudes, and values related to
oral health care and health practices can be changed over time
through development of rapport, communication, persuasion,
education, and new experiences
D. Access to dental insurance benefits—those with benefits are more
likely to utilize care, and the type of dental benefits is associated with
utilization
1. More than one third of the U.S. population do not have dental
benefits;29 coverage varies by age: more than twice as many children
have coverage than adults, and almost twice as many adults have
coverage than older adults;31 this represents an increase in coverage
for children, a decrease for adults, and the same coverage for older
adults compared to 10 years earlier31
2. Of those who have dental benefits, a greater percentage have private
dental coverage (almost 40% more children, five times more adults,
and one and one-half times more older adults) compared to public
insurance (e.g., Medicaid, CHIP); the number of children with public
insurance has increased and is expected to continue to increase
because of the ACA31
3. Utilization rates vary according to the type of insurance; rates are
almost twice as high for those with private insurance compared to
those with no insurance; those who have public insurance have
higher utilization than those with no insurance but considerably
lower use than those with private insurance30
4. Utilization for preventive visits increased in children over the last
decade because of an increase in the number of children enrolled in
Medicaid/CHIP32
5. Because the majority of dental benefits are private, a higher rate of
coverage is associated with higher income levels29
6. Dental insurance coverage influences the types of services used;
concerns exist about insurance companies and government agencies
dictating the care provided based on guidelines for payment
E. Barriers to dental care utilization—factors that block or prevent access
or ability to seek care or adopt healthy behaviors, thus reducing dental
utilization (i.e., low oral health literacy); must be addressed to increase
utilization within a population

1774
1. Barriers not related to cost
a. Lack of perceived need
b. Access to care difficult or impossible
c. Availability of providers (e.g., office hours, distribution of
personnel)
d. Types of services needed not being available because of
practitioners’ lack of skill or interest
e. Geographic isolation
f. Nonambulatory status (e.g., homebound or institutionalized)
g. Lack of public transportation
h. Values, attitudes, and beliefs
i. Unfavorable view of dental personnel—lack of cultural
sensitivity
2. Cost-related barriers
a. Services not affordable
b. Dental insurance benefits issues
(1) Coverage limited or not available (see previous discussion
on access)
(2) Continuing lack of providers available to individuals with
Medicaid/CHIP coverage29
(3) A narrow insurance company definition of “medically
necessary dental care” that sets limits on oral health care
services available to many insured clients, including
Medical Assistance in many states and especially older
adults with Medicare coverage
c. Lost wages resulting from time away from work; more critical
than the perceived need for services
3. Social and psychological barriers
a. Low value placed on dental care and facial appearance related to
the oral cavity
b. Unpleasant prior experience resulting in anxiety
c. Emotional factors such as fear of dental care
4. Cultural barriers
a. Language—client unable to find a provider who speaks his or
her language or a qualified interpreter
b. History and tradition—no importance given to dental care in
the client’s culture
c. Basic cultural beliefs about general and oral health, illness,
disease, and health care model
d. Failure to understand that a missed appointment can be costly
and disruptive

1775
 e. Difficulty in understanding the recommendations for dental
care or dietary changes
f. Few oral health care providers from minority groups—current
emphasis of the dental profession is to increase diversity in the
profession to enhance reaching minority population groups33
F. Most powerful predictors of dental care utilization are gender, SES
(income and education), dentate status, availability of dental benefits,
and overall economy

Shifts in Dental Care Utilization Patterns

A. Reported increase in examinations, preventive services, extractions,
implants, and esthetic dentistry and slight decline in dentures
1. Resulting partially from the changing demographics of the
population; persons over age 65 are the fastest-growing segment of
the U.S. population and have higher tooth retention rates, resulting
in their increased utilization of dental services; dentate individuals
are more likely than edentulous individuals to visit the dentist
2. Each generation demands a different variety of services; older
populations focus on restoration, periodontal treatment, prosthetics,
and control and treatment of root caries; middle-age persons need
some restorative and periodontal services or orthodontic services;
children need more primary prevention and orthodontic services
B. Prevention
1. General interest in prevention has caused an increase in preventive
dentistry services
2. The success of preventive interventions affects the types of future
services required
C. The American society’s interest in appearance and esthetics influences
demand for restorative options, cosmetic dentistry, orthodontics,
periodontal services, and dental implants
D. Increases in Medicaid/CHIP coverage for children have impacted the
shift of services
E. Increased utilization is expected as a result of the ACA
1. Dental coverage is being offered through subsidized health
insurance as a result of the ACA; expected to provide dental benefits
for 3 million children and nearly 18 million adults
2. Parents who want dental coverage for their children can buy dental
insurance–only policies
3. Young adults can stay on their parents’ health insurance, which
usually includes dental coverage, through age 26

1776
 4. Increase in public dental benefits resulting from the ACA will not
necessarily bring about a proportional increase in dental utilization30
F. Increase in utilization and reduction of disparities in oral health care
services require a multi-pronged approach
1. This includes oral health literacy of the population, improved access
to care for underserved populations, increased demand for
preventive oral health care, and reduction of barriers to oral health
care
2. Various interventions are needed that address all the core functions
of public health, assessment, policy development, and assurance,
using evidence-based approaches to health education, health
promotion, and provision of services

1777
Oral health care challenges affecting
community oral health practice
A. Continuing significant burden of oral diseases and disorders in the
U.S. population in the twenty-first century
1. Striking disparities in dental diseases and conditions, depending on
income levels; unprecedented changes in demography and patterns
of diseases and disorders
2. Effect of unintentional injuries on craniofacial tissues
3. Increases in systemic conditions that are associated with oral
diseases and that compromise oral health
4. Prevalence of tobacco-related oral diseases beginning in adolescence
5. Increased prevalence of oral cancer among young adults associated
with more common sexual practices in adolescents and young adults
6. An increase in caries prevalence and rates of untreated caries in
preschool-age children over the last decade
7. Significant loss of school and work hours each year because of
dental-related illnesses
8. Progressive and cumulative nature of oral diseases that become
more complex over time
B. Trends in oral health care delivery
1. Continuing trend of low dental attendance, although utilization
increases each year
2. Significant numbers of uninsured, low-SES children
3. Emphasis on increasing access to care for underserved population to
decrease oral health disparities
4. Changes in health care financing, including greater involvement of
public financing
5. Increase in the cost of oral health care
6. Inability of Medicaid and CHIP to fill the gaps in the provision of
dental care to poor children (fewer than 50% of children covered by
Medicaid and CHIP receive dental care)
7. Potential for increased utilization because of the aging population,
combined with changes in oral disease patterns and a decline in total
tooth loss in older adults
8. Continuing low rates of detecting oral cancer at early stages despite
an increase in the reported rates of annual examinations for oral
cancer
9. Broadening treatment options due to an emphasis on esthetics, adult
orthodontics, and dental implants

1778
 10. Changes in science, technology, and therapeutics; availability of
new biomaterials and biotechnology
11. Access to multiple information systems, including the Internet,
computer-assisted technology, telehealth care, and distance
education technology
12. Access to genetic information that will influence assessment of risk
factors and care planning
13. A philosophy of “best practices,” that is, determining which
treatment will work for which clients and under what circumstances;
an evidence-informed approach to dental and dental hygiene care
based on risk assessment
14. Paradigm shift to a treatment model that focuses on nonsurgical,
noninvasive, biologic, and pharmacologic interventions that are
guided by genetics and risk assessment, requiring a shift in oral
health care education, teaching, and outcome methodologies and a
greater focus on lifelong learning for oral health care personnel
15. Greater emphasis on the use of validated health education, health
promotion, and organizational theories for the individual and
community-based focus of oral health education and promotion for
preventive strategies
16. Coordination and collaboration of dental care and medical care
17. Greater orientation of the current society in general on oral disease
prevention
18. A need to focus on making those who do not seek care aware of
available dental care services, as well as implementing health
promotion strategies to change their oral health behaviors
19. A need to focus on the control and prevention of early childhood
caries, prevention of periodontal disease, control of tobacco use by
young people, and early detection of oral cancer
20. An increase in the complexity of the oral health care delivery
system because of the numerous, multifaceted arrangements for
delivering services and financing care, the changes in supply and
distribution of provider personnel, and the varying state laws
regarding scope of practice for oral health practitioners and midlevel
dental personnel
C. Redirected focus of dental personnel
1. Identify individuals currently not seeking care; for example, special
population groups and low-income and minority individuals
2. Increase access to and availability of care; for example, vary office
hours, offer care in nontraditional settings, improve payment and
financing mechanisms, and continue to explore the use of midlevel

1779
 practitioners
3. Develop creative solutions to meet increasing demands for dental
care personnel during a period of natural retirement of an older
dental profession, decreasing numbers of dentists, increasing
numbers and increased educational levels of dental hygienists, and
emergence of midlevel oral health care practitioners
4. Educate the public with an evidence-based focus on periodontal
disease, caries, oral cancer, tobacco cessation, systemic health–oral
health connection, and preventive interventions
5. Encourage professional lifelong learning to address current scientific
understanding of oral diseases, the changing oral health care needs
of the population, cultural competence and sensitivity, and
technologies to assess and treat populations
6. Develop an understanding within the oral health professions about
the demographic and ethnic changes in the population; cultivate
cultural sensitivity and competence, and apply strategies to improve
health literacy
7. Recognize dentistry’s changing role, with an emphasis on diagnostic
skills and evaluation
8. Accept dental hygienists’ changing role as more autonomous,
interdependent practitioners and as collaborators with other
members of the oral health care team as well as interdisciplinary
health care teams
9. Employ appropriate oral health care personnel; recognize the
capabilities of all team members to increase access to care, and be
aware that the current litigious society demands skilled practitioners
and high-quality services
10. Make changes in oral health care delivery and oral health
promotion that address the current status of oral health and
recommendations made by relevant national agency reports
11. Incorporate scientific evidence into all aspects of oral health care
practice
12. Use innovative collaborations and partnerships to promote oral
health and solve oral health problems
13. Focus on local community needs
14. Develop multiple skills to function in many roles, with
multidisciplinary approaches, and in diverse care delivery
environments
D. Recommendations to reduce oral health and oral health care
disparities
1. Through research, identify biomarkers that will facilitate early

1780
 detection and diagnosis of disease
2. Conduct epidemiologic studies of populations to establish baselines
for the incidence and prevalence of specific oral health problems and
to assist in tracking, reducing, or eliminating identified health
disparities
3. Conduct randomized controlled clinical trials to provide an evidence
base for the effective prevention and management of health
disparities
4. Carry out population-based research to understand the basis of
health disparities
5. Place a high priority on efforts to reduce widespread disparities in
oral health status and access to care
6. Increase measures to ensure oral health and access to care for
children by correcting inadequate government policies, such as
increasing Medicaid funding, implementing school sealant and
fluoride varnish programs, fluoridating water supplies, and
protecting the current status of fluoridated water supplies
7. Emphasize research and community oral health promotion
programs that will result in decreasing incidence and prevalence
rates of oral diseases and conditions for the entire population, as
well as special emphasis on populations at high risk for these
conditions
8. Restructure oral health care professional education programs to
meet the critical requirement of preparing a workforce that is
qualified in public health principles and practice
9. Focus on serving all Americans, regardless of SES, gender, and
ethnic or racial group representation, in the recruitment of students
and faculty, design and implementation of curricula, conduct of
research, provision of services, and participation in community
outreach

1781
Ethical and legal issues
See Box 20-13.

Box 20-13
Ethic al/Legal Issues Related to Community
Oral Health*
General Ethical Issues
• Application to community as the “client”
• Weighing the needs of the individual and the community
• Application of principles of social justice, common good, human
dignity, confidentiality, informed consent, nonmaleficence,
beneficence, integrity and totality, competence and capacity, autonomy,
and surrogacy to community oral health practice
• Encompassing professionalism, personal and professional ethics, and
the role of the profession and the educational system in the context of
the greater society

Ethical Practices in Action

• Focus by educational institutions to develop skilled, ethically and
socially sensitive graduates committed to their professional obligation
to community education and service
• Development and implementation of community-based models of
education and service that may include alumni participation, local
professional society participation, or both
• Commitment of educational institutions to incorporate community
outreach activities as part of the professional curriculum; emphasis on
a multi-disciplinary approach with other health care students and
providers
• Reinforcement of a lifelong commitment to the professional codes of
ethics (ADHA, ADA) that suggest an ethical obligation to community
oral health and well-being
• Development of strategies to develop cultural and linguistic
competence through lifelong learning
• Expansion of minority representation in the profession
• Education of students about the career opportunities in federal, state,
and local public health agencies and in other community organizations
that provide oral health care services to various population groups

1782
 (e.g., IHS, VA, local hospitals)
• Developing mechanisms that encourage and support a perspective of
social responsibility
• Identification and development of mechanisms, such as scholarships
and pay-back programs, to encourage minority and other health care
providers to serve underserved populations
• Increasing knowledge and awareness of community oral health issues,
best practices, skills, and resources by obtaining information from
journals, conferences, seminars, websites, and other means
• Promotion of evidence-informed decision making in relation to all
aspects of community oral health practice, including scientific bases
for disease control and prevention, as well as application of tested
theories of organization, health promotion, and health education
• Setting standards of ethical conduct that reflects social responsibility to
the community through oral health promotion, education, and practice
• Focusing of individual practitioners on social responsibility in their
dental hygiene practice
• Serving on advisory boards to community oral health programs
• Volunteering in community service activities sponsored by local
professional societies, educational institutions, and community
organizations
• Participating in, encouraging the development of, and organizing
community outreach events through private offices of employment
• Commitment to lifelong learning and evidence-based practice in
relation to community oral health practice as well as clinical practice
• Providing leadership in the solution of local public health problems to
improve the oral health of the local community

Legal Issues
• Effect of varying state laws related to scope of practice and supervision
on the ability of various personnel to participate fully in community
programs
• Emerging midlevel practitioners models of practice in some states;
resulting differences among states in the ability to address access-to-
care issues within the state and on a national level

* Refer to Chapter 22 for discussion of ethical principles.

Website Information and Resourc es

1783
Source Website Address Description
American Dental http://adha.org Data on the
Hygienists profession;
Association information
about careers
in public
health,
midlevel
providers, and
advocacy
Association of http://www.astdd.org Access to state
State and and territorial
Territorial Dental public health
Directors agencies of the
United States,
U.S.
territories,
and the
District of
Columbia;
engaged in
legislative,
scientific,
educational,
and
programmatic
issues and
activities on
behalf of
public health;
provides best
practices for
current,
effective
community
oral health
programming
HealthyPeople.gov http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx? Healthy People
topicid=32 2020 oral
health
objectives;
overview of
history and
development,
objectives,
baseline
measures,
target
outcomes,
suggested
interventions
and resources,
and methods
to measure
outcomes
National Maternal http://www.mchoralhealth.org/ A variety of
and Child Oral resources to
Health Resource develop
Center community
oral health
programs for
young
children,
including
publications,

1784
 “how-to”
guides,
toolboxes,
Head Start
information,
and grants
National Institute http://www.nidcr.nih.gov/ Variety of
of Dental and resources for
Craniofacial information
Research useful in
community
programming;
includes links
to Oral Health
in America: a
Report of the
Surgeon
General, A
National Call to
Action to
Promote Oral
Health, and
Healthy People
2020
objectives
(history and
development,
objectives,
baseline
measures,
target
outcomes,
suggestions
for
interventions
and resources,
methods to
measure
outcomes)

1785
1786
References
1 National Cancer Institute. Surveillance, epidemiology, and end
results (SEER) program: SEER stat fact sheets: oral cavity and
pharynx cancer. 2011.
http://seer.cancer.gov/statfacts/html/oralcav.html Accessed
October 1, 2014.
2 Centers for Disease Control and Prevention. Birth defects. August
14, 2012.
http://www.cdc.gov/ncbddd/birthdefects/features/craniofacialdefects.html
Accessed October 2, 2014.
3 National Center for Health Statistics. Healthy people 2010 final
review: overview and selected findings. PHS Pub No 2012-1038
Hyattsville, Md: NCHS; 2012.
http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf
Accessed October 1, 2014.
4 Agarwal M.S.S., Chopra S.S., Jayan B., Verma M.M. Epidemiology
in orthodontics- a literature review. Orthod Cyber J. September
2013. http://orthocj.com/2013/09/epidemiology-in-orthodontics-a-
literature-review/ Accessed October 1, 2014.
5 Perheentupa U. Epidemiology management and outcome of facial
injuries, master’s thesis. Finland: University of Turku; 2014.
http://www.doria.fi/bitstream/handle/10024/96674/AnnalesD1118Perheent
sequence=2 Accessed October 2, 2014.
6 American Academy of Pediatric Dentistry. Policy on prevention of
sports-related orofacial injuries. Oral Health Policies Reference
Manual. 2013. ;35(6):67–71.
http://www.aapd.org/media/Policies_Guidelines/P_Sports.pdf
Accessed October 2, 2014.
7 National Institute of Dental and Craniofacial Research. TMJ
(temporomandibular joint and muscle disorders). July 10, 2014.
http://www.nidcr.nih.gov/oralhealth/topics/tmj/ Accessed October
2, 2014.
8 Myers M.L. New survey shows U.S. youth smoking rates fell to
record low in 2013. June 12, 2014. Campaign for Tobacco-Free Kids..
http://www.tobaccofreekids.org/press_releases/post/2014_06_12_cdc
Accessed October 10, 2014.
9 Valachovic R.W. Current demographics and future trends of the
dentist workforce. The U.S. Oral Health Workforce in the Coming
Decade. Institute of Medicine Workshop; February 9, 2009.
http://www.iom.edu/~/media/Files/Activity%20Files/Workforce/oralhealthw

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 Feb-09/1%20-%20Valachovic.ashx Accessed October 4, 2014.
10 Health Resources and Services Administration. Shortage
designation: health professional shortage areas & medically
underserved areas/populations. June 19, 2014.
http://www.hrsa.gov/shortage/index.html Accessed October 7,
2014.
11 Health Resources and Services Administration. Oral health
workforce.
http://www.hrsa.gov/publichealth/clinical/oralhealth/workforce.html
Accessed October 4, 2014.
12 American Dental Education Association. U.S. dental school
applicants and enrollees, 2010 entering class (ADEA AADSAS
application cycle 2010-11). 2012
file:///C:/Users/CHRIST ~ 1/AppData/Local/Temp/ADEADentalSchoolApp
Accessed October 7, 2014.
13 Commission on Dental Accreditation. DDS/DMD programs. 2014.
http://www.ada.org/en/coda/find-a-program/search-dental-
programs/dds-dmd-programs Accessed October 4, 2014.
14 Anderson E.L. Expansion in dental education: new schools. 2011.
http://www.dentalboards.org/PDFS/2011MidYearPresentations.pdf
Accessed October 4, 2014.
15 Bureau of Labor Statistics. Occupational handbook: dental hygienists.
January 8, 2014. http://www.bls.gov/ooh/healthcare/dental-
hygienists.htm#tab-6 Accessed October 5, 2014.
16 American Dental Hygienists Association. Facts about the dental
hygiene workforce in the United States. 2013.
http://www.adha.org/resources-
docs/75118_Facts_About_the_Dental_Hygiene_Workforce.pdf
Accessed October 4, 2014.
17 American Dental Hygienists Association. Dental hygiene education:
curricula, program, enrollment and graduate information. July 9,
2014.
http://www.adha.org/sites/default/files/72611_Dental_Hygiene_Education_
Accessed October 4, 2014.
18 Pew Charitable Trusts. Pew commends Maine for authorizing dental
hygiene therapists. April 29, 2014.
http://www.pewtrusts.org/en/about/news-room/press-
releases/2014/04/29/pew-commends-maine-for-authorizing-
dental-hygiene-therapists Accessed October 4, 2014.
19 American Dental Hygienists Association. Direct access states. June
2014. https://www.adha.org/resources-

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 docs/7513_Direct_Access_to_Care_from_DH.pdf Accessed
October 7, 2014.
20 American Dental Hygienists Association. The benefits of dental
hygiene-based oral health provider models. July 2014.
http://www.adha.org/resources-
docs/75112_Hygiene_Based_Workforce_Models.pdf Accessed
October 2, 2014.
21 Andrews A. Health law offers dental coverage guarantee for some
children. Kaiser health news. January 14, 2013.
http://www.kaiserhealthnews.org/features/insuring-your-
health/2013/011513-michelle-andrews-on-kids-dental-care-
coverage.aspx Accessed October 5, 2014.
22 Centers for Medicaid and Medicare Services. National health
expenditures 2012 highlights. https://www.cms.gov/Research-
Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/downloads/highlights.pdf
Accessed October 4, 2014.
23 Centers for Medicaid and Medicare Services. National health
expenditure projections 2012-2022 forecast summary.
http://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/downloads/proj2012.pdf
Accessed October 7, 2014.
24 American Dental Association. The advantages of offering a dental
benefits plan. http://www.ada.org/en/public-programs/dental-
benefit-information-for-employers/insurance-and-financing
Accessed October 5, 2014.
25 US Census Bureau: Poverty: 2003 highlights.
https://www.census.gov/hhes/www/poverty/about/overview/.
Accessed October 7, 2014.
26 Helms A.D. Putting teeth in health reform. Kaiser health news.
September 2, 2014.
http://www.kaiserhealthnews.org/stories/2014/september/02/putting-
teeth-in-health-reform.aspx?referrer=search Accessed October 5,
2014.
27 Rudowitz R., Artiga S., Arguello R. Children’s health coverage:
medicaid, CHIP and the ACA. The Kaiser family foundation. March
26, 2014. http://kff.org/health-reform/issue-brief/childrens-health-
coverage-medicaid-chip-and-the-aca/ Accessed October 7, 2014.
28 Association of State and Territorial Dental Directors. Healthy
people 2020 oral health leading health indicator policy statement.

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 March 17, 2014. http://www.astdd.org/docs/hp-2020-oral-health-
leading-health-indicator-march-17-2014.pdf Accessed October 4,
2014.
29 US Senate Committee on Health. Education, labor & pensions,
subcommittee on primary health and aging (Bernard Sanders,
Chairman): dental crisis in America: the need to expand access.
February 29, 2012.
http://www.sanders.senate.gov/imo/media/doc/DENTALCRISIS.REPORT.p
Accessed October 5, 2014.
30 Nasseh K., Vujicic M. Dental care utilization continues to decline
among working-age adults, increases among the elderly, stable among
children. American Dental Association, Health Policy Institute;
October 2013.
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/
Accessed October 5, 2014.
31 Vujicic M., Goodell S., Nasseh K. Dental benefits to expand for
children, likely decrease for adults in coming years. American Dental
Association Health Policy Institute Research Brief; April 2013.
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/
Accessed October 6, 2014.
32 US Government Accountability Office. Dental coverage: information
on coverage, payments, and fee variation. September 6, 2013.
http://www.gao.gov/products/gao-13-754 Accessed October 6,
2013.
33 American Dental Education Association. Need for diversity.
Dentistry. 2015; 101.
http://www.adea.org/GoDental/Dentistry_101/Need_for_diversity.aspx
Accessed April 15, 2015.

1790
Suggested readings
Beatty CF: Community oral health practice for the dental hygienist, ed
4, St Louis, 2017, Elsevier Saunders.
Gagliardi L. Dental health education lesson planning and
implementation. ed 2 Long Grove, Ill: Waveland Press; 2014.
Institute of Medicine. Advancing oral health in America. Washington,
DC: National Academies Press; 2011.
http://www.iom.edu/Reports/2011/Advancing-Oral-Health-in-
America.aspx.
Institute of Medicine. Improving access to oral health care for
vulnerable and underserved populations. Washington, DC: National
Academies Press; 2011. http://iom.edu/Reports/2011/Improving-
Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-
Populations.aspx.
Lamoreux D. Caries management: fluoride and nonfluoride caries-
preventive agents. In: Darby M.L., Walsh M.M., eds. Dental
hygiene theory and practice. ed 7 St Louis: Elsevier Saunders; 2015.
Nathe C.N. Dental public health and research. ed 4 Upper Saddle
River, NJ: Pearson; 2015.
National Maternal and Child Oral Health Resource Center: A guide
for developing and enhancing community oral health programs.
http://www.aacdp.com/guide/.
US Department of Health and Human Services. Oral health in
America: a report of the surgeon general. Rockville, Md: DHHS; 2000.
http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/.
US Department of Health and Human Services. A national call to
action to promote oral health. NIH Pub No 03-5303 Rockville, Md:
DHHS, Public Health Service, National Institutes of Health,
National Institute of Dental and Craniofacial Research; Spring
2003. http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/.

Chapter 20 review questions

Answers and rationales to review questions are available on this text’s

accompanying Evolve site. See inside front cover for details.

Testlet A

1791
You have been employed as a public health dental hygienist in a local
health department to provide educational presentations for the
participants in the WIC program in a nonfluoridated community. The
natural fluoride (F) concentration of the community water supply is
0.3 ppm F. One of your first assignments is to present an educational
program on basic oral health practices for culturally diverse pregnant
teens in three alternative high schools that have day care facilities.

Use Testlet A to answer questions 1 to 5.

1. Which of the following roles of the dental hygienist is illustrated by
this activity?
a. Administrator/manager
b. Advocate
c. Clinician
d. Educator
2. How much additional fluoride is required to bring the F concentration
of the water supply to the optimal level?
a. 0.4 ppm F
b. 0.7 ppm F
c. 1 ppm F
d. 0.4 to 0.9 ppm F
3. What is the first step that should be accomplished to conduct this
program?
a. Develop a lesson plan for the educational session for the pregnant
teens
b. Meet with the people involved to determine program goals and
objectives
c. Plan an educational presentation for the day care children
d. Request funding for oral hygiene supplies from the local health
department
e. Select teaching strategies for the educational program
4. Which index would be appropriate to determine the rate of pregnancy
gingivitis in this population?
a. CPI
b. CPITN
c. GI

1792
 d. PSR
5. Which of the following agencies would be the BEST resource for
program planning for this population?
a. National Maternal and Child Oral Health Resource Center
b. DHHS Centers for Medicare and Medicaid
c. Public Health Service
d. DHHS Human Resources and Services Administration

Testlet B
The director of the Vintage Retirement Center contacts the local dental
hygiene society to provide a seminar on oral health and conduct oral
cancer screenings for the purpose of improving the oral health of the
residents. The facility has a population of 100 well residents between
ages 60 and 78 who have a middle SES; 80% of the residents are dentate,
with varying numbers of teeth present. The oral health assessment
results reveal a mean PlI of 2.1, mean GI of 0.8, mean DMFT of 5.2, mean
D of 2.0, RCI of 2.1, and untreated root caries of 1.5. Correlation analysis
reveals a correlation coefficient of r = 0.81 for the relationship between
the RCI and PlI of this group. About 70% of the residents report having
a dental home where they receive routine dental care. Over 50% of them
report signs and symptoms of xerostomia. A SMART objective is
established to improve the oral hygiene within 6 months by a six-
member team of volunteer members of the Dental Hygiene Society
delivering an oral hygiene educational program for residents and staff,
providing oral hygiene supplies, and following up with reminders and
motivational techniques to enhance the residents’ daily effective oral
hygiene. The Society has a budget for community oral health that can be
used to support the program.

Use Testlet B to answer questions 6 to 12.

6. The correlation between the RCI and PlI demonstrates what
relationship between root caries and plaque biofilm in this target
population?
a. Moderate positive
b. Strong negative
c. Strong positive
d. Weak negative

1793
 e. Little if any
7. What level of oral hygiene is revealed by the mean PlI?
a. No plaque present
b. Slight plaque present
c. Moderate plaque present
d. Severe plaque present
e. Cannot be determined from the information provided
8. What change in the DMFT scores would indicate that the needs are
being met 5 years after implementation of a program?
a. Decrease in the total DMFT score
b. Decrease in D, no change in M, and increase in F
c. No change in D, decrease in M, and increase in F
d. Decrease in D, increase in M, and increase in F
e. Both B and D could be acceptable indicators of success
9. Which component of the SMART objective is missing?
a. Achievable
b. Measurable
c. Relevant
d. Specific
e. Time-bound
10. All the following preventive programs are indicated by the
assessment results EXCEPT one. Which one is this exception?
a. Educational presentation on basic oral hygiene
b. Referral for restorative treatment
c. Use of a 0.12% chlorhexidine rinse daily
d. Daily use of a higher-concentration fluoride dentifrice
11. Which of the following programs should be planned to address one
of the Healthy People 2020 Oral Health objectives for this target
population?
a. Denture marking and educational presentation on denture care
b. Oral cancer screening and referral, as needed
c. Referral to a Medicaid provider for dental treatment
d. Screening of periodontal condition and referral, as needed
e. Treatment with fluoride varnish to control dentinal hypersensitivity

1794
12. What is the BEST measure of the success of this program?
a. Administrative support for the program
b. Improved oral health indicators of the residents
c. Improved oral hygiene of the residents
d. Increased availability of oral hygiene supplies for the use by the
residents
e. Increased oral health knowledge of the staff

Testlet C
The human resources director of an urban county hospital is alarmed by
the rising cost of employee health insurance premiums related to
tobacco-associated health conditions. The administrator charges the
occupational health director, a dental hygienist, with addressing the
issue of employee tobacco consumption. Employee demographics for
the hospital are as follows: 40% Caucasian, 38% African American, 12%
Hispanic, and 10% Asian. The dental hygienist conducts an employee
tobacco usage survey as part of the program planning process. Analysis
of the survey reveals mean cigarette usage per day of 4.6 for
administrators, 19.6 for clerical support staff, 10.6 for nurses, 6.2 for
physicians, and 19.8 for allied health technicians. Standard deviation is
2.2 cigarettes for all groups. Cigarette packs are known to contain 20
cigarettes. A computer-based educational program is planned for the
initial intervention with the goal of reducing daily cigarette usage.

Use Testlet C to answer questions 13 to 17.

13. Based on the survey results, which of the following is the highest-
priority population to target with an intervention?
a. Allied health technicians
b. Clerical support staff
c. Hospital administrators
d. Hospital patients
e. Nurses
f. Physicians
g. All the groups are equally important and should be targeted at the
same time.
14. Which of the following is the BEST instructional objective for this
initiative?

1795
 a. After completing the educational program, participants will
understand the harmful effects of tobacco and how they contribute to
oral and systemic diseases and conditions.
b. Participants will be able to list recommended methods to control
cravings that can lead to failure.
c. Ninety percent of the staff will voluntarily participate in the program
during the first month of availability.
d. On completion of the computer-based educational program, staff
members will be able to correctly identify 80% of the harmful
ingredients in tobacco.
15. What is the MOST important cultural factor to consider when
planning an intervention for this population?
a. Age
b. Gender
c. Educational level
d. Ethnic background
e. Health literacy
16. Which step of program planning is BEST represented by the survey
described in the scenario?
a. Analysis of needs
b. Collection of data
c. Determination of priorities
d. Implementation and strategy development
e. Program evaluation
17. The data reported from the survey represent ordinal data. A pie chart
is the most appropriate graphic representation of these results.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.

Testlet D
The director of a local nursing home has contracted with a public health
dental hygienist to design an oral health protocol for the 300 residents.
Currently, a registered nurse performs the intake oral examination. The

1796
majority of the residents are partially edentulous, have partial removable
dentures, and require assistance with daily hygiene practices. The
caregivers state that the residents have severe halitosis, trouble eating,
and frequently lose their removable partial dentures. The dental
hygienist observes that the caregivers are neglecting daily oral hygiene
care and are not conducting oral cancer screenings. On the basis of these
observations, the dental hygienist determines to carry out oral hygiene
and oral cancer screening of all residents and introduce an educational
component for the facility’s caregivers and interested family members.
Students from the local dental hygiene educational program are
recruited to assist with the educational program. The caregivers’
knowledge is measured prior to and a week following the educational
program; these measures are compared to evaluate changes in
knowledge. The caregivers’ ability to conduct oral cancer screening is
evaluated weekly for several weeks after the educational program. The
success of the program will be evaluated by screening the residents
again 1 year later to identify any lesions that have not been found during
the year. If the data reveal lesions that have not been identified, the
dental hygienist plans to work with the director of nursing to establish a
new protocol for routine oral cancer screening by the registered nurses
on staff. The dental hygienist secures funding from a local foundation
for the equipment needed to screen the residents.

Use Testlet D to answer questions 18 to 23.

18. What type of study is represented by evaluating the change of
knowledge as a result of the educational component?
a. Case-control
b. Correlational
c. Crossover
d. Pretest/posttest
e. Time-series
19. What type of data is being collected by the screening?
a. Qualitative and primary
b. Qualitative and secondary
c. Quantitative and primary
d. Quantitative and secondary
20. Which term BEST describes the extent of oral cancer lesions found at

1797
the 1-year evaluation screening?
a. Count
b. Incidence
c. Prevalence
d. Proportion
e. Rate
21. Which core public health function is exemplified by the potential
future establishment of a new program protocol?
a. Assessment
b. Assurance
c. Policy development
d. Prevention
22. The stakeholders involved in this program represent what level of
public health involvement?
a. Local
b. State
c. National
d. A combination of two or more levels
23. What is the BEST method to use for the weekly evaluation of the
caregivers’ ability to conduct oral cancer screening in this program?
a. Administer a weekly written test over the cancer screening
procedure
b. Interview the residents about the caregivers’ technique
c. Observe the caregivers conducing oral cancer screening
d. Survey the family members about the caregivers’ technique

Testlet E
A high dental caries rate has been reported by the school nurses in Head
Start children in the county on the basis of the rate of toothaches and
absences. The families are primarily Spanish-speaking Hispanic and East
Indian migrant farmworkers. They reside in predominantly rural
settings with individual well-water supplies. At an informational
meeting, the Head Start dental health coordinator introduces the goal of
the program to the Head Start family advocates. A team of dental
hygiene students from the local college is asked to design a

1798
comprehensive program to address the problem of dental caries in this
population. They begin by collecting baseline data using the deft, OHI-S,
and GI and identify a high level of S-ECC.

Use Testlet E to answer questions 24 to 29.

24. Which of the following is indicated by the second component of the
caries index used in this program?
a. Decayed surface
b. Decayed tooth
c. Tooth that needs to be extracted because of the severity of decay
d. Tooth that has been extracted because of decay
e. Tooth that has naturally exfoliated
25. Which of the following would be MOST appropriate to explain
during the informational session?
a. Benefits of community water fluoridation
b. Cause of early childhood caries
c. Effectiveness of daily brushing
d. Value of healthy food choices
26. All the following would be an appropriate source of funding for this
program EXCEPT:
a. CHIP
b. Head Start grant
c. Medicare
d. Medicaid
e. Private funding from a local foundation
27. Which preventive program is indicated for this target population?
a. Distribution of fluoridated dentifrice
b. Professional fluoride applications every 6 moths
c. School fluoride varnish program
d. School sealant program
e. Water fluoridation
28. Which index would be appropriate to evaluate the improvement in
the children’s oral hygiene resulting from strategies introduced in this
program?

1799
 a. OHI-S
b. PHP
c. PlI
d. Turesky modification of the Quigley-Hein Plaque index
e. Any of the above would be appropriate.
29. Which of the following describes the level of ECC for the older age of
this population?
a. No smooth-surface caries is present.
b. No cavitated lesions are present on anterior teeth.
c. Number of carious lesions is less than four.
d. The number of carious lesions is greater than five.

Testlet F
Dental hygiene students from a local program visit a geriatric day care
called Camp Sunshine to implement a service learning project. These
older adults are functionally independent, although they are medically
compromised. Under faculty supervision, the students screen the older
adult clients to identify denture cleanliness and teach them how to clean
their dentures daily. The goals are to improve their oral health by
cleaning their dentures or partial dentures, increase their awareness of
the need for daily oral care, and empower them to clean their dentures.
The students compute the mean scores of the denture cleanliness
measure for future evaluation of the program outcomes. The educational
program consists of three weekly visits to teach and provide practice in
various aspects of denture care. During the first weekly lesson, the
students use motivational interviewing to identify the clients’ current
practices and intentions regarding daily denture cleaning. The students
use this information to plan individualized instruction for each client.
The students return in 6 months to measure denture cleanliness to
evaluate the success of the program. Although the outcomes indicate
improvement in cleanliness for the majority of the clients, the results are
skewed as a result of a large number of them missing one of the weekly
sessions because they came down with the flu that week. At the end of
the program, the students prepare a final report in which they
communicate the outcomes of the program to the facility director and
propose funding of supplies by Camp Sunshine for future programs.

Use Testlet F to answer questions 30 to 35.

1800
30. Which of the following terms BEST describes the situation described
related to the flu?
a. Cluster
b. Endemic
c. Epidemic
d. Occurrence
e. Pandemic
31. Which of the following is an ethical responsibility of the students
and faculty who are implementing this program?
a. Communicate oral findings to the staff of the facility
b. Prepare a formal report of findings to submit to the health
department
c. Refer clients who have suspicious lesions identified during the
program
d. Take the dentures back to the dental hygiene clinic to clean them
more thoroughly
32. What is the BEST teaching method for the psychomotor learning in
this program?
a. Demonstration
b. Guided practice
c. Lecture
d. A video presentation
33. Which health education and health promotion theory is BEST
reflected by the strategies used in the educational program?
a. Health belief model
b. Organizational change theory
c. Social cognitive theory
d. Trans-theoretical model (stages of change theory)
34. Which statistic is BEST to determine the statistical significance of the
improved denture cleanliness?
a. Analysis of variance (ANOVA)
b. Chi-square
c. Correlation coefficient
d. The t test

1801
35. What is the BEST way for the students to provide the final report?
a. Discuss the results at a meeting with the administrators in which
they provide a written proposal of the funding request
b. Include in the written proposal a list of the clients with their
baseline and posttest cleanliness scores
c. Include in the written proposal tables and graphs that summarize
the pretest and posttest denture cleanliness data
d. Write a few paragraphs in the proposal that describe the statistical
analysis of the pretest and posttest denture cleanliness data

Testlet G
A local dental hygienists’ association and a faith-based organization
collaborate to target a school for a comprehensive oral disease
prevention program. The school serves a population that consists of 50%
Medicaid-eligible children, and 75% of them receive the school lunch
program. The ethnic group representation is 15% Hispanic American,
5% African American, and 80% non-Hispanic white. The fluoride
concentration of the community water is below the optimal level. A
public health hygienist screens the children in preschool through grade
5 annually. Data for 2014 indicate a 22% urgent decay rate across all ages.
Further assessment reveals that many of the children are not seeing a
dentist routinely. A sealant program is conducted in grades 2 and 5. Af
luoride varnish program is conducted with the preschoolers and grade
K, including two applications annually; these children are screened for
dental caries with a tongue blade and available light at the time of each
application. An educational program is designed to meet the needs of
the children in this school. Finally, the team explores the option of a
fluoridation campaign to achieve water fluoridation in this community.

Use Testlet G to answer questions 36 to 42.

36. Which of the following is a required action for this program?
a. Phone call to each family to describe the program
b. Presence of a dentist while the fluoride varnish is placed by
hygienists
c. Radiographs before placing sealants
d. Written informed consent form signed by parents or legal guardians
of all children who participate

1802
37. What assessment classification is used with preschoolers and grade K
in this program?
a. Type I
b. Type II
c. Type III
d. Type IV
38. What would have been the BEST means of identifying the reported
decay rate?
a. Basic Screening Survey (BSS)
b. deft
c. DMFT
d. RCI
39. The same education materials can be used with participants in the
other schools in the district, because the cultural diversity of this
population represents the cultural diversity of the general U.S.
population.
a. Both the statement and the reason are correct and related.
b. Both the statement and the reason are correct but NOT related.
c. The statement is CORRECT, but the reason is NOT correct.
d. The statement is NOT correct, but the reason is CORRECT.
e. NEITHER the statement NOR the reason is correct.
40. What is the basis for deciding to target this school with this program?
a. Convenience
b. Cultural diversity of the school
c. Random selection of the school
d. SES of the children in the school
41. Which of the following should be done FIRST in this program?
a. Contact key community leaders to obtain a broad base of support for
fluoridation
b. Determine the fluoride level of the community water supply
c. Organize a massive community education program about the
benefits and safety of fluoridation
d. Schedule a referendum to allow the citizens to express their opinion
about fluoridation

1803
 e. Testify before the city council to convince them to fluoridate the
water
42. Which of the following programs has the HIGHEST priority to
further meet the needs of this population?
a. Conduct a daily classroom fluoride rinse program
b. Establish dental homes and refer children for treatment
c. Make plans to implement school water fluoridation
d. Plan a health fair for the children and the families

Testlet H
A dental hygiene U.S. Public Health Services (USPHS)–commissioned
core officer is assigned to an Indian Health Service (IHS) clinic to
improve the oral care of pregnant women in an American Indian rural
community with a population of 26,000. Approximately 20% of the
pregnant women in this population develop gestational diabetes. When
a woman first sees the physician in the clinic for prenatal care, she is
referred to the dental clinic for a dental examination. Only 25% of the
patients referred over the previous 6 months complied with the dental
referral, scheduled an appointment, and received treatment. The
community is not classified a “dental manpower shortage area” because
of the staffing of this clinic and the existence of this program. A survey
of the pregnant women served by this clinic reveals that the women do
not realize their risk for diabetes, are unaware of the relationship
between oral health status and diabetes, and do not understand the
benefits of an oral health assessment in relation to their overall health
and the health of their babies. For the purpose of discussing the
problem and possible solutions, the dental hygienist arranges a meeting
of the medical clinic director, the dental clinic director, the medicine
man of the Indian tribe, and a dental clinic staff member who is a
member of the tribe. This team sets a goal of doubling the rate of
compliance with the dental referral to 30% within 6 months.

Use Testlet H to answer questions 43 to 47.

43. Which of the following is the BEST intervention to implement first to
meet the goal of the program?
a. Conduct a mailing program to remind pregnant women to schedule
an appointment for a dental examination
b. Develop an oral health screening program to be implemented

1804
 during prenatal care visits
c. Develop written educational materials for distribution during
prenatal visits
d. Document the oral condition of the women who have complied and
received a dental examination
e. Plan an educational presentation for the pregnant women on the
relationship among oral health, systemic health, and the risks and
consequences of diabetes
44. On the basis of the results of the survey, which health education
theory is indicated as the foundation for an oral health education
intervention to meet the goal?
a. Health belief model
b. Learning ladder
c. Social cognitive theory
d. Theory of reasoned action
e. Trans-theoretical model (stages of change theory)
45. Lack of compliance with the dental referral could be a result of which
TWO of the following factors?
a. Cost of dental care
b. Lack of available appointments
c. Lack of transportation to the dental clinic
d. Low dentist-to-population ratio
e. Low health literacy
46. The dental referral by the medical clinic is an example of which
characteristic of public health?
a. Application of biostatistics to analyze population health problems
b. Community rather than the individual as the client
c. Multi-disciplinary team approach to solving public health problems
d. Social responsibility for oral health
47. Which theory of health promotion is exemplified by this program?
a. Community organization
b. Diffusion of innovation
c. Organizational change
d. Sense of coherence

1805
Testlet I
Dental hygiene students conduct a study to compare the effectiveness of
two nonalcohol mouthrinses, a 0.02% NaF rinse (Listerine Zero) and a
0.07% CPC rinse (Crest Pro Health), in controlling plaque biofilm and
gingivitis. A sample of 136 healthy adult volunteers is taken from the
university dental hygiene clinic. Only dentate adults with no to mild
periodontitis are accepted to participate in the study. The study
participants are qualified for inclusion in the study by their plaque
biofilm forming potential and presence of mild gingivitis. Two groups
are formed, and an unmarked bottle of mouthrinse is given to each
participant. Study participants and examiners are unaware of the
formula used by each participant. One group receives the 0.07% CPC
mouthrinse, and the other group receives the 0.02% NaF mouthrinse. All
other ingredients of both rinses are standardized. Two examiners are
calibrated in the use of the PlI and GI to measure plaque biofilm at
baseline, 2 months, and 4 months. The baseline PlI scores are used
during group assignment to ensure that the two groups have equivalent
oral hygiene.

Use Testlet I to answer questions 48 to 52.

48. What sampling technique is used for this study?
a. Convenience sampling
b. Judgmental or purposive sampling
c. Random sampling
d. Stratified random sampling
e. Systematic sampling
49. The application of the PlI in this study is an example of which step in
the scientific method?
a. Collection, organization, and analysis of data
b. Formulation of a hypothesis
c. Identification and statement of the problem
d. Verification, rejection, or modification of the hypothesis
50. Which of the following is a statement of the null hypothesis for this
study?
a. Neither mouthrinse is effective in controlling plaque and gingivitis.
b. Plaque and gingivitis are strongly associated.

1806
 c. The 0.02% NaF mouthrinse and the 0.07% CPC mouthrinse differ in
ability to control plaque and gingivitis.
d. There is no difference between the ability of the 0.02% NaF
mouthrinse and the 0.07% CPC mouthrinse to control plaque and
gingivitis.
e. Which controls plaque and gingivitis better, the 0.02% NaF
mouthrinse or the 0.07% CPC mouthrinse?
51. What type of study is reflected by the methods of this research
study? Select FOUR types of studies from the following list.
a. Analytic study
b. Clinical trial
c. Double-blind study
d. Experimental study
e. Posttest only study
f. Retrospective study
g. Time-series study
52. Which of the following is controlled by the procedures used with the
examiners as they measure the plaque biofilm?
a. Inter-examiner reliability
b. Intra-examiner reliability
c. Inter-examiner variability
d. Intra-examiner variability

Testlet J
The administrator of a group home for mentally challenged adults has
received multiple complaints from the attending caregivers regarding
the residents’ oral health. Limited manual dexterity abilities of the
residents require that they receive assistance with oral hygiene routines;
yet complaints of severe resident halitosis and bleeding during normal
oral hygiene routines have made the caregivers reluctant to provide
assistance. Frustrated by a lack of staff compliance, the group home
administrator contacts the local county public health dental hygienist,
knowing that the county health department has a grant for oral care for
this population. After gathering basic demographic information, the
dental hygienist makes a visit to the home to determine the actual oral
health status of the residents.

1807
 Use Testlet J to answer questions 53 to 57.
53. What is the BEST way for the dental hygienist to assess the actual
oral hygiene routines in the group home?
a. Assess the values of caregivers by conducting focus groups
b. Measure the plaque biofilm and gingivitis scores of residents over
time
c. Observe the residents’ ability to brush correctly
d. Observe the caregivers’ ability to brush correctly
e. Survey the beliefs and attitudes of caregivers with a questionnaire
54. From initial observations, what Healthy People 2020 objective is
MOST applicable to this target group?
a. Reduce untreated dental decay in children and adults
b. Reduce gingivitis and destructive periodontal disease in adults
c. Increase detection of oral cancer lesions at stage I
d. Increase annual use of dental services by residents of long-term care
facilities
55. What known characteristics about this population can be utilized in a
community profile? Select THREE characteristics from the following
list.
a. Age
b. Ethnicity
c. Source of funding
d. Gender
e. Geographic location
f. Literacy level
g. Population setting
56. Which of the following is the BEST use of the dental hygienist in this
situation?
a. Conduct an educational program on daily oral hygiene care for the
residents
b. Make available dental hygiene services for the residents using
portable equipment
c. Present an in-service training program to the group home staff
d. Provide daily oral hygiene care for the residents

1808
57. Which of the following is an effective teaching strategy to raise the
caregivers’ compliance in this situation?
a. Demonstrate to them the proper oral hygiene procedures
b. Provide a lecture for them on the importance of oral hygiene
c. Show them pictures of good oral health versus oral disease
d. Provide training on how to maintain personal oral hygiene skills for
themselves

1809
C HAPT E R
21

1810
Medical Emergencies
Leslie Koberna

Dental hygienists must prevent and effectively manage medical

emergencies that occur in the health care environment. Careful client
observation and questioning during assessment will enable the dental
hygienist to identify, prepare, and care for the client who experiences a
medical complication. The ability to recognize signs and symptoms of
medical disorders, prevent further complications through appropriate
interventions, and manage a medical emergency is essential.

1811
General considerations1–3
A. Medical emergency
1. A medical emergency means a client experiences an unforeseen,
immediate, health-related difficulty that is potentially life
threatening
2. Medical emergencies require prompt recognition and action by the
dental team to maintain the client’s health and, at times, the client’s
life
B. Dental hygienist’s legal responsibilities
1. To provide timely, quality care according to current standards of
practice
a. The dental hygienist must be prepared for managing medical
emergencies and adverse events in a health care environment;
dental hygienists may be held liable if they lack knowledge and
training in medical emergency management
b. All dental hygienists should be current in medical emergency
management, including basic life support (BLS)
2. To maintain complete records of medical emergencies in the health
care setting
a. Documentation must describe the onset and management of the
emergency, the client’s vital signs, nature of the treatment
performed and the client’s response, type and dose of drugs
administered, and the time when treatment was provided
b. Thorough and complete records of medical emergencies are an
important component of continuous quality improvement and
protect the oral health care team in the event of legal action

1812
Medical history1–3
A. Reviewing a client’s health history is the first step in preventing a
medical emergency
B. A thorough health history, taken at the first appointment and updated
at each subsequent appointment, reveals conditions that predispose a
client to medical complications
C. Information obtained from the health history is used to modify the
client’s care plan and reduce the likelihood of the client experiencing a
medical complication or emergency in the oral health care setting
D. If more information regarding the client’s health status is needed, the
dentist or the dental hygienist should consult the client’s general
physician before initiating treatment
E. The assessment and documentation of the client’s vital signs (usually
blood pressure, body temperature, pulse, respiration rate) provide
information regarding the client’s health status
F. The probability of a stress-induced medical emergency in the oral
health care environment may be reduced by careful appointment
planning, stress reduction protocol, good client rapport, and prescribed
stress-reducing medication

1813
Vital signs1–5,8
Basic Concepts
A. Vital signs refer to numerical values given to blood pressure, body
temperature, pulse rate, and respiration rate; dental hygienists should
explain the purpose of and the method for measuring vital signs to the
client before initiating these procedures
B. Vital signs and a health history are used to determine a client’s fitness
to undergo oral health care procedures
C. Abnormal values and significant findings should be brought to the
attention of the dentist, the client, and the client’s physician
D. Vital sign values should be taken for each new client, at each recall
appointment, and more frequently for clients with hypertension and
other cardiac diseases
E. Vital signs should be compared to the baseline readings and
monitored during an emergency; vital signs should be taken every 5
minutes for emergencies related to the heart, diabetes, adrenal
insufficiency, drug-related emergencies, acute allergic reactions, and the
postictal phase of seizures
F. Vital signs should be recorded in the client’s chart

Blood Pressure
A. Definitions
1. Blood pressure (BP)—the force exerted by blood on the walls of the
blood vessels during the contraction and relaxation of the heart; BP
depends on the heart’s contractile force, peripheral vascular
resistance, and vascular volume
a. BP may increase with age or in response to exercise, stress,
certain medications, smoking, and illness
b. BP is recorded as millimeters of mercury (mm Hg), with the
systolic pressure over the diastolic pressure; systolic (mm
Hg)/diastolic (mm Hg)
2. Systolic pressure—the force exerted during ventricular contraction
(heart beat); the highest pressure in the cardiac cycle
3. Diastolic pressure—the resting pressure, which occurs during
ventricular relaxation (heart rest); the lowest pressure of the cardiac
cycle
4. Pulse pressure—the value obtained when diastolic pressure is
subtracted from systolic pressure
5. Hypertension—sustained, abnormally high BP

1814
 6. Hypotension—sustained, abnormally low BP
B. Normal values
1. Children—BP values vary based on age, height, and gender
2. Adults—BP is considered normal when systolic reading is less than
120 mm Hg and diastolic less than 80 mm Hg
3. Normal BP should be checked every 2 years in the dental office
4. BP classifications and recommended management regimen for
adults
a. Prehypertension—clients with systolic reading between 120 and
139 mm Hg and/or diastolic reading between 80 and 89 mm Hg
are considered to be prehypertensive; BP should be rechecked
once a year
b. Stage I hypertension—clients are considered to have stage 1
hypertension when systolic reading is between 140 to 159 mm
Hg and/or diastolic reading is between 90 to 99 mm Hg; BP
should be rechecked in 2 months
c. Stage II hypertension—clients with systolic reading between 160
and 179 mm Hg and/or diastolic reading between 100 and
109 mm Hg are considered to have stage II hypertension and
should be referred to a physician within 1 month
d. Clients with systolic reading of 180 mm Hg or greater and/or
diastolic reading of 110 mm Hg or greater should be referred to
a physician for immediate care; activate the emergency medical
services (EMS) system if the person is symptomatic (i.e.,
experiencing chest pain, shortness of breath, back pain,
numbness/weakness, changes in vision, or difficulty speaking)
C. Equipment for measuring blood pressure
1. Sphygmomanometer—an inflatable cuff and pressure gauge used to
measure BP
2. Stethoscope—an instrument used to listen to the sounds of the
blood as it passes through the brachial artery (Fig. 21-1)

1815
 FIG 21-1 Stethoscope position for blood pressure (BP) measurement.

a. The first sound heard through the stethoscope is the systolic BP,
or Korotkoff sounds
b. The last distinct sound heard is the diastolic BP

Body Temperature
A. Normal oral temperature for both adults and children ranges from
97°F to 99.6°F (36.1°C to 37.5°C)
B. Values higher than 101°F may indicate an active disease process; values
above 99.6°F indicate a fever
C. Body temperature elevation may be caused by exercise, ingestion of
hot food or drink, smoking, or a pathologic condition
D. Body temperature may be decreased because of starvation or shock
E. Body temperature varies during the day
1. Lower in the morning, higher in the afternoon
2. Fever of pyrexia is an abnormal elevation in body temperature

Pulse
A. Definition and basic concepts
1. Pulse—the force of the blood through an artery created by the
heart’s contraction; each contraction creates a wave of blood that can

1816
 be felt by gently pressing a superficial artery against underlying
tissue
2. Pulse is evaluated by rate (fast, slow), rhythm (regular, irregular),
and quality (full or strong, thready or weak)
3. Pulse rate is measured as the number of heartbeats per minute
(beats/min)
4. Pulse rate may increase because of exercise, certain drugs, anxiety,
heat, eating, or disease
5. Pulse rate may decrease because of sleep, certain drugs, fasting, or
disease
B. Heart rate
1. Heart rates of infants and children are more rapid than adult rates
and vary based on age, gender, and size
2. Normal pulse rates for children age 1 to 10 years—60 to 140
beats/min
3. Normal pulse rates for children older than 10 years and adults—60
to 100 beats/min
4. Normal resting heart rate for adults ranges from 60 to 100 beats/min
a. Bradycardia—less than 60 beats/min
b. Tachycardia—greater than 100 beats/min
C. Determining the pulse rate
1. Sites used for determining pulse rates (Fig. 21-2)

1817
 FIG 21-2 Location of pulse points.

a. Brachial pulse—located on the medial aspect of the antecubital

fossa of the elbow
b. Radial pulse—located on the lateral aspect of the wrist (thumb
side) on the ventral surface
c. Carotid pulse—located in the neck groove, just anterior to the
sternocleidomastoid muscle
d. Femoral pulse—located on the medial aspect of the upper thigh
2. In emergency situations, the carotid pulse (which indicates that
blood is flowing to the brain) is monitored
a. Care is required in carotid palpation because vagal stimulation
may occur, resulting in a decrease in BP or syncope
b. It is important not to palpate the carotid arteries simultaneously
because one or both may be partially occluded
3. In nonemergency situations, the brachial or the radial pulse is

1818
 monitored

Respiration Rate
A. Definitions and basic concepts
1. Respiration is the inspiration and expiration of air by the body
2. Respiration rate—the number of breaths taken by a person per
minute; it is counted by the rise and fall of the chest
3. When assessing a client’s respiration, the depth (shallow, deep),
rhythm (regular, irregular), rate, quality (labored, easy), breathing
sounds (wet/noisy, clear), and client position during respiration
should be evaluated
B. Factors that affect respiration
1. Respiration rate may be increased as a result of exercise, pain,
certain drugs, anxiety, shock, or disease
2. Respiration rate may be decreased as a result of sleep, certain drugs,
or disease
C. Normal respiration rate ranges
1. Teens to adults—12 to 20 respirations per minute
2. Preschool children—20 to 25 respirations/min
3. Older children—15 to 25 respirations/min
D. American Society of Anesthesiologists (ASA) Physical Status (PS)
Classification System (see Table 15-3 in Chapter 15)
1. A system developed to determine risk for clients who will undergo
surgery or anesthesia
2. In dentistry, the following classifications are used:
a. ASA 1 (PS1)—normal client without systemic disease; client can
walk up flight of stairs, walk a quarter mile with little distress,
and should be able to handle the stress of a dental appointment
b. ASA 2 (PS2)—client with mild systemic disease or an ASA 1
client who demonstrates extreme anxiety; examples include
clients who have controlled type 2 diabetes, asthma, or
hypertension; should tolerate elective dental care
c. ASA 3 (PS3)—patient with severe systemic disease with limited
activity but functions normally; can climb stairs or walk a
quarter mile with difficulty; examples include persons with
stable angina, post–myocardial infarction (MI) or post–
cerebrovascular accident (CVA), controlled type 1 diabetes, or
chronic obstructive pulmonary disease (COPD); can have
routine dental care but risk is increased
d. ASA 4 (PS4)—patient with an incapacitating or life-threatening

1819
disease; cannot walk up a flight of stairs or walk a quarter mile;
examples include persons with unstable angina, MI within 1
month, CVA within 6 months, uncontrolled type 1 diabetes; risk
is too great, and elective care should not be performed

1820
The emergency kit2
A. A basic medical emergency kit accessible to all treatment areas should
be maintained and readily available for use
1. Staff should be familiar with the content of the kit and its location
2. An emergency kit should contain only the emergency medications
the dentist and staff are trained to use (Table 21-1)

Table 21-1
Medications Typically Supplied with Basic Medical Emergency Kit*

* The drugs and equipment available in the dental office should reflect the training of the dentist and the staff. Only
drugs and equipment that the dentist, the dental hygienist, and the staff are trained to use should be included in
the medical emergency kit.

B. Emergency preparation
1. Each member of the dental team should be current in BLS
(cardiopulmonary resuscitation), including the use of an AED
(automatic external defibrillator), and should be trained to recognize
and manage common medical emergencies
2. Each oral health care team member should have delegated
responsibilities in the event of a medical emergency; simulations
ensure each individual understands his or her role should a medical
emergency arise

1821
Emergency care1,2,4,6–8
A. Definitions and basic concepts
1. Stress reduction protocol
a. Establish good client rapport
b. Create a low-stress environment
c. Possibly administer pretreatment medication
d. Administer pain control
e. Assess anxiety level
2. Cardiopulmonary resuscitation (CPR)—BLS technique with the goal
of providing oxygen to the brain, heart, and other vital organs until
definitive medical treatment can be given; CPR requires assessment
and basic skills in the management of the airway, breathing, and
circulation
3. Emergency medical system (EMS) —a coordinated community
system that uses communication, transportation, prevention,
education, trained personnel, emergency medical facilities, and
other elements in providing emergency medical care
4. Respiratory arrest—sudden cessation of breathing
5. Cardiac arrest—sudden, unexpected cessation of the heartbeat and
circulation
6. Clinical death—cessation of the activity of the heart and of
breathing; may be reversible through life support measures,
especially if initiated within 4 to 6 minutes, or may progress to
biologic death
7. Biologic death—permanent cellular damage, particularly of the
oxygen-sensitive brain cells, resulting from an inadequate supply of
oxygen
B. Administering basic life support—cardiopulmonary resuscitation
1. The steps in CPR are known as CAB:
a. Circulation—the hygienist assesses the client’s circulation and
provides cardiac support by external cardiac compressions and
defibrillation; first step in CPR
b. Airway—the hygienist assesses the airway and establishes a
clear air passage; second step in CPR
c. Breathing—the hygienist assesses breathing and provides
respiration through rescue breathing; third step in CPR
2. Performing CPR
a. Determine the client’s level of consciousness
b. Activate the emergency response system
c. Attain an AED

1822
 d. Place client in supine position
e. Check pulse for less than 10 seconds; use carotid artery for
adults, femoral artery for children ages 1 to 12, and brachial
artery for infants
f. If pulse not present
(1) Begin compressions
(a) Adult—administer 30 compressions at rate of 100 per
minute and depress sternum 2 inches
(b) Child (1 year to puberty)—administer 30
compressions at rate of 100 per minute and depress
sternum 2 inches with heel of hand
(c) Infant (under 1 year)—administer 30 compressions at
rate of 100 per minute and depress sternum 1½ inches
using 2 fingers between nipples
(2) Administer 2 breaths
(3) Continue cycle (compressions/breaths)
(4) Check for pulse after every 4 cycles or 2 minutes
g. Pulse is present—administer 10 to 12 rescue breaths per minute
C. Basic life support in late pregnancy
1. Oxygen demands increase during pregnancy
2. Functional residual capacity of the lungs is decreased because of the
upward displacement of the diaphragm; as a result, oxygen reserve is
compromised when the pregnant woman is in the supine position,
and cardiac output is decreased by 25%
3. To help alleviate the effects of the supine position on circulation, the
uterus should be shifted toward the left side by placing a wedge
under the right hip
4. Aspiration caused by delayed gastric emptying is a concern
5. Chest compressions for CPR should be performed higher than usual
on the sternum, just above the center of the sternum, to
accommodate the upward displacement of the diaphragm
D. Automated external defibrillator
1. Computerized device that analyzes cardiac rhythms and delivers an
electric shock to the heart when appropriate; manual defibrillators
and pediatric-capable AEDs are the preferred devices to be used on
infants and children age 1 to 8 years
2. If available, an AED should be used as soon as possible in the CPR
sequence, since early defibrillation increases the chances of survival
for victims of sudden cardiac arrest
3. Considerations when using an AED
a. Client should be kept dry

1823
 b. Defibrillator pads should be placed at least 1 inch to the side of
implanted pacemakers, not over the implanted pacemaker
c. Transdermal medication patches in the area should be removed
before placing AED

Administration of Oxygen
A. Basic concepts
1. During a medical emergency, the body’s increased need for oxygen,
or its diminished ability to obtain or use oxygen, may call for the
administration of a higher concentration of oxygen than exists in
regular air
2. Indications for oxygen administration include syncope, cardiac
problems, and respiratory difficulties (with the exception of
hyperventilation)
B. Equipment—portable oxygen unit consists of an oxygen tank (an E
cylinder is recommended), regulator, tubing, a self-inflating resuscitation
bag (Ambu bag used for high-flow oxygen, 10 to 15 liters per minute), a
clear oxygen mask with a reservoir bag (covers face and nose; used for
high-flow oxygen, 8 to 15 L/min), and a nasal cannula (used for low-flow
oxygen, up to 6 L/min)
C. Place an unconscious client in the supine position; a conscious client
can be seated in a comfortable position for administration of oxygen

1824
Management of medical emergencies
Obstructed Airway 2
A. Basic concepts for conscious clients
1. An obstructed airway occurs when an object or foreign body
prevents exchange of air during breathing
2. Foreign body obstruction may occur when eating, when unconscious
(the tongue may block the pharynx), during resuscitation (aspiration
of vomitus or blood), or during other events
B. Mild airway obstruction
1. Clients with mild airway obstruction can cough forcefully
2. Management—encourage spontaneous coughing and deep
breathing
C. Severe airway obstruction with poor air exchange
1. Clients experiencing severe airway obstruction may exhibit a weak
cough, cyanosis, high-pitched noises, increased difficulty breathing;
may be unable to speak or breathe, clutching at the neck
2. Management
a. Subdiaphragmatic abdominal thrusts (Heimlich maneuver) are
administered to children and adults for severe foreign body
airway obstruction
b. Back blows and chest thrusts are performed on infants
c. Blind finger-sweep is never performed
d. For severe foreign body airway obstruction in a conscious
woman in her last trimester of pregnancy, chest thrusts rather
than abdominal thrusts are recommended

Unconscious Client1,2,4
A. Definitions and basic concepts
1. Unconsciousness—the inability to respond to stimuli, make
purposeful movements, or gain awareness of events taking place
2. Levels of unconsciousness range from syncope (transient, simple
fainting) to coma (prolonged, deep unconsciousness)
B. Causes
1. Diminished blood supply to the brain (inadequate cerebral
circulation), altered quality of blood flow to the brain (metabolic
disorder), central nervous system (CNS) disorder, or emotional
disturbance.
2. Common causes of unconsciousness in the dental setting are
psychogenic factors (fear, anxiety); treatment for this type of

1825
 unconsciousness is aimed at increasing the amount of oxygenated
blood received by the brain
C. Preventing loss of consciousness
1. Obtain a complete health history, evaluate vital signs, and determine
client’s dental stress level
2. Stress reduction protocols, premedication, and pain management for
treating the anxious client
D. Managing unconsciousness
1. Assess the client’s vital signs
2. Place client in supine position to facilitate cerebral blood flow
3. Implement CAB

Syncope (Fainting, Vasodepressor Syncope)1–3,8

A. Definition—sudden, transient loss of consciousness
B. Causes
1. Decreased cerebral function resulting from impaired circulation or
altered metabolism
2. Psychogenic factors (anxiety, fear)
3. Nonpsychogenic factors (hypoglycemia, position change, heat)
C. Preventing syncope
1. Obtain a complete health history to determine previous syncopal
episodes, dental stress level, illness, if client has eaten, and other
pertinent information
2. Follow stress reduction protocol
3. Clients who “feel faint” should be placed in the supine position
D. Signs and symptoms—three stages of syncope:
1. Presyncope stage—client reports feeling of warmth in neck and face,
not feeling well, weakness and nausea, lightheadedness, and tingling
in the toes and fingers; observation of pallor or gray color of skin,
dilated pupils, piloerection, hypotension, and tachycardia
2. Syncope stage—client exhibits flaccid muscles, impaired
consciousness, pallor, weak slow pulse, shallow breathing;
unconsciousness of less than 5 minutes
3. Postsyncope stage—client wakens and may report feeling weak and
disoriented; BP and pulse rate return to normal
E. Managing syncope
1. Presyncope
a. Place client in supine position with legs slightly elevated; in
most cases, this will prevent syncope
b. Administer oxygen

1826
 c. Consider postponing treatment
2. Syncope
a. Assess client
b. Place client in supine position with legs slightly elevated
c. Implement CAB
d. Administer oxygen
e. Monitor vital signs
f. Place blanket over the client to keep warm
g. Administer atropine (optional) for bradycardia
h. For delayed recovery of 15 to 20 minutes, contact EMS
3. Postsyncope
a. Once recovers, client should remain in the supine position and
rest for a time sufficient to prevent another episode
b. Administer glucose (soft drink or orange juice) for associated
hypoglycemia (optional)
c. Determine cause of the syncope
d. Someone should accompany client home
e. Possible referral to physician

Orthostatic Hypotension or Postural Hypertension1,2

A. Definition—sudden drop in systolic BP of at least 20 mm Hg caused
by a change in body position
B. Cause
1. Sudden change from the supine to sitting or from sitting to standing
position
2. Prolonged bed rest, medications, prolonged standing, pregnancy,
and age can affect the body’s ability to adjust quickly to the impact of
gravity on the cardiovascular system as body position changes
3. Addison’s disease
4. Exhaustion and starvation
C. Signs and symptoms
1. Client will report lightheadedness, blurred or darkened vision, and
nausea
2. Hygienist will observe pallor, syncope, and sweating
D. Prevention
1. Slowly raise the client from the supine to the upright position
2. Have the client change from the sitting position to the standing
position slowly
E. Management of the emergency
1. Assess the client

1827
 2. Position the client back to the supine position with feet slightly
elevated
3. Implement CAB
4. Administer oxygen if needed
5. Monitor vital signs
6. Raise the client slowly; provide assistance
7. If recovery is delayed, EMS should be contacted

Shock1–3,8
A. Definition—circulatory system does not adequately circulate blood
through body tissues, resulting in a lack of oxygen in the cells
B. The client experiencing shock may complain of thirst, restlessness, or
anxiety
1. May exhibit low BP; rapid, weak pulse; shallow, rapid respiratory rate
2. Skin may be pale, cool, and clammy
3. In severe cases, the victim may go into a coma
C. Management procedures for shock
1. Place the client in the supine position with feet slightly elevated or
Trendelenburg position
2. Contact EMS
3. Initiate CAB
4. Administer oxygen
5. Monitor vital signs
D. Types of shock
1. Hypovolemic shock—most common type of shock
a. Cause—severe hemorrhage or dehydration can lead to
inadequate blood volume or venous return
b. Signs and symptoms—dehydration, rapid thready pulse, cool
clammy skin, decreased urine output, confusion, weakness,
pallor
c. Management—follow procedures listed earlier for shock
2. Distributive shock or vasogenic shock—three types: anaphylactic,
septic, neurogenic
3. Anaphylactic shock
a. Cause—acute allergic reaction; release of histamine results in
sudden vasodilation throughout the body and
bronchoconstriction
b. Signs and symptoms—bronchoconstriction, difficulty in
breathing, hypotension, respiratory arrest
c. Management—follow procedures listed earlier for shock; in

1828
 addition, administer epinephrine, histamine blockers, and
corticosteroids
4. Septic shock
a. Cause—infectious agent produces an acute systemic infection
that prevents blood flow to the cells, tissues, and organs; often
fatal; toxic shock syndrome is an example of septic shock
b. Signs and symptoms—fever, vasodilation, increased cardiac
output; tissue edema, pink and warm skin; hypotension;
restlessness and anxiety; tachycardia; thirst; eventual respiratory
failure
c. Management—follow procedures previously listed for shock; in
addition, administer intravenous (IV) fluids and antimicrobial
therapy; client may need surgery
5. Neurogenic shock
a. Cause—psychological or neurologic disorder or injury to the
brainstem or spinal cord from disease, drugs, or trauma; causes
loss of sympathetic nerve activity, impairing nerve impulses to
the blood vessels, which in turn prevents vasoconstriction
b. Signs and symptoms—hypotension, bradycardia, peripheral
vasodilation
c. Management—follow procedures previously listed for shock; in
addition, administer phenylephrine or dopamine and
epinephrine
6. Cardiogenic shock
a. Cause—inadequate cardiac output to peripheral organs and
tissues; common causes are MI, cardiac arrhythmias, and heart
failure; occurs approximately 10 hours after an MI
b. Signs and symptoms—hypotension, rapid weak pulse, cold
clammy skin, peripheral cyanosis, chest pain, shortness of
breath, reduced urine output, confusion
c. Management—follow procedures listed earlier for shock; in
addition, administer IV fluids and medications to restore heart
rate and BP (beta blockers, vasodilators, and positive inotropes)
7. Obstructive shock
a. Cause—obstruction of blood flow peripheral to the heart, as in
arterial stenosis and pulmonary embolism; obstructive shock
prevents the heart from beating
b. Signs and symptoms—severe hypotension and dyspnea
c. Management—follow procedures listed earlier for shock; in
addition, remove or correct obstruction and administer IV fluids
with caution

1829
Asthma1,2,8
A. Definition—chronic inflammatory disease of the airway that causes
reversible airway obstruction from hyperresponsiveness to stimuli,
resulting in episodes of dyspnea, wheezing, and coughing
B. Types and causes
1. Extrinsic or allergic asthma—caused by allergens outside the body
(i.e., airborne, such as dust, foods, and drugs); bronchospasms occur
within minutes of exposure
2. Intrinsic asthma (also known as nonallergic, idiopathic, or infective
asthma)—caused by nonallergic factors such as respiratory
infections, psychological and physiologic stress, physical exertion,
and environmental factors
3. Additional categories in some textbooks include exercise-induced,
drug-induced, and infectious asthma
C. Signs and symptoms—onset of a productive or a nonproductive
cough, dyspnea (shortness of breath), tachypnea (increased respiratory
rate), tachycardia (increased heart rate), anxiety and agitation, wheezing,
cyanosis, chest tightening, nostril flaring, flushing
1. Asthma occurs most often at night
D. Prevention of the emergency
1. Identify clients at risk through thorough health history taking
2. Ask probing questions related to asthma
3. Implement stress reduction protocol
4. Have the client take a prophylactic dose of bronchodilator before the
appointment
5. Encourage clients with asthma to bring their inhalers to all dental
appointments
E. Management of an emergency related to asthma
1. Position the client in the sitting position
2. Initiate CAB
3. Have the client administer own prescribed medications
(bronchodilators); if not available, use bronchodilator from office
emergency kit
4. Administer oxygen if the episode continues
5. Activate the EMS if the episode continues

Hyperventilation2
A. Definition—rapid breathing; often the result of pain, anxiety, or drugs;
rapid breathing causes an excessive elimination of carbon dioxide, which
results in respiratory alkalosis

1830
B. Prevention of the emergency—implement stress reduction protocol
C. Signs and symptoms—tingling or numbness of extremities, giddiness,
lightheadedness, dizziness, confusion, cold hands, heart palpitations,
rapid respirations (25-30 breaths/min), rapid pulse
D. Management of the emergency related to hyperventilation
1. Position the client in the upright position
2. Initiate CAB
3. Calm the client
4. Have the client cup hands over mouth and nose and breathe slowly
and deeply (only 4-6 breaths/min)
5. Oxygen should not be administered

Cardiac Emergencies1,2,8
A. Cardiac emergencies have many causes and require immediate,
definitive medical treatment
1. Sudden, unexpected cessation of cardiac activity is called cardiac
arrest; unless CPR/AED is promptly performed to maintain the
heart’s function and EMS contacted, biologic death may result
2. A cardiac emergency may be caused by accidents (electric shock,
drowning, trauma, asphyxiation) or coronary disease
B. Causes and pathophysiology—coronary disease and emergencies may
result from a change in the heart’s function (arrhythmia, hypertrophy,
ischemia), blood vessels (atherosclerosis, arteriosclerosis), blood volume
(shock, hemorrhage), or blood composition (anemia)
C. Prevention of a cardiac emergency
1. Identify clients at risk with thorough health history taking
2. Recognize signs and symptoms
3. Promptly refer the client to a physician
4. If coronary symptoms develop in the dental office, rapid access to
EMS is indicated
D. Cardiovascular diseases
1. Hypertension—persistent BP elevation indicates the heart is working
harder to supply blood through the arteries; the probability of a CVA
(stroke), MI, congestive heart failure, and kidney disease may be
increased because of a consistently elevated BP
a. Signs and symptoms—may include headaches, dizziness, or no
symptoms; consistent, elevated blood pressure readings
b. Prevention of medical emergencies—for recommendations
regarding treating clients with elevated blood pressure (see
earlier discussion under the section “Blood Pressure”)

1831
2. Angina pectoris—a transient (temporary) ischemia (lack of
oxygenated blood) of the myocardium (heart muscle), usually
manifested by chest pain or discomfort; angina occurs because the
heart requires more oxygen than the amount produced
a. Signs and symptoms
(1) Sudden onset of a dull chest pain or discomfort that may
be described as a constant pressing, crushing, burning, or
squeezing sensation
(2) Pain may radiate to the shoulders (left is most common),
arms, neck, mandible, or epigastrium
(3) Pain is reproducible and predictable and may last 1 to 10
minutes
(4) Pain may be precipitated by exertion, emotional stress,
cold weather, or a heavy meal and may be accompanied by
weakness and shortness of breath
(5) Client may appear apprehensive, have labored breathing,
or is sweating
(6) Heart rate and BP are elevated
b. Prevention
(1) Schedule short, late-morning or early-afternoon
appointments
(2) Take a thorough health history, identifying clients with
angina; discuss questions related to the angina episodes,
cause, length of episode, medication, effectiveness of
medication, frequency of episodes, and usual symptoms
(3) Dismiss clients with unstable angina (pain is increasing in
duration, intensity, and frequency) and refer to a physician
(4) Place the client’s nitroglycerin medication within easy
reach of the clinician and client to use in the event of an
emergency
(5) Use stress reduction protocol
(6) Monitor vital signs
(7) Administer low-flow oxygen during appointment
(8) Administer local anesthetic for pain control when needed
(maximum of 2 carpules local anesthesia with 1:100,000
epinephrine, not to exceed 0.04 mg epinephrine)
(9) Administer nitrous oxide–oxygen (N2O-O2) to provide
psychosedation
(10) Dismiss the client if he or she shows signs of fatigue,
sweating, anxiety, or fidgeting
c. Management of an emergency

1832
 (1) If the client has no history of angina, follow the procedures
listed later for myocardial infarction
(2) Place patient in supine position
(3) Implement CAB, as needed
(4) Administer nitroglycerin
(a) The client’s nitroglycerin is preferred
(b) Administer 1 nitroglycerin tablet or 1 to 2 metered
sprays every 5 minutes; do not exceed three doses
within 15-minutes
(c) The client’s discomfort should lessen within 2 to 4
minutes
(d) If the client’s discomfort has not decreased
significantly after the first dose, the second dose
should come from the office emergency kit
(e) Nitroglycerin should not be taken if the client exhibits
hypotension
(5) Administer oxygen
(6) Monitor the client’s vital signs
(7) If pain is not relieved within 10 minutes, the client
requests EMS, or the pain returns, summon EMS and
administer aspirin
(8) If pain is relieved by rest and nitroglycerin, encourage rest,
discontinue oral health services for that appointment, and
refer the client for further evaluation by a physician
(9) Treatment should be modified for the next visit to alleviate
the client’s stress
3. Myocardial infarction (MI)—diminished or interrupted supply of
oxygenated blood to the heart that causes death (necrosis) of part of
the heart muscle, resulting in impaired heart function and
diminished cardiac output; if a large area of the heart is affected, the
heart may be unable to function and may stop beating (cardiac
arrest)
a. Signs and symptoms
(1) Chest pain, often described as a “crushing pressure,” is
the classic symptom of an MI; the pain often radiates to the
arm (most frequently the left arm), neck, or mandible; the
pain intensifies and lasts for more than 15 to 20 minutes;
nitroglycerin, rest, and changing positions do not alleviate
the pain
(2) Client may have an ashen-gray appearance and may
exhibit a cold sweat, nausea, vomiting, dyspnea, dizziness,

1833
 weakness, and the feeling of impending doom
(3) Vital signs most often will present as a weak, thready, rapid
pulse; low BP; and rapid, shallow respirations
(4) Women do not always present with chest pain but rather
may experience more vague warning signs, such as fatigue,
nausea, vomiting, dizziness, breathlessness, back pain, or
deep throbbing in the left or right bicep or forearm
(5) A client who is developing signs of acute pulmonary
edema will begin to have a slight dry cough; this will
develop into a paroxysmal nocturnal dyspnea, asthmatic-
type wheezing, pallor, sweating, frothy blood-tinged
sputum, tachypnea, dyspnea, and a feeling of suffocation
b. Prevention for clients who have had a previous MI
(1) Take a thorough health history to identify clients at risk
(2) Clients who have had a previous MI should have vital
signs checked at the start and at the end of each
appointment
(3) Implement stress reduction protocol
(4) Administer oxygen at a flow rate of 3 to 5 L/min
(5) Administer N2O-O2 sedation to decrease the client’s stress
(6) Maintain adequate pain control through administration of
local anesthesia with 1:100,000 epinephrine
(7) Keep appointments short, and dismiss the client if he or
she begins to appear anxious and is showing signs of
increased stress
(8) Do not treat a client for the first 30 days after an MI
(9) Refer clients to their physician if they appear unable to
handle the stress of a dental appointment
c. Management of an emergency
(1) Immediately activate the EMS if the client does not have a
history of angina, or if client with history of angina is
experiencing chest pains different than normal, or requests
the EMS
(2) Position a conscious client according to client preference
(3) Implement CAB
(4) Monitor the client’s vital signs (BP, heart rate/rhythm,
respirations) every 5 minutes
(5) Administer oxygen at a flow rate of 4 to 6 L/min
(6) Administer nitroglycerin unless the client exhibits
hypotension (systolic BP < 90 mm Hg or < 30 mm Hg below
baseline); administer 1 nitroglycerin tablet; pain should

1834
 decrease within 2 to 4 minutes if angina is the cause of the
pain; pain will continue or return if the cause is an MI
(7) Administer aspirin (160-325 mg) to prevent thrombus
formation
4. Congestive heart failure (CHF)—results when the heart is unable to
pump an adequate amount of blood to meet the body’s demands;
precipitating factors include hypertension, coronary artery disease
(CAD), congenital and valvular heart disease, toxins, inflammatory
disorders, and endocrinopathies
a. Signs and symptoms
(1) Client may complain of weakness, anxiety, shortness of
breath, unexplained sudden weight gain, cough, and
swelling of the ankles
(2) Client may present with edema, cyanosis, elevated BP,
narrowed pulse pressure, tachycardia, increased respiratory
rate, and prominent jugular veins
(3) Left ventricular failure causes respiratory distress with
accompanying signs of weakness, fatigue, and dyspnea
(4) Right ventricular failure causes venous congestion with
accompanying signs of cyanosis, coolness in the extremities,
peripheral edema, and prominent jugular veins
b. Prevention of an emergency
(1) Identify clients at risk through a thorough health history
(2) Refer clients with symptomatic CHF (experience CHF
symptoms during normal activities) for a medical
consultation before elective dental care; clients who are
asymptomatic and do not experience CHF symptoms
during normal exertion may be seen for dental treatment
(3) Implement stress reduction protocol
(4) Administer low-flow oxygen at a rate of 3 to 4 L/min
(5) Position so that the client is comfortable, generally upright
or semi-supine; if the client has orthopnea (inability to
breath when reclined), needs to be sent for a medical
referral
(6) Watch for signs of acute pulmonary edema (see earlier
myocardial infarction discussion)
c. Management of acute pulmonary edema
(1) Contact EMS
(2) Position a conscious client according to client preference
(3) Calm the client
(4) Perform CAB as needed

1835
 (5) Administer oxygen at a high flow rate of 10 L/min
(6) Monitor vital signs every 5 minutes (BP, heart rate/rhythm,
respirations)
(7) Perform a bloodless phlebotomy if symptoms of acute
pulmonary edema are present—BP cuffs are used as
tourniquets on three extremities (below shoulders and
below the groin), always leaving one of the extremities
without a cuff; the cuffs are inflated for 5 to 10 minutes,
removed, and rotated
(8) Administer 2 or 3 nitroglycerin tablets or sprays every 5 to
10 minutes unless the client is hypotensive
5. Cardiac arrest or sudden cardiac death(SCD)—the unexpected
cessation of heart and lung functions as a result of an electrical
malfunction of the heart
a. Cardiac arrest is cardiopulmonary collapse caused by
ventricular fibrillation, CAD, respiratory arrest, shock, drugs,
arrhythmias, accidents, or anaphylaxis; some sources consider
cardiac arrest and SCD to be the same, whereas other sources
consider them to be different
b. Signs and symptoms
(1) Client loses consciousness and has no pulse, BP, or
respirations (clinical death)
(2) A majority of clients will experience signs and symptoms
before SCD, including chest pain, cough, shortness of
breath, fainting, dizziness, palpitations, and fatigue
(3) About 25% of those who experience SCD or cardiac arrest
will have no signs or symptoms
c. Management of the emergency
(1) Activate EMS
(2) Position the client in supine position
(3) Begin CAB
(4) Implement defibrillation
(5) Continue CAB and defibrillation until the EMS arrives

Allergic Reactions1,2,8
A. Allergic reactions occur from a wide range of physiologic responses
caused by hypersensitivity to an allergen
B. Causes
1. Allergic responses may be evoked by drugs, pollens, foods,
chemicals, insect bites, and other factors

1836
 2. When the body comes into contact with these substances, an
antigen-antibody reaction occurs and results in an inappropriate
response by the body’s immune system
C. Preventing allergic reactions
1. Take a thorough health history, which should reveal a previous
history of allergic reactions to drugs or materials used in dental
therapeutics
2. Ask the client who has a prior history of an allergic reaction to
describe its type and severity
3. Refer the client with a suspected allergy for evaluation by a physician
D. Types of allergic reactions
1. Delayed allergic reactions
a. Signs and symptoms include skin manifestations such as
erythema (redness), urticaria (hives), and angioedema (swelling)
or respiratory reactions (respiratory distress, wheezing,
dyspnea, angioedema) that occur hours or even days after
contact with an allergen
b. Treatment of delayed allergic reactions
(1) Assess the need for CAB.
(2) Administer antihistamine and/or oxygen if allergic
reaction is severe
(3) If the reaction persists, the client should be accompanied
to a physician; if a delayed reaction becomes severe,
epinephrine may need to be administered
(4) If epinephrine is administered, EMS should be contacted
2. Immediate reaction or anaphylaxis
a. Immediate allergic reactions occur within 60 minutes of
exposure to the antigen and are characterized by urticarial
reactions (hives), abdominal cramps, diarrhea, nausea,
angioedema, rhinitis (inflamed mucous membranes of the
nose), respiratory distress (bronchospasms, dyspnea), cyanosis,
and cardiovascular changes, including hypotension, rapid weak
pulse, tachycardia, and arrhythmias, which may progress to
cardiovascular collapse
b. Types of immediate allergic reactions
(1) Food allergies irritate the gastrointestinal tract
(2) Bronchospasms affect the respiratory tract
(3) Urticarial reactions affect the skin
(4) Anaphylactic reactions can be localized (laryngeal edema)
or generalized
c. Treatment for immediate nonanaphylactic reactions

1837
 (1) Assess for CAB
(2) Monitor vital signs every 5 minutes
(3) Administer an antihistamine and oxygen
(4) Position a hypotensive client in the supine position
(5) If the client exhibits signs of cardiovascular or respiratory
distress, or if the heart rate, respirations, or BP change,
administer epinephrine and contact EMS
d. Treatment for bronchospasms
(1) Position the client in the upright position
(2) Assess for CAB
(3) Summon EMS
(4) Calm the client
(5) Administer a bronchodilator
(6) Administer an antihistamine
e. Treatment of laryngeal edema
(1) Position client according to client preference, generally
upright
(2) Assess for CAB; continue to monitor airway
(3) Contact EMS
(4) Administer 0.3 mL of 1:1000 epinephrine; repeat in 3 to 5
minutes if needed
(5) Administer oxygen
(6) Administer histamine blocker (diphenhydramine)
f. Treatment for generalized anaphylaxis
(1) Position the client in the supine position with feet elevated
if hypotensive or unconscious
(2) Implement CAB
(3) Summon EMS
(4) Administer 0.3 mL 1:1000 epinephrine in a preloaded
syringe; administer a second dose if condition does not
improve within 5 minutes; an additional dose can be
administered at 5- to 10-minute intervals depending on
cardiovascular response
(5) Administer oxygen at a rate of 5 to 6 L/min
(6) Administer antihistamine, 25 to 50 mg of
diphenhydramine, orally (PO), intramuscularly (IM), or
intravenously (IV)
(7) Administer corticosteroid, 100 mg of hydrocortisone,
subcutaneously (SC), IM, or IV, once the client has
improved
(8) Perform CPR as needed

1838
 (9) An insufficient dose of medication could cause
anaphylaxis to return within 3 to 10 hours, known as
biphasic anaphylaxis

Drug-Related Emergencies and Poisoning1,2,4

Basic Concepts
A. Drug-related emergencies include allergic response, overdose,
psychogenic response (syncope or hyperventilation), idiosyncratic
reaction, drug interactions, and complications in a client who is
chemically dependent
B. A thorough health history should reveal the client’s drug allergies,
previous adverse reactions, or chemical dependency; these agents,
materials, and drugs must be avoided during dental and dental hygiene
care

Specific Reactions
A. Local anesthetic—result of psychogenic or allergic response, toxic
overdose, or chemical intoxication
1. Psychogenic response—usually manifests as syncope or
hyperventilation; generally the result of fear of the injection rather
than a reaction to the local anesthetic agent; syncope and
hyperventilation should be managed according to the criteria
described earlier in related sections
2. Allergic reactions—occur more often with ester-type anesthetics
(procaine); very rare and should be managed by the criteria
established under the previous section on “Allergic Reactions”
3. Toxic overdoses—result from delayed biotransformation or
elimination of the agent, excess total dose, or IV injection of the
agent
a. Prevention—client factors such as age, weight, and predisposing
medical conditions and drug factors such as amount, rate of
injection, and type of anesthetic used must be considered when
administering local anesthesia
b. Signs and symptoms—very talkative, agitated, anxious,
confused, slurred speech; elevated BP, heart rate, and respiratory
rate; client may complain of headache, dizziness, and
disorientation and may lose consciousness; with moderate to
high levels of local anesthetic, the client may have seizures, lose
consciousness, and undergo respiratory arrest

1839
 c. A mild overdose reaction generally occurs within 5 to 30 minutes
of the injection
d. Steps to manage a toxic overdose
(1) Assess CAB
(2) Administer oxygen, and ask the client to hyperventilate to
lower arterial carbon dioxide tension (Paco2) levels; this will
lower the risk of a seizure
(3) Monitor vital signs every 5 minutes until the client has
recovered
(a) After recovery, the client should be assessed by a
physician or hospital
(b) If the client experiences a seizure with an anesthetic
overdose reaction or has a severe overdose reaction
(signs and symptoms occur during or immediately
after administration of anesthetic), the following steps
should be followed:
[1] Place the client in the supine position
[2] Summon EMS
[3] Assess CAB
[4] Administer oxygen, and have the client
hyperventilate
[5] Monitor the client’s vital signs every 5 minutes
[6] Administer an anticonvulsant IV if needed; if an
anticonvulsant has been administered, EMS
should be contacted
4. Chemically dependent client
a. Prevent emergencies by identifying the chemically dependent
client and adjusting the dental treatment accordingly
b. Cocaine-intoxicated client
(1) Do not administer anesthetic containing epinephrine
within in 24 hours of cocaine use
(2) If cardiac arrest occurs after administration of an
anesthetic containing epinephrine, follow the management
procedures listed earlier for cardiac arrest (SCD)
B. Fluoride poisoning
1. Some oral health care products contain enough fluoride to be
hazardous, especially to children
a. 1 ounce of topical fluoride gel or one 8-ounce tube of fluoridated
toothpaste could be life threatening to a small child
b. A lethal dose of fluoride for a child is 500 to 1000 mg, depending
on the child’s weight and size

1840
 2. Signs and symptoms of fluoride overdose
a. Nausea, abdominal pain, excessive salivation, thirst, vomiting,
and diarrhea within 30 minutes of ingestion
b. Burning sensation in the oral cavity and a sore tongue may also
be present
c. In severe cases, muscle cramping, bronchospasm, and cardiac
arrest may occur
3. Treatment of acute fluoride poisoning (for adults and children age 6
years and older)
a. Administer ipecac syrup to induce vomiting (only if client has a
gag reflex, is conscious, and is not convulsing)
b. Administer milk or 1% calcium gluconate or calcium chloride
PO
c. Activate the EMS
d. Implement CAB
e. N2O-O2 oversedation
f. Sign—lethargy
g. Management of emergency
(1) Increase O2 intake and decrease N2O intake
(2) Assess CAB

Cerebrovascular Accident (CVA)2,8

A. CVA, or stroke, results when the supply of oxygen to the brain cells is
disrupted by ischemia, infarction, or hemorrhage of the cerebral blood
vessels; co-contributing factors include tobacco use, hypertension,
diabetes mellitus, and CAD
B. Prevention
1. Take a thorough health history, and evaluate vital signs to help
identify clients at risk for a CVA
2. Do not alter anticoagulant medication before dental care for post-
CVA clients
3. Post-CVA clients should not be seen for at least 6 months after CVA
or TIA
4. Post-CVA clients with systolic readings above 160 mm Hg and
diastolic readings above 95 mm Hg should be referred to their
physician for an immediate consultation and should not be seen for
dental treatment
5. Stress reduction protocol should be followed
a. Appointments should be short and scheduled for midmorning
b. N2O-O2 can be administered; a pulse oximeter should be used to

1841
 monitor oxygen saturation (So2) levels
c. Light oral sedation (benzodiazepines) can be administered; CNS
suppressants should not be taken
d. Pain control should be monitored; a local anesthetic with
1:100,000 or 1:200,000 epinephrine can be given in limited
amounts
C. Signs and symptoms
1. Clients could experience sudden weakness on one side
(hemiparesis), difficulty of speech, temporary loss of vision
(especially in one eye), unexplained dizziness, altered level of
consciousness, shortness of breath, nausea, sudden severe headache,
and confusion
2. A client experiencing CVA may have an elevated BP and cardiac
arrhythmias (irregular heartbeats)
D. Treatment
1. Conscious client
a. Position the client upright
b. Activate EMS
c. Assess CAB
d. Monitor the client’s vital signs every 5 minutes (heart rate,
rhythm, BP)
e. Administer oxygen
f. Do not administer CNS depressants
2. Unconscious client
a. Place client in the supine position with feet elevated unless BP is
noticeably elevated, in which case, place the client in the semi-
Fowler position (supine position with head and chest elevated)
b. Continue to monitor the vital signs (heart rate, rhythm, BP,
respirations)
E. Transient ischemic attacks (TIAs)
1. TIAs, or “mini-strokes,” can present with similar symptoms as a
stroke; however, the client recovers within 10 minutes
2. Because of a high risk for future strokes, a TIA requires immediate
referral to a physician for preventive treatment

Seizures and Convulsive Disorders1,2,8

A. Seizures and convulsive disorders are the result of changes in brain
function
1. Seizures—characterized by alterations in consciousness, motor
function, and sensory perceptions; usually have a rapid onset and

1842
 brief duration (1 to 3 minutes)
2. Convulsions—involuntary contractions of the voluntary muscles
3. Epilepsy or seizure disorder—condition characterized by recurrent
seizures and convulsions
B. Preventing seizures
1. Thorough health history should identify an individual with a history
of seizures or convulsive disorders
2. Ask questions that address causes, type, and severity of seizure and
the aura the client experiences prior to a seizure
a. If a client has a history of seizures, determine if medications
have been prescribed to control seizures and if the client has
taken the required medication before the appointment
3. Short appointments scheduled early in the day may reduce the
likelihood of a seizure in the oral health care setting
4. Administration of N2O-O2 with at least 20% oxygen is recommended
for the apprehensive client with seizure disorders
5. Benzodiazepines for oral conscious sedation may also be effective
for clients who are less apprehensive
6. Administration of local anesthesia is the most likely cause of a
seizure in a nonepileptic client in the dental setting; care should be
taken in the administration, dose, and type of anesthesia
administered
7. Alcohol can precipitate a seizure; therefore a client who has a history
of seizures should not be seen for dental care if alcohol has been
consumed
C. Types of seizures
1. Convulsive—generalized tonic-clonic (grand mal) seizure
a. Signs and symptoms include an aura (change in taste, smell, or
sight precedes the seizure), loss of consciousness (may be
several minutes), an epileptic cry (sudden expulsion of air
through glottis), involuntary tonic-clonic muscle contractions,
altered breathing, and sometimes involuntary defecation or
urination
b. After the seizure, respirations should spontaneously return,
muscles relax, and consciousness returns; the person may have a
headache or muscle aches and may be drowsy or disoriented
2. Nonconvulsive—absence (petit mal) seizure
a. Signs and symptoms are sudden momentary loss of awareness
without loss of postural tone and a blank stare for up to 90
seconds, although the individual may twitch or blink
b. The person is usually unaware of the seizure

1843
 3. Complex partial (psychomotor) seizure—signs and symptoms may
include an aura, purposeless movements, and loss of awareness
lasting for only a few minutes
D. Management of seizure
1. Convulsive seizure— three phases:
a. Prodromal phase—marked by the presence of an aura
(1) Prepare for the seizure
(2) Remove all dental equipment and removable appliances
from the client’s mouth
(3) Place the client in the supine position with legs elevated
(4) Clear the area of all sharp and dangerous objects
b. Ictal phase—the tonic-clonic phase of the seizure
(1) Make no attempts to restrain the client or place any objects
in the mouth
(2) Protect the client’s head, if needed, by placing a soft item
under the head
(3) Assess and establish an airway
(4) Monitor vital signs, and assess CAB, as needed
(5) Activate EMS
(6) Prevent injury
c. Postictal phase—most dangerous phase of the seizure; the body
experiences a generalized depression that affects the central
nervous, respiratory, and cardiovascular systems; death can
occur during this phase
(1) Keep the client in supine position
(2) Continue CAB
(3) Monitor vital signs every 5 minutes (BP, respirations, heart
rate)
d. Management of an emergency involving a convulsive seizure
(1) Place the client in the supine position with feet elevated
(2) Remove all objects that could harm the client
(3) Lightly restrain the client to protect from injury
(4) Consider contacting EMS
(5) Assess CAB
(6) Once seizure ceases, administer oxygen at a flow rate of 5
to 6 L/min
(7) Assess CAB
(8) Monitor vital signs (BP, heart rate, respirations)
(9) Reassure the client when consciousness returns
(10) Allow the client to recover
(11) Assess the client to send home, to physician, or to

1844
 hospital
2. Status epilepticus
a. Grand mal (tonic-clonic) seizure that lasts longer than 5 minutes
b. Contact EMS if not already contacted
c. Assess CAB
d. Once seizure ceases, administer oxygen at a flow rate of 5 to
6 L/min
e. Administer anticonvulsant drug IV and 50% dextrose IV
3. Nonconvulsive seizure in the oral health care setting
a. Terminate the dental procedure
b. Closely observe the client
c. Reassure the client when the seizure has concluded
d. Discharge the client when he or she has recovered
e. If the seizure lasts longer than 5 minutes, contact EMS
f. Assess CAB

Diabetes Mellitus1,2,8
A. Definition—characterized by elevated levels of blood glucose
resulting from an impaired ability to produce or use the hormone insulin
B. Four types of diabetes
1. Type 1, or insulin-dependent, diabetes mellitus usually occurs in
young persons and is more likely to precipitate a diabetic emergency
known as ketoacidosis or diabetic coma; primarily hereditary or genetic
2. Type 2, or non–insulin-dependent, diabetes mellitus usually occurs
in adulthood and rarely results in an emergency situation; clients
with type 2 diabetes may become insulin dependent; type 2 is a
milder form of diabetes than type 1
3. Gestational diabetes occurs during pregnancy
4. Impaired glucose tolerance, also known as prediabetes; these clients
are at risk for developing diabetes and cardiovascular disease
C. Emergencies related to diabetes may result from two different
situations:
1. Client has too much insulin (hyperinsulinism), resulting in
hypoglycemia (low blood sugar); blood glucose levels are below
50 mg/dL
a. Typical causes are increased insulin dosage, missed meal,
vomiting, or excessive exercise
b. Hypoglycemia can lead to insulin shock
2. Client has inadequate insulin, resulting in hyperglycemia (high
blood sugar); blood glucose levels are above 250 mg/dL

1845
 a. Hyperglycemia can lead to ketoacidosis and diabetic coma
b. Occurs most often with type 1 diabetes from inadequate insulin
levels, infection, or MI
c. Can occur with type 2 diabetes from stress, epinephrine therapy,
or medication
d. Emergency situations develop slowly and generally take more
than 48 hours from the onset of signs and symptoms
D. Prevention
1. A thorough health history is essential to prevent diabetic
emergencies in the oral health care setting; factors to determine
when taking the health history include the type and severity of
diabetes and the client’s medications and their frequency, duration,
and dosage; medical consultation may be necessary
2. Clients whose diabetes is not under control or who exhibit the signs
and symptoms listed next should postpone elective dental and
dental hygiene care
3. Establish that the client’s medications have been taken according to
prescriptions, and that the client has eaten meals according to
schedule on the day of the appointment
4. Minimize the client’s stress and anxiety in the dental office
5. Appointments should be scheduled to ensure that the client is
rested and that the client’s meal and medication schedules are not
interrupted; morning appointments are best, 1 to 1½ hours after
breakfast
E. Signs and symptoms
1. Clients with uncontrolled diabetes may be experiencing xerostomia,
infection, poor healing, increased incidence and severity of caries,
candidiasis, gingivitis, periodontal disease, periapical abscesses, or
burning mouth syndrome
2. Signs and symptoms of hypoglycemia may occur suddenly or
gradually; clients experience an altered state of consciousness
(confusion, anxiousness, incoherence, uncooperative or bizarre
behavior), hunger, headache, pale moist skin, hyperthermia,
dizziness, weakness, trembling, tonic-clonic movements, normal or
depressed respirations, hypotension or loss of consciousness; if left
untreated, will lead to coma and death
3. Signs and symptoms of conscious clients experiencing diabetic
ketoacidosis or impending diabetic coma include the “classic” signs
of polydipsia (excessive thirst), polyuria (excessive urination),
polyphagia (excessive hunger), nausea, vomiting, dry flushed skin,
deep and rapid respirations (Kussmaul respirations or air hunger),

1846
 weak and rapid pulse, and a “fruity” breath odor; blurred vision,
hypotension, and unconsciousness may follow; if left untreated, will
lead to coma and death
F. Management of the emergency
1. Regardless of the cause of the emergency, a diabetic client is treated
based on consciousness or unconsciousness, not on hyperglycemia
or hypoglycemia; all diabetic emergencies are treated based on the
assumption the emergency is hypoglycemia
2. Treatment for the conscious client
a. Place the client in a comfortable position
b. Assess CAB and perform BLS as needed
c. Administer oral carbohydrates and sugars (orange juice, candy
bar, soft drink), 3 to 4 ounces every 5 to 10 minutes
d. Observe for 1 hour before dismissing client
3. Treatment for the unconscious client
a. Place the client in supine position with feet slightly elevated
b. Assess CAB and perform BLS as needed
c. Activate EMS
d. Administer oxygen, 5 to 6 L/min flow rate
e. Administer 5% dextrose IV, or glucagon 1 mg IM; administer
0.5 mg of 1:1000 epinephrine if dextrose or glucagon is not
available
f. Monitor vital signs every 5 minutes

Acute Adrenal Insufficiency, or Adrenal Crisis2,8

A. Definition
1. Adrenal crisis is a life-threatening situation
2. Clients having adrenal insufficiency may go into cardiac arrest or
shock
B. Causes
1. Acute adrenal insufficiency (adrenal crisis) occurs when the adrenal
gland is unable to produce enough cortisol to enable the body to
respond to a stressful situation, either physical or psychological
2. In the dental office, stress from surgical procedures or severe anxiety
of dental and dental hygiene care can cause acute adrenal
insufficiency
3. Results from:
a. An abrupt withdrawal of exogenous administration of
glucocorticosteroids
b. Primary adrenal insufficiency (Addison’s disease)

1847
 c. Secondary adrenal insufficiency, which occurs when the body is
unable to produce cortisol because of prolonged exogenous
glucocorticosteroid use and therefore cannot meet the increased
demand for cortisol during a time of stress
C. Prevention—clients who are extremely anxious or who will be
undergoing surgical procedures and who are at risk for adrenal
suppression should be given two to four times their normal dose of
glucocorticosteroids on the day of the appointment
D. Signs and symptoms
1. Clients will exhibit confusion; weakness; lethargy; abdominal, lower
back, and leg pain; extreme fatigue; wet, clammy skin; headache;
nausea; and vomiting
2. The cardiovascular system will deteriorate; pulse may be rapid and
weak; the client may develop hypotension, followed by shock-like
symptoms and unconsciousness or coma
E. Management of emergency
1. Activate the EMS
2. Place the client in supine position with feet slightly elevated
3. Implement CAB; open and maintain the airway
4. Monitor vital signs every 5 minutes (BP, heart rate)
5. Administer high-flow oxygen at rate of 5 to 10 L/min
6. Administer 100 mg of glucocorticosteroid or 4 mg of dexamethasone
IV
7. May need to also administer a vasopressor drug (epinephrine 1:1000,
0.05 mL) if client is unconscious
8. Transport to hospital via EMS

Aspirated Materials2
A. Dental materials and instruments may be aspirated during oral health
care because of the client’s position, diminished responses caused by
drugs, and diminished “oral awareness” caused by local anesthesia
B. Prevention of aspiration of materials can be accomplished through use
of a rubber dam during many dental procedures
C. If a client is already reclining in the dental chair and aspirates an
object into the oropharyngeal area, lower the back of the chair, and place
client on his or her left side, using gravity to assist the client’s efforts to
dislodge the object; encourage coughing; however, the client may want to
sit upright
D. If an object is aspirated into the trachea, activate the EMS; manage as
mild or severe obstruction; the client may want to sit upright to facilitate

1848
breathing and coughing
E. If an object that has been swallowed cannot be located, the client must
be escorted to seek further medical evaluation; a chest x-ray film may be
indicated to rule out aspiration into a lung
Unless specifically noted, client positioning was determined by the
client’s preference. Although not stated, dental treatment was
discontinued at the onset of all emergencies.

1849
Conclusion
This chapter is only an approximate guideline for some common medical
emergencies encountered in dental hygiene practice. Dental
professionals should use standard operating protocols to manage
emergencies and review or practice them regularly. Please consult current
textbooks and journals for detailed information, and refer to the
American Heart Association and American Red Cross for current
protocol and training in BLS, ACLS, and EMS (see “Website Information
and Resources”).

Website Information and Resourc es

1850
References
1 Grimes E. Medical emergencies: essentials for the dental professional.
ed 2 Boston: Pearson; 2014.
2 Malamed S. Medical emergencies in the dental office. ed 7 St Louis:
Mosby Elsevier; 2015.
3 Pickett F., Gurenlian J. Preventing medical emergencies: use of the
medical history. Baltimore: Lippincott Williams & Wilkins; 2009.
4 Bowen D.M., Walsh M.M. Medical emergencies. In: Darby M.L.,
Walsh M.M., eds. Dental hygiene theory and practice. ed 4 St Louis:
Elsevier; 2015.
5 US Department of Health and Human Services. Seventh report of
the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7). NIH Pub No 03-5231
May 2003.
6 American Heart Association. BLS for healthcare providers: student
manual. Dallas: AHA; 2011.
7 Hazinski F., ed. American Heart Association guidelines for CPR and
ECC 2010. Dallas: AHA; 2010.
8 Little J., Falace D., Miller C., Nelson R. Dental management of the
medically compromised client. ed 8 St Louis: Elsevier; 2013.

Chapter 21 review questions

Answers and rationales to review questions are available on this text’s
accompanying Evolve site. See inside front cover for details.

1. Which of the following emergencies occurs when the cells do not

receive enough oxygen because blood is not circulating through the
tissues adequately?
a. Hypertension
b. Shock
c. Asthma
d. Hyperventilation
2. Which automated external defibrillator (AED) can be used on infants
and children ages 1 to 8 years?
a. Manual

1851
 b. Adult automatic
c. Pediatric-capable
d. All the above
3. How frequently can nitroglycerin be administered for the treatment of
angina?
a. 1 tablet every 5 minutes, not to exceed 3 tablets in 15 minutes
b. 2 or 3 tablets every 5 minutes
c. 1 tablet every 10 minutes, not to exceed 3 tablets in 30 minutes
d. 2 or 3 tablets every 10 minutes
4. Your client has had a cerebrovascular accident (CVA). How long
before his next dental hygiene appointment should you have him
discontinue his anticoagulant?
a. The morning of the appointment
b. 2 days
c. 4 days
d. He should continue to take his anticoagulant.
5. Your client has indicated a fear of injections and begins to breathe
rapidly, complains of tingling or numbness, and is experiencing
tachycardia. Your client most likely is experiencing:
a. Hypertension
b. Hyperventilation
c. Congestive heart failure
d. Shock
6. Heart rates of infants and children are slower than an adult’s normal
heart rate, and pediatric rates will vary based on age, gender, and size.
a. Both statement are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
7. Which of the following is the most common type of shock and can be
caused by dehydration from vomiting and diarrhea?
a. Cardiogenic shock
b. Distributive shock
c. Hypovolemic shock

1852
 d. Neurogenic shock
8. Your client is asymptomatic but presents with blood pressure of
168/107 mm Hg. What should you do?
a. Send home and reschedule for a morning appointment in 2 weeks
b. Refer to the client’s physician for a consultation before seeing
c. Provide hygiene and refer to the client’s physician to be seen within 1
month
d. Activate the EMS to have your client taken to the hospital
9. Clients receiving glucocorticosteroid therapy should NOT be seen for
elective dental care. They should postpone treatment until they have
discontinued glucocorticosteroids for at least 1 year.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
10. In addition to administering 0.3 mL of 1:1000 epinephrine and
additional doses if needed, which of the following is also administered
to treat anaphylactic shock?
a. Oxygen at a rate of 5 to 6 mL/min
b. Antihistamine (25-50 mg of diphenhydramine)
c. Corticosteroid (100 mg of hydrocortisone)
d. All the above
11. All the following management procedures should be utilized to
prevent an angina attack for a client with a history of angina EXCEPT:
a. Short appointments scheduled in the late morning or early
afternoon
b. Do not see a client with unstable angina, and refer to his or her
physician
c. Administer low-flow oxygen
d. Use local anesthetic for pain control; maximum 4 carpules of
1:100,000 epinephrine
12. Treatment for shock includes placing the client in the supine position
and monitoring vital signs. Treatment for shock also includes
administering IV fluids.
a. Both statements are TRUE.

1853
 b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
13. Oxygen is used for all the following emergencies EXCEPT:
a. Hyperventilation
b. Syncope
c. Angina
d. Shock
14. If your client’s blood pressure is 125/85 mm Hg, you should check BP
every:
a. 6 months
b. Year
c. 2 years
d. You only need to take a baseline measurement.
15. Stress reduction protocol includes which of the following?
a. Creating a low-stress environment
b. Administering a premedication (optional)
c. Establishing good client rapport
d. All the above
16. Your diabetic client complains that he is very thirsty and nauseated,
and you notice he is flushed, is taking deep rapid breaths, and his breath
has a fruity odor. First, you realize he is suffering from hyperglycemia.
Second, you know the BEST way to manage this emergency is to
administer insulin.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
17. Match the six types of shock to their corresponding causes (a to f).
____ 1. Hypovolemic shock
____ 2. Neurogenic shock
____ 3. Cardiogenic shock
____ 4. Anaphylactic shock
____ 5. Septic shock

1854
 ____ 6. Obstructive shock
a. Obstruction of blood flow prevents the heart from beating
b. Inadequate cardiac output to the peripheral organs and tissues
c. An acute systemic infection prevents blood flow to the cells, tissues,
and organs
d. Vasoconstriction results from impaired nerve impulses to the blood
vessels or loss of sympathetic nerve activity
e. Inadequate blood volume
f. Histamine release causes sudden vasodilation
18. Which of the following is the result of excessive loss of carbon
dioxide?
a. Asthma
b. Hyperventilation
c. Orthostatic hypotension
d. Shock
19. During his appointment, your client is appears flushed, anxious, and
short-tempered. He begins to cough and wheeze, is experiencing
dyspnea, and begins to appear cyanotic. The emergency your client is
experiencing is related to which of the following?
a. Asthma
b. Congestive heart failure
c. Overdose reaction to local anesthetic
d. Angina
20. Emergencies involving diabetic patients occur MOST frequently
with which type of diabetes?
a. Type 1
b. Type 2
c. Gestational
d. Impaired glucose tolerance
21. Nitroglycerin is contraindicated for emergency treatment of angina
or congestive heart failure when the client has which of the following?
a. Hypoglycemia
b. Hyperglycemia
c. Hypotension

1855
 d. Hypertension
22. Which of the following phases of a seizure poses the greatest risk for
a client?
a. Prodromal
b. Ictal
c. Postictal
d. All phases pose equal risk.
23. The FIRST step in preventing a medical emergency is to:
a. Take the client’s vital signs
b. Create a stress-free environment
c. Become familiar with the client’s health history
d. Place the client in the supine position
24. When should EMS be activated when treating an emergency
involving an asthmatic client?
a. At the beginning of the emergency
b. As soon as CAB has been assessed
c. After a bronchodilator and oxygen have been administered
d. If the bronchodilator fails to stop the asthma attack
25. Your client is becoming very talkative and anxious; these are signs of
N2O-O2 oversedation. Management for oversedation of N2O-O2 includes
increasing the client’s oxygen intake and decreasing his nitrous oxide
intake.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
26. Match the six types of shock with the corresponding signs and
symptoms (a to f).
____ 1. Cardiac shock
____ 2. Anaphylactic shock
____ 3. Septic shock
____ 4. Obstructive shock
____ 5. Hypovolemic shock
____ 6. Neurogenic shock

1856
 a. Difficulty breathing, hypotension, bronchoconstriction, respiratory
arrest
b. Severe hypotension and dyspnea
c. Rapid thready pulse, cool clammy skin, confusion, weakness, pallor,
dehydration, decreased urine output
d. Peripheral cyanosis, chest pain, shortness of breath, hypotension,
confusion, rapid weak pulse, cold clammy skin
e. Tissue edema, pink warm skin, fever, vasodilation, tachycardia,
restlessness and anxiety, thirst, increased cardiac output, eventual
respiratory failure
f. Hypotension, bradycardia, peripheral vasodilation
27. During an emergency involving a toxic overdose of a local anesthetic,
how frequently will vital signs be monitored?
a. Constantly
b. Every 5 minutes
c. Every 10 minutes
d. At the beginning and end of the appointment
28. Normal respiration rates for adults and children are 12 to 20
respirations a minute; normal rates for teens are between 20 and 25
respirations a minute.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
29. How long after a CVA can a client be seen for dental care?
a. Immediately
b. 1 month
c. 3 months
d. 6 months
30. Which of the following statements is NOT correct concerning a
woman in the last trimester of pregnancy?
a. Chest compressions should be performed above the center of the
sternum.
b. Chest thrusts should be performed for a foreign body obstruction.
c. Oxygen demands increase.

1857
 d. While in the supine position, the client’s left hip should be elevated
to displace the uterus in order to increase cardiac output and oxygen
reserve.
31. Systolic pressure is measured when the heart is relaxed. Pulse
pressure is the difference between diastolic and systolic pressure.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
32. It may be beneficial to have your asthmatic clients take a
prophylactic dose of a bronchodilator prior to a dental appointment. In
the event of an emergency with an asthmatic client, position the client in
the supine position.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
33. All the following increase body temperature EXCEPT:
a. Exercise
b. Smoking
c. Shock
d. Pathologic condition
34. Your client has no history of angina and begins to experience a
crushing, squeezing pain in his chest and down his left arm. The pain is
not subsiding with movement. What should you do FIRST?
a. Administer 1 nitroglycerin tablet, wait 5 minutes, and if pain does
not subside, administer a second tablet
b. Administer 2 nitroglycerin tablets, wait 5 minutes, and administer 1
more tablet
c. Administer oxygen
d. Summon EMS
35. Which of the following is the BEST way to stop hyperventilation?
a. Have the client cup the hands over the mouth and nose and take
slow, deep breaths
b. Have the client breathe into a paper bag

1858
 c. Administer low-flow oxygen
d. Administer high-flow oxygen
36. All the following can cause an increase in heart rate EXCEPT:
a. Fasting
b. Exercise
c. Anxiety
d. Heat
37. Your client is elderly, fairly sedentary, and is taking medications for
hypertension. His blood pressure at the beginning of the appointment is
140/90 mm Hg. He has been in the supine position for 45 minutes. When
you raise the chair to the upright position, he begins to feel lightheaded
and nauseated. You notice him sweating and becoming pale. You check
his BP again, and it is now 115/85 mm Hg. What is your client
experiencing?
a. Hypertension
b. Orthostatic hypotension
c. Syncope
d. Hypotension
38. The new American Heart Association guidelines for CPR are:
a. Airway, circulation, breathing
b. Airway, compressions, breathing
c. Circulation, airway, breathing
d. Compressions, airway, breathing
39. Your post-CVA client has a blood pressure of 165/97 mm Hg. What is
the protocol care?
a. Check your client’s BP at the end of the appointment
b. Monitor your client’s BP every 5 minutes
c. Refer your client for an immediate consultation with the physician
d. Continue as you normally would, since there is no concern
40. During an emergency, which of the following pulse points is used to
determine a client’s pulse rate?
a. Brachial
b. Radial
c. Carotid

1859
 d. Femoral
41. Clients experiencing syncope should be placed in the supine position,
and aromatic ammonia should be administered.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
42. Which of the following should be monitored when checking
respirations?
a. Rhythm
b. Rate
c. Breathing sounds
d. All the above
43. Body temperatures are higher in the:
a. Early morning
b. Late morning
c. Early afternoon
d. Late afternoon
44. A transient ischemia of the heart is known as:
a. Cardiogenic shock
b. Anaphylactic shock
c. TIA
d. Angina
45. A heart rate of 105 is considered:
a. Normal
b. Bradycardia
c. Tachycardia
46. How long after a dose of nitroglycerin should angina pain lessen?
a. Instantly
b. 2-4 minutes
c. 5-8 minutes
d. 10-15 minutes

1860
Case A
Your client is a 61-year-old man who is 5′5″ tall and weighs 220 pounds.
His vital statistics are blood pressure (BP) 175/108 mm Hg, pulse 98, and
respirations 20. He is under the care of a physician. He was hospitalized
3 months ago for a heart attack. Three years ago, he had a pacemaker
placed as an outpatient. He is currently being treated for hypertension
and heart disease.

Use Case A to answer questions 47 to 53.

47. How frequently should vital signs, including BP, be taken for your
client?
a. Frequency of vital signs monitoring depends on the BP guidelines;
follow the BP classification
b. Every year
c. Before each appointment
d. Before and after each appointment
48. How soon after your client’s myocardial infarction could he be
scheduled for his hygiene recall appointment?
a. 1 month
b. 3 months
c. 6 months
d. The amount of time does not matter
49. Based on this client’s BP, he has stage II hypertension. He should be
dismissed and told to see his physician immediately.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
50. All the following procedures are considered to be preventive care for
a client with a previous myocardial infarction EXCEPT:
a. Schedule short appointments
b. Administer oxygen with a flow rate of 8 to 12 L/min
c. Administer N2O-O2 sedation
d. Maintain adequate pain control through the administration of no
more than 2 carpules of lidocaine with 1:100,000 epinephrine

1861
51. Your client begins to complain of a crushing feeling in his chest; he
appears ashen gray and begins to exhibit a cold sweat and dyspnea. He
complains of nausea, dizziness, and weakness, and he thinks he is going
to die. First, you realize your client may be experiencing a myocardial
infarction. Second, you should immediately contact the EMS and
implement CAB.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is true; the second statement is FALSE.
d. The first statement is false; the second statement is TRUE.
52. Which of the following should be administered to your client?
a. Oxygen (4-6 L/min)
b. Nitroglycerin (1 tablet every 5 minutes, not to exceed 3 tablets in 15
minutes)
c. Aspirin (160-325 mg)
d. All the above
53. You have been monitoring your client’s vital signs and assessing
CAB, and he goes into cardiac arrest. You will have to use the
defibrillator. Where will you put the electrodes?
a. Directly over the pacemaker
b. The opposite side of the pacemaker
c. One inch to the side of the pacemaker
d. The defibrillator cannot be used on a client with a pacemaker

Case B
Your retired 82-year-old client has been coming to see you for many
years. He is 5′10″ tall and weighs 250 pounds. His vital signs are blood
pressure 150/95 mm Hg, pulse 83, and respirations 20. He is under the
care of a physician and being treated for angina, heart failure, and
diabetes. Today your client has an ashen color, and when you shake his
hand, it feels very cold. During the health history interview, he informs
you that his ankles have been swelling. He presses on his ankle, and it
remains pitted. On the head and neck exam, you notice a prominent
jugular vein.

Use Case B to answer questions 54 to 58.

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54. What is the MOST likely cause of your client’s symptoms?
a. Angina
b. Diabetes mellitus
c. Left ventricular failure
d. Right ventricular failure
55. What is the treatment regimen for your client on this visit?
a. Normal hygiene appointment
b. Shortened hygiene appointment because the longer appointments
will increase his stress
c. Reschedule for next week, when he is exhibiting less symptoms
d. Refer your client to his physician before you see him again
56. When your client has been cleared by his physician to receive dental
care, you can take measures to help prevent an emergency. Positioning
your client in the upright or semi-supine position is one measure.
Another measure is to administer low-flow oxygen at a rate of 3 to
4 L/min.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
57. While working on the maxillary arch, you notice your client has a
slight dry cough and is beginning to wheeze. He coughs into a tissue,
and you notice his sputum is frothy and tinged with blood, and he
develops dyspnea. First, you realize your client is experiencing acute
pulmonary edema. Second, you should immediately contact EMS, calm
your client, and implement CAB.
a. Both statements are TRUE.
b. Both statements are FALSE.
c. The first statement is TRUE; the second statement is FALSE.
d. The first statement is FALSE; the second statement is TRUE.
58. Once the EMS has been contacted, which of the following should be
administered to your client?
a. Oxygen
b. Nitroglycerin
c. Morphine

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d. All the above

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C HAPT E R
22

1865
Ethical and Legal Issues
Pamela Zarkowski*

Understanding and applying legal and ethical principles protects the

provider (dental hygienist), the client, the employer, and the employee.
Dental hygienists make decisions that are influenced by laws and ethics.
At times, these decisions are clear; at other times, ethical dilemmas
create conflict with employers, colleagues, or clients. Dental hygienists
must be cognizant of the laws governing the employer-employee
relationship and influencing the responsibilities and rights of the parties
involved. This chapter reviews the laws and ethics most closely
associated with the dental hygiene profession.

1866
Ethical considerations
A. Definitions
1. Ethics—the science of human duty; correlate motives and attitudes
with moral actions and values
2. Professional ethics—rules or standards governing conduct of
members of a profession
3. Bioethics—ethical and moral implication of new biologic discoveries
and biomedical advances
B. Ethical theories
1. Are the foundation of ethical analysis; explain moral principles
2. Provide a basis for ethical rule, policy development, or both
3. Assist in the resolution of ethical dilemmas
C. Three major theories
1. Teleologic/utilitarian ethics (John Stuart Mill)—comprise rules for
conduct based on consequences of action; an action is considered
right or wrong on the basis of its usefulness; useful actions bring
about the greatest good for the greatest number of individuals
a. Act utilitarianism—examines a situation and determines which
course of action will bring about the greatest happiness or least
harm and suffering to an individual regardless of personal
feelings or societal constraints such as laws
b. Rule utilitarianism—searches for the greatest happiness and
seeks public agreement to define nature of happiness; considers
the law and fairness; an action is considered right if it conforms
to a rule; the rule should have positive results in a wide range of
situations
2. Deontologic ethics (Immanuel Kant)—focus on the morality of the
act rather than the situation or consequences of actions; one would
say, “It’s the principle of the thing”; a person’s intention, not the
consequences of the action, is key; three important elements: applied
universally to all individuals, unconditional, and demand an action
a. Act deontology—based on personal moral values of the
individual making the decision and considers the ethical
principles involved in an action in light of the circumstances; for
example, avoid the truth if it is harmful
b. Rule deontology—based on the belief that certain standards for
ethical decisions are of greater value than an individual’s moral
values; considers the principles and rules in general as they
apply to types of actions
3. Virtue ethics (Aristotle and Plato)—focus on character traits and

1867
 excellence of character; evaluate ethical dilemma by asking, “Is this
what a virtuous person would do?”
4. Other theories
a. Situational ethics—course of action determined by:
(1) The unique characteristics of each individual
(2) The relationship between the health care provider and the
client
(3) The most humanistic action in a given circumstance
b. Principalism—focuses on ethical principles, including
autonomy, veracity, beneficence, nonmaleficence, and justice
c. Professional codes of ethics—designed in a rule-making format;
may include aspirational statements, usually directs decision
making among professionals more than ethical theories
D. Universal principles
1. Veracity—truthfulness; mutual responsibility for the client and the
provider; for example, the client must be truthful to receive
appropriate care, and the provider must provide truthful
information so that the client can exercise his or her autonomy
2. Autonomy—personal liberty; individuals are free to make decisions
regarding their own health; respect for the individual autonomy of
others is basic to the health care provider–client relationship;
informed consent and informed refusal is basic to autonomy (see
discussion on informed consent later in this chapter)
3. Beneficence—the provider ’s duty is a commitment to the health and
welfare of the client above all other considerations; duty to prevent
or remove harm and promote good
4. Nonmaleficence—the provider ’s duty not to use the treatment to
injure or wrong the client; inflict no harm
5. Fidelity (role fidelity)—health care providers are required to provide
services within the scope of their practice; ethics require that health
care providers practice within the constraints of the role assumed
within the health care environment; the provider is expected to
follow through with commitments
6. Confidentiality—based on an individual’s right to privacy; for
example, a client has the right to expect all his or her medical records
and communications to be kept confidential
7. Justice—fair and equitable treatment of clients

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Professionalism
Defining a Profession
A. Characteristics of a profession
1. Special advanced education or preparation
2. Identifiable membership
3. Strong service orientation
4. Promotion of a body of knowledge in the field (research and theory
development)
5. Autonomy of practice
6. Self-regulation
7. The recognized authority with societal sanction
8. Primarily intellectual nature of the work
9. Adherence to a code of ethics
B. Code of ethics
1. Historical evidence of Western medical ethics traced to guidelines
outlining the duties of physicians
2. Early evidence included oaths and rabbinic and Christian sources
3. Common themes include:
a. Respecting autonomy
b. Preventing harm
c. Protecting confidentiality
4. Hippocratic Oath—fifth century bce; statement of principles guiding
the professional conduct of physicians
a. Interpreted to advocate, “Above all, do no harm,” or “First, do
no harm” (The phrase is not found in the original code)
b. Protected the rights of the patients
c. Admonished physicians to maintain patient confidentiality
d. Placed needs of patient above those of society
e. Placed an obligation on physicians to teach the next generation
of physicians
5. Ethical codes for health care professionals continue to be evaluated
and revised to reflect:
a. Current practice issues
b. Protections for population groups that are subjects in research
investigations
c. Identification of impaired health care providers
d. Professional responsibilities
e. Use of social media
6. Common elements of codes

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 a. Self-imposed—the health care professional self-assesses and
determines compliance; range of sanctions from a professional
organization or licensing agency for lack of compliance
b. Set rules governing behavior—the professional uses them as a
framework for action
c. Serving to protect the public—on the basis of ethical principles
that support actions to benefit the client and prevent harm
d. Striving to enhance the profession—adherence to code
characterizes a profession
e. Providing a framework for ethical decision making
7. American Dental Hygienist's Association (ADHA) Code of Ethics
and the Canadian Dental Hygienists Association (CDHA) Code of
Ethics
a. Identify and describe ethical principles to guide the oral health
care provider
b. State the obligations and responsibilities of the dental hygienist
(1) Personal and professional obligations and responsibilities
(2) Obligations and responsibilities to the public and the
scientific community
8. Codes of Ethics—compare all codes
a. For the ADHA’s Code of Ethics, visit the website at
https://www.adha.org/resources-
docs/7611_Bylaws_and_Code_of_Ethics.pdf (also see Appendix
C)
b. For the CDHA’s Code of Ethics, visit the website at
http://www.cdha.ca/CDHA/The_Profession/Resources/Code_of_Ethics.as
c. For the American Dental Association’s Code of Professional
Responsibility and Conduct (revised April 2012), visit the
website at
http://www.ada.org/~/media/ADA/About%20the%20ADA/Files/code_of_
9. Client’s Bill of Rights—outlines client expectations and provides
guidelines for provider conduct; the client has the right to:
a. Respectful, competent, and considerate care irrespective of
ethnicity, gender, national origin, age, or disability
b. Receive current, accurate, and complete information regarding
diagnosis, treatment, and prognosis
c. Receive information necessary to give informed consent or
informed refusal before treatment; be informed of the
consequences of refusing treatment
d. Confidentiality regarding all communications, consultations,
and records except when permission has been granted to submit

1870
 this information to others
e. Obtain information relating to the credentials of all providers
rendering services
f. Reasonable continuity of care
g. Examine and receive accurate copies of professional services
and fees
h. Receive treatment from health care professionals who act within
the limits of their professional licenses (scope of practice) and
adhere to the standard of care in delivering services
10. Types of professional credentials
a. Licensure—state regulation of professionals
(1) Granted by a state agency or board
(2) Limits practice to:
(a) Responsibilities and behaviors prescribed by law in
the state practice act in the United States or
determined by the provincial practice act in Canada
(b) Responsibilities and behaviors delineated by rules
and regulations
(3) Authorized practice by professionals meeting specified
qualifications
(4) Failure to meet responsibilities and expected behaviors
may result in fines, suspension, or removal of license
(5) Status of provider ’s license available to public; may
indicate current license status (e.g., active, pending,
suspended)
(6) The purpose is to protect the public from unqualified or
unethical providers
b. Registration—qualified professionals listed in a directory
(1) Dental hygiene is a self-regulated profession in most
Canadian provinces, and registration is a provincial
responsibility (e.g., College of Dental Hygienists of Ontario
http://www.cdho.org/Registration.asp)
(2) A certificate of registration to practice is issued only to
those who meet established standards of qualification and
practice
c. Certification—state or national recognition
(1) Recognition by a nongovernmental agency (e.g., a
professional association)
(2) Identification of professionals who have met specified
qualifications

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Ethical issues in public policy
A. Ethical issues and public policy
1. Distributive justice—fair allocation of resources involved
a. Macro-allocation of resources—based on public needs (e.g.,
water fluoridation)
b. Micro-allocation of resources—based on individual needs (e.g.,
fluoride varnish treatment)
2. Distributive justice or allocation of scarce resources—determination
of who should receive treatment when all cannot be treated; services
may be allocated on basis of:
a. Equity—all persons receive equal treatment
b. Need—treatment allocated on the basis of prioritized needs
c. Effort—treatment allocated to those who have earned it
d. Contribution—treatment allocated to those who are making a
contribution to society
e. Merit—treatment allocated to those who are most deserving
3. Influenced by principles of human dignity and human rights and
contributing to the common good
4. Current health policy debates
a. Question of whether public health funds should be used for:
(1) Financial assistance and care of the disadvantaged or
seniors
(2) Financial assistance and care for undocumented
immigrants
(3) Financial support for victims of:
(a) Acute or chronic diseases
(b) Personal choices (e.g., tobacco use, risky lifestyle)
(4) Provision of health care services
(a) Appropriate range of services provided
(b) Impact of public versus private funding on the:
[1] Consumer and taxpayer
[2] Provider
[3] Third-party payer
[4] Government (local, state, federal, or all)
(c) Concerns about authority in treatment decisions
(d) Tele–health care
(e) Expanded scope of practice for midlevel providers
(f) Delegation of responsibility to nonhealth providers
b. Research
(1) Identification of appropriate decision makers to identify

1872
 and prioritize research agendas, especially for controversial
topics (e.g., stem cell research)
(2) Identification of sources of financial support (e.g., what
proportion of the national budget should be allocated to
health care and research)
B. Public policy
1. A system of plans of action, regulatory measures, laws, and funding
priorities concerning a specific topic or issue
2. Promulgated by a governmental entity or its representatives
3. Public policy is typically embodied in constitutions, legislative acts,
and judicial decisions
C. Creating public health policy
1. Goal—assessment of a variety of actions and consequences to solve
identified societal problem
2. Action—a decision by all members of society or their elected
representatives (e.g., public vote vs. state legislature passing statute
regarding mandatory use of seat belts)
3. Analysis—determining which policy among alternatives best
achieves the goal, how policy should be implemented, or how to
evaluate what is currently being done
D. Policy makers—usually legislators, members of executive branch of
government, and government officials who write regulations
E. Policy analysts—provide policy makers with information required to
determine the impact of past and current public policies; determine
whether new policy should be implemented or present policy or no
policy should continue
F. Examples of community-based programs requiring public policy
analysis
1. Federal or state partnerships to provide oral health services
2. Fluoridation initiatives (e.g., community water fluoridation and
school fluoride programs)
3. Caries prevention programs such as dental sealant or fluoride
varnish programs in public health settings
4. Provision and funding of oral health care services by nondental
personnel
G. Policy makers may seek input from professionals or professional
associations; health-related professional associations frequently hire
lobbyists to influence government policy makers
H. Distinctions between ethics and law
1. Laws are societal mandates, whereas ethics are professionally based
2. Ethical principles and legal doctrine are related

1873
 a. Ethical principles integral to federal and state legislation that is
enacted
(1) Obligation to obtain informed consent (client autonomy)
(2) Health Insurance Portability and Accountability Act
(HIPAA) regulations (confidentiality)
(3) Discrimination protections for clients with specific disease
states such as human immunodeficiency virus (HIV)
infection (justice)
(4) Tort regulation (nonmaleficence)
(5) Occupational Safety and Health Administration (OSHA)
regulations (beneficence)
b. Ethical issues inherent in the litigation of cases
3. Ethical duties are usually greater than legal duties; for example, a
health care provider who is acquitted in civil or criminal court after
being charged with illegal conduct did not necessarily act ethically
4. Compliance with the law sometimes mandates unethical conduct—
health care providers are ethically and legally bound to keep
confidential all client communications and records; however, the law
makes exceptions and requires disclosure to appropriate authorities
in specific situations (e.g., in cases of suspected child or elder abuse
or threats of inflicting bodily harm to another person or self)
5. Personal values not necessarily congruent with professional ethics or
the law—under law, individuals have a right to control their own
bodies; this includes the right to refuse medical or dental treatment;
health care providers must honor this right despite their own
personal values
6. Differentiating between ethics and law (Table 22-1)

1874
Table 22-1
Differentiating Between Ethics and Law

Ethics Law
Definition Individual Rules and regulations by which society is governed set forth
interpretation of in a formal and legally binding manner
the nature of
right and wrong
and rules of
conduct
Source Internalized; Externalized rules and regulations of society
individual
nature and
beliefs
Emphasis Individual moral Social behaviors that are good for society as a whole
behavior for the
good of the
individual
within society
Conduct Motives and Overt conduct of the individual; what a person actually did or
reasons why the failed to do
individual
behaves the way
he or she does
Sanctions Professional Judicial and administrative bodies—criminal sanctions such as
organization— fines and imprisonment imposed by the courts; civil sanctions
expulsion from such as monetary damages imposed by the courts;
the organization disciplinary sanctions such as fines, license suspension, or
license revocation by a board of dentistry

1875
Legal concepts
A. Law defined
1. Rules and regulations that govern society
2. Reflects society’s attitudes, mores, and needs; therefore, law is
constantly changing to meet the requirements and expectations of
society
B. Sources of law
1. U.S. Constitutional law
a. Constitutional law—supreme law of the land; both state and
federal laws must be consistent with the U.S. Constitution
b. The U.S. Constitution establishes the organization of the federal
government and places limitations on the federal government
through the Bill of Rights (first 10 amendments to the U.S.
Constitution)
c. Delineates the specific powers of the federal government to the:
(1) Executive branch (Office of the President)
(2) Legislative branch (U.S. Congress)
(3) Judicial branch (U.S. Supreme Court)
d. Powers not specifically granted to the federal government are
the powers of state government
e. Each state has its own constitution that grants powers and
places limitations on the powers of the state government
2. Statutory law
a. Laws made by the legislative branch of government (federal,
state, and local governments)
b. State dental practice acts are examples of statutory laws
3. Administrative law
a. Administrative agencies are given the authority to oversee the
specific laws or statutes to ensure that the intent of the law is
enforced
b. Administrative laws are the results of decisions of
administrative agencies; for example, state boards of dentistry
and the College of Dental Hygienists of Ontario implement
rules and regulations to enforce the law
c. Administrative agencies may conduct investigations and
hearings and may issue decisions that suspend or revoke the
license of a dentist, dental hygienist, or dental assistant;
decisions of administrative agencies may be appealed through
the state court system to determine whether:
(1) The agency complied with the regulation

1876
 (2) Evidence supports the agency’s decision
(3) The agency exceeded its authority
(4) The delegation of power to the agency was proper
(5) The agency followed proper procedures
(6) The agency acted in an arbitrary or capricious manner
4. Judicial law
a. Determined by courts (state, provincial, and federal), which
interpret legal issues in dispute
b. Stare decisis1 (Latin, meaning “let the decision stand”)—doctrine
of law whereby the court will base its decision on previous case
law (a prior case with similar facts); the previous case must be
from the same jurisdiction (state); emphasizes the importance
of legal precedent
c. Landmark decisions—court decision that departs from
precedent; for example, new technology may require different
conclusions based on the same facts
d. Res judicata1 (Latin, meaning “a thing or matter settled by
judgment”)—legal doctrine that applies when a legal ruling has
been made by a competent court of jurisdiction, and no appeals
are possible; prevents parties from taking the same issues to
different courts
C. Classifications of law (Fig. 22-1)

FIG 22-1 Classifications of law as it relates to dental hygiene practice.

1. Common law and civil law—two concepts of legal thought, one from
England (common law) and one from Europe (civil law)

1877
 a. Common law—general principles derived from decisions in case
law using the concept of precedent
b. Civil law—civil code system developed by legislature, based on
rules and regulations; enforced through the court system and
protects the legal rights of private persons
c. Level of proof—preponderance of evidence; the greater weight
of the evidence required in a civil (noncriminal) lawsuit for jury
or judge without a jury to decide in favor of one side or the
other
2. Criminal law—relates to acts considered offensive to society as a
whole
a. Classifications of crimes
(1) Misdemeanors—usually involve fines of less than $1000 or
imprisonment for less than 1 year, or both; examples
include vandalism, trespassing, and reckless driving
(2) Felonies—serious crime; usually involve punishment
ranging from fines of more than $1000 or imprisonment of
more than 1 year (or both); receiving a death sentence
depending on the crime committed and the jurisdiction
(state); examples include robbery, illegal drug use or sale,
and battery
b. Certain violations of law may be considered both criminal and
civil; for example, if a client loses his or her life resulting from
gross negligence of a dental hygienist, the estate of the deceased
person could bring civil charges such as wrongful death against
the hygienist, and the state may bring criminal action such as
manslaughter against the hygienist
c. Level of proof—“beyond a reasonable doubt” required to
determine innocence or guilt in a criminal case; the level of
certainty a jury must have to find a defendant guilty of a crime
D. Primary individuals involved in a lawsuit
1. Plaintiff—party bringing the lawsuit
2. Defendant—party against whom the lawsuit is filed
3. Attorney—individual serving as an advocate for either the plaintiff
or the defendant
4. Expert witness—explains specialized information to jurors;
possesses appropriate credentials and expertise
5. Lay witness—testifies as to facts for judge and jury
6. Dental hygienist as a witness (lay or expert)
a. Expert qualifications based on education, licensure or
certification, experience, and publications

1878
 b. Expertise to testify as to standard of care for dental hygiene
c. Familiarity with the state or provincial dental practice act
d. Knowledgeable about all records (written or electronic) relating
to the controversy
e. Knowledge of office, agency, or institutional policy and
procedure where (and at the time) the incident occurred
7. Cannot be lay witness if named in lawsuit
E. Due process and equal protection
1. Due process—protects the public from arbitrary actions of the state;
the law must apply to all persons equally; elements of due process
a. The law, as applied, must be reasonable and definite
b. Fair procedures must be followed in enforcing the law; for
example, the state may not arbitrarily take away a license to
practice dental hygiene; the hygienist must first be given notice
of the violation, a hearing, and an opportunity to respond before
license revocation or suspension is imposed
2. Equal protection—equal protection clause of the Fourteenth
Amendment to the U.S. Constitution protects individuals from state
action; states may not enforce laws based solely on classification of
persons such as race, age, gender, religion, national origin, or
disability
F. Judicial process
1. Questions of law or fact—usually the jury determines what is fact
from the evidence admitted by the court; the judge determines
questions of law
2. Jurisdiction of the courts—authority of the court to determine the
controversy; for example, the bankruptcy court may not hear divorce
cases
3. State courts
a. Trial courts—courts with trial jurisdiction; usually handle cases
such as traffic, probate, family matters, arraignments for
felonies, small claims, juvenile, and criminal misdemeanors
b. Appellate courts—courts with trial, appellate, civil, and criminal
jurisdiction; usually with a monetary restriction (plaintiff must
request a fair minimum amount)
c. State supreme court—appellate jurisdiction only
4. Federal courts
a. Federal district courts—courts with trial jurisdiction; hear only
matters that involve federal law or parties with diversity of
citizenship (residents of different states)
b. U.S. Courts of Appeal—courts with appellate jurisdiction only

1879
 c. U.S. Supreme Court—court with appellate jurisdiction only;
decisions cannot be overturned by any other court (state or
federal); decisions can only be changed by new congressional
legislation or subsequent Supreme Court decisions
G. Statute of limitations
1. Each state (or province) has a statute (law) that delineates specific
periods within which a lawsuit must be filed after the event that
caused the action; after that period, the right to initiate a lawsuit is
lost
2. In tort actions, time may be measured from the time of the injury or
harm or may be measured from when the plaintiff discovers the
injury; periods vary from state to state
H. Case law—case law comprises the decisions, or the interpretations
made by judges while deciding on the legal issues before them which are
considered common law or as an aid for interpretation of a law in
subsequent cases with similar conditions; case law is used by attorneys to
support their views to favor their clients; it also influences the decisions
of the judges; it is public record (occasionally court records are sealed)
1. Legal decisions available in publications appropriate for the level of
the court where the case was tried; most decisions of state appellate
courts are published in regional reports
2. Citations—references to legal authority that provide key information
about the case; for example, in the following citation, Edwards v Penn.
Dental Examining Board, 454, A2d 218 (1983): Edwards is the plaintiff
(party bringing the lawsuit), the Dental Board is the defendant
(party against whom the lawsuit is filed), 454 is the volume number
of A2d (second series of the Atlantic Regional Reporter); 218 is the
page number; and 1983 is the year the case was decided

1880
Civil law and the dental hygienist
A. A lawsuit can be filed against an oral health care provider in two areas
of civil law:
1. Contract violation
2. Tort violation
B. Contract law1—a contract is an agreement between two or more
consenting and competent parties to do or not to do a legal act for which
sufficient consideration exists; breach of contract occurs if either party
fails to comply with the terms of the contractual obligations
1. Two methods to create a contract:
a. Implied contract through signs, inaction, or silence; also called
apparent
b. Express contract entered through oral or written
communication
2. The contract exists between a client and a health care provider when
the client agrees to a specific treatment
3. Contractual responsibilities of the provider to the client
a. Possess proper license and certification
b. Exercise reasonable skill, care, and judgment in diagnosis and
treatment
c. Use standard drugs, materials, and techniques
d. Complete the treatment in a reasonable time
e. Never abandon the client
f. Complete procedures consented to by the client
g. Provide adequate instructions
h. Refer appropriately
i. Maintain confidentiality and client privacy
j. Maintain an appropriate level of knowledge and skill
k. Practice within the scope of practice; never exceed the defined
scope
l. Maintain accurate records
m. Comply with all laws regulating practice
n. Practice in a manner consistent with a code of ethics
4. Contractual obligations of the client
a. Pay a reasonable fee in a reasonable time
b. Cooperate in care
c. Keep appointments
d. Provide accurate history and information
e. Follow instructions
f. Keep the dental provider aware of status

1881
 g. Follow home care instructions
5. Client-practitioner relationship—contractual; both are free to enter
or decline the relationship; a practitioner may decline to undertake
treatment of a client unless the practitioner has agreed to treat the
client by participating in a specific dental insurance plan or the
practitioner is employed by another who makes treatment decisions;
if the practitioner offers services to the public, he or she may not
refuse to treat clients because of race, color, gender, religion,
national origin, disability, or any other basis that would constitute
invidious discrimination; being bound to the code of ethics assumes
a preexisting relationship between the client and practitioner
6. Termination of the client-practitioner relationship may be by:
a. The client
b. The practitioner, after giving the client notice and an
opportunity to secure an alternative source of future treatment
7. Abandonment1—failure of a health care professional to provide
services after the professional has established a relationship with the
client; duty to the client to complete all treatment started; clients
may be dismissed from future treatment
C. Tort law1—deals with civil wrongs committed against a person or a
person’s property; wrongful conduct
1. Unintentional torts
a. Negligence and malpractice
(1) Negligence—failure to use such care as a reasonable
person would use under similar circumstances
(2) Malpractice—wrongful acts of professional persons;
usually failure to meet the standard of care or failure to
foresee consequences that one with his or her particular
skills and education should foresee
b. Elements of negligence or malpractice, which must be shown in
order for a lawsuit to go forward
(1) Duty owed to the client (the plaintiff)
(2) Breach of the duty by the professional or the defendant
(3) Harm to the client (the plaintiff)
(4) Causation—harm must be caused by breach of duty;
foreseeability, that is, the event may reasonably be expected
to cause the result
c. Standard of care—the degree of care that a reasonably prudent
professional should exercise; minimum requirements of
acceptable client care; for example, practicing within the rules
and regulations of the state or provincial dental practice act

1882
 d. Damages (awarded to the defendant; to restore injured party)
(1) Special damages—actual expenses
(2) Nominal damages—at the court’s discretion (could be $1)
(3) General damages—part of harm; difficult to determine
(e.g., can include pain and suffering)
(4) Contract damages—for breach of contract
(5) Punitive damages—to punish deliberately wrongful
conduct (usually not covered by liability insurance)
(6) States may place a cap on the maximum allowable
damages that can be paid
e. Res ipsa loquitur1 (Latin, meaning “the thing speaks for itself ”)—
legal doctrine that permits the plaintiff to prove negligence or
malpractice without proving fault; no expert testimony required
if the plaintiff shows a particular result occurred and would not
have occurred except for someone’s negligence
(1) The type of injury does not occur unless negligence has
occurred
(2) The injury is caused by something or someone under
exclusive control of defendant
(3) The injury was not caused by plaintiff by contributing to
own injury in any manner (no contributory negligence)
f. Defenses to unintentional torts (protect defendant from
liability)—not limited to, but include:
(1) Statute of limitations—time limit for initiating lawsuit has
passed
(2) Comparative or contributory negligence—injured party is
held responsible for a portion or all of the injury (states or
provinces differ regarding degree of responsibility)
(3) Release—signed during the settlement of claim to prevent
future claims
(4) Immunity—protection from prosecution; for example, the
action may fall within a state’s Good Samaritan law
(5) Defense of fact—no causation exists
2. Intentional tort—an act must be willful; the defendant must have
intended to cause the harm or injury; the act must have been a
substantial factor in bringing about the injury
a. Assault—any action that places one in fear of bodily harm (e.g.,
threatening behaviors)
b. Battery—intentional infliction of offensive or harmful bodily
contact; unwanted touching
c. Defamation—communication to a third person of an untrue

1883
 statement about another person
(1) Libel—written defamation (e.g., untrue or unflattering
statement entered into a client’s record)
(2) Slander—spoken defamation (e.g., discussing an employer
in a derogatory manner while dining in a restaurant and
being overheard by a third person)
d. Invasion of privacy—protects one’s right to privacy
(1) Intrusion on seclusion—invasion of a private place or
affairs of another; must be highly offensive to a reasonable
person
(2) Appropriation—use of another ’s name or likeness for
financial gain (e.g., unauthorized photographs of dental
clients used in a research article or textbook)
(3) Publicity of private life—publicizing details of another
person’s private life; must be highly offensive to a
reasonable person; health care professionals must not
disclose a client’s information without written authorization
(e.g., no disclosure of client information over the phone or
via email or to client’s relatives, including spouse or friends)
(4) False light—putting another person before the public eye
in a false light; highly offensive to a reasonable person
e. Infliction of mental distress—outrageous conduct that causes
emotional distress; behavior must be beyond standards of
rudeness; behavior was intended to cause mental distress and
actually did cause mental distress (e.g., publicly revealing
client’s nonpayment; notifying neighbors or relatives of
nonpayment)
f. Fraud or intentional misrepresentation—intentional perversion
of truth (misrepresentation) for the purpose of gaining another
person’s trust and reliance whereby that person suffers harm or
loss as a result of trusting and relying (e.g., never guarantee
treatment outcomes)
g. Interference with advantageous relations—generally prevents
an individual from interfering with the gainful employment of
another; name and definitions may vary from state to state;
giving a former employee a poor reference is not a basis for this
tort
h. Wrongful discharge—illegal termination of an employee; most
dental hygienists are hired without employment contracts and
are employees-at-will; they can be fired for any reason except:
(1) If reason for firing was against federal and/or state anti-

1884
 discrimination laws (e.g., pregnancy of employee)
(2) If firing is against public policy (e.g., sexual harassment or
“whistleblower ” cases)
(3) Office policy and procedures (oral and written) may be
considered an implied employment contract (e.g., office
manual must address the issue in controversy)
i. Defenses against intentional torts are not limited to, but include:
(1) Statute of limitations—whether the time limit for initiating
lawsuit has passed
(2) Privilege—person making the statement has the duty to do
so; for example, dental hygienists are often required by
state law to report cases of suspected child abuse; in that
case, they are not held legally liable for doing so
(3) Disclosure statutes (state and federal)—permit access to
client records by specific individuals or agencies without
client consent (e.g., workers’ compensation statutes allow
for such access to client information if a claim is filed)
(4) Consent—oral, implied by law (e.g., during emergencies,
when a client is not capable of consent) or apparent (e.g.,
client sits in dental chair and opens mouth for an
examination)
(5) Self-defense or defense of others—behavior is justified to
protect self or others from harm; if force is necessary, one
may use only the amount of force necessary for protection
(reasonable force)
(6) Necessity—allows personal property to be confiscated
(e.g., weapon)
3. Informed consent—from concept of battery and individual rights to
make choices regarding own body
a. Content—legal requirements vary from state to state; in general,
a client must have information that a reasonable person would
find material in making a decision regarding treatment
b. Client should be told in a language or format that the client can
understand
c. Specifically, client must be informed of:
(1) Diagnosis
(2) Proposed treatment and benefits
(3) Risks regarding proposed treatment and chances of
success
(4) Alternative forms of treatment; and benefits; risks
associated with the alternatives offered

1885
 (5) Prognosis if treatment is refused
(6) Provided with an opportunity to ask questions
(7) Needs to sign a consent form indicating that the client
fully understands the information provided (minimum to
no technical language on form, or explanation provided if
technical language is used)
d. Competency of consent
(1) Client must be of legal age and mentally competent (able
to understand material facts)
(2) Consent must be based on knowledge and understanding
and voluntary (cannot force someone to consent to a
procedure)
(3) Minors and incompetent adults
(a) Parents or legal guardian must sign for a child;
children of divorced parents may have specific
requirements for consent related to divorce decree
(b) Emancipated minor (individual is not a legal adult;
most states define adult as 18 years or older) may sign
for themselves; teenager can obtain emancipation by:
[1] Proving independence from parental control to
the court; legal process involved
[2] Being legally married
[3] Enlisting in one of the U.S. Armed Forces
(c) Legal guardians or health care decision maker must
sign for incompetent adults
e. Informed refusal2,3—client may refuse treatment; to refuse
(1) Client must be provided with same type information as
provided informed consent; include general and oral health
risks
(2) Documentation of refusal, including information provided
to client, must be placed in the client’s record
(3) Client, operator, and witness signature recommended
D. Dental practice acts
1. Statutes regulating the dental professions; in all legal jurisdictions
(e.g., states and the District of Columbia or provinces)
2. Enacted by state or provincial legislature; grant authority to a board
of dentistry (board of dental examiners or other administrative
agency) to adopt rules and regulations for dentistry, dental hygiene,
and dental assisting and for dental laboratory technologists and
denturists
a. Rules and regulations must be consistent with the statute

1886
 b. A board may not waive provisions unless specifically authorized
to do so by statute
3. Practice acts are enacted to protect the public; boards of dentistry or
other agencies grant licenses to individuals to engage in a specific
profession after demonstrating a minimal level of competence to
perform the responsibilities required of the profession
4. Composition of dental boards—usually elected or appointed officials
a. Dentists
b. Dental hygienists
c. Consumers
d. Others (e.g., lawyers, dental assistants, denturists)
5. Board duties
a. Regulate applications for licensure
b. Implement mechanisms for measuring competence of
applicants, that is, credentials, examinations, mandatory
continuing education or other certifications
c. Implement mechanisms for investigating complaints made
against practitioners
d. Grant and revoke licenses
e. Draft laws pertaining to the dental professions for the
legislature
f. Design rules and regulations pertaining to the dental
professions
g. Monitor educational standards
h. Monitor other procedures related to licensure (e.g., licensure
renewal, continuing education requirements)
6. Elements of dental practice act (vary from jurisdiction to
jurisdiction)
a. Requirements for licensure and renewal to show minimum
competence
(1) Minimum age and education
(2) Character references
(3) Examinations (regional, written) required
(4) Continuing education requirements for relicensure
(5) Evidence of specific requirements (e.g., current CPR
certification)
(6) Exemptions—“grandfather ” clauses (e.g., licensure of
dental hygienists trained in jurisdictions where
preceptorship is legal)
(7) Provisions for licensure across jurisdictions
(a) Reciprocity—agreements between states for

1887
 recognition of licensure from another state
(b) Endorsement—granting of licensure if the applicant is
licensed in another state and can present specific
documents or credentials, and the states’ requirements
were the same or similar
(c) Licensure by examination—when no reciprocity or
endorsement is granted by states
(d) Licensure by waiver—when a step toward licensure
can be omitted (e.g., waiver of the clinical examination
requirement)
(8) Disciplinary action—boards have this authority with the
power to enforce licensure requirements
(a) License revocation or refusal to renew
(b) License suspension
(c) Probation
(d) Reprimand—public or private
b. Requirements for practice—defines scope of practice, that is,
legally permissible tasks or procedures (Table 22-2)

Table 22-2
Dental Hygiene Practice Act Overview: Permitted Functions and Supervision
Levels by State

1888
1889
 D—Direct Supervision levels; dentist needs to be present.
G—General Supervision levels; dentist needs to authorize prior to services, but need not be present.
A—Direct Access Supervision levels; hygienist can provide services as she or he determines appropriate
without specific authorization.
Two letters denote separate supervision levels depending on setting Private/Public.
DH, Dental hygiene.
Footnotes apply to both settings if applicable.
Disclaimer: Information based on ADHA staff research. This document should not be considered a legal
document.
1 Rules pending,

2 On direct order.

3 On patients 18 years or older.

4 Public health supervision applies to fluoride varnish only.

5 Participating in remote supervision pilot program.

(1) List regulations—many states have a list of legal tasks

delegated to dental hygienists
(2) Open provision—some states have a general statement of
what cannot be delegated; tasks delegated are at the
discretion of the supervising dentist
c. Legally problematic areas (scope of practice)
(1) If a negligent act presents a scope-of-practice issue, a
dental hygienist’s actions should be within the scope of
practice for the particular jurisdiction; procedures billed to
the insurance company must be performed by the
appropriately licensed professional, or the state insurance
board also could take action
(2) When the standard of care changes or increases because of
the type of procedure performed or the addition of a legally
recognized duty; for example, a dental hygienist
administering a local anesthetic agent would be held to the
same standard of care as a comparably trained professional
such as a dentist
(3) When issues arise relating to use of new technology that
may not yet be addressed in the dental practice act (e.g., use
of lasers to fuse deep pits and fissures)
(4) Wide variations exist from state to state in the scope of
dental hygiene practice; for example, practicing in a new
jurisdiction where the dental practice act is more restrictive
does not always allow the dental hygienist to deliver the
treatment he or she was trained to perform or is competent
to provide in another jurisdiction
d. Supervision (varies from state to state, and province to

1890
 province)
(1) General supervision and assignment—licensed dentist
authorizes the procedures on the basis of his or her
diagnosis and treatment plan; need not be physically
present when procedures are performed; some states
require that the dentist or a designated dentist be available
for consultation, if needed
(2) Indirect or close supervision—licensed dentist authorizes
procedures and remains in dental facility while procedures
are being performed
(3) Direct and immediate supervision—licensed dentist
diagnoses the condition to be treated, authorizes
procedures to be performed, and remains on premises
while treatment is being performed, before the client is
dismissed; some states do not require a dentist to approve
the work before dismissal
(4) Personal supervision—licensed dentist provides a service
for a client and authorizes an auxiliary to aid treatment by
concurrently performing supportive procedures
(5) Unsupervised practice—services may be performed by a
licensed dental hygienist without the supervision of a
licensed dentist
(6) States are diverse in requirements for dental hygienists
(a) Forty-seven states allow general supervision, which
does not require that a dentist be physically present
during traditional dental hygiene procedures in offices
(b) Thirty-seven states allow direct access, which means
that the dental hygienist can initiate treatment on the
basis of his or her assessment of a client’s needs
without the specific authorization of a dentist to treat
the client and without the presence of a dentist and can
maintain a provider-client relationship (Box 22-1 and
Fig. 22-2)

Box 22-1
States Where Dental Hygienists Can Provide
Direc t Ac c ess (Direc t Ac c ess States)
For purposes of this document, “direct access” means that the dental
hygienist can initiate treatment based on his or her assessment of a

1891
client’s needs without the specific authorization of a dentist, treat the
client without the presence of a dentist, and can maintain a provider-
client relationship.

Alaska 2008
AS 08.32.115

Collaborative Agreement:
Hygienist may provide services according to terms of collaborative
agreement. Dentist’s presence, diagnosis, or treatment plan is not
required unless specified by agreement. Care under the agreement can
be provided in settings outside a dentist’s “usual place of practice” (e.g.,
private dental office).
Special Requirements: Hygienist must have minimum of 4000 hours of
clinical experience within preceding 5 years. Agreement must be
approved by state board of dental examiners.
Services: Agreement can authorize nearly the entire dental hygiene scope
of practice (e.g., client education, prophylaxis, sealants, x-ray films).
Notes:
• Dentists are limited to 5 or less collaborative agreements with dental
hygienists.

Arizona 2006
32-1289B
Dental hygienist working under contract for schools, public health
settings, and institutions may screen and apply fluoride unsupervised.

Arizona 2004
Sec. 32-1281 H, 32-1289

Affiliated Practice Agreement:

A dental hygienist with a written affiliated practice agreement may
perform dental hygiene services on clients who meet certain financial
criteria and are enrolled in a federal, state, county or local health care
program. Written agreement must be submitted to state board of dental
examiners. Hygienists must refer clients for additional treatment by a
dentist within 12 months of first treatment.
Special Requirements: Hygienist must have 5 years of practice experience
and must have been actively engaged in dental practice for at least
2000 hours in the preceding 5 years.
Services: The agreement must outline practice settings and services

1892
 provided (nearly all of dental hygiene scope except root planing, local
anesthesia, and nitrous oxide administration are allowed).
Notes:
• Direct Medicaid reimbursement allowed.

Arkansas 2010
Sec. 17-82-701

Collaborative Agreement:
A dental hygienist with a Collaborative Care Permit I or II who has
entered into a collaborative agreement may perform dental hygiene
services on children, senior citizens, and persons with developmental
disabilities in long-term care facilities, free clinics, hospitals, Head Start
programs, residence of homebound clients, local health units, schools,
community health centers, and state and county correctional
institutions. Hygienist must have written agreement with no more than
one dentist.
Special Requirements: Must have malpractice insurance. Collaborative
Care Permit I: hygienist must have 1200 hours of clinical practice
experience or must have taught dental hygiene courses for 2 of the
proceeding 3 years. Collaborative Care Permit II: hygienists must have
1800 hours of clinical practice experience or has taught dental hygiene
courses for 2 of the proceeding 3 years and has completed 6 hours of
continuing education (CE) courses.
Services: Collaborative Care Permit I may provide prophylaxis, fluoride
treatments, sealants, dental hygiene instruction, assessment and other
services in scope if delegated by consulting dentist to children in
public settings without supervision or prior examination. Collaborative
Care Permit II may provide prophylaxis, fluoride treatments, sealants,
dental hygiene instruction, assessment, and other services in scope if
delegated by the consulting dentist to children, senior citizens, and
persons with developmental disabilities in public settings without
supervision or prior examination.

California 2002
Sec 1763 (a) 2002
Any dental hygienist may provide screening and apply fluorides and
sealants without supervision in government-created or government-
administered public health programs.

California 1998

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Sec. 1774, 1775

Registered Dental Hygienist in Alternative Practice

(RDHAP):
RDHAPs may provide unsupervised services for homebound persons or
at schools, residential facilities, institutions, and in dental health
professional shortage (DHPS) areas. RDHAPs can offer a client care for
up to 18 months and provide additional care if the client obtains a
prescription from a dentist or physician.
Special Requirements: RDHAP must have a bachelor ’s degree (or
equivalent), 3 years of clinical experience, completion of additional 150
clock hours in designated courses, and pass exam. RDHAP must
provide board with documentation of an existing relationship with at
least one dentist for referral, consultation, and emergency services.
Services: All services permitted under general supervision, including
prophylaxis, root planing, pit-and-fissure sealants, charting, and
examination of soft tissue.
Notes:
• Direct Medicaid reimbursement is allowed.

Colorado 1987
Sec. 12-35-122.5

Unsupervised Practice:
There is no requirement that a dentist must authorize or supervise most
dental hygiene services. Hygienist may also own a dental hygiene
practice.
Special Requirements: None.
Services: Hygienist can provide dental hygiene diagnosis; take x-ray films;
remove deposits, accretions, and stains; do curettage without
anesthesia; apply fluorides and other recognized preventive agents;
administer topical anesthetic; and perform oral inspection and
charting. Local anesthesia requires general supervision.
Notes:
• Direct Medicaid reimbursement allowed.

Connecticut 1999
Section 20-126 l

Public Health Dental Hygienist:

Dental hygienists with 2 years of experience may practice without

1894
supervision in institutions, public health facilities, group homes, and
schools.
Special Requirements: Hygienist must have at least 2 years of experience.
Services: Hygienist can provide oral prophylaxis; remove deposits,
accretions, and stains; perform root planing; apply sealants; and do
assessment, treatment planning, and evaluation.
Notes:
• Direct Medicaid reimbursement allowed.

Florida 2011
Section 466.003. 466.024
Dental hygienists may provide services without the physical presence,
prior examination, or authorization of a dentist, provided that a dentist
or physician gives medical clearance before performance of prophylaxis
in “health access settings.” A dentist must examine a client within 13
months following prophylaxis, and an exam must take place before
additional oral services may be performed.
Health access settings are a program of the Department of Children
and Family Services, the Department of Health, the Department of
Juvenile Justice, a nonprofit community health center centers, a Head
Start centers, a Federally Qualified Health Center (FQHC), a school-
based prevention program, or a clinic operated by an accredited dental
or dental hygiene program.
Services: Dental charting, take vital signs, record histories, apply sealants
and fluorides (including varnish), and perform the prophylaxis.
Notes:
• The setting operating the program may bill a third party for
reimbursement of the hygienist’s services.
• The hygienist must maintain professional liability insurance.

Idaho 2004
I.C. 54-903 (9)/54-904

Extended Access Endorsement:

Hygienist can provide services in a hospital, long-term care facility,
public health facility, health or migrant clinic, or other board-approved
setting if the dentist affiliated with setting authorizes services.
Special Requirements: Hygienist must be an employee of the facility or
obtain Extended Care Permit; ECP requires 1000 hours experience in
last 2 years.
Services: As determined by authorizing dentist.

1895
Iowa 2004
Rule 650-10.5 (153)

Public Health Dental Hygienist:

Hygienist may administer care based on standing orders and a written
agreement with a dentist.
Services can be administered in schools, Head Start settings, nursing
facilities FQHCs, public health vans, free clinics, community centers, and
public health programs.
Special Requirements: Hygienist must have 3 years of clinical experience
and must submit an annual report to the state department of health
noting the number of clients treated and services administered.
Services: All services in the dental hygiene scope (except local anesthesia
and nitrous) may be provided once to each client. To offer repeat
services other than assessment, screening, and fluoride, a dentist must
examine the client.

Kansas 2003/2012
Sec. 65-1456

Extended Care Permit (ECP) I, II, and III:

Hygienist may practice without the prior authorization of a dentist if the
hygienist has an agreement with sponsoring dentist who will monitor
his or her practice. Examples of settings are schools, Head Start
programs, state correctional institutions, local health departments,
indigent care clinics, and in adult care homes, hospital long-term units,
or at the home of homebound persons on medical assistance. The ECP I
permit authorizes treatment on children in various limited-access
categories, whereas the EPT II permit is for seniors and persons with
developmental disabilities. ECP III permit authorizes hygienists to treat
a wider range of clients, including underserved children, seniors, and
developmentally disabled adults, and to provide more services than ECP
I and II.
Special Requirements: Hygienist must have 1200 clinical hours or 2 years of
teaching in last 3 years for ECP I and 1600 hours or 2 years of teaching
in last 3 years plus 6-hour course for ECP II. Hygienist must also carry
liability insurance and must be paid by dentist or facility. ECP III
requires 2000 hours clinical experience plus 18 clock hours of board-
approved course.
Services: ECP I and II provide prophylaxis, fluoride treatments, dental

1896
 hygiene instruction, assessment of the client’s need for further
treatment by a dentist, and other services if delegated by the
sponsoring dentist. ECP III can additionally provide atraumatic
restorative technique, adjustment and soft reline of dentures,
smoothing sharp teeth with handpiece, local anesthesia in setting
where medical services available, and extraction of mobile teeth.
Notes:
• Dentist can only monitor 5 practices.

Kentucky 2010
313.040

Volunteer Community Health Settings:

A dental hygienist may provide the services listed below without the
supervision of a dentist in volunteer community health settings.
Services: Hygienist can provide dental hygiene instruction, nutritional
counseling, oral screening with subsequent referral to a dentist,
fluoride application, demonstration of oral hygiene technique, and
sealants.

Maine 2008
Sec. B-1. 32 MRSA c. 16, sub-c. 3-B

Independent Practice Dental Hygienist:

A dental hygienist licensed as an independent practice dental hygienist
may practice without supervision by a dentist in all settings.
Special Requirements: Hygienist must possess a bachelor's degree from a
Commission on Dental Accreditation (CODA)–accredited dental
hygiene program and 2000 work hours of clinical practice during the 2
years preceding the application or possess an associate degree from a
CODA-accredited dental hygiene program and 6000 work hours of
clinical practice during the 6 years preceding the application. They are
also required to provide a referral plan to clients in need of additional
care by a dentist.
Services: Hygienist may interview patients and record complete medical
and dental histories, take and record the vital signs of blood pressure,
pulse and temperature, perform oral inspections, recording all
conditions that should be called to the attention of a dentist; perform
complete periodontal and dental restorative charting; perform all
procedures necessary for a complete prophylaxis, including root
planing; apply fluoride to control caries; apply desensitizing agents to

1897
 teeth; apply topical anesthetics; apply sealants; smooth and polish
amalgam restorations, limited to slow-speed application only; cement
pontics and facings outside the mouth; take impressions for athletic
mouthguards and custom fluoride trays; place and remove rubber
dams; place temporary restorations in compliance with the protocol
adopted by the board; and apply topical antimicrobials, excluding
antibiotics, including fluoride, for the purposes of bacterial reduction,
caries control, and desensitization in the oral cavity. The independent
practice dental hygienist must follow current manufacturer's
instructions in the use of these medicaments.

Maine 2001
Rule 02 313 Chap. 1. Sec. 4

Public Health Dental Hygienist:

Hygienist may provide services in a public or private school, hospital, or
other, nontraditional practice setting under a public health supervision
status granted by the dental board on a case-by-case basis. The hygienist
may perform services rendered under general supervision. The dentist
should have specific standing orders and procedures to be carried out,
although the dentist need not be present when the services have been
provided. A written plan for referral or an agreement for follow-up shall
be provided by the public health hygienist recording all conditions that
should be called to the attention of the dentist. The supervising dentist
shall review a summary report at the completion of the program or once
a year.
Special Requirements: A dental hygienist must apply to the board to
practice providing such information the board deems necessary. The
board must take into consideration whether the program will fulfill an
unmet need, whether a supervising dentist is available, and that the
appropriate public health guidelines and standards of care can be met
and followed.
Services: All services that can be provided under general supervision.
Dentist’s diagnosis for sealants is not needed in public health or school
sealant programs.
Notes:
• Direct Medicaid reimbursement allowed.

Maryland 2010/2014
10.44.21.10

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General Supervision:
A dental hygienist may practice dental hygiene under the general
supervision of a dentist in a long-term care facility in accordance with
this regulation. A dental hygienist practicing under the general
supervision of a licensed dentist in a long-term care facility must have a
written agreement with the supervising dentist that clearly sets forth the
terms and conditions under which the dental hygienist may practice.
Special Requirements: A dental hygienist must hold an active license to
practice dental hygiene in the State, hold a current certificate
evidencing Health Care Provider Level C Proficiency, or its equivalent,
in cardiopulmonary resuscitation, have at least 2 years of active clinical
practice in direct client care, and ensure that the long-term care facility
where the dental hygienist will practice under general supervision has:
(a) A written medical emergency plan in place
(b) Adequate equipment, including portable equipment and
appropriate armamentarium, available for the appropriate delivery
of dental hygiene services
(c) Adequate safeguards to protect the client’s health and safety
Services: Limit dental hygiene tasks and procedures to toothbrush
prophylaxis, application of fluoride, dental hygiene instruction, and
other duties as may be delegated, verbally or in writing, by the
supervising dentist.

Massachusetts 2009
Chap. 112, Sec. 51.

Public Health Dental Hygienist:

Hygienist may provide dental hygiene services without the supervision
of a dentist in public health settings, including, and not limited to,
hospitals, medical facilities, schools, and community clinics. Prior to
providing services, a public health dental hygienist must have a written
collaborative agreement with a local or state government agency or
institution, or licensed dentist that states the level of communication
with the dental hygienist to ensure client health and safety. Public health
dental hygienists must provide clients with a written referral to a dentist
and an assessment of further dental needs.
Special Requirements: Hygienist must have at least 3 years of full-time
clinical experience practicing in a public health setting and any other
training deemed appropriate by the department of health.
Services: Hygienist can provide full scope of dental hygiene practice

1899
 services allowed under general supervision in the private office,
including prophylaxis, root planing, curettage, sealants, and fluoride.
Notes:
• Direct Medicaid reimbursement allowed.

Michigan 2005
Sec. 333.16625

PA 161 Dental Hygienist:

Hygienist with grantee status can practice in a public or nonprofit entity,
or a school or nursing home that administers a program of dental care to
a dentally underserved population. Collaborating dentist need not be
present for or authorize treatment, but hygienist must have continuous
availability of direct communication with a dentist to establish
emergency protocol and review client records.
Special Requirements: Hygienist must apply to the state department of
community health for designation as grantee health agency.
Services: Hygienist can provide full scope of dental hygiene services
allowed under general supervision, including prophylaxis, sealants,
and fluoride treatments.

Minnesota 2001
Section 150A. 10, Subd. 1a

Collaborative Practice:
Hygienist must enter into a written collaborative agreement with a
licensed dentist that designates authorization for the services provided
by the dental hygienist (agreement need not be submitted to state).
Collaborative practice hygienist can be employed or retained by a health
care facility, program, or nonprofit organization.
Special Requirements: Hygienist must have at least 2400 hours of clinical
experience in the preceding 18 months or a career total of 3000 hours,
including a minimum of 200 hours of clinical practice in 2 of the past 3
years. Hygienist must also meet additional CE requirements.
Services: Collaborative practice hygienist can administer prophylaxis,
application of topical preventive and prophylactic agents, application
of sealants, fluoride varnishes, coronal polishing, preliminary charting,
x-ray films, and root planing.
Notes:
• Direct Medicaid reimbursement allowed.

1900
Missouri 2001
Statute 332.311.2

Public Health Dental Hygienist:

Hygienist may provide services without supervision in public health
settings to Medicaid-eligible children and can be directly reimbursed by
Medicaid.
Special Requirements: Hygienist must have 3 years of experience.
Services: Hygienist can provide oral prophylaxis, sealants, and fluorides.
Notes:
• Direct Medicaid reimbursement allowed.

Montana 2003
Sec. 37-4-405

Public Health Dental Hygienist/Limited Access Permit

(LAP):
Dental hygienists may obtain an LAP to practice under public health
supervision in a variety of federally funded health centers and clinics,
nursing homes, extended care facilities, home health agencies, group
homes (elderly, disabled, youth), Head Start programs, migrant work
facilities, and local and state public health facilities. Public health
supervision means the hygienist can provide services without the
authorization of a dentist provided the hygienist follows protocols to be
established by the board and refers any clients needing dental
treatment.
Special Requirements: Hygienist must have 2400 hours experience in the
last 3 years; 3000 hours over career with 350 hours each of the last 2
years. An additional 12 hours CE every 2 years and liability insurance
are also required.
Services: Hygienist can provide prophylaxis, fluoride, root planing,
sealants, polishing of restorations, x-ray films for diagnosis by a
dentists, and oral cancer screening.
Notes:
• Direct Medicaid reimbursement allowed.

Nebraska 2007
Sec. 71-193.18

Public Health Dental Hygienist:

1901
The Department of Health may authorize an unsupervised RDH to
provide public health–related services in a public health setting or a
health care or related facility.
Special Requirements: Hygienist must have 3000 hours experience in at
least 4 of last 5 years. Hygienist must also have professional liability
insurance.
Services: Hygienist can perform prophylaxis for a healthy child, pulp
vitality testing, and preventive measures, including fluorides and
sealants.
Notes:
• Direct Medicaid reimbursement allowed.

New Hampshire 1993

Rule 302.02(d); 402.01 (c)

Public Health Supervision:

Hygienist may treat clients in public or private school, hospital or
institution, or residence of a homebound client. Supervising dentist
must authorize hygienist to provide services (i.e., standing orders) but
need not be present for care.
Special Requirements: None.
Services: Hygienist can provide instruction in oral hygiene, topical
fluorides, and oral prophylaxis; assess medical/dental history; do
periodontal probing/charting; and apply sealants.

New Mexico 2007

Sec. 61-5-C
No supervision required for any dental hygienist to apply fluorides,
and remineralization agents.

New Mexico 1999/2011

Sec. 61-5A-4D, Rule 16.5.17

Collaborative Practice:
Hygienist can practice in any setting with collaborative agreement and
can own or manage a collaborative dental hygiene practice. Hygienist
must enter into a written agreement with one or more collaborative
dentist(s), which must contain protocols for care. Hygienist must refer
clients for annual dental exam.
Special Requirements: Hygienist must have 2400 hours of active practice in
preceding 18 months or 3000 hours in 2 of the past 3 years.

1902
Services: Collaborative practice hygienist can provide a dental hygiene–
focused assessment, x- ray films, oral prophylaxis, fluoride treatments,
assessment for and application of sealants, root planing, and may
prescribe and administer and dispense topically applied fluoride and
antimicrobials, depending on the specific services allowed in
agreement with collaborating dentist.
Notes:
• Dentist may not collaborate with more than 3 hygienists.
• Direct Medicaid reimbursement allowed.

New York 2005

Rules Sec. 61.9

General Supervision:
Hygienist can initiate client care in any public or private setting. Dentist
must authorize (i.e., issue standing orders) for dental hygienist and be
available for consultation, diagnosis, and evaluation.
Services: Hygienist can provide prophylaxis, root planing, fluoride
treatments, client education, charting, and x-ray films without a prior
dental examination, the presence of a dentist, or need to refer to a
dentist.

Nevada 1998
Sec. 631.287

Public Health Dental Hygienist:

Dental hygienists may obtain approval to work as public health dental
hygienists in schools, community centers, hospitals, nursing homes, and
such other locations as the state dental health officer deems appropriate
without supervision.
Special Requirements: Special endorsement from the dental board.
Submissions of protocol to describe the methods a hygienist will use to
provide services.
Services: May provide most hygiene services and may administer local
anesthesia and nitrous oxide in a facility with certain equipment and
dentist authorization.
Notes:
• Direct Medicaid reimbursement allowed.

Ohio 2010
Sec. 4715.363

1903
Oral Health Access Supervision Permit Program:
Dental hygienists who possess an oral health access supervision permit
may provide dental hygiene services through a written agreement with a
dentist in public health settings, including, and not limited to, health
care facilities, state correctional institutions, residential facilities,
schools, shelters for victims of domestic abuse or runaways, foster
homes, nonprofit clinics, dispensaries, and mobile dental clinics. Before
providing services, a dental hygienist with an oral health access
supervision permit must have a written agreement with a dentist, who
possesses an oral health supervision permit, that states the dentist has
evaluated the dental hygienist’s skills and has reviewed and evaluated
the client’s health history. The dentist need not be present or examine
the client before the dental hygienist may provide care. The
collaborating dentist must perform a clinical evaluation of the client
before the dental hygienist may provide subsequent care. The evaluation
may be done using electronic communication.
Special Requirements: Two years and a minimum of 3000 hours of clinical
experience; minimum of 24 CE credits during the 2 years before
applying for the Oral Health Access Supervision Permit, including a
course on identification and prevention of potential medical
emergencies; and completed an oral health access supervision permit
class approved by the board.
Services: Prophylactic, preventive, and other procedures a dentist can
delegate to a hygienist, except definitive root planing, definitive
subgingival curettage, administration of local anesthesia, and other
procedures specified in rules adopted by the board.

Ohio 2013
House Bill 59 (amendment adopted; not yet codified)
The requirement for a dentist to perform an examination and diagnose
a client before the client receives dental hygiene services through a
program operated by a school district or other specified entity does not
apply when the only services to be provided are the placement of pit-
and-fissure sealants.

Oklahoma 2003
Sec. 328.34 C

General Supervision:
Hygienist may provide services outside the private dental office for a

1904
client not examined by the dentist. Dentist must authorize care in
writing.
Special Requirements: Hygienist must have at least 2 years of experience.
Services: Most dental hygiene services, including sealants, fluorides, and
prophylaxis, to a client one time before a dental exam.

Oregon 2011
Sec 680.205

Expanded Practice Dental Hygienist (EPDH)

Replaces Limited Access Permit (LAP); adds services to clients below
federal poverty level and other settings approved by the board to EPDH
practice settings; adds limited prescriptive authority, local anesthesia,
temporary restorations, and dental assessments to unsupervised EPDH
scope if EPDH has agreement with a dentist; requires insurance
reimbursement of EPDHs.

Oregon 1997
Sec. 680.200
Rule 818-035-0065

Limited Access Permit (LAP):

Dental hygienists who have obtained an LAP may initiate unsupervised
services for clients in a variety of limited-access settings such as
extended care facilities, facilities for mentally ill or disabled persons,
correctional facilities, schools and preschools, medical offices or offices
operated or staffed by a nurse practitioner midwives or physician
assistants, and job training centers. Hygienist must refer the client
annually to a licensed dentist available to treat the client.
Special Requirements: Hygienist must have 2500 hours of supervised
dental hygiene practice and has completed 40 hours of board-approved
courses in an accredited dental hygiene program or completed a board-
approved course of study that includes at least 500 hours of dental
hygiene practice on clients with limited access while under direct
faculty supervision. Hygienist must also have liability insurance.
Services: LAP hygienists can provide all dental hygiene services; however,
some services (local anesthesia, pit-and-fissure sealants, denture
relines, temporary restorations, radiographs, nitrous oxide) must be
supervised by a dentist. Hygienist may prescribe fluorides and assess
the need for sealants.
Notes:

1905
 • Direct Medicaid reimbursement allowed.

Pennsylvania 2007
Sec. 2 (Definitions), Sec. 11.9

Public Health Dental Hygiene Practitioner:

Dental hygienists who are certified as public health dental hygiene
practitioners may provide care in a variety of public health settings
without the supervision or prior authorization of a dentist.
Special Requirements: Hygienist must have 3600 hours experience and
liability insurance. Hygienist must also complete 5 hours of continuing
education in public health during each licensure period.
Services: Dental hygienists in the state are authorized to provide
educational, preventive, therapeutic, and intraoral services, including
complete prophylaxis and sealants.

Rhode Island 2006

Sec. 5-31.1-6.1

General Supervision:
Dental hygienists working under a dentist’s general supervision can
initiate dental hygiene treatment to residents of nursing facilities.
Dental hygienists working in nursing facilities can treat clients,
regardless of whether or not the client is a patient of record, as long as
documentation of services administered is maintained and necessary
referrals for follow-up treatment are made.
Special Requirements: None.
Services: Hygienist can initiate dental hygiene services, including oral
health screening assessments, prophylaxis, fluoride treatments,
charting, and other duties delegable under general supervision.

South Carolina 2003

Sec. 40-15-110 (A) (10)

General Supervision:
Hygienists employed by, or contacted through, the Department of
Health and Environment Control (DHEC) may provide services under
general supervision that does not require prior examination by a dentist
in settings such as schools or nursing homes.
Special Requirements: Hygienist must carry professional liability
insurance.

1906
Services: Hygienist employed by, or contacted through, the DHEC may
provide prophylaxis, fluorides, and sealants.

South Dakota 2011

Sec 36-6A-40
Collaborative practice was enacted, but the rules needed to implement
are pending. It will enable a dental hygienist actively engaged in clinical
practice for 2 of the last 3 years to enter into a collaborative agreement
with a dentist to provide preventive and therapeutic services to a client
for up to 13 months before the dentist must evaluate the client.
Services: To be established in rules.

Tennessee 2013
Sec. 63-5-109
Dental hygienists may apply dental sealants or topical fluoride to the
teeth of individuals in a setting under the direction of a state or local
health department, without requiring an evaluation by a dentist prior to
such application, under a protocol established by the state or a
metropolitan health department.

Texas 2001
Sec. 262.1515

General Supervision:
Hygienist may provide services for up to 6 months without dentist
seeing the client. Services may be performed in school-based health
center, nursing facility, or community health center. Hygienist must refer
the client to a dentist after treatment and may not perform a second set
of services until the client has been examined by a dentist.
Special Requirements: Hygienist must have at least 2 years of experience.
Services: No limitations; dentist must authorize services in writing.

Vermont 2008
Rule 10.2

General Supervision Agreement:

Hygienist may provide services in a public or private school or
institution under the supervision of a dentist through a general
supervision agreement. The agreement authorizes the hygienist to
provide services, as agreed to between the dentist and the dental
hygienist. The agreement does not require physical presence of the

1907
dentist but stipulates that the supervising dentist review all client
records.
Special Requirements: Hygienist must have 3 years licensed clinical
practice experience.
Services: Hygienist can provide sealants, fluoride varnish, prophylaxis and
x-ray films; periodontal maintenance is allowable to clients with mild
periodontitis.

Virginia 2009
Sec. 54.1-2722

Remote Supervision:
Virginia Pilot Project seeks to assess the impact that dental hygienists
practicing in an expanded capacity under remote supervision have on
increasing access to dental health care for underserved populations.
Hygienist will refer clients without a dental provider to a dentist with
the goal of establishing a dental home. Hygienists must enter into a
remote supervision agreement with a licensed dentist and maintain
regular, periodic communication (14-day intervals) with the licensed
dentist (protocol must be submitted to Department of Health).
Special Requirements: Hygienists must have 2 years of experience and
must be employed by the Department of Health.
Services: Hygienists can provide initial examination of teeth and
surrounding areas, prophylaxis, scaling, sealants, topical fluoride,
education services, assessments, and screening.

Washington 2007
Sec. 18.29.056

Off-Site Supervision:
Hygienist can provide care to clients in “senior centers” if hygienist has
a written agreement with dentist to provide “off-site” supervision.
Special Requirements: Hygienist must have 2 years of clinical experience.
Hygienist must collect client data to submit to the Department of
Health.
Services: Hygienist can provide prophylaxis, root planing, curettage, and
apply preventive agents.

Washington 2001
Sec. 18.29.220

1908
Public Health Dental Hygienist:
Dental hygienists who are school endorsed may assess for and apply
sealants and fluoride varnishes and perform prophylaxis in community-
based sealant programs carried out in schools.
Special Requirements: Sealant/Fluoride Varnish Endorsement from
Department of Health. Hygienist must submit data to the Department
of Health concerning patient demographics, treatment,
reimbursement, referrals, etc.

Washington 1984
Sec. 18.29.056

Unsupervised Practice:
Unsupervised practice in hospitals, nursing homes, home health
agencies, group homes (elderly, handicapped, or youth), state
institutions under Department of Health and Human Services (DHHS),
jails, and public health facilities, provided the hygienist refers the client
to a dentist for dental treatment and needed care.
Special Requirements: Hygienist must have 2 years clinical experience
within the last 5 years.
Services: Hygienist can provide prophylaxis, application of typical
preventive or prophylactic agents, polishing and smoothing of
restorations, root planing, and curettage.
Notes:
• Direct Medicaid reimbursement allowed.

West Virginia 2008

Sec. 5-1-8.5

Public Health Dental Hygienist:

Hygienist may provide care in hospitals, schools, correctional facilities,
jails, community clinics, long-term care facilities, nursing homes, home
health agencies, group homes, state institutions under DHSS, public
health facilities, homebound settings, and accredited dental hygiene
education programs. Dentist must authorize hygienist to provide care
(i.e., standing orders) but need not be present have previously seen the
client.
Special Requirements: Hygienist must have 2 years and 3000 hours of
clinical experience and take six additional CE hours. Hygienist and
dentist must submit annual written report of care to state board of
dental examiners.

1909
Services: Hygienist can provide patient education, nutrition counseling,
and oral screening with referral to dentist; apply fluoride and sealants;
and offer complete prophylaxis (pursuant to a collaborative agreement
or written order).

Wisconsin 2007
Sec. 447.06
The statute does not require the presence or supervision of a dentist in
a public or private school, a dental or dental hygiene school, or a facility
owned by a local health department.
Special Requirements: None
Services: Hygienist can provide prophylaxis, root planing, screening,
treatment planning, sealants, and delegable duties.
Notes:
• Direct Medicaid reimbursement allowed.
From the American Dental Hygienists Association, 2014. https://www.adha.org/resources-
docs/7524_Current_Direct_Access_Map.pdf.

FIG 22-2 States in which dental hygienists can provide direct

access. (From the American Dental Hygienists Association.
https://www.adha.org/resources-docs/7524_Current_Direct_Access_Map.pdf.)

(c) Forty-five states permit dental hygienists to

1910
 administer a local anesthetic agent (Table 22-3 and
Fig. 22-3); all states except Oregon require the
administration of a local anesthetic agent to be
completed under direct supervision
Table 22-3
Local Anesthesia Administration by Dental Hygienists: State Chart

1911
1912
Data compiled from 51 practice acts/rules.
Accredited—Course must be provided within a Commission on Dental Accreditation
(CODA)–accredited dental hygiene (DH) program or an institution housing a CODA
program.
Approved—Course must be approved by the state licensing agency
Specific—Course is specified in law.
Direct Supervision—means the dentist must be present.
General Supervision—means dentist need not be present.
NERB, Northeast Regional Board of Dental Examiners, Inc.; WREB, WREB: A National
Dental and Dental Hygiene Testing Agency.

1913
 FIG 22-3 States in which dental hygienists can administer local
anesthesia. (From the American Dental Hygienists Association.
http://www.adha.org/resources-docs/7521_Local_Anesthesia_by_State.pdf.)

(d) Thirty states and Washington D.C. permit dental hygienists to

administer nitrous oxide–oxygen (N2O-O2) analgesia (Table 22-4 and Fig.
22-4)

Table 22-4
Nitrous Oxide Administration by Dental Hygienists

1914
CODA, Commission on Dental Accreditation; CPR, cardiopulmonary resuscitation.
* Most states require dentist to be present. Please check with the state licensing agencies
for specific information on any one state.

1915
 FIG 22-4 States in which dental hygienists can administer nitrous
oxide–oxygen analgesia. (From the American Dental Hygienists Association.
http://www.adha.org/resources-docs/7522_Nitrous_Oxide_by_State.pdf.)

(e) Thirty-five states allow dental hygienists to perform restorative

procedures (Table 22-5)

Table 22-5
Dental Hygienists Restorative Duties by State

1916
1917
This chart is for comparative purposes only. If information does not indicate whether one
of the functions is prohibited or allowed, no assumptions should be made.
Disclaimer: Information based on American Dental Hygienists Association (ADHA) staff
research of state statutes and legislation. This document should not be considered a legal
document.
RDAEF, Registered Dental Assistant in Expanded Functions; EFDA, Expanded Functions
Dental Assistant; WREB, WREB: A National Dental and Dental Hygiene Testing Agency.
*Can do services by virtue of inclusion in dental assistants’ scope of practice. Please
check practice act for education requirements.

7. State dental hygiene committee

a. Seventeen states have dental hygiene committees
b. These committees assist in varying degrees in the regulation of dental
hygiene practice (Box 22-2)

Box 22-2
Dental Hygiene Partic ipation in Regulation
The following states have dental hygiene advisory committees or varying
degrees of self-regulation for dental hygienists.
1. Arizona
The Arizona advisory committee consists of one dentist and one dental
hygienist from the board, plus four additional dental hygienists and
one public member. The committee serves as a forum for discussion of
dental hygiene issues and advises the board on rules and proposed
statute changes concerning dental hygiene education, regulation, and
practice. In addition, the committee evaluates continuing education
(CE) classes for expanded functions and monitors dental hygienists’
compliance with CE requirements.
2. California
The Dental Hygiene Committee of California is a self-regulating dental
hygiene committee in conjunction with the Department of Consumer
Affairs. The committee consists of four dental hygienists, four public

1918
 members, and one dentist appointed by the governor.
3. Connecticut
Connecticut is unique. Dental hygiene is directly under the
Department Public Health. Although there is no standing dental
hygiene committee, if there is a need to address rules or disciplinary
matters, the department director has the ability to appoint an ad hoc
committee of dental hygienists.
4. Delaware
Delaware’s advisory committee is appointed by the governor and
consists of three dental hygienists. The committee writes the
examination for dental hygiene licensure, in conjunction with the
dental board. In addition, the committee votes with the board on
issues of dental hygiene licensure by credentials, disciplinary
decisions, CE requirements for dental hygiene licensure, disciplinary
action involving dental hygienists, and issues involving the policy and
practice of dental hygiene, but not the scope of practice.
5. Florida
Florida has both dental hygiene and dental assisting councils. The
dental hygiene council is composed of four dental hygienists, one of
whom sits on the board, and one dentist member of the board. The
council is expected to develop all dental hygiene rules to submit to the
board for its approval.
6. Iowa
Beginning in 1999, both dental hygienists on the dental board and one
of the dentists became a dental hygiene committee of the board. This
committee has the power to make all rules pertaining to dental
hygiene. The board will be required to adopt those rules and enforce
the committee rules.
7. Maine
Maine has a subcommittee on dental hygiene. The subcommittee
consists of five members: one dental hygienist, who is a member of the
board; two dental hygienists appointed by the governor; and two
dentists, who are members of the board and appointed by the board
president. The duties of the subcommittee are to perform an initial
review of all applications for licensure as a dental hygienist,
submissions relating to continuing education of dental hygienists, and
all submissions relating to public health supervision status of dental
hygienists.
8. Maryland
Maryland’s advisory committee consists of three dental hygienists, one
dentist, and one public member, all of whom are full voting members

1919
 of the dental board. The committee was created during sunset review
as a compromise to the creation of a separate dental hygiene
regulatory board. According to statute, all matters pertaining to dental
hygiene must first be brought to the committee for its review and
recommendation.
9. Michigan
This six-member committee, comprising two dental hygienists, two
dentists, one dental assistant, and one public member, considers
matters related to the dental hygiene profession and makes
recommendations to the full board of dentistry. All members of the
committee are voting members on the board. The existence of the
committee is not mandated by state rules or statutes, but instead is a
committee appointed by the chairperson of the board.
10. Missouri
A five-member advisory commission, composed of the dental
hygienist on the dental board and four dental hygienists appointed
by the governor, was created by the state legislature in 2001. The
commission makes recommendations to the board concerning
dental hygiene practice, licensure, examinations, discipline, and
educational requirements.
11. Montana
In 2002, the dental board assigned both dental hygienist members
and one dentist member to be a standing committee to consider and
address dental hygiene issues in a timely manner. The committee
formulates specific recommendations to bring to the entire board for
action.
12. Nevada
Legislation in 2003 added a third dental hygienist to the dental
board who, together with a dentist appointed by the board,
constitute a dental hygiene committee who may formulate
recommendations on dental hygiene rules for the board and may be
assigned additional duties by the board.
13. New Mexico
New Mexico has a board of dental health care comprising five
dentists, two dental hygienists, and two public members. A dental
hygiene committee is composed of five dental hygienists, two public
members, and two dentists. The committee selects two of its dental
hygiene members to serve as the dental hygienists on the board. The
board’s public members and two of its dentist members are the
dentist and public members of the committee. The committee
adopts all the rules pertaining to dental hygiene and is also

1920
 responsible for the discipline of dental hygienists. The board
enforces the dental hygiene committee’s rules.
14. New Hampshire
The New Hampshire Dental Hygienists’ Committee is a five-member
advisory committee composed of one dental hygienist member of
the board, one dentist member of the board, and three dental
hygienist members appointed by the governor. The Committee
proposes rules concerning the practice, discipline, education,
examination, and licensure of dental hygienists. The rules proposed
by the Committee may be accepted by the Board of Dental
Examiners for adoption.
15. Oklahoma
The dental hygiene advisory committee is composed of the dental
hygiene board member and four dental hygienists appointed by the
board.
16. Oregon
Under its authority to create standing committees, the Oregon
dental board has appointed a committee composed of three dentists,
three dental hygienists, and one nondental health care provider to
advise the board concerning dental hygiene issues.
17. Texas
In 1995, a dental hygiene advisory committee composed of three
dental hygienists and two public members appointed by the
governor and one dentist appointed by the board was established.
All rules relating to the practice of dental hygiene must be
submitted to the committee for review 30 days prior to board
adoption. The committee has been responsible for researching and
developing rules for licensure by credentials and the application of
tetracycline fibers. Legislation in 2003 gave the committee the
authority to propose specific rules for board action.
18. Washington
The state of Washington has a uniform disciplinary code that applies
to all health professions and creates the regulatory bodies to
implement each practice act. Dentistry and dental hygiene have
separate practice acts. Dentists are regulated by the Dental Quality
Assurance Commission (an independent dental board with no
dental hygiene members). Dental hygienists are regulated by the
Department of Health, but the statute requires that the Department
develop rules and definitions to implement the dental hygienist act
in consultation with the Dental Hygiene Examining Committee. The
committee is composed of three dental hygienists and one public

1921
 member appointed by the department

8. Alabama dental hygiene practice and education

a. The state practice act allows only direct supervision of dental
hygienists
b. Prohibits performance of restorative functions by dental hygienists
(see Table 22-4)
c. Prohibits administration of a local anesthetic agent or N2O-O2
analgesia by a dental hygienist
d. Has unique educational and licensing procedures for dental hygienists
(1) Alabama Dental Hygiene Program, since 1919
(2) Only such preceptorship program in the United States
(3) Eligibility—1-year employment as a dental assistant, followed by an
educational program that includes basic science and clinical theory
(4) Dentists are “preceptors,” who provide on-the-job training in the
dental office
(5) Program replaces formal dental hygiene education from an accredited
academic program; graduates are not eligible to take the National Board
Dental Hygiene Examination; therefore, their practice is limited to
Alabama
(6) Graduates are not eligible for membership in the American Dental
Hygienists Association
9. Updating dental practice acts
a. Revision or amendments made by state legislatures
b. Sunset laws—set review of the entire act at a fixed interval (e.g., every 7
years, to keep act updated and relevant to society); if not completed by
legislature by designated date or if found to no longer serve its function
to society, the act will automatically expire (thus the term sunset)
10. Due process requirements for disciplinary action—if a complaint is
filed against a professional, with the licensing board, the licensee has a
right to:
a. Receive a clear statement of charges
b. Question opposing witnesses
c. Produce witnesses and give testimony (answer charges)
d. The services of an attorney
e. Receive a firm conclusion based on the evidence
f. Contest the board’s decision at a court of law
g. If these rights are not provided, the board’s decision could be reversed
by a court of law
11. Practicing without a license—penalties vary from state to state

1922
a. Criminal charges—usually result in a fine (~$50 to $500) or
imprisonment (usually not to exceed 60 days), or both
b. Civil suits—may be filed for monetary damages by individuals who
have been harmed
c. Criminal or civil actions, or both, may be brought against the
unlicensed person
12. Reporting professional violations—failure to report a violation is
grounds for disciplinary action; failure to report is considered
unprofessional conduct; reporting a violation requires the following:
a. Facts must be documented in writing with complete description of
violation
b. Report must list other witnesses and clients involved, if applicable
13. National Practitioner Data Bank (NPDB)
a. Created by the U.S. Department of Health and Human Services
(DHHS) in 1990
b. Purpose—electronic repository that collects information on adverse
licensure actions, certain actions restricting clinical privileges, and
professional society membership actions taken against physicians,
dentists, and other practitioners
c. Medical and dental regulatory boards are required to report certain
actions taken against licensees
d. Health care entities such as hospitals are required to report certain
disciplinary action taken against staff members
e. Licensees are not required to report incidents
f. Access to data bank information
(1) Individuals, who may request their own record
(2) State licensing boards
(3) Researchers, health care entities (e.g., hospitals, nursing homes)
(4) Professional societies
(5) Attorneys
g. The law prohibits the release of information in the NPDB to the public
14. Health Care Integrity and Protection Data Bank (HIPDB)
a. Combats fraud and abuse in health insurance and health care delivery
b. Flagging system used to alert users
c. Intended to augment, not replace, traditional forms of review and
investigation, serving as an important supplement to a review of a
practitioner ’s, providers, or supplier ’s past actions

1923
Dental records and record keeping
A. Purpose of dental records
1. Provides all privileged parties with information; method of
communication with dental and other medical providers
2. Tool for quality assessment and management
3. Documents assessment findings, treatment, care provided, and
outcomes
4. Serves as an important document in third-party relationships
5. Provides evidence of compliance with state record-keeping
requirements
6. Resource in forensic identification
7. Reference in litigation and provides information for the client and
provider
8. Useful in research
B. Written record management
1. Adheres to state dental practice or state medical records guidelines,
if required
2. Legible and written in black ink or ballpoint, not pencil
3. Consistent style for all entries; uniformly spaced
4. Corrections and additions clearly explained
5. Deletions noted by single line through entry
6. Signed and initialed by appropriate operator
C. Electronic dental records
1. Same record-keeping principles as for paper records
2. System should include protections from tampering
3. Courts accept as documentation
D. Client records—must be clear, complete, and accurate and include:
1. Client identification data—client’s name, address, employment,
home and cell telephone numbers, Social Security number, birth
date, emergency contact, physician’s name and phone number,
financial information; legal guardian information, if appropriate
2. Consent forms—informed consent and informed refusal
3. Health, pharmacologic, and dental histories—before treatment,
updated at each visit, signed and dated by the client and oral health
care professional
4. Referrals—referrals made to other professionals, reports of tests, or
reports from other providers
5. Clinical observations—intraoral and extraoral examination results,
findings of pathology, periodontal evaluation, radiographs, study
models, diagnostic photographs

1924
 6. Progress or treatment notes—chronologic notation of treatment,
pretreatment procedures, unusual incidents or circumstances,
diagnosis and care plans, oral hygiene recommendations, client
noncompliance, postoperative instructions, telephone conversations
with the client or other health care providers, medications taken or
prescribed with dosage, client’s missed or canceled appointments
7. Failure to maintain or store dental records for a specified period may
violate state dental practice acts; considered medical malpractice in
some jurisdictions in a court of law
8. Records also include radiographs, photographs, and models
9. State regulations or statutes may delineate specific costs for
duplication of records
E. Confidentiality—client confidentiality is protected by federal and state
laws; state laws often regulate the disclosure of substance abuse, mental
health history, human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS) status; improper disclosure
can result in liability for breach of fiduciary duty, breach of implied
contract, or invasion of privacy
1. Health Insurance Portability and Accountability Act (HIPAA)
a. Purpose—this federal act allows employees to move their health
insurance when changing jobs and is in place to develop
standards for health information, provide greater safeguards
regarding privacy of protected health information (PHI), and
reduce health care fraud and abuse
b. Protects health information by establishing transaction
standards for the exchange of health information, security
standards, and privacy standards for the use and disclosure of
individually identifiable health information (IIHI)
c. PHI includes all individually identifiable health information
that is:
(1) Sent or stored in any form
(2) Identifies the client or can be used to identify the client
(3) Created or received by a covered entity
(4) About the client’s past, present, or future treatment and
payment for services
d. Three major areas addressed relating to requirements for
privacy and confidentiality of health information (effective April
14, 2003)
(1) Privacy standards
(a) Client notification of privacy policies of office or
institution

1925
 (b) Written acknowledgment of receipt of notice of
privacy policies
(c) Written and signed authorization and consent
(2) Client’s rights
(a) Right to inspect and copy confidential health care
information
(b) Right to amend confidential information in the client
record
(c) Right to obtain a list of disclosures of PHI
(d) Right to confidential communication
(e) Right to complain to the practice, to the DHHS
Secretary, or to both
(3) Administrative requirements
(a) Develop policies, procedures, and documentation
(b) Provide notice of privacy policy to clients
(c) Designate a privacy officer and a contact person to
receive complaints
(d) Implement complaint systems
(e) Provide training for employees
(f) Execute business associate contracts
(g) Mitigate any breach of confidentiality
2. Exceptions to nondisclosure of client information—original client
records should never be released
a. Client consent—with written authorization only, specifying
name of the client, name of the person authorized to disclose
the information, amount and type of information to be released,
name of the person or entity to receive the information, the date
information is to be released, the date authorization expires,
and the client’s signature
b. Relevant copies of a client’s medical records may be released to
the court where the client’s medical condition is put in issue by
filing a lawsuit4
c. Duty to disclose—state reporting statutes may require release of
client information (e.g., in cases of child or elder abuse); state
statutes identify health care providers who are obligated by law
to report suspected cases of abuse; statutes also provide
immunity from civil liability for health care providers involved
in reporting suspected abuse, unless it can be proved that a
false report had been made, and the person knew that the report
was false; access statutes allow for release of client information
with no client authorization required (e.g., workers’

1926
 compensation statutes)
3. PHI in electronic form is sometimes referred to as ePHI, which can
include client information in an email, in an electronic file, or on a
CD or memory stick
4. Health Information Technology for Economic and Clinical Health
(HITECH); enacted as part of the American Recovery and
Reinvestment Act of 2009; signed into law on February 17, 2009
a. Expands HIPAA’s privacy and security provisions
b. Requires covered entities to provide notice of any breaches or
unauthorized disclosures of PHI

1927
Employer and employee rights and
responsibilities
A. Employment
1. Employer—person, business, or organization that hires and
compensates one or more workers; engages the services of an
individual
2. Employee—person who is hired to provide services to a company on
a regular basis in exchange for compensation
3. Status
a. At will; individual can be hired or terminated without notice
(1) Employees without a contract
(2) Should a dispute arise relating to termination of
employment, courts often examine the office policy and
procedure manual in determining an implied contract
b. Contract—a legally binding agreement between two or more
parties
(1) Elements (to be enforced by a court)
(a) Offer—one party proposes a bargain
(b) Acceptance—the other party agrees to the proposed
bargain
(c) Consideration—one party gives up something of
value, and the other party makes a promise in exchange
for that something of value
(d) Mutuality—parties must reach an agreement or
understanding
(e) Legal capacity—all parties must have legal capacity
(i.e., must be the age of majority and mentally
competent)
(2) Contract must be for a lawful purpose
(3) Breach of contract—failure of performance of a contractual
agreement by one or more parties
(a) Remedies for breach of contract
[1] Specific performance (the court requires
performance of the contract)
[2] Monetary damage
[3] Injunctions (the court orders a party to refrain
from specific behavior)
(4) Employment contracts (Box 22-3)

1928
Box 22-3
Employment Contrac t Terms
An employment contract describes the conditions of employment,
including wages, hours, and type of work. Depending on the level of
employment, the responsibility of the new employee, and the nature of
the business, the conditions of employment should be detailed
regarding the following elements:
Parties, including the name of the employer and the entity and the name
of the employee
Time and place: hours of employment and location
Duties: general and specific, scope of practice, if appropriate
Term and conditions of employment
Compensation, including salary, bonus pay, vacation, sick leave,
continuing education policies and reimbursement, and professional
memberships
Benefits, including disability, medical, life insurance, and retirement plan
Termination provisions

(a) Define duties and responsibilities of the position; location and hours
(b) Define salary and benefits
(c) Describe notice and termination requirements
(d) Provide written description of understanding between the parties
4. Independent practitioner—one who provides services directly to the
public; dental hygienists who perform as independent practitioners may
do so only in a state where it is allowed by the dental practice act; a
dental hygienist as an independent practitioner must follow the state’s
(province’s) dental practice act and regulations (Box 22-4)

Box 22-4
Independent Prac tic e
There is virtually no legal guidance—even in the laws of states which
allow it—about what “independent practice” means. If one equates it
with other health practices, one would expect that the practice is a
business entity that can be sold to another, can be directly reimbursed
for services, and has patients of record.
Four states that have specific authorization in the practice act law
allowing a hygienist to own a dental hygiene practice: Colorado (any
hygienist), Maine (hygienists licensed as independent dental hygiene
practitioners), New Mexico (hygienists in collaborative practice) and

1929
California (RDHAPs, registered dental hygienists in alternative
practice). In several other states, including Washington and Oregon,
where dental hygienists may practice with no or little supervision in
various types of settings outside the dental office, dental hygienists do
own dental hygiene businesses.
If you are interested in what business ownership options are available
in a state other than these, you need to review the practice laws to see
whether there is an actual or implied prohibition. Some state practice
acts specify or strongly imply that a dental hygienist must be employed
or must be an independent contractor. Others define owning, operating,
or managing a dental practice as the practice of dentistry.
Keep in mind that supervision issues are different from worker status
(employee vs. independent contractor) and business option issues.
Supervision concerns the degree of oversight of client treatment that the
practice law requires. Even owners of dental hygiene practices in
Colorado and Maine must have an agreement with a dentist to provide
supervision for some services; New Mexico practitioners need to practice
in an agreed protocol with a collaborating dentist, and patients of
California RDHAPs need a prescription from a dentist or physician to
obtain dental hygiene services.

5. Independent contractor—contracted by another person, company, or

agency to produce a certain result, but not subject to the control of the
employer and may do the work in a manner he or she selects; a dental
hygienist as an independent contractor must follow both Internal
Revenue Service (IRS) rules and the state’s dental practice act and
regulations
6. Vicarious liability—one party is responsible for another ’s action;
respondeat superior (Latin, meaning “let the master answer ”), an employer
is legally responsible for the wrongs committed by an employee acting
within the scope of his or her employment; dentist employer may be held
responsible for negligent acts of a dental hygienist
a. Vicarious liability or negligent retention may shield a dental hygienist
from liability in tort cases
b. Dental hygienists are liable for their actions
7. Negligent hiring and retention—employer can be held liable for acts or
omissions of employees if the client can show that the employee was
incompetent and the employer knew or should have known
B. Employment laws—offer protections for employer and employee
1. Equal Employment Opportunity Commission (EEOC)—enforces
federal laws passed to prevent discrimination in the workplace;

1930
 investigates complaints and assists an individual or the Department
of Justice in bringing a lawsuit
2. Title VII of the Civil Rights Act of 1964—forbids discrimination
against employees by federal, state, and local governments, by
employers with 15 or more employees, and by labor organizations, if
the basis of discrimination is race, color, national origin, religion, or
gender
3. Civil Rights Act of 1991—expanded rights under federal anti-
discrimination law
4. Sexual harassment—“unwelcome sexual conduct that is a term of
employment”5 is considered sexual discrimination and is prohibited
under Title VII
a. Quid pro quo (Latin, meaning “something for something”) sexual
harassment6 criteria
(1) The employee was in a “protected group” (a subordinate
position)
(2) The employee encountered unwelcome sexual advances or
requests for sexual favors
(3) Conduct was sexually motivated (e.g., hostile acts toward
an individual because of his or her gender)
(4) Harassment must affect a “tangible aspect of the job,”
such as salary, benefits, and promotions
b. Hostile work environment as sexual harassment criteria
—“verbal or physical conduct of a sexual nature that has the
purpose or effect of creating an intimidating, hostile, or
offensive work environment”7
(1) Created by the words or conduct of an employer,
colleague, vendor, or client
(2) Examples
(a) Unwanted touching
(b) Suggestive comments about one’s appearance
(c) Display of sexually suggestive objects or pictures
(d) Use of diminutive terms such as “honey” or “cutey”
(3) Employer has legal duty to take action to stop or prevent
sexual harassment
(4) Sexual harassment may occur between members of the
opposite sex or members of the same sex
5. Age Discrimination in Employment Act of 1967 (ADEA)—forbids
discrimination against persons over age 40 by federal, state, and
local governments and by employers with 20 or more employees
6. Equal Pay Act of 1963 (EPA)—illegal to pay lower wage to employees

1931
 of one gender if the jobs have equal responsibility, working
conditions, requirements for mental or physical effort, and
requirements in experience, education, or training
7. Uniformed Services Employment and Reemployment Rights Act of
1994 protects civilian job rights and benefits for veterans and
members of Reserve components
8. Occupational Safety and Health Act of 1970 (OSHA)—see Chapter 10
a. The dental profession must comply with all General Industry
standards8 of primary importance to the dental practice, such as
OSHA’s Bloodborne Pathogens Standard (1991)
b. Requirements for employers—employers must:
(1) Identify employees at risk
(2) Provide personal protective equipment to employees (e.g.,
gloves, protective eyewear, masks)
(3) Provide hepatitis B vaccinations to employees
(4) Provide safety needles for the workplace
(5) Provide puncture-proof containers for sharps
(6) Ensure that standard precautions are practiced in the work
environment
(7) Provide prompt treatment to employees who have
needlestick or other exposures (includes immediate medical
screening and follow-up treatment)
(8) Provide annual employee education relating to bloodborne
diseases
c. OSHA amended the Bloodborne Pathogens Standard6 (2001)—
stricter requirements to prevent needlesticks and other
exposures to blood
(http://www.osha.gov/SLTC/bloodbornepathogens/); employers
covered by the standards must:
(1) Provide safety needles
(2) Maintain a log of needlestick or other injuries to
employees
(3) Enlist the assistance of employees who provide direct
client care to prevent needlestick and other exposures by
seeking input regarding equipment selection and work
practices
(4) State OSHA laws—if a state has a health and safety law
that meets or exceeds federal OSHA standards,
enforcement of the law is assumed by the state rather than
by a federal agency
(5) Twenty-five states, Puerto Rico, and the Virgin Islands have

1932
 OSHA-approved state plans that cover public and private
sector employees; five states have plans that cover only
public sector employees; and the states have adopted their
own standards and enforcement policies; for the most part,
these states adopt standards that are identical to federal
OSHA; however, some states have adopted different
standards applicable to this topic or may have different
enforcement policies; contact state agency for copy of the
safety and health standards (state plans, see
https://www.osha.gov/dcsp/osp/states.html)
9. Family and Medical Leave Act of 1993 (FMLA)—protects job security
for women and men by allowing unpaid leave for medical reasons
(e.g., care of a child, spouse, or parent; birth; adoption; or serious
illness); updated January 19, 2009, to include military family leave
entitlements
10. Pregnancy Discrimination Act of 1978 (PDA)—protects rights of
pregnant women in the workplace; maternity-related medical
conditions must be treated as all other medical conditions
a. FMLA and Americans with Disabilities Act (ADA) both require
an employer to grant medical leave to an employee in certain
circumstances; FMLA and Title VII both have requirements
governing leave for pregnancy and pregnancy-related conditions
b. FMLA covers private employers with 50 or more employees
within a 75-mile radius of the workplace; ADA and Title VII
cover private employers with 15 or more employees; only those
private employers with 50 or more employees are covered
concurrently by FMLA, ADA, and Title VII
c. State and local government employers are covered by ADA and
FMLA, regardless of the number of employees; state and local
government employers are covered by Title VII, but only if they
have 15 or more employees
11. Americans with Disabilities Act (ADA of 1990)—prohibits
discrimination against qualified applicants and employees on basis
of disability
a. Must be a mental or physical impairment that substantially
limits one or more of the major life activities
b. Disabilities include visual and hearing impairments, epilepsy,
HIV-positive status, and AIDS
c. Employer must make reasonable accommodations for employee
d. Updated by the ADA Amendments Act of 2008 and expanded
list of major life activities protected by the Act

1933
 (http://www.ada.gov/pubs.adastatute08mark.htm#12102)
12. Fair Employment Statutes—many federal employment laws apply
to workplaces with as many as 50 employees (e.g., FMLA); therefore,
most do not apply to dentistry; most states have passed statutes that
enhance these federal laws; each state’s statutes differ; contact
specific state’s attorney general for information
13. Workers’ compensation: insurance program regulated by each
state’s insurance commission; employer must purchase insurance
through an insurance company to protect employees should they
become seriously ill or injured as a result of conditions in the
workplace; programs vary from state to state; employees are covered
on first date of employment, and benefits include medical expenses
and income

1934
Risk management and avoiding litigation
A. Concepts
1. Risk management—clinical and administrative activities undertaken
to identify, evaluate, and reduce the risk of injury to clients, staff, and
visitors
2. Risk assessment
a. Evaluation of personnel, policies, and protocol to identify and
address risk factors
b. Strategies
(1) Personnel evaluations; conducted by employer or peer
review
(2) Office audits
(a) Review and updating of staff handbook
(b) Assessment of policies related to client care (e.g.,
record keeping, referral policies, documentation)
(c) Evaluation of equipment (e.g., condition)
(d) Protocol reviews (e.g., accident protocol)
(e) Personnel assessment (e.g., current licenses,
communication style)
c. Identified risks are addressed and remedied
B. Individual risk management
1. Maintain a current license and certifications, if required (e.g., CPR
certification)
a. Be knowledgeable of state dental practice act and statutes or
guidelines impacting health care providers
b. Comply with state guidelines, federal guidelines, or both for
infection control, record keeping, reporting requirements,
confidentiality, and other specified mandates
2. Obtain membership in a professional association such as ADHA or
CDHA that provides legal updates through various publications
3. Provide evidence-informed care in all aspects of client care activities
4. Maintain competence by participation in continuing education;
continuing education is mandatory in 47 states; from a legal
perspective, it is advisable to document current competency with
tasks routinely performed and those within the scope of practice
5. Possess knowledge of legally protected employee rights and
responsibilities
a. Use legal or state or federal resources that provide guidance
b. Document in detail any incidents occurring in the workplace
c. Seek legal advice, if necessary

1935
 6. Purchase professional liability insurance; keep the policy current
a. Policy classifications
(1) Occurrence-based policy—covers injuries arising out of
incidents that occurred during the time the insurance was
in effect, even if cancelled at a later date (preferred type)
(2) Claims-made policy—covers injuries occurring and
reported during the period in which the policy premiums
are paid and in force
b. Declaration—states policyholder ’s personal data (name,
address, occupation) and limits of liability coverage (dollar
figure for each claim and aggregate for policy period)
c. Exclusions—liabilities not covered by policy; usually injuries
resulting from criminal behavior, those involving alcohol or
drug abuse on the part of health care provider, or cases
involving practice beyond the scope of one’s license
d. Injuries covered—listed in policy (e.g., bodily injury,
defamation, invasion of privacy)
e. Supplemental coverage—lost earnings
f. Conditions—subrogation of rights, policyholder ’s right to hire
counsel versus insurance company’s right to retain counsel
(1) Policyholder ’s interest and insurance company’s interest
may be in conflict
(2) A conflict of interest could also arise if a health care
provider relies on the employer ’s insurance for liability
coverage; protection is broader with an individual policy; an
employer ’s policy provides coverage only when acting
within the scope of employment; if the health care provider
(by his or her action or failure to act) was liable for the
client’s injury, the employer (or his or her insurance
company) may bring an indemnity claim and recover a
portion of dollar amount awarded by the court to the client
C. Professional risk management
1. Maintain knowledge of professional and legal responsibilities
related to the provision of oral health care services
2. Be familiar with and adhere to the professional code of ethics
(ADHA Code of Ethics and CDHA Code of Ethics)
3. Maintain a professional and respectful relationship with employers,
colleagues, and clients
4. Provide accurate and appropriate communication to clients, verbally
and in writing; poor record keeping can contribute to a poor
outcome in a lawsuit

1936
 5. Maintain confidentiality—obtain proper written authorization from
the client before release of any client information; ensure that any
disclosure is covered by a reporting or access law and is
appropriately followed
6. Document informed consent or informed refusal in client record
before treatment
7. Ensure that all progress notes and client records are complete,
accurate, factual, legible, unaltered, and promptly recorded; failure
to do so is considered malpractice; a client’s record may be obtained
by an opposing party in a lawsuit
8. Be familiar with professional guidelines, including ADHA Standards
for Clinical Dental Hygiene
9. Remain up-to-date on state or provincial dental hygiene practice acts
and regulations

Website Information and Resourc es

1937
1938
1939
References and legal citations
1 Garner B.A. Black’s law dictionary. ed 10 Thomson West; 2014.
2 Norwood Hospital v Munoz, 564 NE 2d 1017, 1991.
3 Thor v Superior Court, 855 P2d 375, 21 Cal. Rept. 2d 357, 1993.
4 Harlan v Lewis, 141 F.D.R. 107, 109, n5.
5 729 CRF, § 1604.11(a).
6 29 CRF 1910.1030, Occupational exposure to bloodborne
pathogens, needlestick and other sharps injuries; Final rule. Fed
Reg. January 18, 2001;66:5317–5325.
7 Harris v Forklift Sys. Inc., 510 US 17, 1993.
8 29 CRF 1910.

1940
Suggested readings
American Dental Hygienists Association. Standards for clinical
dental hygiene practice. Chicago: ADHA; 2008.
http://www.adha.org/resources-
docs/7261_Standards_Clinical_Practice.pdf Accessed October 25,
2014.
American Dental Hygienists Association. Bylaws—codes of ethics.
Chicago: ADHA; 2010. http://www.adha.org/resources-
docs/7611_Bylaws_and_Code_of_Ethics.pdf Accessed October 15,
2014.
Beemsterboer P.L. Ethics and law in dental hygiene. ed 2 St Louis:
Saunders; 2010.
Canadian Dental Hygienists Association. Codes of ethics. Ontario:
CDHA; 2002.
http://www.cdho.org/reference/english/codeofethics_pocketmanual.pdf
Accessed October 15, 2014.
Darby M.L., Walsh M.M. Dental hygiene theory and practice. ed 4 St
Louis: Saunders; 2014.

Chapter 22 review questions

1. The dental hygienist obtains a new client’s consent to obtain dental

records from a previous dental provider. In reviewing the record, it
appears the client was not truthful concerning his health history. Which
of the following ethical principles did the client violate?
a. Autonomy
b. Beneficence
c. Justice
d. Veracity
2. A new dental office manager distributes guidelines to staff dental
hygienists indicating that client appointments will be reduced by 50%.
The dental hygienist is concerned about the substandard care that will
be delivered because of lack of adequate time. Which of the following
ethical principles is violated by this request?
a. Informed consent

1941
 b. Acts of mercy and charity; promoting the good
c. Provision of care within the scope of practice
d. Fairness and equity
e. Obligation not to inflict harm
3. A front desk staff person at a dental clinic receives a telephone call
from an insurance company representative who is seeking health-related
information about a client. The person is concerned about sharing
information without the client’s consent. Which of the following ethical
principles is guiding the front desk person in her decision making?
a. Respecting the client’s privacy
b. Acts of mercy and charity; promoting the good
c. Provision of care within the scope of practice
d. Fairness and equity
e. Do not inflict harm intentionally
f. Truthfulness and honesty
4. A state has a dental hygiene board that oversees the practice of dental
hygiene, disciplinary matters, and licensure requirements. This reflects a
profession’s obligations to:
a. Provide guidance and a framework for regulating practice
b. Protect the public
c. Ensure dental hygienists practice legally and ethically
d. All the above
5. After a client’s assessment and data collection, a dentist determines
that referral to a periodontist is necessary for the client to receive
appropriate treatment. The dental hygienist does not agree and does not
give the client a referral slip for a periodontist. Which of the following
BEST describes this situation?
a. Risk of losing the client
b. Failing to fulfill a duty that results in harm
c. Justice
d. A difference of opinion
6. A client does not take premedication as instructed before dental
treatment. Which of the following BEST describes this situation?:
a. Contributory negligence
b. Standard negligence

1942
 c. Defamation
d. An expressed contract
7. A state law requires that a dental malpractice case must be filed
against a dental provider within 2 years from the time the client was
treated by the provider. This time limit refers to:
a. An area of law that governs actions of administrative agencies of
government
b. An area of law that protects people, property, and privacy
c. An area of law that protects society
d. A maximum period allowed before filing a lawsuit
e. Standard provider protections and guidelines
8. A dentist describes an unusual case study in his practice that is
published in the state dental society journal with pictures of the client.
The client contacts the office upset about the use of the photographs.
Which of the following violations of privacy occurred?
a. Implied contract
b. Paternalism
c. Informed consent
d. Appropriation
9. A 16-year-old client informs you that he no longer lives with his
parents, identifying himself as an “emancipated minor.” However, the
parents continue to pay for his dental treatment. Which of the following
statements BEST describes the situation?
a. A declaration is sufficient to create emancipated status.
b. Client needs only to be physically separated from parents.
c. Client is not emancipated because of financial connection with
parents.
d. Specific conditions must be met for an individual less than 18 years
old to become emancipated.
10. A state’s dental practice act is revised and mandates that dental
providers take at least one continuing education course on pain
management as a requirement for license renewal. This action falls
within which board duty?
a. Description by dental practice act or policies and procedures
b. Authority to revoke or suspend licenses

1943
 c. Required continuing education that supports maintaining
competence
d. Credentialing
11. A dental hygienist is scheduled to provide treatment to clients when
the dentist is not in the office. The dental hygienist only performs those
procedures within the accepted scope of practice as described in the
dental practice act. This type of supervision falls within which type of
arrangement?
a. General supervision
b. Indirect supervision
c. Direct supervision
d. Unsupervised practice
12. A dental hygienist relocates to another state and practices dental
hygiene without obtaining a license in that state. Which of the following
may be a consequence of practicing without a license?
a. Patient abandonment
b. Violation of tort law
c. A civil and/or criminal lawsuit
d. Breach of contract
13. A client writes an article in the newspaper containing false
statements about her dental hygienist’s care and treatment. What tort
does this describe?
a. Defamation
b. Slander
c. Libel
d. Beneficence
14. A boating accident results in victims requiring positive identification.
A request is made to a dental office to provide dental records, and the
office agrees to assist in the process. which of the following functions is
the record satisfying?
a. Resource in forensic identification
b. Documentation used in a lawsuit and reviewed by plaintiff and
defendant attorneys
c. Source of data collection for analysis
d. Allowed sharing of patient information with all providers

1944
 e. Documentation of information to assess quality control and risk
management information
15. During a PTA meeting, a client makes false statements about his
dentist. The statement has a negative effect on the provider’s reputation
in the community. Which of the following intentional torts does this
BEST describe?
a. Battery
b. Defamation
c. Libel
d. Slander
e. Miscommunication
16. A client is provided with a prescription for an antibiotic after dental
treatment but fails to have the prescription filled and take the
medication as directed. The client experiences a serious infection and is
hospitalized. The client sues the dental provider, but the legal
determination is that the injured individual is responsible for a portion
of the injury suffered. What is the legal concept being used as part of the
dental provider’s defense?
a. Creating apprehension about harmful or offensive touching or
contact
b. Individual contributed to the harm suffered
c. Legal permission to provide health care
d. The harm speaks for itself; duty of care
17. A dental hygienist observes clinical findings that may indicate child
abuse. Her employer refuses to report the abuse and suggests if the
dental hygienist does take action, she may lose her job. The dental
hygienist decides to report the abuse. Which of the following ethical
concepts do the dental hygienist’s actions BEST follow?
a. Action will bring greatest happiness or least harm
b. Seek greatest happiness and public agreement
c. Basis in personal moral values of individual decision making
d. Standards greater than individual morals
18. Which of the following from the ADHA Code of Ethics provides
guidance to the dental hygienist about obligations to report cases of
suspected abuse or violence against adults and children?
a. Most states require dental providers to report child and adult abuse

1945
 b. Situation described not related to personal circumstances
c. Actions that promote well-being and professional development and
expertise
d. Supporting patient information confidentiality and HIPAA
compliance
19. After a discussion with a client concerning proposed dental hygiene
treatment, including alternatives, risks and benefits, and outcomes, the
client accepts and signs an informed consent form. Which of the ethical
principles guiding oral health care did the process of obtaining informed
consent satisfy?
a. Autonomy
b. Beneficence
c. Fair and equitable care
d. Reliability or trustworthiness does not apply to the process of
informed consent
e. Truthfulness
20. Faculty in a dental hygiene program collaborate with the local dental
hygiene group on a research investigating the impact of a new
mouthrinse on burning mouth syndrome in perimenopausal women.
Which of the following characteristics of a profession does this research
project support?
a. Formal education, credentials, and licensure
b. Charitable and community-based activities impacting oral health
c. Contribution to research and creating evidence-based outcomes
d. Peer review
e. Ethical codes guide decision making
21. A client bill of rights provides:
a. Specific recommendations regarding oral health services
b. A paper or electronic dental record
c. List of services provided for client information or insurance
purposes
d. A framework that guides patient expectations
e. Scope of practice for oral health providers
22. The Hippocratic Oath is an example of an early ethical code that
advocates health providers should do no harm. Which universal ethical

1946
principle BEST supports this recommendation?
a. Autonomy
b. Nonmaleficence
c. Justice
d. Beneficence
e. Veracity
23. A state dental board or dental hygiene committee monitors the
behavior of licensed oral health care providers and recommends
sanctions for individuals who violate a state dental practice act because:
a. Sanctions are mandated by the principles in the code of ethics
b. There is no federal mandate
c. Dental boards are created to protect the citizens of a state
d. Accrediting agencies mandate this oversight
24. A city council votes to allocate health department funds for a dental
sealant program. After consultation with appropriate individuals, the
council determines children enrolled in either a hot lunch program or a
state-funded program for medical services for children from low-income
families should receive the sealants. On which principle of allocation of
resources is this determination based?
a. An individual’s contribution to society
b. Prioritized needs
c. Individuals receiving treatment because they have earned it
d. Individuals receiving equal services
e. The most deserving individuals receiving services
25. A dental hygienist has allegations of professional misconduct
reported to the state board. A hearing is conducted, and the dental
hygienist has an opportunity to hear and respond to the allegations.
These actions BEST demonstrate which of the following?
a. Right to communicate one’s ideas and opinions
b. Protection of an individual from discrimination
c. Protected right for notification of detailed charges and response
d. Illegal activity based on race, gender, national original, color,
religion, or disability
e. Written or spoken untrue statement
26. A dentist examines a client, develops a treatment plan, and obtains

1947
informed consent. The client nods in agreement and indicates that she
will be making further appointments. On the basis of the dentist’s and
client’s actions, which of the following may exist?
a. Contract established through written communication
b. Implied contract established through nonverbal communication
c. A specific ethical obligation
d. Contract between an insurer and insured
27. A dental hygienist recently relocated to a state and is seeking to
apply for a dental hygiene license. The license application asks the
applicant to indicate whether he or she has been convicted of any
felonies. A felony is:
a. A violation of the scope of practice defined by a dental or dental
hygiene board
b. Description of a misdemeanor
c. A crime punishable by death or imprisonment of at least 1 year
d. Description of a civil rights violation
28. A dental provider and a client discuss a proposed dental hygiene
treatment plan. The written plan outlines the treatment, the fees, the
risks and benefits, the client’s financial obligations, and the expectations
of the provider concerning the client’s responsibilities. The provider and
client sign the treatment plan. This situation BEST describes:
a. The written terms of the planned treatment imply a contract exists
between the client and provider
b. Supported by the ethical principle of justice
c. There is no agreement between parties, thus no contractual
agreement
d. Agreement between an insurer and insured individual
29. A dental office employs a dental hygiene student approximately 6
months before graduation. The dentist in the office was scheduled to
provide a maintenance visit with a client. However, an emergency client
is also waiting to be assessed for care. The dentist asks the dental
hygiene student to provide a “quick cleaning.” Which area of
jurisprudence does the dentist’s action fall under?
a. Case law is formulated by judge or determined by court decisions.
b. Failure to remain current and use evidence-based therapies is not an
area of jurisprudence.

1948
 c. Professional negligence is a failure to perform a clinical action.
d. Administrative law prohibits nonlicensed individuals from
performing functions clearly defined by the scope of practice for a
licensee.
30. The trial for a dental hygienist alleged to have committed negligence
is complete. The judge prepares to give the jury instructions pertaining
to the level of proof the jury must consider to make their decision about
the guilt or innocence of the defendant. Which of the following is
needed to convict the defendant?
a. Unanimous agreement of all jurors
b. A preponderance of evidence
c. The level a reasonable person finds useful to reach a conclusion
d. Information or items presented in court must prove or disprove an
allegation
31. A client’s contractual responsibilities include all the following
EXCEPT:
a. Keeping appointments, making timely cancellations, or rescheduling
appointments
b. Providing accurate and truthful information to the provider and
following recommendations and instructions regarding accepted
treatment
c. Obligation to pay for dental services
d. Providing accurate and complete health history information
e. Compliance with a 6-mouth dental hygiene recare interval
32. A new client presents to a dental office for treatment. Client
demographic and clinical data are collected and reviewed by the dentist
and the dental hygienist, who together determine the case is too complex
for the office to manage and suggest the client seek another provider.
The client is informed that he will not be accepted into the practice.
Which statement BEST describes this situation?
a. Abandonment
b. Dental office is not obligated to treat all clients as long as the
decision is not made for a discriminatory reason
c. Risk management
d. Breach of contract
33. A dental hygienist has demonstrated behaviors that include

1949
purposefully using a loud voice and waving syringes and handpieces in
a threatening manner. The dental hygienist is aware of the actions and
their potential impact on a client. Which of the following intentional
torts may the dental hygienist be accused?
a. Assault
b. Battery
c. Loss of or damage to a person’s rights, property, or mental well-being
d. Defamation
e. Negligence
34. Adam is scheduled for sealants on his four first molars. His record
indicates he is somewhat uncooperative during dental appointments. As
the appointment progresses, the dental hygienist and the dental
assistant become increasingly aggravated at Adam’s uncooperative
actions. At one point, the assistant holds Adam’s hands down, and the
dental hygienist firmly takes Adam’s chin to position his face. At the
end of the appointment, red marks are seen on Adam’s hands and
cheeks. As he enters the reception area, Adam’s mother looks at her son
and says to the assistant, “What did you do to my son?” Which of the
following might the dental hygienist and the assistant be accused?
a. Action that results in apprehension or threat of harm
b. Intentional offensive or harmful physical contact
c. Loss of or damage to a person’s rights, property, or mental well-being
d. Intentional perversion of the truth to gain a person’s trust
e. Failure to exercise care expected of a reasonably prudent provider
35. All the following are key elements of obtaining an informed refusal
EXCEPT one. Which one is the exception?
a. An oral refusal is considered a legal agreement
b. Explanation and justification for the recommended treatment and
alternatives
c. Documentation as to why the client is refusing treatment
d. The risks of refusing treatment
e. Signature of client, provider, and witness
36. The dental hygienist is performing root planing and scaling and
removes a portion of a client’s amalgam during the procedure. The
dental hygienist fails to inform the client, who later experiences pain
and swallows a portion of the remaining restoration. The intentional tort

1950
committed is:
a. Malpractice
b. Misrepresentation
c. Negligence
d. Breach of contract
37. A dentist is accused of a serious criminal violation against a client.
After the trial, the jury will be asked to judge the facts and make a
decision based on which of the following standards?
a. Level of proof must be beyond a reasonable doubt.
b. A majority of jurors is needed for a conviction.
c. In regulatory discipline cases, a state board or agency has the burden
of proof.
d. The victim must be compensated.
38. Dr. Miller recently joined a private practice as a partner. The office
staff can check email or order supplies using the Internet from a
computer in the staff lounge. The mostly female staff use the lounge to
eat lunch. During lunch, Dr. Miller frequently logs on to read his email.
He usually reads his email, laughs out loud, and without anyone asking,
proceeds to read some of the jokes, poems, and “stories” out loud. Most
of the jokes would be considered crude or inappropriate. Which
workplace law is being violated?
a. Affirmative action
b. Sexual harassment
c. Occupational Safety and Health Act of 1970 (OSHA)
d. Americans with Disabilities Act
39. A dental hygienist is terminated from a full-time position in a dental
office with 25 employees. The dental hygienist recently turned 65 and
suspects the reason for the termination is based on age. Which of the
following federal regulations provides legal protection for the
employee?
a. Age Discrimination Act
b. Civil Rights Act of 1964
c. Occupational Safety and Health Act
d. The state’s dental practice act
40. The level of care a reasonably prudent practitioner would provide in
the same or similar circumstances BEST describes:

1951
 a. Informed consent
b. Harm-avoidance model
c. Paternalism
d. Standard of care
e. Risk management
41. To assist in maintaining competence and reduce the risks of
malpractice allegations, it is advisable for a dental provider to:
a. Maintain membership in a professional organization
b. Participate in continuing education courses
c. Purchase malpractice liability insurance
d. Understand legally protected employee rights
42. A client requests and is allowed to review his or her dental record.
Which of the following regulations supports this?
a. Health Insurance Portability and Accountability Act (HIPAA)
b. Occupational Safety and Health Act of 1970
c. Patient Bill of Rights
d. Fraud, Waste, Abuse
e. Clients do not have a legal right to review their record
43. A dental hygienist realizes that an entry made 2 days ago in a client’s
dental record incorrectly recorded the number of carpules that were
used for anesthesia. The dental hygienist obtains the record to correct
the entry. Which is the appropriate method to make a correction?
a. It is not advisable to delete or obliterate any entry.
b. Provider should white-out the incorrect entry.
c. Provider should use a pen to draw a line through incorrect entry and
is allowed to make corrections and note reason for the correction.
d. Provider should insert the correct entry above or below a previously
recorded entry.
44. A dental provider accepts a client and during the course of treatment
decides not to complete the treatment because of an antagonistic
relationship with the client. To legally terminate a client, which of the
following steps must be followed?
a. A client must be given 2 weeks to find another dentist.
b. Client dismissal requires formal written notification.
c. Client may be given a referral, but this is not necessary.

1952
 d. Client termination is the process of verbally notifying the client that
the provider-client relationship is formally ended.
45. A dental provider seeking to obtain informed consent discusses a
client’s diagnosis, proposed treatment including risks and benefits; and
anticipated outcomes of the treatment; allows the client to ask questions;
and provides answers. Which element of informed consent is lacking?
a. Photographs and diagrams pertinent to the treatment plan
b. A witness present for signing of the informed consent form
c. Alternative options for treatment with a description of benefits and
risks
d. Payment plans available
46. Legislation is passed in a state to allow dental hygienists to
administer local anesthetic agents under the direct supervision of a
dentist. Direct supervision usually requires that a licensed dentist has
authorized the procedure and that the dentist:
a. Be available via a pager or cell phone
b. Give oversight to the dental hygienist
c. Be present on the premises
d. Evaluate the procedure within a given number of days
47. Which of the following expanded HIPAA privacy and security
provisions require notification of breaches or unauthorized disclosures
of protected health information?
a. Health Care Reform Act
b. Health Information Technology Economic and Clinical Health Act
(HITECH)
c. Medical Injury Compensation Reform Act
d. Occupational Safety and Health Act
e. Patient Protection and Affordable Care Act
48. All the following are recommended personal risk management
strategies EXCEPT:
a. All licenses and certifications should be up-to-date.
b. Clinical decisions and care should be based on scientific, evidence-
based information.
c. Lifelong learning and participation in continuing education courses
contribute to competent care.

1953
 d. Dental providers are responsible for their own decision making and
the consequences of that decision making.
e. Liability insurance provides financial protection for the provider.
49. A dental hygienist is informed that the employment situation is “at
will.” This situation is BEST described as:
a. The hygienist’s willingness to work for an employer
b. An employment status that someone can be hired or fired without
cause
c. A form of insurance that protects professionals from incurring the
full cost of defending allegations of negligence
d. A form of insurance providing wage replacement and medical
benefits to employees injured in the course of employment in
exchange for not suing the employer
Answers and rationales to review questions are available on this text’s
accompanying Evolve site. See inside front cover for details.

*Pamela Zarkowski and the publisher acknowledge the past contribution of Judith A.
Davison to this chapter.

1954
APPE NDI X A

1955
Medical Terminology

1956
Prefixes
a-, ab-, abs- From; away; departing from normal
ad- Addition to; toward; nearness
amb-, ambi- Both; ambidextrous, having the ability to work effectively
with either hand
amphi- On both sides
ampho- Both
an- Negative; without or not
ana- Upper, away from
andro- Signifying man; human
ant-, anti- Against
ante-, antero- Front; before
bili- Pertaining to bile
brady- Slow
brom-, bromo- A stench
broncho- Pertaining to the bronchi
cac- Bad
cardi-, cardio- Pertaining to the heart
cata- Down or downward
cervico- Pertaining to the neck
circa- About
circum- Around
co- With or together
con- Together with
contra- Opposite; against
demi- Half
di- Twice
dia- Through
dialy- To separate
en- In
end-, endo-, ento- Inward; within
ep-, epi- On; in addition to
ex- Out; away from
exo- Without; outside of
extra- Outside of; in addition to
fibro- Pertaining to fibers
gaster-, gastr-, gastro- Pertaining to the stomach
hemi- Half
hemo- Pertaining to the blood
hepat-, hepatico-, hepato- Pertaining to the liver

1957
heter-, hetero- Denoting other; relationship to another
homeo- Denoting likeness or resemblance
homo- Denoting sameness
hyal-, hyalo- Transparent
hyper- Above; excessive; beyond
hypo- Below; less than
ideo- Pertaining to mental images
idio- Denoting relationship to one’s self or to something separate and
distinct
in- Not; in; inside; within; also intensive action
infra- Below
inter- In the midst; between
intra- Within
intro- In or into
iso- Equal or alike
juxta- Of close proximity
karyo- Pertaining to a cell’s nucleus
kypho- Humped
laryngo- Pertaining to the larynx
medi- Middle
myelo- Pertaining to the spinal cord or bone marrow
omni- All
ovari-, ovario- Pertaining to the ovary
per- Through; by means of
peri- Around; about
post- Behind or after
postero- Pertaining to the posterior
pre- Before
pro- Before, in front of
pseudo- False
re- Back; again (contrary)
retro- Backward
semi- Half
steato- Fatty
sub- Under; near
syn- Joined together
trans- Across; over
un- Not; reversal

1958
Suffixes
-able, - ible, - ble The power to be
-ad Toward; in the direction of
-aemia, - emia Pertaining to blood
-age Put in motion; to do
-agra Denoting a seizure; severe pain
-algia Denoting pain
-ase Forms the name of an enzyme
-blast Designates a cell or a structure
-cele Denoting a swelling
-centesis Denoting a puncture
-ectomy A cutting out
-esthesia Denoting sensation
-facient That which makes or causes
-gene, - genesis, - genetic, - genic Denoting production; origin
-gog, - gogue To make flow
-gram A tracing; a mark
-graph A writing; a record
-iasis Denoting a condition or pathologic state
-id Denoting shape or resemblance
-ite Of the nature of
-itis Denoting inflammation
-logia Denoting discourse, science, or study of
-oid Denoting form or resemblance
-oma Denoting a tumor
-osis Denoting a morbid process
-ostomosis, - ostomy, - stomy Denoting an outlet; to furnish with an
opening or mouth
-plasty Denoting molding or shaping
-rhaphy Denoting suturing or stitching
-rhea Denoting a flow or discharge
-rrhagia Denoting a discharge; usually bleeding
-scope, - scopy Generally an instrument for viewing
-tomy Denoting a cutting operation
-trophy Denoting a relationship to nourishment

1959
Combining forms
aer-, aero- Denoting air or gas
alge-, algesi-, algo- Pertaining to pain
allo- Other; differing from the normal
anomalo- Denoting irregularity
arthro- Pertaining to a joint or joints
brevi- Short
celio- Denoting the abdomen
centro- Center
cheil-, cheilo- Denoting the lip
chol-, chole-, cholo- Pertaining to bile
chondr-, chondri- Pertaining to cartilage
chrom-, chromo- Pertaining to color
cole-, coleo- Denoting a sheath
colp-, colpo- Pertaining to the vagina
cranio- Pertaining to the cranium of the skull
crymo-, cryo- Denoting cold
crypt- To hide; a pit
cyano- Dark blue
cyclo- Pertaining to a cycle
cysto- Pertaining to a sac or cyst
cyto- Denoting a cell
dacryo- Pertaining to the lacrimal glands
dactylo- Pertaining to digits
dent-, dento- Pertaining to teeth
derma-, dermat- Pertaining to skin
desmo- Pertaining to a bond or ligament
dextro- Right
diplo- Double; twofold
dorsi-, dorso- Pertaining to the back
duodeno- Pertaining to the duodenum
electro- Pertaining to electricity
encephalo- Denoting the brain
entero- Pertaining to the intestines
episio- Pertaining to the vulva
eso- Inward
esthesio- Pertaining to feeling or sensation
facio- Pertaining to the face
gangli-, ganglio- Pertaining to a ganglion
geno- Pertaining to reproduction

1960
gero-, geronto- Denoting old age
giganto- Huge
gingivo- Pertaining to the gingiva or gum
gloss-, glosso- Pertaining to the tongue
gluco- Denoting sweetness
glyco- Pertaining to sugar
gnath-, gnatho- Denoting the jaw
gon- Denoting a seed
grapho- Denoting writing
hapt-, hapte-, hapto- Pertaining to touch or a seizure
helo- Pertaining to a nail or callus
hist-, histio-, histo- Pertaining to tissue
holo- Pertaining to the whole
hydr-, hydro- Denoting water
hygro- Denoting moisture
hyl-, hyle-, hylo- Denoting matter or material
ileo-, ilio- Pertaining to the ileum
ipsi- Denoting self
irido- Pertaining to a colored circle
iso- Equal
jejuno- Pertaining to the jejunum
kerato- Pertaining to the cornea
kino- Denoting movement
labio- Pertaining to the lips
lacto- Pertaining to milk
laparo- Pertaining to the loin or flank
latero- Pertaining to the side
leido-, leio- Smooth
leuk-, leuko- Denoting deficiency of color
lip-, lipo- Pertaining to fat
litho- Denoting a calculus
macr-, macro- Large; long
mast-, masto- Pertaining to the breast
meg-, mega- Great; large
meli- Sweet
meningo- Denoting membranes; covering the brain and the spinal cord
micr-, micro- Small in size or extent
mono- One
morpho- Pertaining to form
multi- Many
my-, myo- Pertaining to muscle

1961
myc-, mycet- Denoting a fungus
myringo- Denoting the tympanic membrane or the eardrum
myx-, myxo- Pertaining to mucus
narco- Denoting stupor
naso- Pertaining to the nose
necro- Denoting death
neo- New
nephr-, nephro- Denoting the kidney
normo- Normal or usual
oculo- Denoting the eye
odyno- Denoting pain
oleo- Denoting oil
onco- Denoting a swelling or mass
onycho- Pertaining to the nails
oo- Denoting an egg
opisth-, opistho- Backward
ophthal-, ophthalmo- Pertaining to the eye
optico- Pertaining to the eye or vision
orchi-, orcho- Pertaining to the testes
oro- Pertaining to the mouth
ortho- Straight; right
oscillo- Denoting oscillation
osteo- Pertaining to the bones
ot-, oto- Denoting an egg
palato- Denoting the palate
patho- Denoting disease
pedia-, pedo- Denoting a child
perineo- Combining form for the region between the anus and the
scrotum or vulva
phago- Denoting a relationship to eating
pharyngo- Pertaining to the pharynx
phleb-, phlebo- Denoting the veins
phon-, phono- Denoting sound
phot-, photo- Pertaining to light
phren- Pertaining to the mind
picr-, picro- Bitter
pilo- Denoting hair
plasmo- Pertaining to plasma or the substance of a cell
pneuma-, pneumono-, pneumoto- Denoting air or gas
pod-, podo- Denoting the foot
poly- Many

1962
proct-, procto- Denoting the anus and rectum
psych-, psycho- Pertaining to the mind
ptyalo- Denoting saliva
pubio-, pubo- Denoting the pubic region
pulmo- Denoting the lung
pupillo- Denoting the pupil
py-, pyo- Denoting pus
pyel-, pyelo- Denoting the pelvis
pyloro- Pertaining to the pylorus
recto- Denoting the rectum
rhin-, rhino- Denoting the nose
salpingo- Denoting a tube, specifically the fallopian tube
schizo- Split
sclero- Denoting hardness
scoto- Pertaining to darkness
sero- Pertaining to serum
sialo- Pertaining to saliva or the salivary glands
sidero- Denoting iron
sinistro- Left
somato- Denoting the body
somni- Denoting sleep
spasmo- Denoting a spasm
spermato-, spermo- Denoting sperm
sphero- Denoting a sphere; round
sphygmo- Denoting a pulse
splen-, spleno- Denoting the spleen
staphyl-, staphylo- Resembling a bunch of grapes
steno- Narrow; short
sterco- Denoting feces
steth-, stetho- Pertaining to the chest
stomato- Denoting the mouth
sym-, syn- With; along
tacho-, tachy- Swift
tarso- Pertaining to the flat of the foot
terato- Denoting a marvel, prodigy, or monster
thoraco- Pertaining to the chest
thrombo- Denoting a clot of blood
toxico-, toxo- Denoting poison
tracheo- Denoting the trachea
trichi-, tricho- Denoting hair
ur-, uro-, urono- Pertaining to urine

1963
varico- Denoting a twisting or swelling
vaso- Denoting a vessel
veno- Denoting a vein
ventri-, ventro- Denoting the abdomen
vertebro- Pertaining to the vertebra
vesico- Denoting the bladder
viscero- Denoting the organs of the body
vivi- Denoting alive
xantho- Denoting yellow
xero- Denoting dryness

1964
Terminology frequently used to designate
body parts or organs
anus Anal, ano-
arm Brachial, brachio-
blood Hem-, hemat-
chest Thoracic, thorax
ear Auricle, oto-
eye Ocular, oculo-, ophthalmo-
foot Pedal, ped-, - pod
gallbladder Chole-, chol-
head Cephalic, cephalo-
heart Cardium, cardiac, cardio-
intestines Cecum, colon, duodenum, ileum, jejunum
kidney Renal, nephric, nephro-
lip Cheil-
liver Hepatic, hepato-
lungs Pulmonary, pulmonic, pneumo-
mouth Oral, os, stoma, stomat-
muscle Myo-
neck Cervix, cervical, cervico-
penis Penile
rectum Rectal
skin Derma, integumentum
stomach Gastric, gastro-
testicle Orchio-, orchi-, orchido-
urinary bladder Cysti-, cysto-
uterus Hystero-, metra
vagina Vulvo, vaginal

1965
APPE NDI X B

1966
Professional Organizations of
Interest to Dental Hygienists
Academy of General Dentistry
560 W. Lake Street, Sixth Floor
Chicago, IL 60661
Phone: (888) 243–3368
Fax: (312) 335–3443
http://www.agd.org
American Academy of Pediatric Dentistry
211 E. Chicago Avenue, Suite 1600
Chicago, IL 60611
Phone: (312) 337–2169
Fax: (312) 337–6329
http://www.aapd.org
[email protected]
American Association for Dental Research
1619 Duke Street
Alexandria, VA 22314
Phone: (703) 548–0066
Fax: (703) 548–1883
http://www.aadronline.org
[email protected]
American Association of Public Health Dentistry
3085 Stevenson Drive, Suite 200
Springfield, IL 62703
Phone: (217) 529–6941
Fax: (217) 529–9120
http://www.aaphd.org
[email protected]
American Dental Association
211 E. Chicago Avenue
Chicago, IL 60611
Phone: (312) 440–2500
Fax: (312) 440–2800
http://www.ada.org
American Dental Education Association
655 K Street, NW, Suite 800

1967
Washington, DC 20001
Phone: (202) 289–7201
Fax: (202) 289–7204
http://www.adea.org
American Dental Hygienists Association
444 N. Michigan Avenue, Suite 3400
Chicago, IL 60611
Phone: (312) 440–8900
http://www.adha.org
American Public Health Association
800 I Street NW
Washington, DC 20001
Phone: (202) 777–2742
Fax: (202) 777–2534
http://www.apha.org
[email protected]
Association of Schools of Allied Health Professions
122 C Street, NW, Suite 650
Washington, DC 20001
Phone: (202) 237–6481
Fax: (202) 237–6485
http://www.asahp.org
Canadian Dental Association
1815 Alta Vista Drive
Ottawa, Ontario
Canada K1G 3Y6
Phone: (613) 523–1770
Fax: (613) 523–7736
http://www.cda-adc.ca/
[email protected]
Canadian Dental Hygienists Association
1122 Wellington Street W
Ottawa, Ontario
Canada K1Y 2Y7
Phone: (613) 224–5515 or (800) 267–5235
Fax: (613) 224–7283
http://www.cdha.ca
[email protected]
Canadian Public Health Association
404–1525 Carling Avenue
Ottawa, Ontario

1968
Canada K1Z 8R9
Phone: (613) 725–3769
Fax: (613) 725–9826
http://www.cpha.ca
[email protected]
Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30329
Phone: (800) 232–4636 or (888) 232–6348
http://www.cdc.gov
[email protected]
FDI World Dental Federation
Avenue Louis Casaï 51
P.O. Box 3
1216 Geneve-Cointrin
Switzerland
Phone: 41 22 560 81 50
Fax: 41 22 560 81 40
http://www.fdiworldental.org
[email protected]
Hispanic Dental Association
3910 South IH-35, Suite 245
Austin, Texas 78704
Phone: (512) 904–0252
http://www.hdassoc.org
[email protected]
International Association for Dental Research
1619 Duke Street
Alexandria, VA 22314
Phone: (703) 548–0066
Fax: (703) 548–1883
http://www.iadr.com
[email protected]
International Association for Disability and Oral Health
Spoorstraat 94
6591 GV Gennep
Netherlands
http://www.iadh.org
International Federation of Dental Hygienists
100 South Washington Street
Rockville, MD 20850

1969
Phone: (240) 778–6790
Fax: (240) 778–6112
http://www.ifdh.org
[email protected]
National Center for Dental Hygiene Research & Practice
USC School of Dentistry
925 W. 34th Street
Los Angeles, CA 90089
Phone: (213) 740–8669
Fax: (213) 740–1072
http://www.usc.edu/hsc/dental/dhnet/
National Dental Hygienists’ Association/National Dental Association
6411 Ivy Lane, Suite 703
Greenbelt, MD 20770
Phone: (202) 588–1697
Fax: (240) 297–9181
http://www.ndaonline.org
[email protected]
Special Care Dentistry Association
330 North Wabash Avenue, Suite 2000
Chicago, IL 60611
Phone: (312) 527–6764
Fax: (312) 673–6663
http://www.scdaonline.org
[email protected]
World Health Organization
Avenue Appia 20
1211 Geneva 27
Switzerland
Phone: 41 22 791 21 11
Fax: 41 22 791 31 11
http://www.who.int
[email protected]

1970
APPE NDI X
C

1971
American Dental Hygienists
Association and Canadian Dental
Hygienists Association Codes of
Ethics

1972
The american dental hygienists’ code of
ethics*
1 Preamble
As dental hygienists, we are a community of professionals devoted to the
prevention of disease and the promotion and improvement of the
public’s health. We are preventive oral health professionals who provide
educational, clinical, and therapeutic services to the public. We strive to
live meaningful, productive, satisfying lives that simultaneously serve us,
our profession, our society, and the world. Our actions, behaviors, and
attitudes are consistent with our commitment to public service. We
endorse and incorporate the Code into our daily lives.

2 Purpose
The purpose of a professional code of ethics is to achieve high levels of
ethical consciousness, decision making, and practice by the members of
the profession. Specific objectives of the Dental Hygiene Code of Ethics
are:
• To increase our professional and ethical consciousness and sense of
ethical responsibility.
• To lead us to recognize ethical issues and choices and to guide us in
making more informed ethical decisions.
• To establish a standard for professional judgment and conduct.
• To provide a statement of the ethical behavior the public can expect
from us.
The Dental Hygiene Code of Ethics is meant to influence us
throughout our careers. It stimulates our continuing study of ethical
issues and challenges us to explore our ethical responsibilities. The Code
establishes concise standards of behavior to guide the public’s
expectations of our profession and supports existing dental hygiene
practice, laws, and regulations. By holding ourselves accountable to
meeting the standards stated in the Code, we enhance the public’s trust
on which our professional privilege and status are founded.

3 Key Concepts
Our beliefs, principles, values, and ethics are concepts reflected in the
Code. They are the essential elements of our comprehensive and
definitive code of ethics, and are interrelated and mutually dependent.

1973
4 Basic Beliefs
We recognize the importance of the following beliefs that guide our
practice and provide context for our ethics:
• The services we provide contribute to the health and well-being of
society.
• Our education and licensure qualify us to serve the public by
preventing and treating oral disease and helping individuals achieve
and maintain optimal health.
• Individuals have intrinsic worth, are responsible for their own health,
and are entitled to make choices regarding their health.
• Dental hygiene care is an essential component of overall healthcare and
we function interdependently with other healthcare providers.
• All people should have access to healthcare, including oral healthcare.
• We are individually responsible for our actions and the quality of care
we provide.

5 Fundamental Principles
These fundamental principles, universal concepts, and general laws of
conduct provide the foundation for our ethics.

Universality
The principle of universality assumes that if one individual judges an
action to be right or wrong in a given situation, other people considering
the same action in the same situation would make the same judgment.

Complementarity
The principle of complementarity assumes the existence of an obligation
to justice and basic human rights. It requires us to act toward others in
the same way they would act toward us if roles were reversed. In all
relationships, it means considering the values and perspective of others
before making decisions or taking actions affecting them.

Ethics
Ethics are the general standards of right and wrong that guide behavior
within society. As generally accepted actions, they can be judged by
determining the extent to which they promote good and minimize harm.
Ethics compel us to engage in health promotion/disease prevention
activities.

1974
Community
This principle expresses our concern for the bond between individuals,
the community, and society in general. It leads us to preserve natural
resources and inspires us to show concern for the global environment.

Responsibility
Responsibility is central to our ethics. We recognize that there are
guidelines for making ethical choices and accept responsibility for
knowing and applying them. We accept the consequences of our actions
or the failure to act and are willing to make ethical choices and publicly
affirm them.

6 Core Values
We acknowledge these values as general guides for our choices and
actions.
Individual Autonomy and Respect for Human Beings
People have the right to be treated with respect. People have the right
to informed consent prior to treatment, and they have the right to full
disclosure of all relevant information so that they can make informed
choices about their care.

Confidentiality
We respect the confidentiality of client information and relationships as a
demonstration of the value we place on individual autonomy. We
acknowledge our obligation to justify any violation of a confidence.

Societal Trust
We value client trust and understand that public trust in our profession
is based on our actions and behavior.

Nonmaleficence
We accept our fundamental obligation to provide services in a manner
that protects all clients and minimizes harm to them and others involved
in their treatment.

Beneficence

1975
We have a primary role in promoting the well-being of individuals and
the public by engaging in health promotion/disease prevention activities.

Justice and Fairness

We value justice and support the fair and equitable distribution of
healthcare resources. We believe all people should have access to high-
quality, affordable oral healthcare.

Veracity
We accept our obligation to tell the truth and assume that others will do
the same. We value self-knowledge and seek truth and honesty in all
relationships.

7 Standards of Professional Responsibility

We are obligated to practice our profession in a manner that supports
our purpose, beliefs, and values in accordance with the fundamental
principles that support our ethics. We acknowledge the following
responsibilities:

To Ourselves as Individuals …
• Avoid self-deception, and continually strive for knowledge and
personal growth.
• Establish and maintain a lifestyle that supports optimal health.
• Create a safe work environment.
• Assert our own interests in ways that are fair and equitable.
• Seek the advice and counsel of others when challenged with ethical
dilemmas.
• Have realistic expectations of ourselves and recognize our limitations.

To Ourselves as Professionals …
• Enhance professional competencies through continuous learning in
order to practice according to high standards of care.
• Support dental hygiene peer-review systems and quality-assurance
measures.
• Develop collaborative professional relationships and exchange
knowledge to enhance our own lifelong professional development.

1976
To Family and Friends …
• Support the efforts of others to establish and maintain healthy
lifestyles and respect the rights of friends and family.

To Clients …
• Provide oral healthcare utilizing high levels of professional knowledge,
judgment, and skill.
• Maintain a work environment that minimizes the risk of harm.
• Serve all clients without discrimination and avoid action toward any
individual or group that may be interpreted as discriminatory.
• Hold professional client relationships confidential.
• Communicate with clients in a respectful manner.
• Promote ethical behavior and standards of care by all dental hygienists.
• Serve as an advocate for the welfare of clients.
• Provide clients with the information necessary to make informed
decisions about their oral health and encourage their full participation
in treatment decisions and goals.
• Refer clients to other healthcare providers when their needs are beyond
our ability or scope of practice.
• Educate clients about high-quality oral healthcare.

To Colleagues …
• Conduct professional activities and programs, and develop
relationships in ways that are honest, responsible, and appropriately
open and candid.
• Encourage a work environment that promotes individual professional
growth and development.
• Collaborate with others to create a work environment that minimizes
risk to the personal health and safety of our colleagues.
• Manage conflicts constructively.
• Support the efforts of other dental hygienists to communicate the
dental hygiene philosophy of preventive oral care.
• Inform other healthcare professionals about the relationship between
general and oral health.
• Promote human relationships that are mutually beneficial, including
those with other healthcare professionals.

To Employees and Employers …

1977
• Conduct professional activities and programs, and develop
relationships in ways that are honest, responsible, open, and candid.
• Manage conflicts constructively.
• Support the right of our employees and employers to work in an
environment that promotes wellness.
• Respect the employment rights of our employers and employees.

To the Dental Hygiene Profession …

• Participate in the development and advancement of our profession.
• Avoid conflicts of interest and declare them when they occur.
• Seek opportunities to increase public awareness and understanding of
oral health practices.
• Act in ways that bring credit to our profession while demonstrating
appropriate respect for colleagues in other professions.
• Contribute time, talent, and financial resources to support and
promote our profession.
• Promote a positive image for our profession.
• Promote a framework for professional education that develops dental
hygiene competencies to meet the oral and overall health needs of the
public.

To the Community and Society …

• Recognize and uphold the laws and regulations governing our
profession.
• Document and report inappropriate, inadequate, or substandard care
and/or illegal activities by any healthcare provider to the responsible
authorities.
• Use peer review as a mechanism for identifying inappropriate,
inadequate, or substandard care and for modifying and improving the
care provided by dental hygienists.
• Comply with local, state, and federal statutes that promote public
health and safety.
• Develop support systems and quality-assurance programs in the
workplace to assist dental hygienists in providing the appropriate
standard of care.
• Promote access to dental hygiene services for all, supporting justice
and fairness in the distribution of healthcare resources.
• Act consistently with the ethics of the global scientific community of
which our profession is a part.

1978
• Create a healthful workplace ecosystem to support a healthy
environment.
• Recognize and uphold our obligation to provide pro bono service.

To Scientific Investigation …
• We accept responsibility for conducting research according to the
fundamental principles underlying our ethical beliefs in compliance
with universal codes, governmental standards, and professional
guidelines for the care and management of experimental subjects. We
acknowledge our ethical obligations to the scientific community:
• Conduct research that contributes knowledge that is valid and useful to
our clients and society.
• Use research methods that meet accepted scientific standards.
• Use research resources appropriately.
• Systematically review and justify research in progress to ensure the
most favorable benefit-to-risk ratio to research subjects.
• Submit all proposals involving human subjects to an appropriate
human subject review committee.
• Secure appropriate institutional committee approval for the conduct of
research involving animals.
• Obtain informed consent from human subjects participating in
research that is based on specifications published in Title 21 Code of
Federal Regulations Part 46.
• Respect the confidentiality and privacy of data.
• Seek opportunities to advance dental hygiene knowledge through
research by providing financial, human, and technical resources
whenever possible.
• Report research results in a timely manner.
• Report research findings completely and honestly, drawing only those
conclusions that are supported by the data presented.
• Report the names of investigators fairly and accurately.
• Interpret the research and the research of others accurately and
objectively, drawing conclusions that are supported by the data
presented and seeking clarity when uncertain.
• Critically evaluate research methods and results before applying new
theory and technology in practice.
• Be knowledgeable concerning currently accepted preventive and
therapeutic methods, products, and technology and their application
to our practice.

1979
The canadian dental hygienists
association code of ethics
“Dental hygienists believe that oral health is an integral part of a
person’s overall health, well-being, and quality of life.”

Table of Contents
Preamble
Summary of the Main Principles in the Code
Principle I: Beneficence
Principle II: Autonomy
Principle III: Privacy and Confidentiality
Principle IV: Accountability
Principle V: Professionalism
Appendix A: Ethical Challenges/Problems
Appendix B: Reporting Suspected Incompetence or Unethical Conduct
Appendix C: Decision—Procedure
References

Preamble
Dental hygienists believe that oral health is an integral part of a person’s
overall health, well-being, and quality of life. The profession of dental
hygiene is devoted to promoting optimal oral health for all. Dental
hygiene has an identified body of knowledge and a distinctive expertise
which dental hygienists use to serve the needs of their clients and
promote the public good.
The Code of Ethics sets down the ethical principles and ethical practice
standards of the dental hygiene profession. The principles express the
broad ideals to which dental hygienists aspire and which guide them in
their practice. The standards provide more specific direction for conduct.
They are more precise and prescriptive as to what a given principle
requires under particular circumstances. Clients, colleagues, and the
public in general can reasonably expect dental hygienists to be guided by,
and to be accountable under, the principles and standards articulated in
this Code.
The purpose of the Code of Ethics is to
• Elaborate the ethical principles and standards by which dental
hygienists are guided and under which they are accountable;
• Serve as a resource for education, reflection, self-evaluation, and peer

1980
 review;
• Educate the public about the ethical principles and standards of the
profession; and,
• Promote accountability.
The Code of Ethics is a public document that augments and
complements the relevant laws and regulations under which dental
hygienists practise. By elaborating on the profession’s ethical principles
and standards, the Code promotes accountability and worthiness of the
public’s trust.
The Code of Ethics applies to dental hygienists and dental hygiene
students in all practice settings including, but not limited to, private
practice, institutions, research, education, administration, community
health, and industry.
Interpretation and application of the Code in specific circumstances
requires individual judgment. Several aids are appended to the Code to
assist in this.

Summary of the Main Principles in the Code

The fundamental principle underlying this Code is that the dental
hygienist’s primary responsibility is to the client, whether the client is an
individual or a community.

Principle I: Beneficence
Beneficence involves caring about and acting to promote the good of
another. Dental hygienists use their knowledge and skills to assist clients
to achieve and maintain optimal oral health and to promote fair and
reasonable access to quality oral health services.

Principle II: Autonomy

Autonomy pertains to the right to make one’s own choices. By
communicating relevant information openly and truthfully, dental
hygienists assist clients to make informed choices and to participate
actively in achieving and maintaining their optimal oral health.

Principle III: Privacy and Confidentiality

Privacy pertains to the individual’s right to decide the conditions under
which others will be permitted access to his or her personal life or
information. Confidentiality is the duty to hold secret any information

1981
acquired in the professional relationship. Dental hygienists respect the
privacy of clients and hold in confidence information disclosed to them,
subject to certain narrowly defined exceptions.

Principle IV: Accountability

Accountability pertains to the acceptance of responsibility for one’s
actions and omissions in light of relevant principles, standards, laws, and
regulations and the potential to self-evaluate and to be evaluated
accordingly. Dental hygienists practise competently in conformity with
relevant principles, standards, laws and regulations, and accept
responsibility for their behavior and decisions in the professional
context.

Principle V: Professionalism
Professionalism is the commitment to use and advance professional
knowledge and skills to serve the client and the public good. Dental
hygienists express their professional commitment individually in their
practice and communally through their professional associations and
regulatory bodies.

Principle I: Beneficence
Beneficence involves caring about and acting to promote the good of
another. Dental hygienists use their knowledge and skills to assist clients
to achieve and maintain optimal oral health and to promote fair and
reasonable access to quality oral health services.

Standards for Principle I

Dental hygienists:
1a. provide services to their clients in a caring and respectful manner, in
recognition of the inherent dignity of human beings;
1b. provide services to their clients with respect for their individual
needs and values and life circumstances;
1c. provide services fairly and without discrimination, in recognition of
fundamental human rights;
1d. put the needs, values, and interests of their clients first and avoid
exploiting their clients for personal gain;
1e. seek to improve the quality of care and advance knowledge in the
field of oral health through such activities as quality assurance, research,

1982
education, and advocacy in the public arena.

Principle II: Autonomy

Autonomy pertains to the right to make one’s own choices. By
communicating relevant information openly and truthfully, dental
hygienists assist clients to make informed choices and to participate
actively in achieving and maintaining their optimal oral health.

Standards for Principle II

Dental hygienists:
2a. actively involve clients in their oral health care and promote informed
choice by communicating relevant information openly, truthfully, and
sensitively in recognition of the client’s needs, values, and capacity to
understand;
2b. in the case of clients who lack the capacity for informed choice,
actively involve and promote informed choice on the part of the client’s
substitute decision-makers, involving the client to the extent of the
client’s capacity;
2c. honour the client’s informed choices, including refusal of treatment,
and regard informed choice as a precondition of treatment;
2d. do not rely upon coercion or manipulative tactics in assisting the
client to make informed choices;
2e. recommend or provide only those services they believe are necessary
for the client’s oral health or as consistent with the client’s informed
choice.
Note: Critical elements of informed choice include disclosure (i.e.,
revealing pertinent information, including risks and benefits);
willingness (i.e., the choice is not coerced or manipulated); and
capacity (i.e., the cognitive capacity to understand and process the
relevant information). “Informed choice” encompasses what is
sometimes referred to as “informed consent.”

Principle III: Privacy and Confidentiality

Privacy pertains to the individual’s right to decide the conditions under
which others will be permitted access to his or her personal life or
information. Confidentiality is the duty to hold secret any information
acquired in the professional relationship. Dental hygienists respect the
privacy of clients and hold in confidence information disclosed to them,
subject to certain narrowly defined exceptions.

1983
Standards for Principle III
Dental hygienists:
3a. demonstrate regard for the privacy of their clients;
3b. hold confidential any information acquired in the professional
relationship and do not use or disclose it to others without the client’s
express consent, except:
3b.i as required by law
3b.ii as required by the policy of the practice environment (e.g., quality
assurance)
3b.iii in an emergency situation
3b.iv in cases where disclosure is necessary to prevent serious harm to
others
3b.v to the guardian or substitute decision-maker of a client, in these
cases, disclose to others only as much information as is necessary to
accomplish the purpose for the disclosure;
3c. may infer the client’s consent for disclosure to others directly involved
in delivering and administering services to the client, provided there is
no reason to believe the client would not give express consent if asked;
3d. obtain the client’s express consent to use or share information about
the client for the purpose of teaching or research;
3e. inform their clients in advance of treatment about how they will use
or share their information, in particular about any uses or sharing that
may occur without the client’s express consent;
3f. promote practices, policies, and information systems that are
designed to respect client privacy and confidentiality.

Principle IV: Accountability

Accountability pertains to the acceptance of responsibility for one’s
actions and omissions in light of relevant principles, standards, laws, and
regulations and the potential to self-evaluate and to be evaluated
accordingly. Dental hygienists practise competently in conformity with
relevant principles, standards, laws and regulations, and accept
responsibility for their behaviour and decisions in the professional
context.

Standards for Principle IV

Dental hygienists:
4a. accept responsibility for knowing and acting consistently with the
principles, standards, laws and regulations under which they are

1984
accountable;
4b. accept responsibility for providing safe, quality, competent care
including, but not limited to, addressing issues in the practice
environment within their capacity that may hinder or impede the
provision of such care;
4c. take appropriate action to ensure first and foremost the client’s safety
and quality of care when they suspect unethical or incompetent care;
4d. practise within the bounds of their competence, scope of practice,
personal and/or professional limitations, and refer clients requiring care
outside these bounds;
4e. inform the dental hygiene regulatory body when an injury,
dependency, infection, condition, or any other serious incapacity has
immediately affected, or may affect over time, their continuing ability to
practise safely and competently;
4f. promote workplace practices and policies that facilitate professional
practice in accordance with the principles, standards, laws and
regulations under which they are accountable.

Principle V: Professionalism
Professionalism is the commitment to use and advance professional
knowledge and skills to serve the client and the public good. Dental
hygienists express their professional commitment individually in their
practice and communally through their professional associations and
regulatory bodies.

Standards for Principle V

Dental hygienists:
5a. uphold the principles and standards of the profession before clients,
colleagues, and others;
5b. maintain and advance their knowledge and skills in dental hygiene
through continuing education and the quality of the care they provide
through ongoing self-evaluation and quality assurance;
5c. advance general knowledge and skills in the field of oral health by
supporting, participating in, or conducting ethically approved research;
5d. participate in professional activities such as meetings, committee
work, peer review, and participation in public forums to promote oral
health;
5e. participate in mentoring, education, and dissemination of knowledge
and skills in oral health care;

1985
5f. support the work of their professional associations and regulatory
bodies to promote oral health and professional practice;
5g. inform potential employers about the principles, standards, laws and
regulations to which they are accountable and determine whether
employment conditions facilitate professional practice accordingly;
5h. collaborate with colleagues in a cooperative, constructive, and
respectful manner toward the primary end of providing safe, competent,
fair, quality care to clients;
5i. communicate the nature and costs of professional services fairly and
accurately.

Appendix A: Ethical Challenges/Problems

No code of ethics can be expected to resolve definitively all ethical
challenges or problems that may arise in practice. The analysis below is
intended to help dental hygienists understand the nature of ethical
challenges or problems and thereby better resolve them.
Ethical challenges or problems faced by practicing dental hygienists
tend to fall into the categories of ethical violations, ethical dilemmas, and
ethical distress.
Ethical violations: when dental hygienists fail to meet or neglect their
specific ethical responsibilities as expressed in the Code’s standards. An
example would be a dental hygienist who recommends unnecessary
treatment in order to achieve personal gain at the expense of the client.
Ethical dilemmas: when one or more ethical principles conflict either
with other ethical principle(s) or with self-interest(s) and no apparent
course of action will satisfy both sides of the dilemma. An example
would be a client with a hip prosthesis who may refuse to be
premedicated prior to receiving invasive dental treatment. In this case,
the principle of autonomy conflicts with the principle of beneficence.
Ethical distress: when dental hygienists experience constraints or
limitations in relation to which they are or feel powerless and which
compromise their ability to practise in full accordance with their
professional principles or standards. An example would be a dental
hygienist who is expected by the employer to complete dental hygiene
treatment in a length of time insufficient to render quality care or to
provide an acceptable level of infection control.
This Code is a useful guide in helping dental hygienists to identify,
work through, and put into words ethical issues in light of their
responsibilities as articulated in the Code’s principles and standards, and
to decide on an ethically responsible course of action. It is important to

1986
realize that some challenges or problems are perceived to be primarily
ethical in nature when, in fact, they arise less from conflicting principles
than from poor communication or lack of information. Reflecting on a
perceived challenge or problem in light of the Code can help determine
to what extent the problem or challenge is truly rooted in conflicting
ethical principles, and to what extent it can be resolved by improved
communication or by new information.
The Code provides clear direction for avoiding ethical violations. When
a course of action is mandated by a standard in the Code or by a
principle where there exists no opposing principle, ethical conduct
requires that course of action.
In the case of ethical dilemmas and ethical distress, the Code cannot
always provide a clear direction. The resolution of dilemmas often
depends on the specific circumstances of the case in question. Total
satisfaction by all parties involved may not be achieved. Resolution may
also depend on which opposing ethical principle is considered to be
more important, a matter on which reasonable people may disagree.
Ethical distress often arises in situations where the dental hygienist is
significantly limited by factors beyond his or her immediate control that
may not be resolvable in the specific context.
In all cases, dental hygienists are accountable for how they conduct
themselves in professional practice. Even in situations of ethical dilemma
or distress where the Code does not prescribe a specific course of action,
the hygienist can be expected to give account of his or her chosen action
in light of the principles and standards expressed in the Code. Ultimately,
dental hygienists must reconcile their actions with their consciences in
caring for clients.

Appendix B: Reporting Suspected Incompetence or

Unethical Conduct
The first consideration of the dental hygienist who suspects
incompetence or unethical conduct in colleagues or associates is the
welfare of present clients and/or potential harm to future clients.
Adherence to the following guidelines could be helpful:
1. First, confirm the facts of the situation.
2. Ensure you are familiar with existing protocols in the practice setting
for reporting incidents, incompetence, or unethical care and follow those
protocols.
3. Document and report issues that cannot be resolved within the
practice setting and report to the appropriate authority or regulatory

1987
body.
The dental hygienist who attempts to protect clients threatened by
incompetent or unethical conduct should not be placed in jeopardy (e.g.,
loss of employment). Colleagues and professional organizations are
morally obligated to support dental hygienists who fulfil their ethical
obligations under the Code.

Appendix C: Decision—Procedure
Guidance Regarding the Process for Resolving
Ethical Challenges
Ethical problems or challenges arise in a variety of contexts and require
thoughtful analysis and careful judgment. The following guide may be
useful to assist dental hygienists faced with an ethical challenge,
recognizing that other stakeholders may need to be involved in resolving
the matter. Talking with or getting advice from others at any step on the
way to a decision can be very helpful.
1. Identify in a preliminary way the nature of the challenge or problem.
What is the issue? What kind of issue is it? What ethical principles are at
stake?
2. Become suitably informed and gather information (e.g., talk to others
to find out the facts; research relevant policy statements) relevant to the
challenge or problem, including:
a. Factual information about the situation. What has happened? What
is the sequence of events?
b. Applicable policies, laws or regulations. Does a workplace policy
address the issue? What does the Code say? What does law or
regulation say?
c. Who are the relevant stakeholders? How do they view the situation?
3. Clarify and elaborate the challenge or problem after getting this
information. Now that you are better informed, What is the issue? What
ethical principles are at stake? What stakeholders need to be consulted
or involved in resolving the challenge or problem?
4. Identify various options for actions, recognizing that the best option
may not be obvious at first and realizing it may require creativity or
imagination.
5. Assess the various options in light of applicable policy, law or
regulation, being as clear as possible in your mind of the pluses and
minuses of each option as assessed in this light.
6. Decide on a course of action, mindful of how you would justify or

1988
defend your decision in light of the applicable policy, law or regulation, if
you are called to account.
7. Implement your decision as thoughtfully and sensitively as possible,
communicating a willingness to explain or justify the reasons for taking
it.
8. Assess the consequences of your decision. Evaluate the process you
used to arrive at the decision and the decision itself in light of those
consequences. Did things turn out as you thought they would? Would
you do the same thing again? What went wrong? Or, what went right?
In all of this, bear in mind that reasonable people can disagree about
what is the right thing to do when faced with an ethical challenge or
problem. If you cannot be certain whether you have made the right
decision, you can at least have some assurance that you came to your
decision in a responsible way. The test for this is whether you are able to
defend your decision in light of relevant laws, principles, and regulations,
and to defend the process by which you came to your decision. Reference
to the above guidelines will help in this.
In addition, there is a very rich literature on ethics that can be very
helpful for thinking through ethical challenges and problems in dental
hygiene or for ongoing professional education and development.
Dental hygienists may also find it useful to familiarize themselves with
various ethical theories, which tend to guide or orient ethical thinking
along different lines. The main ethical theories current today are briefly
described below:
• Deontology guides ethical thinking in terms of duties and rights, which
the philosopher Immanuel Kant grounds in the fundamental
imperative to act in relation to others according to principles that
apply universally to all people, and that one would also wish for others
to apply in their actions in relation to oneself.
• Utilitarianism guides ethical thinking in terms of harms and benefits,
which the philosopher J.S. Mill grounds in the fundamental imperative
to promote the greatest good for the greatest number.
• The ethic of care guides ethical thinking in terms of preserving and
enhancing relationships and service to others. This theory derives from
the work of Carol Gilligan, who found in her research that this style of
ethical thinking tends to be more associated with females than with
males.
• Virtue ethics guides ethical thinking in terms of habits of acting and
assesses actions in terms of virtues and vices of character. This theory
derives from the work of the philosopher Aristotle, who emphasized
that ethics cannot be reduced to rules or formulas and held that the

1989
 person of good character (the “good man”) is the ultimate standard of
right and wrong and should be emulated by others as a role model.
• Feminist ethics guides ethical thinking in terms of sensitivity to the
power or political dimension of human interaction. The philosopher
Susan Sherwin grounds feminist ethics in the allegiance to those who
are oppressed, vulnerable, or disadvantaged and the imperative to
improve their situation.
This is by no means a complete listing of ethical theories, nor is the
richness of these theories captured in the condensed descriptions given.
Moreover, considerable controversy exists not only among these theories
but also among adherents of each theory.1

1990
References
American Dental Hygienists Association. Code of ethics for dental
hygienists. Chicago: ADHA; 1995.
Canadian Dental Assistants Association. CDAA code of ethics.
Ottawa: CDAA; 2000.
Canadian Dental Association. Code of ethics. Ottawa: CDA; August
1991.
Canadian Dental Hygienists Association. Code of ethics. Ottawa:
CDHA; July 1997.
Canadian Dental Hygienists Association. Dental hygiene: client’s bill
of rights. Ottawa: CDHA; October 2001.
Canadian Medical Association. Code of ethics of the Canadian Medical
Association. Ottawa: CMA; 1997.
Canadian Nurses Association. Code of ethics for registered nurses.
Ottawa: CNA; March 1997.
College of Dental Hygienists of British Columbia. Code of ethics.
Victoria: CDHBC; March 1, 1995.
Canadian Dental Hygienists Association
1122 Wellington Street W
Ottawa, ON K1Y 2Y7
Telephone (613) 224–5515 or (800) 267–5235
Fax (613) 224–7283
www.cdha.ca

*Reprinted with permission from the American Dental Hygienists Association

(www.adha.com).
1Reprinted with permission from the American Dental Hygienists’ Association
homepage (www.adha.com).

1991
1992
Index
Note: Page numbers followed by b indicate boxes, f indicate figures and t
indicate tables.

Numbers
3 As (analgesic/antipyretic/anti-inflammatory) 337
3- to 7-day food record or diary 384
5-Fluorouracil (5-FU) 352

A
Abandonment 713
Abbreviations, Latin 326t
Abdominopelvic cavity 55, 56f
Abducens nerve (CN VI) 122
Abscesses 433
Absence (petit mal) seizure 699
Absolute refractory period 76, 548
Absorption 327
Abutment 500
Academy of General Dentistry 746
Acarbose (Pre-cose) 349
Acceptance 482
Access, to oral health care 568
Accessory nerve (CN IX) 123
Accessory structures 61
Accountability 751–752
Acetylcholine 72, 330
Acid-fast stain 258

1993
Acidogenic bacteria 364
Acidulated phosphate fluoride (APF) 503
Acquired deformities 433–436 See also Periodontium.
Acquired immunodeficiency syndrome (AIDS) 234b, 268
Acrylic appliances 415–416
Acrylic denture bases 416
Act deontology 707
Act utilitarianism 707
Actinomyces israelii 266t
Action mechanism 550
Action potential 548
Activation 525
Active listening 482
Active site 60
Active transport 20, 59, 361
Activity, in weight management 379
Acute adrenal insufficiency 701
Acute disease 625t
Acute inflammation 177–181, 178f See also Inflammation.
chemotaxis in 179
mediators
arachidonic acid 180
chemical 179, 179t
outcomes of 181
phagocytosis in 179
vascular changes in 177, 178f
Acute lymphoblastic leukemia (ALL) 231
Acute myeloblastic leukemia (AML) 231
Acyclovir 287t, 343

1994
ADA See American Dental Association (ADA)
Adaptation 525
Addison anemia 228
Adenohypophysis (anterior pituitary) 82
Adenosine triphosphate (ATP) 259, 378
Adenovirus 264t
ADEX See American Board of Dental Examiners (ADEX)
ADHA See American Dental Hygienists Association (ADHA)
ADHD See Attention deficit hyperactivity disorder (ADHD)
Adipose-derived stem cells (ASCs) 185
Administration, routes of 326
Administration for Children and Families (ACF) 621b
Administrative law 711
Administrative requirements 733
Adolescence 387
Adrenal crisis 348, 701
Adrenal glands 84
Adrenal insufficiency, acute 701
Adrenergic agents 328–329, 328f, 329t
adverse reactions of 328
drug interactions of 329
pharmacologic effects of 328
therapeutic uses of 329
as vasoconstrictors 329
Adrenergic agonists 328, 350
β2-Adrenergic agonists 350
β-Adrenergic blocker antagonists 330
α-Adrenergic blockers 329–330
Adrenergic drug 552

1995
Adrenergic neuronal agonists and antagonists 330
α-Adrenergic receptors 553
β-Adrenergic receptors 553
Adrenocorticosteroids (steroids) 348, 348t
for asthma 351
Adrenocorticotropic hormone 363
Adult stem cells 185
Advanced dental therapist (ADT) 669t
Advanced instrumentation techniques 535–536
Advanced root instrumentation 523
Advancing Oral Health in America 623
Adverse reactions 327–328
pharmacokinetics and 327–328
receptors and 328
side effects 327
Aerobic bacteria 262
AFSCs See Amniotic fluid-derived stem cells (AFSCs)
Age, pain and 548
Age Discrimination in Employment Act (ADEA) of 1967 735
Aggressive periodontitis 431–432 See also Periodontitis.
Agonist agents 328
Agonist-antagonist agents 338
Agranulocytes 115
AIDS See Acquired immunodeficiency syndrome (AIDS)
Air polishing, conventional supragingival 537
Airborne microbes, reduction of 308
Airway, obstructed 692
Alabama dental hygiene practice and education 718
Albendazole 287t

1996
Alcohol abuse and dependence 353, 594
Alcoholism 366
Alcohol-related neurodevelopmental disorders (ARND) 571
Alkylating agents 352
ALL See Acute lymphoblastic leukemia (ALL)
Allergic contact dermatitis 306, 467
Allergic reactions 327, 697–698
Allergy 270f
Allopurinol (Zyloprim) 339
“All-or-none” principle 76
Allosteric effectors 60
Alloys See also Biomaterials.
casting 412–413
chromium 413
porcelain-fused-to-metal 413–414
Alternative hypothesis 629
Aluminum discs 159f
Alveolar bone 43–44
components of 44f
Alveolar mucosa 131t
examination of 470
Alveolar process 429, 429f
of mandible 112
of maxillae 110
Alveolar ridges, examination of 470
Alzheimer ’s disease 574–575
Amalgam
dental 399–401, 399–400f
tattoo 246, 246f

1997
Amantadine 287t
Ameloblasts 36f, 377
depositing hydroxyapatite crystals 41f
Amelogenesis, process of 40
Amelogenesis imperfecta 240–241, 240–241f
American Academy of Pediatric Dentistry 746
American Association for Dental Research 746
American Association of Public Health Dentistry 746
American Board of Dental Examiners (ADEX) 1, 9
American Dental Association (ADA)
Code D9215 549
contact data for 746
standards of
biomaterials 398
dental hygiene process as 458
American Dental Education Association 746
American Dental Hygienists Association (ADHA)
code of ethics of 748–750
contact data for 746
dental hygiene process 458
Practice Act overview 716t
American National Standards Institute (ANSI) 398
American Public Health Association 746
American Society of Anesthesiologists (ASA) 464
physical status classification system and stress reduction
protocols 465t
Americans with Disabilities Act (ADA of 1990) 735
Amine hormones 80
Amino acid pool 367

1998
Aminobisphosphonates 352
Aminoglycosides 342
AML See Acute myeloblastic leukemia (AML)
Amniotic fluid-derived stem cells (AFSCs) 185
Amorphous calcium phosphate 504, 647
Amoxicillin 285t
Amphetamine 329t, 353
Amphotericin B 287t
Ampicillin 285t
Amprenavir (AP) 272
Anabolic hormones 363
Anabolism 368
Anaerobic bacteria 295
Analgesic nephropathy 338
Analgesics 337, 337t
acetaminophen (n-acetyl-p-aminophenol) 338
aspirin 337
general considerations for 337
gout drugs 339
nonsteroidal anti-inflammatories
adverse reactions to 338
agents (NSAIAs) 338
drugs (NSAIDs) 331t, 338
opioid (narcotic) 338–339, 339t
salicylates 337
Analytic research 628t
Anaphase, of mitosis 21
Anaphylactic shock 693
Anaphylaxis 697

1999
Anastomosis 115
Anatomic crown 129
Anatomic nomenclature 53–55, 107, 108f
Anatomical position 107
Anatomy and physiology 53–106
basic concepts in 53–55
anatomic nomenclature in 53–55
body cavities 55, 56f
levels of organization in 53, 54f
body systems and components 61–103
cells 55–61 See also Cells.
dental 134–142
clinical oral structures 129, 130–131f, 131t
dentition 134, 136t
eruption 142–143
interarch relationships 143–147
intra-arch relationships 143–147
periodontium 428f See also Periodontium.
review questions for 148, 148–149b, 148–149f
terminology for 129–134
website information and resources for 147b
head and neck 107–128
bones of 109–112
circulatory system and 115–117 See also Circulatory system.
glands of 118–119
lymphatic system and 117–118, 117f
muscular system and 112–114 See also Muscular system.
nervous system and 119–123 See also Nervous system.
osteology 107–112 See also Osteology.

2000
 paranasal sinuses of 112
review questions for 123–128, 127b
temporomandibular joint 114–115, 114f
website information and resources for 123b
review questions for 103, 104–106b
tissues 61
Anemia
Addison 228
aplastic 229–230
primary 229
secondary 229
Biermer 228
Cooley 229–230
iron deficiency 228–229, 229f
pernicious 228
primary 228
sickle cell 227–228, 227–228f
Anesthesia stages 561
and planes 334
Anesthetic agents
general 334–335
local See Local anesthetic agents
specific 334–335
Aneurysmal bone cyst 226
Angina pectoris 587, 695
Angiogenesis 182
Angle, Edward H. 145
Angled shank 518
Angular cheilitis 247, 247f

2001
Angulation 525, 525f
Anode 153
Anodontia 244
Anorexia bulimia 574
Anorexia nervosa 380, 574
ANSI See American National Standards Institute (ANSI)
Antagonist 328
Anterior middle superior alveolar (AMSA) nerve block 558
Anterior superior alveolar (ASA) nerve 120, 120t
Anthropometric analysis 381
Antiacne agents 331t
Antianginal agents 344
Antiarrhythmics 344–347
antianginal agents 344
anticoagulants 344–345
anticonvulsants 346–347, 346t
antihypertensives 344, 345t
diuretics 344
Antibacterial agents 285t
Antibiotics, premedication guidelines for 464t
Anticholinergic agents 331, 331t
Anticoagulants 344–345
warfarin (Coumadin) 344–345
Anticonvulsants 331t, 346–347, 346t
Antidepressants 331t, 347–348
Antidiabetic agents 329
Antidiarrheal 331t
Antidiuretic hormone 83
Antiemetics 351–352

2002
Antifungal agents 287t, 343
Antihistamines 331t
Antihypertensives 331t, 338, 344, 345t
Anti-infectives (antibiotics) 339–343
aminoglycosides 342
antifungal agents 343
as antineoplastic agent 352
antituberculosis agents 343
antiviral agents 343
cephalosporins 341
clindamycin 341
general considerations for 339–340
general dental concerns for 340
general side effects of 340
macrolides 341
metronidazole 342–343
penicillins 340–341
quinolones 342
sulfonamides 342
tetracyclines 341–342
Anti-inflammatories
adverse reactions to 338
nonsteroidal anti-inflammatory agents (NSAIAs) 338
nonsteroidal anti-inflammatory drugs (NSAIDs) 331t, 338
Antimetabolites 352
Antimicrobial substances 267
Antinauseants 331t
Antineoplastic agents 352–353
Antiparasitic agents 287t

2003
Antiparkinson drugs 331t
Antipsychotics 331t, 347, 347t
Antiretroviral drugs 343
Antispasmodics 331t
Antituberculosis agents 343
Antiviral agents 287t, 343
Anxiety and pain management 547–566
armamentarium for 548–549
cartridge in, anesthetic 549, 549f
needle in 548, 548f
record keeping and documentation in 549
syringe in, anesthetic 549, 549f
Computer-controlled local anesthesia delivery device (CCLADD)
in 556–559, 558t
Basic CCLADD procedure and 556–558
components of 556
injection administration with 558–559
vs. traditional syringe 558t
local anesthetic agents for 550–553
biotransformation of 550–551
calculations for 552
chemical structure of 550, 551t
comparison of 551t
maximum recommended dose (MRD) for 552
mechanism of action of 550
metabolism of 550–551
potency of 550
topical 552
toxicity of 550

2004
 vasoconstrictors 552–553, 552t
nitrous oxide-oxygen in, conscious sedation with 559
advantages and disadvantages of 562
anesthesia stages for 561
chemistry of 559
contraindications to 562
equipment for 562
indications for 562
pharmacology of 561
physiology of 561
record keeping and documentation for 562
safety measures for 562
signs and symptoms of 562
synonymous terms in 559
pain characteristics and physiology in 547–548, 548f
review questions for 563, 565b
trigeminal nerve, mandibular division of 554–556
block injections for 556, 557t
innervation of 554–555
trigeminal nerve, maxillary division of 554
block injections for 554, 555t, 556f
innervation of 554
website information and resources for 563b
Apex 107, 129
Aphthous pharyngitis 209–210, 210f
Aphthous ulcers
major See Major aphthous ulcers
minor 205–206, 206f
recurrent aphthous stomatitis 205–206

2005
 recurrent ulcerative stomatitis (RUS) 205–206
Apical convergence 139f
Aplastic anemia 229–230
primary 229
secondary 229
Apoptosis 179
Appellate courts 712
Appendicular skeleton 64–66, 65f
Appliances 415–416, 500
Applied epidemiology 624
Appropriation 714
Arachidonic acid 180
Arachnoid 76, 76f
Arbovirus 264t
Arc, reflex 77
Arches 143–147
Area-specific curet 522f, 522–523 See also Curet.
Aristotle 707
Arm muscle circumference 381
Armamentarium 548–549
ARND See Alcohol-related neurodevelopmental disorders (ARND)
Arrested caries 471
Arrhythmias, cardiac 586
Arteries 26
Arthritis 580–581, 580t
Artificial fats 370
ASA See American Society of Anesthesiologists (ASA)
Ascaris lumbricoides 287t
Ascomycota 263

2006
Asepsis 300
maintaining, in oral health care environment 308–311
Aspartame 365
Aspergillus 263
Aspirated materials 701
Aspirin 337
Assault 714
Assessment
of community intervention 650–654, 651t, 653t
of dentition 471–474, 474b
extraoral 468–471
as function of public health 620
human needs theory and 458, 460–461f
intraoral 468–471
oral hygiene 476
periodontal 472t, 475
periodontal instrumentation for 518–546 See also Periodontal
instrumentation.
radiographic evaluation for 475–476
risk factor 476–477 See also Risk factors.
Assignment 718
Association of Schools of Allied Health Professions 746
Assurance
as function of public health 620
quality 162
Asthma
agents for 350–351
emergencies 694
Ataxia 578

2007
Athetosis 578
Athletic mouthguards 417
Atlas 112
Atropine 331, 331t
Attention deficit hyperactivity disorder (ADHD) 573
Attorney 712
Attribution theory 491
Aura 575
Auricular lymph nodes, assessment of 469
Auriculotemporal nerve 121
Auscultation, in extraoral and intraoral assessment 468
Autism spectrum disorders (ASD) 572–573
Autolysis 57
Automated external defibrillator 692
Autonomic nervous system (ANS) agents 328–334
β-adrenergic blocker antagonists 330
α-adrenergic blockers 329–330
adrenergic neuronal agonists and antagonists 330
parasympathomimetic (cholinergic) 328f, 330–332
sympathetic (adrenergic) 328–329, 328f, 329t
xerostomia-producing drug groups 331t
Autonomic reflex 77
Autonomy 708, 751
Autophagy 57
Autoregulation 90
Axial positioning 143, 144f
Axial skeleton 64–65, 109–112
cranial bones 109
ethmoid bone 109f, 110

2008
 facial bones 110, 111f
frontal bone 109, 109f
neck bones 112
neurocranium 109
occipital bone 109f, 110
parietal bones 109, 109f
sphenoid bone 110
temporal bones 109
viscerocranium 110, 111f
Axis 112
Axon 75, 75f
Azithromycin 285t, 341

B
Bacillary dysentery 277
Bacillus anthracis 266t
Bacillus fusiformis 205
Backward caries 471
Bacteria 263 See also Microbiology and immunology.
Firmicutes 263
Gracilicutes 263
of human importance 266t
Mendosicutes 263
Tenericutes 263
Bacterial plaque 290–291
Bacterial production 261f
Bacteriophages 264
Balanced, low-calorie diet 379
Bar graph 662

2009
Barbiturates 336
abuse of 353
adverse reactions to 336
intermediate-acting 336
long-acting 336
pharmacologic effects of 336
short-acting 336
therapeutic uses of 336
ultrashort-acting 335
Barrier-free environment 568
Barriers
disease 267
to oral health care 569–570
Basal ganglia 78
Basal metabolic rate (BMR) 378
Bases
cement 405–406, 405f
denture, acrylic 416
Basic life support (BLS) 688
Basic CCLADD Procedure 556–558
Basic screening 625t
Basic Screening Survey (BSS) 640
Basidiomycota 263
Basophils 115
Battery 714
Beam intensity 155
Beam quality 154
Beam quantity 154
Behavior change theory 490–493

2010
Behavior modification, in weight management 379
Behçet syndrome 212, 212f
Bell’s palsy 579, 579f
Beneficence 708, 749, 751
Benefits plans 671
providers of 672, 672t
Benign intraosseous neoplasms 199–201
characteristics of 199
chondroma 200
exostosis 201
torus mandibularis 201, 201f
torus palatinus 201, 201f
odontogenic myxoma 200–201, 200f
odontoma 201, 202f
osteoma 199–200, 200f
Benign migratory glossitis 247, 247f
Benign mixed tumor 219–220, 220f
Benign mucous membrane pemphigoid 206–207, 207f
Benign oral lesions
characteristics of 193
hemangioma 194–195, 195f
irritative fibroma 193, 194f
lipoma 195, 195f
papilloma 193, 194f
soft tissue origins of 193–195
traumatic fibroma 193, 194f
verruca vulgaris 193–194, 194f
wart 193–194, 194f
Benzocaine 333

2011
Benzodiazepine receptor agonists 336
Benzodiazepines 331t, 335–336, 336t, 346
Bicarbonate 367
Bidigital palpation 468
Biermer anemia 228
Biguanides 349
Bilateral palpation 468
Bile acid sequestrant 349
Bimanual palpation 468
Biochemistry 360–393
review questions for 390, 393b
web site information and resources for 390b
Bioelectrical impedance 382
Bioethics 707
Biohazard symbol 314f
Biologic death 691
Biologic properties 398 See also Biomaterials.
Biologic value (BV) 367
Biomaterials 394–426
applications of 394
classification of 394
general considerations for 394
preventive and restorative, direct 399–409
amalgam, dental 399–401, 399–400f
bonding agents 403–405, 403–404f
cement applications 406
cement bases 405–406, 405f
cement liners 405
cements, orthodontic 406

2012
 composites, dental 401–402, 401f
dentifrices 408–409
dressings, surgical 406
fluoride varnishes 407–408
fluoride-releasing restorative materials 406–407, 406f, 408f
fluorides, topical 407–408
gingival tissue packs 406
infiltrants 403
pastes, prophylactic 408–409
sealants, pit-and-fissure 402–403
sealers, root canal 406
whitening agents 409
preventive and restorative, indirect 409–420
alloys, casting 412–413
alloys, chromium 413
alloys, porcelain-fused-to-metal 413–414
appliances, acrylic 415–416
athletic mouthguards 417
cast materials 411–412, 411t
cements, crown-and-bridge 415, 415t
ceramics, dental 414–415
denture bases, acrylic 416
denture cleansers 417
denture soft liners 417
denture teeth 416
die materials 411–412, 411t
implants, dental 418–419
impression materials 409–410, 410t
investment materials 412

2013
 model materials 411–412, 411t
mouth protectors 417
provisional materials 410–411
restorations, computer-assisted design/computer-assisted
machining 418
solders, dental 413
tissue engineering 419–420
veneers 417–418
waxes 412
properties of 395–398
biologic 398
chemical 395
electrical 395
electrochemical 396, 396f
mechanical 396, 397–398t, 397f
physical 395
thermal 395, 395f
review questions for 420
structure of 394
website information and resources for 420b
Biotransformation 327
of local anesthetic agents 550–551
Bipolar neurons 29f
Bitewing radiographs 164, 164f
Black hairy tongue 248, 248f
Blastocyst, embryology 31
Blind 628
Block injections, for trigeminal nerve
mandibular 556, 557t

2014
 maxillary 554, 555t, 556f
Blood 26–27, 85
characteristics of 86
components of 27, 86, 86f
groups 87
transport of gases of 95
Blood analysis 381
Blood disorders 227–233
anemia See also Anemia.
Addison 228
aplastic 229–230
Biermer 228
Cooley 229–230
iron deficiency 228–229, 229f
pernicious 228
primary 228
sickle cell 227–228, 227–228f
characteristics of 227
hemophilias 233
human immunodeficiency virus (HIV) 233–234 See also Human
immunodeficiency virus (HIV).
leukemia 231–232 See also Leukemia.
neutropenia, cyclic 231, 231f
Plummer-Vinson syndrome 228–229, 229f
polycythemia 230
purpura 232–233
thalassemia 229–230
Blood dyscrasias 346
Blood glucose

2015
 energy from 378
reactions of 362
sources of 361
Blood pressure
classification of 466t
medical emergencies and 689, 689f
Blood supply 429–430
Blood vessels 26
Blood-brain barrier (BBB) 77
Blurred images 166, 167f
Board duties 715
Board examinations
administration of 9–10
client recruitment and 10–11
clinical facilities for 10
clinical testing and 9
content of 14
ethical and legal issues in 12–14
examiner selection and training 9–10
formats of 11–12
forms for 10
instruments for 10
Joint Commission on National Dental Examinations (JCNDE) and 4
licensure 1–2
National Board Dental Hygiene Examination (NBDHE) and 4–9
preparing for 1–15
results of 12
review questions for 15
state boards of dentistry and 2–4

2016
 website information and resources for 14b
Body cavities 55, 56f
Body mass index (BMI) 378, 378t
Body membranes 61
Body part designations 745 See also Medical terminology.
Body temperature 689
Body tissues, clinical examination of 381
Bonding agents 403–405, 403–404f
Bone 24–26
formation, stages of 26f
tissue, microscopic morphology of 25f
Bone cysts See also Cysts.
aneurysmal 226
hemorrhagic 226
simple 226
Stafne 226–227, 227f
static 226–227, 227f
traumatic 226, 227f
Bone destruction patterns, in periodontitis 438, 438f
Bone marrow-derived stem cells (BMSCs) 185
Bony depressions 108
Bony openings 108
Bony prominences 108
Bordetella pertussis 266t
Borrelia vincentii 205
Botulism 277
Bound ribosomes 56
Brachial plexus 77
Bradycardias 586

2017
Brain 74, 77–78, 77f
deformity of 583
Brainstorming, for oral health 659
Branchial cleft cyst 222–223, 223f
Brand names 325
Breach of contract 733
Bronchitis 585
Bronchospasms, treatment for 697
Brucella spp. 266t
Brush biopsy 509–510, 509f
laboratory findings in 510
Brushes
interdental 497–498, 497f
single-tufted 495
toothbrushes
maintenance of 496
manual 494
power 495
Buccal block 120t
Buccal frena 131t
Buccal mucosa 130f, 131t
assessment of 470
Buccal nerve 121
Bulimia 380, 574
Bupropion (Zyban) 354
Burden of disease 624
and community oral health practice 677

2018
Caffeine 353
Calcitonin 84
Calcium sodium phosphosilicate (NovaMin) 647
Calculations, for local anesthetic agents 552
Calculus
dental 530
removal of, steps for 526–527, 526f
Calibration 625t
Calorimetry 378
CAMBRA See Caries management by risk assessment (CAMBRA)
Canadian Dental Association 746
Canadian Dental Hygienists Association
code of ethics 750–754
contact information for 746
Canadian Public Health Association 746
Canal, pulp 129
Cancers 588–589, 589f
carcinoma, squamous cell 217–218, 218–219f
oral 634
brush biopsy for 509–510, 509f
detection of, diagnostic tools for 509–510
examination technique for 508–509
high-risk factors of 508
other devices and oral examination for 510
risk assessment of 508–509
pharyngeal 634
Candida 263
Candidiasis 274
Canines 135, 136t See also Dentition.

2019
Cannon disease 215
Carbamazepine (Tegretol) 346, 348
Carbohydrates 360–366
absorption of 361, 362f
biologic role and functions of 364
complex 360
definition of 360
digestion of 361, 361t
metabolism of 361, 363f
in oral biology 364
in persons with disease conditions 365, 366t
requirements for 365
simple 360
structure of 360
Carboxylases 60
Carcinoma, squamous cell 217–218, 218–219f
Cardiac arrest 691, 696
Cardiac cycle 88, 89f
Cardiac emergencies 694–697
Cardiac muscle 30
Cardiogenic shock 694
Cardiopulmonary resuscitation (CPR) 690–691
Cardiovascular agents 343
digitalis glycosides 343
Cardiovascular disease (CVD) 371
questions regarding 464
Cardiovascular system 85–91, 87f
Care plans 129, 442–443
Caries, dental 291–292, 291f, 381, 471, 630, 630t, 631f

2020
 classification of 474
dietary modifications for 365, 366t, 387
distribution of 631, 632t
examinations and inspections, types of 653t
indices for 636t
lower rates of, factors contributing to 631
management of 502–504, 647
caries management by risk assessment (CAMBRA) in 502
fluoride in 502–504 See also Fluorides.
xylitol in 504
measures for preventing and controlling 641–648, 642t, 644–645b
occurrence of 630
rampant 387
risk factors for 476, 477t, 633
Caries activity tests 386
Caries management by risk assessment (CAMBRA) 502
Carious lesions 471, 531
Carotid artery 115, 116f
Carpal bones 65, 66f
Carrier-mediated passive transport 58t See also Facilitated diffusion.
Cartilage 24, 108
Cartilaginous joints 67, 70f
Cartridge, anesthetic 549, 549f
Caruncle, sublingual 131t
Case law 711
Case presentation 481
Case-control research 628t
Casein phosphopeptides-amorphous calcium phosphate (CPP-ACP) 647
Casting

2021
 alloys 412–413
materials 411–412
Catabolic hormones 363
Catabolism 368
Cataracts 576
Catecholamines 84, 328
Cathode 153
Cauda equina 77
Caudal structures 107
Causality, vs. risk 627, 628t
Cefotaxime 285t
Ceftizoxime 285t
Ceftriaxone 285t
Celecoxib (Celebrex) 338
Cell-derived mediators 179
Cells 17f, 55–61
blood components 27
connective tissue 23
eukaryotic 259, 260t
growth and reproduction of 61
internal environment and homeostasis 20
membrane 17
movement of substances through 58–59
metabolism 59–61
anabolism 60
catabolism 60
enzymes in, role of 59
prokaryotes 256, 260t
regulation of 262–263

2022
 replication 21–31
specialization of 16
structure of 55–58, 57f
synthesis activities of 18
transport 20
Cellulose 360
Cement See also Biomaterials.
applications of 406
bases 405–406, 405f
crown-and-bridge 415, 415t
liners 405
orthodontic 406
Cementoblasts 377
Cementocytes 377
Cemento-dentin junction (CDJ) 134
Cemento-enamel junction (CEJ) 43, 129, 139, 139f
Cementoma 236
Cementum 43f, 129, 429
formation 36, 42f
tooth tissue 42–43
Centers for Disease Control and Prevention (CDC) 318, 621b, 747
National Center for Health Statistics (NCHS) 624
ten great public health achievements 641b
Centers for Medicare and Medicaid Services (CMS) 621b
Central giant cell granulomas 197–198, 198f
Central nervous system (CNS) 27
infections of 284–285
symptoms associated with lesions in 582t
Central Regional Dental Testing Service, Inc. (CRDTS) 2b

2023
Centrally-acting agents, muscle relaxants 336
Centrioles 20
Centromere 61
Cephalosporins 285t, 341
Ceramics, dental 414–415
Cerebellum 78
Cerebral lobes 78
Cerebral palsy 578–579, 578–579f
Cerebrospinal fluid (CSF) 77
Cerebrovascular accident (CVA) 587–588, 588t, 699
Cerebrum 78
Cervical lesion levels, functional significance of 584t
Cervical line 129
Cervical lymph nodes, assessment of 469
Cervical plexus 77
Chamber, pulp 129
Channel-mediated passive transport 58t
Cheeks 131t
Cheilitis, angular 247, 247f
Cheilosis 381
Chemical dependency 592–594
Chemical disinfectants 310
Chemical fibromatosis 202–203, 203f
Chemical names 325
Chemical properties 395 See also Biomaterials.
Chemical synapses 76
Chemokines 179t, 181
Chemotaxis 179
Chemotherapeutic agents 285–287, 285t, 287t, 504–505

2024
Cherubism 235–236
Chest cavity 55, 56f
CHF See Congestive heart failure (CHF)
Chickenpox 274
Children
dental hygienists working with 493b
prevention principles for 492–493
Children’s Health Insurance Program (CHIP) 620, 673
Chlorhexidine gluconate 646
Chlorines 310t
Chloroquine 287t
Cholera 277
Cholesterol 370
Cholinergic agents 330–332
Chondroitin sulfate 361
Chondroma 200
Chorda tympani nerve 122
Christmas disease 233
Chromatids 61
Chromatin 18
Chromium alloys 413 See also Alloys.
Chromosomes 18
Chronic alcohol abuse and dependence 594
Chronic caries 471
Chronic disease 625t
Chronic hyperplastic pulpitis hyperplasia 198, 198f
Chronic inflammation 181–182
Chronic lymphocytic leukemia (CLL) 232
Chronic myeloid leukemia (CML) 232

2025
Chronic obstructive pulmonary disease (COPD) 585
Chronic pancreatitis 371
Chronic periodontitis 431, 293b, 293 See also Periodontitis.
Chylomicrons 370
Cicatricial pemphigoid 206–207, 207f
Ciliophora 264
Cingulum 134, 135f
Ciprofloxacin 285t
Circle of Willis 77
Circular compression 468
Circulatory system 89–91, 115–117
blood
components of 115
supply, to head and neck 115
classification and function of 115
descriptive terminology in 115
infections of 280–281
microbial diseases of 281
vascular system of 115
Circumvallate papillae 131t
CITA See Council of Interstate Testing Agencies (CITA)
Citations 712
Citric acid cycle 60
Civil action 725
Civil law 711–727
Civil Rights Act
of 1964 (Title VII) 734
of 1991 734
Civil suits 725

2026
Claims-made policy 736
Clarithromycin 285t, 341
Clasp 500
Cleansers, denture 417
Clear (blank) radiographs 161
Cleft involvement, classifications of 577
Cleft lip or palate 577–578, 578f, 635
Client care
maintaining oral health care environment after 313–318
maintaining treatment area during 311–313
Client records 728
Client-clinician relationship 492
Client-practitioner relationship 713
Client-related controls 301
Clients
adherence to preventive regimen, factors influencing 492
consent 733
contractual responsibilities of 713
rights of 733
selection for 387
with special needs, dietary considerations for 389
support systems of 492
Clindamycin 285t, 341
Clinical attachment levels (CALs) 529, 529f
Clinical competencies, clinical examination format and 11
Clinical crown 129
Clinical death 691
Clinical examinations, future trends in 13
Clinical impression 189

2027
Clinical oral structures 129, 130f, 131t
review questions for 148, 148–149b, 148–149f
Clinical trials, vs. epidemiologic surveys 629t
Clinician, position of 523–524, 523f
Clonazepam (Clonopin) 346
Close supervision 718
Clostridium spp. 266t
Clotrimazole (Mycelex) 343
Clotting system 180
Cluster 625t
Cocaine 353
Coccidioides 263
Coccidioidomycosis 276
CODA See Commission on Dental Accreditation (CODA)
Code of ethics
American Dental Hygienists Association 748–750
Canadian Dental Hygienists Association 750–754
Coenzymes 363
Cognitive challenges 570, 570–571f
Coherent scatter 154
Cohort research 628t
Colchicine 339
Cold sore 208, 208f
Collagen fibers 23
Collimation 156
Combining forms 744–745 See also Medical terminology.
Comfort 482
Commensalism 263
Commission on Dental Accreditation (CODA) 1

2028
Commissure, labial 131t
Common law 711
Communication, and process of care 482
Community, principle of 748–749
Community dental health coordinator (CDHC) 669t
Community Fluorosis Index (CFI) 636t
Community intervention 650–661, 650f
assessment and problem identification in 650–654, 651t, 653t
health education and health promotion in 654–658
characteristics of different types of learners in 660
methods of 658–660
in school setting 661
theories of 655t
implementation in 654
planning 654
role of dental hygienist in 650
strategies in 650
surveillance in 650
Community oral health planning and practice 619–687
basic concepts of 619–623
access 620
community 620
community health 620
community oral health 620
dental public health 619
health 619
health determinants 619
national documents 621
oral health 619

2029
 prevention 620
private vs. community health 620, 620t
public health 619
public health problem, criteria for identification of 620
wellness 619
challenges affecting 677–678
community intervention 650–661, 650f
assessment and problem identification in 650–654, 651t, 653t
health education and health promotion in 654–658, 655t, 657t
implementation in 654
methods of oral health education in 658–660
planning in 654
role of dental hygienist in 650
strategies in 650
surveillance in 650
epidemiology 623–626
characteristics of 624, 625f
concepts in 625t
definitions of 623, 624b
measurement concepts in 625t
measurement of diseases and conditions in 624
of oral diseases and conditions 629–640, 630t, 631f, 632t
and research 626–629, 628t
uses of 624, 624b
ethical and legal issues in 678, 679b
financing oral health care in 670–674
mechanisms of payment in 670–672, 671t
providers of dental benefits plans in 672
public 673–674, 673t

2030
 preventing and controlling oral diseases in 641–650
measures for dental caries 641–648, 642t, 644–645b
measures for other oral diseases and anomalies 648–650
measures for periodontal diseases 648
public health measures in 641
program evaluation 661–665
general principles of 661
of professional literature 665, 665b
statistics in 661–664, 662b, 663f
provision of oral health in 665–670
dental practice, diverse modes of 665–666, 666t
personnel workforce in 667–670, 668f, 669t
review questions for 681, 681–686b
utilization, of dental services 674–677, 675t
patterns of, shifts in 676–677
website information and resources for 679b
Community oral health research, categories of 627
Community Periodontal Index (CPI) 636t
Community Periodontal Index of Treatment Needs (CPITN) 636t
Community profile 652
Comparative negligence 713
Competition 263
Complement system 267
Complementarity, principle of 748
Complex partial (psychomotor) seizure 699
Complex shank 518
Complexity of therapy 492
Composites, dental 401–402, 401f
Compton scatter 154

2031
Computer-assisted design/computer-assisted machining
(CAD/CAM) 418
Computer-controlled local anesthesia delivery system 556–559, 558t
Basic CCLADD procedure and 556–558
components of 556
injection administration with 558–559
vs. traditional syringe 558t
Concavity 129
Concrescence 242, 243f
Concreteness 482
Conductive hearing loss 576
Confidentiality 708, 728, 749, 751–752
Confocal-scanning laser microscopy 257
Congenital heart disease 585–586
Congenital syphilis 283f
Congestive heart failure (CHF) 587, 696
Conjugation 263
Conjunctiva 78
Connective tissue 22–26
components of 23–24
fibers 45f
Conscious sedation, with nitrous oxide-oxygen 559
advantages and disadvantages of 562
anesthesia stages for 561
chemistry of 559
contraindications to 562
equipment for 562
indications for 562
pharmacology of 561

2032
 physiology of 561
record keeping and documentation for 562
safety measures for 562
signs and symptoms of 562
synonymous terms in 559
Consent 714
competency of 715
informed 481
vs. informed refusal 715
Constitutional law 710
Contact area 134
Contact information, regional testing agencies and 2b
Continued-care 483
Continuous conduction 76
Contract
damages 713
elements of 733
employment 733
law 712
Contracture 183
Contralateral structures 107
Contrast 160
Contributory negligence 713
Control group 630t
Controlling oral malodor 499–500
Convenience sample 630t
Conventional supragingival air polishing 537
Convulsion 575
Convulsive disorders 699–700

2033
Convulsive seizures 699–700
Cooley anemia 229–230
COPD See Chronic obstructive pulmonary disease (COPD)
Coronal plane See Frontal plane
Coronary heart disease 586–587
Corynebacterium diphtheriae 266t
Council of Interstate Testing Agencies (CITA) 2b
Count 625t
Counter-dislodgement forces 388
Courts of Appeal 712
COX-1 and COX-2 180
Cranial bones 109
Cranial cavity 55, 56f
Cranial nerves (CN) 30, 78, 119
cranial nerve I (olfactory nerve) 119
cranial nerve II (optic nerve) 119
cranial nerve III (oculomotor nerve) 119
cranial nerve IV (trochlear nerve) 119
cranial nerve V (trigeminal nerve) 119 See also Trigeminal nerve.
cranial nerve VI (abducens) 122
cranial nerve VII (facial) 122, 122f
cranial nerve VIII (vestibulocochlear nerve) 122
cranial nerve IX (glossopharyngeal nerve) 122
cranial nerve X (vagus nerve) 123
cranial nerve XI (accessory nerve) 123
cranial nerve XII (hypoglossal nerve) 123
Cranial structures 107
Craniofacial birth defects, measures for 649
Craniofacial injuries 635

2034
CRDTS See Central Regional Dental Testing Service, Inc. (CRDTS)
C-reactive protein (CRP) 181
Cribriform plate 110
Criminal action 725
Criminal charges 725
Criminal law 711
Crisis, adrenal 701
Cromolyn sodium 351
Crossbites 146
Crossover 628
Cross-sectional plane See Transverse plane
Cross-sectional research 628t
Crown-and-bridge cements 415, 415t
Crowns 129
characteristics of 136t
lingual inclination of 140f
Cryptococcus neoformans 263
Cumulative trauma disorders 482
Curet
advance, designs for 523
area-specific 522–523, 522f
universal 522, 522f
Curve of Spee 143
Curve of Wilson 143
Curved shank 518
Cushing syndrome 348
Cusp 134
Cuspal inclines 134
Cutaneous membranes 61

2035
Cutaneous wound healing 183, 184f
CVA See Cerebrovascular accident (CVA)
Cyclic neutropenia 231, 231f
Cyclin-dependent kinases (CDKs) 61
Cyclins 61
Cystic fibrosis 371, 584–585
Cysts 220–221
classification of 220
developmental 221–223
dermoid 223
lymphoepithelial 222–223, 223f
nonodontogenic 221–222, 222f
thyroglossal tract/duct cysts 222, 222f
odontogenic 223–227
dentigerous 224–225, 225f
follicular 224–225, 225f
keratocyst 223–224
lateral periodontal 223, 224f
mucocele 225–226
necrotizing sialometaplasia 226, 226f
oral soft tissue injuries 225–226
primordial 224
ranula 225, 225f
periapical 220, 220f
radicular 220, 220f
residual 220–221, 221f
root-end 220, 220f
true 220
Cytodifferentiation, tooth development 34–35

2036
Cytogenetic analysis 187
Cytokines 179t
Cytomegalovirus (CMV) infections 281
Cytoplasm 17, 56
Cytoskeleton 56, 57f
Cytosol 56

D
Dactinomycin 352
Damages 713
Dark radiographs 161, 161f
Dark roller lines 162
Darkfield microscopy 257
Darunavir 272
Data 661
analysis of 654
collection 458, 650
methods for 651t
distribution of 663, 663f
De novo synthesis 368
Deamination 368
Dean Fluorosis Index 636t
Decarboxylases 60
Decayed-Missing-Filled Teeth (DMFT) Index 636t
Deciduous dentition 141
Decision making, evidence-based 129, 479
Decision-procedure 753–754
Decongestants 331t
Decontamination area 315

2037
Deep, as directional term 107
Defamation 714
Defendant 712
Defense of fact 714
Deficient scar formation 183
Deformities, periodontium See also Periodontium.
acquired 433–436
developmental 433–436
Degradation 179
Dehydrogenases 60
Delayed cutaneous hypersensitivity skin tests 381
Delayed tooth eruption 570f
Delta hepatitis 280
Demographic risk factors 628t
Dendrite 75, 75f
Dens evaginatus 243, 244f
Dens in dente 242–243, 243–244f
Dens invaginatus 242–243, 243–244f
Dense connective tissue 22
Density, of x-ray image 160
Dental amalgam 399–401, 399–400f
Dental anatomy 134–142 See also Anatomy and physiology.
clinical oral structures 129, 130–131f, 131t
dentition 134, 136t
eruption 142–143
interarch relationships 143–147
intra-arch relationships 143–147
review questions for 148, 148–149b, 148–149f
terminology for 129–134

2038
 website information and resources for 147b
Dental biofilm, bacterial 438–440
Dental biomaterials See Biomaterials
Dental boards 715
Dental caries 291–292, 291f, 630, 630t, 631f
distribution of 631, 632t
examinations and inspections, types of 653t
high incidence of 570f
indices for 636t
lower rates of, factors contributing to 631
management of 647
measures for preventing and controlling 641–648, 642t
occurrence of 630
radiographic appearance of 171, 171f
risk and associated factors of 633
Dental ceramics 414–415
Dental composites 401–402, 401f
Dental fluorosis 635
causes of 639
indices for 636t
measures for 650
prevalence of 639
prevention of 640
recommendations to reduce risk of 640b
Dental health aide therapist (DHAT) 669t
Dental health care personnel, infection control procedures for 302–308
Dental health professions shortage areas (DHPSAs) 667
Dental hygiene licensure 1–2
clinical examinations for 3f

2039
 regional testing agencies and 2b
Dental hygiene paradigm 458
Dental hygiene personnel, supply of 668
Dental hygiene therapist (DHT) 669t
Dental hygienist
civil law and 712–727
dental hygiene board examinations and 1, 3–4
direct access states 719b, 725f
roles of 623
in community intervention 650
Dental implants 418–419, 452–453
definition of 501
design of 452
endosseous 452
goals of 453
instrumentation of 535–536
limiting factors for 452
maintenance of 501–502
management of 453
transosteal 453
types of 452
Dental index 636t, 640
Dental laboratory, infection control for 313
Dental mirror 519–520
Dental papilla 35
Dental plaque biofilm detection 493–494
Dental practice acts 715, 716t, 718
Dental public health 619
Dental radiographs, guidelines for prescribing 158t

2040
Dental records 728–733
Dental sac 35
Dental school enrollment 668
Dental sealants 505–507, 634, 647, 648b
application guidelines for 506–507
contraindications to application of 506
general considerations for 505
indications for application of 505–506
school-based 647
Dental services, utilization of 674–677, 675t
patterns of, shift in 676–677
Dental solders 413
Dental stem cells 185
Dental therapist (DT) 669t
Dental tissues, concepts relating to 21
Dental unit water 311
asepsis and 310
improving quality of 311
Dental unit water lines (DUWLs) 308
Dental water jet 498
Dental x-ray film 157–161
image characteristics 159–160, 160t
processing 160–161
Dentifrices 408–409, 498–499
selection of, guidelines for 499
therapeutic and active ingredients of 499
use of, guidelines for 499
Dentigerous cysts 224–225, 225f
Dentin 38–39, 129

2041
 formation 35–36
pulp and 40
Dentinal hypersensitivity
assessment of 510
desensitization methods for 511–512
desensitizing agents for 511
desensitizing treatments for, types of 511
etiology of 511–512
pain
mechanism 511
stimuli 511
Dentinogenesis imperfecta 241, 241f
Dentist, supply and distribution of 667, 668f
Dentition
assessment of 471–474, 474b
comparison 141f
mixed 142, 145
permanent 134, 136t, 142
primary 141–142
Dentition charting 471, 474b
Dento-enamel junction (DEJ) 134
Dentogenesis, process of 38
Dento-gingival junction 46–47
formation 36
Dentures
bases, acrylic 416
cleansers for 417
definition of 500
hyperplasia, denture-induced 196–197, 197f See also Hyperplasia.

2042
 liners, soft 417
teeth 416
use of 634
problems related to, measures for 649
Deontologic ethics 707
Deoxyribonucleic acid (DNA) 60
replication 61
Department of Defense (DoD) 621b
Dependent variable 629
Depolarization 548
Depressants 353
Depression 147
Dermatitis 306
Dermis 61
Dermoid cysts 223
Descriptive research 628t
Desensitizing
agents for 511
treatments, types of 511
Design
computer-assisted design/computer-assisted machining 418
of dental implants 452 See also Dental implants.
of instrument 518–519
characteristics of 519
Desmosomes, in cells 16
Determinants 624
Deuteromycota 263
Developmental challenges 570, 570–571f
Developmental cysts 221–223

2043
 dermoid 223
lymphoepithelial 222–223, 223f
nonodontogenic 221–222, 222f
thyroglossal tract/duct cysts 222, 222f
Developmental groove 134
Developmental research 628t
DHCP-related controls 301
Diabetes 366
dietary recommendations for 366
glycemic management for 467b
signs and symptoms of 366
type 1 366
type 2 366
Diabetes mellitus 348
agents for 348–349
insulin 349
oral hypoglycemic agents 349
emergencies 700–701 See also Medical emergencies.
special care needs and 590–592, 591t, 592f
Diagnosis
differential 188–189
preliminary 189
process of care and 469f, 478, 478f
Diazepam (Valium) 346
Didanosine 272, 287t
Die materials 411–412, 411t
Diencephalon 78
Diet, computerized analysis of 386
Dietary aids 379

2044
Dietary fluoride supplements 641, 645, 645t
Dietary Guidelines for Americans 383
Dietary intake, methods for assessment of 382–386
Dietary modifications 381
for specific dental conditions 387–388
types of 379
Dietary Reference Intake (DRI) 382
Dietary sugars 388
Dietary sweeteners 364, 364t
Differential diagnosis 188–189
Differential staining procedures 257, 257t
Diffuse scleroderma 581
Diffusion 58
facilitated 361
membrane transport and 20
passive 361
Diffusion hypoxia 334
Digastric muscle 113
Digestive system 96–97, 96f
Digital imaging 162–163
Digital palpation 468
Digitalis glycosides 343
Digoxin 338
Dilaceration 241, 242f
Diphtheria 275
Direct access states 719b, 725f
Direct digital imaging 163
Direct observation, in extraoral and intraoral assessment 468
Direct preventive and restorative materials, biomaterials 399–409 See also

2045
 Biomaterials.
amalgam, dental 399–401, 399–400f
bonding agents 403–405, 403–404f
cement
applications 406
bases 405–406, 405f
liners 405
orthodontic 406
composites, dental 401–402, 401f
dentifrices 408–409
dressings, surgical 406
fluoride
fluoride-releasing restorative materials 406–407, 406f, 408f
varnishes 407–408
gingival tissue packs 406
infiltrants 403
pastes, prophylactic 408–409
sealants, pit-and-fissure 402–403
sealers, root canal 406
topical 407–408
whitening agents 409
Direct supervision 718
Direct-acting drugs 330
Disaccharides 360
Disciplinary action 715
Disclosing agents 493–494
Disclosure statutes 714
Discovery learning, for oral health 658
Discussion, for oral health 658

2046
Diseases
barriers to 267
mechanisms of spread and prevention of 302t
of periodontium 430–436 See also Periodontics.
abscesses 433
classification of 430
deformities, acquired 433–436
epidemiology of 434–436
gingival 430–431
immunology and microbiology of 292–294, 293b
necrotizing 432–433
periodontitis, aggressive 431–432
periodontitis, associated with endodontic lesions 433
periodontitis, chronic 431
risks of 434–436
prevention of, legal and ethical issues in 320, 320b
skin 210–213
Behçet syndrome 212, 212f
characteristics of 210
erythema multiforme 210–211, 211f
pemphigus vulgaris 212–213, 213f
Stevens-Johnson syndrome 211–212, 211f
transfer 265–287, 301f
transmission 300–302
Disinfection 300
categories of 309t
surface, chemical agents for 310t
Distal, as directional term 107
Distal tooth surfaces 134

2047
Distortion 160, 160t
Distributive shock 693
Diuretics 331t, 344
Docosanol (Abreva) 343
Documentation, and process of care 483–484
Dopamine-norepinephrine reuptake inhibitors 347
Doppler flowmetry, laser 512
Dorsal cavity 55, 56f
Dorsal structures 107
Dorsum, of the tongue 130f
Dosage
effective dose (ED) 325, 326f
forms of 327
lethal dose (LD) 325
log dose-response curve 325, 326f
pediatric dose 327
variables 327
Double-blind 628
Down syndrome 571–572, 572f
Doxycycline 285t, 342
DPP-4 inhibitors 349
Dressings
periodontal 451
surgical 406
Drug Enforcement Administration (DEA) 325
schedules used in dentistry (I-V) 326t
Drugs See also Pharmacology.
action of 325–327
distribution of 327, 328f

2048
 drug-induced gingival enlargement 202–203, 203f, 575, 576f
use of, during pregnancy 353–354
Dry-heat sterilization 316
Dual-energy x-ray absorptiometry (DEXA) 382
Duchenne’s muscular dystrophy 582t
“Ductless glands” See Endocrine glands
Due process 712, 725
Dumping syndrome 366, 371
Dura mater 76, 76f
Duration 325
Duty to disclose 733
Dysplasia
ectodermal 244
familial white folded 215
fibrous 234–236
cementoma 236
characteristics of 234
cherubism 235–236
monostotic 235
osteitis deformans 236
Paget disease 236
periapical cemento-osseous 236
polyostotic 235
Dysrhythmias, cardiac 586

E
Eastman Interdental Bleeding Index (EIBI) 636t
Eating disorders 380, 574
Eating disorders not otherwise specified (EDNOS) 380

2049
Ebner ’s glands 38
ECM deposition 183
Ectodermal dysplasia 244
Ectopic beats, isolated 586
Edentulism 387
Edrophonium (Tensilon) 330
Efavirenz (EFV) 272
Effective dose 325, 326f
Effective teaching, concepts of 492
Efficacy 326, 327f
Elastic cartilage 24
Elastic fibers 23
Electrical properties 395 See also Biomaterials.
Electrical pulp tester 512
Electrical synapses 76
Electrical testing devices, traditional 512
Electrochemical corrosion 396f, 396 See also Biomaterials.
Electromagnetic energy spectrum 153f
Electron microscopy 258
Electron transport system (ETS) 60
Elevation 147
Embrasure 134
Embryology
general 31–33
histology and 16–52
review questions for 48, 48b, 50b
Embryonic stem cells 184
Emergencies, medical See Medical emergencies
Emergency kit 690–691

2050
 medications typically supplied with 691t
Emergency medical system (EMS) 691
Emetics 351–352
Emetine 287t
Emotion, pain and 548
Emotional disturbance 573
Empathy 482
Emphysema 585
Employer vs. employee rights, and responsibilities 733–735, 734b
Employment 733
Employment contracts 733, 734b
Employment laws 734
Enabling 353
Enamel 129
clinical appearance of 241
formation 35–36
hypocalcification of 240
hypomaturation of 240
hypoplasia of 240
hypoplastic-hypomaturation of 241
organ, layers of 35f
rod 41, 41f
tooth tissues 40–42
Encapsulated nerve endings, definition of 30
End point, of instrumentation 532
Endemic, definition of 625t
Endochondral ossification 25, 107
Endocrine agents 348–350
adrenocorticosteroids 348, 348t

2051
 diabetes mellitus agents 348–349
estrogens and progesterones 350
oral contraceptives 350
thyroid agents 349–350
Endocrine disorders 236–238
characteristics of 236
hyperparathyroidism 236–237, 237f
Langerhans cell disease 238, 238f
osteomalacia 237
rickets 237
Endocrine glands 80
of neck 119
Endocrine system 80–85
gastric and intestinal mucosa 85
glands of
adrenal 84
parathyroid 84
pineal 83
pituitary 82–83
thymus 85
thyroid 83–84
gonads 85
heart and 85
hormones of 80–82
pancreatic islets of 85
placenta 85
prostaglandins in 82
Endocytosis 59
Endodontic lesions, periodontitis associated with 433 See also

2052
 Periodontitis.
Endoplasmic reticulum 19–20, 56, 57f
Endorsement 715
Endosseous implants 452 See also Dental implants.
Endothelial progenitor cells (EPCs) 182
Endotoxins 267
End-stage renal disease 594–595
Energy
for activity 378
for basal metabolism 378
measurement of 378
thermic effect of food 378
Energy balance 377–380
energy-producing systems in 378
Engineering, tissue 419–420
Engineering controls 300
Engulfment 179
Entamoeba histolytica 264, 287t
Enteric infections 277
Enteric plexuses 75
Enterobius vermicularis 287t
Enterococcus spp. 285t
Enterovirus 285
Entrance, furcation 129
Entry inhibitors 272
Environmental Protection Agency (EPA) 310, 318, 639
Eosinophilic granuloma 238, 238f
Eosinophils 115, 177
Epidemic, definition of 625t

2053
Epidemiologic examination 625t
Epidemiologic survey, vs. clinical trials 629t
Epidemiology
applied 624
characteristics of 624, 625f
concepts in 625t
definitions of 623, 624b
of diseases
oral 623–626, 629–640, 630t, 631f, 632t
periodontium 434–436
measurement concepts in 625t
measurement of diseases and conditions in 640–641
and research 626–629, 628t
uses of 624, 624b
Epidermis 61
Epidermophyton 263
Epilepsy 371
Epinephrine 90, 329, 329t, 363
Epithelial cells 377
Epithelial membranes 61
Epithelial tissues 22, 62
classification of 23f
Epstein-Barr virus (EBV) 281
Epulis fissuratum 196–197, 197f
Equal Employment Opportunity Commission (EEOC) 734
Equal Pay Act (EPA) of 1963 735
Equal protection 712
Equilibrium, hearing and 79, 79f
Eradication 625t

2054
Ergonomic hazards, prevention of 482
Ergonomics 482
Errors
film-processing 161–162
focal through positioning 167, 168f
radiographic 166–169
Eruption 142–143
Erythema infectiosum 275
Erythema migrans 247, 247f
Erythema multiforme 210–211, 211f
Erythema multiforme major 211–212, 211f
Erythrocytes 115
Erythromycin 285t, 341
Escherichia coli 266t
Essential fatty acids (EFAs) 371
Estrogen 350
Ethanol, for energy 378
Ethical challenges/problems 753
guidance regarding the process for resolving 753–754
Ethical considerations 707–708
bioethics 707
codes of ethics 708
of American Dental Association’s Code of Professional
Responsibility and Conduct 708
of American Dental Hygienists Association 708, 748–750
of Canadian Dental Hygienists Association 708, 750–754
of community oral health planning and practice 679b
of process of care 484
professionalism 708–709

2055
 public policy 709–710
review questions for 738
theories of 707
deontologic 707
situational ethics 707
teleologic 707
utilitarian 707
virtue 707
universal principles 707
vs. legal considerations 710, 710t
web resources for 737b
Ethics 707
definition of 707
principle of 748
vs. law 710, 710t
Ethosuximide 346
Ethylene oxide gas sterilization 316
Eubacteria 256
Eukaryotic cell structure 259, 260t
Evaluation 482–483
of health history 459–468
Evidence-based decision making 479
Evidence-based practice (EBP) 626, 626–627f
Examination anxiety, managing 8b
Examination procedure
extraoral 468–469
intraoral 470–471
Examination review committee, clinical testing and 9
Excessive scar formation 183

2056
Excitability, of cells 16
Excitation 547
Excitatory neurotransmitter 76
Excretion 328
Exemptions 715
Exocrine glands, of head 118
Exocytosis 59, 59t
Exostosis 201
torus mandibularis 201, 201f
torus palatinus 201, 201f
Exotoxins 266
Experimental group 630t
Experimental research 628t
designs for 628
Expert witness 712
Explorer 520–521, 520f
clinical assessment with 530–531
Exposure, to radiation 156–157
Express contract 713
Extended lower shank 518
External ear 79
Extracellular matrix (ECM) 182
Extraneous variable 629
Extraoral assessment 468–471
Extraoral film, screens used with 159
Extraoral radiographic examinations, types of 165–166
Extraoral technique errors 167–169
Extreme bruxism 579, 579f
Extrinsic stains 536

2057
Extrinsic tongue muscles 114
Eyes
components of 78, 79f
examination of 468
infections of 285
visual impairment and 576
Eyewear
protective 307
types of 307

F
Face, examination of 468
Facial artery 115, 116f
Facial bones 110, 111f
Facial development 32, 33f
Facial injury or trauma, measures for 649
Facial nerve (CN VII) 122, 122f
Facial tooth surfaces 134
Facial vein 116
Facilitated diffusion 58, 58t, 361
Facio-scapulo-humeral muscular dystrophy 582, 582t
Factors 629
Fainting 692–693
Fair employment statutes 735
Fairness 749
False light 714
Familial white folded dysplasia 215
Family and Medical Leave Act of 1993 (FMLA) 735
FAS See Fetal alcohol syndrome (FAS)

2058
FASD See Fetal alcohol spectrum disorders (FASD)
Fat, as energy source 378
Fatigue, pain and 548
Fat-soluble vitamins 372
Fauces 131t
FDI World Dental Federation 747
Federal courts 712
Federal district courts 712
Fédération Dentaire Internationale (FDI) 398
Fee-for-service 671
Felonies 711
Femur 66, 67f
Fenfluramine 379
Fetal alcohol spectrum disorders (FASD) 571, 571f
Fetal alcohol syndrome (FAS) 571
Fever 267
Fever blister 208, 208f
Fiber 363
diameter of 547
excessive dietary 364
insoluble 363
periodontal ligament 45
soluble 363
specific 363
Fibrinogen 181
Fibroblast emigration 183
Fibroblasts 377
Fibrolipoma 195
Fibromatosis, gingival 201–203

2059
 characteristics of 201–202
chemical 202–203, 203f
hereditary 202
irritative 202
Fibromyalgia syndrome (FMS) 581
Fibrosis 183
Fibrous cartilage (fibrocartilage) 24
Fibrous dysplasia 234–236
cementoma 236
characteristics of 234
cherubism 235–236
monostotic 235
osteitis deformans 236
Paget disease 236
periapical cemento-osseous 236
polyostotic 235
Fibrous joints 67, 69f
Fibrous matrix, of connective tissue 23
Fibula 66, 67f
Fidelity 708
Fifth disease 275
“Fight-or-flight” response 119
Filaments 20
File, periodontal 521–522
Filiform papillae 131t
Filtration 59, 100
Financing, of oral health care 670–674
mechanisms of payment in 670–672, 671t
providers of dental benefits plans in 672

2060
 public 673–674, 673t
Firmicutes 263
Fissure 134
Fixed-membrane-receptor hypothesis See Second messenger mechanism
Fixed-prosthesis maintenance 501
Flagellar staining 258
Floor, of mouth, examination of 470
Flora, oral
development of 290
normal 288–290, 289t
Flosses 496–497, 497f
Flossing
aids for 497
improper 497
technique for 497
Fluconazole (Diflucan) 343
Flucytosine 287t
Fluid mosaic model, of cell 17f
Fluorescence microscopy 257
Fluoridated milk 642t, 646
Fluoridated salt 642t, 646
Fluorides 502–504, 631 See also Biomaterials.
application of 503–504
amorphous calcium phosphate in 504
guidelines for client preparation 503
self-applied 504
tray systems for 503–504
xylitol, for dental caries prevention 504
considerations for 502

2061
 dentifrices 642t, 646
ingested 502
materials, fluoride-releasing restorative 406–407, 406f, 408f
mouthrinse 642t, 646
poisoning 698
for professional application
agents for 503
indications for 503
topical 407–408
varnishes 407–408, 503
Fluoxetine 379
Fogged radiographs 161, 161f
Foliate papillae 131t
Folic acid analog 352
Follicular cyst 224–225, 225f
Follow-up care 451
Food and Drug Administration (FDA) 318, 325, 398
Food flavors 388
Food poisoning 277
Food record diary 381
Food texture 388
Food-frequency questionnaires 381
Foot 66, 68f
Foramen 129
Fordyce granules 247, 247f
Fossa 134
Francisella tularensis 285t
Frankfort plane, positioning errors 167, 168f
Fraud 714

2062
Free base 332f
Free nerve endings, definition of 30
Free ribosomes 56
Frenum 131t
Frequency distribution table 662
Frequency polygon 662
Frontal bones 109, 109f
Frontal nerve 120
Frontal plane 55, 55f, 107, 108f
Frontal process, of maxillae 110
Frontal sinuses 112
Fructose 360
Fructose intolerance 365
Full-mouth survey 165, 165f
Functional shank 518, 519f
Fungal diseases 263
Fungal infections 273, 276
Fungi 256, 287t
Fungiform papillae 131t
Furcal concavity 129
Furcation 129, 475
involvement 530, 530f
Fusion, tooth 242, 242f
Fusobacterium 289

G
Galactose 360
Galactosemia 365
Gallbladder 370

2063
Gallbladder disease 371
Ganciclovir 287t, 343

2064
Ganglia 75, 119
Gap junctions, in cells 16
Gardner syndrome 199
Gastric mucosa 85
Gastric ulcers 371
Gastroesophageal reflux disease, agents for 351
Gastrointestinal agents 351–352
affecting gastrointestinal motility 351
emetics and antiemetics 351–352
histamine (H2-) blockers 351
proton pump inhibitors 351
Gastrointestinal tract, infections of 277–280
Gemination 242, 243f
Gender, pain and 548
Gene 60
General anesthetics 334–335
anesthesia stages and planes in 334
specific agents 334–335
General concepts, for pathology 182, 185
differential diagnosis of 188–189
genetics 185–188
genomics 185
regeneration and wound healing 182–184, 182f
regenerative medicine 184–185
review questions for 190
website information and resources for 189b
wound healing and regeneration 182–184, 182f
General damages 713
General supervision 718

2065
Generalized tonic-clonic seizures 699
Generic names 325
Genetics 185–188
chromosomes 186
genes and DNA sequences 185
genetic counseling referrals and 187
mutations 186
single-gene disorders 186
Genioglossus muscle 114
Geniohyoid muscle 114
Gentamicin 285t
Genuineness 482
Geographic tongue 247, 247f
German measles 275
Germicidal chemicals 309f
“Ghost teeth” 244, 245f
Giant cell granulomas See also Granulomas.
central 197–198, 198f
peripheral 197, 197f
Giardia lamblia 287t
Gingiva 131t, 427–428, 428f
Gingival Bleeding Index (GBI) 636t
Gingival diseases 430–431
Gingival enlargement, drug-induced 202–203, 203f
Gingival fiber groups 45
Gingival fibromatosis 201–203
characteristics of 201–202
chemical 202–203, 203f
hereditary 202

2066
 irritative 202
Gingival margin 131t
Gingival tissue packs 406
Gingivitis 381
indices for 636t
therapy for 480
Glands
adrenal 84
endocrine 80
of neck 119
exocrine, of head 118
of head and neck 118–119
lacrimal 78, 119
mammary 102
parathyroid 84, 119
pineal 83
pituitary 82–83
salivary 118
sebaceous 62
sudoriferous 62
thymus 85, 119
thyroid 83–84, 119, 119f
Glandular fever 210
Glandular tissue 22
Glaucoma 576
Glial cells 30
Globulomaxillary cyst 221, 222f
Glossitis 381
Glossopalatine arch 131t

2067
Glossopharyngeal nerve (CN IX) 122
Gloves 305
protocol for 305
risks associated with 305
types of 305, 306t
Glucagon 363
Glucocorticoids 348
Glucose 360
α-Glucosidase inhibitors 349
Glycemic management 467b See also Diabetes mellitus.
Glycogen 360
Glycogenesis 362
Glycolipids 361, 369
Glycolysis 60, 362
Glycoproteins 361
Golgi complex 18–19, 19f, 57, 57f
Gonads 85
Gonococcal glossitis 281f
Gonorrhea 281, 281f
Gout 369
Governmental agencies
and infection control 318–320
state board of dentistry and 3
Gracilicutes 263
Gram-positive vs. gram-negative bacteria 257t
“Grandfather ” clauses 715
Granulocytes 115
Granulomas 195–199
characteristics of 195

2068
 epulis fissuratum 196–197, 197f
giant cell
central 197–198, 198f
peripheral 197, 197f
hyperplasia
chronic hyperplastic pulpitis 198, 198f
denture-induced 196–197, 197f
inflammatory 196–197
papillary, palate 196, 196f
papillomatosis, palatal 196, 196f
periapical 199, 199f
pulp polyp 198, 198f
pulpal 198
pyogenic 195–196, 196f
resorption, internal 198–199, 199f
Gray matter 75, 76f, 77
Greater palatine (GP) nerve 120t, 121
Greater petrosal nerve 122
Grills 501
Griseofulvin 287t
Groove 134
Ground substance, in connective tissue 24
Group assignment 629, 630t
Growth hormone 363

H
Haemophilus influenzae 266t
Hair 61
infection of 273–275

2069
Hairy leukoplakia 272f
Half-life (t½) 326
Halogenated hydrocarbons 335
Hand hygiene 304
Hand-activated instruments 519–523
advanced root in 523
area-specific curet as 522–523, 522f
classifications of 519
dental mirror as 519–520
explorer as 520–521, 520f
periodontal file as 521–522
probe as 520, 520t
sharpening of 532, 533t
sickle scaler as 521, 521f
steps for calculus removal with 526–527, 526f
universal curet as 522, 522f
use of 519t
Handle 518
Hand-Schüller-Christian disease 238
Hantavirus pulmonary syndrome 277
Hard palate 131f, 131t See also Palate.
examination of 470
Haversian systems See Osteons
Hazardous waste removal service 314
Head and neck, anatomy and physiology of 107–128
bones of 109–112
circulatory system 115–117 See also Circulatory system.
glands of 118–119
lymphatic system 117–118, 117f

2070
 muscular system 112–114
nervous system 119–123 See also Nervous system.
osteology 107–112 See also Osteology.
paranasal sinuses 112
review questions for 123–128, 127b
temporomandibular joint of 114–115, 114f
website information and resources for 123b
Health belief model 491
Health Care Integrity and Protection Data Bank (HIPDB) 725
Health continuum 655
Health determinants 619
Health education 654–658
characteristics of different types of learners in 660
goals of 657
methods of 658–660
plan development for 660–661
in school setting 661
selection of media for 659
theories in 655t
topics for 658
Health history 459
blood pressure classification in 466t
evaluation of 459–468
form for 459
glycemic management in 467b
information 463–468
Physical Status Classification System for 465t
screening questions for 460–463, 462f, 463t
Health Information Technology for Economic and Clinical Health

2071
 (HITECH) 733
Health Insurance Portability and Accountability Act (HIPAA) 484, 729
Health literacy 492, 657t
Health promotion 654–658
in school setting 661
theories in 655t
Healthy People 2020 621
objectives and targets of 622t
and oropharyngeal cancer 635
role of 629
Hearing
and equilibrium 79, 79f
impairment 576–577, 577t
Hearing loss 576, 577t
Heart 87, 87f
diseases of 280–281
endocrine role of 85
Heat sterilization methods, comparison of 316t
Helicobacter peptic disease syndrome 277
Helminths (worms) 256
Hemangioma 194–195, 195f
Hemidesmosomes, in cells 16
Hemispheres, of brain 78
Hemophilias 233, 590
Hemorrhagic bone cyst 226
Hemostatic additive 329
Heparin 361
Hepatitis
hepatitis A virus 277, 279t

2072
 hepatitis B virus 278, 279t
hepatitis C virus 279t, 280
hepatitis D virus 279t, 280
hepatitis E virus 279t, 280
hepatitis G virus 280
immunoglobulins 279t
non-ABCDE 279t
Hepatitis B vaccine 303
Hepatotoxicity 338
Hereditary gingival fibromatosis 202
Hereditary opalescent dentin 241, 241f
Herpangina 209–210, 210f
Herpes 207–209
herpes labialis 208, 208f, 274f
herpesvirus 264t
primary herpetic gingivostomatitis 207–208, 207f
zoster (shingles) 208–209, 209f
Herpetic keratitis 285
Hertwig’s root sheath 36
Heteropolysaccharides 361
Hexoses 360
Hierarchy of needs, Maslow’s 490–491, 491f
High-density lipoproteins (HDLs) 370
High-fiber diet 379
Hippocratic Oath 708
Hispanic Dental Association 747
Histamine (H2-) blockers 351
Histamines 179t
Histogram 662

2073
Histology 16–52 See also Embryology.
basic tissues 21–31
cell replication and 21–31
general
cells 16–18
inclusions 18–20
oral
soft tissue 36–38
supporting tissues 43–47
tissues of the tooth 38–43
tooth development 33–36
review questions for 48, 48b, 50b
website information and resources for 47b
Histoplasma 263
History 459
blood pressure classification in 466t
evaluation of 459–468
form for 459
glycemic management in 467b
information 463–468
Physical Status Classification System for 465t
screening questions for 460–463, 462f, 463t
Home irrigation 500
Homeostasis, cells and 20
Horizontal angulation 166, 167f
Horizontal plane 107, 108f See also Transverse plane.
Hormones 80–82, 352
amino acid derivative 80
anabolic 80

2074
 classification of 80
function of 80
glycoprotein 80
mechanism of action of 80
nonsteroid 80
peptide 80
protein 80
regulation of, secretion 82
secreted by the adenohypophysis 83
sex 80
steroid 80
tropic 80
Horns, pulp 129
Hostile work environment 734
24-hour recall method 381, 384
Human behavior principles 490
Human immunodeficiency virus (HIV) 233–234
acquired immune deficiency syndrome (AIDS) and 234b
antiviral agents 287t
CDC classification system for 270
dietary considerations for infection with 389
incidence and prevalence of 272
oral lesions associated with 233, 234b
oral manifestations of 272
transmission of 233
Human needs theory 458, 460–461f
Human T lymphotropic virus (HTLV) 264t
Humerus 65, 66f
Hyaline cartilage 24

2075
Hyaluronic acid 361
Hydrases 60
Hydrocarbons, halogenated 335
Hydrochloric acid 367
Hydrogenases 60
Hydrogenation 369
Hydrolyzing enzymes 60
Hygiene assessment, oral 476
Hyoglossus muscle 114
Hyoid bone 112
Hyoid muscles 113
Hyperglycemia 349
Hyperkeratosis 217, 217f
Hyperlipoproteinemias 371
Hyperparathyroidism 236–237, 237f
Hyperplasia See also Granulomas.
chronic hyperplastic pulpitis 198, 198f
denture-induced 196–197, 197f
inflammatory 196–197
papillary, palate 196, 196f
Hypersensitivity 270f
assessment of 510
desensitization methods for 511–512
desensitizing agents for 511
desensitizing treatments for, types of 511
etiology of 511–512
pain
mechanism 511
stimuli 511

2076
Hypertension 465, 466t, 586, 695
postural 693
Hypertensive disease 586
Hypertensive heart disease 586
Hyperthyroidism 329, 349
Hypertonic solution 20, 58
Hyperventilation 694
Hyphae 263
Hypnotic-sedative medications 335–339, 335b
barbiturates 336
benzodiazepines 335–336, 336t
general considerations for 335
nonbarbiturate nonbenzodiazepines 336–337
Hypocalcification, enamel 240
Hypodontia 244, 244f
Hypoglossal nerve (CN XII) 123
Hypoglycemia 349
reactive 366
Hypoglycemic agents 349
Hypomaturation, enamel 240
Hypoplasia, enamel 240
Hypoplastic-hypomaturation, enamel 241
Hypotension, orthostatic 693
Hypothalamus 78
Hypothesis 629
null 629
research 629
testing of 664
Hypothyroidism 349

2077
Hypotonia 578
Hypotonic solution 20, 58
Hypovolemic shock 693

I
Ideal body weight (IBW) 379
Ideal occlusion 145
Idiosyncrasy 327
IFDH See International Federation of Dental Hygienists (IFDH)
Imagery 129
Imipenem 285t
Immediate supervision 718
Immune system 92–93, 92f
duality of 268f
questions regarding 465
Immunity 714
Immunizations 303
Immunodeficiency 267–273
Immunoglobulin (Ig), classes of 93
Immunoglobulin G (IgG) 179
Immunology terms 269b
Imperfect fungi 263
Implants, dental 418–419, 452–453
definition of 501
design of 452
endosseous 452
goals of 453
identification of 474
instrumentation for 535–536

2078
 limiting factors for 452
maintenance of 501–502
management of 453
transosteal 453
types of 452
Implementation, in process of care 481–482
Implied contract 713
Impression materials 409–410, 410t
Improving Access to Oral Health Care for Vulnerable and Underserved
Populations 623
Incidence 625t
Incisal guidance 147
Incisal tooth surfaces 134
Incisive block 120t
Incisive canal cyst 221
Incisive nerve 122
Incisive papilla 131t
Incisor(s) 135, 136t
Incompetence, reporting suspected 753
Incomplete penetrance 186
Independent contractor 734
Independent practice for dental hygienists (IPDH) 669t
Independent practitioner 734, 734b
Independent variable 629
Indian Health Service (IHS) 621b
Indices 476
Indinavir (IDV) 272
Indirect digital imaging 163
Indirect preventive and restorative materials 409–420 See also

2079
 Biomaterials.
alloys
casting 412–413
chromium 413
porcelain-fused-to-metal 413–414
appliances, acrylic 415–416
athletic mouthguards 417
cast materials 411–412
cements, crown-and-bridge 415, 415t
ceramics, dental 414–415
denture
bases, acrylic 416
cleansers 417
soft liners 417
teeth 416
die materials 411–412, 411t
implants, dental 418–419
impression materials 409–410, 410t
investment materials 412
model materials 411–412
mouth protectors 417
provisional materials 410–411
restorations, computer-assisted design/computer-assisted
machining 418
solders, dental 413
tissue engineering 419–420
veneers 417–418
waxes 412
Indirect supervision 718

2080
Indirect-acting drugs 330
Individual risk management 736
Induced pluripotent stem cells (iPs) 185, 185t
Infections See also Microbiology and immunology.
of central nervous system 284–285
of circulatory system 280–281
control of 300
dental laboratory in 313
dental unit water and 311
evaluation programs in 319–320, 319t
governmental agencies and 318–320
procedures for dental health care personnel 302–308
of eye 285
factors related to 301f
of gastrointestinal (GI) tract 277–280
of hair 273–275
of nails 273–275
opportunistic 295
of oral cavity 288–295
oral-facial tissue 294–295
periapical 294–295
of reproductive system 281–284, 281f
of respiratory tract 275–277
of skin 273–275
urinary tract 284
Infectious diseases
development of 300
diagnosis and management of 187
Infectious mononucleosis 210

2081
Infectious waste, regulated 314
Infective endocarditis 280
Inference 627
Inferior alveolar (IA) nerve 120t, 122
Infiltrants 403
Inflammation 267
acute 177–181, 178f
chemotaxis in 179
mediators, arachidonic acid 180
outcomes of 181
phagocytosis in 179
vascular changes in 177, 178f
cardinal signs of 177
cells involved in 177, 178f
eosinophils 177
lymphocytes 177
mast cells 177
chronic 181–182
principal mediators of, actions of 179t
types of 177
Inflammatory hyperplasia 196–197 See also Hyperplasia.
Inflammatory tumors 195–199
characteristics of 195
epulis fissuratum 196–197, 197f
giant cell
central 197–198, 198f
peripheral 197, 197f
hyperplasia
chronic hyperplastic pulpitis 198, 198f

2082
 denture-induced 196–197, 197f
inflammatory 196–197
papillary, palate 196, 196f
papillomatosis, palatal 196, 196f
periapical 199, 199f
pulp polyp 198, 198f
pulpal 198
pyogenic 195–196, 196f
resorption, internal 198–199, 199f
Infliction of mental distress 714
Influenza virus infection 276
Informed consent 714
and process of care 481
Informed refusal 715
Informed refusal form 481
Infrabony pocket 437f
Infrahyoid muscle group 114
Infraorbital (IO) nerve 120, 120t, 554
Ingested fluorides 502
Inhalers 350
Inhibitory neurotransmitter 76
Initial care plan 442–443
Inner ear 79
Inner enamel epithelium (IEE) 35
Innervation
of periodontium 429–430 See also Periodontium.
of trigeminal nerve
mandibular division 554–555
maxillary division 554

2083
Instrument
design for 518–519
characteristics 519
hand-activated 519–523
advanced root in 523
area-specific curet as 522–523, 522f
classifications of 519
dental mirror as 519–520
explorer as 520–521, 520f
periodontal file as 521–522
probe as 520, 520t
sharpening of 532, 533t
sickle scaler as 521, 521f
steps for calculus removal with 526–527, 526f
universal curet as 522, 522f
use of 519t
mechanized, tip area of 534f
parts of 518, 519f
processing of 314
tip design for 533
Instrumentation, periodontal
advanced, techniques in 535–536
for assessment 527–531
clinical, using periodontal probes 528–530
with dental explorer 530–531
with periodontal probes 527, 527f
probing technique in 527–528
concepts in 531–532
end point of 532

2084
 nonsurgical, rationale for 531–532
overhang removal, rationale for 532
preparation of, steps for 532
terminology in 531
ethical, legal, and safety issues in 537
principles of 523–526
activation 525
adaptation 525
angulation 525, 525f
clinician position 523–524, 523f
stabilization 524–525, 524f
strokes 526
review questions for 538, 538–539b, 541–543b
selective stain removal in 536–537
ultrasonic and sonic 532–535
website information and resources for 538b
Insulin 349
Insurance 670
types of 671, 672t
Integumentary system 61–62
Intentional misrepresentation 714
Intentional tort 714
Interarch relationships 143–147
Intercellular substances, tissue components 21
Intercuspation 145, 145f
Interdental alveolar bone 44
Interdental brushes 497–498, 497f
Interdental plaque biofilm control 496–498
cleaning methods for, factors to consider when selecting 496, 496f

2085
Interdental tip 498
Interdental wedges 498
Interdigitation 145, 145f
Inter-examiner (rater) reliability 625t, 641
Interference with advantageous relations 714
Interferons 267
Interfurcal area 129
Intermediate-acting drugs
barbiturates 336
insulin 349
Internal environment, of cell 20
Internal resorption 198–199, 199f
Internal Revenue Service (IRS) 734
International Association for Dental Research 747
International Association for Disability and Oral Health 747
International Federation of Dental Hygienists (IFDH) 13–14, 747
International numbering system 139
International requirements, for dental hygiene board examinations 13–14
International Standards Organization (ISO) 398
Interneurons 30
Interpersonal communication 482
Interphase, of mitosis 21
Interradicular alveolar bone 44
Interstitial fluid 91
Interview, health history information from 467
Intestinal mucosa 85, 370
Intra-alveolar pocket 437
Intra-arch relationships 143–147
Intrabony pocket 437

2086
Intra-examiner (rater) reliability 625t, 641
Intramembranous ossification 25, 107
Intramuscular (IM) administration 326
Intraoral assessment 468–471
Intraoral film, components of 159
Intraoral radiographic examinations, types of 164–165
Intraoral radiographic techniques 163, 163f
Intraoral technique errors 166–167
Intraosseous neoplasms, benign 199–201
characteristics of 199
chondroma 200
exostosis 201
torus mandibularis 201, 201f
torus palatinus 201, 201f
odontogenic myxoma 200–201, 200f
odontoma 201, 202f
osteoma 199–200, 200f
Intrapersonal communication 482
Intravenous (IV) administration 326
Intrinsic stains 536
Intrinsic tongue muscles 114
Intrusion on seclusion 714
Invasion of privacy 714
Investment materials 412
Iodine number 369
Iodophors 310t
Iodoquinol 287t
Ionization, degree of 327
Ipratropium bromide (Atrovent) 351

2087
Iris 78
Iron deficiency anemia 228–229, 229f
Irreversible index 640
Irrigation, oral 500
Irritant contact dermatitis 306, 467
Irritative fibroma 193, 194f
Irritative fibromatosis 202
Ischemic heart disease 586–587
Isomerases 60
Isotonic solution 20, 58
Isthmus, faucial 131t
Itraconazole (Sporanox) 343

J
Jaw, osteonecrosis of 352
JCNDE See Joint Commission on National Dental Examinations
(JCNDE)
Joint Commission on National Dental Examinations (JCNDE) 4
Joints 67–68
Judgmental sample 630t
Judicial law 711
Jugular veins, internal and external 116
Junction
of surfaces 134
of tooth tissues 129
Junctional epithelium 47, 47f
Justice 708, 749

2088
Kant, Immanuel 707
Kaposi’s sarcoma 273f
Karyotypes 187
Keratin sulfate 361
Ketamine 335
α-Keto acid 368
Ketoconazole 287t, 343
Ketone production 370
Kidneys 97–98, 98f
functions of 100
Killing and degradation 179
Kilovoltage peak (kVp) 153
Kinin system 180
Kinins 179t
Klebsiella spp. 266t
Krause’s end bulbs 80, 81t
Krebs cycle 60, 362
Kwashiorkor 369

L
Labeling 568
Labial commissure 131t
Labial frenum 131t
Labial mucosa 130f, 131t
examination of 470
Lacrimal bones 110, 111f
Lacrimal glands 78, 119
Lacrimal nerve 120
Lactase 361

2089
Lactose 360
Lactose intolerance, dietary modifications for 365
Lamina dura 44
Lamivudine 287t
Landmark decisions 711
Langerhans, islets of 85
Langerhans cell disease 238, 238f
Large intestine, in digestion of carbohydrates 361
Laryngeal edema, treatment for 697
Larynx 94
assessment of 468
Laser Doppler flowmetry 512
Lateral periodontal cyst (LPC) 223, 224f
Lateral structures 107
Latex allergy 306, 467
procedures for management of persons with 306
Latin abbreviations 326t
Law
classification of 711, 711f
definition of 710
sources of 710
vs. ethics 710, 710t
Laws and legislation
Age Discrimination in Employment Act of 1967 (ADEA) 735
Civil Rights Act
of 1964 (Title VII) 734
of 1991 734
disclosure statutes 714
Equal Employment Opportunity Commission (EEOC) 734

2090
 Equal Pay Act (EPA) of 1963 735
fair employment statutes 735
Family and Medical Leave Act of 1993 (FMLA) 735
Health Information Technology for Economic and Clinical Health
(HITECH) 733
Health Insurance Portability and Accountability Act (HIPAA) 729
Occupational Safety and Health Act of 1970 (OSHA) 735
pharmacology-related 325, 326t
Practice Act overview 716t
Uniformed Services Employment and Reemployment Rights Act of
1994 735
Laxatives 351
Lay witness 712
Lean body mass 377
Lecture-demonstration, for oral health 658
Lectures, for oral health 658
Legal issues 707–742
in disease prevention 320, 320b
employer vs. employee rights 733–735, 734b
fundamentals of
administrative law 711
case law 711–712
classification of 711, 711f
common law 711
constitutional law 710
criminal law 711
due process 712
equal protection 712
judicial law 711

2091
 judicial process 712
lawsuit participants 712
level of proof 711
statute of limitations 712
statutory law 711
litigation avoidance strategies 736
of process of care 484
record keeping 728–733
risk management 736
web resources for 737b
Legally problematic areas 718
Legionella pneumophila 266t
Legionnaires disease 275
Legislations See Laws and legislation
Lens 78
Leprosy 273
Leptospira spp. 266t
Lesions, endodontic, periodontitis associated with 433 See also
Periodontitis.
Lesser palatine nerve 121
Lethal dose (LD) 325
Letterer-Siwe disease 238
Leukemia 231–232, 589–590, 590f
acute 231–232, 232f
lymphoblastic (ALL) 231
myeloblastic (AML) 231
characteristics of 231
chronic 232
lymphocytic (CLL) 232

2092
 myeloid (CML) 232
Leukocyte products, release of 179
Leukocytes 115
lysosomal components of 181
Leukocytosis 181
Leukoderma 214
Leukotrienes 179t
Level of proof 711
Levonordefrin (Neo-Cobefrin) 329, 329t
Libel 714
Licensure 715
by examination 715
future trends in 13
by waiver 715
Lichen planus 215–217, 216f
Lidocaine 333
Life span approach, to care 567, 568t
Ligament, periodontal 428–429
Light microscopes 257
Light radiographs 161, 161f
Lignin 361
Limb girdle muscular dystrophy 582t
Limbic system 78
Limiting factor 553
Line angle 134
Linea alba 214, 214f
Liners
cement 405
denture, soft 417

2093
Lingual artery 115, 116f
Lingual frenum 131t
Lingual mandibular bone concavity 226–227, 227f
Lingual nerve 122
Lingual thyroid nodule 33
Lingual tonsils 118, 131t
Lingual tooth surfaces 134
Lingual veins 131t
Linnaeus, Carolus 256
Lipid solubility 327
Lipids (fats) 369–371
absorption and transport of 370
biologic role and functions of 371
compound 369
definition of 369
derived 370
dietary modifications for disease 371
digestion of 370
metabolism of 370
regulators of 370
nutritional requirements 371
simple 369
Lipogenesis 362, 370
Lipoma 195, 195f
Lipoproteins 369
Lipoxins 180
Lips 131t
examination of 470
Liquid chemical sterilants 316

2094
Liquid formulas (protein) 379
List regulations 716
Listeria monocytogenes 285t
Lithium 338, 348
Litigation avoidance strategies 736
Local anesthetic agents 332–334, 332f, 334t, 550–553
administration regulations for 718, 726t, 728f
adverse reactions 333
allergic reactions to 333
armamentarium for 548–549
cartridge in, anesthetic 549, 549f
needle in 548, 548f
record keeping and documentation in 549
syringe in, anesthetic 549, 549f
biotransformation of 550–551
calculations for 552
chemical structure of 550, 551t
chemistry of 332
comparison of 551t
compositions of 333
computer-controlled delivery system of See Computer-controlled local
anesthesia delivery device (CCLADD)
dental hygiene considerations for 333
drug interactions of 333
injection sites for administration of
mandibular 120t
maxillary 120t
injection-free 333
maximum recommended dose (MRD) for 552

2095
 mechanism of action of 332, 550
metabolism of 332, 550–551
pharmacokinetics of 332
potency of 550
reactions of 698
reversal agent 334
topical 333, 552
toxicity of 550
vasoconstrictors 552–553, 552t
Local anesthetic reversal agents 334
Localized scleroderma 581
Locus of control 491
Log dose-response curve 325, 326f
Long-acting agents
barbiturates 336
insulin 349
Longitudinal, definition of 625t
Loose connective tissue 23
Low-carbohydrate, high-protein diet 379
Low-density lipoproteins (LDLs) 370
Lower respiratory system infections 275–277
Lower (terminal) shank 518, 519f
Low-fat diet 379
Lumbar lesion levels, functional significance of 584t
Lumbosacral plexus 77
Lyme disease 273
Lymph 26–27, 117, 429–430
Lymph nodes 117
assessment of 468

2096
Lymphatic system 27, 91–93, 91f, 117–118, 117f
Lymphatic vessels 117
Lymphocytes 115, 177
Lymphoepithelial cyst 222–223, 223f
Lysergic acid diethylamide (LSD) 353
Lysosomes 18, 57, 57f

M
mA See Milliamperage (mA)
Macrodontia 245
Macroparasites 256
Magnification 160, 160t
Mainstreaming 568
Maintenance therapy 482
Major aphthous ulcers 206–210
benign mucous membrane pemphigoid 206–207, 207f
cicatricial pemphigoid 206–207, 207f
glandular fever 210
herpangina 209–210, 210f
herpes 207–209
infectious mononucleosis 210
Mikulicz aphthae 206, 206f
mucous membrane pemphigoid 206–207, 207f
periadenitis mucosa necrotica recurrens 206, 206f
pharyngitis, aphthous 209–210, 210f
recurrent scarifying ulcerative stomatitis (RSUS) 206, 206f
Sutton disease 206, 206f
Malignant hyperthermia 333
Malnutrition 380–381

2097
Malocclusion 145, 146f, 571f, 635
Malodor, oral 499–500
Malpractice 713
Maltase 361
Maltodextrim 370
Maltose 360
Managed care 671
Mandible 111, 111f
assessment of 468
radiographic anatomy of 170, 170f
Mandibular division, of trigeminal nerve 554–556
block injections for 556, 557t
innervation of 554–555
Mandibular labial frenum 131t
Mandibular nerve 121, 121f
Manual palpation 468
Manual scrubbing technique 315
Manual toothbrushes 494
Marasmus 369
Maraviroc 272
Margin, gingival 131t
Marginal ridge 134
Margination 178
Marijuana (cannabis) 353
Masking 628
Masks 306
Maslow’s hierarchy of needs 490–491, 491f
Masseter, assessment of 468
Mast cells 177

2098
Mastigophora 264
Materials 394–426
applications of 394
classification of 394
general considerations for 394
preventive and restorative, direct 399–409
amalgam, dental 399–401, 399–400f
bonding agents 403–405, 403–404f
cement applications 406
cement bases 405–406, 405f
cement liners 405
cements, orthodontic 406
composites, dental 401–402, 401f
dentifrices 408–409
dressings, surgical 406
fluoride varnishes 407–408
fluoride-releasing restorative materials 406–407, 406f, 408f
fluorides, topical 407–408
gingival tissue packs 406
infiltrants 403
pastes, prophylactic 408–409
sealants, pit-and-fissure 402–403
sealers, root canal 406
whitening agents 409
preventive and restorative, indirect 409–420
alloys, casting 412–413
alloys, chromium 413
alloys, porcelain-fused-to-metal 413–414
appliances, acrylic 415–416

2099
 athletic mouthguards 417
cast materials 411–412
cements, crown-and-bridge 415, 415t
ceramics, dental 414–415
denture bases, acrylic 416
denture cleansers 417
denture soft liners 417
denture teeth 416
die materials 411–412, 411t
implants, dental 418–419
impression materials 409–410, 410t
investment materials 412
model materials 411–412
mouth protectors 417
provisional materials 410–411
restorations, computer-assisted design/computer-assisted
machining 418
solders, dental 413
tissue engineering 419–420
veneers 417–418
waxes 412
properties of 395–398
biologic 398
chemical 395
electrical 395
electrochemical 396, 396f
mechanical 396, 397–398t, 397f
physical 395
thermal 395, 395f

2100
 restorative, radiographic appearance of 171, 171f
structure of 394
website information and resources for 420b
Maxilla 110, 111f
radiographic anatomy of 169, 169f
Maxillary artery 116
Maxillary division, of trigeminal nerve 554
block injections for 554, 555t, 556f
innervation of 554
Maxillary fourth molar 245
Maxillary labial frenum 131t
Maxillary nerve 120, 120f
Maxillary paramolar 245
Maxillary tuberosity 131t
Maximum (safe) dose (MD) 329
Maximum permissible dose (MPD) 157
Maximum recommended dose (MRD), for local anesthetic agents 552
Measles 275
German 275
Measurement, methods of 256–258
Measures, for public health 641
Mebendazole 287t
Mechanical properties, of biomaterials 396, 397–398t, 397f
Mechanized instrument, active tip area of 534f
Medial structures 107
Median mandibular cyst 221
Median palatine cyst 221
Median plane 107
Median sulcus 131t

2101
Mediastinum 55, 56f
Medicaid 620, 673
Medical consultation, request for 462f
Medical emergencies 688–706
acute adrenal insufficiency 701
adrenal crisis 701
allergic reactions 697–698
asthma 694
cardiac 694–697
care 691–692
cerebrovascular accident (CVA) 699
dental hygienist’s legal responsibilities 688
diabetes mellitus 700–701
drug-related 698
emergency kit 690–691
general considerations in 688
history in 688
hyperventilation 694
obstructed airway management 692
orthostatic hypotension 693
oxygen administration 692
poisoning 698
postural hypertension 693
review questions for 702–706, 705–706b
seizures and convulsive disorders 699–700
shock 693–694
syncope 692–693
transient ischemic attacks (TIAs) 699
unconscious client 692

2102
 vital signs 688–690
blood pressure 689, 689f
body temperature 689
pulse 689–690, 690f
respiration rate 690
website information and resources for 702b
Medical terminology 743–745
body part designations 745
combining forms 744–745
prefixes 743
suffixes 743–744
Medications
analgesics 337, 337t
acetaminophen (n-acetyl-p-aminophenol) 338
general considerations for 337
gout drugs 339
nonsteroidal anti-inflammatory agents (NSAIAs) 338
nonsteroidal anti-inflammatory drugs (NSAIDs) 331t, 338
opioid (narcotic) 338–339, 339t
salicylates (aspirin) 337
antiarrhythmics 344–347
antianginal agents 344
anticoagulants 344–345
anticonvulsants 346–347, 346t
antihypertensives 344, 345t
diuretics 344
antifungal agents 287t
anti-infectives 339–343
aminoglycosides 342

2103
 antifungal agents 343
antituberculosis agents 343
antiviral agents 343
cephalosporins 341
clindamycin 341
general considerations for 339–340
macrolides 341
metronidazole 342–343
penicillins 340–341
quinolones 342
sulfonamides 342
tetracyclines 341–342
antineoplastic agents 352–353
antiparasitic agents 287t
antiviral agents 287t
autonomic nervous system agents 328–334
α-adrenergic blocker 329–330
β-adrenergic blocker antagonists 330
adrenergic neuronal agonists and antagonists 330
local anesthetic agents 332–334, 332f, 334t
parasympathetic (cholinergic) 328f, 330–332
sympathetic (adrenergic) 328–329, 328f, 329t
xerostomia-producing drug groups in 331t
cardiovascular agents 343
digitalis glycosides 343
emergencies, drug-related 698
endocrine agents 348–350
adrenocorticosteroids 348, 348t
agents for diabetes mellitus 348–349

2104
 estrogens and progesterone 350
oral contraceptives 350
thyroid agents 349–350
gastrointestinal agents 351–352
affecting gastrointestinal motility 351
emetics and antiemetics 351–352
histamine (H2-) blockers 351
proton pump inhibitors 351
general anesthetics 334–335
anesthesia stages and planes in 334
specific agents 334–335
general considerations for 325–328
adverse reactions 327–328
agencies 325
definitions 325
drug action 325–327
legislations 325, 326t
nomenclature 325, 326t
listing of current 467
local anesthetic reversal agents 334
psychotherapeutic agents 347–348
antidepressants 347–348
antipsychotics 347, 347t
respiratory system agents 350–351
agents for asthma in 350–351
sedative-hypnotic 335–339, 335b
barbiturates 336
benzodiazepines 335–336, 336t
general considerations for 335

2105
 nonbarbiturate nonbenzodiazepines 336–337
smoking cessation and 354
substance abuse and 353
definitions in 353
drugs 353
Mediterranean anemia 229–230
Medium-chain fatty acids 370
Medulla oblongata 77, 77f
Meglitinides 349
Meiosis 61
Meissner ’s corpuscles 80, 81t
Melanin 129
Melatonin receptor agonist 336
Membership, in regional testing agencies 2b, 9
Membrane potential 75
Membrane transport, of cells 16, 20
Meninges 76
Meningocele 583
Meningomyelocele 583
Mental block 120t
Mental illness 573
Mental nerve 122
Mentalis muscle, assessment of 468
Merkel discs 81t
Mesial tooth surfaces 134
Mesiodens 245
Messenger RNA (mRNA) 18, 262
Metabolic pathways 262
Metabolic syndrome (MetS) 466

2106
Metabolism 327
anabolic hormones in 363
anabolism in 368
of carbohydrates 361, 363f
catabolic hormones 363
catabolism in 368
of local anesthetic agents 550–551
nitrogen balance in 368
transamination in 368
Metaphase, of mitosis 21
Metformin (Glucophage) 349
Methamphetamine abuse, and addiction 239–240
Methicillin 285t
Methotrexate (MTX) 337–338
Methylphenidate (Ritalin) 329t
Methylxanthines 351
Metronidazole 285t, 342–343
Mezlocillin 285t
Miconazole 287t
Microbiology and immunology 256–299
bacteria 263
Firmicutes 263
Gracilicutes 263
of human importance 266t
Mendosicutes 263
Tenericutes 263
cell regulation 262–263
cell structure/function
eukaryotic 259, 260t

2107
 helminths (worms) 256
prokaryotic 258–259, 260t
chemotherapeutic agents 285–287, 285t, 287t
disease barriers and 267
disease transfer and 265–287
fungi 263–264
immunodeficiency 267–273
infections
central nervous system 284–285
circulatory system 280–281
eye 285
gastrointestinal (GI) tract 277–280
hair 273–275
nails 273–275
reproductive system 281–284, 281f
respiratory tract 275–277
skin 273–275
urinary tract 284
measurement methods for 256–258
metabolism for 262–263
microorganisms 256–265
binomial nomenclature for 256
genetics of 263
growth and cultivation of 259–262
medically important 256
relationships of 263
observation methods for 256–258
of oral cavity 288–295
bacterial plaque 290–291

2108
 dental caries 291–292, 291f
opportunistic infections 295
oral flora, development of 290
oral flora, normal 288–290, 289t
oral-facial tissue infections 294–295
periapical infections 294–295
periodontal diseases 292–294, 293b
prokaryotes 256, 260t
protozoa 264
review questions for 296, 298b
virulence factors and 266–267
viruses 256, 264–265, 264t, 287t
website information and resources for 296b
Microdontia 245, 246f
Microorganisms 256–265
binomial nomenclature for 256
medically important 256
metabolism of 262–263
relationships of 263
Microscopy
confocal-scanning laser 257
darkfield 257
electron 258
fluorescence 257
phase-contrast 257
Microspora 264
Microsporum 263
Microtubules 20
Microvasculature 26–27

2109
 increased permeability of 178
Midbrain 77, 77f
Middle ear 79
Middle superior alveolar (MSA) nerve 120, 120t
Mikulicz aphthae 206, 206f
Mill, John Stuart 707
Milliamperage (mA) 153
Mineralocorticoids 84, 348
Minerals 372–375
chemistry and general functions of 372
classification 372
definition of 372
effects on oral cavity 373t
Minimal threshold stimulus 547
Mirror, dental 519–520
Misdemeanors 711
Mitochondria 19, 19f, 57
Mitosis 61
phases of 21f
Mixed dentition 142, 145
Mobility, of teeth 475
Model materials 411–412
Modified Navy Plaque Index (MNPI) 636t
Molars 136t, 139 See also Dentition.
parts of 133f
Molds 256
Monoamine oxidase inhibitors (MAOIs) 329, 347
Monocytes 115, 179
Mononucleosis, infectious 210

2110
Monostotic fibrous dysplasia 235
Moraxella 289t
Morbidity 625t
Morphodifferentiation, in tooth development 34
Morphology, root 129–151 See also Dental anatomy.
Mortality 625t
Motility, gastrointestinal, agents affecting 351
Motivation, in human behavior principles 490
Motivation theories 491
Motivational interviewing, evidence-based approach 492
Motor disorders 578
Motor neurons 75, 119
Mounting, film 169
Mouth, and digestion of carbohydrates 361
Mouth protectors 417
Mouthrinses 504–505
Mucobuccal fold 131t
Mucocele 225–226
Mucogingival examination 529
Mucogingival line 131t
Mucopolysaccharides 361
Mucor 263
Mucosa 130f, 131t
classifications of 38
gastric and intestinal 85
oral 36–38
of tongue 38
Mucous membrane pemphigoid 206–207, 207f
Mucous membranes 61

2111
Mucus, extravasation 225–226
“Mulberry molars” of congenital syphilis 283f
Multifactorial approach 624
Multifactorial inheritance disorders 187
Multiple sclerosis 581–582, 582t
Multi-polar neurons 29, 29f
Muscarinic receptors 330
Muscle contraction 31
Muscle fiber 31f
Muscle relaxants 331t, 336
Muscle tissues 30–31, 62
Muscular dystrophies 582, 582t
Muscular system 69–74, 112–114
anatomy of 69–74, 71f
cervical muscles 113
descriptive terminology in 112
facial expression muscles 112
hyoid muscles 113
mastication muscles 113, 113f
muscles
head and neck 70
lower limb 70
trunk 70
upper limb 70
and posture 70–71
skeletal muscle 69
function of 71–73
organs, functions of 72f, 73
structure of 69–74, 72f

2112
 sternocleidomastoid muscle 113
tongue muscles 114
trapezius muscle 113
Musculoskeletal system, questions regarding 466
Mutases 60
Mutations 263
Myasthenia gravis 579–580
Myasthenic crisis 579
Mycelium 263
Mycobacterium leprae 266t
Mycobacterium tuberculosis 266t
Mycoplasmal pneumonia 276
Myelin 75, 75f, 581
Myelin sheath 30
Myelomeningocele See Meningomyelocele
Mylohyoid muscle 114
Mylohyoid nerve 122
Myocardial infarction (MI) 587, 695
Myotonic muscular dystrophy 582t
MyPerioIDSM PST 187
MyPerioPathSM 187
Myxoma, odontogenic 200–201, 200f
Myxoviruses 264t

N
Nails 62
infection of 273–275
Nasal administration 326
Nasal bones 110, 111f

2113
Nasociliary nerve 120
Nasolabial cyst 221
Nasolacrimal duct 78
Nasopalatine canal cyst 221
Nasopalatine (NP) nerve 120t, 121
Natal teeth 244
National Board Dental Hygiene Examination (NBDHE) 4–9 See also Board
examinations.
application process for 6
eligibility for 6
examination day guidelines 6
format of 4–5
case-based item 6
cause and effect item 5
competencies and 4
completion item 5
Dental Hygiene Test Specifications 4
item 5–6
negative item 5
paired true-false item 5
question item 5
testlet item 5–6
future trends in 9
multiple-choice tests, guidelines for 8–9
preparing for 7–8
results of 6–7
National Call to Action to Promote Oral Health 621
National Center for Dental Hygiene Research & Practice 747
National Center for Health Statistics (NCHS) 624

2114
National Dental Hygiene Certification Board of Canada (NDHCB) 14
National Dental Hygienists’ Association/National Dental Association 747
National documents 621
National Health and Nutrition Examination Survey (NHANES) 624
National Institute of Dental and Craniofacial Research 567
National Institutes of Health (NIH) 621b
National Oral Health Surveillance System (NOHSS) 624
National Practitioner Data Bank (NPDB) 725
National Society for Genetics Counselors (NSGC) 188
Nationality, pain and 548
NBDHE See National Board Dental Hygiene Examination (NBDHE)
NDHCB See National Dental Hygiene Certification Board of Canada
(NDHCB)
Necessity 714
Neck bones 112
Necrotizing periodontal diseases 432–433
Necrotizing sialometaplasia 226, 226f
Necrotizing ulcerative gingivitis (NUG) 205, 205f, 381
Needle 548, 548f
Needs theory, human 458, 460–461f
Negative reversal 625t
Negative staining 258
Negligence 713
Negligent hiring and retention 734
Neisseria gonorrhoeae 266t, 285t
Neisseria meningitides 266t, 285t
Neoplasia, oral 217–218
Neostigmine (Prostigmin) 330
Nerve 119

2115
Nervous system 74–80, 74f, 119–123
action potentials in 75–76
autonomic 27, 75, 78, 119
brain of 74, 77–78, 77f
cellular organization of 75–76
central 74, 119
classification and function of 119
cranial nerves 119, 78 See also Cranial nerves.
descriptive terminology 119
local anesthetic agent administration for, injection sites of 120t
parasympathetic 119
peripheral 75, 119
somatic 75
special senses in 78–80
spinal cord of 76–77, 76f
structure of 75, 75f
sympathetic 119
synaptic transmission in 76
Nervous tissues 62
Net protein utilization (NPU) 367
Neurilemma 75
definition of 30
Neurocranium 109
Neurogenic shock 694
Neuroglia 75
definition of 30
Neurohypophysis (posterior pituitary) 83
Neuroleptanalgesia 335
Neurologic disorders, questions regarding 467

2116
Neurons 29, 29f, 119
Neuropeptides 181
Neurotransmitters 30
types of 76
Neutral sodium fluoride (NaF) 503
Neutrophils 115, 179
Nevirapine (NVP) 272
Nevus, white sponge 215
Niclosamide 287t
Nicotine 353
reduction systems for 354
stomatitis 213–214, 214f
Nicotinic receptors 330
Nitric oxide (NO) 179t, 181
Nitrogen balance 368
Nitrogen mustards 352
Nitrosureas-carmustine (BiCNU) 352
Nitrous oxide-oxygen (N2O-O2)
administration regulations 718, 729t, 730f
analgesia 334
administration of 334
advantages of 334
adverse effects of 334
contraindications to 334
disadvantages of 334
conscious sedation with 559
advantages and disadvantages of 562
anesthesia stages for 561
chemistry of 559

2117
 contraindications to 562
equipment for 562
indications for 562
pharmacology of 561
physiology of 561
record keeping and documentation for 562
safety measures for 562
signs and symptoms of 562
synonymous terms in 559
Nociceptors 80, 81t, 547
Nodes of Ranvier 75, 75f
Nominal damages 713
Nonbarbiturate nonbenzodiazepines 336–337
Nonconvulsive seizure 700
Nonmaleficence 708, 749
Nonnutritive sweeteners 365
Nonodontogenic cysts 221–222, 222f
Nonshivering thermogenesis 378
Nonspecific immunity 92, 267
Nonsterile (examination) gloves 306t
Nonsteroid hormones 80
mechanism of action 82
Nonsteroidal anti-inflammatories
adverse reactions to 338
agents (NSAIAs) 338
contraindications to 338
drug interactions in 338
drugs (NSAIDs) 331t, 338
therapeutic use of 338

2118
Nonsurgical periodontal therapy (NSPT) 443, 444t
Nonthrombocytopenic purpura 233
Nonverbal behaviors 482
Noradrenergic drugs, for weight loss 379
Norepinephrine 90, 328–329
Norepinephrine-serotonin modulator-mirtazapine 348
Normal (bell) curve 663, 663f
Normal occlusion 145
Normalization 568
Norwalk virus and Norwalk-like virus 280
Nose, examination of 468
Nucleolus 18
Nucleus 18, 57, 57f
Null hypothesis 629
testing of 664
Nursing bottle syndrome 471
Nutrient data file 386
Nutrients
deficiencies in 380
manifestations of 381
effects on oral cavity 373t
effects on oral tissues and role in tooth formation 376t
essential, six major classes of 360–377
carbohydrates 360–366
lipids (fats) 369–371
minerals 372–375
proteins 366–369
vitamins 371–372
water 376–377

2119
 overconsumption of 380
role of, in host defense system 388
and specialized cells of oral tissues, effects of 377
Nutrition 360–393
review questions for 390, 393b
web site information and resources for 390b
Nutritional assessment and counseling 380–389
complete 381–382, 382f
daily guide to food choices in 384t
dietary considerations for immunocompromised clients 388–389
dietary modifications for specific dental conditions in 387–388
for malnutrition 380–381
methods for 382–386
techniques for 386–387
Nutritional Screening and Assessment of Dietary Intake
Questionnaire 384, 385f
Nutritive sweeteners 364
Nystatin 287t, 343

O
Oatrim 370
Obesity
carbohydrates in 365
lipids for 371
Oblique ridge 134
Observation methods 256–258
Observational research 628t
Obstructed airway management 692
Obturator 500

2120
Occipital lymph nodes, assessment of 468
Occlusal convergence 139f
Occlusal plane, curves of 143, 144f
Occlusal radiograph(s) 164, 164f
Occlusal tooth surfaces 134, 134f
Occlusal trauma 448
Occlusion 145, 146f
assessment of 471
Occupational exposure report 312b
Occupational Safety and Health Act of 1970 735
Occupational Safety and Health Administration 303, 318
Occurrence 625t
Occurrence-based policy 736
Oculomotor nerve (CN III) 119
Odontoblastic process 38f
Odontoblasts 36f, 377
Odontodysplasia 244, 245f
Odontogenic cysts 223–227
dentigerous 224–225, 225f
follicular 224–225, 225f
keratocyst 223–224
lateral periodontal 223, 224f
mucocele 225–226
necrotizing sialometaplasia 226, 226f
oral soft tissue injuries 225–226
primordial 224
ranula 225, 225f
Odontogenic keratocyst 223–224
Odontogenic myxoma 200–201, 200f

2121
Odontoma 201, 202f
Older adults, special needs of 595–596, 595f
Olestra 370
Olfaction, in extraoral and intraoral assessment 468
Olfactory nerve (CN I) 119
Olfactory sense 80
Oligosaccharides 360
Omohyoid muscle 114
Onset 325
Open bite 146
Open contacts 143
Open provision 718
Operon 262
Ophthalmic nerve 120
Opioid (narcotic) analgesic agents 338–339, 339t
abuse of 353
adverse reactions to 339
drug interactions with 339
pharmacologic effects of 338
therapeutic uses of 339
Opportunistic infections 295
Optic disc 78
Optic nerve (CN II) 119
Oral administration 326
Oral (PO) administration 326
Oral and maxillofacial radiology 152–176
dental x-ray film 157–161
image characteristics of 159–160, 160t
processing 160–161

2122
 digital imaging and 162–163
film mounting 169
film-processing errors and 161–162, 161–162f
general considerations in 152–155
radiation physics 152–154, 153–154f
x-radiation 152, 154–155
quality assurance in 162
radiation biology and 155–157
measurements and sources 156, 156–157f
protection 156–157, 158t, 159f
radiographic errors in 166–169
extraoral technique 167–169, 168f
intraoral technique 166–167, 166–167f
radiographic interpretation in 169–172, 169–172f
review questions for 172, 172b, 173–174f
techniques in 163–166
extraoral radiographic examinations 165–166, 165f
intraoral radiographic 163, 163–165f
website information and resources for 172b
Oral and maxillofacial surgery 387
dietary modifications for 388
Oral cancer 387, 634
brush biopsy for 509–510, 509f
laboratory findings in 510
detection of, diagnostic tools for 509–510
dietary considerations for 388
examination technique for 508–509
high-risk factors of 508
other devices and oral examination for 510

2123
 risk assessment of 508–509
Oral cavity
bacterial genera found in 289t
bacterial plaque 290–291
dental caries 291–292, 291f
immunology and microbiology of 288–295
oral flora, normal 288–290, 289t
opportunistic infections 295
oral flora, development of 290
oral-facial tissue infections 294–295
periapical infections 294–295
periodontal diseases 292–294, 293b
soft tissue of 36–38
classifications of mucosa 38
oral mucosa 36–38
tooth emerging into 47f
Oral contraceptives 340, 350
Oral epithelium, structure of 37f
Oral flora
development of 290
normal 288–290, 289t
Oral health
dietary guidelines for 383
promotion of, and disease prevention and control
ethical, legal, and safety issues in 513
review questions for 514, 515–516b
website information and resources for 513b
Oral health care
challenges in, affecting community oral health practice 677–678

2124
 delivery, trends in, and community oral health practice 677
environment and promotion of infection control 308–318
financing of 670–674
mechanisms of payment in 670–672, 671t
providers of dental benefits plans 672
public 673–674, 673t
infection control and prevention of disease transmission in 300–324,
321b
review questions for 321, 321b
website information and resources for 320b
maintaining asepsis 308–311
pathogenic agents important in 301t
provision of 665–670
dental practice, diverse modes of 665–666, 666t
personnel workforce in 667–670, 668f, 669t
Oral Health in America: A Report of the Surgeon General 621
Oral health surveys 652, 653t
Oral histology See also Histology
supporting tissues
alveolar bone 43–44, 44f
dento-gingival junction 46–47
periodontal ligament 44–46
tooth development 33–36
cytodifferentiation 34–35
dentin formation 35–36
enamel formation 35–36
morphodifferentiation 34
tooth tissues
cemento-enamel junction 43

2125
 cementum 42–43, 42–43f
dentin 38–40
enamel 40–42, 41f
pulp 39–40
Oral hygiene
assessment of 476
indices for 636t
Oral hypoglycemic agents (sulfonylureas) 349
Oral irrigation 500
Oral lesions, benign 193–195 See also Benign oral lesions.
Oral malodor, controlling 499–500
Oral mucosa 36–38, 130f, 131t
Oral pathology 193–255
aphthous ulcers 205–210, 206f
benign intraosseous neoplasms 199–201
benign lesions 193–195
benign mixed tumor 219–220, 220f
blood dyscrasias 227–233
cysts 220–221
developmental 221–223
odontogenic 223–227
dysplasia, fibrous 234–236
endocrine disorders 236–238
gingival fibromatosis 201–203
granulomas 195–199
human immunodeficiency virus (HIV) 233–234
inflammatory tumors 195–199
neoplasia 217–218
pleomorphic adenoma 219–220, 220f

2126
 review questions and answers for 248, 248b, 249–252f, 250b
skin diseases 210–213
soft tissue conditions 246–248
tongue abnormalities 247–248
teeth abnormalities 238–245
ulcerative diseases 203–205
website information and resources for 248b
white lesions 213–217
Oral soft tissue conditions 246–248
mucous membrane abnormalities 246–247
skin abnormalities 246–247
tongue abnormalities 247–248
Oral soft tissue injuries 225–226
Oral structures, clinical 129, 130f, 131t
Oral tissues
clinical examination of 381
specialized cells of, effects of nutrients on 377
Oral trauma, example of 579, 579f
Oral-facial tissue infections 294–295
Organelles 56
Orlistat 379
Oropharyngeal cancers, measures for 648
Oropharynx
assessment of 470
soft palate and 131f
Orthodontic band 501
Orthodontic bracket 501
Orthodontic cements 406
Orthodontic treatment 635

2127
Orthodontic wire 501
Orthodontics, dietary modifications for 388
Orthostatic hypotension 693
Osmosis 58, 58t
membrane transport and 20
Osmotic pressure 20
Osteitis deformans 236
Osteoarthritis 580t
Osteocytes 377
Osteology 107–112
axial skeleton See Axial skeleton
bony depressions 108
bony openings 108
bony prominences 108
cartilage 108
ossification
endochondral 107
intramembranous 107
skeletal articulations 108
Osteoma 199–200, 200f
Osteomalacia 237
Osteonecrosis of the jaw (ONJ) 352
Osteons 63
Outer enamel epithelium (OEE) 34
Outlines, comparison of 139f
Overbite 143, 145f
Overdenture 500
Overgloves 306t
Overhangs 474

2128
 removal of, rationale for 532
Overjet 143, 145f
Oxidases 60
β-Oxidation 370
Oxidation-reduction enzymes 60
Oxidative phosphorylation 362
Oxygen administration 692
Oxytalan fibers 23
Oxytocin 83

P
Pacinian corpuscles 80, 81t
Packaging area 315
Packs, gingival tissue 406
Paget disease 236
Pain
definition of 547
fibromyalgia syndrome in 581
intensity of 548
perception of 547
reaction 547
Pain and anxiety management 547–566
armamentarium for 548–549
cartridge in, anesthetic 549, 549f
needle in 548, 548f
record keeping and documentation in 549
syringe in, anesthetic 549, 549f
Computer-controlled local anesthesia delivery device (CCLADD)
in 556–559, 558t

2129
 Basic CCLADD procedure and 556–558
components of 556
injection administration with 558–559
vs. traditional syringe 558t
local anesthetic agents for 550–553
biotransformation of 550–551
calculations for 552
chemical structure of 550, 551t
comparison of 551t
maximum recommended dose (MRD) for 552
mechanism of action of 550
metabolism of 550–551
potency of 550
topical 552
toxicity of 550
vasoconstrictors 552–553, 552t
nitrous oxide-oxygen in, conscious sedation with 559
advantages and disadvantages of 562
anesthesia stages for 561
chemistry of 559
contraindications to 562
equipment for 562
indications for 562
pharmacology of 561
physiology of 561
record keeping and documentation for 562
safety measures for 562
signs and symptoms of 562
synonymous terms in 559

2130
 pain characteristics and physiology in 547–548, 548f
review questions for 563, 565b
trigeminal nerve, mandibular division of 554–556
block injections for 556, 557t
innervation of 554–555
trigeminal nerve, maxillary division of 554
block injections for 554, 555t, 556f
innervation of 554
website information and resources for 563b
Pain mechanism 511
Pain stimuli 511
Pain-reaction threshold 547
Palatal development 32
Palatal-anterior superior alveolar (P-ASA) nerve block 559
Palate 131t, 131f
cleft 577–578, 578f
papillary hyperplasia 196, 196f
“pipe smokers” 213
Palatine bones 111
Palatine fovea 131t
Palatine processes 111
Palatine raphe 131t
Palatine tonsils 118
Palpation, in extraoral and intraoral assessment 468
Palsy
Bell’s 579, 579f
cerebral 578–579, 578–579f
Pan-American Health Organization (PAHO) 621
Pancreas 367, 370

2131
Pancreatic islets 85
Pancreatic juices 361
Pandemic, definition of 625t
Panoramic radiograph(s) 165, 165f
Papillae 131t
Papillary hyperplasia, palate 196, 196f
Papilloma 193, 194f
Papillomavirus 264t, 275
Paradigm 458
Paranasal sinuses 112
Paraphrasing 482
Paraplegia 583
Parasites 287t
Parasitism 263
Parasympathetic division 29
Parasympathetic ganglia See Terminal ganglia
Parasympathetic nervous system (PANS) 328f, 330
Parasympathomimetic (cholinergic) agents 328f, 330–332
Parathyroid glands 84, 119
Parenteral administration 326
Parietal bones 109, 109f
Parietal membranes 61
Parkinson’s disease 580
Parotid glands, examination of 469
Parotid lymph nodes, assessment of 469
Parotid papilla 131t
Parotid salivary gland 118
Partial anodontia 244, 244f
Partial fetal alcohol syndrome (PFAS) 571

2132
Passive diffusion 361
Passive transport processes 58, 58t
Pastes, prophylactic 408–409
Patella 66, 67f
Pathogens
Bacillus fusiformis 205
Borrelia vincentii 205
Pathology
general 177–192
differential diagnosis of 188–189
genetics of 185–188
inflammation 177–182
regeneration and wound healing of 182–184, 182f
regenerative medicine in 184–185
review questions for 190
website information and resources for 189b
oral 193–255
aphthous ulcers 205–210, 206f
benign intraosseous neoplasms 199–201
benign lesions 193–195
benign mixed tumor 219–220, 220f
blood dyscrasias 227–233
cysts 220–221
developmental cysts 221–223
dysplasia, fibrous 234–236
endocrine disorders 236–238
gingival fibromatosis 201–203
granulomas 195–199
human immunodeficiency virus (HIV) 233–234

2133
 inflammatory tumors 195–199
neoplasia 217–218
odontogenic cysts 223–227
pleomorphic adenoma 219–220, 220f
review questions and answers for 248, 248b, 249–252f, 250b
skin diseases 210–213
soft tissue conditions 246–248
teeth abnormalities 238–245
ulcerative diseases 203–205
website information and resources for 248b
white lesions 213–217
Pathoses 188
Pathways
anesthetic 556–558
metabolic 262
Patient Hygiene Performance (PHP) 636t
“Pavementing” 178
Pectin 361
Pediatric dose 327
Pemphigus vulgaris 212–213, 213f
Penicillins 285t, 340–341
adverse effects of 340
extended-spectrum 340–341
penicillin G 340
penicillin V 340
penicillinase (β-lactamase)-resistant 340
pharmacokinetics of 340
stability of 340
Penicillium 263

2134
Pentoses 360
Pepsin 367
Perception, tactile 129
Perfringens poisoning 277
Periadenitis mucosa necrotica recurrens 206, 206f
Periapex 129
Periapical cemento-osseous dysplasia 236
Periapical cysts 220, 220f
Periapical infections 294–295
Periapical radiograph 164f
Pericardial cavity 55, 56f
Perimylolysis 239
Periodontal diseases 293b
causal and risk factors for 634
and denture use 634
dietary modifications for 365, 366t, 387
identification of the bacterial cause 294b
measures for preventing and controlling 648
and oral and pharyngeal cancers 634
prevalence of 634
indices for 636t
principal bacteria associated with 294b
radiographic appearance of 172, 172f
risk assessment 508
tooth retention and tooth loss in 634
Periodontal file 521–522
Periodontal instrumentation
advanced, techniques in 535–536
for assessment 527–531

2135
 clinical, using periodontal probes 528–530
with dental explorer 530–531
with periodontal probes 527, 527f
probing technique in 527–528
concepts in 531–532
end point of 532
nonsurgical, rationale for 531–532
overhang removal, rationale for 532
preparation of, steps for 532
terminology in 531

2136
ethical, legal, and safety issues in 537
principles of 523–526
activation 525
adaptation 525
angulation 525, 525f
clinician position 523–524, 523f
stabilization 524–525, 524f
strokes 526
review questions for 538, 538–539b, 541–543b
selective stain removal in 536–537
ultrasonic and sonic 532–535
website information and resources for 538b
Periodontal ligament 44–46, 428–429
Periodontal ligament (PDL) injection 559
Periodontal pocket formation 437, 437f
Periodontal probes See also Probe.
assessments with 527, 527f
clinical assessment using 528–530
Periodontics 427–457
assessments for 440–442, 472t, 475
documentation for 440
indices 440
bacterial dental biofilm 438–440
dental implants in 452–453
design of 452
endosseous 452
goals of 453
limiting factors for 452
management of 453

2137
 transosteal 453
types of 452
periodontium changes, disease-associated 436–438
pathogenesis of 436
periodontal pocket formation 437, 437f
stages of 436
periodontium diseases in 430–436
abscesses 433
classification of 430
deformities, acquired 433–436
deformities, developmental 433–436
epidemiology of 434–436
gingival diseases 430–431
necrotizing 432–433
periodontitis, aggressive 431–432
periodontitis, as systemic disease manifestation 432
periodontitis, chronic 431
periodontitis associated with endodontic lesions 433
risks of 434–436
systemic effects of 442
periodontium features in 427–430
alveolar process 429, 429f
anatomy of 428f
blood supply 429–430
cementum 429
gingiva 427–428, 428f
innervation 429–430
lymph 429–430
periodontal ligament 428–429

2138
 radiographic 429, 429f
postoperative care 451–452
client instructions and education 451
follow-up care 451
periodontal maintenance 451–452
review questions for 454
risk factors in 476
treatment 442–451
additional clinical interventions 448–450
care plan, initial 442–443
gingival curettage 448
healing following 450
nonsurgical periodontal therapy 443, 444t
occlusal trauma 448
periodontal dressings and 451
surgical interventions 449–450
sutures and 450–451
website information and resources for 453b
Periodontitis
aggressive 431–432
associated with endodontic lesions 433
chronic 431
as systemic disease manifestation 432
therapy for 480
Periodontium
diseases of 430–436
abscesses 433
classification of 430
deformities, developmental 433–436

2139
 epidemiology of 434–436
gingival 430–431
immunology and microbiology of 292–294
periodontitis, aggressive 431–432
periodontitis, as systemic disease manifestation 432
periodontitis, chronic 431
periodontitis associated with endodontic lesions 433
risks of 434–436
systemic effects of 442
features of 427–430
alveolar process 429, 429f
anatomy of 428f
blood supply 429–430
cementum 429
gingiva 427–428, 428f
innervation 429–430
lymph 429–430
periodontal ligament 428–429
radiographic 429, 429f
Peripheral giant cell granulomas 197, 197f
Peripheral nervous system (PNS) 27
Peritoneum 61
Permanent dentition 134, 136t
development of 142
Pernicious anemia 228
Perpendicular plate 110
Personal protective equipment (PPE) 300, 305
Personal supervision 718
PFAS See Partial fetal alcohol syndrome (PFAS)

2140
Phagocytosis 59, 59t, 92, 267
membrane transport and 20
Pharmacodynamics 325
Pharmacokinetics 327–328
Pharmacology 325–359
analgesics 337, 337t
acetaminophen (n-acetyl-p-aminophenol) 338
general considerations for 337
gout drugs 339
nonsteroidal anti-inflammatory agents (NSAIAs) 338
nonsteroidal anti-inflammatory drugs (NSAIDs) 331t, 338
opioid (narcotic) 338–339, 339t
salicylates (aspirin) 337
antiarrhythmics 344–347
antianginal agents 344
anticoagulants 344–345
anticonvulsants 346–347, 346t
antihypertensives 344, 345t
diuretics 344
anti-infectives 339–343
aminoglycosides 342
antifungal agents 343
antituberculosis agents 343
antiviral agents 343
cephalosporins 341
clindamycin 341
general considerations for 339–340
macrolides 341
metronidazole 342–343

2141
 penicillins 340–341
quinolones 342
sulfonamides 342
tetracyclines 341–342
antineoplastic agents 352–353
autonomic nervous system agents 328–334
α-adrenergic blocker 329–330
β-adrenergic blocker antagonist 330
adrenergic neuronal agonists and antagonists 330
local anesthetic agents 332–334, 332f, 334t
parasympathomimetic (cholinergic) 328f, 330–332
sympathetic (adrenergic) 328–329, 328f, 329t
xerostomia-producing drug groups in 331t
cardiovascular agents 343
digitalis glycosides 343
drug use during pregnancy and 353–354
endocrine agents 348–350
adrenocorticosteroids 348, 348t
agents for diabetes mellitus 348–349
estrogens and progesterone 350
oral contraceptives 350
thyroid agents 349–350
gastrointestinal agents 351–352
affecting gastrointestinal motility 351
emetics and antiemetics 351–352
histamine (H2-) blockers 351
proton pump inhibitors 351
general anesthetics 334–335
anesthesia stages and planes in 334

2142
 specific agents 334–335
general considerations for 325–328
adverse reactions 327–328
agencies 325
definitions 325
drug action in 325–327
legislations 325, 326t
nomenclature 325, 326t
local anesthetic reversal agent 334
in nitrous oxide-oxygen conscious sedation 561
psychotherapeutic agents 347–348
antidepressants 347–348
antipsychotics 347, 347t
respiratory system agents 350–351
for asthma 350–351
review questions for 355, 355–357b, 359b
sedative-hypnotic medications 335–339, 335b
barbiturates 336
benzodiazepines 335–336, 336t
general considerations for 335
nonbarbiturate nonbenzodiazepines 336–337
smoking cessation and 354
substance abuse 353
definitions 353
drugs 353
website information and resources for 354b
Pharmacotherapy 325
Pharmacy 325
Pharyngeal cancers 634

2143
Pharyngeal tonsils 118, 131t
Pharyngitis, aphthous 209–210, 210f
Pharyngopalatine arch 131t
Pharynx 97
Phase-contrast microscopy 257
Phencyclidine (PCP) 353
Phenylephrine (Neo-Synephrine) 329t
Phenylketonuria (PKU) 369
Phenytoin (Dilantin) 346
Philtrum 131t
Phospholipids 369
Phosphorylating enzymes 60
Photoelectric effect 154
Physical dependence 353
Physical properties 395
Physical Status Classification System 465t
Physiology, of pain 547–548, 548f
Physostigmine (Eserine) 330
Phytic acid 364
Pia mater 76, 76f
PICO mnemonic 479, 479t
Picornaviruses 264t
Pie graph 662
Piercing, oral 470
Pigmentation, melanin 129, 246, 246f
Pilot study 629
Pineal gland 83
“Pink tooth” 199
Pinocytosis 59, 59t

2144
 membrane transport and 20
Pinworm 287t
Pioglitazone (Actos) 349
“Pipe smoker ’s palate” 213
Piperazine 287t
Pit 134
Pit-and-fissure caries 471
Pit-and-fissure sealants 402–403
Pituitary gland 82–83
Placenta 85
Plaintiff 712
Planes, anatomic 53, 55f, 107, 108f
Planning and practice strategies
basic concepts of 619–623
access 620
community 620
community health 620
dental public health 619
health determinants 619
national documents 621
oral health 619
prevention 620
private vs. community health 620, 620t
public health 619
challenges affecting 677–678
community intervention in 650–661, 650f
assessment and problem identification in 650–654, 651t, 653t
health education and health promotion in 654–658, 655t, 657t
implementation in 654

2145
 methods of oral health education in 658–660
planning in 654
role of dental hygienist in 650
strategies in 650
surveillance in 650
epidemiology 623–626
characteristics of 624, 625f
concepts in 625t
definitions of 623, 624b
measurement concepts in 625t
measurement of diseases and conditions in 640–641
of oral diseases and conditions 629–640, 630t, 631f, 632t
and research 626–629, 628t
uses of 624, 624b
financing oral health care in 670–674
mechanisms of payment 670–672, 671t
providers of dental benefits plans in 672
public 673–674, 673t
preventing and controlling oral diseases in 641–650
measures for dental caries 641–648, 642t, 644–645b
measures for other oral diseases and anomalies 648–650
measures for periodontal disease 648
public health measures in 641
in process of care 479–481, 480t
program evaluation in 661–665
general principles of 661
of professional literature 665, 665b
statistics in 661–664, 662b, 663f
provision of oral health care in 665–670

2146
 dental practice, diverse modes of 665–666, 666t
personnel workforce in 667–670, 668f, 669t
utilization of dental services in 674–677, 675t
patterns of, shifts in 676–677
Plant alkaloids 352
Plant viruses 264
Plaque 581
accumulation, scattered 581
and gingival indices 494
Plaque Index (PII) 636t
Plasma 55, 57f, 115
Plasma membrane 17
Plasma proteins 180
Plasma-derived mediators 179
Platelet adhesiveness 337
Platelet-activating factor (PAF) 179t
Platelets 86, 115
Plato 707
Pleomorphic adenoma 219–220, 220f
Pleura 61
Pleural cavity 55, 56f
Plexus 115
Plica fimbriata 131t
Plummer-Vinson syndrome 228–229, 229f
Pneumococcal pneumonia 275
Pneumocystis 263
Pneumonia
mycoplasmal 276
pneumococcal 275

2147
Pockets, periodontal 437, 437f
Point angle 134
Poisoning 698
Policy, classifications of 736
Policy development, as function of public health 620
Polishing
adverse effects of 536
contraindications to 536
Polyarthritis 580
Polycythemia 230
characteristics of 230
primary 230
relative 230
secondary 230
vera 230
Polygon 662
frequency 662
Polymerase chain reaction (PCR) 187
Polymorphonuclear leukocyte (PMN) 177
Polyoma-papilloma 264t
Polyostotic fibrous dysplasia 235
Polyps, pulp 198, 198f
Pons 77, 77f
pneumotaxic center in 96
Pontic 500
Population at risk 625t, 628t
Porcelain-fused-to-metal (PFM) alloys 413–414 See also Alloys.
Position
anatomical 107

2148
 of clinician 523–524, 523f
Position-indicating device (PID), alignment problems 166, 167f
Positive hypothesis 629
Posterior superior alveolar (PSA) nerve 120t, 121, 554
Postnatal chromosome analysis 187
Postoperative care 451–452
Postsyncope stage 693
Posttest only 628
Postural hypertension 693
Potency 326, 327f, 550
Potential osmotic pressure 58
Power interdental cleaning devices 498
Power toothbrushes 495
Power-driven polisher 537
Poxviruses 264t
Practicing without a license 725
Pralidoxime (2-PAM/Protopam) 331
Praziquantel 287t
Predation 263
Predictive value 625t
Prefixes 743 See also Medical terminology.
Pregnancy 387
drug use during 353–354
Pregnancy Discrimination Act (PDA) of 1978 735
Preliminary diagnosis 189
Premolars 135, 136t
Prenatal chromosome analysis 187
Pressure receptors 81t
Presyncope stage 693

2149
Pretest/posttest 628
Prevalence 625t
Prevention 655
Preventive and restorative materials See also Biomaterials.
direct 399–409
amalgam, dental 399–401, 399–400f
bonding agents 403–405, 403–404f
cement applications 406
cement bases 405–406, 405f
cement liners 405
cements, orthodontic 406
composites, dental 401–402, 401f
dentifrices 408–409
dressings, surgical 406
fluoride varnishes 407–408
fluoride-releasing restorative materials 406–407, 406f, 408f
fluorides, topical 407–408
gingival tissue packs 406
infiltrants 403
pastes, prophylactic 408–409
sealants, pit-and-fissure 402–403
sealers, root canal 406
whitening agents 409
indirect
alloys, casting 412–413
alloys, chromium 413
alloys, porcelain-fused-to-metal 413–414
appliances, acrylic 415–416
athletic mouthguards 417

2150
 cast materials 411–412
cements, crown-and-bridge 415, 415t
ceramics, dental 414–415
denture bases, acrylic 416
denture cleansers 417
denture soft liners 417
denture teeth 416
die materials 411–412, 411t
implants, dental 418–419
impression materials 409–410, 410t
investment materials 412
materials 409–420
model materials 411–412
mouth protectors 417
provisional materials 410–411
restorations, computer-assisted design/computer-assisted
machining 418
solders, dental 413
tissue engineering 419–420
veneers 417–418
waxes 412
Preventive care planning 490
Prilocaine 332–333
Primaquine 287t
Primary anemia 228
Primary aplastic anemia 229
Primary deficiency 380
Primary dentition 141
development of 142

2151
Primary herpetic gingivostomatitis 207–208, 207f, 284f
Primary polycythemia 230
Primary radiation 154
Primary teeth 141f, 143f
Primordial cyst 224
Principal fiber groups 45
Principalism 707
Prion 256
Priority population 629
Privacy 751–752
Privacy standards 733
Private vs. community health 620, 620t
Privilege 714
Probability level (p value) 664
Probe 520
markings, examples of 520t
periodontal
assessments with 527, 527f
clinical assessment using 528–530
Probenecid (Benemid) 337, 339
Probing
bleeding on 528
periodontal 475
technique in 527–528
Probiotics 647
Problem identification, in community intervention 650–654, 651t, 653t
Process of care 458–489
algorithm for 459f
assessments in

2152
 of dentition 471–474, 474b
extraoral 468–471
human needs theory and 458, 460–461f
intraoral 468–471
oral hygiene 476
periodontal 472t, 475
radiographic evaluation for 475–476
risk factor 476–477
case presentation and 481
communication and 482
concepts of 458–459
dental hygiene paradigm and 458
diagnosis in 469f, 478, 478f
documentation and 483–484
ethical issues of 484
evaluation and 482–483
evidence-based decision making in 479
health history in 459
blood pressure classification in 466t
evaluation of 459–468
form for 459
glycemic management in 467b
information 463–468
Physical Status Classification System for 465t
screening questions for 460–463, 462f, 463t
implementation in 481–482
informed consent and 481
legal issues of 484
planning in 479–481, 480t

2153
 prognosis in 478–479
review questions for 486, 486–487b
safety issues of 484
as standard of practice 458
website information and resources for 484b
Processing, of DNA 61
Professional associations, state board of dentistry and 3
Professional ethics 707
Professional literature, evaluation of 665, 665b
Professional organizations, of interest, to dental hygienists 746–747
Professional risk management 736
Professionalism 708–709, 751–753
Progesterone 350
Prognosis, process of care and 478–479
Program evaluation 661–665
general principles in 661
of professional literature 665, 665b
statistics in 661–664, 662b, 663f
Progressive irreversible brain disorder 574
Prokaryotes 256, 260t
Prokaryotic function 258–259
Proliferation 183
Properties, biomaterials 395–398 See also Biomaterials.
Prophase, of mitosis 21
Prophylactic pastes 408–409
Proprietary (trade) name 325
Proprioceptive sensations 80
Prospective 625t
Prostaglandins 82, 179t

2154
Prostate gland 101
Prostheses, fixed and removable, care of 500–502
Prosthetic appliances 474
Prosthodontics, dietary modifications for 388
Protease inhibitors (PIs) 272
Proteases 179t
Protected health information (PHI) 733
Protective (barrier) clothing 307
Protective eyewear 307
Protectors, mouth 417
Protein digestibility-corrected amino acid score (PDCAAS) 367
Protein efficiency ratio (PER) 367
Proteins 366–369
binding of 327
classifications of 366
biologic 367
chemical 366
structure 367
complementary 367
complete 367
compound 366
definition of 366
dietary modifications for disease 369
digestion of 367
as energy source 378
functions of 368
incomplete 367
metabolic regulation and 368
metabolism of 367

2155
 quality of 367
requirements for 369
simple 366
synthesis of 18, 262
Proteus spp. 266t
Protozoa 256
Protrusion 147
Provider, contractual responsibilities of 713
Provision, of oral health care 665–670
dental practice, diverse modes of 665–666, 666t
personnel workforce in 667–670, 668f, 669t
Provisional materials 410–411
Proximal, as directional term 107
Proximal tooth surfaces 134
Pseudocysts 226–227
aneurysmal 226
hemorrhagic 226
lingual mandibular bone concavity 226–227, 227f
simple 226
Stafne 226–227, 227f
static 226–227, 227f
traumatic 226, 227f
Pseudoephedrine (Sudafed) 329t
Pseudomonas aeruginosa 266t
infections 273
Psilocybin 353
Psittacosis 285t
Psychedelics 353
Psychological dependence 353

2156
Psychological disorders, questions regarding 467
Psychotherapeutic agents 347–348
antidepressants 347–348
antipsychotics 347, 347t
Pterygomandibular raphe 131t
Pterygopalatine nerves 554
Public financing 673–674, 673t
Public health 619
core functions of 620
governmental levels of 621, 621b
measures for 641
Public Health Service (PHS) 621b
Public health solution 620, 620b
Public policy 709–710
Publicity of private life 714
Pulp 129
polyp 198, 198f
tissue 39–40
dentin and 40
Pulpal granulomas 198
Pulpal vitality testing 474
devices 512–513
laser Doppler flowmetry in 512
thermal testing in 512–513
traditional electrical testing devices in 512
Pulse 689–690, 690f
Pumping 59t
Punitive damages 713
Pupil 78

2157
Purine antagonists 352
Purposive sample 630t
Purpura 232–233
characteristics of 232
nonthrombocytopenic 233
thrombocytopenic 232
Pyogenic granuloma 195–196, 196f See also Granulomas.
Pyrazinamide 285t
Pyrimethamine 287t
Pyrimidine antagonists 352

Q
Quadriplegia 583
Quality assurance 162
Quasi-experimental research 628t
Quaternaries, dual or synergized 310t
Questionnaires, health history information from 467
Questions, health history 460–463, 463t
Quid pro quo 734
Quinacrine 287t
Quinolones 342

R
Radiation biology 155–157
measurements and sources 156, 156–157f
protection 156–157, 159f
Radiation physics 152–154, 153–154f
Radicular cysts 220f, 220 See also Cysts.
Radiographic features, of periodontium 429, 429f

2158
Radiography
history information from 463
process of care and 475–476
Radiology 152–176
dental x-ray film 157–161
image characteristics of 159–160, 160t
processing 160–161
digital imaging and 162–163
film mounting 169
film-processing errors and 161–162, 161–162f
general considerations in 152–155
radiation physics 152–154, 153–154f
x-radiation 152, 154–155
quality assurance in 162
radiation biology and 155–157
measurements and sources 156, 156–157f
protection 156–157, 158t, 159f
radiographic errors in 166–169
extraoral technique 167–169, 168f
intraoral technique 166–167, 166–167f
radiographic interpretation in 169–172, 169–172f
review questions for 172, 172b, 173–174f
techniques in 163–166
extraoral radiographic examinations 165–166, 165f
intraoral radiographic 163, 163–165f
website information and resources for 172b
Radiolucent 160
Radiopaque 160
Radius 65, 66f

2159
Rainbow® Stabilizing System 609f
Raltegravir 272
Rampant caries 471
Ramus 112
Rancidity 369
Random sample 630t
stratified 630t
systematic 630t
Ranula 225, 225f
Rapid-acting insulin 349
Rate 625t
Ratio 625t
Reactive hypoglycemia 366
Reactive oxygen species 179t
Recaldent 647
Receptor placement 166, 166f
Receptors 328
Recessive inheritance
autosomal 186
X-linked 186
Reciprocity 715
Recombinant DNA 187
Recommended Dietary Allowance (RDA) 382
Record keeping requirements 728–733
electronic 728
purpose of 728
written 728
Rectal administration 326
Recurrent aphthous stomatitis 205–206

2160
Recurrent caries 471
Recurrent scarifying ulcerative stomatitis (RSUS) 206, 206f
Recurrent ulcerative stomatitis (RUS) 205–206
Redistribution 327
Reduced penetrance 186
Reevaluation 483
Reflective responding 482
Reflex arc 77
Refractory period 548
absolute 76
Regeneration and wound healing 182–184, 182f
Regenerative medicine 184–185
Regional Clinical Board Examinations, preparing for 12–13
Relative polycythemia 230
Relative refractory period 548
Release 714
Reliability 625t
Removable-prosthesis maintenance 501
Reoviruses 264t
Repair process 182
Replication, of cell 21–31
Repolarization 548
Reporting professional violations 725
Reproduction, of cells 16
Reproductive system 101–103
female 102–103
infections 281–284, 281f
male 101–102
Res ipsa loquitur 713

2161
Res judicata 711
Research 626
community oral health 627
and epidemiology 626–629, 628t
experimental 627
Research hypothesis 629
Resident flora 304
Resistance 340
Resorption, internal 198–199, 199f
Respect 482
Respiration rate 690
Respiratory arrest 691
Respiratory disease, questions regarding 466
Respiratory system 93–96, 93f
agents 350–351
infections 276t
lower 275–277
upper 275
lower respiratory tract 94
physiology of 94–96
upper respiratory tract 94
Responsibility, principle of 749
Responsiveness 482
Resting membrane potential 76
Resting nerve cell membrane 547
Restorations 474
biomaterials for, computer-assisted design/computer-assisted
machining 418
dental hygienist duties for 718, 730t

2162
Reticular activating system 78
Reticular formation 77
Reticulin fibers 23
Retina 78
Retinitis pigmentosa 576
Retrolental fibroplasia 576
Retromolar area 131t
Retromolar triangle 112
Retrospective 625t
Retrovirus 264t
Retrusion 147
Reversal, definition of 625t
Reversed film 167, 167f
Reversed polarity 548
Reversible index 640
Reye syndrome 337
Rheumatic fever 280
Rheumatoid arthritis 580t
Rhinovirus 276t
Rhizopus 263
Ribavirin 287t
Ribonucleic acid (RNA) analysis 187
Ribosomal RNA (rRNA) 18
Ribosomes 18f, 56, 57f
Ribs 65
Rickets 237
Ridge 134
Rifampin 285t
Ringworm infections 273

2163
Risk, vs. causality 627, 628t
Risk factors
assessment of 476–477, 736
for caries 476, 477t
definition of 476
management 736
for oral and pharyngeal cancer 476
for periodontium disease 434–436
for systemic disease 476
Root canal sealers 406
Root caries 474
Root-end cysts 220f, 220 See also Cysts.
Roots
advanced instrumentation for 523
characteristics of 136t, 140, 140f
furcation 129
morphology 129–151
Rotavirus 280
Roundworm 287t
RSUS See Recurrent scarifying ulcerative stomatitis (RSUS)
Ruffini’s corpuscles 80, 81t
Rugae 131t
Rule deontology 707
Rule utilitarianism 707
RUS See Recurrent ulcerative stomatitis (RUS)

S
S. mutans 364
Sac fungi 263

2164
Saccharomyces 263
Safety issues, of process of care 484
Sagittal plane 55, 55f, 107, 108f
Salicylates 337
Salicylism 337
Salivart 331
Salivary amylase (ptyalin) 361
Salivary duct openings 131t
Salmonella spp. 266t
Salmonellosis 277
Salt 332f
Salutatory conduction 76
Sample 629
Sample size 629
Sampling 630t
Saquinavir 287t
Sarcomastigophora 264
Saturated fatty acids 369
Scaler, sickle 521, 521f
Scar formation 183
Scatter radiation 154
Scattergram 663
Schaeffer-Fulton spore stain 258
Schedules I-V 326t
School setting, health education and health promotion in 661
Scientific method 626, 627f
Sclera 78
Scleroderma 581
Scope of practice 718

2165
Screening questions 463t
Sealants 402–403 See also Biomaterials.
Sebaceous glands 62
Second messenger mechanism 82
Secondary aplastic anemia 229
Secondary deficiency 380
Secondary radiation 154
Secondary union 183
Sedation, conscious See Conscious sedation
Sedative-hypnotic medications 335–339, 335b
barbiturates 336
benzodiazepines as 335–336, 336t
general considerations for 335
nonbarbiturate nonbenzodiazepines 336–337
Seizure disorders 575–576, 576f
Selective polishing 481
Selective serotonin reuptake inhibitors (SSRIs) 348
Selective stain removal 536–537
Self-applied fluorides 504
Self-defense 714
Self-disclosure 482
Sensation 78
Senses, special 78–80
Sensitivity 625t
Sensorineural hearing loss 577
Sensory neurons 75, 119, 547, 548f
Sepsis 181
Septic shock 694
Serotonergic drugs, for weight loss 379

2166
Serotonin 179t
Serotonin and norepinephrine reuptake inhibitors 348
Serotonin modulators 348
Serous membranes 61
Serum amyloid A protein (SAA) 181
SES See Socioeconomic status (SES)
Sexual harassment 734
Shank 518, 519f
Sharpening, of hand-activated instruments 532, 533t
Sharpey’s fibers 46
Sharpness 160, 160t
Shigella spp. 266t
Shigellosis 277
Shingles 208–209, 209f, 275
Shock 693–694
Short-acting drugs
barbiturates 336
insulin 349
Short-chain fatty acids 370
Shunts, types of 584f
Sialometaplasia, necrotizing 226, 226f
Sibutramine (Meridia) 379
Sickle cell
anemia 227–228, 227–228f
disease 588
trait 588
Sickle scaler 521, 521f
Side effects 327
Signatures, genetic 187

2167
Simple bone cyst 226 See also Cysts.
Simple diffusion 58, 58t
Simple shank 518
Simplesse 370
Simplified Oral Hygiene Index (OHI-S) 636t
Single-food (monotonous) diet 379
Single-gene disorders 186
Single-tufted brushes 495
Sinuses, paranasal 112
SIRS See Systemic inflammatory response syndrome (SIRS)
Situational ethics 707
Skeletal articulations 108
Skeletal (striated) muscle 30
Skeletal system 62–68, 62f
bone, microscopic structure of 63
bone marrow 63–64
bone tissue 63
divisions of 64–66
appendicular 65–66
axial 64–65
joints 67–68
regulation of blood calcium level in 64
Skeleton, axial See Axial skeleton
Skewed distribution 663, 663f
Skin 61
color 61
diseases of 210–213
Behçet syndrome 212, 212f
characteristics of 210

2168
 erythema multiforme 210–211, 211f
pemphigus vulgaris 212–213, 213f
Stevens-Johnson syndrome 211–212, 211f
examination of 468
infection of 273–275
Skinfold thickness measurements 381
Slander 714
SLE See Systemic lupus erythematosus (SLE)
Small intestine, in digestion
of lipids 370
of proteins 367
Smooth muscle 30
stimulation 330
Smooth surface caries 474
Societal trust 749
Socioeconomic status (SES) 625t
Sodium bicarbonate 647
Soft liners, denture 417
Soft palate 131f, 131t See also Palate.
examination of 470
Soft tissue
conditions 246–248
mucous membrane abnormalities 246–247
skin abnormalities 246–247
tongue abnormalities 247–248
injuries 225–226
origins, benign lesions 193–195
Solders, dental 413
Solubility 327

2169
Somatic reflex 77
Somatic sensory receptors, classification of 81t
Somatic stem cells 185
Sonic instruments 533
Southern Regional Testing Agency, Inc. (SRTA) 2b
Spastic-type cerebral palsy 578f
Special Care Dentistry Association 747
Special care needs
dental hygiene care for clients with 567–618
dental hygienist and individuals with 568
dental management considerations for 596, 597t, 608–610f
general definitions of 568
incidence and prevalence of individuals with 567, 568t
life span approach to care for 567, 568t
normalization goals for persons with 568–569
potential barriers to oral health care 569–570
review questions for 610, 614–615f, 617f
specific conditions 570–596
alcohol abuse and dependence, chronic 594
alcohol-related neurodevelopmental disorders 571
Alzheimer ’s disease 574–575
arrhythmias, cardiac 586
arthritis 580–581, 580t
asthma, bronchial 585
attention deficit hyperactivity disorder 573
autism spectrum disorders 572–573
Bell’s palsy 579, 579f
cancer 588–589, 589f
cerebral palsy 578–579, 578–579f

2170
cerebrovascular accident 587–588, 588t
chemical dependency 592–594
chronic obstructive pulmonary disease 585
cleft lip or palate 577–578, 578f
congenital heart disease 585–586
congestive heart failure 587
coronary heart disease 586–587
cystic fibrosis 584–585
developmental and cognitive challenges 570, 570–571f
diabetes mellitus 590–592, 591t, 592f
Down syndrome 571–572, 572f
dysrhythmias, cardiac 586
eating disorders 574
emotional disturbance 573
end-stage renal disease 594–595
fetal alcohol spectrum disorders 571, 571f
fetal alcohol syndrome 571
fibromyalgia syndrome 581
hearing impairment 576–577, 577t
hemophilias 590
hypertensive disease 586
ischemic heart disease 586–587
leukemia 589–590, 590f
mental illness 573
multiple sclerosis 581–582, 582t
muscular dystrophies 582, 582t
myasthenia gravis 579–580
older adults 595–596, 595f
Parkinson’s disease 580

2171
 partial fetal alcohol syndrome 571
scleroderma 581
seizure disorders 575–576, 576f
sickle cell disease 588
spina bifida 583–584, 584f
spinal cord injuries 582–583, 583–584t
stroke 587–588, 588t
thyroid disease 592, 592t, 593f
visual impairment 576
website information and resources for 610b
Special damages 713
Special senses 78–80
equilibrium 79, 79f
eye, components of 78, 79f
hearing 79, 79f
olfactory sense 80
proprioceptive sensations 80
tactile sensation 80, 81t
tongue 80
Specific immunity 92–93
Specific receptor theory 332
Specificity 625t
Specimen preparation 257
Sperm 101
Spina bifida 583–584, 584f
Spina bifida occulta 583
Spinal cord 74, 76–77, 76f
cross section of 27f
Spinal cord injuries 582–583, 583–584t

2172
Spinal nerves 77
Spinal reflexes 77
Spirillum 258
Split-mouth 628
Spoken defamation 714
Sporothrix 263
Spots, radiographs with 162, 162f
Squamous cell carcinoma 217–218, 218–219f
SRTA See Southern Regional Testing Agency, Inc. (SRTA)
Stabilization, during instrumentation 524–525, 524f
Stafne bone cyst 226–227, 227f
Stain
assessment of 474
removal of, selective 536–537
Staining 257, 257t
Standard of care 713
Standard precautions 301
Standards 482
Staphylococcal food poisoning 277
Staphylococcal infections 273
Staphylococcus aureus 266t, 285t
Starch 360
Stare decisis 711
State boards of dentistry 2–4
State Clinical Board Examinations, preparing for 12–13
State courts 712
State dental hygiene committee 718, 732b
State practice act, dental hygiene licensure and 1
State supreme court 712

2173
Static bone cyst 226–227, 227f
Static electricity artifacts 162, 162f
Stationary relationships 143
Statistical significance 664
Statistics 661–664, 662b, 663f
clinical significance of 664
correlation 662
data in 661
descriptive 662
distributions of data in 663, 663f
errors in 664, 664f
hypothesis testing in 664
inferential 663
scales of measurement in 661
summary presentation of 662
Status 625t
Status epilepticus 575, 700
Statute of limitations 713–714
Statutory law 711
Stavudine (d4T) 272
Stellate reticulum (STR) 35
Stem cells
adult 185
types of 185t
Sterile (surgical) gloves 306t
Sterilization 301, 315
failure 317
methods 315
verification of 317

2174
Sterilization area procedures 315
Sterilizing chemicals 309t
Sternocleidomastoid muscle 113
Sternohyoid muscle 114
Sternothyroid muscle 114
Steroid hormones 80, 363
mechanism of action 82
Steroids 370
adrenocorticosteroids 348, 348t
Sterols 263, 370
Stevens-Johnson syndrome 211–212, 211f
Stimulants 353
Stimulus 547
Stomach, in digestion
of carbohydrates 361
of lipids 370
of proteins 367
Stomatitis 381
gingivostomatitis, primary herpetic 207–208, 207f
nicotine 213–214, 214f
recurrent
aphthous 205–206
ulcerative (RUS) 205–206
Storage area 315
Stratified random sample 630t
Stratum intermedium (STI) 35
Streptococcal infections 273
Streptococcus mutans 266t
Streptococcus pneumoniae 266, 266t

2175
Streptococcus pyogenes 266t
Streptococcus viridans 266t
Streptomycin 285t
Stress, reduction protocols for 465t
Stroke 587–588, 588t
Structures, oral, clinical 129, 130f, 131t
Styloglossus muscle 114
Stylohyoid muscle 114
Subcrestal pocket 437
Subcutaneous (SC, SQ) administration 326
Sublingual administration 327
Sublingual caruncle 131t
Sublingual folds 131t
Sublingual salivary gland 118
Submandibular glands, examination of 469
Submandibular salivary gland 118
Submental glands, examination of 469
Substance abuse 353
Successional lamina 35
Sucrase 361
Sucrose 360
Sudden cardiac death (SCD) 696
Sudoriferous glands 62
Suffixes 743–744 See also Medical terminology.
Sugar, analysis and evaluation of 386
Sugar alcohols 365
Sulcus Bleeding Index (SBI) 636t
Sulfonamides ("sulfa" drugs) 342
Summation 76

2176
Sunset laws 725
Superficial structures 107
Supernumerary teeth 244–245, 245f
Supervised neglect 482
Supervision 718
Supplemental groove 134
Supporting tissues
alveolar bone 43–44, 44f
dento-gingival junction 46–47
periodontal ligament 44–46
Supportive therapy 482
Supra-alveolar pocket 437
Supracrestal pocket 437
Suprainfection 340
Supreme Court 712
Surface disinfection, chemical agents for 310t
Surface epithelia 22
Surfaces, of tooth 134
Surfactant 310
Surgical dressings 406
Surgical therapy 379
Surround® Toothbrush 610f
Surveillance 624
in community intervention 650
Sutton disease 206, 206f
Sutures 450–451
Symbiosis 263
Sympathetic agents 328–329, 328f
adverse reactions of 328

2177
 drug interactions of 329
pharmacologic effects of 328
therapeutic uses of 329
as vasoconstrictors 329
Sympathetic autonomic nervous system (SANS) 328–329
Sympathetic division 29
Sympathetic ganglia 78
Sympathetic nerves 28f
Sympathomimetic amine 552
Symphysis 112
Synapse, definition of 30
Synaptic transmission 76
Syncope 692–693
Syncope stage 693
Synergism 80
Synovial joints 67, 70f
Synovial membranes 61
Synthesis, in cells 16, 18
Synthetic phenolics 310t
Syntrophism 263
Syphilis 282, 282f
congenital 283f
primary, chancre lesion of 283f
Syringe
anesthetic 549, 549f
traditional, vs. CCLADD 558t
Systematic random sample 630t
Systemic disease, risk factor for 476
Systemic inflammatory response syndrome (SIRS) 181

2178
Systemic lupus erythematosus (SLE) 214–215, 215f
Systems, body 61–103

T
Tachycardias 586
Tactile perception 129
Tactile sensation 80, 81t
Target population 629
Tattoo, amalgam 246, 246f
TB See Tuberculosis (TB)
Teeth See Tooth
Teleologic ethics 707
Telodendria 75f
Telophase, of mitosis 21
Temperature, body 689
Temporal bones 109
Temporalis muscle, assessment of 468
Temporomandibular joint (TMJ) 114–115, 114f
assessment of 468
Temporomandibular joint disease 635
Ten Great Public Health Achievements-United States, Twentieth
century 641b
Tenericutes 263
Tentative diagnosis 189
Teratogenic effect 327
Terbinafine 287t
Terminal ganglia 78
Terminology, medical 743–745
body part designations 745

2179
 combining forms 744–745
prefixes 743
suffixes 743–744
Tetanus 273
Tetracaine 333
Tetracycline 285t
Tetracycline stain 240
Thalamus 78
Thalassemia 229–230
Therapeutic index (TI) 325
Therapeutic polishing 481
Thermal properties 395, 395f
Thermal testing 512–513
Thermic effect of food (TEF) 378
Thiabendazole 287t
Thiazolidinediones 349
Thin tissue layers 61
Thirst response 377
Thoracic (chest) cavity 55, 56f
Thoracic lesion levels, functional significance of 584t
Three As (analgesic/antipyretic/anti-inflammatory) 337
Thrombocytopenic purpura 232
Thymus gland 85, 119
Thyroglossal tract/duct cysts 222, 222f
Thyrohyoid muscle 114
Thyroid agents 349–350
Thyroid crisis 329
Thyroid disease 592, 592t, 593f
Thyroid gland 83–84, 119, 119f

2180
 assessment of 469
Thyroid storm 329, 348
Thyroxine 363
TIAs See Transient ischemic attacks (TIAs)
Tibia 66, 67f
Ticarcillin (Ticar) 285t
Tight junctions, in cells 16
Time-series 628
Tiotropium bromide (Spiriva) 351
Tip
frequency 534
instrument, design for 533
interdental 498
Tissue fluid, tissue components 21
Tissue hormones See Prostaglandins
Tissues 21–31, 61
binding to 327
and body membranes 62
connective 22–26, 62
membranes 61
engineering 419–420
epithelial 22
muscle 30–31
nerve 27–30
components of 29–30
packs, gingival 406
remodeling 183
tooth 38–43
Title VII of the Civil Rights Act of 1964 734

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TMJ See Temporomandibular joint (TMJ)
TNF See Tumor necrosis factor (TNF)
Tobacco cessation interventions 507–508
Tobacco use interventions 507–508
Tolerance 326
Toluidine blue-O staining 258
Tomes’ process, enamel formation and 36
Tongue 80, 97
abnormalities of 247–248
benign migratory glossitis 247, 247f
black hairy tongue 248, 248f
erythema migrans 247, 247f
geographic tongue 247, 247f
anatomy of 130f, 131t
development of 32–33
examination of 470
muscles of 114
surfaces of 107
Tonsillar recess 131t
Tonsillar region 131t, 131f
Tonsils 117–118, 131t
Tooth
anatomy, radiographic 169, 169f
anomalies 571f
classes of 135
development of 33–36, 34f
cytodifferentiation 34–35
dentin formation 35–36
enamel formation 35–36

2182
 morphodifferentiation 34
sequential cellular interactions in 35
form 139, 140f
considerations for 140
loss 634
measures for 649
parts of 129
retention 634
surfaces of 134
tissues of 34f
cemento-enamel junction 43
cementum 42–43, 42–43f
dentin 38–40
enamel 40–42, 41f
pulp 39–40
trauma 635
Tooth abnormalities 238–245
developmental defects 240–241
amelogenesis imperfecta 240–241, 240–241f
anodontia 244
concrescence 242, 243f
dens evaginatus 243, 244f
dens in dente 242–243, 243–244f
dens invaginatus 242–243, 243–244f
dentinogenesis imperfecta 241, 241f
dilaceration 241, 242f
fusion 242, 242f
gemination 242, 243f
hypodontia 244, 244f

2183
 macrodontia 245
microdontia 245, 246f
natal teeth 244
supernumerary teeth 244–245, 245f
tooth numbers 244–245
of tooth shape 241–244
of tooth size 245
drug-induced 239–240
methamphetamine abuse and addiction 239–240
tetracycline stain 240
tooth structure loss 238–239
abfraction 239
abrasion 238–239, 239f
attrition 238, 239f
erosion 239, 240f
Toothbrushes
maintenance of 496
manual 494
power 495
Toothbrushing
effectiveness, factors in 495–496
improper 496
manual, methods of 494–495
Toothpicks 498
Topical administration 326
Topical anesthetic 552
Topical fluorides 407–408 See also Fluorides.
Tort 712
Tort law 713

2184
Torus mandibularis 201, 201f
Torus palatinus 201, 201f
Total body water 376
Touch receptors 81t
Toxic overdoses 698
Toxic reaction 327
Toxic shock syndrome (TSS) 283
Toxicity 550
Toxicology 325
Toxoplasma gondii 287t
Trade (proprietary) name 325
Traditional electrical testing devices 512
Transamination 368
Transcription 60, 262
Transduction 263
Transfer
disease 265–287
energy storage and 262
Transfer RNA (tRNA) 18
Transformation 263
Transient flora 304
Transient ischemic attacks (TIAs) 699
Transitional dentition 142
Translation 60
Transmission, of disease 300–302
Transmission electron microscope 258
Transmission-based precautions 301
Transosteal implants 453 See also Dental implants.
Transport processes

2185
 active 59, 59t
passive 58, 58t
Trans-theoretical model 491
Transverse plane 55, 55f
Transverse ridge 134
Trapezius muscle 113
Traumatic bone cyst 226, 227f See also Cysts.
Traumatic fibroma 193, 194f
Traumatic ulcers 203–205, 204f
Tray systems 503–504
Trench mouth 205, 205f
Trend 625t
Treponema pallidum 266t
Triad, epidemiologic 624, 625f
Trial courts 712
Triangular ridge 134
Tricalcium phosphate 647
Tricarboxylic acid cycle (TCA) 362
Trichophyton 263
Trigeminal nerve (CN V) 119
divisions of 120
mandibular nerve 121
maxillary nerve 120
ophthalmic nerve 120
mandibular division of 554–556
block injections for 556, 557t
innervation of 554–555
maxillary division of 554
block injections for 554, 555t, 556f

2186
 innervation of 554
Trimethoprim-sulfamethoxazole 285t
Trioses 360
Trochlear nerve (CN IV) 119
Trophozoite 264
True fats 369
Trunk, root 129
Trypsin 367
Tubal tonsils 118
Tuberculin skin test (TST) 304
Tuberculosis (TB) 276, 304, 343
Tubules 20
Tumor, benign mixed 219–220, 220f
Tumor necrosis factor (TNF) 181
Tumor-node-metastasis (TNM) staging system 218, 219b
Turesky modification of the Quigley-Hein Plaque Index (TPI) 636t
Typhoid fever 277
Tzanck cells 213

U
Ulcerative diseases 203–205
characteristics of 203
necrotizing ulcerative gingivitis (NUG) 205, 205f
traumatic ulcers 203–205, 204f
trench mouth 205, 205f
Vincent’s infection 205, 205f
Ulna 65, 66f
Ultrashort-acting barbiturates 335
Ultrasonic devices 532–533

2187
Ultrasound methods 382
Umbilical cord blood stem cells (UCBSCs) 185
Unconsciousness 692
Underwater weighing 382
Unethical conduct, reporting suspected 753
Uniformed Services Employment and Reemployment Rights Act of
1994 735
Unintentional torts 713
Unipolar neurons 29f, 30
Universal curet 522f, 522 See also Curet.
Universal Numbering System 139, 471 See also Dentition.
Universal principles 707
Universality, principle of 748
Unprotected eyes, risks for 307
Unregulated medical waste 314
Unsaturated chemical vapor sterilization 316
Unsaturated fatty acids 369
Unsupervised practice 718
Upper respiratory system infections 275
Urea cycle 368
Urinary bladder 99, 99f
Urinary system 97–101, 99f
physiology of 100
Urinary tract infections 284
Urine analysis 381
USDA MyPlate 382f, 384, 386
Utilitarian ethics 707 See also Ethical considerations.
Utility gloves 306t
Uvula 131t

2188
V
Vagus nerve (CN X) 123
Validity 625t
Valproate 348
Valproic acid (Depakene, Depakote) 346
Values, in human behavior principles 490
Vancomycin 285t
Varenicline (Chantix) 354
Variable 629
Variable expressivity 186
Varicella 264t
Varicella zoster virus (VZV) 208, 274
Variola 264t
Varnish programs 642t, 645, 645b
Varnishes, fluoride 407–408 See also Fluorides.
Vascular endothelial growth factor (VEGF) 183
Vascular system 115
Vasoactive amines 180
Vasoconstrictors 552–553, 552t
adrenergics as 329
Vasodepressor syncope 692–693
Vasodilation 178
Vasogenic shock 693
VEGF See Vascular endothelial growth factor (VEGF)
Veins 26
VELscope 510
Veneers 417–418
Venous drainage, of head and neck 116
Venous sinus 115

2189
Ventral cavity 55, 56f, 57t
Ventral structures 107
Veracity 707, 749
Verbal behaviors 482
Vermillion zone 131t
Verruca vulgaris 193–194, 194f
Versions 143
Vertebral cavity 55, 56f
Vertebral column 64, 64f
Vertical angulation 166, 166f
Very-low-density lipoproteins (VLDLs) 370
Vestibule 131t
Vestibulocochlear nerve (CN VIII) 122
Vibrio cholerae 266t
Vicarious liability 734
Vincent’s infection 205, 205f
Viral hepatitis 278–279t
Viral infections 274, 276, 276t, 284
Virtue ethics 707 See also Ethical considerations.
Virulence factors, microbial 266–267
Viruses 256, 264–265, 264t, 287t
Visceral membranes 61
Viscerocranium 110, 111f
Visual examination 188
Visual impairment 576
Vital signs 467, 688–690
blood pressure 689, 689f
body temperature 689
pulse 689–690, 690f

2190
 respiration rate 690
Vitalometer 512
Vitamin K 345
Vitamins 371–372
classification of 371
definition of 371
effects on oral cavity 373t
effects on oral tissues and role in tooth formation 376t
fat-soluble 372
general functions of 372
nutritional requirements for 372
water-soluble 372
Vitreous body 78
ViziLite 510
Volatile solvents, abuse of 353
Volpe-Manhold Index (VMI) 636t
Vomer 111
Von Ebner glands 118
von Willebrand’s disease 233
VZV See Varicella zoster virus (VZV)

W
Waist circumference 379
Warfarin (Coumadin) 337, 340, 344–345
Warmth 482
Warts 275
oral 193–194, 194f
Waste disposal 314
Waste management 314

2191
Water 376–377
balance of 377
biologic role and functions of 376
definition of 376
regulation of 377
requirements for 377
total body 376
Water fluoridation 641, 642t, 644–645b
benefits of
indirect 643
posteruption 643
preeruption 643
compounds used for 643
methods of implementing 644
promotion of 644
public attitudes towards 644
role of government agencies in 644
safety of 643
school 642t, 646
Water jet, dental 498
Water-soluble vitamins 372
Waxes 369, 412
WBCs See White blood cells (WBCs)
Web-based learning, for oral health 659
Wedges, interdental 498
Weight control 377–380
Weight loss, prescription drugs for 379
White blood cells (WBCs) 86, 115
White lesions 213–217

2192
 Cannon disease 215
characteristics of 213
familial white folded dysplasia 215
hyperkeratosis 217, 217f
leukoderma 214
lichen planus 215–217, 216f
linea alba 214, 214f
nicotine stomatitis 213–214, 214f
systemic lupus erythematosus (SLE) 214–215, 215f
white sponge nevus 215
White matter 75, 76f, 77
White sponge nevus 215
Whitening agents 409
WHO See World Health Organization (WHO)
Whooping cough 276
Withdrawal 353
Withdrawal reflex 77
Work practice controls 301
Workers’ compensation 735
Working diagnosis 189
Working end 518
World Health Organization (WHO) 621, 747
Worms (helminths) 256
Wound healing and regeneration 182–184, 182f
Wound strength 183
WREB: A National Dental and Dental Hygiene Testing Agency 2b
Written defamation 714
Written record management 728
Wrongful discharge 714

2193
X
Xero-lube 331
Xerostomia-producing drug groups 331t
X-linked recessive inheritance 186
X-radiation
characteristics of 154–155
discovery of 152, 153f
production of 153, 154f
X-rays 152
film, dental 157–161
image characteristics 159–160, 160t
machine 152
with matter, interactions of 154
tube 153
diagram of 154f
types of 153
Xylitol 365, 646
for dental caries prevention 504

Y
Yellow-brown stained radiographs 162
Yersinia pestis 266t

Z
Zalcitabine 287t
Zidovudine 272, 287t
Zone, vermillion 131t
Zygomatic arch 110
Zygomatic bones 110, 111f

2194
Zygomatic nerve 120, 554
Zygomatic process 111
Zygomycota 263

2195
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