QUICK FIND GUIDE

MODULE COMMUNICATION SKILLS FOR ASSESSMENT

MODULE MAKING OUR WORDS UNDERSTANDABLE
MODULE OVERCOMING COMMUNICATION BARRIERS

MODULE MOTIVATIONAL INTERVIEWING FOR

INFORMATION GATHERING
MODULE MEDICAL HISTORY
MODULE READY REFERENCES: MEDICAL HISTORY
MODULE DENTAL HEALTH HISTORY
MODULE VITAL SIGNS: TEMPERATURE
MODULE VITAL SIGNS: PULSE AND RESPIRATION
MODULE VITAL SIGNS: BLOOD PRESSURE
MODULE TOBACCO CESSATION COUNSELING
MODULE SOFT TISSUE LESIONS
MODULE HEAD AND NECK EXAMINATION
MODULE ORAL EXAMINATION
MODULE GINGIVAL DESCRIPTION
MODULE MIXED DENTITION AND OCCLUSION
MODULE DENTAL RADIOGRAPHS
MODULE COMPREHENSIVE PATIENT CASES F TO K

GLOSSARY

ONLINE @ thePoint INSTRUCTOR RESOURCES

STUDENT RESOURCES
Acquisitions Editor: Jonathan Joyce
Product Development Editor: John Larkin
Marketing Manager: Leah Thomson
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Design Coordinator: Holly McLaughlin
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Fourth Edition

Copyright © 2018, 2013, 2010, 2007 Wolters Kluwer

All rights reserved. This book is protected by copyright. No part of this book may be
reproduced or transmitted in any form or by any means, including as photocopies or
scanned-in or other electronic copies, or utilized by any information storage and retrieval
system without written permission from the copyright owner, except for brief quotations
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the above-mentioned copyright. To request permission, please contact Wolters Kluwer at
Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at
[email protected], or via our website at lww.com (products and services).

987654321

Printed in China

Library of Congress Cataloging-in-Publication Data

Names: Gehrig, Jill S. (Jill Shiffer), author.

Title: Patient assessment tutorials : a step-by-step guide for the dental hygienist / Jill S.
Gehrig.
Description: Fourth edition. | Philadelphia : Wolters Kluwer Health, [2018] | Includes
bibliographical references and index.
Identifiers: LCCN 2016041559 | ISBN 9781496335005
Subjects: | MESH: Diagnosis, Oral—methods | Dental Hygienists | Dental Records |
Programmed Instruction
Classification: LCC RK60.5 | NLM WU 18.2 | DDC 617.6/01—dc23 LC record available
at https://lccn.loc.gov/2016041559

This work is provided “as is,” and the publisher disclaims any and all warranties, express
or implied, including any warranties as to accuracy, comprehensiveness, or currency of the
content of this work.
This work is no substitute for individual patient assessment based upon health care
professionals’ examination of each patient and consideration of, among other things, age,
weight, gender, current or prior medical conditions, medication history, laboratory data,
and other factors unique to the patient. The publisher does not provide medical advice or
guidance, and this work is merely a reference tool. Health care professionals, and not the
publisher, are solely responsible for the use of this work including all medical judgments
and for any resulting diagnosis and treatments.
Given continuous, rapid advances in medical science and health information,
independent professional verification of medical diagnoses, indications, appropriate
pharmaceutical selections and dosages, and treatment options should be made and health
care professionals should consult a variety of sources. When prescribing medication, health
care professionals are advised to consult the product information sheet (the manufacturer’s
package insert) accompanying each drug to verify, among other things, conditions of use,
warnings, and side effects and identify any changes in dosage schedule or
contraindications, particularly if the medication to be administered is new, infrequently
used, or has a narrow therapeutic range. To the maximum extent permitted under
applicable law, no responsibility is assumed by the publisher for any injury and/or damage
to persons or property, as a matter of products liability, negligence law or otherwise, or
from any reference to or use by any person of this work.

LWW.com
 CONTRIBUTORS

Kimberly S. Bray, RDH, MS

Director, Division of Dental Hygiene
School of Dentistry
University of Missouri—Kansas City
Kansas City, Missouri

Delwyn Catley, PhD

Professor of Psychology and Dentistry
Director Health Behavior Change Lab
Department of Psychology
University of Missouri—Kansas City
Kansas City, Missouri

Aurora M. Graves DeMarco, CDA, RDH, BA

Private Practice
Orlando, Florida

Richard Foster, DMD

Dental Director
Guilford Technical Community College
Jamestown, North Carolina

Cynthia Biron Leiseca, RDH, EMT, MA

President
Educational Methodology
DH Methods of Education, Inc.
Fernandina Beach, Florida

Remberto J. Leiseca, BBA, CSI, CCPR, MAI

Consultant and Media Specialist
DH Methods of Education, Inc.
Fernandina Beach, Florida

Sharon Logue, RDH, MPH

Virginia Department of Health
Dental Health Program
Richmond, Virginia

Robin B. Matloff, RDH, BSDH, JD

Associate Professor
Dental Hygiene Program
Mount Ida College
Newton, Massachusetts

Kami Piscitelli, RDH

Virginia Department of Health
Division of Dental Health
Richmond, Virginia

John Preece, DDS, MS

Dental Diagnostic Science (Retired)
University of Texas Health Science Center at San Antonio
San Antonio, Texas

Carol Southard, RN, MSN

Tobacco Cessation Specialist
Osher Center for Integrative Medicine
Northwestern Medical Group
Northwestern Medicine
Chicago, Illinois

Rebecca Sroda, RDH, MA

Dean
Health Sciences
South Florida State College
Avon Park, Florida

Melany F. Thien, RDH, BS, MAE

St. Louis Community College at Forest Park
New Baden, Illinois

Karen Williams, RDH, MS, PhD

Professor and Chair
Department of Health Informatics
School of Medicine
University of Missouri—Kansas City
Kansas City, Missouri

Donald E. Willmann, DDS, MS

Professor Emeritus
Department of Periodontics
University of Texas Health Science Center at San Antonio
San Antonio, Texas
 PREFACE FOR COURSE
INSTRUCTORS

Patient Assessment Tutorials: A Step-by-Step Guide for the Dental

Hygienist, Fourth Edition, is a detailed instructional guide to patient
assessment procedures. Tutorials is unique in two regards: First, the “Peak
Procedures” sections teach the “how to” of patient assessment procedures in a
clear step-by-step manner; and second, Tutorials places a unique emphasis on
the human element of patient assessment. Content on the human interaction
aspect of patient assessment includes four chapters on communication and
information gathering techniques as well as the Human Element sections and
communication role-plays throughout the book.
Patient Assessment Tutorials is designed for student use in two settings.
Initially, the modules are designed to guide student practice of assessment
and communication techniques in preclinical and clinical settings. Later, the
Ready References from the modules—when laminated and assembled in a
notebook—create a reference book that provides quick access to information
during patient treatment.

Online Features
Patient Assessment Tutorials includes online resources for both instructors
and students that are available on the book’s companion website, thePoint.
ONLINE INSTRUCTOR RESOURCES
Approved adopting instructors will be given access to the following
additional resources:
• Image Bank
 • PowerPoint Presentations
• Test Bank Questions
• Video clip that allows students to hear the Korotkoff sounds and practice
recording blood pressure readings
• Video clips showing proper head, neck, and oral examination techniques
• Morita CBCT Viewer
• Practical Focus Case Studies, Patient Case Studies, and Active Learning
Cases
• Role-Playing Exercises
• Instructions on how to use the textbook and instructor resources
• WebCT- and Blackboard-ready cartridges
ONLINE STUDENT RESOURCES
See the inside front cover of this text for more details, including the passcode
needed to gain access to the website. Students who have purchased Patient
Assessment Tutorials, Fourth Edition, have access to the following additional
resources:
• Video clip that allows students to hear the Korotkoff sounds and practice
recording blood pressure readings
• Video clips showing proper head, neck, and oral examination techniques
• Morita CBCT Viewer
• A searchable online version of the full text

Book Features
Patient Assessment Tutorials: A Step-by-Step Guide for the Dental
Hygienist has many features designed to facilitate learning and teaching.
1. Module Overview and Outline. Each module begins with a concise
overview of the module content. The module outline makes it easier to
locate material within the chapter. The outline provides the reader with
an organizational framework with which to approach new material.
Learning objectives assist students in recognizing and studying
important concepts in each chapter.
2. Peak Procedures. Step-by-step instructions are provided for each
patient assessment procedure.
• For students, the “Peak Procedures” section provides a
straightforward, step-by-step guide for practicing and perfecting
assessment techniques. The self-instructional format allows the
learner to work independently—fostering student autonomy and
decision-making skills.
• For educators, the “Peak Procedures” section provides a reliable,
evidence-based blueprint for the standardization of faculty members
in the instruction and evaluation of patient assessment procedures.
3. The Human Element. This module feature focuses on the “people part”
of patient assessment. Students, patients, and experienced clinicians
were invited to share their experiences in this section of the modules.
The features Through the Eyes of a Student and Through the Eyes of a
Patient features speak to the human element of the assessment process.
In these real-life accounts, students share their struggles and triumphs
with patient assessment procedures. Patient accounts evoke empathy and
pride in the impact of caregiving.
Patient and Communication Scenarios and Ethical Dilemmas allow
students to develop important communication skills.
4. Ready References. The Ready References provide rapid access to
important information on each assessment topic. For example, there is a
Ready Reference with the most commonly prescribed medications. The
Ready Reference features are designed to be removed from the book,
laminated or placed in plastic page protectors, and assembled in a
notebook for use in the clinical setting.
5. English-to-Spanish Phrase Lists. As the Spanish-speaking population
increases, clinicians encounter growing numbers of Spanish-speaking
patients in dental clinics and offices. Teaching students to pronounce
and speak Spanish is well beyond the scope of this book and indeed,
beyond the scope of most professional curriculums. For those times
when a trained translator is not available, however, the modules include
 English-to-Spanish phrase lists with phrases pertinent to the assessment
process. To use these phrase lists, the student clinician simply points to a
specific phrase in the list to facilitate communication with a Spanish-
speaking patient.
6. Fictitious Patient Cases A to E. Fictitious patient cases A to E promote
the student’s application of chapter information to patient care, much in
the same way that he or she needs to do when caring for a real patient.
With each module, more information is revealed about each patient’s
assessment findings. For example, Module 5 reveals the medical
histories of fictitious patients A to E. Module 10 provides the patients’
blood pressure readings. This progressive disclosure of assessment
findings parallels the manner in which students collect information on a
patient in the clinical setting, gleaning new nuggets of information with
each assessment procedure performed. In each module, the student is
asked to interpret the assessment findings revealed in the module, relate
it to information about the patient from previous chapters, and make
decisions about patient care based on these assessment findings.
7. Skill Check. The module skill evaluation procedure checklists allow a
student to self-evaluate his or her strengths and limitations in performing
the assessment procedure and to identify additional learning needs. The
checklists also provide benchmarks for instructor evaluation of student
skill proficiency.
Suggestions for communication role-plays are available on the
book’s companion website, thePoint. Refer to inside cover page for
details on accessing online resources. Communication checklists in the
modules allow students to practice and self-evaluate their
communication skills and to identify areas for improvement. The
checklists also provide benchmarks for instructor evaluation of student
skill proficiency in communicating with patients.
8. Terminology and Glossary of Terms. Terminology pertinent to patient
assessment is highlighted in bold type and clearly defined within each
module. The Glossary in the back of the book provides quick access to
 terminology.
9. Comprehensive Fictitious Patient Cases F to K. Module 18 of the
book is composed of comprehensive patient cases. This module presents
six entirely new comprehensive patient cases. Patient assessment data is
presented for each patient, and the student is challenged to interpret and
use this assessment information in care planning for the patient.
 USER’S GUIDE

The ability to accurately assess patients is vital to the practice of dental

hygiene—a complete and accurate assessment is the starting point to
providing thorough patient care. Patient Assessment Tutorials: A Step-
by-Step Guide for the Dental Hygienist takes you through the process
of patient assessment and provides you with information on both the
actual physical assessment as well as effective patient communication.
The highly visual, step-by-step style teaches you vital assessment
processes quickly and thoroughly.

You’ll Find These Great Features in the Text

Module Overviews—Module Outlines—Objectives

Give an orientation to the information in the chapter and what you are
expected to know after reading the chapter material.
Detailed Illustrations and Photographs
Bring the material in the book to life and help to visually guide you
through the patient assessment process.
Procedure Boxes
Outline procedures in an easy-to-follow, step-by-step format. Lists of
necessary equipment and a rationale for each step are also provided.
Ready References
Provide vital information for use during the patient assessment process.
Ready Reference pages can be removed from the book. Laminating or
placing pages in plastic sleeves will make them ready to use in a clinical
setting.
The Human Element
Case studies and personal experiences of other students and hygienists
relate to the chapter content and explain why each assessment procedure
is clinically relevant to dental hygiene practice.
English-to-Spanish Phrase Lists
These phrase lists facilitate communication with Spanish-speaking
patients.
Practical Focus Cases
Case studies present you with a clinical scenario. Questions at the end of
these sections require you to think critically about the situation and
apply the information you have learned.
Skill Checks
Assess your understanding and ability to perform the skills presented in
the chapter.
 ACKNOWLEDGMENTS

I am extremely grateful to my many colleagues who have contributed to the

completion of this project. Without their contributions, this textbook would
not have been possible. Our thanks to all who generously gave their time,
ideas, and resources and gratefully acknowledge the special contributions of
the following individuals:
• Holly R. Fischer, MFA, and Charles D. Whitehead, the highly skilled
medical illustrators who created all the wonderful illustrations for the
book.
• Dee Robert Gehrig, PE, Gehrig Photographic Studio, the talented
individual who created the hundreds of photographs for this book.
• Kevin Dietz, colleague and friend, for his vision and guidance for this
book.
• And finally, and with great thanks, my wonderful team at Wolters
Kluwer, without whose guidance and support this book would not have
been possible: Jonathan Joyce, John Larkin, and Jennifer Clements.
Jill S. Gehrig
 CONTENTS

PART 1 • Communication Techniques for Assessment

MODULE 1 COMMUNICATION SKILLS FOR ASSESSMENT

JILL S. GEHRIG
The Communication Process
The Patient–Hygienist Relationship
Patient-Centered Communication
The Impact of Electronic Records on Communication
Difficult Conversations with Patients
The Human Element
Skill Check

MODULE 2 MAKING OUR WORDS UNDERSTANDABLE

JILL S. GEHRIG
Roadblocks to Effective Communication
Making Health Care Words Understandable
Using the Internet to Improve Communication Skills
The Human Element
Skill Check

MODULE 3 OVERCOMING COMMUNICATION BARRIERS

JILL S. GEHRIG AND KAMI PISCITELLI
 Language Barriers
Age Barriers
Vision and Hearing Barriers
Speech Barriers
Special Health Care Needs
The Human Element
Skill Check

MODULE 4 MOTIVATIONAL INTERVIEWING FOR

INFORMATION GATHERING
KIMBERLY S. BRAY, KAREN WILLIAMS, AND
DELWYN CATLEY
Introduction to Motivational Interviewing
Motivational Interviewing Approach to Assessment
The Human Element
Skill Check

PART 2 • Assessment Skills

MODULE 5 MEDICAL HISTORY

JILL S. GEHRIG AND ROBIN B. MATLOFF
The Health History
The Medical History Assessment
Informed Consent and the Medical History
Conducting a Medical History Assessment
Peak Procedure
The Human Element
Practical Focus—Fictitious Patient Cases
Skill Check
MODULE 6 READY REFERENCES: MEDICAL HISTORY
CYNTHIA BIRON LEISECA
Medical Conditions and Diseases
Common Prescription Medications

MODULE 7 DENTAL HEALTH HISTORY

JOHN PREECE AND JILL S. GEHRIG
Adult Dental Health History Questionnaire
Children’s Dental History Questionnaire
Peak Procedure
Sample Dental Questionnaires
The Human Element
Practical Focus—Fictitious Patient Cases
Skill Check

MODULE 8 VITAL SIGNS: TEMPERATURE

JILL S. GEHRIG
Introduction to Vital Signs Assessment
Peak Procedures
Ready References
The Human Element
Skill Check

MODULE 9 VITAL SIGNS: PULSE AND RESPIRATION

JILL S. GEHRIG
Peak Procedure for Pulse Assessment
Peak Procedure for Assessing Respiration
Ready References
The Human Element
 Skill Check

MODULE 10 VITAL SIGNS: BLOOD PRESSURE

DONALD E. WILLMANN
Blood Pressure Assessment in the Dental Setting
Equipment for Blood Pressure Measurement
Measurement and Documentation of Korotkoff Sounds
Critical Technique Elements
Peak Procedure
Ready References
The Human Element
Practical Focus—Fictitious Patient Cases for Vital Signs
Modules
Skill Check

MODULE 11 TOBACCO CESSATION COUNSELING

CAROL SOUTHARD
Health Effects of Tobacco Use
Harmful Properties of Tobacco
Why Should Dental Health Care Providers Intervene?
Guidelines for Tobacco Cessation Counseling
Peak Procedure: Tobacco Cessation
Patient Education Resources
The Human Element
Practical Focus—Fictitious Patient Case for Tobacco
Cessation
Skill Check

MODULE 12 SOFT TISSUE LESIONS

 JILL S. GEHRIG
Learning to Look at Lesions
Peak Procedure: Describing Lesions
Detection Tools
Ready References
The Human Element
Practical Focus—Describing and Documenting Lesions

MODULE 13 HEAD AND NECK EXAMINATION

JILL S. GEHRIG
Examination Overview
Methods for Examination
Peak Procedure
The Human Element
Practical Focus—Fictitious Patient Cases
Skill Check

MODULE 14 ORAL EXAMINATION

JILL S. GEHRIG
Examination Overview
Peak Procedure
The Human Element
Practical Focus—Fictitious Patient Cases
Skill Check

MODULE 15 GINGIVAL DESCRIPTION

JILL S. GEHRIG
Learning to Look at the Gingiva
Peak Procedure
 Ready References
The Human Element
Practical Focus—Fictitious Patient Cases
Skill Check

MODULE 16 MIXED DENTITION AND OCCLUSION

CYNTHIA BIRON LEISECA, JILL S. GEHRIG, AND
RICHARD FOSTER
Sorting Out a Mixed Dentition
Learning to Look at the Occlusion
Peak Procedures
Ready References: Mixed Dentition
Ready References: Occlusion
The Human Element
Practical Focus—Mixed Dentition
Practical Focus—Occlusion
Skill Check

MODULE 17 DENTAL RADIOGRAPHS

JOHN PREECE
Review of Radiographic Anatomy
Interpreting Radiographs
Peak Procedure
Cone Beam Computed Tomography
Ready References
The Human Element
Practical Focus—Fictitious Patient Cases
Practical Focus—Panoramic Radiographs
Skill Check
PART 3 • Comprehensive Patient Cases

MODULE 18 COMPREHENSIVE PATIENT CASES F TO K

JILL S. GEHRIG AND RICHARD FOSTER
Fictitious Patient F, Frasier Fairhall
Fictitious Patient G, Gumercindo de la Garza
Fictitious Patient H, Harry Haversmith
Fictitious Patient I, Ida Iannuzzi
Fictitious Patient J, John Jolioceur
Fictitious Patient K, Kwan Kang
The Human Element
Skill Check

GLOSSARY

ETHICAL DILEMMAS
ROBIN B. MATLOFF

thePoint: ONLINE RESOURCES

AURORA M. GRAVES DEMARCO, MELANY F. THIEN, SHARON
LOGUE, ROBIN B. MATLOFF, REBECCA SRODA, AND RICHARD
FOSTER

INDEX
 PART 1
Communication
Techniques for
Assessment
 MODULE
1

COMMUNICATION
SKILLS FOR
ASSESSMENT
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
Clear communication provides the foundation for the patient assessment
procedures from history taking to explaining assessment findings to the
patient. Being able to communicate effectively—or participate in the
exchange of information—is an essential skill for dental health care
providers.
To a great extent, the patient’s satisfaction with dental care is
determined by the dental health care provider’s ability and willingness to
communicate and empathize with patient needs and expectations. Good
communication during the assessment process sets the tone for quality care
and loyal patients.
This module summarizes techniques for—as well as obstacles to—
effective communication during the patient assessment process.
MODULE OUTLINE
SECTION 1 The Communication Process
What Is Communication?
Ineffective Communication
Effective Communication
Communication Filters
Nonverbal Communication
First Impressions
Use of Space
Touch as Nonverbal Communication
Empathy
SECTION 2 The Patient–Hygienist Relationship
The Nature of the Helping Relationship
Patients’ Rights in the Helping Relationship
Paternalistic versus Patient-Centered Care
Integrating Communication and Therapeutic Tasks
SECTION 3 Patient-Centered Communication
Framework for Patient–Clinician Communication
Patient-Centered Communication as a Key Clinical Skill
Patient-Centered Communication Techniques
Techniques that Hinder Communication
Questioning Skills
Communication Tasks during Patient Assessment
SECTION 4 The Impact of Electronic Records on
Communication
Integrating Computerized Records and Patient-Centered
Communication
Improved Communication with Standardized
Nomenclature
 SECTION 5 Difficult Conversations with Patients
Communication in a Difficult Patient Encounter
Sharing Bad News
SECTION 6 The Human Element
Through the Eyes of a Patient
Patient Advocacy
Communication Scenario
SECTION 7 Skill Check
KEY TERMS
Communication • Personal filters • Verbal communication • Nonverbal
communication • Stereotypes • Proxemics • Personal space • Territory •
Low-contact cultures • High-contact cultures • Empathy • Diplomacy •
Helping relationship • Paternalism • Patient-centered care • Finding the
problem • Fixing the problem • Engagement • Education • Enlistment •
Patient-centered communication • Closed questions • Open-ended
questions • Electronic dental record • Systematized Nomenclature of
Medicine—Clinical Terms (SNOMED CT) • Systematized Nomenclature
of Dentistry (SNODENT)

OBJECTIVES
• Define communication and describe the communication process.
• Describe how ineffective communication hinders the provision of
quality dental care.
• Describe the two major forms of communication and give examples
of each.
• Discuss techniques that promote effective communication.
• Understand the role of effective communication in the provision of
quality dental care.
• List and describe three ways in which people communicate
nonverbally.
 • Explain why appearance can often lead to incorrect assumptions about
an individual.
• Identify the purpose of the patient–hygienist relationship.
• Discuss patients’ rights as consumers of dental health care services.
• Define patient-centered care.
• Identify patient-centered communication techniques.
• Define bad news.
• During role-plays or in the clinical setting, demonstrate the SPIKES
model communication strategy when sharing bad news with a patient.
• Describe how a nomenclature system, such as SNODENT, may
improve communication between clinicians and different settings
(offices).
• Develop improved clinical communication skills and the ability to
role model those skills through simulated patient scenarios.

SECTION 1 • The Communication Process

What Is Communication?
Communication is the exchange of information between individuals. The
word “exchange” is essential to understanding the act of communicating. The
process of communication is an exchange of information that moves back
and forth between two people. A dental health care provider must be a
successful communicator, both as a sender and receiver of information.
Communication with a patient not only involves telling the person something
(sending information) but also is about listening to the patient’s response—
receiving information—in return. The understanding of how to convey and
interpret meaning is essential for effective communication. In the context of
dental care, communication’s primary function is to establish understanding
between the patient and dental health care provider.

Ineffective Communication
There are always at least two parties involved in any communication.
Communication blocks can occur when the clinician assumes that the patient
knows what he or she is thinking (Fig. 1-1). (The patient should know that
the health history is important, shouldn’t he?) Box 1-1 shows examples of
the impact of poor patient communication.

BOX The Impact of Poor Patient Communication

1-1

POOR COMMUNICATION
• Decreases the patient’s confidence and trust in dental care
• Deters the patient from revealing important information
• Leads to the patient not seeking further care
• Leads to misunderstandings
• Leads to the misinterpretation of advice
• Underlies most patient complaints
These difficulties may lead to poor or suboptimal dental health for the
patient.

Effective Communication
Being a good listener is key to interacting and responding to the patient in a
manner that conveys empathy for as well as interest in his or her concerns. A
successful communication begins by recognizing the patient’s needs and
concerns (Fig. 1-2). Box 1-2 shows examples of the benefits of effective
communication.

BOX The Benefits of Good Patient Communication

1-2

GOOD COMMUNICATION
• Builds trust between the patient and health care provider
• May make it easier for the patient to disclose information
• Enhances patient satisfaction
• Allows the patient to participate more fully in health decision making
• Helps the patient to make better dental health decisions
• Leads to more realistic patient expectations
The benefits of good communication may contribute to better dental
health for the patient.

Communication Filters
Each person involved in the act of communication interprets a message based
on many factors such as his or her life experiences, age, gender, and cultural
diversity. These factors act as personal filters that “distort” messages being
sent and received (Fig. 1-3). For this reason, the message received may not
be the message sent. Normal human biases or personalized filters create
major barriers to effective communication. Communication is promoted by
awareness that human beings have personalized filters that can impede
accurate communication. Means of encouraging accurate communication
include using a vocabulary that is easily understood by patients combined
with an awareness of physical limitations, life experiences, and cultural
differences.

Nonverbal Communication

There are two major forms of communication: verbal and nonverbal.1–5 Dr.
Albert Mehrabian, who pioneered the study of communication, found that
only about 7% of the meaning of a message is communicated through verbal
exchange (Fig. 1-4).6 About 38% is communicated by the use of the voice
and tone. About 55% comes through gestures, facial expression, posture, etc.
Dr. Mehrabian’s communication model is useful in illustrating the
importance of considering factors other than words when trying to convey
meaning (as the speaker) or interpret meaning (as the listener). Patients
interpret meaning from what the clinician actually says, but they also infer
meaning from the way in which the message is conveyed—that is, messages
conveyed through voice, facial expression, and body cues. The understanding
of how to convey and interpret meaning is essential for effective
communication.
1. Verbal communication is the use of spoken, written, or sign language
to exchange information between individuals. In the context of dental
care, communication’s primary function is to establish understanding
between the patient and clinician.
2. Nonverbal communication is the transfer of information between
persons without using spoken, written, or sign language (Box 1-3).
• In nonverbal communication “wordless” messages are sent and
received by means of facial expression, appearance, gaze, gestures,
postures, tone of voice, hairstyle, grooming habits, and body
positioning in space.
• Each of us gives and responds to literally thousands of nonverbal
messages daily in our personal and professional lives.
• We all react to wordless nonverbal messages emotionally, often
without consciously knowing why.

BOX Nonverbal Communication

1-3

Nonverbal communication can include posture, facial expression,

appearance, hairstyle, clothing, shaking hands, smiling, proximity to others,
touch, color choice, and silence.

First Impressions
1. Unconscious First Impressions. Although health care providers prefer
to be judged on their knowledge, skills, and the care they provide to
patients, other factors such as first impressions often influence patients’
judgments about clinicians.
• It seems unfair, but first impressions count (Fig. 1-5).

• When a person walks into a room, others make subconscious decisions

about him or her. Within about 60 seconds, others have judged the
person’s educational background, likeability, and level of success.
• After about 5 minutes, conclusions have been drawn about the
person’s trustworthiness, reliability, intelligence, and friendliness.
• Impressions are based on instinct and emotion, not on rational thought
or careful investigation.
• We all make associations between outward characteristics and the
 inner qualities we believe they reflect.
• We filter everything we see and hear through our own experiences.
We all have assumptions—stereotypes—regarding what it means to
be short or tall, heavy or thin, clean or dirty, native or foreign, young
or old, and male or female.
2. Creating Positive First Impressions. What can health care providers
do to be in control of a patient’s first impression of us?
• Each clinician has to determine his or her objectives and make choices
in dress and behavior that convey competence and caring.
• First impressions can open the lines of communication and build trust.

Use of Space
1. Proxemics is the study of the distance an individual maintains from
other persons and how this separation relates to environmental and
cultural factors.
• Every person has around him (or her) an invisible “personal zone of
comfort” defined as personal space. We have all felt uneasiness in an
elevator or airplane when the stranger on either side inadvertently
touches us.
• When our personal zone of comfort has been invaded, we feel
uncomfortable and resentful. Personal space—or distance from other
persons—is a powerful concept that we use in determining the
meaning of messages conveyed by another person (Table 1-1).

• For example, an angry person is perceived as less threatening if the

person is not standing nearby. If an angry person is close, however,
the individual’s anger is perceived as more threatening.
• Personal space is a subtle but powerful part of nonverbal
 communication that health care providers must understand in order to
relate better to the patient in the dental setting.
• Entering the personal or intimate zones of comfort is necessary in
the dental health care setting and, if not carefully handled, may
cause the patient to feel threatened or insecure.
2. Territory is the space we consider as belonging to us.
• The way that people handle space is largely determined by their
culture.
• Differences in culture can lead to different interpretations of personal
space and touching. Misunderstandings can occur when low-contact
cultures interact with high-contact cultures and either invade or avoid
personal space and physical contact.
• North Americans and Latin Americans, for example, have
fundamentally different proxemic systems.
• While North Americans usually remain at a distance from one another,
Latin Americans stay very close to each other.
• Remland and colleagues7 reported that in their sample of seven
nations, the British sample showed on average the greatest distance
between persons in a conversation (15.40 in). Southern European
countries such as Greece (13.86 in) and Italy (14.18 in) showed a
closer distance between persons engaged in conversation.7
• Low-contact cultures (North American, Northern European, Asian)
favor the Social Zone for interaction and little, if any, physical
contact. (Box 1-4 shows examples of low-contact and high-contact
cultures.)
• High-contact cultures (Mediterranean, Arab, Latin) prefer the
Intimate and Personal Zones and much contact between people. In
Saudi Arabia, persons engaged in conversation might be almost nose
to nose with each other because their social space equates to a North
American’s intimate space.

BOX Low-Contact versus High-Contact Cultures

1-4
LOW-CONTACT CULTURES
Asian: China, Indonesia, Japan, Philippines, Thailand
Southern Asian: India and Pakistan
Northern European: Austria, England, Germany, the Netherlands,
Norway, Scotland
North American: United States and Canada

HIGH-CONTACT CULTURES
Arab: Iraq, Kuwait, Saudi Arabia, Syria, United Arab Republic
Latin American: Bolivia, Cuba, Ecuador, El Salvador, Mexico, Paraguay,
Peru, Puerto Rico, Venezuela
Southern European: France, Italy, Turkey

Touch as Nonverbal Communication

1. The Importance of Touch. Touching is perhaps the most powerful
nonverbal communication tool.
• We can communicate a wide variety of emotions through touching
such as support, protection, anger, tenderness, or intimacy.
• Touch is culturally determined. Each culture has a clear concept of
what parts of the body one may not touch. Low-contact cultures—
English, German, Scandinavian, Chinese, and Japanese—have little
public touch. High-contact cultures—Latino, Middle-Eastern, and
Jewish—accept frequent touches.
2. Touch Is Universal. Touch is perhaps the most universal of all forms of
communication.
• The comforting aspect of touch is significant in health care.
• A comforting touch can say more than words (Fig. 1-6). A light pat on
the shoulder or on the top of the hand is comforting and establishes a
bond between the health care provider and patient.
3. Touch Taxonomy. Richard Heslin has developed a taxonomy that
classifies touch (Box 1-5).
• Heslin’s five categories are functional/professional, social/polite,
friendship/warmth, love/intimacy, and sexual arousal.8
• Dental care involves being in close proximity to the patient—
invading the patient’s space—and touching the patient.
• A patient may be acutely aware of the clinician’s touch, and some
patients may question the appropriateness of touching.
• Dental health care providers should recognize that the patient is
entitled to know why and where he or she is to be touched.
• Clinicians should respect, as much as possible, the patient’s personal
space.

BOX Heslin’s Categories of Touching Behavior

1-5

1. Functional/professional
2. Social/polite
 3. Friendship/warmth
4. Love/intimacy
5. Sexual arousal

Empathy
Empathy—identifying with the feelings or thoughts of another person—is an
essential factor in communicating with patients. Communication between the
dental health care provider and the patient is more complicated than a normal
conversation. For many patients, being in a dental office is a high-stress
situation. Pain, worry, and waiting can make a patient anxious or irritable.
Many problems can be prevented by keeping patients informed about waiting
times, billing or insurance charges, and other office policies that might trigger
angry emotions. Diplomacy is the art of treating people with tact and genuine
concern. Courtesy is based on sensitivity to the needs and feelings of others.
As a health care professional, it is important to be aware of what you say and
how you say it. Patient complaints about dental care often revolve around a
seemingly innocent comment made by a dental team member. The wrong
words can affect a patient’s perceptions of the care that he or she receives.
Table 1-2 presents some common situations encountered in a dental office
and analyzes both effective and ineffective responses.
 SECTION 2 • The Patient–Hygienist Relationship
Have you ever been in the patient role: feeling vulnerable, unsure, or
frightened? A friendly smile or a question about how you are feeling can
reassure and calm. As hygienists, the dental office becomes our “daily
world,” and we forget that it can be an unsettling place for a dental patient.
Dental hygienists commonly have a high level of dental health and therefore
have had mainly pleasant experiences in the dental office. Many patients, on
the other hand, have had—or have a fear of—painful experiences with dental
care. This section presents concepts that are effective for building successful
relationships with patients.
The Nature of the Helping Relationship
1. The Professional Helping Relationship. The professional hygienist–
patient relationship differs from that which occurs between friends
(social relationships), colleagues (working relationships), or family
members (kinship relationships).
• There may be some similarities between interactions with family and
friends, but one factor in particular differentiates helping relationships
from social relationships. A helping relationship is a relationship that
is established for the benefit of the patient, whereas kinship and
friendship relationships are designed to meet mutual needs (i.e., needs
of both friends in the relationship).
• In particular, the hygienist–patient relationship is established to help
the patient achieve and maintain optimal health.
2. Technical versus Interpersonal Skills
• Psychomotor skills—such as periodontal instrumentation—develop
when an individual practices the skills over a long period of time.
Since periodontal instrumentation cannot be learned overnight, of
necessity, a great deal of time in the dental hygiene curriculum is
spent on learning this psychomotor skill.
• It is important that dental hygiene students understand that the amount
of practice time devoted to instrumentation does not indicate that this
procedure is “what the profession of dental hygiene is all about.”
Rather, the role of the dental hygienist is that of a patient advocate
who assists patients in maintaining their dental health.
• A research study at the University of Sydney confirms that patients
value interpersonal skills as highly as they value technical skills and
wanted to be treated like a “real person.”9
• Interactions hygienists have with patients can be caring and helpful or
unfeeling and even harmful.
• As a dental hygiene student, stop to consider whether you focus your
attention on a procedure—such as the head and neck exam—or on the
 patient as a person (Box 1-6).

BOX How Do YOU See Your Role as a Dental

1-6 Hygienist?
• A technician . . . as a “tooth-cleaning” technician.
• A patient advocate . . . as a dental health specialist and patient advocate
whose primary focus is on preventing and treating dental disease to
improve oral health, in support of the patient’s overall health.

Patients’ Rights in the Helping Relationship

As the “consumers” of dental services, patients have the rights summarized in
Box 1-7.

BOX Patients’ Rights in the Helping Relationship

1-7

• To expect a systematic and accurate assessment of their oral health

status
• To be informed about their oral health status so that they clearly
understand what the hygienist means
• To have all their questions answered
• To receive care from a dental hygienist who has current knowledge and
is able to provide safe, efficient care that meets the standards of care
• To be treated courteously by a dental hygienist who shows genuine
interest in them
• To trust that the confidentiality of any personal information will be
respected
• To consent to or refuse any proposed treatment without jeopardizing
their relationship with their dental hygienist
• To receive quality care
Paternalistic versus Patient-Centered Care
Traditionally, medical and dental health care has taken a paternalistic
approach. The patient-centered approach is a relatively new care model,
being only a few decades old.
1. Traditional “Paternalistic Model of Care”
a. Paternalism is the belief that health decisions (e.g., whether to have
periodontal surgery, appropriateness of a fixed bridge versus a dental
implant) are best left in the hands of those providing the health care.10
b. This traditional approach assumes that patients don’t have the
capacity to understand medical or dental care.
1) It also assumes that the patient does not need to understand his or
her own health care.
2) In this traditional approach, the physician or dentist decides “what
is best for the patient” and then carries out that treatment.
2. Patient-Centered Health Care
a. Patient-centered care is defined as respecting and responding to
patients’ wants, needs, and preferences, so that the patient can make
choices in his or her care that best fits his or her individual
circumstances.11 Such care is characterized by a positive patient–
provider relationship, shared understanding, emotional support, trust,
patient enablement, and informed choices.12
b. A patient-centered approach to patient care recognizes that there are
two experts present during the interaction between a health care
provider and patient. Both the health care provider and the patient
have rights and needs, and both have a role in decision making about
care and implementation of treatment.
1) One expert is the health care provider who has clinical knowledge.
2) The second expert is the patient who brings experience, beliefs, and
values to the dental treatment planning process.
c. A clinical example of traditional versus patient-centered models
of care. A clinical example of the traditional approach versus the
 patient-centered approach is the instance of a patient with periodontal
pockets.
1) In the traditional model, the dentist explains the condition and tells
the patient why she needs periodontal surgery.
2) In the patient-centered model, the dentist explains the condition
and the various treatment options (surgery or frequent professional
periodontal instrumentation) and the expected outcomes of these
options. Then the dentist and the patient discuss the patient’s needs
and preferences and come to a joint decision about the treatment
plan. For example, even though periodontal surgery provides the
best possible outcome, the patient may be unable to afford surgery
and opt instead to come every 3 months for periodontal
instrumentation.
3) Table 1-3 summarizes the differences between traditional and
patient-centered care models.

Integrating Communication and Therapeutic Tasks

Dental therapy involves two important tasks, or the “2Fs” of finding the
problem (diagnosis) and fixing the problem (treatment). New and
experienced clinicians, alike, often find it difficult to combine these “2Fs”
with communication skills.
The E4 model for clinician–patient communication defines the critical
communication tasks—the “4Es”—to engage, empathize, educate, and enlist
the patient. The “4Es” are of equal importance to the therapeutic “2Fs” tasks
for successful patient care. Derived from an extensive review of the literature
on clinician–patient communication, the model has proved to be a useful tool
for health care providers regardless of specialty, experience, or practice
setting.13–15 Figure 1-7 depicts the relationship between the “4Es” of
communication with the “2Fs” of dental therapy.

Engagement establishes an interpersonal connection between the

patient and clinician. Empathy demonstrates the hygienist’s understanding of
and concern about the patient’s thoughts and feelings—the patient is seen,
heard, and understood by the hygienist. Education delivers information to
the patient—the patient learns something. Enlistment invites the patient to
actively participate in decision making and acknowledges that the patient
controls much of what can happen in his or her dental health care treatment
plan.16

SECTION 3 • Patient-Centered Communication

Patient-centered communication embraces three core attributes of “patient-
centered care”:
1. Consideration of patients’ needs, perspectives, and individual
 experiences
2. Provision of opportunities for patients to participate in their care
3. Enhancement of the patient–clinician relationship12
Box 1-8 contains one example of a patient-centered conversation.

BOX Patient-Centered Communication: An Example

1-8

Hygienist: “Good morning, Mrs. Jamison. It’s nice to meet you. It must
have been difficult driving here today with all this snow.” (small talk)
Patient: “Yes, driving is dangerous. I left early for this appointment to
make sure that I got here on time.”
Hygienist: “Tell me why you decided to come to the dental office today.”
(open-ended question)
Patient: “Well, I have been seeing blood when I brush my teeth and I am
wondering if this is a problem. And then I keep thinking about what my
mother went through.”
Hygienist: “Your mother? Can you tell me more about that?” (facilitating
question)
Patient: “Well, my mother had terrible dental problems and had to see a
periodontist and then she had to have surgery and it was very painful!”
Hygienist: “So, you are worried that the same thing might happen to you?”
(reflective listening)
Patient: “Yes, that is it exactly.”
Communication Tip: Note that the hygienist in this example refrains from
immediately launching into an explanation of inflammation or periodontal
disease. Instead, the hygienist concentrates on understanding the patient’s
concerns.
Framework for Patient–Clinician Communication
Patient-centered communication is organized around six core functions of
patient–clinician communication, as depicted in Figure 1-8.

Patient-Centered Communication as a Key Clinical Skill

A number of national organizations acknowledge that communication is a
key clinical skill for health care providers.11,17 The increased interest in
effective communication between health care providers and patients is
motivated by the desire to provide the best possible care for patients. There is
a growing recognition that the education and training of health care providers
should focus on helping student clinicians acquire these skills.
Good communication is not “common sense”; rather, it is a set of
skills and attitudes that need to be central to the practice of dental hygiene.
The hygienist’s ability to communicate clearly with compassion, to meet or
even exceed the patient’s expectations, is the essence of a helping
relationship. Many patient complaints about dental care are not about how
procedures are performed but about perceived lack of caring on the part of
the dental staff. Table 1-4 is a self-assessment tool that explores the skills
needed for effective communication and customer service.

Patient-Centered Communication Techniques

Surveys conclude that patients strongly desire a patient-centered
communication approach.18,19 During patient assessment, being patient-
centered consists of making a conscious effort to understand the patient’s
concerns and beliefs.16 Table 1-5 presents a set of practical and evidence-
based suggestions to help improve the quality of the hygienist–patient
relationship during the patient assessment process.16,20–23
Techniques that Hinder Communication
In contrast to communication techniques that facilitate the hygienist–patient
relationship, there are certain communication habits that hinder this
relationship. Such habits include asking irrelevant personal questions, stating
personal opinions, or showing disapproval. Table 1-6 summarizes
communication techniques that hinder the hygienist–patient relationship.
Questioning Skills
Questioning skills are particularly important during the health history portion
of the assessment process to gather complete and accurate information from
the patient. Tips for effective questioning are summarized in Box 1-9.

BOX Tips for Effective Questioning

1-9

1. General Tips for Gathering Information

• Use language that is understandable to the patient. Avoid
medical/dental terminology if the patient does not have a medical or
dental background. Most people have difficulty understanding the
words used in health care. For example, rather than asking if the
 patient has ever experienced vertigo, ask if she felt dizzy.
• Ask one question at a time. Keep questions brief and simple and give
the patient plenty of time to answer.
• Avoid leading questions. Avoid putting words in the patient’s mouth.
• Avoid interrupting the patient. If you need to ask a follow-up
question, wait until the patient has completed his or her thought. Let
the patient do the talking.
• All questions should be asked in a positive way. Avoid accusing
language in your questions (e.g., Why don’t you floss every day?).
2. Use of Closed Questions
Closed questions can be answered with a yes or no or a one- or two-
word response and do not provide an opportunity for the patient to
elaborate. Closed questions limit the development of rapport between
the clinician and the patient. Use closed questions primarily to obtain
facts and zero in on specific information. Examples of closed questions
include:
• Are you allergic to latex?
• How frequent are your seizures?
• Did you check your blood sugar levels this morning?
3. Use of Open-Ended Questions
Open-ended questions require more than a one-word response and
allow the patient to express ideas, feelings, and opinions. This type of
questioning helps the clinician gather more information than can be
obtained with closed questions. Open-ended questions facilitate good
clinician–patient rapport because they show that the clinician is
interested in what the patient has to say. Examples of such questions
include:
• What happens to you if you are exposed to latex?
• What things can trigger your seizures?
• What were your blood sugar levels this morning?
4. Exploring Details with Open-Ended Questions
Focused, open-ended questions define a content area for the response
 but pose the question in a manner that cannot be answered in a simple
word.
• Please describe the pain that you are feeling.
• Please start from the beginning and tell me how this began and how
it has progressed.
• Do cold temperatures like an ice-cold drink cause the pain?
• Which of your family members have diabetes?

Communication Tasks during Patient Assessment

When performing assessment procedures, the dental health care provider
should remember to communicate with the patient. It is easy for the clinician
to concentrate so completely on the steps involved in a procedure that he or
she forgets to explain the procedure to the patient or forgets to keep the
patient involved in what is happening.
Communication tasks during the patient assessment process include
giving information to the patient, explaining a procedure to the patient,
seeking the patient’s cooperation, providing encouragement to the patient,
reassuring the patient, and giving feedback to the patient. Box 1-10 shows a
sample dialogue for communication during blood pressure assessment.
1. Giving Information
Example: We do this to make sure that your temperature, pulse,
respiration, and blood pressure are OK before starting any treatment.
Other ways of phrasing this include:
• This is . . .
• I need to . . .
• This is important because . . .
2. Explaining a Procedure
Example: I am going to wrap this cuff around your arm and pump some
air into it so that I can read your blood pressure. Other ways of
phrasing this include:
• I just want to . . .
 • Now I would like to . . .
• Now I am going to . . .
3. Seeking Cooperation from the Patient
Example: Could you roll up your sleeve? Other ways of phrasing this
include:
• I would like you to . . .
• If you would just . . .
• Would you please . . .
4. Offering Encouragement
Example: Yes, that is fine. Other ways of phrasing this include:
• That’s good.
• Well done.
5. Offering Reassurance
Example: Don’t worry; you will only feel the pressure of the cuff around
your arm. Other ways of phrasing this include:
• It won’t take long.
• This might feel a bit strange at first.
• Have you had your blood pressure taken before?
6. Giving Feedback
Example: Your readings are quite normal. Other ways of phrasing this
include:
• Everything is OK.
• Your blood pressure is a bit high, so I’ll let Dr. King know what your
readings are.

BOX Sample Dialogue: Communication Tasks during

1-10 Blood Pressure Assessment
Clinician: Now, Mrs. Tanner, I need to take your blood pressure. We do
this to make sure that your blood pressure readings are normal before
beginning any dental treatment. [giving information to the patient]
Patient: Oh . . . I see. I have been taking blood pressure pills; my doctor
 says that it is important to keep my blood pressure under control.
Clinician: I am going to wrap this cuff around your arm and pump some air
into it so that I can read your blood pressure. [explaining the procedure
to the patient] Could you please roll up your sleeve a bit? [seeking
cooperation from the patient]
Patient: Yes. (rolls up sleeve) Is this far enough?
Clinician: Yes, that’s just fine. (attaches the cuff and begins inflating the
cuff) [giving feedback]
Patient: It feels a bit funny.
Clinician: Yes, it does feel funny, but don’t worry. I am almost done
pumping up the cuff. Then, I will start releasing the air, and you will feel
less pressure against your arm. [offering reassurance to the patient]
Patient: Is my blood pressure OK?
Clinician: Yes. It is quite normal. Your readings today are 110 over 70.
[giving feedback to the patient]

SECTION 4 • The Impact of Electronic Records on

Communication

Integrating Computerized Records and Patient-Centered

Communication
An electronic dental record refers to a computerized system for maintaining
patient health information in an electronic, digital format. Electronic dental
records are used as a substitute for the traditional paper medical record;
material is easier to access and update. Computerized patient records are
almost a universal feature in today’s dental office. Electronic dental records
let dental health care providers easily access information about their patients.
Many hygienists, however, find that the computer screens distract from the
clinician–patient relationship.
Experts report that a lack of eye contact is the biggest problem with
having to input information into a computer. Eye contact establishes trust
with patients. A lack of eye contact also prevents the hygienist from being
able to read body language and cues from patients.
Several authors have proposed a patient-centered model for the
interaction among the clinician, the patient, and the computer.34,35 Box 1-11
summarizes guidelines, nicknamed POISED, designed to help health care
providers communicate effectively with patients while recording data
electronically.

BOX Tips for Effective Use of Computerized Records

1-11

P Prepare: Review the electronic record before seeing the patient.

O Orient: Briefly explain how the computer will be used during the visit.
I Information Gathering:
• Start with your patient’s concerns.
• Look at your patient. Make sure your full attention is in listening to
the patient.
• As much as possible, indicate your full attention by taking your
hands off of the keyboard and facing the patient.
• At various points in the information gathering, explain to the patient
that you will pause the conversation to enter information in the chart.
• Enter data to show patient’s concerns are being taken seriously.
S Share: Tell your patient what you are doing as you do it.
E Educate:
• Point to the computer screen; highlight discussed data.
• When possible, display data, such as the patient’s blood pressure or
probing depths over time.
D Debrief: Make sure the patient understands what you said.

Improved Communication with Standardized Nomenclature

With the advent of computerized, electronic records, the medical and dental
communities foresaw a need for a standardized nomenclature in patient
records. The Systematized Nomenclature of Medicine—Clinical Terms
(SNOMED CT) is a comprehensive clinical nomenclature of medical
terminology. In 1999, the Systematized Nomenclature of Medicine—Clinical
Terms (SNOMED CT) was created by the merger and restructuring of
clinical terminologies developed by the College of American Pathologists
and the National Health Service of the United Kingdom. As of April 2007,
SNOMED CT is owned, maintained, and distributed by the International
Health Terminology Standards Development Organization, a not-for-profit
association in Denmark, in order to promote international adoption and use of
SNOMED CT. SNOMED is a multinational and multilingual terminology
that can manage different languages and dialects.
The American Dental Association developed the Systematized
Nomenclature of Dentistry (SNODENT), a system of descriptive dental
codes for use in electronic dental records. SNODENT is a comprehensive
nomenclature that contains codes for identifying not only diseases and
diagnoses but also anatomy, dental and medical conditions, morphology, risk
behaviors (e.g., smoking), and social factors that may affect dental health or
treatment. SNODENT is distributed by the American Dental Association as a
set of downloadable files.
SNODENT-enabled electronic dental records benefit individuals and
evidence-based dental health care by:
• Providing standardized terms for describing dental disease
• Enabling information to be recorded consistently during office visits and
among different settings and locations
• Allowing detailed information to be recorded by different people, in
different locations, and to be combined into the patient record
• Enabling analysis of patient care services and outcomes
• Enabling the exchange of clinical details between different systems and
devices, such as electronic sharing of detailed patient information
between the general dental practice and a periodontal practice
• Allowing identification of patients who need follow-up for specific
conditions and improved coordination of care
 • Enabling a platform-independent, language-independent, cross-cultural
oral health record with precise, highly detailed recording of all oral
health information
• Enabling terminology to be updated in collaboration with oral health
subject matter experts to represent current oral health knowledge

More Information on SNODENT

The SNODENT User Guide may be downloaded at http://www.ada.org.

SECTION 5 • Difficult Conversations with Patients

Communication in a Difficult Patient Encounter

Communication skills are particularly important when dealing with angry
patients, disappointed patients, or patients with unrealistic expectations.
Anger may be a patient’s way to express anxiety (about his or her oral health
or a treatment procedure) or dissatisfaction with the care that he or she is
receiving.36 In such situations, the health care provider’s first instinct often is
to provide additional information about the patient’s dental condition or a
treatment procedure. Often, a more helpful approach is to acknowledge the
emotion that the patient appears to be feeling and explore its causes—before
explaining. Helpful skills in these situations include:
• If a patient is angry, acknowledge this feeling and explore its causes
before attempting to explain or defend your position.
• If the patient is disappointed, say something like “I wish things were
different.”
• Box 1-12 provides an example of a communication with a disappointed
patient.

BOX Example of Communication with a

1-12 Disappointed Patient
 Patient: “I left my old dentist and came here today because nothing is
working for me. My old dentist keeps prescribing antibiotics for me. But
as soon as I am done taking the medicine, my gums start bleeding again
and feel ‘itchy.’ I have taken antibiotics several times over the past year,
and they just don’t seem to be working for me. I am very frustrated!”
Hygienist: “So what you are saying is that the antibiotics don’t fix the
problem. Sounds like you are disappointed.” [repeating what you heard
and naming the emotion]
Patient: “Yes, I thought the antibiotics would get rid of the bleeding.”
Hygienist: “I wish that I could tell you that antibiotics cure gum disease,
but they do not. Would it be OK if I explain how gum disease works and
then we can discuss where we go from here?” [validating the patient’s
feeling of disappointment and asking permission before explaining]

Sharing Bad News

Unfortunately, the dental team sometimes has to convey bad news to patients.
Examples include telling a patient that he or she has a cancerous lesion,
periodontitis, or many teeth that need restorations. Although the dentist
usually tells the patient about his or her treatment needs, the hygienist often is
asked to clarify the information after the dentist leaves the treatment room.
Difficult conversations with patients are necessary and, when done well,
can actually empower patients and help them plan for the future. Sharing bad
news with a patient covers several general considerations, including the
environment in which the bad news is shared, the components of bad news
including emotions, and following up with the patient once the bad news has
been shared.
The SPIKES mnemonic is a six-step model for sharing bad news with a
patient.37 Table 1-7 summarizes this six-step model for communicating bad
news. It is important to realize that even though this is a six-step linear
model, the steps may overlap to some degree when having a conversation
about bad news.
 SECTION 6 • The Human Element
Patient assessment procedures provide critical information for planning
dental hygiene care. These complex procedures require practice and
experience to master and methodical attention to detail to perform. Most
textbook space—as well as classroom and laboratory time—tends to be
devoted to the technical aspects, the steps that comprise the patient
assessment procedures. Yet, the nonprocedural human element of the
assessment process is equally critical to the success of the assessment
process. The Human Element section of each module reflects the struggles,
fears, and triumphs of the students, clinicians, and patients who engage in the
assessment process. In addition, this section may include a fictitious patient
scenario that addresses communication and treatment challenges frequently
faced by dental hygienists.

Through the Eyes of a Patient

REMEMBER PATIENTS ARE PEOPLE

I know that, as a student, you come into clinic today thinking about what
you will accomplish during this appointment. Perhaps you wonder if you
will remember to do all of the steps and if you will do them correctly. I am
sure that you are worried about your clinic requirements and the
instructor’s comments about your performance today.
As the patient, I, too, come to this appointment with some needs and
concerns. I am not simply a 60 year-old woman with bleeding gums who
only has 20 teeth in her mouth. I wish that you would take a moment to
consider what is important to me. Most of my needs are simple things that
you can do each time that I have an appointment:
• Do not keep me waiting.
• Ask me what I think.
• Really listen to me.
• Do not dismiss or ignore my concerns.
• Talk to me, not at me.
• Keep me informed about what you are doing.
• Do not treat me like a clinical requirement; treat me like a person.
• Do not tell me what I need to do without telling me why it is important
and how to do it.
• Respect my privacy; do not talk about me to your classmates.
 • Remember who I used to be. I was not always a 60 year-old woman; I
used to be a young, enthusiastic research chemist.
• Let me know that you care about me.
Mrs. G, dental patient,
South Florida Community College
Used with permission and excerpted from a letter to the students of the Dental Hygiene
Program, South Florida Community College.

PATIENT PARTICIPATION IN CARE DECISIONS

Directions: Think about the last time you were a patient or client (of a
physician, nurse, dentist, or attorney). How much did this professional
engage you in mutual problem solving? What did this professional do to
make you feel included (or excluded) in the planning?
• In what ways did the professional make you feel that your opinions are
important?
• In what ways could this professional have included you more in the
decision-making process?
• How do your feelings differ when you are included and when the
professional takes over and does not consult you?
Compare your experiences with those of your classmates. What has this
discussion taught you about mutual problem solving?

Patient Advocacy
YOUR BELIEFS ABOUT HEALTH AND THE
PATIENT–HYGIENIST RELATIONSHIP

Directions: The following questions are designed to help you think about
yourself as a patient advocate. These questions are challenging because
they focus on your values about being a helper. To begin, answer the
questions on your own. Later, discuss your responses with your classmates.
You and your peers will learn a lot from each other.
• What does health mean to you?
• Do you think that dental health is a right or a privilege?
• To what extent do you believe individuals are responsible for the
development of their own dental health problems?
• What can you do, as a dental hygienist, to increase the likelihood that
patients will take better care of their dental health?
• What degree of independence are you comfortable with allowing your
patients to make decisions about their own dental treatment?
• What is it you like most about helping patients?
Communication Scenario

THE BUSY PATIENT

You are a dental hygienist who is employed in a general dental practice

with a patient base that includes a number of important individuals in the
community. You see that Ms. Murphy, a local bank president, is scheduled
for her 3-month maintenance appointment with you at 4:00 p.m.
At her last visit, she arrived 15 minutes late due to a “very important
meeting that ran late,” and stated that she had to be out in 30 minutes for
her next engagement across town. Ms. Murphy also constantly interrupted
the appointment by using her cell phone for both incoming and outgoing
calls. You found her self-care (plaque biofilm control) to be poor, and she
presented with a number of areas of toothbrush abrasion that you wanted to
address with her during your self-care instruction, but you simply ran out
of time. When you attempted to start the conversation, she abruptly stood
up stating that she had “more important things to do than talk about the
way I brush my teeth.” She also refused to return until her next scheduled
3-month appointment. You relay this information to the dentist in the
office, who agreed that she was a difficult patient, but encourages you to
address her self-care needs at her next appointment.

Discussion Points:
1. How can you best establish rapport with Ms. Murphy?
 2. How can good communication benefit Ms. Murphy?
3. What nonverbal communication techniques could be used with Ms.
Murphy during her dental hygiene appointment?
4. What kinds of questions would most effectively engage Ms. Murphy in
her treatment planning?
5. How can you relay to Ms. Murphy that you are empathetic of her busy
schedule yet want her to value and appreciate the importance of
effective self-care at home?

SECTION 7 • Skill Check

Skill Checklist: Communications Role-Play

ROLES:
• Student 1 = Plays the role of the patient.
• Student 2 = Plays the role of the clinician.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, each U equals 0 point.

CRITERIA: S E
Uses appropriate nonverbal behavior such as
maintaining eye contact, sitting at the same level as
the patient, nodding head when listening to patient,
etc.
 Interacts with the patient as a peer and avoids a
condescending approach. Collaborates with the
patient and provides advice.

Communicates using common, everyday words.

Avoids dental terminology.
Listens attentively to the patient’s comments.
Respects the patient’s point of view.
Listens attentively to the patient’s questions.
Encourages patient questions. Clarifies for
understanding, when necessary.
Answers the patient’s questions fully and
accurately.
Checks for understanding by the patient. Clarifies
information.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

NOTE TO COURSE INSTRUCTOR: A collection of role-play scenarios—

for use with the Communications Skill Checks—can be downloaded from
http://thepoint.lww.com/GehrigPAT4e.
ABOUT THE SKILL CHECK PAGES: The Skill Check pages in the book are designed so
that the forms can be removed from the book without loss of text content. They can be torn
out and used for role-plays and exercises. If desired, they can be collected and retained for
course grade determination.
References
1. Andersen PA. Nonverbal Communication: Forms and Functions. 2nd ed. Long Grove,
IL: Waveland Press Inc.; 2008.
2. Frank MG, Hwang HS, Matsumoto DR. Nonverbal Communication Science and
Applications. Thousand Oaks, CA: Sage; 2013.
3. Manusov VL, Patterson ML. The Sage Handbook of Nonverbal Communication.
Thousand Oaks, CA: Sage; 2006.
4. Matsumoto DR, Frank MG, Hwang HS. Nonverbal Communication: Science and
Applications. Thousand Oaks, CA: Sage; 2013.
5. Poyatos F. Nonverbal Communication Across Disciplines. Amsterdam, The
Netherlands: John Benjamins Publishing; 2002.
6. Mehrabian A. Nonverbal Communication. Chicago, IL: Aldine-Atherton; 1972.
7. Remland MS, Jones TS, Brinkman H. Interpersonal distance, body orientation, and
touch: effects of culture, gender, and age. J Soc Psychol. 1995;135(3):281–297.
8. Heslin R, Patterson ML. Nonverbal Behavior and Social Psychology. New York, NY:
Plenum Press; 1982.
9. Geanellos R. Patients value friendly nurses. Aust Nurs J. 2004;11(11):38.
10. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA.
1992;267(16):2221–2226.
11. Institute of Medicine Committee on Quality of Health Care in America. Crossing the
Quality Chasm: A New Health System for the 21st Century. Washington, DC: National
Academy Press; 2001.
12. Epstein RM, Franks P, Fiscella K, et al. Measuring patient-centered communication in
patient-physician consultations: theoretical and practical issues. Soc Sci Med.
2005;61(7):1516–1528.
13. Bayer Institute for Health Care Communication. Clinician-Patient Communication to
Enhance Health Outcomes. West Haven, CT: Bayer Institute for Health Care
Communication; 2003.
14. Keller VF, Carroll JG. A new model for physician-patient communication. Patient
Educ Couns. 1994;23(2):131–140.
15. Nanchoff-Glatt M. Clinician-patient communication to enhance health outcomes. J
Dent Hyg. 2009;83(4):179.
16. Makoul G. Essential elements of communication in medical encounters: the
Kalamazoo consensus statement. Acad Med. 2001;76(4):390–393.
17. Duffy FD, Gordon GH, Whelan G, et al. Assessing competence in communication and
interpersonal skills: the Kalamazoo II report. Acad Med. 2004;79(6):495–507.
18. Bendapudi NM, Berry LL, Frey KA, Parish JT, Rayburn WL. Patients’ perspectives
 on ideal physician behaviors. Mayo Clin Proc. 2006;81(3):338–344.
19. Little P, Everitt H, Williamson I, et al. Preferences of patients for patient centred
approach to consultation in primary care: observational study. BMJ.
2001;322(7284):468–472.
20. Epstein R, Street RL; for the National Cancer Institute. Patient-Centered
Communication in Cancer Care: Promoting Healing and Reducing Suffering.
Bethesda, MD: National Cancer Institute, National Institutes of Health, U.S.
Department of Health and Human Services; 2007.
21. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for
patient-centered care. Health Aff (Millwood). 2010;29(7):1310–1318.
22. McCormack LA, Treiman K, Rupert D, et al. Measuring patient-centered
communication in cancer care: a literature review and the development of a systematic
approach. Soc Sci Med. 2011;72(7):1085–1095.
23. Smith RC, Dwamena FC, Grover M, Coffey J, Frankel RM. Behaviorally defined
patient-centered communication—a narrative review of the literature. J Gen Intern
Med. 2011;26(2):185–191.
24. Prose NS. A piece of my mind: paying attention. JAMA. 2000;283(21):2763.
25. Eide H, Graugaard P, Holgersen K, Finset A. Physician communication in different
phases of a consultation at an oncology outpatient clinic related to patient satisfaction.
Patient Educ Couns. 2003;51(3):259–266.
26. Gross DA, Zyzanski SJ, Borawski EA, Cebul RD, Stange KC. Patient satisfaction
with time spent with their physician. J Fam Pract. 1998;47(2):133–137.
27. Strasser F, Palmer JL, Willey J, et al. Impact of physician sitting versus standing
during inpatient oncology consultations: patients’ preference and perception of
compassion and duration. A randomized controlled trial. J Pain Symptom Manage.
2005;29(5):489–497.
28. Desmond J, Copeland LR. Communicating with Today’s Patient: Essentials to Save
Time, Decrease Risk, and Increase Patient Compliance. San Francisco, CA: Jossey-
Bass; 2000.
29. Schwartz B, Tesser A, Powell E. Dominance cues in nonverbal behavior. Soc Psychol
Q. 1982;45(2):114–120.
30. Kacperek L. Non-verbal communication: the importance of listening. Br J Nurs.
1997;6(5):275–279.
31. Roter DL, Hall JA, Katz NR. Relations between physicians’ behaviors and analogue
patients’ satisfaction, recall, and impressions. Med Care. 1987;25(5):437–451.
32. Olson KP. “Oh, by the way . . . ”: agenda setting in office visits. Fam Pract Manag.
2002;9(10):63–64.
33. Robinson JD. Closing medical encounters: two physician practices and their
implications for the expression of patients’ unstated concerns. Soc Sci Med.
 2001;53(5):639–656.
34. Duke P, Frankel RM, Reis S. How to integrate the electronic health record and
patient-centered communication into the medical visit: a skills-based approach. Teach
Learn Med. 2013;25(4):358–365.
35. Ventres WB, Frankel RM. Patient-centered care and electronic health records: it’s still
about the relationship. Fam Med. 2010;42(5):364–366.
36. Breen KJ, Greenberg PB. Difficult physician-patient encounters. Intern Med J.
2010;40(10):682–688.
37. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—a six-
step protocol for delivering bad news: application to the patient with cancer.
Oncologist. 2000;5(4):302–311.
 MODULE
2

MAKING OUR WORDS

UNDERSTANDABLE
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
Clear communication provides the foundation for the patient assessment
procedures; yet, many people—even highly educated people—have trouble
understanding words used in health care. In addition, health care terminology
is filled with jargon—much of which can be difficult for patients to
understand. This module explores strategies that dental health care providers
can employ to help patients understand dental health information and advice.

MODULE OUTLINE
SECTION 1 Roadblocks to Effective Communication
Medical and Dental Terminology
Reading Ability
SECTION 2 Making Health Care Words
Understandable
Words that May Confuse Dental Patients
 SECTION 3 Using the Internet to Improve
Communication Skills
Procedure 2-1. Procedure for Searching the Internet
SECTION 4 The Human Element
Through the Eyes of a Student
Researching Medical Conditions
SECTION 5 Skill Check
KEY TERM
Health literacy

OBJECTIVES
• Discuss how effective communication improves health outcomes.
• Discuss strategies for making health care words understandable to the
patient.
• Develop improved clinical communication skills and the ability to
role model those skills through simulated patient scenarios.

SECTION 1 • Roadblocks to Effective Communication

Medical and Dental Terminology

1. Unfamiliar Words
a. Health literacy in dentistry is “the degree to which individuals
have the capacity to obtain, process, and understand basic health
information and services needed to make appropriate oral health
decisions.”1–3
b. Limited health literacy is a potential barrier to the diagnosis,
treatment, and prevention of oral disease.2 Clear, accurate, and
effective communication is an essential skill for effective dental
 practice.
c. The American Dental Association (ADA) developed a strategic
action plan to provide guidance to dental professionals, policy
makers and others to improve health literacy. The plan, Health
Literacy in Dentistry Action Plan 2010-2015, may be downloaded
from the ADA’s website in pdf format.
2. Words in a New Context
a. Because health information can be complex and scientific, people
often have difficulty reading and understanding written materials
such as informational brochures about dental problems and
treatments, medical history forms, consent forms, and directions on
medication labels.
b. In many cases, a word may be familiar, but the person may not
understand it in a health care context.
1) For example, “you have a 6-mm pocket around this molar tooth”
might have no meaning to a patient. The patient might know
what the words deep and pocket mean in everyday speech but
have no idea what these words mean in terms of dental health.
2) Even a patient who understands these dental terms may need
more information than this sentence provides. He or she may
need to know what constitutes normal bone support for the teeth.
c. Box 2-1 provides suggestions for ways in which dental health care
providers can improve communication with patients.

BOX Best Practices for Promotion of Clear, Accurate

2-1
Communication1
• Create an environment that is respectful and “shame-free,” where
patients are offered assistance to better understand and use printed and
written communications.4–6
• Use clear and plain language in talking, writing, and printed education
materials.7–14
 • Encourage question asking by patients and dialogue between clinicians
and patients.15–19
• Check for successful communication by asking patients to explain their
interpretation of instructions and other information that has been
provided.20–25
• Offer patient education materials designed for easy use with clear
directions.26–32
• Periodically assess office/clinic for ways to improve
communication.33,34

3. Embarrassment. Many patients, because they are embarrassed or

intimidated, do not ask health care providers to explain difficult or
complicated information. If patients do not understand treatment or self-
care instructions, a crucial part of their dental care is missing, which
may have an adverse effect on their dental health.

Reading Ability
Reading ability can present another roadblock to effective communication.
1. Reading Ability Correlates to Health Status. According to a report
published in the Journal of the American Medical Association, the
ability to read is a stronger indication of health status than other
variables, including race, age, ethnic group, and educational level.35,36
2. Reading at Eighth to Ninth Grade Level
a. One out of five American adults reads at the fifth grade level or
below (Fig. 2-1).
 b. The average American reads at the 8th to 9th grade level, yet most
health care materials are written about the 10th grade level.37
c. Nearly 9 out of 10 U.S. adults have difficulty understanding and
using everyday health information that is generally available in
health care facilities.38
d. Individuals with low health literacy are less likely to seek health
care, comply with recommended treatment, and maintain self-care
regimens.1
3. Stigma of Illiteracy. Patients often are embarrassed or ashamed to
admit they have trouble understanding health information and
instruction.
a. There is a strong stigma attached to reading problems, and nearly
all nonreaders or poor readers try to conceal the fact that they have
trouble reading.39
b. Many people with poor reading skills have developed coping skills
that allow them to maneuver in the health care system with the least
amount of embarrassment.
c. Box 2-2 lists some clues that might indicate that the patient may
need additional help with written material.

BOX Clues that a Patient May Have Reading

2-2 Problems
• Registration, health history, or other forms filled out incompletely or
 incorrectly
• Written materials handed to a relative or other person accompanying
the patient
• “Can you help me fill out this form, I forgot my glasses?”
• “I will take this with me and read it at home.”
• “I can’t read this now; I forgot my glasses.”

SECTION 2 • Making Health Care Words

Understandable

Words that May Confuse Dental Patients

Many people, even highly literate people, have trouble understanding words
used in health care. In some instances, a word may be totally unfamiliar. In
other cases, a word may be familiar, but the person may not understand it in a
health care context.
• Words with a Latin or Greek prefix present special problems. The health
science field is full of such words. Here is a small sampling: pre-op,
post-op, prenatal, premature, unsweetened, decontaminate, antibacterial.
For example, the risk factor for poor readers with diabetes is that they
may recognize one part of the word, such as the sweetened in
unsweetened, and then skip the “un.” This kind of guessing can lead to
the opposite behavior.
• The National Patient Safety Foundation believes that three kinds of
words cause much of the misunderstanding:
• Medical words
• Concept words
• Value judgment words
• Tables 2-1 to 2-3 provide examples of common words and phrases that
may be confusing to patients and suggestions for common words and
phrases that can make health care information more understandable.
Table 2-4 provides examples of dental terminology that could be
confusing to patients.
 SECTION 3 • Using the Internet to Improve
Communication Skills
One effective mechanism for health care providers to improve
communication skills is through information gathering on the Internet. Dental
hygienists can search the Internet for information on medical conditions,
medications, and communication techniques. Procedure 2-1 provides
guidelines for conducting Internet searches.

Procedure 2-1. Procedure for Searching the Internet

EQUIPMENT:
Computer with Web browser software, a modem to connect to the
Internet, and an active Internet connection

Steps Purpose
1. Connect a computer to the The Internet browser is a
Internet and open an software program used for
Internet browser. Some of searching and viewing various
the most popular browsers kinds of Internet resources
are Internet Explorer, such as information on a
Safari, and Netscape. website.

2. Locate a search engine. The Internet has millions of

Most browsers have a pages of information. Search
built-in search engine. engines help you sift through
Popular search engines all those pages to find the
include Google, Lycos, information that you need.
AltaVista, Yahoo, and
Excite.

3. Look at the search engine’s The words that you type in the
Web page. Near the top of search box are called
the page, you will see a “keywords.” Keywords tell the
white box with the word search engine what to look for.
SEARCH next to it. Click For best results, it is important
the search box and type a to choose the keywords
carefully. Use one to three
 word or phrase that words that are as specific as
describes what you are possible.
looking for. Next, (1) press
the GO button next to the
search box or (2) hit the
Return key on your
keyboard.

4. View the results of your If the keywords are misspelled

search. If you did not find or not specific enough, the
what you are looking for, search engine will not find the
check spelling and retype information that you need.
or choose new keywords
and try the search again.

5. From the search results This allows you to view the

page, select an appropriate information on the website.
site and double click the
address written in blue to
open the website.

6. If the website information Downloading the information

is helpful, either download or bookmarking the website
the information or gives you access to it in the
bookmark the page. If you future.
need additional
information, return to the
results page or conduct
another search.

7. Try to complete the search The ability to effectively

process within 10 or 15 search the Internet is a vital
minutes. information-accessing tool for
dental health care providers.
SECTION 4 • The Human Element

Through the Eyes of a Student

SPEAKING IN PLAIN LANGUAGE

The first semester of school, I struggled to learn all the dental terminology.
I had never worked in a dental office and I felt that I was falling behind the
others in my class. Each day brought new words for me to understand and
learn to pronounce—words like armamentarium, line angle, and fossa. The
dental terminology was like a whole new language.
Then, overnight, I found myself speaking a “new language.” I felt so
proud of all the new words I had learned. I even told my parents that one of
the actresses on their favorite television show has a diastema.
Soon I was in clinic, explaining things to my patients using my dental
terminology. I thought that I was giving my patients a lot of very important
information. That is, until Mrs. M. was my patient. On our first
appointment, I told Mrs. M. all about how I would be scaling her teeth in
sextants. I asked her if she understood this treatment plan and Mrs. M.
gave me this big smile. She said, “I am sure that you are a very good dental
hygienist, but my goodness, I have not understood one word you said in
the past 10 minutes! If you want me to understand what you are saying you
are going to have to talk in everyday English.”
Well, Mrs. M. was so nice and had that big grin on her face and we
both just stated to laugh. So, right then and there, I told Mrs. M. just to
interrupt me every single time that I used a word that she did not
understand.
Now, I never talk to a patient without thinking of Mrs. M. Of all the
things that I have learned, I think that she taught me one of the most
important things. Now, I talk with patients in everyday words.
Kim, student,
South Florida Community College

Researching Medical Conditions

USING THE INTERNET

Select a medical or oral disease/condition to research on the Internet. Try

using www.google.com to search for information on the condition. Next,
search for support groups or chat rooms that might be helpful for a patient
who is experiencing the condition.
• How do you determine which Internet site provide reliable, correct
information about the disease or condition? Which sites are simple
opinion or a mechanism to sell a product?
• Which chat rooms or support groups are helpful to a patient? Which are
not helpful? Why?
• Participate in a discussion about the benefits and dangers of information
obtained from an Internet search.
 SECTION 5 • Skill Check

Skill Checklist: Communications Role-Play

ROLES:
• Student 1 = Plays the role of the patient.
• Student 2 = Plays the role of the clinician.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, each U equals 0 point.

CRITERIA: S E
Uses appropriate nonverbal behavior such as
maintaining eye contact, sitting at the same level as
the patient, nodding head when listening to patient,
etc.

Interacts with the patient as a peer and avoids a

condescending approach. Collaborates with the
patient and provides advice.
Communicates using common, everyday words.
Avoids dental terminology.
Listens attentively to the patient’s comments.
Respects the patient’s point of view.
Listens attentively to the patient’s questions.
 Encourages patient questions. Clarifies for
understanding, when necessary.

Answers the patient’s questions fully and

accurately.
Checks for understanding by the patient. Clarifies
information.
OPTIONAL GRADE PERCENTAGE
CALCULATION

Using the E column, assign a point value of 1 for

each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

NOTE TO COURSE INSTRUCTOR: A series of role-play

scenarios for the modules in this textbook can be found at
http://thepoint.lww.com/GehrigPAT4e.

References
1. American Dental Association Council on Access, Prevention and Interprofessional
Relations. Health Literacy in Dentistry Action Plan 2010-2015. Chicago, IL:
American Dental Association; 2009.
2. American Dental Association. Transactions. Chicago, IL: American Dental
Association; 2006.
3. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed.
Washington, DC: U.S. Department of Health and Human Services; 2000.
4. Weiss BD. Health Literacy and Patient Safety: Help Patients Understand. Chicago,
IL: American Medical Association Foundation; 2007.
http://nces.ed.gov/pubs2006/2006483.pdf. Accessed.
5. Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the
medical costs of Medicare managed care enrollees. Am J Med. 2005;118(4):371–377.
6. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health
literacy: the unspoken connection. Patient Educ Couns. 1996;27(1):33–39.
 7. Center for Plain Language. What is plain language?
http://centerforplainlanguage.org/about-plain-language-2/. Accessed May 30, 2016.
8. What is plain language? Improving communication from the federal government to
the public. http://www.plainlanguage.gov/whatisPL/. Accessed May 30, 2016.
9. Doak CC, Doak LG, Root JH. Teaching Patients with Low Literacy Skills. 2nd ed.
Philadelphia, PA: JB Lippincott Company; 1996.
10. Friedman DB, Hoffman-Goetz L. An exploratory study of older adults’
comprehension of printed cancer information: is readability a key factor?J Health
Commun. 2007;12(5):423–437.
11. Jefford M, Moore R. Improvement of informed consent and the quality of consent
documents. Lancet Oncol. 2008;9(5):485–493.
12. Ridpath JR, Wiese CJ, Greene SM. Looking at research consent forms through a
participant-centered lens: the PRISM readability toolkit. Am J Health Promot.
2009;23(6):371–375.
13. Safeer RS, Keenan J. Health literacy: the gap between physicians and patients. Am
Fam Physician. 2005;72(3):463–468.
14. Stableford S, Mettger W. Plain language: a strategic response to the health literacy
challenge. J Public Health Policy. 2007;28(1):71–93.
15. Agency for Healthcare Research and Quality. Questions to ask your doctor. Questions
are the answer. http://www.ahrq.gov/questionsaretheanswer. Accessed May 30, 2016.
16. Mika VS, Wood PR, Weiss BD, Treviño L. Ask me 3: improving communication in a
Hispanic pediatric outpatient practice. Am J Health Behav. 2007;31(suppl 1):S115–
S121.
17. Norlin C, Sharp AL, Firth SD. Unanswered questions prompted during pediatric
primary care visits. Ambul Pediatr. 2007;7(5):396–400.
18. Roter DL, Hall JA. Communication and adherence: moving from prediction to
understanding [editorial]. Med Care. 2009;47(8):823–825.
19. Sleath B, Roter D, Chewning B, Svarstad B. Asking questions about medication:
analysis of physician-patient interactions and physician perceptions. Med Care.
1999;37(11):1169–1173.
20. Baker DW. The meaning and the measure of health literacy. J Gen Intern Med.
2006;21(8):878–883.
21. Marcus EN. The silent epidemic—the health effects of illiteracy. N Engl J Med.
2006;355(4):339–341.
22. Parker RM, Ratzan SC, Lurie N. Health literacy: a policy challenge for advancing
high-quality health care. Health Aff (Millwood). 2003;22(4):147–153.
23. Rothman RL, DeWalt DA, Malone R, et al. Influence of patient literacy on the
effectiveness of a primary care-based diabetes disease management program. JAMA.
2004;292(14):1711–1716.
24. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication
with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–
90.
25. Youmans SL, Schillinger D. Functional health literacy and medication use: the
pharmacist’s role. Ann Pharmacother. 2003;37(11):1726–1729.
26. Jacobson TA, Thomas DM, Morton FJ, Offutt G, Shevlin J, Ray S. Use of a low-
literacy patient education tool to enhance pneumococcal vaccination rates. A
randomized controlled trial. JAMA. 1999;282(7):646–650.
27. Korhonen T, Huttunen JK, Aro A, et al. A controlled trial on the effects of patient
education in the treatment of insulin-dependent diabetes. Diabetes Care.
1983;6(3):256–261.
28. Kreuter MW, Strecher VJ, Glassman B. One size does not fit all: the case for tailoring
print materials. Ann Behav Med. 1999;21(4):276–283.
29. McGuckin M, Taylor A, Martin V, Porten L, Salcido R. Evaluation of a patient
education model for increasing hand hygiene compliance in an inpatient rehabilitation
unit. Am J Infect Control. 2004;32(4):235–238.
30. McGuckin M, Waterman R, Porten L, et al. Patient education model for increasing
handwashing compliance. Am J Infect Control. 1999;27(4):309–314.
31. Meade CD, McKinney WP, Barnas GP. Educating patients with limited literacy skills:
the effectiveness of printed and videotaped materials about colon cancer. Am J Public
Health. 1994;84(1):119–121.
32. Soltner C, Lassalle V, Galienne-Bouygues S, et al; for the Lifrea Group. Written
information that relatives of adult intensive care unit patients would like to receive—a
comparison to published recommendations and opinion of staff members. Crit Care
Med. 2009;37(7):2197–2202.
33. Detmar SB, Muller MJ, Wever LD, Schornagel JH, Aaronson NK. The patient-
physician relationship. Patient-physician communication during outpatient palliative
treatment visits: an observational study. JAMA. 2001;285(10):1351–1357.
34. Fitzpatrick LA, Melnikas AJ, Weathers M, Kachnowski SW. Understanding
communication capacity. Communication patterns and ICT usage in clinical settings. J
Healthc Inf Manag. 2008;22(3):34–41.
35. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American
Medical Association. Health literacy: report of the Council on Scientific Affairs.
JAMA. 1999;281(6):552–557.
36. Nielsen-Bohlman L, Panzer AM, Kindig DA. Health Literacy: A Prescription to End
Confusion. Washington, DC: National Academies Press; 2004.
37. Kirsch IS. Adult Literacy in America: A First Look at the Results of the National Adult
Literacy Survey. 2nd ed. Washington, DC: U.S. Department of Education, Office of
Educational Research and Improvement; 1993.
38. Kutner MA. The Health Literacy of America’s Adults: Results from the 2003 National
Assessment of Adult Literacy. Washington, DC: U.S. Department of Education,
National Center for Education Statistics; 2006.
http://nces.ed.gov/pubs2006/2006483.pdf. Accessed May 30, 2016.
39. Center for Health Care Strategies. What is health literacy?
http://www.chcs.org/media/CHCS_Health_Literacy_Fact_Sheets_2013.pdf. Accessed
May 30, 2016.
 MODULE
3

OVERCOMING
COMMUNICATION
BARRIERS
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
Being able to communicate effectively—or to participate in the exchange of
information—is an essential skill for dental health care providers. For many
dental health care providers in the United States and Canada, providing
patient-centered care involves learning to communicate effectively with
patients even when various barriers to communication are present.
This module presents strategies for effectively communicating with:
• Patients who speak a different language than that of the dental health
care provider
• Patients with culturally influenced health behaviors that differ from the
health care beliefs of the dental clinician
• Young and school age children
• Adolescents
• Older adults
 • Children with attention deficit hyperactivity disorder
• Patients who are deaf, blind, or unable to speak
• Patients with disabilities

MODULE OUTLINE
SECTION 1 Language Barriers
Cross-Cultural Communication
Cultural Competence
SECTION 2 Age Barriers
Communicating with Children and Adolescents
Communicating with Older Adults
SECTION 3 Vision and Hearing Barriers
Communication with People Who Are Blind or Have Low
Vision
Providing Directions to People Who Are Blind or Have
Low Vision
Communication with People Who Are Deaf or Hard of
Hearing
SECTION 4 Speech Barriers
Communication with People Who Are Unable to Speak
Effectively
Communication with People Who Have Had a
Laryngectomy
SECTION 5 Special Health Care Needs
Disability Cultural Awareness and Etiquette
“People-First” Language
Potential Barriers to Dental Care for Patients with Special
Needs
Communication with People Who Have an Intellectual
Disability
 Communication with Children with Attention Deficit
Hyperactivity Disorder
Communication with People Who Have an Autism
Spectrum Disorder
Communication with People Who Have Cerebral Palsy
SECTION 6 The Human Element
Through the Eyes of a Student
Through the Eyes of Others
Communication Scenario
SECTION 7 Skill Check
KEY TERMS
Cultural competency • Low vision • Service animal • Presbycusis •
Dysarthria • Aphasia • Laryngectomy • Patients with special needs •
People-First language • Intellectual/cognitive disability • Down syndrome
• Attention deficit hyperactivity disorder (ADHD) • Autism spectrum
disorder • Cerebral palsy

OBJECTIVES
• Describe some of the changes in the population of North America
during the last few decades and explain how these changes can affect
dental health care.
• Give an example of how cultural differences could affect
communication.
• Define cultural competence.
• Discuss effective communication techniques for interacting with
patients from different cultures.
• Explore how cultural variables impact the delivery of health care
services.
• Discuss strategies that health care providers can use to improve
communication with children.
 • Discuss strategies that health care providers can use to improve
communication with adolescents.
• Discuss strategies that health care providers can use to improve
communication with older adults.
• Discuss strategies that health care providers can use to improve
communication with children with attention deficit hyperactivity
disorder (ADHD).
• Discuss strategies that health care providers can use to improve
communication with patients who are blind, deaf, or unable to speak.
• Discuss strategies that health care providers can use to improve
communication with patients who have a disability or special health
care need.

SECTION 1 • Language Barriers

Cross-Cultural Communication
MULTICULTURALISM
1. Ethnic and Cultural Diversity. North American communities are
becoming increasingly diverse in their ethnic and cultural makeup. This
increasingly diverse cultural makeup means that strategies need to be
developed to ensure that all segments of the population are receiving the
oral health care that they need.1–5
a. Findings from the “Unequal Treatment” report in the United States
indicated that health care providers might contribute to ethnic health
disparities because of prejudice, stereotyping, and lack of knowledge
regarding how to provide care to diverse ethnic populations.6–8
b. In Canada, the report “Building on Values: The Future of Health Care
in Canada” identifies ethnic minorities as populations whose health is
at greatest risk.9
c. Factors that contribute to health disparities are ethnicity,
 socioeconomic status, gender, level of education, and age.1–5 These
same factors contribute to oral health disparities in dental caries rates,
periodontal disease, tooth loss, oral cancer, and tobacco use.1
2. Non-English-Speaking Communities. For many dental health care
providers in North America, providing patient-centered care involves
learning to communicate effectively with patients from non-English-
speaking communities and with cultural backgrounds that may be
unfamiliar (Table 3-1).
a. The United States has always had a significant foreign-born
population, but the number of foreign born reached an all-time high of
32.5 million in 2002—equal to 11.5% of the U.S. population—
according to the Current Population Survey (CPS).10 By the year
2030, the United States Census Bureau predicts that 60% of the U.S.
population will self-identify as White, non-Hispanic, and 40% will
self-identify as members of other diverse racial and ethnic groups.
b. The Canadian 2001 population census indicates that 18.5% of the
population in Canada is foreign-born.
c. More than one-half of the 2002 foreign-born residents in the United
States were born in Latin America—with 30% from Mexico alone.
Among foreign-born residents in the United States, 26% were born in
Asia, 14% in Europe, and 8% from Africa and other regions.
d. Data from the 2000 census show that over 47 million persons speak a
language other than English at home, up nearly 48% since 1990.
Although the majority are able to speak English, over 21 million
speak English less than “very well,” up 52% from 14 million in
1990.11,12
e. Communication problems can easily occur if a patient is not fluent in
English. An individual who is just learning the language may
communicate well in everyday situations, but in the dental setting,
however, the same person may not fully understand what is being
discussed.
f. Being competent to meet the communication challenge created by a
 multicultural population requires a set of skills, knowledge, and
attitudes that enable the clinician to understand and respect patients’
values, beliefs, and expectations.

MINORITY POPULATIONS IN THE UNITED STATES

According to the United States Census Bureau,10,11 the proportion of the
overall population in the United States considered to be minority will
increase from 26.4% in 1995 to 47.2% in 2050. Figure 3-1 shows the racial
distribution of current U.S. population. Figure 3-2 shows the percentage
increases in each racial minority group that occurred between 2000 and 2010
in the United States.
THE HISPANIC POPULATION IN THE UNITED STATES
• Hispanics are the largest minority ethnic group in the United States, and
this group continues to grow in number; as reported in the 2010 United
States Census, the Hispanic population increased by 43.0% between
2000 and 2010 (Fig. 3-3).

• Among all Hispanics living in this country, 62% are native born and
38% are foreign born.
• Currently in the United States, the Hispanic population makes up 16.3%
of the overall population (Fig. 3-4). Geographically, there are a number
of areas—particularly in the South and West—that have much larger
Hispanic populations.

• English language skills vary throughout the U.S. Hispanic population,

and developing strategies for communicating with Hispanics who have
limited skills in English is an important goal for all health care providers
in the United States.

Cultural Competence
Cultural competency is the application of cultural knowledge, behaviors,
interpersonal skills, and clinical skills to enhance a dental health care
provider’s effectiveness in managing patient care.
• Cultural competence indicates an understanding of important differences
 that exist among various ethnic and cultural groups in our country.
• Understanding patients’ diverse cultures—their values, traditions,
history and institutions—is not simply political correctness. It is
essential in providing quality patient care.
• Culture shapes individuals’ experiences, perceptions, decisions, and how
they relate to others. It influences the way patients respond to dental
services, preventive interventions, and impacts the way dental health
care providers deliver dental care.
• In a culturally diverse society, dental professionals need to increase their
awareness of and sensitivity toward diverse patient populations and
work to understand culturally influenced health behaviors. Box 3-1
outlines actions to develop cultural competence.

BOX Ways to Develop Cultural Competence

3-1

• Recognize your own assumptions.

• Value diversity. Demonstrate an appreciation for the customs, values,
and beliefs of people from different cultural and language
backgrounds.
• Demonstrate flexibility. Carry out changes to meet the needs of your
diverse patients.
• Communicate respect. Do not judge. Show empathy.

CULTURAL DIFFERENCES
Dental professionals interact with people from varied ethnic backgrounds and
cultural origins who bring with them beliefs and values that may differ from
the care provider’s own.
• Understanding cultural differences can aid communication and thereby
improve patient care.
• Preconceived ideas about a given culture can hinder a clinician from
providing good care.
• Each patient is unique, and his or her dental care needs differ. Some
 cultures may be offended by the intensely personal questions necessary
for a health history and may perceive them as an inexcusable invasion of
privacy.
• People of various backgrounds also perceive the desirability of making
direct eye contact differently.
• To help avoid miscommunication and offending patients, dental health
care providers must be sensitive to these cultural differences.
TIPS FOR IMPROVING CROSS-CULTURAL COMMUNICATION
Cross-cultural communication is about dealing with people from other
cultures in a way that minimizes misunderstandings and maximizes trust
between patients and health care providers. The following simple tips will
improve cross-cultural communication.
1. Speak slowly, not loudly. Slow down and be careful to pronounce
words clearly. Do not speak loudly. A loud voice implies anger in many
cultures. Speaking loudly might cause the patient to become nervous.
Use a caring tone of voice and facial expressions to convey your
message.
2. Separate questions. Try not to ask double questions. Let the patient
answer one question at a time.
3. Repeat the message in different ways. If the patient does not
understand a statement, try repeating the message using different words.
Be alert to words that the patient understands and use them frequently.
4. Avoid idiomatic expressions or slang. American English is full of
idioms. An idiom is a distinctive, often colorful expression whose
meaning cannot be understood from the combined meaning of its
individual words, for example, the phrase “to kill two birds with one
stone.”
5. Avoid difficult words and unnecessary information. Use short,
simple sentences. Do not overwhelm the patient with too many facts and
lengthy, complicated explanations.
6. Check meanings. When communicating across cultures never assume
 that the other person has understood. Be an active listener. Summarize
what has been said in order to verify it. This is a very effective way of
ensuring that accurate cross-cultural communication has taken place.
7. Use visuals where possible. A picture really is worth a thousand words;
the universal language of pictures can make communication easier.
Picture boards (Fig. 3-5) with medical/dental images are helpful in
getting your message across.

8. Avoid negative questions. For example, “So then, you don’t want an
appointment on Monday?” A better question would be “What day of the
week is best for you?” Questions with negative verbs such as “don’t” or
“can’t” are particularly confusing to Asian patients.
9. Take turns. Give the patient time to answer and explain his or her
response.
10. Be supportive. Giving encouragement to those with weak English skills
gives them confidence and a trust in you.
11. Use humor with caution. In many cultures, health care is taken very
seriously. Some foreign-born patients may not appreciate the use of
humor or jokes in the dental office setting.
12. Watch for nonverbal cues. Be attentive for signs of fear, anxiety, or
confusion in the patient.
13. Use interpreters to improve communication. If the patient speaks no
 English or has limited understanding, use a trained clinical interpreter
who is fluent in the patient’s native language as well as in medical and
dental terminology. When using an interpreter, speak directly to the
patient rather than to the interpreter.
14. Don’t use family members as translators. A family member who is
not knowledgeable in medical and dental terminology is likely to
translate your message incorrectly. The presence of a family member or
friend may also constitute a serious breach of patient confidentiality.
15. Ask permission to touch the patient. Ask permission to examine the
patient and do not touch the patient until permission is granted.
16. Check for understanding. Ask the patient to repeat instructions.
Correct any misunderstandings. This can be done diplomatically by
saying something like “Will you repeat the instructions that I gave you
to make sure that I did not forget anything?”
17. Provide written material. When possible, provide simple, illustrated
materials for the patient to take home.

SECTION 2 • Age Barriers

Young children, adolescents, and older patients present unique
communication concerns. Even experienced health care providers can find it
challenging to communicate effectively with individuals who are much
younger or older in age. It can be difficult to relate to the life experiences or
health problems of someone who is 30 or 40 years older. Some health care
providers with limited experience with young children find it difficult to
know what to say and what not to say when speaking with young children.
Children and adolescents frequently are accompanied to the office by a
parent. An adult child or caregiver may accompany older adults. Parents,
adult children, and caregivers add a unique aspect to the communication
process. The patient should always be the focus of the clinician’s attention
and, where possible, information is exchanged directly with the patient.
Suggestions for communicating with children, adolescents, and older adults
are outlined in Box 3-2, Box 3-3, and Box 3-4.
Communicating with Children and Adolescents

BOX Strategies for Communicating with Children

3-2

• Introduce yourself to the child. Speak softly; use simple words and the
child’s name.
• Adjust your height to that of the child.
• Treat children with respect—over the age of 4 years, they can
understand a lot.
• Describe actions before carrying them out.
• Make contact with the child (e.g., “I promise to tell you everything I’m
going to do if you’ll help me by cooperating.”).
• Talk to young children throughout the assessment procedure.
• Give praise during each stage of the assessment, such as “that’s good,”
“well done,” etc.
• Be aware of needs and concerns that are unique to children. For
example, children may avoid wearing orthodontic headgear due to
pressures and comments from peers.
• Do not ask the child’s permission to perform a procedure if it will be
performed in any case.
• Do not talk about procedures that will be done later in the appointment
to children who are younger than 5 years of age. Very young children
have no clear concept of future events and will imagine the worst about
what could happen.
• Communicate all information directly to the child or to both child and
parent, ensuring that the child remains the center of your attention. If
complex information must be communicated to the parent, arrange to
speak to the parent alone (without the child’s presence).

BOX Strategies for Communicating with Teens

3-3
 • Speak in a respectful, friendly manner, as to an adult.
• Respect independence; address the teenager directly rather than the
parent.
• Obtain health history information directly from the teenager, rather
than the parent, if possible.
• Recognize that a teenager may be reluctant to answer certain questions
honestly in the parent’s presence.
• Ask questions about tobacco, drug, or alcohol use privately.
• Some teenagers may be intensely shy or self-conscious; others may be
overconfident and boastful. Allow silence so that the teenager can
express opinions and concerns.

BOX Strategies for Communicating with Older

3-4 Adults
• Before you begin your conversation, reduce background noises that
may be distracting (close the treatment room door; move from a noisy
reception area to a quieter place).
• Begin the conversation with casual topics such as the weather or
interests of the person.
• Keep your sentences and questions short. Avoid quick shifts from topic
to topic.
• Allow extra time for responding. As people age, they function better at
a slower pace; do not hurry them.
• Take time to understand the patient’s true concerns. Some older people
will hold back information feeling that nothing can be done or not
wanting to “waste your time.”
• Take time to explain in easy-to-understand language the findings of
your examination.
• Look for hints from eye gaze and gestures that your message is being
understood.
• Speak plainly and make sure that the patient understands by having him
 or her repeat instructions. For example, say, “I may have forgotten to
tell you something important. Would you please repeat what I told
you?”

Communicating with Older Adults

The U.S. population is aging at a dramatic rate. The U.S. population of
persons 65 years and older will increase by 76% from 2010 to 2030. The
numbers of persons 85 years and older in the United States will increase by
116% from 2010 to 2030. This tremendous demographic shift will have a
profound effect on the health care sector. Over the next 50 years or so, there
will most likely be an increased demand for dental health care providers
skilled in caring for the geriatric population. Communicating with older
people often requires extra time and patience because of physical,
psychological, and social changes of normal aging. Communicating with
older adults requires many of the same rules as for children—the patient
should always be the focus of the dental health care provider’s attention.

SECTION 3 • Vision and Hearing Barriers

Communication with People Who Are Blind or Have Low

Vision
According to the National Eye Institute, 1.3 million Americans are blind and
2.9 million Americans have low vision.15 Low vision means that even with
corrective lenses and/or medical treatment, people have difficulty performing
everyday tasks. Box 3-5 presents suggestions for effective communication
with a person who is blind or has low vision.

BOX Strategies for Communicating with a Person

3-5 Who Is Blind or Has Low Vision
• As soon as you enter the room, be sure to greet the person. This alerts
the person to your presence, avoids startling him or her, and eliminates
uncomfortable silences. Address the person by name, so he or she will
immediately know that you are talking to him or her rather than
someone who happens to be nearby. When greeting a person who is
blind or has low vision, do not forget to identify yourself. For example,
“Hello, Mrs. Jones. I am Robin Shiffer, the dental hygienist here in Dr.
Rolfs’ office.”
• Speak directly to person who is blind, not through an intermediary,
such as a relative or caregiver.
• Speak distinctly, using a natural conversational tone and speed. Unless
the person is hard of hearing, you do not need to raise your voice.
• Explain the reason for touching the person before doing so.
• Be an active listener. Give the person opportunities to talk. Respond
with questions and comments to keep the conversation going. A person
who has low vision cannot necessarily see the look of interest on your
face, so give verbal cues to let him or her know that you are actively
listening.
• Always answer questions and be specific or descriptive in your
responses.
• Orient the person to sounds in the environment. For example, explain
and demonstrate the sound that an ultrasonic instrument makes before
using it in the patient’s mouth.
• Tell the patient when you are leaving the room and where you are
going (i.e., “I am going to develop the x-rays that we just took.”).
• Be precise and thorough when you describe people, places, or things to
someone who is blind. Do not leave out things or change a description
because you think it is unimportant or unpleasant.
• Feel free to use words that refer to vision during the course of a
conversation. Vision-oriented words such as look, see, and watching
TV are a part of everyday verbal communication. Making reference to
colors, patterns, designs, and shapes is perfectly acceptable. The word
blind is also acceptable in conversation.
 • Indicate the end of a conversation with a person who is blind or has
low vision to avoid the embarrassment of leaving the person speaking
when no one is actually there.
• When you speak about someone with a disability, refer to the person
and then to the disability. For example, refer to “a person who is blind”
rather than to “a blind person.”

Providing Directions to People Who Are Blind or Have

Low Vision
When giving directions from one place to another, people who are not blind
tend to use gestures—pointing, looking in the direction referred to, etc.—at
least as much as they use verbal cues. That is not helpful to a person who is
blind or has low vision. And often, even verbal directions are not precise
enough for a person who cannot see—for example, “It’s right over there” or
“It’s just around the next corner.” Where is “there”? Where is “the next
corner”? In the dental office, you might say something like “Walk along the
wall to your left past three doorways. The room that we want is at the fourth
doorway; make a sharp turn to the right to enter the room.”
The Americans with Disabilities Act (ADA) prohibits businesses that
serve the public from banning service animals. A service animal is defined
as any guide dog or other animal that is trained to provide assistance to a
person with a disability. The animal does not have to be licensed or certified
by the state as a service animal. The service animal should not be separated
from its owner and must be allowed to enter the treatment room with the
patient. The ADA law supersedes local health department regulations that
ban animals in health care facilities. Box 3-6 provides suggestions for useful
techniques when acting as a sighted guide for a person who is blind or has
low vision.

BOX Acting as a Sighted Guide

3-6
 Sighted guide technique enables a person who is blind to use a person
with sight as a guide. The technique follows a specific form and has
specific applications.
• Offer to guide a person who is blind or has low vision by asking if he
or she would like assistance. Be aware that the person may not need or
want guided help; in some instances, it can be disorienting and
disruptive. Respect the wishes of the person you are with.
• If your help is accepted, offer the person your arm. To do so, tap the
back of your hand against the palm of his or her hand. The person will
then grasp your arm directly above the elbow. Never grab the person’s
arm or try to direct him or her by pushing or pulling.
• Relax and walk at a comfortable normal pace. Stay one step ahead of
the person you are guiding, except at the top and bottom of stairs. At
these places, pause and stand alongside the person. Then resume travel,
walking one step ahead. Always pause when you change directions,
step up, or step down.
• It is helpful, but not necessary, to tell the person you are guiding about
stairs, narrow spaces, elevators, and escalators.
• The standard form of sighted guide technique may have to be modified
because of other disabilities or for someone who is exceptionally tall or
short. Be sure to ask the person you are guiding what, if any,
modifications he or she would like you to use.
• When acting as a guide, never leave the person in “free space.” When
walking, always be sure that the person has a firm grasp on your arm.
If you have to be separated briefly, be sure the person is in contact with
a wall, railing, or some other stable object until you return.
• To guide a person to a seat, place the hand of your guiding arm on the
seat. The person you are guiding will find the seat by following along
your arm.

Communication with People Who Are Deaf or Hard of

Hearing
An estimated 30 million or 12.7% of Americans 12 years and older had
bilateral hearing loss from 2001 to 2008, and this estimate increases to 48.1
million or 20.3% when also including individuals with unilateral hearing loss.
Approximately 15% of American adults (37.5 million) report some trouble
hearing.16–18 In describing hearing loss, people who are hard of hearing may
say that they can hear sounds but cannot understand what is being said. For
many people who are hard of hearing, low-frequency speech sounds such as
“a,” “o,” and “u” may be clearly heard, while other high-frequency sounds
such as “s,” “th,” and “sh” may be much less distinct. In this situation, speech
is heard but often misunderstood. “Watch” may be mistaken for “wash” and
“pen” for “spent.” A clearer comprehension of speech may be gained with a
hearing aid or a cochlear implant. However, use of these devices does not
restore normal hearing.
Presbycusis (presby = elder, cusis = hearing) is the loss of hearing that
gradually occurs in most individuals as they grow old. Everyone who lives
long enough will develop some degree of presbycusis, some sooner than
others. It is estimated that 40% to 50% of people 75 years and older have
some degree of hearing loss. The loss associated with presbycusis is usually
greater for high-pitched sounds.
Box 3-7 provides suggestions for actions that can promote effective
communication with a person who is deaf or hard of hearing.

BOX Strategies for Communicating with a Person

3-7 Who Is Deaf or Hard of Hearing
• Move closer to the person. Shortening the distance between the speaker
and listener will increase the loudness of sound. This approach is much
more effective than raising your voice. Never shout as a person who is
hard of hearing.
• Reduce background noise. Many noises that we take for granted are
 amplified by a hearing aid or cochlear implant, especially while
utilizing nitrous oxide analgesia or conscious sedation.
• Talk face to face. Speak at eye level. Do not cover your mouth with a
mask when you ask the patient questions or give instructions.
• Try rewording a message. At times, a person with a hearing loss may
be partially dependent on speech reading (lip reading) because some
sounds may not be easily heard even with a hearing aid. Because some
words are easier to speech read than others, rephrasing a message may
make it easier for the person to understand.
• Use a notepad to write down important questions or directions so that
the person can read them. This helps eliminate misunderstandings. If
the person cannot read or reads in a language that is unfamiliar to you,
a picture board (see Fig. 3-5) may be quite helpful.
• Make sure that the person fully understands what you said. Some
people, especially if the hearing loss is recent, are reluctant to ask
others to repeat themselves. They feel embarrassed by their hearing
loss. Simply ask the person to repeat what you said. For example, say,
“If you could please repeat back to me what I said, I can make sure I
told you everything that I need to.”
• Show special awareness of the hearing problem. Call the person with a
hearing loss by name to initiate a communication. Give a frame of
reference for the discussion by mentioning the topic at the outset (“I
would like to review your medications.”).
• Be patient, particularly when the person is tired or ill and may be less
able to hear.

SECTION 4 • Speech Barriers

Communication with People Who Are Unable to Speak

Effectively
It is important to remember that problems with speech or language do not
necessarily mean that the person has an intellectual impairment. For example,
people who have suffered a stroke are often frustrated when others think that
their intellect has been impaired because of their problems with
communication. Difficulty with speech does not have anything to do with
intelligence. If understanding is difficult, it may be useful to ask the person to
write a word or phrase. Box 3-8 provides suggestions for useful actions when
communicating with patients with speech impairment.

BOX Strategies for Communicating with a Person

3-8 Who Is Unable to Speak Effectively
• Book longer appointment times to allow for the longer time needed for
communication.
• Whenever possible, speak directly to the patient; even if
comprehension is limited, the patient will be more responsive if he or
she is an active participant.
• Develop a tolerance for silences. Many patients require extra time to
process your questions and/or to formulate a response.
• Do not talk while the patient is formulating a response—this is very
distracting.
• Try not to panic when communicating with a person who cannot speak
effectively. If you feel nervous, do not let it show.
• Never finish a sentence for someone who is struggling with his or her
speech—be patient and wait for him or her to finish.
• Find out if the patient has his or her own way of indicating “yes” or
“no” (e.g., looking up for yes).
• If you are having problems understanding the person, say so. Do not
pretend you understand if you do not as this will inevitably create
problems later on. Simply apologize and ask if the patient would mind
writing down what it is he or she wants to say.
• If you are having difficulties communicating with the patient, ask
permission to direct your questions to the support person. Remember to
look directly at the patient from time to time so that he or she still feels
 a part of the conversation.
• Use gestures and pictures to help the patient understand. For example,
wave hello and goodbye, point to a tooth, or show simple pictures to
clarify procedures.

DYSARTHRIA
Dysarthria refers to speech problems that are caused by the muscles
involved with speaking or the nerves controlling them. Individuals with
dysarthria have difficulty expressing certain words or sounds. Speech
problems experienced include:
• Slurred speech
• Speaking softly or barely able to whisper
• Slow rate of speech
• Rapid rate of speech with a “mumbling” quality
• Limited tongue, lip, and jaw movement
• Abnormal rhythm when speaking
• Changes in vocal quality (“nasal” speech or sounding “stuffy”)
• Drooling or poor control of saliva
• Chewing and swallowing difficulty
• Common causes of dysarthria are poorly fitting dentures, stroke, any
degenerative neurological disorder, and alcohol intoxication.
• After a stroke or other brain injury, the muscles of the mouth, face, and
respiratory system may become weak, move slowly, or not move at all.
• Some former severe alcoholics who have developed brain damage due to
drinking may have continued problems with language, even after years
of sobriety.
APHASIA
Aphasia is a disorder that results from damage to language centers of the
brain.
• It can result in a reduced ability to understand what others are saying, to
express ideas, or to be understood.
• Some individuals with this disorder may have no speech, whereas others
 may have only mild difficulties recalling names or words.
• Others may have problems putting words in their proper order in a
sentence.
• The ability to understand oral directions, to read, to write, and to deal
with numbers may also be disturbed.
• For almost all right-handers and for about half of left-handers, damage
to the left side of the brain causes aphasia. As a result, individuals who
were previously able to communicate through speaking, listening,
reading, and writing become more limited in their ability to do so.
• The most common cause of aphasia is stroke, but gunshot wounds,
blows to the head, other traumatic brain injury, brain tumor, Alzheimer
disease, and transient ischemic attack (TIA) can also cause aphasia.

Communication with People Who Have Had a

Laryngectomy
Laryngectomy—the surgical removal of the voice box due to cancer—
affects approximately 9,000 individuals each year; most are older adults.
People who have undergone laryngectomy have several options for
communication:
• The artificial larynx. Held against the neck, the artificial larynx
transmits an electronic sound through the tissues, which is then shaped
into speech sounds by the lips and tongue. The user articulates in the
normal way.
• Esophageal voice. Esophageal voice is achieved by learning to pump air
from the mouth into the upper esophagus. The air is then released,
causing the pharyngoesophageal segment to vibrate to produce a hoarse
low-pitched voice.
• Surgical voice restoration. Fitting a prosthesis or valve into a puncture
hole between the trachea and esophagus either at the time of surgery or
at a later date may restore voice. The individual occludes the stoma
when he or she wishes to speak. Air then passes through the valve into
 the esophagus, producing voice in the same way as for esophageal voice.
• Silent mouthing/writing/gesture. A small percentage of patients never
acquire a voice and are unable to use an electronic larynx. They
communicate by silently articulating words or a mixture of writing and
gesture.
Box 3-9 provides suggestions for actions that can promote effective
communication with a person with a laryngectomy.

BOX Strategies for Communicating with a Person

3-9 with a Laryngectomy
• Use the suggestions provided in Box 3-8.
• Give the patient plenty of time to speak. Do not hurry the person; if the
patient feels pressured, it can affect the ability to communicate.
• Ask the patient to repeat if you do not understand. Do not pretend you
understand if you do not—it will be obvious to the patient that you do
not understand.
• Watch a person’s lips if you are finding it hard to understand.
• Do not assume it is a hoax call or that someone playing is a joke if you
hear an electronic sounding voice or someone struggling to
communicate over the telephone.

SECTION 5 • Special Health Care Needs

Disability Cultural Awareness and Etiquette

American Dental Association defines patients with special needs as “those
[individuals] who due to physical, medical, developmental or cognitive
conditions require special consideration when receiving dental treatment.
This can include people with autism, Alzheimer’s disease, Down syndrome,
spinal cord injuries, and countless other conditions or injuries that can make
standard dental procedures more difficult.”
 According to the United States Census Bureau 2010 survey,
approximately 56.7 million people (18.7%) living in the civilian
noninstitutionalized population of the United States have some kind of
disability. About 38.3 million people (12.6%) have a severe disability.19
People with disabilities constitute our nation’s largest and most diverse
minority group. Everyone is represented: all genders, all ages, all religions,
all socioeconomic levels, and all ethnic backgrounds. There are many
different types of disabilities: vision, hearing, physical, cognitive/intellectual,
mental health, visible versus invisible, and developmental versus acquired.
Most people think of cultural awareness as relating to ethnic
populations. However, the population of people with disabilities is a growing
group that deserves attention in the realm of cultural awareness. Disability
etiquette is a large part of cultural awareness for people with special health
care needs. As with all patients, each person with a disability or special health
care need is unique even within the grouping or classification of a condition,
disease or disability they have.

“People-First” Language
The language a society uses to refer to persons with medical conditions or
disabilities shapes its beliefs and ideas about them. When we describe people
by their medical conditions—such as “He is diabetic,” “She is a spina bifida
patient”—we devalue them as individuals. In contrast, using thoughtful
terminology—such as, “He has diabetes,” “The baby has spina bifida”—
indicates that he or she has a condition (that does not define him or her as a
person). One suggested tool for communicating with and about people with
medical conditions or disabilities is “People-First language.” People-First
language emphasizes the person, not the condition/disability. By placing the
person first, the disability is no longer the primary, defining characteristic of
an individual, but one of several aspects of the whole person. For example, a
person who wears glasses doesn’t say, “I have a problem seeing,” they say, “I
wear/need glasses.” Similarly, a person who uses a wheelchair doesn’t say, “I
have a problem walking,” they say, “I use/need a wheelchair.”
 The significant push to use “People-First” language to avoid an
unintentional offense has been met with mixed emotions in the disability
community. Regardless of the intent, recognizing and expressing the
importance of the value of each individual regardless of their particular
abilities is paramount to the relationship between the dental professional,
patient, and family/caregivers. Table 3-2 provides examples of “People-First”
language.

In addition to language, examples of other types of disability etiquette

are presented in Box 3-10.

BOX Examples of Disability Etiquette

3-10

• Greet and talk directly to the person with a disability.

• Talk to adults like adults unless you know their intellectual age is much
lower.
• Assistive devices (wheelchairs, braces, walkers, etc.) are an extension
of the person—avoid touching, leaning on, or removing items from
their reach without permission.
• Ask permission before offering help.
• When in doubt . . . ask!
• Ask if you can fist bump or shake hands.
• Treat with respect and dignity.
• Relax.
• Don’t worry if you unintentionally use a word or phrase connected to
the disability (Saying “Do you see what I mean?” to a patient who is
 visually impaired.).

Potential Barriers to Dental Care for Patients with Special

Needs
Communication with people who have a disability or special health care need
includes recognizing possible barriers these patients might encounter prior to
arriving at the dental office. Perceptions about dental care for people with
special health care needs include positive and negative biases on the part of
the dental team, medical team, patient, and patient’s family/caregivers.
The dental experience for a patient with a special health care needs
begins long before the actual dental appointment. Understanding how many
potential barriers the patient has overcome to arrive at the dental appointment
can be the key to successful communication and treatment.
• Depending on the nature of the disability or health condition, the patient
might be completely dependent on someone else to recognize the need
for dental care and act on that need. In some instances, the health values
of the family or caregiver may determine the frequency of dental care
appointments.
• Like anyone else, a patient with a disability may have concerns about the
cost of dental treatment. There is a common misconception that all
people with special health care needs cannot afford dental care.
However, people with special health care needs come from all
socioeconomic backgrounds. They have various degrees of insurance
coverage and financial resources.
• Regardless of their desire to get dental treatment, transportation barriers
are also a concern for some people who rely on others to get them to
their appointment. Mistaking a failed appointment or consistently late
arrivals as a lack of patient concern for oral health can lead to additional
barriers.
• Effective communication with someone who has a disability affecting
speech or cognitive abilities can be a challenge in some cases.
Communication with People Who Have an Intellectual
Disability
People with an intellectual/cognitive disability typically have an IQ score of
70 or less with a diagnosis or onset before 18 years of age on the Wechsler &
Stanford-Binet Scales. They also have concurrent impairments in adaptive
functioning in at least one of the following areas:
• Communication, social skills, self-direction
• Daily home living, self-care activities
• Functional academic, work, health, and safety skills20,21
Determining the intellectual age of the patient with a
cognitive/intellectual disability is the key to utilizing communication
strategies appropriate for the patient. The parent or caregiver can inform the
clinician of the patient’s intellectual age. (e.g., A 56-year-old man with the
intellectual age of a 5-year-old presents for clinical assessment. The hygienist
should communicate with the man in a manner appropriate for a 5-year-old
child and include the parent/caregiver in discussions.)
Down syndrome is a set of physical and mental traits caused by a gene
problem that happens before birth.20,22 Children who have Down syndrome
tend to have certain features, such as a flat face and a short neck. Down
syndrome is a lifelong condition. Down syndrome is one of the most common
causes of intellectual disability diagnosed in the United States. Patients with
Down syndrome are typically affectionate, gentle, and cheerful, with the
occasional bout of stubbornness. The hygienist should avoid providing overly
friendly attention to the patient, especially of the opposite sex. Patients with
Down syndrome tend to be hypersexual and easily convinced that you are
their boyfriend or girlfriend. Box 3-11 provides suggestions for
communicating with an individual with an intellectual disability.

BOX Strategies for Communicating with a Person

3-11 with an Intellectual Disability
• Determine the intellectual age of the patient and communicate based on
that age rather than the chronological age of the patient.
• Speak slowly in simple, easy-to-understand sentences.
• Give only one simple command at a time.
• Give the patient plenty of time to speak. Do not hurry the person; if the
patient feels pressured, it can affect the ability to communicate.
• Focus the majority of your attention on the patient but also review with
the family/caregiver.
• If the patient is fairly dependent on the family/caregiver, ask the
caregiver what works best at home when providing oral health care.
• Describe actions before carrying them out (tell-show-do).
• Praise often with verbal praise, high fives, fist bumps, etc.
• Do not ask permission to perform a procedure if it will be performed in
any case. (e.g., “I am going to check your teeth now, is that OK?—
What if the patient’s answer is NO?)

Communication with Children with Attention Deficit

Hyperactivity Disorder
Attention deficit hyperactivity disorder (ADHD) is a developmental
disorder believed to be caused primarily by genetic factors. Although this
disorder occurs mainly in boys, it can also occur in girls. Currently, many
researchers think certain neurotransmitters in the brain may be deficient in
patients with this disorder. ADHD is a chronic condition with 30% to 50% of
those individuals diagnosed in childhood continuing to display some
symptoms into adulthood. Since adolescents and adults with ADHD tend to
develop coping mechanisms for some or all of their behavioral impairments,
management of children with this condition is the greatest challenge in a
dental setting. Children with ADHD can display an inability to regulate their
behavior to such a degree that it can have significant effects on their daily
lives. These patients can display a variety of problems that can make the
delivery of dental care difficult. Examples of these types of problems include
the following:
• Difficulties with sustained attention
• Difficulties with impulse control
• Excessive activity
• Increased distractibility
• Difficulty following rules or instructions
Treatment for patients with this disorder can involve some combination
of medications, behavior modifications, lifestyle changes, and counseling.
Box 3-12 outlines strategies that can aid in communicating with children with
ADHD during an appointment in a dental setting.

Strategies for Improving Communication with

BOX
3-12 Children with Attention Deficit Hyperactivity
Disorder
• If the child is on medications for ADHD, remind the parents to have
the child take the medications (as prescribed by the patient’s physician)
on the day of the appointment.
• Schedule the child for the time of the day when the child will best
tolerate the appointment—this is usually morning appointments, but
 the child’s parents can guide you as to what is best for the individual
patient.
• Explain to the child what is expected of him or her during the
appointment; during the explanation to the child, always use clear and
concise words.
• When giving instructions to the child during the appointment, give only
one direction or command at a time.
• Sincerely praise the child who is doing well during the appointment.
• Consider using small rewards for reinforcement as you might with
other children.
• Focus on the task and ignore minor inappropriate behaviors in the
child.

Communication with People Who Have an Autism

Spectrum Disorder
Autism spectrum disorder describes a range of conditions classified as
neurodevelopmental disorders that impair a child’s ability to communicate
and interact with others. It also includes restricted repetitive behaviors,
interests, and activities. These issues cause significant impairment in social,
occupational, and other areas of functioning. The autism spectrum disorder
diagnosis encompasses and replaces the older individual disorder names of
autism, Asperger syndrome, pervasive developmental disorder not otherwise
specified, and childhood disintegrative disorder.23 According to a 2010
Centers for Disease Control and Prevention survey of 8-year-olds, 1 in 68
children have autism spectrum disorder.20,24 Unlike patients with Down
syndrome—whose behavior and communication skills are fairly easy to
predict and manage—symptoms of autism spectrum disorder may vary
greatly from individual to individual and even within the same person on a
different day or time of day.
Symptoms of autism spectrum disorder fall into two categories and vary
by individual. Individuals with social symptoms may look, listen, and respond
to people less; respond unusually to anger, distress, or affection or rarely
share toys/activities or show things to others. Persons with repetitive and
stereotypical behaviors may exhibit behaviors such as arm flapping or unique
walking patterns or fixed routines, such as lining up toys, books, etc.
Associated conditions that can affect communication may include sensory
issues (over- or under-reaction to sights, sounds, smells, textures, and tastes),
intellectual disability, or mental disorders. Box 3-13 presents strategies for
communicating with a person with autism spectrum disorder.

BOX Strategies for Communicating with a Person

3-13 with Autism Spectrum Disorder
• If possible, speak to a family member or caregiver prior to the
appointment to learn about the patient’s likes/dislikes, fears,
mannerisms, etc. This information can be invaluable! (e.g., Johnny is
an 18-year-old with autism spectrum disorder that cooperates well at
the physician’s office and at home for toothbrushing but screams when
he tastes or smells mint. Good to know. Remove mint products from
the treatment room prior to seating the patient.)
• Prepare a photo book of the dental office showing all the rooms,
equipment, and staff to be sent to the patient/family prior to the
appointment to prepare the patient for the new surroundings.
• Schedule appointments for times when the waiting room is not as
crowded and quieter.
• If the patient has an intellectual disability, adjust communication based
on intellectual age rather than the chronological age of the patient.
• Do not insist on eye contact. Speak with a soft tone and calm
demeanor. Do not hurry the person or insist on a response; if the
patient feels pressured, it can affect the ability to communicate.
• Be prepared for unusual reactions to lights, sounds, textures, taste, and
touch. Be creative when something elicits an unfavorable reaction.
(e.g., If the dental chair light is irritating to the patient, try a lighted
mouth mirror.)
 • If multiple visits are required, consistency and routine are very
important (same person, room, colors, etc.).

Communication with People Who Have Cerebral Palsy

Cerebral palsy is a group of neurological disorders diagnosed in infancy and
early childhood. Body movement and muscle coordination are permanently
affected but do not worsen over time. Cerebral palsy is the most common
motor disability in childhood. The Centers for Disease Control and
Prevention estimates that an average of 1 in 323 children in the United States
has cerebral palsy. Associated conditions include intellectual disability in
approximately 30% to 50% of individuals with cerebral palsy. However, not
all patients with cerebral palsy should be assumed as having intellectual
disabilities. Other associated conditions may include seizures (up to 50%);
delayed growth and development; and problems with vision, hearing, or
speech.20
Individuals with cerebral palsy may exhibit stiff muscles and awkward
movements or uncontrollable movements in the hands/arms and feet/legs.
Common dental issues or concerns that could hamper communication and
assessment may include difficulty swallowing with risk of aspirating
food/fluid, drooling, and/or an overactive bite or gag reflex. Refer to Box 3-
11 for strategies for patients with intellectual disability. Box 3-14 provides
suggestions for communicating with a person who has cerebral palsy.

BOX Strategies for Communicating with a Person

3-14 with Cerebral Palsy
• Determine the intellectual age of the patient and communicate based on
that age rather than the chronological age of the patient.
• Maintain eye contact when the patient is able to remain focused on you.
• Speak with a soft tone and calm demeanor. A relaxing environment can
reduce anxiety and uncontrolled body movements.
• Do not hurry the person or insist on a response; if the patient feels
 pressured, it can affect the ability to communicate.
• Maintain clear paths in the office and operatory to allow for
uncontrolled gait.
• Allow patient to settle into the most comfortable position that is
possible for them. Don’t force them into position.
• Follow the patient’s movements and observe patterns in order to
predict the uncontrolled movements of hands, arms, legs, or feet.
• Avoid trying to restrict or harness movement which might intensify the
muscle response.
• Ask the patient before moving them. Use gentle, slow position changes
and pressure.
• Describe actions before carrying them out (tell-show-do).
• Keep appointments short and take frequent breaks. Use mouth props as
needed.
• Praise often to eliminate the patient’s stress. The patient’s anxiety and
strong desire to cooperate will sometimes make involuntary
movements more pronounced.
• Focus the majority of your attention on the patient but also review with
the family/caregiver as needed.
• If the patient is fairly dependent on the family/caregiver, ask them what
works best at home when providing oral health care.

SECTION 6 • The Human Element

Through the Eyes of a Student

HELPING PATIENTS WITH SPECIAL NEEDS

I have this 92-year-old patient, Mrs. W., who always comes with her
daughter. Mrs. W. lives in an assisted living facility. I saw Mrs. W. in the
dental clinic last year, too, and she always has a heavy amount of plaque
when she comes in. I talked to her daughter about this in the past. The
daughter lives an hour away from her mother and so cannot be there to
brush her mother’s teeth every day. Today, the daughter said that she asked
the staff at the assisted living facility to assist her mother in brushing her
teeth, but she doesn’t think that they have been helping her. I felt sorry for
Mrs. W. because I know assisted living facilities commonly are
understaffed and oral hygiene care is not a priority.
The daughter said that there is a problem getting the staff to do things
for her mother because they are so busy. She said that her mother has low
blood sugar and is supposed to have a protein snack each afternoon. Her
mother didn’t get her needed snack until her physician wrote it as “a
prescription” to the staff.
For me, her story about the snack was like a light bulb going off in
my head! What a great idea! So I talked with our clinic’s dentist and he
wrote “brush teeth after evening meal” on a prescription and signed it.
Mrs. W.’s daughter was very pleased that we cared enough about her
mother to write this “prescription.”
Melissa, recent graduate
East Tennessee State University

Through the Eyes of Others

BEING DIFFERENT

Exercise: Understanding Others. Read the lyrics to the song “Don’t

Laugh at Me” written by Allen Shamblin and Steve Seskin. Write or
participate in a group discussion about a childhood experience of your own
or one that you witnessed in which being different was a source of pain.
Don’t Laugh at Me
By Steve Seskin and Allen Shamblin
I’m a little boy with glasses
The one they call a geek
A little girl who never smiles
‘Cause I’ve got braces on my teeth
And I know how it feels
To cry myself to sleep
I’m that kid on every playground
Who’s always chosen last
I’m the one who’s slower
Than the others in my class
You don’t have to be my friend
But is it too much to ask?
Chorus:
Don’t laugh at me don’t call me names
Don’t get your pleasure from my pain
 In God’s eyes we’re all the same
Someday we’ll all have perfect wings
Just how much you care

THE ELDERLY

Directions. Think of the first words that come to mind when you envision
providing dental care to an “old” patient.
• Reflect on how your expectations may influence or bias your interaction
with the patient.
• Reflect upon what it means to allow someone to “save face.”
• Consider ways in which a dental hygienist can help an elderly patient
preserve his or her dignity in the face of a limitation he or she
experiences (i.e., loss of hearing, memory loss, arthritis of the hands).

Communication Scenario

THE JOB INTERVIEW

You are a dental hygienist who is deaf and have just graduated from a
dental hygiene program at the top of your class. Although you have
speech, you always sat in the front row of the classroom so that you could
read the lips of your professors. During your schooling, the only
accommodation that you utilized was assistance from a note taker. Your
clinical instructors also utilized the use of face shields as opposed to face
masks for easier communication.
You have applied for a dental hygiene position at the office of Dr.
Daniel and will be the only employee in the dental office who is hearing-
impaired. The patient population of Dr. Daniel’s practice is vastly
multicultural. Dr. Daniel wants to offer you the position but is concerned
about communication barriers.

Discussion Points:
1. What if any modifications must be made to ensure you are able to
effectively communicate with all of the office staff?
2. What if any accommodations must be made to ensure that you are able
to effectively communicate with your patients during your hygiene
appointments?
3. What tips can be used for improving cross-cultural communication
between you and your dental hygiene patients?
4. Is it ethical for Dr. Daniel to refuse to hire you based on your hearing
impairment?
 SECTION 7 • Skill Check

Skill Checklist: Communications Role-Play

ROLES:
• Student 1 = Plays the role of the patient.
• Student 2 = Plays the role of the clinician.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, each U equals 0 point.

CRITERIA: S E
Uses appropriate nonverbal behavior such as
maintaining eye contact, sitting at the same level as
the patient, nodding head when listening to patient,
etc.

Interacts with the patient as a peer and avoids a

condescending approach. Collaborates with the
patient and provides advice.
Communicates using common, everyday words.
Avoids dental terminology.
Listens attentively to the patient’s comments.
Respects the patient’s point of view.
Listens attentively to the patient’s questions.
 Encourages patient questions. Clarifies for
understanding, when necessary.

Answers the patient’s questions fully and

accurately.
Checks for understanding by the patient. Clarifies
information.
OPTIONAL GRADE PERCENTAGE
CALCULATION

Using the E column, assign a point value of 1 for

each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

NOTE TO COURSE INSTRUCTOR: A collection of role-play scenarios—

for use with the Communications Skill Checks—can be downloaded from
http://thepoint.lww.com/GehrigPAT4e.

References
1. Dong M, Loignon C, Levine A, Bedos C. Perceptions of oral illness among Chinese
immigrants in Montreal: a qualitative study. J Dent Educ. 2007;71(10):1340–1347.
2. Fitch P. Cultural competence and dental hygiene care delivery: integrating cultural
care into the dental hygiene process of care. J Dent Hyg. 2004;78(1):11–21.
3. Formicola AJ, Klyvert M, McIntosh J, Thompson A, Davis M, Cangialosi T. Creating
an environment for diversity in dental schools: one school’s approach. J Dent Educ.
2003;67(5):491–499.
4. Formicola AJ, Stavisky J, Lewy R. Cultural competency: dentistry and medicine
learning from one another. J Dent Educ. 2003;67(8):869–875.
5. Mertz E, O’Neil E. The growing challenge of providing oral health care services to all
Americans. Health Aff (Millwood). 2002;21(5):65–77.
6. Betancourt JR, Maina AW, Soni SM. The IOM report unequal treatment: lessons for
clinical practice. Del Med J. 2005;77(9):339–348.
 7. Betancourt JR, Maina AW. The Institute of Medicine report “Unequal Treatment”:
implications for academic health centers. Mt Sinai J Med. 2004;71(5):314–321.
8. Betancourt JR, King RK. Unequal treatment: the Institute of Medicine report and its
public health implications [editorial]. Public Health Rep. 2003;118(4):287–292.
9. Romanow RJ. Building on Values: The Future of Health Care in Canada. Saskatoon,
Canada: Commission on the Future of Health Care in Canada; 2002.
10. United States Census Bureau, Ethnic and Hispanic Statistics Branch. The Foreign-
Born Population in the United States, March 2001. Washington, DC: United States
Census Bureau; 2003.
11. Hobbs F, Stoops N. Demographic Trends in the 20th Century. Washington, DC:
United States Census Bureau; 2002.
12. Economics and Statistics Administration. Census 2000. Modified Race Data Summary
File Census of Population and Housing. Washington, DC: U.S. Department of
Commerce, Economics and Statistics Administration, United States Census Bureau;
2002. http://purl.access.gpo.gov/GPO/LPS32088. Accessed May 30, 2016.
13. Mackun P, Wilson S. Population Distribution and Change: 2000 to 2010.
Washington, DC: U.S. Department of Commerce, Economics and Statistics
Administration, United States Census Bureau; 2011.
14. Humes KR, Jones NA, Ramirez RR. Overview of Race and Hispanic Origin: 2010.
Washington, DC: U.S. Department of Commerce, Economics and Statistics
Administration, United States Census Bureau; 2011.
15. U.S. Department of Health and Human Services, National Institutes of Health,
National Eye Institute. Eye Disease Statistics. Bethesda, MD: U.S. Department of
Health and Human Services, National Institutes of Health, National Eye Institute;
2014.
16. Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults:
National Health Interview Survey, 2012. Vital Health Stat. 2014;10(260):1–161.
17. U.S. Department of Health and Human Services, National Institutes of Health. Health
Information: Statistics and Epidemiology. Statistics about Hearing, Ear Infections, and
Deafness. Bethesda, MD: National Institute of Health; 2015.
18. Lin FR, Niparko JK, Ferrucci L. Hearing loss prevalence in the United States. Arch
Intern Med. 2011;171(20):1851–1852.
19. Brault MW. Americans with Disabilities: 2010—Household Economic Studies,
Current Population Reports. Washington, DC: United States Census Bureau.
20. Centers for Disease Control and Prevention. People with Disabilities. Multiple
Disability Topics. Bethesda, MD: Centers for Disease Control and Prevention;
http://www.cdc.gov/ncbddd/index.html. Accessed May 30, 2016.
21. American Association on Intellectual and Developmental Disabilities. Intellectual
Disability, Definition, Frequently Asked Questions on Intellectual Disability.
 Washington, DC: American Association on Intellectual and Developmental
Disabilities. http://aaidd.org/. Accessed May 30, 2016.
22. Parker SE, Mai CT, Canfield MA, et al; National Birth Defects Prevention Network.
Updated national birth prevalence estimates for selected birth defects in the United
States, 2004–2006. Birth Defects Res A Clin Mol Teratol. 2010;88:1008–1016.
23. American Psychiatric Association. Autism Spectrum Disorder Fact Sheet. Arlington,
VA: American Psychiatric Association; 2013.
http://www.dsm5.org/Documents/Autism%20Spectrum%20Disorder%20Fact%20Sheet.pdf
Accessed May 30, 2016.
24. Wingate M, Kirby RS, Pettygrove S, Cunniff C, Schulz E, Ghosh T, et al. Prevalence
of autism spectrum disorder among children aged 8 years—autism and developmental
disabilities monitoring network, 11 sites, United States, 2010. MMWR Surveill Summ.
2014;63(2):1–21.
 MODULE
4

MOTIVATIONAL
INTERVIEWING FOR
INFORMATION
GATHERING
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
This module introduces the motivational interviewing perspective on
assessment. Motivational interviewing offers both a philosophy and specific
communication strategies that can be useful in conducting assessments in a
more patient-centered fashion. Readers are also encouraged to learn more
about motivational interviewing in order to fully appreciate the information
provided in this module.

MODULE OUTLINE
SECTION 1 Introduction to Motivational Interviewing
Approaches to Fostering Behavioral Change in Patients
Motivational Interviewing and Patient Assessment
 SECTION 2 Motivational Interviewing Approach to
Assessment
Interpersonal Communication Styles
Core Motivational Interviewing Skills
Using the Tools
Potential Concerns of Using Motivational Interviewing for
Patient Assessment
Benefits of Using Motivational Interviewing for Patient
Assessment
SECTION 3 The Human Element
Sample Communication Scenario
SECTION 4 Skill Check
KEY TERMS
Motivational interviewing • Directing communication style • Following
communication style • Guiding communication style • Open questions •
Affirmations • Reflections • Summaries • Asking permission • Elicit–
provide–elicit

OBJECTIVES
• Describe the continuum of communication styles and the placement of
motivational interviewing on the continuum.
• Describe the relevance of motivational interviewing for information
gathering during the patient assessment process.
• During role-plays or in the clinical setting, integrate motivational
interviewing communication strategies into existing assessment intake
processes.
• During role-plays or in the clinical setting, encourage a patient-
centered approach for acquisition of clinical information.
• During role-plays or in the clinical setting, demonstrate the use of
open questions and clarification to acquire medical histories.
 • During role-plays or in the clinical setting, demonstrate listening skills
and reflections to respond to patient’s point of view and/or emotional
needs.
• During role-plays or in the clinical setting, demonstrate the
importance of empathy when obtaining a health history.
• During role-plays or in the clinical setting, employ motivational
interviewing techniques to elicit supplemental information from the
patient, such as social determinants of health, belief systems, and
social supports.

SECTION 1 • Introduction to Motivational Interviewing

Approaches to Fostering Behavioral Change in Patients

Motivational interviewing is a person-centered counseling approach that is
shown to positively foster health behavior change related to drug addiction,
tobacco cessation, exercise, weight reduction, diabetes management,
medication adherence, and oral hygiene.1–3 Hygienists often advise patients
to change certain habits or behaviors in order to improve their health.
Patients, however, often feel ambivalent about behavior change—that is, they
have mixed feelings and attitudes toward behavior change.4,5 For example,
the hygienist may wish that a patient did not smoke, as smoking is a major
risk factor for periodontal disease. The patient, on the other hand, might like
to have a healthier mouth but really enjoys smoking—so he has mixed
feelings about quitting (i.e., behavior change). The main purpose of
motivational interviewing is to strengthen the individual’s motivation for and
commitment to healthy behavior change. Motivational interviewing is based
on a philosophy or “spirit” that emphasizes the partnership between clinician
and patient, communicating acceptance to the patient, and evoking the
patient’s experience and wisdom. Acceptance includes support for patient
autonomy or accepting a patient’s right to decide what is right for him or her.
In contrast, traditional approaches to behavior change may involve
interactions in which the clinician might direct, instruct, or try to persuade
the patient to make behavior change. In this traditional approach, the clinician
provides information to the patient that the clinician considers important or
persuasive (e.g., reasons why diabetes should be well-controlled for general
and oral health) rather than listening to gain insight into the patient’s
perspective on the advantages and disadvantages of change. In these types of
conversations, the clinician is typically in the role of the expert directing the
patient who takes a passive or sometimes resistant role (e.g., giving reasons
why it is hard to afford regular physician care or why the patient may not
want to change his or her diet) leading to a poor working relationships and
negative health outcomes.

Motivational Interviewing and Patient Assessment

While effective counseling for behavior change may seem unrelated to
assessment, the opportunity to establish a partnership—a good working
relationship—between the hygienist and patient first presents at the patient’s
initial visit to the clinic or dental practice. The initial visit in the dental setting
often begins with a medical/dental history intake process that is controlled by
the clinician. For example, the initial patient assessment usually begins with a
battery of standardized checklist-type questions that are closed-ended and
narrowly focused. The patient’s role is diminished to passively providing
short answers to questions whose importance is not necessarily clear to the
patient.
Although motivational interviewing does not prescribe a particular
method for patient assessment, its philosophy supports the methods for
conducting assessments in a more patient-centered fashion. Using
motivational interviewing communication strategies in advance of the
structured assessment may allow the clinician to gather most of the necessary
information and then ask a greatly diminished set of questions to complete
the assessment. Additionally, motivational interviewing strategies provide an
opportunity to respond in an empathetic manner to personally sensitive
information. For example, a female patient may experience feelings of
remorse when reporting her recent hospitalization for a miscarriage.

SECTION 2 • Motivational Interviewing Approach to

Assessment

Interpersonal Communication Styles

One way of thinking about how the motivational interviewing approach to
assessment might differ from a traditional approach is to consider the
different communication styles available to clinicians. Dental hygienists
manage their conversations with patients using different “styles.” A
clinician’s professional style may be thought of as existing on a continuum
(Fig. 4-1). The continuum presents a range of styles related to the degree of
authority used by the clinician and to the amount of freedom available to the
patient in the conversation.6 On one extreme of the continuum is the
directing communication style. In the directing style, the practitioner is “in
charge” of the conversation, typically asking focused questions or providing
instruction or giving advice. At the opposite end of the continuum is the
following communication style in which listening to the patient
predominates. A clinician with a following style has no agenda other than to
understand the world through the patient’s eyes. In the middle of the
continuum is the guiding communication style in which the practitioner
may gently direct the conversation but the direction is determined by
listening to the patient. Figure 4-2 summarizes these three styles.
 While all three communication styles may have their place, motivational
interviewing is characterized most by the use of a guiding style. When
thinking about the continuum of styles, it is reasonable to assume that patient
assessment procedures may call for more of a directing style because the
clinician has to ensure that all critical information is collected. On the other
hand, patients also have a lot to offer the assessment process through their
unique knowledge, experience, and wisdom regarding their own lives.
Patient-provided information is critical to patient care and management. With
this in mind, the skilled motivational interviewing practitioner seeks to use
the guiding style to capitalize on the expertise of the patient while still
collecting all of the necessary information for a thorough patient
assessment.

Core Motivational Interviewing Skills

Specific communication strategies are used in order to employ the
motivational interviewing spirit and guiding style during patient assessment
procedures. Five of these strategies include permission, open questions,
affirmations, reflections, and summaries. Examples of these strategies are
provided in Figure 4-3. An additional tool is the three-step process known as
elicit–provide–elicit as explained in Figure 4-4.
OPEN QUESTIONS
These are questions that cannot be answered with a simple “yes” or “no” or
with an option from a limited set of responses (e.g., “How old are you?”).
Open questions invite more detailed responses from the patient (e.g., “Tell
me a little bit about your dental history.”). Although technically not open
questions, statements or directives such as “Tell me about what happened
with that tooth” can also serve this function and are often used by
motivational interviewing practitioners to encourage more detailed responses
from patients.
AFFIRMATIONS
Affirmations are statements that support patients’ strengths or efforts. These
serve to strengthen the bond between clinician and patient and may
encourage patients to be more forthcoming or have more confidence in their
efforts to adhere to clinician recommendations.
REFLECTIONS
Reflections are statements in which the clinician paraphrases what the patient
has said. These statements communicate to the patient what the clinician has
actively listened and heard what the patient said. Reflective statements
encourage patients to elaborate, keeping them as active partners in the
discussion. In motivational interviewing, reflections are used in sophisticated
ways for different purposes, but most importantly, they provide a valuable
alternative to asking questions and can be used to skillfully guide
conversations, as explained below.
SUMMARIES
Summaries are “elongated” reflections that also serve to highlight key points
of the discussion and mark transition points in the conversation.
ASKING PERMISSION
Motivational interviewing practitioners use “asking permission” as a means
to communicate the desire to partner with patients. Asking permission is the
act of providing the patient with the right to decide if something will be
allowed or permitted. For example, “Is it OK if we discuss your medications
so that I can better plan your oral care?”
ELICIT–PROVIDE–ELICIT
When providing information or advice in motivational interviewing, the
clinician goes to great lengths to ensure that the information or advice is not
perceived as an unwelcome effort to direct or push the patient in a particular
direction. The goal is always to support patient autonomy in decision making
and foster a true partnership between clinician and patient. In motivational
interviewing, this can be achieved with the three-step process, elicit–
provide–elicit, as summarized in Figure 4-4.
Using the Tools
OPEN QUESTIONS AND REFLECTIVE LISTENING
From a motivational interviewing perspective, the best method for beginning
the assessment process is to engage the patient in a guided conversation
rather than with a battery of exhaustive questions. Sitting at the same level as
the patient and making eye contact conveys the hygienist’s compassion and
interest in the patient’s welfare (Fig. 4-5). The motivational interviewing
practitioner usually begins with a single open question designed to get the
patient to start sharing his or her perspective and then starts the process of
listening to the patient perspective. For example, the practitioner might begin
by asking, “What is the problem that has brought you in today?” and then
respond with a reflective statement (e.g., “So, you’re concerned that your
gums are bleeding when you brush?”). This encourages the patient to
elaborate and clarify his or her understanding of the problem. Motivational
interviewing practitioners then intersperse open questions and reflections as
needed to guide the conversation through an exploration of the patient’s
history and presenting problem.

There are a number of clear advantages of the motivational interviewing

approach.
 • First, by allowing the patient an opportunity to explain the problem as he
or she sees it, the clinician gains valuable insight as to how best to work
with the particular patient. For example, the patient may highlight
particular concerns or express misinformation that can guide the
clinician’s efforts to help. Patient-provided information is particularly
important when trying to understand health care beliefs or priorities or
culturally determined preferences.
• Second, patients may introduce unexpected important information that
the clinician would not have thought to ask about.
• Third, patient elaboration can often help to focus assessment more
efficiently. For example, the clinician might be able to begin the
assessment process by focusing on aspects that patient has highlighted
as most important to him or her, thus, letting the patient know that his or
her concerns are important and will be addressed as early in the
assessment process as possible. Similarly, the clinician may be able to
narrow the focus of questioning and listening to expand on patient-
provided information.
STRATEGIC USE OF REFLECTIONS
Reflective listening is an ideal way to express empathy and encourage the
patient to be an active partner in the conversation. One concern clinicians
have is that emphasizing reflections might lead to a predominance of
following (i.e., just listening to the patient) which may not be suitable for
conducting an assessment. In motivational interviewing, however, reflections
are used to guide the conversation in different ways:
1. Elaboration. By choosing whether or not to reflect what the patient
says, the clinician can encourage or dissuade the patient from
elaborating on a topic.
• If the clinician does not wish to know more about a particular topic, he
or she may choose not to make reflective statements.
• Most often, the clinician will choose to reflect to encourage the patient
to elaborate and clarify information. This generally works best when
reflections are brief and focused on the part of the patient’s statement
 that the practitioner wishes to hear more about.
• When clinicians make reflections, they also verify that their
understanding of the patient perspective is correct. If the clinician’s
reflection is off target, the patient usually will respond with a
clarification that allows the clinician to correct his or her
misperception.
• Reflections allow the clinician to gather information for assessment
purposes while simultaneously developing accurate empathy and
validating patients.
2. Directing and Redirecting. Although reflections are primarily a tool of
listening (or following), they also allow the skilled clinician to guide the
conversation. When clinicians make reflections about what a patient has
said, there are typically choices about what to reflect. The patient will be
prompted to elaborate on whatever the clinician reflects. Table 4-1
provides examples how a clinician might use reflection.

SHARING INFORMATION AND ASKING PERMISSION

At times during the assessment process, the clinician may want to provide
information that seems pertinent to convey to the patient. To avoid being
perceived as “pushing” the patient toward a certain decision, the clinician can
ask permission (e.g., “May I share some information about diabetes and oral
health that you might find interesting?”) and use the steps of elicit–provide–
elicit.
• It should be noted that when a patient requests information, the clinician
should provide that information.
• The goal of asking permission and elicit–provide–elicit is to ensure
advice supports patient autonomy and is perceived as welcome. It is
human nature to be more accepting of those ideas or reasons we offer
than to accept those offered by others.
• For example, the hygienist might ask the patient what he already knows
or is interested in knowing about general or oral health (“What, if any,
concerns do you have about your general health?”). Use of a simple
inquiry shows respect for the patient’s knowledge and avoids telling him
something he already knows. The hygienist can then follow up on only
the information not yet covered after the patient tells what he already
knows or is most interested in knowing more about.
SUMMARIZING
Summarizing can be used to organize the assessment conversation.
• When a particular area of assessment has been covered, the clinician
may summarize the key points and then open up the conversation in a
new direction (e.g., “OK, I think I understand the history here. In a
nutshell it began with . . . and now you have come to me. So now I’d
like to learn a little more about your daily self-care habits at home.
Could you fill me in on what you have been doing to try to take care of
your gums?”).
• These brief summaries help to communicate where the conversation has
been and where it is going.
• Summarizing can also be used to wrap up an area of conversation.
Unlike reflections, summarizing does not typically invite elaboration,
although this technique still communicates empathy.
AFFIRMATIONS
Affirmations can be used at any point during the assessment process.
• In motivational interviewing, the clinician actively seeks opportunities to
affirm patient strengths or efforts throughout the encounter.
• For example, a clinician who learns a patient is trying to improve his or
her daily self-care habits might say, “So you have really made it your
goal to floss regularly.”
• An affirmation can also be as simple as thanking the patient for
participating in the assessment process (e.g., “Thank you for answering
all my questions and sharing your experiences with me.”).

Potential Concerns of Using Motivational Interviewing for

Patient Assessment
Clinicians are often concerned assessment will be slow and inefficient if the
patient is encouraged to speak more freely and the encounter is not conducted
through a series of focused questions. While this is a possibility, assessments
often are more efficiently conducted when a patient-centered conversation is
used. As noted, patients bring a wealth of knowledge about their lives that
guides them in prioritizing their concerns for discussions with their
practitioner.
• Frequently, the hygienist can quickly gather the most salient information
by listening to the patient rather than completing an exhaustive list of
questions.2,7
• Skilled clinicians also use the tools of motivational interviewing to
influence the extent of patient elaboration and the duration of the
conversation. It is often efficient and effective to engage in a free-
flowing conversation with the patient (that may include occasional
probing questions as appropriate) and then using focused questions
toward the end of the assessment to gather essential missing
information.

Benefits of Using Motivational Interviewing for Patient

Assessment
As with any method, clinicians will need to determine how motivational
interviewing tools may be used to enhance assessment so that it is efficient,
effective, and engaging to patients. Using motivational interviewing methods
to make assessment more patient-centered is likely to yield dividends for
patients and clinicians alike.

SECTION 3 • The Human Element

Sample Communication Scenario

The communication scenario below presents a brief excerpt of dialogue from
a clinician conducting a motivational interviewing–based assessment with a
patient. The motivational interviewing strategies are identified in bold text.

MOTIVATIONAL INTERVIEWING–BASED
ASSESSMENT CONVERSATION

Mr. Roberts is a 59-year-old construction foreman visiting the dental

practice for the first time. His medical history is unknown and provides a
good opportunity to conduct a directed, patient-centered medical history.
Hygienist (H): Hi Mr. Roberts, what brings Patient (P): It’s been a
you in today? (open question) while since I’ve been to
the dentist. And, now my
company offers dental
insurance, so I scheduled
a checkup. I think I am
overdue to have things
checked.
H: You want to make sure your mouth is in P: Yes. I think I have a
good shape (reflection). fair amount of tartar build
up so you might have
your work cut out for
you!
H: Anything else? (open question) P: I do have this rough
spot up here. I think I
might have lost part of
my filling.
H: So your concerns are that you might have P: Yes.
lost a filling and that you have a lot of tartar
build up. Have I got that right? (summary)
H: I am really glad you came in today P: Sure, that’s fine with
(affirmation). Sounds like there are some me.
very specific oral conditions we can help you
with. Before we jump into fixing your teeth,
would it be alright if we reviewed your
general health to determine the best means of
treating your current conditions? (ask
permission)
H: So you mentioned you were here today for P: That visit didn’t go so
a dental checkup, tell me about your last visit well. I collapsed at work
to a physician? (open question) and had to be taken to the
emergency room.

H: That’s scary (reflection). How did it turn P: I had double

out? (open question) pneumonia which I am
susceptible to due to my
asthma. They also
determined I have type 2
diabetes.
H: What did you make of all of that? (open P: [Sighing] They gave
question) me a whole list of foods I
can and cannot eat and
told me to lose weight.
H: Sounds like you are not sure if this is P: I am taking the
something you need to do? (reflection) medicine they gave me
but I have not changed
anything else.
H: What medications do you take? (open P: Glyburide/metformin
question) 2.5 mg/500 mg twice a
day. Advair 250/100 two
puffs twice daily morning
and night. Albuterol as
needed.
H: So, glyburide/metformin 2.5 mg/500 mg P: Yes, that’s right.
twice a day for the diabetes. And Advair
250/100 two puffs twice daily morning and
night and Albuterol as needed for asthma. Is
that correct? (summary)
H: So you are taking your medications and P: I am back to work but
you have been able to go back to work. they tell me my blood
(reflection) sugar is too high.
 H: Tell me more about that. (open question) P: They do a special
blood test and I am
supposed to try to get
below a 6. Last time I
was at an 8.

H: Sounds like your blood glucose level is P: Well I certainly do not

elevated (reflection). Do you have any want to go through
concerns about that? (open question) another emergency like
the one I had recently.
H: You’re worried about getting sick again. P: I don’t see what
(reflection) What do you know about diabetes diabetes has to do with
and your oral health? (open question) my teeth.
H: Actually, diabetes and oral health are P: Sounds good.
related. Let’s finish this medical history and I
will tell you more about it. To make sure that
we don’t miss anything, I am going to use a
checklist of other conditions and you let me
know if you have or have had any of these in
the past. (redirect)

SECTION 4 • Skill Check

Skill Checklist: Communications Role-Play

ROLES:
• Student 1 = Plays the role of the patient.
• Student 2 = Plays the role of the clinician.
DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as
S (satisfactory) or U (unsatisfactory).
DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S
(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, each U equals 0 point.

CRITERIA: S E
Uses appropriate nonverbal behavior such as
maintaining eye contact, sitting at the same level as
the patient, nodding head when listening to patient,
etc.
Interacts with the patient as a peer and avoids a
condescending approach. Collaborates with the
patient and provides advice.
Communicates using common, everyday words.
Avoids dental terminology.
Listens attentively to the patient’s comments.
Respects the patient’s point of view.
Listens attentively to the patient’s questions.
Encourages patient questions. Clarifies for
understanding, when necessary.

Answers the patient’s questions fully and

accurately.
Checks for understanding by the patient. Clarifies
information.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
 and divide by the total points possible to calculate a
percentage grade.

NOTE TO COURSE INSTRUCTOR: A series of role-play scenarios for the

modules in this textbook can be found at http://thepoint.lww.com/GehrigPAT4e.

References
1. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed.
New York, NY: Guilford Press; 2012.
2. Lundahl B, Moleni T, Burke BL, et al. Motivational interviewing in medical care
settings: a systematic review and meta-analysis of randomized controlled trials.
Patient Educ Couns. 2013;93(2):157–168.
3. Lundahl W, Kunz C, Brownell C, Tollefson D, Burke B. A meta-analysis of
motivational interviewing: twenty-five years of empirical studies. Res Soc Work Prac.
2010;20(2):137–160.
4. Bandura A. Self-Efficacy: The Exercise of Control. New York, NY: W.H. Freeman;
1997.
5. Fishbein M. Factors influencing behavior and behavior change. In: Baum A,
Revenson T, Singer J, eds. Handbook of Health Psychology. Mahwah, NJ: Lawrence
Erlbaum Associates; 2001.
6. Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping
Patients Change Behavior. New York, NY: Guilford Press; 2008.
7. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a
systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305–312.

Suggested Readings
Catley D, Goggin K, Lynam I. Motivational interviewing (MI) and its basic tools. In:
Ramseier C, Suvan J, eds. Health Behavior Change in the Dental Practice. Hoboken,
NJ: Wiley-Blackwell; 2010:59–92.
Catley D, Williams K, Ramseier CA. Using motivational interviewing to enhance patient
behavior change. In: Gehrig JS, Willmann DE, eds. Foundations of Periodontics for
the Dental Hygienist. 4th ed. Baltimore, MD: Wolters Kluwer; 2016:531–550.
Ramseier CA, Catley D, Krigel S, Bagramian R. Motivational interviewing. In: Lindhe J,
Lang NP, Karring T, eds. Clinical Periodontology and Implant Dentistry. 5th ed.
Oxford, United Kingdom: Blackwell/Munksgaard; 2008:107–123.
 PART 2
Assessment Skills
 MODULE
5

MEDICAL HISTORY
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
The medical history is a critical step in the care of every dental patient. The
medical history provides important information related to the patient’s
physical and psychological condition. The information gathered during the
medical history is ultimately used when determining how a patient’s systemic
health may be impacted by the planned dental care. This information allows
the clinician to determine whether dental treatment alterations are necessary
for the patient to safely undergo each specific dental procedure.
In addition, a thorough understanding of the implications of the findings
from the medical history is a critical component in interprofessional
collaboration. One of the key foundations of the concept of interprofessional
practice is for all health care providers to share a common vocabulary and
common understanding of caring for the patient as a whole. A thorough
health history is the first step for a dental hygienist or dentist to participate in
collaborating with other health care providers about the overall welfare of a
patient.
This module covers taking and interpreting the medical history,
including:
 • Gathering information regarding a patient’s medical conditions and
diseases
• Gathering information regarding a patient’s medications and
supplements
• Informed consent and the medical history
• Determining how a patient’s medical conditions and/or medications
impact dental care

MODULE OUTLINE
SECTION 1 The Health History
Caring for Patients in a Multicultural Society
Multi-Language Health History Project
Obtaining and Using the University of the Pacific Multi-
Language Forms
SECTION 2 The Medical History Assessment
Relationship between Systemic and Oral Health
Dental Practices as Health Screening Sites
Risk Assessment: Physical Status
Interprofessional Collaboration
Consultation with a Physician
SECTION 3 Informed Consent and the Medical History
SECTION 4 Conducting a Medical History Assessment
Information Gathering
Medical Alert Box
Stress Reduction Protocol for Anxious Patients
SECTION 5 Peak Procedure
Procedure 5-1. Review of Written Questionnaire and
Patient Interview
SECTION 6 The Human Element
 Through the Eyes of Clinicians and Patients
Ethical Dilemma
English-to-Spanish Phrase Lists
SECTION 7 Practical Focus—Fictitious Patient Cases
SECTION 8 Skill Check
KEY TERMS
Multi-Language Health History Project • Medical risk •
Interprofessional collaborative practice • Medical consult • Informed
consent • Capacity for consent • Informed refusal • Information-
gathering phase • Medical alert box

OBJECTIVES
• Recognize the manifestations of systemic disease and how the disease
and its management may affect the delivery of dental care.
Demonstrate skills in conducting online research on medical
conditions/diseases and medications.
• Demonstrate the use of communication strategies and questioning
techniques that facilitate complete, accurate information gathering.
• Recognize the need for conducting risk assessments on dental
patients.
• Communicate effectively with individuals from diverse populations.
• Discuss the ways in which a hygienist’s choice of words can facilitate
or hinder communication with patients regarding patient assessment
procedures.
• Apply principles of risk management, including informed consent and
appropriate record keeping in patient care.
• Demonstrate skills necessary to obtain a complete and thorough
medical history.
• Describe the types of information that should be entered in the
medical alert box on the medical history form.
 • Participate with dental team members and other health care
professionals in the management and health promotion for all
patients.
• Practice within one’s scope of competence and consult with or refer to
professional colleagues when indicated.
• Describe contraindications and complications for dental care
presented by various medical conditions/diseases and medications.
• Identify findings that have implications in planning dental treatment.
• Provide appropriate referral to a physician or dental specialist when
findings indicate the need for further evaluation.
• Demonstrate the ability to apply information learned in the classroom
and clinical activities to the fictitious patient cases A to E in this
module, including reviewing completed health history forms,
conducting research, formulating follow-up questions, conducting a
patient interview, and determining the medical risk of dental treatment
to the patient.

SECTION 1 • The Health History

A health history form is used to gather subjective data about the patient and
explore past and present problems. Health history forms assist patients in
providing an account of their health history.
• Health history forms are available in many different formats and lengths.
• Many health history forms include a list of diseases and medical
conditions that aid patients in recalling their medical history.
• Most forms ask the patient to check a box or circle “yes” or “no” for
each question or item on the form. Some health history forms have space
that allows patients to provide additional information in response to
questions and to list their medications.
• Regardless of the format or length, the health history form should
provide the health care professional with complete information
regarding the past and present health of each patient.
Caring for Patients in a Multicultural Society
The United States and Canada are multicultural societies where many
residents report being born in a foreign country. This diversity in ethnicity,
culture, and language enriches these countries, but it also complicates efforts
to provide safe dental care.
• For many dental health care providers in the United States and Canada,
assessing a patient’s history involves finding a way to communicate
with patients who speak another language.
• Ideally, an interpreter who is specially trained to conduct translations
involving medical and dental terminology, conditions, and procedures
would be a member of every dental staff. However, employing a trained
medical/dental interpreter who is fluent in many different languages is
an unrealistic option for most dental offices and clinics.
• Using a health history form that has been translated into different
languages is a more practical solution to the problem of obtaining
history information from non-English-speaking patients.

Multi-Language Health History Project

The Multi-Language Health History Project began as an initiative of the
University of the Pacific (UOP) Arthur A. Dugoni School of Dentistry to
address the needs of patients and dental health care providers who do not
speak the same language. With the assistance of the California Dental
Association and MetLife Inc., the history form has been translated into over
25 different languages. Transcend, a California company specializing in
translations services certifies that the translations are correct.

Obtaining and Using the University of the Pacific Multi-

Language Forms
• Directions for downloading copies of the UOP multi-language health
 history forms are found in Box 5-1.

BOX Instructions for Downloading the University of

5-1 the Pacific Multi-Language Forms
The multi-language health history forms can be downloaded at no cost on
the Internet.
1. Connect a computer to the Internet and open an Internet browser.
2. On an Internet browser, enter the website address in the rectangular box
near the top of the browser:
• http://oralfitnesslibrary.com/Multi-Language-Health-History-Forms
• Click on “GO” or hit the “return key” on the keyboard. The selected
web page should open.
NOTE: A software application—Adobe Acrobat Reader—is needed to open and view a
pdf document and can be downloaded at http://get.adobe.com/reader.

• The English version of the UOP health history form was translated into
over 25 different languages, keeping the same question numbering
sequence. Using a translated form, a dental health care provider who
speaks English and is caring for a patient who doesn’t can ask the
patient to complete the health history in his or her own language.
• The clinician then compares the English health history to the patient’s
translated health history, scanning the translated version for “yes”
responses. When a “yes” is found, the dental health care provider is able
to look at the question number and match it to the question number on
the English version. For example, question 34 on the Japanese version is
the same as question 34 on the English version and relates to high blood
pressure.
• In the same manner, a dental health care provider who speaks Spanish
could use the multi-language health history form with a patient who
speaks French. A few examples of the UOP health history form are
shown in Figures 5-1 to 5-4.
 • The UOP multi-language health history form is used in each of the
fictitious patient activities that appear at the end of this module.

SECTION 2 • The Medical History Assessment

Relationship between Systemic and Oral Health
There are many reasons for conducting a thorough assessment of the patient’s
past and current health status. The most important reason is to protect the
health of the patient. There is a strong two-way relationship between systemic
health and oral conditions.
• Systemic diseases and conditions may have oral implications. For
example, patients with poorly controlled diabetes do not respond well to
periodontal therapy.
• Medications used to treat systemic diseases and conditions can produce
changes in oral health. For example, certain medications can result in
gingival hyperplasia (overgrowth of the gingiva).
• Systemic conditions, diseases, or medications may necessitate
precautions to ensure that planned dental treatment will not be harmful
to the patient’s systemic health. For example, a patient who has a history
of well-controlled congestive heart failure may need certain treatment
modifications such as short appointments and supplemental oxygen by
nasal cannula.
• Oral manifestations may identify conditions that should be evaluated by
a primary care physician. For example, periodontal disease that does not
respond to treatment may be an indication of uncontrolled diabetes
because this condition increases susceptibility to infection and results in
slower healing rates.
• Substances, materials, or drugs used in dental treatment may produce an
adverse reaction in certain patients. For example, a patient with allergies
may be allergic to latex.
Dental hygienists are preventive specialists and as such are responsible
for the oral and general health of their patients. Increasing numbers of
patients with complex medical problems are seeking dental care.1 The U.S.
Surgeon General’s Report on Oral Health emphasizes the importance of oral
health and its essential role in overall general health. The report highlights the
need for interdisciplinary care between dental health care providers and
physicians for the joint management of systemic and oral health problems.2
Dental hygienists play an important role in the early identification and
referral of patients with medical conditions and collaboration with other
health professionals for comprehensive patient care.
In the United States, the most rapidly growing segment of the population
is over the age of 85 years.3 By the year 2050, it is estimated that 56% of the
U.S. population will be at least 55 years of age and 25% of the population
will be at least 65 years of age.3 As the population ages, the prevalence of
chronic systemic diseases—such as diabetes and cardiovascular diseases—is
increasing.

Dental Practices as Health Screening Sites

Dental practices can serve as alternate sites of opportunity to identify health
concerns among diverse groups of patients.1,4–6 Many individuals seek
dental care more often than other health care services and could benefit from
the screening for medical conditions in dental offices.6 Analysis of data from
a nationally representative sample of United States’ households finds that
26.0% of children and 24.1% of adults did not visit a medical health care
provider in 2008.6 Of these individuals (who did not see a medical provider),
37% of the children and 23.1% of the adults visited a dental office (a total of
19.5 million people ).6 Researcher Sheila Strauss suggests that dental health
care providers can help patients by (1) examining the oral cavity for signs of
systemic disease elsewhere in the body; (2) taking detailed medical histories,
including information that could indicate medical conditions for follow-up;
and (3) using tools such as blood pressure cuffs and finger-stick glucose
monitors to check for biomarkers for such conditions as diabetes and
hypertension.6 Glucose monitors are inexpensive, and the screening can be
done in less than 60 seconds. Box 5-2 outlines common methods for
measuring blood glucose levels and how these findings relate to the risk of
infection for planned treatment.
 BOX Glucose Blood Levels in Diabetes
5-2

Test Glucose Levels

Hemoglobin Goal for most people with diabetes = less than 7%
A1c High susceptibility to infection = above 8%
Glucose level at appointment time:
Finger-stick • Acceptable = 80–120 mg/dl
test • Risk of infection = 180–300 mg/dl
• Unacceptable = greater than 300 mg/dl

Risk Assessment: Physical Status

At this stage in the health history assessment process, the dental health care
provider should consider the patient’s medical risk when undergoing dental
treatment. Modification of dental treatment may be necessary in certain
medically complex patients.7 Today, many patients seen in the dental office
have multiple medical conditions and are taking many medications. It is more
difficult to manage these types of patients, and thorough assessment of their
physical status is an important part of clinical practice.
The American Society of Anesthesiologists (ASA), pioneers in the field
of patient safety in medical and dental care, developed a physical status
system for assessing the risk to the patient of medical or dental treatment.
The American Society of Anesthesiologists Physical Status Classification
System (ASA-PS) serves an integral part of risk assessment in determining
how the dental team should manage a patient.7,8 The ASA-PS is described
in Table 5-1. This table outlines how a patient’s physical status can affect the
planning of dental care.
Interprofessional Collaboration
Interprofessional collaborative practice occurs when multiple health
workers from different professional backgrounds work together with patients
and family members/carers to deliver the highest quality of care.9
Interprofessional collaboration involves continuous interaction and
knowledge sharing between professionals—such as dentistry, medicine,
medical radiation sciences, nursing, occupational therapy, pharmacy,
physician assistant, physical therapy, social work, and speech-language
pathology—with each individual contributing within the limits of his or her
scope of practice.
Interprofessional education has been identified as a critical issue in
dental education. Accreditation standards for dental education contain
language promoting collaboration with other health professionals.10 Research
suggests that interprofessional collaboration improves coordination,
communication, and ultimately, the quality and safety of patient care. It uses
both the individual and collective skills of professionals, allowing them to
function more effectively and deliver a higher level of services than each
would working alone.
Consultation with a Physician
If all health questions are not completely answered through research and the
patient interview, or if there is any question or doubt in making the best
decisions, consulting with the patient’s physician is necessary. A medical
consult is simply a request for additional information and/or advice about the
medical implications of oral health care treatment. A written request and
reply referral is ideal because there is no doubt about either the question or
the answer. Figures 5-5A and 5-5B provide an example of a two-page written
request form for consultation with a physician.
1. Request in Writing. A consultation request may be faxed to the
physician to expedite the process. The request should be specific,
concise, and directly to the point; therefore, a consultation form may be
used to standardize and simplify the written request and physician’s
reply. All consultation requests should clearly indicate the following:
 a. Medical condition or disease of concern
b. An explanation of the planned dental treatment and the likely
systemic consequences
c. A request for additional information and/or the physician’s
professional opinion
d. The patient’s signature authorizing the release of information; the
dentist’s signature; and the dental office’s address, phone number, and
fax number
e. Preferably, the consult form should be in triplicate. One copy of the
form is kept in the patient’s chart, one copy is given to the patient for
his or her records, and one is sent or faxed to the physician.
2. Explain Planned Treatment. When consulting with a physician, it is
important to remember that the physician is a medical expert who may
have little or no knowledge regarding dental treatment procedures and
how these procedures may relate to the patient’s systemic health. The
use of dental terminology or jargon should be avoided when explaining
the planned dental treatment.
3. Outline Procedures. When explaining the planned dental treatment to
the physician, it is important to outline the procedures planned; length of
time for each appointment; what surgical procedures will be done—
including periodontal instrumentation; the amount of anticipated blood
loss; possible complications, if any; and medications or anesthetics that
will be used.
4. Obtain Patient Consent. Before contacting a patient’s physician, the
patient must grant written consent for the physician to release
information about the patient’s medical findings.
5. Meet Legal Requirements. Telephone consultations are not acceptable
from a legal standpoint. If a consultation is conducted by telephone,
request that the physician provide the information in writing by mail or
fax.

When consulting with a physician, it is important to remember that the

 physician is a medical expert who may have little or no knowledge
regarding dental treatment procedures and how these procedures may
relate to the patient’s systemic health.

SECTION 3 • Informed Consent and the Medical

History
The core value of “Individual Autonomy and Respect for Human Beings”
within the Code of Ethics for the American Dental Hygienists’ Association
(ADHA) discusses informed consent.11 According to this core value, “People
. . . have the right to full disclosure of all relevant information so they can
make informed choices about their care.”
1. Informed Consent for Patient Assessment
a. It is the responsibility of the dental hygienist to provide complete and
comprehensive information about patient assessment procedures and
planned dental hygiene treatments so that the patient can make a well-
informed decision about either accepting or rejecting the proposed
treatment.
b. Informed consent not only involves informing the patient about the
expected successful outcomes of assessment procedures but the
possible risks, unanticipated outcomes and alternative treatments as
well. The patient also should be made aware of the costs for each of
the options involved, which may influence the patient’s ultimate
decision.
2. Capacity for Consent. A patient must also have the capacity to consent.
a. Capacity for consent—the ability of a patient to fully understand the
proposed treatment, possible risks, unanticipated outcomes, and
alternative treatments—takes into account the patient’s age, mental
capacity, and language comprehension.
b. A dialogue between the patient and the hygienist is the best way to
initiate the informed consent process.
3. Informed Refusal. Despite being informed of the proposed treatments,
 risks, and alternatives, the patient may decide to refuse one or more of
the recommended assessment procedures. This is called “informed
refusal.”
a. Autonomy, as defined by the ADHA Code of Ethics, guarantees “self-
determination” of the patient and is linked to informed consent.11
b. Only after the patient has received informed consent can a decision be
made to either accept or reject the proposed treatment. Radiographs,
fluoride treatments, and sealants are a few of the dental services for
which patients have exercised informed refusal.
c. Although refusal may not be the optimal choice of the treating
hygienist, the patient has a right to make any decision about his or her
treatments that only affects him or her personally and does not pose a
threat to others.
d. In the case of Erickson v. Dilgard, the patient’s right of refusal of a
blood transfusion was upheld by the court despite the possibility of
causing the patient’s death (Erickson v. Dilgard, 44 Misc. 2d 27, 252
N.Y.S. 2d 705 [Sup. Ct., 1962]). Patients may refuse treatment for a
number of reasons including religious beliefs, fear, or simply impulse.
Proceeding with a treatment that has been refused by a patient can
subject the clinician to liability for assault (causing fear) and/or
battery (unconsented touching).
4. Patient Responsibilities
a. The patient also has responsibilities and duties when receiving oral
health care. One duty is to provide accurate responses on the medical
history assessment regarding his or her current health status.
1. In a case in Newfoundland, Canada, the judge stated that “ . . . a
patient has a duty to herself to do everything reasonably necessary
to ensure she is properly diagnosed . . . As part of that duty, the
patient must disclose all relevant and pertinent information in order
to permit . . . a proper diagnosis of her medical condition.”12
2. Simply stated, the practitioner and patient relationship is a “two-
way street.” A practitioner should attempt to put the patient at ease
 when filling out a medical history, so the patient is comfortable
revealing the most private of medical details.
b. For some patients, the obstacles of comprehending the medical
history questions prevent them from filling out the forms completely.
For others, there may be embarrassment in being truthful, and fear of
being judged or refused treatment.
c. Other patients may ask about the necessity of filling out such a
comprehensive medical history assessment when “I only want my
teeth cleaned.” All patients must be made aware of the link between
systemic and oral health, as noted in the text, and the importance of an
accurate medical history in order for the practitioner to provide
optimal treatment. Box 5-3 provides an example of how a clinician
might respond to a patient’s questions about why it is necessary to fill
out a comprehensive medical history in the dental office.

BOX Sample Explanation on the Importance of a

5-3 Medical History
It is extremely important for you to fill out a complete and accurate medical
history today. The decision about what treatments are best for you cannot
be decided unless Dr. __________ is aware of all of your medical
conditions and medications/supplements that you take. This information is
needed to protect your health and, in turn, not cause you harm.
Some medical conditions require premedication, such as an antibiotic,
before dental treatment. Some medical conditions may cause you to have a
poor outcome of a proposed dental treatment. Some materials/drugs used in
dentistry may conflict with medications you are presently taking and/or
cause an adverse reaction. It is impossible to know how you are going to
react to a given dental treatment if we are unaware of your total physical,
mental, and dental health. By taking the time to fill out comprehensive
medical history, you can help Dr. __________ decide which dental
treatments are optimal and designed specifically for you, without the
possible risks of medical or dental complications.
 It is also important that your medical history be reviewed at each
appointment to account for any changes since your last visit. Even if you
were in a week before, you could have started a new medication or had a
medical procedure that could influence your dental treatment.
You and the dental team assume equal roles in your overall dental
care. Your role is to provide correct medical information so that the dental
team can, in turn, provide dental treatment individually designed for your
dental care needs.

SECTION 4 • Conducting a Medical History Assessment

To conduct a thorough medical history assessment, the dental health care
provider must have a methodical plan for information gathering and review.
The plan should prevent oversights or omissions of important information
about the patient’s medical history. This section describes a methodical plan
for conducting the thorough medical history assessment required for safe
patient treatment. The main steps in conducting a medical history assessment
are (1) information gathering and (2) determination of medical risk.
The goal of the medical history assessment is to obtain complete
information about the patient’s past and present history of medical conditions
and diseases, including prescription and over-the-counter medications. One
successful approach for obtaining information is to combine the use of a
written questionnaire to be completed by the patient with an interview of the
patient. The interview provides an opportunity to clarify information and ask
follow-up questions about information on the written questionnaire.

Information Gathering
The information-gathering phase of patient’s medical history involves:
• Reading thoroughly. Carefully read every line and every check box on
the history form completed by the patient.
• Prioritizing. Determine if the patient is in pain. If the patient is in pain,
remember that alleviating pain takes precedence over other dental
 treatment.
• Researching conditions. Research medical conditions and diseases.
• Researching drugs. Research medications—prescription and over-the-
counter.
• Formulating questions. Formulate questions to ask the patient during
the medical history interview.
• Interviewing. After a thorough review of the health history form, the
clinician should interview the patient. In order to acquire a
comprehensive picture of the patient’s health and medications, the
clinician asks questions to clarify information on the form and to obtain
additional information.
• Consulting. Determine the need for consultation with a physician or
other health specialist.

Medical Alert Box

Medical conditions/diseases or medications that necessitate modifications or
special precautions should be clearly marked in a medical alert box on the
patient record (Box 5-4).

BOX Contents of Medical Alert Box

5-4

• Any medical condition or disease that will alter dental treatment

• Any medical condition or disease that will alter drugs used during
dental treatment or prescribed for the patient to treat dental conditions
• Any medical condition or disease that places the patient at risk for
medical emergency during dental treatment
• Any medical condition or disease that could result in a postoperative
complication

Stress Reduction Protocol for Anxious Patients

For certain individuals, an upcoming dental appointment causes considerable
anxiety and stress. For anxious patients, stress reduction strategies are
recommended (Box 5-5).

BOX Strategies for Stress Reduction

5-5

• Good communication. Use empathy and effective communication to

establish trust and determine the cause(s) of the patient’s anxiety.
• Reduce anxiety. Premedicate as needed with an antianxiety medication
for use (1) the night before the appointment to aid the patient in getting
a good night’s sleep and (2) the day of the appointment.
• Scheduling. Schedule appointments early in the day (so that patient
will not have all day to worry about the upcoming treatment).
• Suggestions for patient. Suggest that the patient eat a normal meal
before the appointment and allow ample travel time to get to the dental
office or clinic.
• Length of treatment. Keep appointments short.
• Pain control. Ensure good pain control before, during, and after the
appointment, as appropriate, including the use of pain medications and
local anesthesia.

SECTION 5 • Peak Procedure

Procedure 5-1. Review of Written Questionnaire and

Patient Interview

Action Rationale
1. Read through every line • Complete information is
and check box. Are all the important to protect the
questions answered? patient’s health.
 2. Can you understand what • Make a note to ask the
is written? patient about anything that
is not clear.

3. Did the patient sign and • The history must be signed

date the form? and dated.

4. Circle YES responses in • YES answers should be

red pencil. discussed during the
interview.

5. Read through handwritten • Discuss concerns during

responses made by the the interview.
patient. Circle concerns in
red pencil.

6. Research medical • This is basic data that will

conditions and diseases be used to formulate
including: questions for the patient
a. Definition and to determine if dental
b. Symptoms or care involves any risks for
manifestations the patient.
c. Treatments and Common medical
medications conditions and diseases
d. Systemic side effects may be researched by
that may necessitate using the Ready
treatment modifications References found in
e. Oral manifestations Module 6.
f. Impact on dental care

7. Identify risks to the patient’s • Dental health care

overall health, such as poorly providers should identify
controlled diabetes, obesity, systemic health risks and
periodontal disease, and promote wellness.
 tobacco use. • There is a connection
Identify systemic factors that between periodontitis and
increase the risk of systemic health.
periodontal disease, such as Periodontal infection may
tobacco use, poorly contribute to the
controlled diabetes, hormone development of heart
alterations, psychosocial disease,
stress, and medications. premature/underweight
Circle concerns in red babies, poorly controlled
pencil. diabetes, and respiratory
diseases.
• Dental health care
providers should be alert
for systemic factors that
may increase the risk of
developing periodontal
disease.

8. Research the patient’s • It is important to

medications, prescribed and determine why each
nonprescription, including: medication is being taken.
a. Drug use • Some patients are not
knowledgeable about their
b. Systemic side effects
medical conditions. In
c. Oral side effects
such cases, medications
d. Dental treatment can be a valuable clue to
modifications or concerns the patient’s health status.
Medications can be • Many medications have
researched on the Internet, in systemic side effects that
drug reference books, and may necessitate
using the Ready References modifications to dental
found in Module 6 of this treatment. For example,
book. many medications cause
 dizziness or orthostatic
hypotension, thus
indicating that the
clinician should adjust the
chair position slowly.
• Other medications have
side effects that can alter a
patient’s dental health.
Xerostomia, gingival
overgrowth, and gingival
bleeding are examples of
oral side effects.
• Some medications dictate
modifications or
precautions before, during,
or after to dental
treatment. For example, a
blood thinning medication
reduces the ability of the
blood to clot.

9. Ask the patient questions • This factual information is

about his or her medical important in determining
conditions or diseases. if the patient can be
a. Duration—When was the treated safely.
condition first diagnosed? • Certain medical conditions
b. Treatments and and diseases have oral
Procedures—What is manifestations.
being done to treat the • Certain medical conditions
condition? affect the health of the
periodontium.
c. Episodes—What brings on
the condition? What
changes the severity?
 10. Ask the patient questions • This factual information is
about the medications, important in determining
prescription and over-the- if the patient can be
counter, as well as any treated safely.
herbal/vitamin supplements • Certain medical conditions
that he or she is taking. and diseases have oral
a. How long? Date started manifestations.
and ended
b. How much? Dosage

NOTE: The next chapter, Module 6: Ready References: Medical

History, contains two Ready References designed to provide fast access to
commonly encountered medical conditions and medications.
• Ready Reference 6-1. Common Conditions of Concern in Dentistry
• Ready Reference 6-2. Commonly Prescribed Drugs

SECTION 6 • The Human Element

Through the Eyes of Clinicians and Patients

A COMPLICATED MEDICAL HISTORY

It was my third week of clinic, and I was feeling quite confident about
medical history assessments. I started thinking that the lecture we had in
clinic theory on assessing medical histories was very unrealistic. The
example the instructor gave us was a patient on seven different drugs and
three different diseases.
Well today was the day! The health history form seemed to have as
many questions checked in the “Yes” column as the “No” column. I started
to panic, thinking that it was going to take me all day to review the medical
history and that the patient would be upset with me for taking so long. The
patient was overweight and had diabetes, high blood pressure, and high
cholesterol. She checked “Yes” to chest pain on exertion, sleep disorder,
and being out of breath. Her medications included several cardiac drugs as
well as insulin.
I began looking things up in a reference book when my instructor
looked over my shoulder and asked me if I had ever heard of “metabolic
syndrome.” I looked it up in a reference book. Suddenly, all the “Yes”
questions made sense. I felt I had a handle on the patient’s overall
condition. That confidence allowed me to readily gather the rest of the
information, link it together, and conduct the patient interview. It turned
out to be a great appointment. My patient was so nice, and I learned a lot
about her and her health history.
Stephanie, student
Tallahassee Community College

SATISFACTION WITH DENTAL CARE

Interview someone who has recently received dental hygiene care in a
dental office. Using open-ended questions, encourage the person to relate
his or her experiences as a dental patient receiving care from a dental
hygienist. Listen for what this person perceived as positive and supportive
or negative and nonsupportive about the care provided by the hygienist.
Reflect on the person’s experience and write a paragraph or participate in a
group discussion on how this information will impact how you provide
care as a dental hygienist.

MEDICAL HISTORIES MAY ELICIT SENSITIVE

INFORMATION

Generate a list of topics you would find embarrassing to discuss with

patients when gathering information during the medical history
assessment. For example, when inquiring about recent hospitalizations or
current medications, would you feel uncomfortable if the patient shared
that she was hospitalized 2 months ago after a miscarriage; or a patient that
shares that he is taking a medication for a sexually transmitted disease?
With other students, generate a list of potentially embarrassing topics (for
the clinician and/or the patient) and discuss potential strategies to approach
these topics and manage embarrassment.

Ethical Dilemma

CAN A 17-YEAR-OLD CONSENT TO

TREATMENT?

Your last patient of the morning is Sandy L., a 17-year-old who is new to
the dental practice. Her mother is sitting with Sandy in the waiting room,
helping her fill out her medical history assessment. You call Sandy into
your operatory. Her mother tells you that she will wait for Sandy and
would like to speak to the dentist before she is discharged today.
You begin reviewing Sandy’s medical history with her, which appears
uneventful. After you complete her extra- and intraoral exam, you discuss
with Sandy the office policy of taking radiographs on new patients. Sandy
states that she has not had any x-rays in a few years and agrees. As you are
about to place the first radiograph in her mouth, Sandy begins to cry.
Assuming she has fear of the dental office, you stop and try to comfort her.
Sandy states that she has no fear but suspects that she may be pregnant and
has heard that radiation “could harm the baby.” Sandy pleads with you not
to tell anyone, especially her mother.
1. What is the best way for you to handle this ethical dilemma?
2. Can a 17-year-old consent to treatment or must you receive parental
consent?
3. Under the ethical principle of confidentiality, can you discuss this with
your employer dentist, without violating Sandy’s confidentiality?
4. Do you have the right to divulge Sandy’s pregnancy to her mother?

English-to-Spanish Phrase Lists

USING THE ENGLISH-TO-SPANISH PHRASE

LISTS
According to the United States Census Bureau, more than one-half of the
2002 foreign-born residents in the United States were born in Latin
America. Communication problems can occur when an English-speaking
clinician tries to communicate with a patient who is not fluent in English.
• Teaching student clinicians to pronounce and speak Spanish is well
beyond the scope of this book and, indeed, of most professional
curriculums.
• For those times when a trained medical translator is not available, the
modules in this textbook include English-to-Spanish phrase lists with
phrases pertinent to the assessment process. The first of these phrase
lists is found in Table 5-2 on the following page.
• To use these phrase lists, the student clinician simply points to a
specific phrase in the patient’s native language to facilitate
communication.
 SECTION 7 • Practical Focus—Fictitious Patient Cases
This section contains the medical history and medication list for five
fictitious patients, patients A to E. In addition, Health History Interview and
Medical Consultation Request forms are provided for patients A to E (Figs.
5-6 to 5-25).
DIRECTIONS
• Remove the forms for patients A to E from the book for ease of use.
• For each patient, follow the steps outlined below to conduct an
assessment of the medical history and medications.
1. Review Medical History
• Carefully read the patient’s completed medical history form.
• Circle all “Yes” answers in red.
• Circle any unanswered questions.
2. Research Medical Conditions and Diseases
• Research all medical conditions and diseases.
• Start by locating the Ready Reference 6-1. Common Conditions of
Concern in Dentistry located in Module 6 of this book.
• As needed, conduct additional research. If a computer connected to the
Internet is available, go online to locate additional information. If you do
not have a computer, use oral medicine books to do additional research.
3. Research Medications—Prescription and Over-the-Counter
• Research all medications.
• Start by using Ready Reference 6-2. Commonly Prescribed Drugs
located in Module 6 of this book.
• As needed, conduct additional research either on the Internet or using
drug reference books.
4. Summarize Information and Formulate Questions
• Complete the Health History Interview form for each patient.
• At this point—after reviewing the patient’s medical history, medications,
and doing your research—do you have concerns about treating the
patient?
• Do you think any modifications will need to be made in order to treat
this patient safely?
• Make a list of follow-up questions that you should ask during the patient
interview. Write your questions on page 2 of the Health History
Interview form.
5. Determine if a Medical Consultation Is Needed
• For each patient, assess the need for a medical consultation. If needed,
complete page 1 of the Medical Consultation Request.

SECTION 8 • Skill Check

Technique Skill Checklist: Medical History Questionnaire

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, each U equals 0 point.

CRITERIA: S E
Reads through every line and “Yes/No” answer on
the completed health history form. Identifies any
unanswered questions on the health history form
and follows up to obtain complete information.
Makes notes about any information that is not clear
or difficult to read. Confirms that the patient has
signed and dated the form.
Circles YES responses in red. Reads through all
hand written responses and circles concerns in red.
Researches medical conditions and diseases
including definition, symptoms, and manifestations.
Lists potential impact on oral health and any
treatment concerns or needed modifications for
dental treatment.
Researches all prescription and OTC medications.
Lists potential impact on oral health and any
concerns or needed modifications for dental
treatment.
 Formulates a list of follow-up questions for the
patient interview.

Formulates a preliminary opinion of the medical

risk to the patient of dental treatment and whether a
medical consult will be needed. (After completing
the patient interview, discusses medical risk and
need for medical consultation with a clinical
instructor.)

OPTIONAL GRADE PERCENTAGE

CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

Communication Skill Checklist: Role-Play for Medical

History

ROLES:
• Student 1 = Plays the role of a fictitious patient.
• Student 2 = Plays the role of the clinician.
• Student 3 or instructor = Plays the role of the clinic instructor near
the end of the role-play.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, each U equals 0 point.

CRITERIA: S E
Explains the purpose of the medical history
assessment to the patient.
After researching medical conditions and
medications, asks appropriate follow-up questions
to gain complete information from the patient.
Encourages patient questions before and during the
medical history assessment.
Answers the patient’s questions fully and
accurately.
Communicates with the patient at an appropriate
level and avoids dental/medical terminology or
jargon.
Accurately communicates the findings to the
clinical instructor. Discusses the implications of the
medical history findings for dental treatment. Uses
correct medical and dental terminology.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

References
 1. Stoopler ET. The importance of hospital-based training for dentists. Spec Care
Dentist. 2013;33(3):101.
2. Oral health in America: a report of the Surgeon General. J Calif Dent Assoc.
2000;28(9):685–695.
3. Cohen MM Jr. Major long-term factors influencing dental education in the twenty-
first century. J Dent Educ. 2002;66(3):360–373, discussion 80–84.
4. Bowen DM. Medical screenings in dental settings. J Dent Hyg. 2012;86(4):260–264.
5. Greenberg BL, Thomas PA, Glick M, Kantor ML. Physicians’ attitudes toward
medical screening in a dental setting. J Public Health Dent. 2015;75(3):225–233.
6. Strauss SM, Alfano MC, Shelley D, Fulmer T. Identifying unaddressed systemic
health conditions at dental visits: patients who visited dental practices but not general
health care providers in 2008. Am J Public Health. 2012;102(2):253–255.
7. Maloney WJ, Weinberg MA. Implementation of the American Society of
Anesthesiologists Physical Status classification system in periodontal practice. J
Periodontol. 2008;79(7):1124–1126.
8. Malamed SF, Orr DL. Medical Emergencies in the Dental Office. 7th ed. St. Louis,
MO: Mosby.
9. Gilbert JH, Yan J, Hoffman SJ. A WHO report: framework for action on
interprofessional education and collaborative practice. J Allied Health. 2010;39(suppl
1):196–197.
10. ADEA Competencies for the New General Dentist. J Dent Educ. 2015;75:813–816.
11. American Dental Hygienists’ Association. Bylaws: Code of Ethics. Chicago, IL:
American Dental Hygienists’ Association; 2014.
12. Malik P. The perils of omission. Can J Cardiol. 2006;22(12):1011.
 MODULE
6

READY REFERENCES:
MEDICAL HISTORY
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
This module contains two ready references designed to provide fast access to
commonly encountered medical conditions and prescription medications.
• Ready Reference 6-1. Common Conditions of Concern in Dentistry
• Ready Reference 6-2. Commonly Prescribed Drugs

MODULE OUTLINE
SECTION 1 Medical Conditions and Diseases
Ready Reference 6-1. Common Conditions of Concern in
Dentistry
SECTION 2 Common Prescription Medications
Ready Reference 6-2. Commonly Prescribed Drugs

OBJECTIVES
• Demonstrate skills in using the “Ready References” in this module to
 research patient medical conditions/diseases and prescription
medications.
• Describe contraindications and complications for dental care
presented by various medical conditions/diseases and medications.

INTRODUCTION TO READY REFERENCES

In a dental office or clinic, using the Internet or reference books to research
medical conditions and medications may not be practical within minutes of
seeing a newly appointed patient. This module contains Ready References
designed to provide fast access to dentally relevant information on medical
conditions/diseases and prescription medications commonly encountered
in dental offices and clinics.
• These Ready References may be removed from the book.
• Laminating or placing these pages in plastic protector sheets will allow
them to be disinfected for use in a clinical setting.

SECTION 1 • Medical Conditions and Diseases

Ready Reference 6-1. Common Conditions of Concern in

Dentistry

Treatment Considerations
Red font = Potential Medical
Medical Condition or Disease Emergency Alert

Addison disease (Adrenal Body less able to respond to

insufficiency)—endocrine or stress Increased susceptibility
hormonal disorder to infection
characterized by weight loss, Acute adrenal insufficiency
muscle weakness, fatigue, low
blood pressure, and sometimes
darkening of the skin; Addison
disease occurs when the adrenal
glands do not produce enough
of the hormone cortisol and, in
some cases, the hormone
aldosterone.

AIDS—see HIV

Alcoholism—addiction to Avoid mouthwashes or other

alcohol products containing alcohol.
Bleeding tendency
Caution when using conscious
sedation or central nervous
system (CNS) depressant drugs
Patient may lack interest in
dental health.

Allergy—a sensitivity to a Possible allergy to latex, other

normally harmless substance products, or materials used in
that provokes a strong reaction dentistry
from the person’s body Possible xerostomia due to
medications
Anaphylaxis

Alzheimer—progressive Communication and patient

deterioration of intellectual management
functions such as memory

Amyotrophic lateral sclerosis

(ALS)—see Lou Gehrig
disease

Anemia—a blood condition in Gingival inflammation

which there are too few red Bleeding tendency
blood cells or the red blood
cells are deficient in
hemoglobin

Angina—a medical condition If taking aspirin therapy,

in which lack of blood to the clotting may be reduced.
heart causes severe chest pains Reduce stress by scheduling
shorter, early morning
appointments, minimize stress.
Anginal attack

Anticoagulant therapy—used Anticoagulants work by

to prevent blood clots from increasing the time it takes the
forming in the deep veins of the blood to clot; increased
body for prevention of stroke bleeding from invasive dental
and heart attack treatment, including
periodontal instrumentation

Arthritis—inflammation of the Daily plaque control may be

joints causing pain, swelling, difficult; suggest alternatives to
enlargement, and redness; also hand brushing and flossing.
see Rheumatoid arthritis If taking prednisone or other
corticosteroid, increased
susceptibility to infection (see
Corticosteroid therapy)
If taking aspirin, bleeding (see
Aspirin/antiplatelet therapy)

Aspirin/antiplatelet therapy Control of bleeding after

—used to prevent platelet periodontal instrumentation or
clumping and formation of surgical procedures
blood clots

Asthma—a respiratory disease If taking prednisone: increased

that causes blockage and risk for infection, poor wound
narrowing of the airways, healing, adrenal insufficiency
making it difficult to breathe Asthma attack

Autism—a Repetitive behaviors such as

neurodevelopmental disorder slapping, head banging, and
that causes mild to severe jerking may occur, making
difficulty with social dental treatment and care
communication and interaction. challenging. Clumsiness may
The disorder often includes require special techniques for
repetitive behaviors, oral hygiene self-care.
clumsiness, and lack of muscle
tone.

Bell palsy—a paralysis or Protect the eye on the affected

weakness of the muscles on one side due to the absence of
side of the face; it causes one blinking.
side of the face to droop and
affects taste sensation and tear
and saliva production.

Bipolar affective disorder—a If taking lithium, this drug can

condition that causes extreme interact with nonsteroidal anti-
shifts in mood, energy, and inflammatory agents used for
functioning pain control.

Bulimia nervosa—overeating Frequent vomiting causes

(binging) and self-induced erosion of tooth enamel of
vomiting (purging) usually lingual and occlusal aspects of
associated with anxiety and maxillary teeth.
body dysmorphic disorder (self-
image of being overweight and
unattractive)

Cerebral palsy—a group of Patient management

motor problems and physical Dental problems
disorders that result from a
brain injury or abnormal brain
development; results in
uncontrolled reflex movements
and muscle tightness
(spasticity)

Cerebrovascular accident Patient positioning during

(CVA) (stroke)—a sudden treatment
blockage or rupture of a blood If taking anticoagulants,
vessel in the brain resulting in bleeding tendency
loss of speech, movement, or If taking corticosteroids,
sensation for a period of 24 increased susceptibility to
hours or longer infection and less able to
withstand stress

Chemotherapy—the use of Immune suppression results in

chemical agents to treat increased risk of infection and
diseases, infections, or other poor wound healing.
disorders, especially cancer

Chronic bronchitis—a long- Patient positioning

term inflammation and Respiratory difficulty
irritation of the airways of the
lungs; symptoms include a
cough that produces too much
sputum, mild wheezing, and
chest pain; common in smokers

Congenital heart defects— Consult physician to determine

structural heart problems or need for antibiotic
abnormalities that have been premedication.
present since birth Susceptibility to bacterial
 endocarditis

Congestive heart failure May have breathing problems,

(CHF)—a condition in which may prefer semi-upright
the heart pumps ineffectively, position in dental chair
leading to a buildup of fluid in Minimize stress
the lungs, legs, and elsewhere; If taking diuretic, possible
people with CHF often xerostomia
experience shortness of breath Respiratory difficulty
and/or ankle or leg swelling
related to this excess fluid

Coronary artery disease May carry their own

(CAD)—a condition caused by nitroglycerine if history of
a combination of high angina; depending on level of
cholesterol, high blood severity, patient is at risk for:
pressure, unhealthy lifestyle Anginal attack or myocardial
(diet, lack of exercise, smoking) infarction (heart attack)
that leads to plaque,
inflammation and stiffening of
walls of the coronary artery

Corticosteroid therapy— Immune suppression with

corticosteroids are anti- increased risk of infection and
inflammatory drugs widely poor wound healing; lowered
used for treating a variety of tolerance for stress
conditions in which tissues
become inflamed; an example
is prednisone.

Crohn disease—an Immune suppression with

inflammatory bowel disease increased risk of infection and
(IBD) thought to be an poor wound healing
autoimmune response to
bacterial flora in intestines

Cushing syndrome—a rare Immune suppression with

disorder that develops when the increased risk of infection and
body is exposed to too much of poor wound healing
the hormone cortisol; may
cause weight gain, skin
changes, and fatigue and lead to
such serious conditions as
diabetes, high blood pressure,
depression, and osteoporosis

Cystic fibrosis (CF)—a Increased susceptibility to

genetically inherited disease; in infection
the lungs, CF causes thicker- Patient positioning
than-normal mucus to form in
the airways and lungs, leading
to respiratory problems and
infections

Diabetes (Type I)—a lifelong Increased susceptibility to

disease that develops when the infection and poor wound
pancreas stops producing healing
insulin; insulin injections must Appropriate appointment time
be taken daily. in regard to insulin therapy and
meals
Frequent maintenance
appointments
Insulin reaction if using
insulin

Diabetes (Type II)—a chronic Increased risk of infection

disease that develops when the Poor wound healing
pancreas cannot produce Frequent maintenance
enough insulin, or the body appointments
cannot use it properly; it can Insulin reaction if taking oral
often be treated without insulin hypoglycemic drugs or using
injections. insulin

Down syndrome—people with Increased risk of infection,

Down syndrome have an extra leukemia, and hypothyroidism
or irregular chromosome in May need caregiver’s
some or all of their body’s assistance with daily plaque
cells; the chromosomal control self-care
abnormalities impair physical
and mental development with
mild to moderate below-normal
intelligence

Emphysema—a chronic lung Breathing problems, may prefer

disease in which the alveoli of semi-upright position in dental
the lungs are damaged; air is chair
trapped in the lungs, leading to If emergency situation, no
shortness of breath. high concentrations of
supplemental oxygen

Endocarditis—an infection of History of endocarditis

the endocardium (inner lining indicated high risk for
of the heart) recurrence from dental
procedures.

Epilepsy—a brain disorder Dilantin: gingival hyperplasia

involving recurrent seizures; a Minimize stress.
seizure can be a sudden, Document type, frequency, and
violent, uncontrollable precipitating factors.
contraction of a group of Seizures
muscles or consists of only a
brief “loss of contact” or what
appears to be daydreaming

Fibromyalgia—a syndrome One-third of fibromyalgia

distinguished by chronic pain in patients have
the muscles, ligaments, temporomandibular joint (TMJ)
tendons, or bursae around joints disorders
May appreciate shorter
appointments

Gastroesophageal reflux Erosion of teeth

disease (GERD)—the Drugs for GERD may interact
abnormal backflow of stomach with antibiotics, analgesics
acid and juices into the
esophagus, the tube that leads
from the throat to the stomach;
results in heartburn and damage
to the esophagus

Glaucoma—damage to the Avoid drugs that increase

optic nerve, accompanied by an ocular pressure (i.e., atropine).
abnormally high pressure inside
the eyeball that can lead to
blindness if untreated

Glomerulonephritis—a kidney Medical consultation

disease caused by inflammation Toxic accumulation of drugs,
or scarring of the small blood including local anesthesia, due
vessels (glomeruli); if chronic, to poor drug elimination
leads to kidney failure; also see Increased susceptibility to
Kidney disease, chronic infection
Less able to withstand stress

Graves disease—the most Epinephrine given to

common cause of hyperthyroid patient could
hyperthyroidism in which the cause the medical emergency
thyroid gland produces too thyroid storm.
much thyroid hormone

Heart attack—see Myocardial

infarction

Hemophilia—a rare genetic Hemorrhage from dental

bleeding disorder caused by a procedures, including
shortage of certain clotting periodontal instrumentation
factors that are needed to help
stop bleeding after a cut or
injury and to prevent
spontaneous bleeding

Hepatitis B—a serious liver Laboratory clearance (ensure

infection from hepatitis B virus that infection has been
(HBV); infection may become successfully treated)
chronic, leading to liver failure, Infection, bleeding, delayed
cancer, or cirrhosis. wound healing
Universal precautions

Hepatitis C—the most serious Laboratory clearance (ensure

of all hepatitis viruses; usually that infection has been
leads to liver failure, liver successfully treated)
cancer, or cirrhosis Infection, bleeding, delayed
wound healing
Universal precautions

High blood pressure—see

Hypertension

HIV/AIDS—the HIV (human Oral lesions and infections

immunodeficiency virus) is a Risk of infection from dental
virus that attacks the immune procedures
system, making it difficult for Severe periodontal disease
the body to fight off infection Universal precautions
and some disease; HIV
eventually causes AIDS
(acquired immunodeficiency
syndrome).

Hypertension—high blood Epinephrine contraindication

pressure; a resting blood If taking diuretic, possible
pressure consistently 140/90 xerostomia
mm Hg or higher If taking calcium blocker,
possible gingival enlargement
CVA (stroke), MI (heart
attack)

Hyperthyroidism—an Epinephrine given to

overproduction of thyroid hyperthyroid patient could
hormone cause medical emergency
“thyroid storm.”

Hypothyroidism—an In severe hypothyroidism, CNS

insufficient production of depressant drugs can pose a
thyroid hormone risk of myxedema coma.

Implantable cardioverter Medical consultation

defibrillator—a device that Ultrasonic instrumentation
delivers an electrical shock to may be contraindicated.
prevent potentially dangerous
heart rhythm abnormalities

Kidney dialysis—a mechanical Medical consultation

process that performs part of Toxic accumulation of drugs
the work that healthy kidneys including local anesthesia due
normally do by removing to poor drug elimination
wastes and extra fluid from the Increased susceptibility to
blood infection
Less able to withstand stress
Salt restriction
Bleeding tendency

Kidney disease, chronic— Medical consultation

develops when the kidneys Toxic accumulation of drugs
permanently lose most of their including local anesthesia due
ability to remove waste and to poor elimination
maintain fluid and chemical Increased susceptibility to
balances in the body; in chronic infection
kidney disease, the kidneys Less able to withstand stress
have not stopped working Salt restriction
altogether but are not working Bleeding tendency
as well as they should. Dialysis
or kidney transplantation is
required when kidney function
drops to about 15% of normal.

Latex allergy—an unusual Avoid latex products; in a

sensitivity to latex that varies clinical setting, all clinicians
from a mild allergic reaction to should avoid “snapping” gloves
an anaphylactic response which creates airborne latex
particles

Leukemia—cancer of the Bleeding tendency

blood cells in which the bone Periodontal disease; need for
marrow produces abnormal excellent self-care
white blood cells that over time Immune compromised
crowd out the normal white Medical consultation
blood cells, red blood cells, and recommended
platelets

Liver disorder—impaired Infection, bleeding, delayed

function of the liver due to wound healing
cirrhosis, hepatitis, cancer,
alcoholism

Lou Gehrig disease Swallowing difficulties;

(Amyotrophic lateral physical disabilities make
sclerosis)—a progressive patient positioning a challenge
wasting away of certain nerve Daily plaque control may be
cells of the brain and spinal difficult; suggest alternatives to
column; walking, speaking, hand brushing and flossing or
eating, swallowing, breathing, educate caregiver.
and other basic functions
become more difficult as the
disease progresses

Lupus erythematosus—an Increase susceptibility to

autoimmune disease in which a infection due to compromised
person’s immune system immune system.
attacks its own tissues as Adrenal crisis
though they were foreign
substances; may cause
problems with kidneys, heart,
lungs, or blood cells

Ménière disease—a problem in Medications may cause

the inner ear that affects xerostomia.
hearing and balance, Hearing loss in affected ear
characterized by repeated Dizziness; raise chair slowly
attacks of dizziness that occur from supine position
suddenly and without warning; Might need assistance in
the vertigo experienced during walking due to dizziness
an attack can be intense,
leading to nausea and vomiting,
and can last anywhere from
several minutes to many hours

Mental disorder—any disease Reduced stress tolerance

or condition affecting the brain Xerostomia
that influences the way a person Avoid mouth rinse containing
thinks, feels, behaves, and/or alcohol.
relates to others and to his or
her surroundings

Metabolic syndrome—a group Monitor blood pressure at every

of abnormal findings related to appointment.
the body’s metabolism
including excess body fat, high
triglycerides and blood
pressure, and high cholesterol;
causes increased risk of
diabetes, heart disease, or
stroke

Mitral valve prolapse—an Medical consult and probable

improper closing of the leaflets preoperative antibiotic
of the mitral valve; may cause premedication
back flow of blood into the left
atrium

Mitral valve stenosis—a heart Medical consult and probable

condition in which the mitral antibiotic premedication
valve fails to open as wide as it
should; can cause irregular
heartbeats and possibly heart
failure or other complications,
including stroke, heart
infection, pulmonary edema,
and blood clots
Mononucleosis—a viral illness Standard precautions as the
usually caused by the Epstein- usual route of transmission is
Barr virus (EBV); most through saliva
common symptoms of
mononucleosis include high
fever, severe sore throat,
swollen glands (especially the
tonsils), and fatigue; once
infected with EBV, the body
may periodically shed (or give
off) the virus throughout a
person’s lifetime, possibly
spreading the virus

Multiple myeloma—a rare Antibiotics may be indicated to

form of cancer characterized by control or reduce the incidence
excessive production and of infection.
improper function of the plasma
cells found in the bone marrow;
symptoms may include bone
pain, anemia, weakness,
fatigue, and lack of color, and
kidney abnormalities; affected
individuals are more
susceptible to bacterial
infections such as pneumonia.

Multiple sclerosis (MS)—a Adverse reactions to drugs may

chronic neurological disease include risks for infection,
involving the brain, spinal cord, difficulties keeping mouth open
and optic nerves; causes during long appointments
problems with muscle control Daily plaque control may be
and strength, vision, balance, difficult; suggest alternatives to
sensation, and mental functions hand brushing and flossing or
educate caregiver.

Muscular dystrophy (MD)—a Daily plaque control may be

group of inherited diseases in difficult; suggest alternatives to
which the muscles that control hand brushing and flossing or
movement progressively educate caregiver.
weaken Muscle weakness and range of
motion decrease as the disease
progresses will eventually
require oral hygiene assistance
for patient.

Myasthenia gravis—a Patients may have difficulty in

neuromuscular disorder chewing, swallowing, and
primarily characterized by talking.
muscle weakness and muscle Daily plaque control may be
fatigue; most individuals difficult; suggest alternatives to
develop weakness and drooping hand brushing and flossing or
of the eyelids, double vision, educate caregiver.
and excessive muscle fatigue;
additional features commonly
include weakness of facial
muscles, impaired articulation
of speech, difficulties chewing
and swallowing, and weakness
of the arms/legs.

Myocardial infarction (MI)— No elective dental treatment for

a heart attack; caused by a lack 6 months
of blood supply to the heart for Bleeding tendency if taking
an extended time period, results anticoagulant or aspirin
in permanent damage to the Monitor vital signs.
heart muscle Minimize stress with shorter
appointments, early morning
appointments

Narcolepsy—a chronic sleep Be alert for sudden episodes of

disorder mainly characterized sleeping.
by an excessive daytime Stress may cause cataplexy
drowsiness with episodes of resulting in slurred speech or
suddenly falling asleep total physical collapse.

Non-Hodgkin lymphoma— Swollen lymph nodes may be

cancer of the lymphatic system only sign of condition in early
resulting in painless, swollen phase.
lymph nodes; symptoms
include fever, drowsiness,
weight loss

Oral/head and neck cancer— Radiation therapy

cancerous lesions of the oral Medical consultation
cavity and/or head and neck recommended; may need
region antibiotic premedication
Xerostomia may be present.
Increased susceptibility to
infection
Risk of dental caries due to
radiation
Prevention: early detection of
lesions

Organ transplant—a surgical Extra precautions to avoid

procedure to remove a damaged infections
or diseased organ and replace it Adrenal insufficiency
with a healthy donor organ;
heart, intestine, kidney, liver,
lung, pancreas replacement

Osteonecrosis of the jaw—a Further question patients who

medication known as have a history of taking
bisphosphonates, alone or in bisphosphonate drugs. Consult
combination with other drugs, with patient’s physician for
has been linked to medication- approval of treatment plan.
related osteonecrosis of the jaw
(MRONJ). Risk of MRONJ
varies with route of
administration (IV), length of
time of treatment, combinations
of drugs (i.e., cortisone), and
patient diseases (i.e., diabetes)
and conditions.

Pacemaker—a small device Avoid use of ultrasonic

that sends electrical impulses to devices.
the heart muscle to maintain a
suitable heart rate and rhythm;
it is implanted just under the
skin of the chest during a minor
surgical procedure.

Panic disorder—consists of Provide a stress reduction

several, unexpected panic protocol if the patient is
attacks, which usually begin apprehensive about dental
with a sudden feeling of treatment.
extreme anxiety; an attack can
be triggered by a stressful event
or occur for no apparent reason
and can last several minutes;
symptoms may include a
feeling of intense fear or terror,
difficulty breathing, chest pain
or tightness, heartbeat changes,
dizziness, sweating, and
shaking; patients can mistake a
panic attack for a heart attack.

Parkinson disease—a chronic, Assist patient with positioning

progressive motor system in dental chair and when
disorder; the four primary walking to and from treatment
symptoms are tremor or area.
trembling in hands, arms, legs, Swallowing difficulties
jaw, and face; rigidity or Poor motor control; daily
stiffness of the limbs and trunk; plaque control may be difficult;
slowness of movement; and suggest alternatives to hand
impaired balance and brushing and flossing or
coordination; patients may have educate caregiver.
difficulty walking, talking, or
completing other simple tasks.

Peripheral arterial disease Patient may not be able to

(PAD)—poor circulation to tolerate long appointments
limbs, especially the legs; without frequent walking
occurs when arteries supplying breaks.
blood to limbs become clogged
or partially blocked

Polymyalgia rheumatica—an If on long-term corticosteroid

inflammatory disorder that therapy, increased
causes widespread muscle susceptibility to infection
aching and stiffness, especially
in the neck, shoulders, thighs,
and hips
Rheumatic fever—a rare but If patient taking prednisone or
potentially life-threatening another corticosteroid,
disease, rheumatic fever is a increased susceptibility to
complication of untreated strep infection
throat Adrenal crisis

Rheumatic heart disease—a Medical consultation

condition that can result from Antibiotic premedication
rheumatic fever; usually a Minimize stress.
thickening and constriction of Monitor vital signs.
one or more of the heart valves
that often requires surgery to
repair or replace the involved
valve(s)

Rheumatoid arthritis—a If patient taking corticosteroids,

relatively common disease of susceptibility to infection
the joints; the tissues lining the Adrenal crisis
joints become inflamed; over
time, the inflammation may
destroy the joint tissues, leading
to disability. Rheumatoid
arthritis affects women twice as
often as men and frequently
begins between the ages of 40
and 60 years.

Schizophrenia—a severe brain Personality problems; may be

disease that interferes with paranoid, feel threatened,
normal brain and mental apprehensive
function—it can trigger If taking medications faithfully,
hallucinations, delusions, most problems will be well
paranoia, and significant lack of controlled; may be drowsy or
motivation; without treatment, react slowly to requests or
schizophrenia affects the ability questions
to think clearly, manage
emotions, and interact
appropriately with other people.

Scleroderma—a connective Cardiac, circulatory,

tissue disorder characterized by pulmonary, and kidney
abnormal thickening of the complications
skin; some types affect specific
parts of the body, while other
types can affect the whole body
and internal organs

Sexually transmitted diseases Refer to physician and

(STDs)—those diseases that are postpone treatment when oral
spread by sexual contact; STDs lesions or other signs suggest
can also be spread from a infection.
pregnant woman to her fetus
before or during delivery.

Sickle cell anemia—an Patients have episodes of pain

inherited disease in which the in the chest, abdomen, and
red blood cells, normally disc joints.
shaped, become crescent At greater risk for infection due
shaped; these cells function to sickle cell damage to the
abnormally and cause small spleen
blood clots; these clots give rise
to recurrent painful episodes
called “sickle cell pain crises.”

Sjögren syndrome Xerostomia predisposes

(pronounced “showgrins”)—is patients to dental caries.
a disorder in which the immune If major organs are involved,
system attacks the body’s there is greater risk for
moisture-producing glands, infection.
such as the tear and salivary
glands; these glands may
become scarred and damaged,
and exceptional dryness in the
eyes and mouth may develop

Splenectomy—the removal of Increased susceptibility to

a spleen that is enlarged or infection
injured; patients without a
spleen are termed asplenic

Stroke—see Cerebrovascular
accident

Thrombophlebitis—a blood Consult with physician

clot and inflammation in one or regarding anticoagulant therapy
more veins, typically in the and risks for hemorrhage.
legs; cause is inactivity due to
travel or convalescence
Cerebrovascular accident

Tinnitus—ringing or buzzing Tinnitus can be caused or

in the ears, that is, constant or worsened by TMJ disorder.
intermittent and usually caused Patient may not tolerate
by noise exposure ultrasonic instrumentation.

Tourette syndrome—a Patient management if tics are

condition that causes patients to not controlled.
exhibit uncontrolled behaviors
known as tics; tics range from
bouts of lip smacking, blinking,
shrugging, repetitive phrases, or
shouting obscenities.
 Tuberculosis (TB)—a bacterial Active TB may spread through
infection that usually affects the aerosols in clinic (patient
lungs but can affect other parts should not receive elective
of the body; is classified as dental care).
latent or active; active TB can Consult with physician if
be spread to others. patient presents with history of
TB.

Ready Reference 6-1 adapted with permission from Cynthia Biron Leisica, DH Meth-Ed.

SECTION 2 • Common Prescription Medications

Key:
Areas for concern are printed in a red font color.
Brand names are printed in bold letters.
Generic names are printed in italics.
GLOSSARY OF ABBREVIATIONS OF COMMON DRUG
CATEGORIES
High Blood Pressure Medications
ACEI: angiotensin-converting enzyme inhibitor
AIIB: angiotensin II blockers
BB: beta blockers
CCB: calcium channel blockers
HCTZ: hydrochlorothiazide diuretics

Cholesterol-Lowering Drugs
STATIN: limit lipid synthesis

Vasoconstrictors in Local Anesthesia

EPI: epinephrine
LFRN: levonordefrin
Antidepressants
TCA: tricyclic antidepressants
SSRI: selective serotonin reuptake inhibitors

Asthma/COPD Medications
CORT: cortisone
BRNC: bronchodilators

Pain Relievers (Analgesics)

NSAID: nonsteroidal anti-inflammatory drug

Ready Reference 6-2. Commonly Prescribed Drugs

Concerns/Oral
Drug Use Manifestations

Abilify, aripiprazole Antipsychotic drug used to Involuntary muscle

treat various psychoses contractions and tremo
(such as hallucinations, that can present proble
delusional beliefs, with patient managem
disorganized thinking) during the appointmen

Abstral, fentanyl (sublingual) Sublingual administration of Dizziness, nausea,

fentanyl, a powerful opioid fainting
pain reliever

Acarbose, Precose Oral drug for the control of Hypoglycemia, dizzine

diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Accupril, quinapril ACEI to treat high blood Altered taste, dizzines

pressure and heart failure nausea, vomiting;
and prevent kidney failure minimize use of
 due to high blood pressure vasoconstrictors in loc
and diabetes anesthetic; angioedem
hypotension

Accutane, Amnesteem, A strong vitamin A oral Causes serious and fat

Claravis, Sotret, isotretinoin medication used to treat birth defects
acne when other medications Frequently causes
are not effective depression

Acebutolol, Sectral BB to treat angina and high Feeling faint, swelling

blood pressure irregular heartbeat

Acetaminophen/codeine, Acetaminophen is used for Nausea, vomiting

Tylenol 3 the relief of pain and fever.
Codeine is added to increase
pain relief.

Aciphex, rabeprazole Medication for treatment of Xerostomia, altered ta

heartburn, gastroesophageal nausea, dizziness,
reflux disease (GERD) (acid nervousness
reflux disease)

Actiq, fentanyl (lozenge) Narcotic oral lozenge for Dental caries, respirato
pain depression

Actonel, risedronate Bisphosphonate medication Nausea, medication-

for the treatment of Paget related osteonecrosis o
disease (a disease in which the jaw (MRONJ)
the formation of bone is possibility
abnormal) and in persons
with osteoporosis

Actos, pioglitazone Oral medication used to treat Respiratory tract

type II diabetes infection, headache,
sinusitis, low blood su
sore throat; if diabetes
 poorly controlled,
increased risk of
periodontitis

Acyclovir, Zovirax Antiviral: herpes I, II, herpes Lightheadedness, dry l

zoster (shingles)

Adderall, dextroamphetamine Medication to treat attention Xerostomia, nervousne

deficit hyperactivity disorder anxiety, restlessness,
(ADHD) and narcolepsy excitability, dizziness,
(CNS disease causing tremor; blood pressure
excessive daytime and heart rate may
sleepiness) increase.

Advair, salmeterol/fluticasone BRNC/CORT inhaler to Xerostomia, upper

treat asthma, chronic respiratory infections
bronchitis, or emphysema

Advil, ibuprofen NSAID for relief of mild to Xerostomia, ulceration

moderate pain lichen planus on bucca
mucosa/lateral border
tongue, dizziness,
drowsiness, nausea,
heartburn, increased
bleeding

Aggrenox, Antiplatelet that reduces the Hemorrhage, headache

aspirin/dipyridamole clumping of platelets in the
blood; used to prevent blood
clots and stroke

Aldara, imiquimod (topical) Medication for warts in Treatment for oral war
sexually transmitted diseases
(STDs) also used to treat
some cancers
Alendronate, Fosamax Bisphosphonate medication Possibility of
used for the treatment of osteonecrosis of the ja
persons with osteoporosis

Aleve, naproxen NSAID for relief of mild to Xerostomia, dizziness,

moderate pain drowsiness, nausea,
heartburn, increased
bleeding tendency

Allegra, fexofenadine Antihistamine to treat Xerostomia, dizziness,

Allegra-D (with allergy symptoms. Allegra- headache, anxiety, trem
pseudoephedrine) D has a decongestant to
reduce mucus and running
nose

Allopurinol, Alloprin, A xanthine inhibitor that Salty taste

Zyloprim reduces uric acid production
for the treatment of gouty
arthritis

Alphagan, brimonidine Medication for the treatment Xerostomia

of glaucoma

Alprazolam, Xanax Benzodiazepine to treat Xerostomia,

anxiety associated with lightheadedness
situations such as dental
appointments, or in general
anxiety disorders

Altace, ramipril ACEI to treat high blood Altered taste, dizzines

pressure, heart failure, and nausea, vomiting; use
for preventing kidney failure vasoconstrictors in loc
due to high blood pressure anesthetic should be
and diabetes minimized; angioedem
hypotension
Alupent inhaler, albuterol BRNC inhaler for asthma Xerostomia

Amaryl, glimepiride Oral drug for the control of Hypoglycemia, dizzine

diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Ambien, zolpidem Insomnia treatment (sleep Xerostomia, sore throa

aid) lightheadedness, dayti
fatigue, weakness,
increased appetite

Ambien CR, zolpidem Controlled release formula Xerostomia, sore throa

for insomnia lightheadedness, dayti
fatigue, weakness,
increased appetite

Amiodarone HCl, Cordarone Antiarrhythmic medication Altered saliva flow an

for irregular heartbeat taste

Amitiza, lubiprostone Treatment for chronic Xerostomia, nausea,

constipation stomach pain

Amitriptyline, Elavil TCA with pain relieving Xerostomia, orthostati

effects; also used to treat hypotension, altered ta
temporomandibular joint use of vasoconstrictors
(TMJ) pain local anesthetic should
minimized.

Amlodipine, Norvasc CCB used to treat angina Gingival hyperplasia;

involuntary muscle
contractions, tremors,
changes in breathing a
heart rate
Amlodipine/atorvastatin Combination CCB/STATIN Gingival hyperplasia;
to treat both angina and high involuntary muscle
cholesterol contractions, tremors,
changes in breathing a
heart rate, muscle pain
and weakness, fatigue,
flu-like symptoms

Amlodipine/benazepril Combination CCB/ACEI to Gingival hyperplasia;

treat angina and lower blood involuntary muscle
pressure contractions, tremors,
changes in breathing a
heart rate, altered taste
cough, dizziness, naus
vomiting; minimize us
vasoconstrictors in loc
anesthetic; angioedem
hypotension

Amlodipine/valsartan Combination CCB/AIIB to Gingival hyperplasia;

treat angina and lower blood involuntary muscle
pressure contractions, tremors,
changes in breathing a
heart rate, hypotension

Amoxicillin, Amoxil Penicillin-type antibiotic Oral candidiasis, black

used to treat infections and hairy tongue, dizziness
for the prevention of nausea
bacterial endocarditis

Amphetamine salt, Dyanavel Stimulant used to treat Nervousness,

XR narcolepsy, ADHD hypertension, rapid he
rate, anorexia, interact
with vasoconstrictors i
 local anesthesia

AndroGel, testosterone Hormone medication for low Ankle swelling

testosterone levels in men

Anoro Ellipta, Anticholinergic/beta2 Xerostomia, sore throa

umeclidinium/vilanterol agonist inhaler for chronic sinusitis
obstructive pulmonary Never for asthma att
disease (COPD)
(contraindicated for asthma)

Apri, ethinyl estradiol Birth control (oral Antibiotics taken for

contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

Aranesp, darbepoetin alfa A medication to treat anemia Hypertension/hypoten

in patients having in 20% of patients
chemotherapy

Aricept, donepezil Treatment for Alzheimer Slow heartbeat, faintin

disease

Aripiprazole, Abilify Antipsychotic drug to treat Involuntary muscle

various psychoses contractions and tremo
(hallucinations, delusional may present problems
beliefs, disorganized with patient managem
thinking) at appointment.

Arnuity Ellipta, fluticasone CORT inhaler for Candidiasis of mouth a

furoate maintenance therapy for throat Patient must rin
asthma and expectorate after
inhalation therapy

Asacol, mesalamine Treatment for ulcerative Pharyngitis

colitis in inflammatory
 bowel disease or Crohn
disease

Asmanex Twisthaler, CORT inhaler for Inflammation of nose,

mometasone furoate maintenance therapy for throat, and sinuses
asthma

Aspirin, Bayer, Bufferin NSAID to treat fever, pain, Bleeding, heartburn, u

and inflammation; heart stomach, nausea, and
attack: chew two aspirin, vomiting If aspirin
swallow with water allergy: never give
aspirin.

Astelin, azelastine Nasal spray for swelling and Xerostomia, aphthous

inflammation of the mucous ulcers, altered taste
membranes inside the nose

Atacand, candesartan AIIB for lowering high Runny nose, sore throa
blood pressure cough, back pain,
headache, dizziness

Atelvia, risedronate sodium Bisphosphonate for the Possibility of

treatment of persons with osteonecrosis of the ja
osteoporosis

Atenolol, Tenormin BB to treat angina and high Feeling faint, swelling

blood pressure irregular heartbeat

Atenolol chlorthalidone, BB combined with HCTZ to Hypotension, irregular

Tenoretic treat angina and high blood heartbeat, cold hands a
pressure feet

Ativan, lorazepam Benzodiazepine for anxiety, Dizziness; xerostomia

also used as a sleep aid

Atorvastatin, Lipitor STATIN to lower Muscle pain, tenderne

cholesterol to prevent weakness, fever or flu
 coronary artery disease symptoms; nausea,
stomach pain, loss of
appetite

Atripla, efavirenz, Combination of three Upset stomach, headac

emtricitabine, tenofovir medications in one tablet for dizziness, drowsiness
treatment of HIV+

Atrovent, ipratropium BRNC for chronic bronchitis Xerostomia, tremor,

and emphysema nervousness

Augment ES-600, amoxicillin Penicillin-type antibiotic Black hairy tongue,

used to treat bacterial coated tongue, oral
infections candidiasis, nausea, an
vomiting

Avalide, Irbesartan/HCTZ AIIB for lowering high Dizziness, nausea,

blood pressure hypotension

Avandamet, Oral medication used to treat If patient is experienci

rosiglitazone/glimepiride type II diabetes increased stress, there
risk of hypoglycemia.

Avandia, rosiglitazone Oral medication used to treat If patient is experienci

maleate type II diabetes increased stress, there
risk of hypoglycemia.

Avapro, irbesartan AIIB to treat high blood Dizziness; minimize

pressure and congestive vasoconstrictor use in
heart failure local anesthetic.

Avelox, moxifloxacin Antibiotic to treat Dizziness, fainting, rap

pneumonia and eye and skin and loud heartbeat
infections

Aviane, levonorgestrel, Birth control (oral Antibiotics taken for

estradiol contraceptive) dental infections can
 decrease the effectiven
of oral contraceptives.

Avinza, morphine sulfate Narcotic for moderate to Dizziness, nausea

severe pain

Avodart, dutasteride Medication for benign None

prostate enlargement

Avonex, interferon beta-1a Medication for relapsing Headache, nausea

forms of multiple sclerosis

Axiron, topical testosterone Testosterone for Nausea

hypogonadism in men

Azathioprine, Azasan, Imuran Immunosuppressant for Fever, malaise, rash,

lichen planus, erythema gastrointestinal effects
multiforme, pemphigus

Azithromycin, Z-Pak, Antibiotic, alternative for Caution in liver disord

Zithromax prevention of endocarditis

Azor, amlodipine and Combined medications to Hypotension, xerostom

olmesartan lower high blood pressure

Baclofen, Lioresal Muscle relaxant for multiple Drowsiness

sclerosis

Bactroban, mupirocin Topical antibiotic for None

treatment of impetigo,
infected eczema, also used
as a nasal ointment

Belsomra, suvorexant Treatment for insomnia, Xerostomia, headache

sleep aid drowsiness during the

Benazepril, Lotensin ACEI to treat high blood Altered taste, dizzines

 pressure and heart failure nausea, vomiting;
and for preventing kidney minimize use of
failure due to high blood vasoconstrictors in loc
pressure and diabetes anesthetic; angioedem
hypotension

Benicar, olmesartan AIIB/HCTZ combination to Altered taste, dizzines

Benicar HCT, olmesartan treat high blood pressure nausea, vomiting;
HCTZ minimize use of
vasoconstrictors in loc
anesthetic; angioedem
hypotension

Benzonatate, Tessalon Cough medicine, topical None

anesthetic

Betaseron, interferon beta-1b Medication for treatment of Flu-like syndrome

multiple sclerosis

Beyaz, drospirenone, ethinyl Combination of drugs for Antibiotics taken for

estradiol, and levomefolate birth control, premenstrual dental infections can
disorders and acne decrease the effectiven
of oral contraceptives.

Biaxin XL, clarithromycin Antibiotic used to treat Oral candidiasis, altere

bacterial infections taste, cough, dizziness
nausea

Bisoprolol/HCTZ BB/HCTZ to lower blood Abnormal taste,

pressure hypotension, hypokale

Bonine, meclizine Used for the treatment of Xerostomia, drowsines

nausea, vomiting, and
dizziness

Boniva, ibandronate Bisphosphonate used to treat Possibility of

 osteoporosis osteonecrosis of jaw

Breo Ellipta, fluticasone Anticholinergic/beta2 Xerostomia, sore throa

furoate/vilanterol agonist Inhaler for COPD sinusitis
—contraindicated for Never for asthma att
asthma)

Budesonide, Entocort Enteric coated cortisone Candidiasis of mouth a

tablets for short-term flare throat, heartburn, naus
up of Crohn disease

Bupropion, Budeprion SR Antidepressant Xerostomia, altered ta

Wellbutrin SR (sustained
release)
Wellbutrin XL (extended
release)

Buspirone, BuSpar Medication for the Dizziness, nausea,

management of anxiety xerostomia

Butalbital/APAP/caffeine, Combination of drugs for Dizziness,

Fioricet pain relief lightheadedness

Bydureon, exenatide Injectable noninsulin Hypoglycemia, nausea

medication for type II
diabetes

Byetta, exenatide Oral medication for type II Hypoglycemia, nausea

diabetes

Bystolic, nebivolol BB for treatment of high Headache, nausea,

blood pressure fatigue, insomnia

Cabergoline, Dostinex Treatment of Xerostomia, toothache

hyperprolactinemia throat irritation

Caduet, CCB/STATIN; combination Muscle pain, tenderne

amlodipine/atorvastatin to lower blood pressure and weakness, fever, flu
high cholesterol to prevent symptoms, nausea,
coronary artery disease stomach pain, loss of
appetite

Calcitonin (salmon), Calcimar Hormone that stops bone None

resorption

Calcitriol, Calcijex, Rocaltrol A form of vitamin D used to Metallic taste, xerosto

treat and prevent low levels
of calcium in the blood

Candesartan, Atacand AIIB/HCTZ to treat high Lightheadedness,

Candesartan with HCTZ blood pressure and kidney hypotension, swelling
problems hands and feet; HCTZ
hypokalemia, increase
risk of hypotension

Captopril, Capoten ACEI to treat high blood Altered taste, dizzines

pressure, heart failure, and nausea, vomiting;
for preventing kidney failure minimize use of
due to high blood pressure epinephrine or
and diabetes levonordefrin in local
anesthetic; angioedem
hypotension

Carafate, sucralfate Medication to heal or Stomach pain,

prevent stomach and indigestion, xerostomi
duodenal ulcers itching or skin rash,
insomnia, dizziness,
drowsiness, spinning
sensation, headache, o
back pain

Carbamazepine, Carbatrol, Anticonvulsant, also for Xerostomia

Epitol, Tegretol trigeminal or
glossopharyngeal neuralgia

Carbidopa/levodopa, Lodosyn Medication used to treat Hypotension, fainting,

Parkinson disease anxiety

Carisoprodol, Soma Medication used for muscle Hypotension, fainting

relaxant and TMJ pain

Cartia XT, diltiazem CCB for chest pain from Gingival hyperplasia
angina

Carvedilol, Coreg CR BB to lower blood pressure Xerostomia, hypotensi

Casodex, bicalutamide Chemotherapy for prostate Xerostomia

cancer

Catapres, clonidine Medication for the treatment Drowsiness, xerostom

hydrochloride of hypertension; also used to salivary gland
manage the symptoms of enlargement, dizziness
narcotic withdrawal, minimize vasoconstric
nicotine withdrawal in local anesthetic.

Cefadroxil, Duricef Antibiotic alternative to None

penicillin for prevention of
infective endocarditis

Cefdinir, Omnicef Antibiotic medication for Nausea, headache

pneumonia, ear infection,
sinusitis, pharyngitis,
tonsillitis, skin infections

Cefprozil, Cefzil Antibiotic: ear, respiratory, Nausea, headache

and skin infections

Ceftin, cefuroxime Antibiotic: lower Nausea, headache

respiratory, skin, bone, full
 body infection (sepsis)

Celebrex, celecoxib NSAID for relief of mild to Possible increased risk

moderate pain of arthritis heart attack, xerostom
altered taste, vomiting
aphthous ulcers,
stomatitis

Celexa, citalopram SSRI for treatment of Xerostomia, altered ta

depression, obsessive- nausea, oral candidiasi
compulsive disorders dizziness
(OCDs), panic disorders

CellCept, mycophenolate Immunosuppressant: to Oral ulcers, oral

prevent rejection of organ candidiasis, sore mout
transplant gingival hyperplasia

Cephalexin, Keflex Antibiotic: alternative to Nausea, headache

penicillin for prevention of
infective endocarditis

Cetirizine, Zyrtec Antihistamine: for allergy, Xerostomia

hay fever

Chantix, varenicline Non-nicotine medication Bad taste; suicidal

designed to help smokers thoughts while using
quit more easily than medication and follow
without the drug withdrawal from
medication; nausea,
heartburn, depression,
agitation, drowsiness,
headache; changes in
mood, behavior

Cholestyramine powder Lowers cholesterol by None

absorbing bile acids in blood
Choline fenofibrate, Antara Adds fiber to the stomach to Stomach pain, headach
remove fats from dietary stuffy nose
intake

Cialis, tadalafil Erectile dysfunction If chest pain—

nitroglycerine

Cilostazol, Pletal Antiplatelet agent: used to Headache in 27%–34%

prevent platelets from patients
clumping and forming clots

Cimzia, certolizumab pegol Medication for inflammation Chest pain, cough, fee
in Crohn disease, short of breath, swellin
rheumatoid arthritis, in neck, fatigue
psoriatic arthritis

Cipro, ciprofloxacin Antibiotic for treatment of Oral candidiasis, nause

bacterial infections; also
used for periodontitis
associated with
Actinobacillus
actinomycetemcomitans

Ciprodex, Combination of None

Ciprofloxacin/dexamethasone ciprofloxacin and cortisone
for ear infections

Citalopram, Celexa SSRI for treatment of Xerostomia, altered ta

depression, OCDs, panic nausea, oral candidiasi
disorders dizziness

Clarinex, desloratadine Nasal spray for runny nose Xerostomia

and nasal congestion

Clarithromycin, Biaxin Antibiotic used to treat Oral candidiasis, altere

bacterial infections taste, cough, dizziness
 nausea

Claritin, loratadine Antihistamine used to treat Xerostomia, tachycard

Claritin-D (with decongestant) the symptoms of allergy palpitations

Clindamycin, Cleocin Antibiotic for treatment of Oral candidiasis,

infections, prevention of dizziness
bacterial endocarditis

Clindamycin (topical), Cleocin Antibacterial agent for acne None

T

Clobetasol propionate, Topical cortisone: erosive None

Clobevate disorders such as lichen
planus, aphthae

Clomipramine, Anafranil TCA for the treatment of Dizziness, drowsiness,

obsessions and compulsions xerostomia, constipatio
in patients with OCDs stomach upset, nausea
vomiting, changes in
appetite/weight, flushi
sweating, tiredness, an
blurred vision

Clonazepam, Klonopin Medication for certain types Dizziness, hypotension

of seizures in the treatment fainting
of epilepsy and for the
treatment of panic disorders

Clonidine, Catapres Medication for the treatment Drowsiness, xerostom

of hypertension; also used to salivary gland
manage the symptoms of enlargement, dizziness
narcotic withdrawal, vasoconstrictors in loc
nicotine withdrawal anesthetic should be
minimized.
Clopidogrel, Plavix A medication that reduces Increased bleeding
the clumping of platelets in
the blood; reduces risks for
heart attack and stroke

Clorazepate, Tranxene Medication used to treat Xerostomia, drowsines

general anxiety disorder, hypotension, fainting
partial seizures

Clotrimazole, Lotrimin Topical antifungal None

medication in the form of a
lozenge (troche) used to
treat oral candidiasis

Clotrimazole/betamethasone, Antifungal with cortisone: None

Lotrisone topical
Dental use: oral lesions

Colchicine, probenecid Medication for the treatment Dizziness, headache, s

for gout gums, nausea

Colestipol, Colestid Lowers cholesterol by Constipation, heartbur

binding with bile in the
intestines

Combigan, brimonidine Eye drops for treatment of None

tartrate/timolol glaucoma

Combivent, BRNC inhaler for COPD Xerostomia

ipratropium/albuterol

Combivent Respimat, BRNC inhaler for COPD Cough, headache, sore

albuterol and ipratropium throat, bronchitis

Combivir, Two antiretroviral drugs Headache, joint or mu

zidovudine/lamivudine combined for treatment of pain, nausea, nervousn
HIV+ tiredness, vomiting,
 weakness

Complera, emtricitabine, Three antiretroviral drugs Headache, joint or mu

rilpivirine, tenofovir combined for treatment of pain, nausea, nervousn
HIV+ tiredness, vomiting,
weakness

Concerta, methylphenidate XR Medication for treatment of Hypertension

ADHD

Conjugated estrogens, Hormone replacement None

Premarin therapy

Copaxone, glatiramer acetate Medication for relapsing MS Anxiety, back pain,

flushing, headache,
nausea, vomiting,
weakness

Coreg, carvedilol BB to treat high blood Hypotension, dizzines

pressure and congestive minimize use of
heart failure vasoconstrictors in loc
anesthetic

Cosopt, dorzolamide/timolol Used to decrease intraocular Altered taste

pressure (pressure within the
eyeball)

Cotrim, co-trimoxazole Antibiotic used for urinary Oral candidiasis,

tract infections, respiratory dizziness, nausea
tract infections, middle ear
infections

Coumadin, warfarin Anticoagulant helpful in Ulcerations; increased

preventing blood clot bleeding tendency,
formation in patients with medical consult
atrial fibrillation and
 artificial heart valves to
reduce the risk of strokes

Cozaar, losartan AIIB to treat high blood Xerostomia, dizziness;

pressure, congestive heart hypotension, dizziness
failure minimize use of
vasoconstrictors in loc
anesthetic

Crestor, rosuvastatin STATIN to lower high Muscle pain, tenderne

cholesterol to prevent or weakness with feve
coronary artery disease flu symptoms; or naus
stomach pain, low feve
loss of appetite

Cromolyn inhaler sodium, Anti-inflammatory Throat irritation, bad

Intal maintenance inhaler for taste, cough, wheeze,
bronchial asthma nausea

Cyclobenzaprine, Flexeril Muscle relaxant, also used Dizziness, syncope,

for TMJ dysfunction edema

Cyclosporine, Sandimmune Immunosuppressant in organ Gingival hyperplasia,

transplant lesions

Cymbalta, duloxetine SSRI and norepinephrine Xerostomia, dizziness,

inhibitor for depression tiredness, nausea

Deltasone, prednisone An oral corticosteroid used Oral candidiasis

to treat arthritis, colitis, With long-term use:
asthma, bronchitis increased susceptibilit
infection, adrenal
insufficiency

Depakote, divalproex Medication for the treatment Dizziness, nausea, trem

of seizures, bipolar disorder, periodontal abscess, ta
 and prevention of migraines abnormality

Desipramine, Norpramin TCA for treatment of Tingly feeling, weakne

depression lack of coordination;
xerostomia, nausea,
vomiting, blurred visio
tinnitus

Desogestrel/ethinyl estradiol, Birth control (oral Antibiotics taken for

contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

Desoximetasone, Topicort Topical corticosteroid used None

to treat inflammation of the
skin

Detrol LA, tolterodine Used to treat uncontrollable Xerostomia

urination due to what is
often referred to as an
“overactive” bladder

Dexilant, dexlansoprazole Medication for GERD Xerostomia, stomach

upset, gastrointestinal
disorders

Dextroamphetamine sulfate, Stimulant used to treat Nervousness,

Dexedrine narcolepsy and ADHD hypertension, rapid he
rate, anorexia, interact
with vasoconstrictors i
local anesthesia

Diazepam, Valium Benzodiazepine for Nausea

treatment of general anxiety
disorder
Diclofenac, Voltaren NSAID for treatment of Dizziness, drowsiness,
rheumatoid arthritis headache, heartburn,
nausea

Didanosine, Videx Medication for the treatment Headache, joint or mu

of HIV+ pain, nausea, nervousn
tiredness, vomiting,
weakness

Differin, adapalene Topical treatment for acne Erythema, scaling,

dryness

Diflucan, fluconazole Antifungal used to treat oral, Dizziness, nausea

esophageal, urinary, vaginal
infections caused by the
fungus Candida

Digitek, digoxin Used to treat heart failure Hypotension, gagging;

and abnormal heart rhythms minimize use of
vasoconstrictors in loc
anesthesia as it can cau
arrhythmia with digox

Dilantin, phenytoin An anticonvulsant Gingival hyperplasia,

medication used to prevent dizziness
seizures

Diltiazem, Cardizem, Cartia Medication for chest pain Gingival hyperplasia

XT from angina

Diovan, valsartan AIIB to lower high blood Dizziness; use of

pressure, and treat vasoconstrictors in loc
congestive heart failure anesthetic should be
minimized

Diovan HCT, HCTZ HCTZ to lower high blood Hypotension,

 pressure and treat congestive hypokalemia
heart failure

Diphenoxylate/atropine, Medication for adults with Xerostomia

Lomotil symptoms of diarrhea and
intestinal spasms

Ditropan XL, oxybutynin Used for adults with Xerostomia

symptoms of overactive
bladder

Divalproex, Depakote Used for the treatment of Dizziness, nausea, trem

seizures, bipolar disorder periodontal abscess, ta
and prevention of migraines abnormality

Docusate sodium, Colace Stool softener to treat None

constipation

Dovonex, calcipotriene Treatment for psoriasis (a None

(topical) skin disease in with red,
scaly patches)

Doxazosin, Cardura XL For the treatment of high Xerostomia, dizziness,

blood pressure and benign fatigue, drowsiness,
enlargement of the prostate headache, shortness of
breath, nausea, runny
nose, diarrhea, abdomi
pain, swelling,
hypotension

Doxepin HCl, Prudoxin Antidepressant Xerostomia, altered ta

Doxycycline, Vibramycin Antibiotic for treatment of Glossitis, tooth stainin

numerous infections and opportunistic
including periodontitis candidiasis

Duexis, ibuprofen and NSAID for the relief of Bleeding

famotidine signs and symptoms of
rheumatoid arthritis and
osteoarthritis

Dulera, Inhaler for the treatment of Can lower patient

formoterol/mometasone asthma immune system and
increase chances of
infection

Duloxetine extended release, SSRI and norepinephrine Xerostomia, dizziness,

Cymbalta inhibitor for depression tiredness, nausea

Duragesic, fentanyl Transdermal patch used for Hypotension

patients with severe chronic
pain, for example, the pain
of cancer

Econazole nitrate, Spectazole Antifungal agent: topical None

Edarbi, azilsartan/medoxomil For the treatment of high Hypotension

blood pressure

Edluar, zolpidem Sublingual tablet for Dizziness, xerostomia;

treatment of insomnia not to be used with oth
CNS depressants

Effient, prasugrel Antiplatelet agent in heart Easy bleeding, bruisin

and cardiovascular disease headache, dizziness, b
pain, minor chest pain
fatigue, nausea, cough

Elidel, pimecrolimus (topical) Used for the treatment of Respiratory tract and v
mild to moderate dermatitis infections

Eliquis, apixaban Antiplatelet agent in heart Easy bleeding, bruisin

and cardiovascular disease headache, dizziness, b
pain, minor chest pain
 fatigue, nausea, cough

Elocon, mometasone furoate Corticosteroid lotion used Increased glucose

for the relief of itching and concentration in blood
skin conditions adrenal insufficiency

Enalapril, Vasotec ACEI to treat high blood Altered taste, persisten

Enalapril with HCTZ pressure and heart failure cough, dizziness, naus
and for preventing kidney vomiting; minimize us
failure due to high blood vasoconstrictors in loc
pressure and diabetes anesthetic; angioedem
hypotension; combine
with HCTZ: hypokalem
increased risk of
hypotension

Enbrel, etanercept Medication for treatment of Increased risk for

rheumatoid arthritis infection

Endocet, oxycodone/APAP Narcotic analgesics and Nausea, dizziness

acetaminophen used to
relieve pain

EpiPen, EpiPen Jr, For anaphylaxis—severe For anaphylaxis—seve

epinephrine allergic reaction; automatic allergic reaction
injector for intramuscular
injection into the thigh

Epzicom, Trizivir, abacavir, Three antiretroviral drugs Headache, joint or mu

lamivudine, Zidovudine combined for treatment of pain, nausea, nervousn
HIV+ tiredness, vomiting,
weakness

Erythromycin, Akne-Mycin, Antibiotic Oral candidiasis

E.E.S.
Escitalopram, Lexapro SSRI for major depression Xerostomia, nausea,
or generalized anxiety insomnia
disorder

Esidrix, HCTZ Diuretic commonly used to Hypotension

lower high blood pressure

Eskalith, lithium Medication used most Fine hand tremor, dry

frequently for bipolar mouth, altered taste,
affective disorder (manic- salivary gland
depressive illness) enlargement

Esomeprazole, Nexium Decreases the amount of Nausea

acid produced in the
stomach, treatment of
GERD

Estradiol, Alora Estrogen replacement Headache

therapy by transdermal patch

Ethinyl Birth control (oral Antibiotics taken for

estradiol/norethindrone, contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

Etodolac, Lodine NSAID medication for pain, Abnormal taste

arthritis

Evista, raloxifene Estrogen agonist/antagonist Hot flashes, headache,

prevention of osteoporosis in dizziness, spinning
postmenopausal women at sensation, leg and join
risk for breast cancer pain, nausea, vomiting
upper respiratory
congestion

Evoclin, clindamycin Alternative antibiotic for —

 amoxicillin for infective
endocarditis

Exelon, rivastigmine tartrate Medication to treat dementia Upset stomach, weigh

caused by Alzheimer disease loss, weakness, dizzine
swelling in hands or fe
joint pain, cough, nasa
congestion, sweating,
drowsiness, insomnia,
headache, shakiness

Exforge, amlodipine /valsartan CCB, AIIB for treatment of Dizziness, spinning

high blood pressure sensation, stuffy nose,
sore throat

Famotidine, Pepcid Decreases the amount of Dizziness, headache

acid produced in the
stomach, treatment of
GERD

Famvir, famciclovir Antiviral medication for Headache in 17%–39%

herpes zoster (shingles), patients, nausea 7%–1
herpes labialis, genital of patients, diarrhea
herpes

Felodipine, Plendil For the management of high Gingival hyperplasia

blood pressure and headache in 11%–15%
congestive heart failure patients

Femara, letrozole Chemotherapy for breast Numerous adverse effe

cancer

Fenofibrate, Lipidil Medication that lowers Xerostomia, tooth

cholesterol and triglycerides disorder

Fentanyl transdermal, Narcotic pain reliever, Hypotension, fainting

Duragesic transdermal

Ferrous sulfate, Feosol Supplement for iron Liquid FeSO

deficiency anemia

Fexofenadine, Allegra An antihistamine used to Xerostomia, dizziness,

with pseudoephedrine Allegra- treat the signs and symptoms headache, anxiety, trem
D of allergy

Flecainide acetate, Tambocor Medication used to treat Dizziness 19%–30% o

irregular heartbeat patients

Flomax, tamsulosin Treatment of men who are Orthostatic hypotensio

having difficulty urinating
due to enlarged prostate

Flonase, Flovent, fluticasone Topical corticosteroid used Oral candidiasis

for the control of the
symptoms of allergic rhinitis
(stuffy nose)

Fluconazole, Diflucan Antifungal used to treat oral, Dizziness, nausea

esophageal, urinary, vaginal
infections caused by the
fungus Candida

Fluocinonide, Lidex (topical) Treatment for psoriasis (a None

skin disease in with red,
scaly patches)

Fluoxetine, Prozac Medication for treatment of Oral candidiasis,

depression xerostomia, hypotensio
nausea; can initiate
bruxism

Fluticasone and salmeterol, Inhaled drug that is used to Xerostomia, upper

Advair treat asthma, chronic respiratory infections
 bronchitis, or emphysema

Fluvastatin, Lescol Treatment to lower high Muscle pain, tenderne

cholesterol to prevent or weakness with feve
coronary artery disease flu symptoms; or naus
stomach pain, low feve
loss of appetite

Fluvoxamine, Luvox SSRI for treatment of Xerostomia, bruxism

depression and OCD

Focalin XR, dexmedetomidine For treatment of ADHD Xerostomia, headache

Folvite, folic acid Vitamin: water soluble None

Foradil Aerolizer, formoterol Adjunct temporary therapy Viral infection,

fumarate for out of control asthma; bronchitis, asthma
maintenance therapy for exacerbation
COPD

Forteo, teriparatide Parathyroid hormone for Tooth disorder

osteoporosis

Fortesta, testosterone Testosterone gel for topical Ankle swelling

(topical) treatment of hypogonadism
in men

Fosamax, alendronate Used for the treatment of Possibility of

persons with osteoporosis osteonecrosis of the ja

Fosamax Plus D, with vitamin Used for the treatment of Possibility of

D persons with osteoporosis osteonecrosis of the ja

Fosinopril, Monopril ACEI/HCZT to treat high Altered taste, dizzines

Fosinopril with HCTZ blood pressure and heart nausea, vomiting;
failure and for preventing minimize use of
kidney failure due to high vasoconstrictor in loca
 blood pressure and diabetes anesthetic angioedema
hypotension; combine
with HCTZ: hypokalem
increased risk of
hypotension

Furosemide, Lasix Diuretic used to treat high Orthostatic hypotensio

blood pressure and hypokalemia
congestive heart failure

Fuzeon, enfuvirtide Antiretroviral agent: HIV-1 Xerostomia, altered ta

Gabapentin, Neurontin Anticonvulsant (used to Xerostomia, dizziness

prevent seizures)

Gatifloxacin, Tequin, Zymar Antibiotic for the bacterial Oral candidiasis

infections

Gemfibrozil, Lopid Medication used to lower None known

triglycerides

Geodon (oral), ziprasidone Antipsychotic used to treat Xerostomia, hypotensi

schizophrenia, bipolar tooth disorder, tongue
disorder with or without edema
psychosis

Gleevec, imatinib Chemotherapy for sarcomas, Numerous adverse effe

leukemia

Glimepiride, Amaryl Oral drug for the control of Hypoglycemia, dizzine

diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Glipizide, Glucotrol Oral drug for the control of Hypoglycemia, dizzine

diabetes nausea; if diabetes is
 poorly controlled,
increased risk of
periodontitis

Glipizide/metformin Combination of oral drugs Hypoglycemia, dizzine

for the control of diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Glucagon, GlucaGen Emergency treatment for Available in injectable

unconscious diabetic form; there is a paste f
patients in insulin shock oral administration in
patients who are
conscious.

Glucophage XR, metformin Oral drug for the control of Oral candidiasis, altere
type II diabetes taste, hypoglycemia,
dizziness, nausea; if
diabetes is poorly
controlled, increased r
of periodontitis

Glucotrol, glipizide Oral drug for the control of Hypoglycemia, dizzine

type II diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Glucovance, Oral drug for the control of Hypoglycemia, dizzine

glyburide/metformin type II diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis
Glyburide, DiaBeta Oral drug for the control of Hypoglycemia, dizzine
type II diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Glyburide/metformin, Oral drug for the control of Hypoglycemia, dizzine

Glucovance type II diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Griseofulvin, Gris-PEG Antifungal drug for Mouth/tongue irritatio

infections of the skin or nails thrush
caused by fungi

Guaifenesin, Tussin, Fenesin Cough medicine and None

expectorant that loosens
phlegm

Guanethidine, Ismelin Medication to lower high Hypotension

blood pressure

Haloperidol, Haldol Used for treating psychotic Gingival bleeding,

disorders and for tics and xerostomia, ulceration
vocal utterances of Tourette sudden motions of the
syndrome head, neck, arms,
involuntary movement
mouth/tongue, dizzine
orthostatic hypotensio

Harvoni, ledipasvir/sofosbuvir Antiviral drug to treat Fatigue, headache,

chronic hepatitis C nausea, diarrhea,
insomnia

HCTZ, Esidrix HCTZ diuretic for lowering Hypokalemia (below

 high blood pressure and normal levels of
treating congestive heart potassium in the blood
failure hypotension

Herceptin, trastuzumab Breast cancer drug given Altered sense of taste,

after chemotherapy mouth sores, sore thro
cold symptoms, nause
vomiting, insomnia,
muscle/joint pain

Humalog, insulin preparation Injectable insulin for Respiratory tract

diabetes infection, hypoglycem
sore throat; if diabetes
poorly controlled,
increased risk of
periodontitis

Human Insulin NPH, insulin Injectable insulin for Respiratory tract

diabetes infection, hypoglycem
sore throat; if diabetes
poorly controlled,
increased risk of
periodontitis

Humira, adalimumab Medication for treatment of Nausea; runny or stuff

rheumatoid arthritis, Crohn nose
disease

Humulin 70/30, insulin Injectable insulin for Oral candidiasis,

diabetes respiratory tract infect
hypoglycemia, sore
throat; if diabetes is
poorly controlled,
increased risk of
periodontitis
Hydralazine, Apresoline Medication for treatment of Hypotension
severe high blood pressure

Hydrocodone/ibuprofen, Narcotic combined with Xerostomia, dizziness,

Reprexain, Vicoprofen NSAID for moderate to nausea, vomiting
severe pain

Hydrocodone with APAP, Narcotic combined with Xerostomia, dizziness,

Vicodin, Lortab acetaminophen for pain nausea, vomiting

Hydrocortisone, Solu-Cortef Corticosteroid: anti- Infection, adrenal crisi

inflammatory agent taken long term

Hydromorphone HCl, Narcotic medication for Hypotension, nausea,

Dilaudid severe pain vomiting

Hydroxychloroquine sulfate, Used to treat acute attacks of Nausea, dizziness,

Plaquenil malaria; also used to treat headache, eyesight
lupus erythematosus and problems
rheumatoid arthritis in
patients whose symptoms
have not improved with
other treatments

Hydroxyzine, Atarax, Vistaril Antihistamine to treat Xerostomia

allergic reactions;
antianxiety agent used as a
preoperative sedative

Hyoscyamine, Anaspaz Medication to stop spasms Xerostomia

of the intestines associated
with diarrhea with irritable
bowel syndrome

Hyzaar, losartan/HCTZ AIIB/HCTZ combination of Hypotension

two medications to lower
 high blood pressure

Ibuprofen, Motrin, Advil NSAID for relief of mild-to- Xerostomia, dizziness,

moderate pain drowsiness, nausea,
heartburn, bleeding

Imipramine HCl, Tofranil-PM Treatment for depression Xerostomia, hypotensi

Imitrex, sumatriptan Medication for relief of Bad taste, dysphagia,

migraine headaches mouth/tongue discomf

Incruse Ellipta, umeclidinium Anticholinergic inhaler for Respiratory infection,

obstructed airflow in COPD cough, sore throat, join
pain, muscle pain, toot
pain, stomach pain,
bruising or dark areas
skin, and fast or irregu
heartbeat

Indapamide, Lozol Diuretic to lower blood Xerostomia, hypotensi

pressure and treat congestive palpitations, rhinorrhe
heart failure

Inderal LA, propranolol BB medication used to Hypotension, minimiz

lower high blood pressure use of vasoconstrictors
and prevent angina, tremor, local anesthetic
arrhythmias

Indinavir, Crixivan Antiviral agent for treatment Headache, joint or mu

of HIV+ pain, nausea, nervousn
tiredness, vomiting,
weakness

Indomethacin, Indocin NSAID for relief of mild to Xerostomia, ulceration

moderate pain dizziness, drowsiness,
nausea, heartburn,
 increased bleeding
tendency

InnoPran XL, propranolol BB with extended release Feeling faint, swelling

extended release used to lower high blood irregular heartbeat;
pressure and prevent angina, minimize use of
tremor, arrhythmias vasoconstrictors in loc
anesthetic

Insulin preparations, Humalog Injectable insulin for Respiratory tract

diabetes infection, hypoglycem
sore throat; if diabetes
poorly controlled,
increased risk of
periodontitis

Invokamet, Combination of two oral Hypoglycemia, dizzine

canagliflozin/metformin medications to treat diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Invokana, canagliflozin Oral medication to treat Hypoglycemia, dizzine

diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Ipratropium/albuterol, Inhaler for respiratory Xerostomia

Combivent diseases

Ipratropium bromide, Inhaler used for chronic Xerostomia, tremor,

Atrovent bronchitis and emphysema nervousness

Irbesartan, Avapro Medication used to lower Dizziness; minimize u

Irbesartan with HCTZ high blood pressure and of vasoconstrictors in
 relieve symptoms of local anesthetic
congestive heart failure HCTZ: hypokalemia,
increased risk of
hypotension

Isocarboxazid, Marplan One of four monoamine Dizziness, drowsiness,

oxidase inhibitors (MAOIs) hypotension; this drug
for generalized depression interacts with most dru
that does not respond to and cannot be used wi
other antidepressants local anesthesia with
vasoconstrictors.

Isosorbide dinitrate, Isordil CCB for angina, high blood Gingival hyperplasia,
pressure, rapid heart rhythm dizziness

Isosorbide/mononitrate, Imdur Medication to prevent Headache

angina attacks

Isotretinoin, Accutane A strong vitamin A oral Causes serious and fat

medication used to treat birth defects; frequentl
acne when other medications causes depression
are not effective

Itraconazole, Sporanox Antifungal agent used in None

immunocompromised
patients with oropharyngeal
candidiasis

Janumet, sitagliptin/metformin Combination of two oral Hypoglycemia, dizzine

medications for diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Januvia, sitagliptin Oral medication for diabetes Hypoglycemia, dizzine

nausea; if diabetes is
 poorly controlled,
increased risk of
periodontitis

Jardiance, empagliflozin Oral medication for diabetes Hypoglycemia, dizzine

nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Kadian, morphine sulfate Narcotic medication for Hypotension, nausea,

severe pain vomiting

Kaletra, lopinavir, ritonavir Antiretroviral drug for Headache, joint or mu

treatment of HIV+ pain, nausea, nervousn
tiredness, vomiting,
weakness

Kapidex, dexlansoprazole Medication for erosive Swelling of lips, tongu

esophagitis and GERD cheeks (candidiasis),
fainting, chest tightnes

Kapvay, clonidine HCl Medication for treatment of Dizziness, fainting,

ADHD xerostomia, headache;
severe reaction:
candidiasis

K-Dur, Klor-Con, potassium Electrolyte supplement: to Xerostomia

chloride prevent potassium depletion
(hypokalemia)

Keppra, levetiracetam An antiseizure medication Gingival hyperplasia;

(anticonvulsant) used to dizziness
prevent seizures

Ketoconazole, Nizoral Antifungal agent used to Numerous drug

 treat fungal infections such interactions
as oral candidiasis

Kombiglyze XR, metformin, Extended release medication Stress-induced

saxagliptin for type II diabetes hypoglycemia

Labetalol HCl, Trandate Treatment for high blood Hypertensive crisis, lo

pressure heart rate (bradycardia

Lamictal, lamotrigine Anticonvulsant medication Xerostomia

to prevent seizures

Lamisil, terbinafine Antifungal drug for Taste disturbance

ringworm/athlete’s foot

Lanoxin, digoxin Used to treat congestive Hypotension, gagging

heart failure

Lansoprazole, Prevacid Reduces stomach acid Xerostomia, oral

production candidiasis, altered tas
aphthous ulcers,
stomatitis

Lantus, insulin glargine Insulin for type I diabetes Hypoglycemia

Lasix, furosemide Diuretic used to treat high Orthostatic hypotensio

blood pressure and
congestive heart failure

Latanoprost, Xalatan Ophthalmic agent (eye None

preparation) for treatment of
glaucoma

Latuda, lurasidone Antipsychotic drug to treat Drowsiness, dizziness,

schizophrenia nausea, diarrhea, stom
pain, loss of appetite,
shaking, muscle stiffne
 weight gain, mask-like
facial expression, inab
to keep still, restlessne
agitation, blurred visio

Leflunomide, Arava Medication for rheumatoid Sore mouth (stomatitis

arthritis candidiasis, abnormal
taste, tooth disorder,
gingivitis

Lescol XL, fluvastatin sodium STATIN to lower high Muscle pain, tenderne
cholesterol to prevent or weakness with feve
coronary artery disease flu symptoms; or naus
stomach pain, low feve
loss of appetite

Levalbuterol, Xopenex Nebulizer bronchodilation Headaches, anxiety,

treatment for asthma xerostomia, insomnia,
muscle pain

Levaquin, levofloxacin Antibiotic for treatment of Oral candidiasis

sinusitis, urinary tract
infections

Levemir, insulin detemir Injectable insulin for Hypoglycemia, dizzine

diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Levitra, vardenafil Medication for erectile If patient has chest p

dysfunction —no nitroglycerine
should be given.

Levonorgestrel/ethinyl Birth control Antibiotics taken for

estradiol, Aviane dental infections can
 decrease the effectiven
of oral contraceptives.

Lexapro, escitalopram SSRI treatment of major Xerostomia, nausea,

depression and generalized insomnia
anxiety disorder

Linzess, linaclotide Medication to treat Diarrhea, abdominal p

constipation in irritable bloating, heartburn,
bowel syndrome vomiting, headache,
stuffy nose, sneezing,
sinus pain

Lipitor, atorvastatin STATIN to lower high Muscle pain, tenderne

cholesterol to prevent or weakness with feve
coronary artery disease flu symptoms; or naus
stomach pain, low feve
loss of appetite

Lisinopril, Prinivil, Zestril Used to treat high blood Altered taste, dizzines
pressure and heart failure nausea, vomiting; use
and for preventing kidney vasoconstrictors in loc
failure due to high blood anesthetic should be
pressure and diabetes minimized; angioedem
hypotension

Lisinopril/HCTZ combination Used to treat high blood Altered taste, dizzines

pressure and heart failure nausea, vomiting; use
and for preventing kidney vasoconstrictors in loc
failure due to high blood anesthetic should be
pressure and diabetes minimized; angioedem
hypotension

Lithium, Eskalith, Lithobid Used most frequently for Fine hand tremor, dry
bipolar affective disorder mouth, altered taste,
 (manic-depressive illness) salivary gland
enlargement

Livalo, pitavastatin Treatment to lower high Muscle pain, tenderne

cholesterol to prevent or weakness with feve
coronary artery disease flu symptoms; or naus
stomach pain, low feve
loss of appetite

L-Norgestrel/ethinyl estradiol Birth control Antibiotics taken for

dental infections can
decrease the effectiven
of oral contraceptives.

Loestrin Fe, ethinyl estradiol Birth control (oral Antibiotics taken for
and norethindrone contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

Loratadine, Claritin Antihistamine for allergies Xerostomia, stomatitis

Loratadine/pseudoephedrine, tachycardia, palpitatio
Claritin-D

Lorazepam, Ativan Benzodiazepine for anxiety; Xerostomia

also a sleep aid

Losartan, Cozaar Used to treat high blood Xerostomia, dizziness;

pressure, congestive heart use of vasoconstrictors
failure local anesthetic should
minimized

Losartan/HCTZ, Hyzaar Used to treat high blood Xerostomia, dizziness;

pressure, congestive heart use of vasoconstrictors
failure local anesthetic should
minimized
Lotensin, benazepril Used to treat high blood Altered taste, dizzines
pressure and congestive nausea, vomiting; use
heart failure vasoconstrictors in loc
anesthetic should be
minimized; angioedem
hypotension

Lotrel, amlodipine, benazepril Medication used to lower Altered taste, orthostat

high blood pressure hypotension, dizziness
fatigue, headache, nau
vomiting; use of
vasoconstrictors in loc
anesthetic should be
minimized.

Lovastatin, Altoprev, Treatment to lower high Muscle pain, tenderne

Mevacor cholesterol to prevent or weakness with feve
coronary artery disease flu symptoms; or naus
stomach pain, low feve
loss of appetite

Lovaza, omega-3-acid ethyl Prescription level of omega- Burping, indigestion

esters 3 fish oil for the treatment of
high triglyceride blood
levels

Low-Ogestrel, Birth control (oral Antibiotics taken for

norgestrel/estradiol contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

Lumigan, bimatoprost Ophthalmic agent (eye None

preparation) for treatment of
glaucoma
Lunesta, eszopiclone Sleep aid for insomnia Bad taste, xerostomia

Lyrica, pregabalin Medication for either Xerostomia

fibromyalgia or prevention
of seizures in epilepsy

Macrobid, nitrofurantoin Antibiotic Nausea

Maxalt-MLT, rizatriptan Medication for migraine Xerostomia

headaches and symptoms

Meclizine, Antivert, Bonine Used for the treatment of Xerostomia, drowsines

nausea, vomiting, and
dizziness

Medroxyprogesterone, Birth control (oral May cause gingival

Provera contraceptives) bleeding

Meloxicam, Mobic NSAID for relief of mild to Oral ulcers, xerostomi

moderate pain

Mercaptopurine, Purinethol Chemotherapy for leukemia Stomatitis, mucositis

Metaxalone, Skelaxin Skeletal muscle relaxant Dizziness

Metformin, Glucophage Medication for type II Stress-induced

diabetes hypoglycemia

Methadone HCl, Dolophine Narcotic for moderate to Xerostomia, glossitis

severe pain

Methocarbamol, Robaxin Skeletal muscle relaxant Metallic taste

Methotrexate, Rheumatrex Used to treat rheumatoid Ulcerative stomatitis,

arthritis, severe psoriasis and glossitis, dry cough
also for some cancers

Methylphenidate HCl, Ritalin A stimulant to treat ADHD, Fast, uneven heartbeat

 narcolepsy headache, sore throat,
restlessness

Methylprednisolone, Medrol, Corticosteroid, systemic: Ulcerative esophagitis

Solu-Medrol anti-inflammatory, Adrenal insufficiency
immunosuppressant taken long term

Metoclopramide, Reglan Used short term for Xerostomia

persistent heartburn

Metolazone, Zaroxolyn Diuretic for lowering high Hypotension, xerostom

blood pressure

Metoprolol, Lopressor For lowering high blood Hypotension

pressure

Metronidazole, Flagyl Amebicide (a substance used Xerostomia; avoid

to kill or capable of killing mouthwash containing
amebas); antibiotic alcohol

Miacalcin, calcitonin A hormone that prevents Nasal inflammation in

bone resorption 12% of patients

Microgestin FE, Birth control (oral Antibiotics taken for

norethindrone/ethinyl estradiol contraceptive) dental infections can
decrease the effectiven
of oral contraceptives
this medication.

Midodrine, Amatine Medication for treatment of Xerostomia

fainting spells

Minocycline, Dynacin Broad-spectrum antibiotic, Dizziness, long-term u

also used to treat oral candidiasis,
periodontitis associated with discoloration of teeth i
Actinobacillus used in patients below
actinomycetemcomitans years of age
MiraLAX, polyethylene glycol Laxative Nausea, weakness,
3350 stomach cramping

Mirapex, Pramipexole Medication for Parkinson Xerostomia, dysphagia

disease

Mircette, estradiol/desogestrel Birth control (oral Antibiotics taken for

contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

Mirtazapine, Remeron For treatment of depression Xerostomia

Mobic, meloxicam NSAID for relief of mild to Oral ulcers, xerostomi

moderate pain

Moexipril, Univasc, moexipril ACEI/HCTZ used to treat Altered taste, persisten

with HCTZ high blood pressure and cough, dizziness, naus
heart failure and for vomiting; minimize us
preventing kidney failure vasoconstrictors;
due to high blood pressure angioedema, hypotens
and diabetes combined with HCTZ:
hypokalemia, increase
risk of hypotension

Mometasone, Elocon, Nasonex Topical corticosteroid: two Xerostomia

types (topical, inhaled)

Monopril, Fosinopril ACEI used to treat high Altered taste, dizzines

blood pressure and heart nausea, vomiting;
failure and for preventing minimize use of
kidney failure due to high vasoconstrictors in loc
blood pressure and diabetes anesthetic; angioedem
hypotension

Montelukast, Singulair Oral medication used for the Dizziness, sore throat
 treatment of asthma and
seasonal allergic rhinitis

Morphine sulfate, Opioid medication for pain Xerostomia

Astramorph/PF relief

Multivitamins with fluoride Vitamin supplement Refer to individual

vitamins

Myrbetriq, mirabegron Medication to treat urinary Sinus pain, dry mouth,

incontinence in women sore throat, diarrhea,
constipation, bloating,
memory issues, headac
joint pain, dizziness,
blurred vision, fatigue
stomach pain, and nau

Nabumetone, Relafen NSAID pain medication for Xerostomia, stomatitis

rheumatoid arthritis and
osteoarthritis

Nadolol, Corgard BB for lowering high blood NSAIDs increase

pressure hypotensive effects.

Namenda, memantine Medication for Alzheimer Dizziness, fainting

Naproxen, Aleve, Anaprox NSAID analgesic used Bleeding

mostly for arthritis

Nasacort AQ, triamcinolone Corticosteroid: anti- None

inflammatory nasal, oral
topical, inhalation
administration; use: lichen
planus, aphthous, stomatitis

Nasonex, mometasone Corticosteroid: topical, None

inhaled
Necon, ethinyl estradiol, Birth control Antibiotics taken for
norethindrone dental infections can
decrease the effectiven
of oral contraceptives.

Nefazodone, Serzone Serotonin moderator used Xerostomia, hypotensi

for depression dizziness, risk for liver
damage

Neulasta pegfilgrastim Increases white blood cells Bone pain, pain in arm
to improve immune system or legs
during chemotherapy

Neupogen, Filgrastim For treatment of leukemia

Neurontin, gabapentin Anticonvulsant to prevent Xerostomia, dental

seizures problems

Nexium, esomeprazole Medication to lower acid Xerostomia

production in the stomach
for treatment of GERD

Niacin extended release Cholesterol-lowering Flushing of the skin

medication

Niaspan, niacin Cholesterol-lowering Flushing of the skin

medication

Nicotine transdermal, Smoking cessation aid, Numerous effects from

Nicorette patch or gum gum

Nifediac CC, nifedipine (NOT CCB for the treatment of Gingival hyperplasia
for emergencies) angina, and high blood
pressure

Nifedical XL, nifedipine CCB for the treatment of Gingival hyperplasia

(NOT for emergencies) angina, and high blood
pressure

Nifedipine, Procardia CCB for the treatment of Gingival hyperplasia

angina, and high blood
pressure

Nitrofurantoin, Macrobid Antibiotic None known

Nitroglycerin, Nitrostat, Medication that is placed Xerostomia, hypotensi

NitroQuick (EMERGENCY under the tongue for angina call emergency medica
DRUG) attacks services (EMS) if no
relief in 2 minutes.

Norethindrone, Aygestin Birth control (oral Antibiotics taken for

contraceptive) dental infections can
decrease the effectiven
of oral contraceptives

Nortriptyline, Pamelor TCA for treatment of Hypotension, xerostom

depression

Norvasc, amlodipine For treatment of high blood Gingival hyperplasia;

pressure and congestive involuntary muscle
heart failure contractions, tremors,
changes in breathing a
heart rate

Norvir, ritonavir Antiretroviral agent for Xerostomia, taste

HIV+ perversion

Novolin 70/30 Injectable insulin for Hypoglycemia, dizzine

Novolin N diabetes nausea; if diabetes is
Novolin R poorly controlled,
increased risk of
periodontitis
NovoLog, insulin aspart Injectable insulin for Hypoglycemia, dizzine
protamine diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

NovoLog Mix 70/30 Injectable insulin for Hypoglycemia, dizzine

diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

NuvaRing, Birth control (vaginal None

Etonogestrel/Ethinyl estradiol transmucosal)

Nystatin, Mycostatin Antifungal agent: Avoid occlusal dressin

candidiasis

Nystatin-triamcinolone, Antifungal with Avoid occlusal dressin

Mycolog corticosteroid for cheilitis,
cutaneous candidiasis

Olanzapine/fluoxetine, Antidepressant/antipsychotic Xerostomia, tooth

Zyprexa for depression with bipolar disorder, abnormal tas
episodes

Oleptro, trazodone extended Medication for treatment of Xerostomia, headache

release depression nausea, hypotension

Olysio, simeprevir Medication to treat chronic Skin rash, itching, nau

hepatitis C infection muscle pain, and
indigestion

Omeprazole, Prilosec Reduces stomach acid Xerostomia, esophage

production for treatment of candidiasis, mucosal
GERD atrophy
Omnicef, Cefdinir Antibiotic for sinusitis and Nausea, vomiting,
ear infections headache

Onglyza, saxagliptin Oral medication for diabetes Hypoglycemia, dizzine

nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Oravig, miconazole (buccal) Buccal adhesive for Dizziness, hypotension

oropharyngeal candidiasis xerostomia, headache

Orencia, abatacept Medication to treat the Headache, nausea,

symptoms of rheumatoid diarrhea, stomach pain
arthritis and prevent joint dizziness, flushing, sor
damage throat, cold symptoms
back pain

Ortho Evra, Birth control (oral Antibiotics taken for

norelgestromin/ethinyl contraceptive) dental infections can
estradiol decrease the effectiven
of oral contraceptives.

Ortho-Novum, norethindrone Birth control (oral Antibiotics taken for

estradiol contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

Ortho Tri-Cyclen Lo, Birth control (oral Antibiotics taken for

norgestimate, ethinyl estradiol contraceptive) dental infections can
decrease effectiveness
oral contraceptives.

Oxandrin, oxandrolone Medication to help Also for pain with

underweight patients to gain osteoporosis
weight
Oxybutynin chloride, Ditropan Bladder control medication Xerostomia, sedation,
for adults with symptoms of nausea
overactive bladder

Oxycodone/APAP, OxyContin Narcotic for moderate to Xerostomia, sedation,

severe pain also contains nausea
acetaminophen

OxyContin, oxycodone Narcotic for moderate to Xerostomia, sedation,

severe pain nausea

Pantoprazole, Protonix Reduces stomach acid Headache

production for treatment of
GERD

Paroxetine, Paxil, Paxil CR Medication for depression Xerostomia, hypotensi

and general anxiety disorder

Patanol, olopatadine Medication for allergic Xerostomia

conjunctivitis of eye

Pegasys, peginterferon alfa-2a For treatment of hepatitis C Fatigue, headache, mu

and joint pain, nausea

Penicillin V potassium, Pen Antibiotic, penicillin: not for Oral candidiasis

VK prevention of infectious
endocarditis

Percocet, oxycodone, Narcotic with Xerostomia, sedation,

acetaminophen acetaminophen for moderate nausea
to severe pain

Perindopril erbumine, Aceon Used to treat high blood Altered taste, persisten
pressure and heart failure cough, dizziness, naus
and for preventing kidney vomiting; minimize us
failure due to high blood vasoconstrictors in loc
 pressure and diabetes anesthetic; angioedem
hypotension.

Phenazopyridine, Pyridium Medication for pain relief Temporarily turns urin

Phenelzine from urinary tract infections an orange color
One of only four available MAOI: last resort whe
MAOIs available for no other antidepressan
treatment of depression or effective. Certain food
Parkinson disease drugs including
vasoconstrictors can
cause hypertensive cri

Phenergan, promethazine Medication for treatment of Hypotension, xerostom

nausea and motion sickness

Phenobarbital, Lumina An antiseizure medication Bradycardia, syncope

(anticonvulsant) used to
prevent seizures

Phenytoin, Dilantin An antiseizure medication Gingival hyperplasia

(anticonvulsant) used to
prevent seizures

Pioglitazone, Actos Oral medication used to treat Stress-induced

diabetes hypoglycemia

Pioglitazone, metformin Combination of two oral Hypoglycemia, dizzine

medications for diabetes nausea; poorly control
diabetes increases risk
periodontitis

Pindolol, Visken BB for treatment of high Feeling faint, swelling

blood pressure, angina, irregular heartbeat
tremor, arrhythmias

Plavix, clopidogrel A medication that reduces Bleeding

 the clumping of platelets in
the blood; reduces risk of
heart attack and stroke

Plendil, felodipine For the management of high Gingival hyperplasia,

blood pressure and headache
congestive heart failure

Polyethylene glycol, GlycoLax Laxative Nausea

Potassium chloride, K-Dur Electrolyte supplement to Xerostomia

prevent potassium depletion
(hypokalemia)

Pradaxa, dabigatran Anticoagulant to preventing Bruising, minor bleedi

clotting and stroke nausea, stomach pain,
stomach heartburn,
nausea, diarrhea, skin
rash, or itching

Pravachol, Pravastatin Medication to lower high Muscle pain, tenderne

cholesterol to prevent or weakness with feve
coronary artery disease flu symptoms; or naus
stomach pain, low feve
loss of appetite

Prednisone, Deltasone Corticosteroid to treat a Infection, adrenal

variety of diseases, insufficiency if taken l
inflammation term

Premarin, conjugated Hormone replacement Nausea, sinus irritation

estrogens therapy

Prempro, Hormone replacement Nausea, sinus irritation

medroxyprogesterone therapy

Prevacid, lansoprazole Reduces stomach acid Xerostomia, oral

 production for treatment of candidiasis, altered tas
GERD aphthous ulcers,
stomatitis

Prezista, darunavir Antiviral medication for the Diarrhea, nausea,

treatment of HIV+ vomiting, heartburn,
stomach pain, weakne
headache

Primidone, Mysoline Anticonvulsant for Overexcitement, nause

prevention of seizure and vomiting
benign familial tremor

Prinivil, lisinopril Used to treat high blood Altered taste, orthostat

pressure and congestive hypotension, dizziness
heart failure fatigue, headache, nau
vomiting; use of
epinephrine or
levonordefrin in local
anesthetic should be
minimized.

Pristiq, desvenlafaxine SSRI and serotonin Sweating, dizziness,

norepinephrine reuptake drowsiness, xerostomi
inhibitor (SNRI) used to insomnia, loss of appe
treat major depressive tightness in the jaw,
disorder nausea

ProAir HFA, albuterol Inhaler for bronchodilation Xerostomia, back pain

in prevention of body aches and pains,
bronchospasm upset stomach, sinus
headache, and urinary
tract infection

ProAir RespiClick, albuterol Inhaler for bronchodilation Xerostomia, back pain

sulfate in prevention of body aches and pains,
bronchospasm upset stomach, sinus
headache, and urinary
tract infection

Procrit, epoetin alfa Used to treat anemia High blood pressure,

associated with kidney water retention, heada
failure, HIV patients rapid heart rate, nausea
undergoing treatment,
cancer patients undergoing
therapy

Prograf, tacrolimus (topical) Ointment for skin rash Headache, acne

Prolia, denosumab Used to osteoporosis in Weakness, back pain,

women after menopause muscle pain, pain in ar
and legs, anemia,
diarrhea, or skin probl
like eczema

Promethazine, Phenergan Medication for treatment of Hypotension, xerostom

nausea and motion sickness

Promethazine/codeine, Antihistamine/decongestion Fast heart rate, loss of

Prothazine DC for upper respiratory cold, muscle control, twitch
flu xerostomia

Prometrium, progesterone Hormone replacement Gingival bleeding

therapy for menopause

Propafenone, Rythmol Medication for treatment of Xerostomia

irregular heartbeat

Propranolol, Inderal Medication for treatment of Feeling faint, swelling

high blood pressure, angina, irregular heartbeat
tremor, arrhythmias
Proscar, Propecia, finasteride Medication for treatment of Hypotension
male pattern baldness

Protonix, pantoprazole Reduces stomach acid Headache

production for treatment of
GERD

Provigil, modafinil Medication for treatment of Xerostomia, ulcers,

daily drowsiness gingivitis
(narcolepsy)

Prozac, fluoxetine Medication for treatment of Oral candidiasis,

depression xerostomia, hypotensio
nausea; can initiate
bruxism

Pulmicort, budesonide Inhaler for prevention of Oropharyngeal

asthma candidiasis

Pulmozyme, dornase alfa Enzyme for treatment of Sore throat, nasal

cystic fibrosis inflammation

Quinapril, Accupril ACEI/HCTZ combination to Altered taste, dizzines

Quinapril with HCTZ treat high blood pressure and nausea, vomiting;
heart failure and for minimize use of
preventing kidney failure vasoconstrictors;
due to high blood pressure angioedema; HCTZ:
and diabetes hypokalemia, hypoten

Qvar, beclomethasone CORT inhaler for Candidiasis of mouth a

dipropionate maintenance of asthma throat; patient must rin
and spit out after
inhalation therapy.

Rabeprazole, AcipHex Acid blocker for treatment Xerostomia, altered ta

of heartburn and GERD nausea, dizziness,
 nervousness

Raloxifene, Evista Estrogen agonist/antagonist Hot flashes, headache,

prevention of osteoporosis in dizziness, spinning
postmenopausal women at sensation, leg and join
risk for breast cancer pain, nausea, vomiting
upper respiratory
congestion

Ramipril, Altace Used to treat high blood Altered taste, dizzines

pressure, heart failure and nausea, vomiting;
for preventing kidney failure minimize use of
due to high blood pressure vasoconstrictors in loc
and diabetes anesthetic; angioedem
hypotension

Ranexa, ranolazine Medication to treat Nausea; vomiting;

chronic angina stomach pain; headach
xerostomia; weakness,
tinnitus; swelling in
hands, ankles, or feet;
irregular heartbeats;
tremors; blood in the
urine; and shortness of
breath

Ranitidine HCl, Zantac Stomach acid blocker for Drowsiness, headache

GERD nausea

Relpax, eletriptan Medication for relief of Headache, xerostomia

migraine headaches and pain in jaw, neck, or
symptoms throat

Remeron, mirtazapine Medication for treatment of Xerostomia

depression
Renagel, sevelamer Prevents calcium depletion Nausea, vomiting,
in patients with kidney stomach pain
disease and undergoing
hemodialysis

Renvela, sevelamer carbonate To reduce phosphorus blood Headache, diarrhea,

levels in chronic kidney stomach upset, cough,
disease in patients on gas, constipation
dialysis

Repaglinide, Prandin Oral medication for diabetes Hypoglycemia, dizzine

nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Requip, ropinirole Medication for treatment of Xerostomia, dysphagia

Parkinson disease

Restasis, Sandimmune, Immunosuppressant in organ Gingival hyperplasia,

cyclosporine transplant lesions

Revlimid, lenalidomide Treatment of patients with Nausea, diarrhea,

anemia and multiple constipation, dry or itc
myeloma skin, nasal congestion,
muscle or joint pain,
headache, fatigue

Reyataz, atazanavir sulfate Antiretroviral drug for HIV Feeling faint, back pai
infection sore throat, headache,
like symptoms

Rhinocort Aqua, budesonide CORT inhaler/spray: asthma Oropharyngeal

candidiasis

Ribavirin, Copegus Medication that controls Xerostomia, taste

 symptoms by reducing the perversion, sore throat
number of viruses in headache, flu-like
hepatitis C patients symptoms

Rituxan, rituximab Combined with other cancer Headache, fever, chills

drugs to treat non-Hodgkin stomach pain, flushing
lymphoma; Rituxan is also night sweats, weaknes
combined with methotrexate muscle or joint pain, b
to treat rheumatoid arthritis. pain, dizziness

Risperdal, risperidone Antipsychotic medication Hypotension, xerostom

for schizophrenia, mania

Rosiglitazone maleate, Oral medication for type II Stress-induced

Avandia diabetes hypoglycemia

Roxicet, oxycodone, APAP Narcotic pain reliever Nausea, sedation,

combined with xerostomia
acetaminophen

Salmeterol, Serevent Inhaler for asthma Xerostomia, dental pai

oropharyngeal candidi

Salmeterol/fluticasone, CORT inhaler that for Xerostomia, dental pai

Flonase treatment of asthma oropharyngeal candidi

Savella, milnacipran Medication for the Dizziness, xerostomia,

management of fibromyalgia headache, hot flush,
sweating, nausea,
vomiting

Sensipar, cinacalcet Medication used to treat Numbness or tingling

hypoparathyroidism around the mouth,
(decreased functioning of irregular heart rate,
the parathyroid glands) in dizziness, muscle pain
people who are on long-term
 dialysis for kidney disease

Serevent Diskus, salmeterol Inhaler for asthma and other Xerostomia, dental pai
respiratory conditions oropharyngeal candidi

Seroquel, quetiapine Antipsychotic medication Xerostomia, white

for the treatment of patches or sores on lip
schizophrenia manic and inside the mouth,
episodes in bipolar disorder throat

Sertraline, Zoloft Treatment for depression Anxiety, mood change

Sildenafil citrate, Viagra Treatment for erectile If chest pain: no

dysfunction nitroglycerine

Silenor, doxepin Sleep aid medication for the Dizziness, drowsiness,

treatment of insomnia nausea

Simcor, niacin and simvastatin STATIN/niacin combination Muscle pain, tenderne

to lower high cholesterol to or weakness with feve
prevent coronary artery flu symptoms; or naus
disease stomach pain, low feve
loss of appetite, flushin
of face

Simvastatin, Zocor STATIN to lower high Muscle pain, tenderne

cholesterol to prevent or weakness with feve
coronary artery disease flu symptoms; or naus
stomach pain, low feve
loss of appetite

Singulair, montelukast Medication for maintenance Dizziness, dental pain

therapy to prevent asthma
attacks

Skelaxin, metaxalone Skeletal muscle relaxant Dizziness

SMZ-TMP, Bactrim, Septra, Antibiotic: urinary tract Stomatitis
sulfamethoxazole and infection
trimethoprim

Sotalol, Betapace Medication for irregular Minimize use of

heartbeat vasoconstrictors in loc
anesthesia

Sovaldi, sofosbuvir Antiviral used to treat Fatigue, headache,

chronic hepatitis C nausea, insomnia, anem
weakness, rash, flu-lik
illness, joint pain,
irritability

Spiriva, tiotropium Treatment of bronchospasm Xerostomia, ulcerative

in respiratory diseases stomatitis

Spironolactone, Aldactazide Diuretic to reduce edema in Hypotension

congestive heart failure

Sprycel, dasatinib Medication to treat leukemia Headaches, flu-like

symptoms, skin rash,
mouth sores, weakness
weight loss, fatigue,
muscle and joint pain,
nausea, vomiting,
diarrhea or constipatio

Strattera, atomoxetine Medication for ADHD Xerostomia

Stribild, elvitegravir, Four HIV+ medications in Kidney problems, bon

cobicistat, emtricitabine, one capsule problems; changes in f
tenofovir disoproxil distribution to head an
neck, immune system
problems
Suboxone, Medication for drug Headache, dizziness,
buprenorphine/naloxone withdrawal nausea

Sucralfate, Carafate Liquid for coating duodenal None

ulcers to help with healing

Sumatriptan, Imitrex Medication for relief of Bad taste, dysphagia,

migraine headaches mouth/tongue discomf

Sustiva, efavirenz Antiviral agent for HIV-1 Abnormal taste

Symbicort, budesonide with Beta2 agonist inhaler for Sore throat, oral
formoterol fumarate dihydrate maintenance is asthma candidiasis, headache,
uncontrolled by upper respiratory, back
corticosteroid inhalants; pain, stomach pain
maintenance in COPD

Symbyax, fluoxetine and Combined drugs for the Dizziness, drowsiness,

olanzapine treatment of resistant xerostomia, sore throa
depression weakness

Synthroid, levothyroxine Thyroid replacement High blood pressure

Tamiflu, oseltamivir Antiviral medication to Nausea, vomiting,

phosphate prevent influenza in people diarrhea, dizziness,
who have been exposed but headache, nosebleed, e
have no symptoms, and in redness or discomfort,
those with less than 2 days insomnia, or cough or
of symptoms. other respiratory
problems

Tamoxifen, Nolvadex Chemotherapy treatment and Nausea, vomiting, hot

prevention of breast cancer flashes

Tamsulosin, Flomax Improves urinary flow in Hypotension

men with enlarged prostate
Tarceva, erlotinib Chemotherapy for lung and Nausea, vomiting
pancreatic cancer

Telmisartan, Micardis AIIB/HCTZ to treat high Xerostomia, dizziness;

Telmisartan HCTZ blood pressure, congestive use of epinephrine or
heart failure levonordefrin in local
anesthetic should be
minimized

Temazepam, Restoril Sleep aid for insomnia Xerostomia, hypotensi

Tequin, gatifloxacin Antibiotic Taste disturbance

Terazosin, Hytrin Medication to lower high Xerostomia

Terbutaline blood pressure

Terconazole, Terazol Antifungal agent: vaginal None

candidiasis

Tetracycline, Achromycin, Antibiotic for many Candidiasis, intrinsic

Sumycin infections tooth stain

Thalomid, thalidomide Medication for multiple Xerostomia, moniliasi

myeloma, erythema stomatitis
nodosum leprosum

Theophylline, Slo-Bid Treatment for asthma, Nausea, vomiting

bronchitis

Tiazac, Cardizem, diltiazem CCB lower blood pressure Gingival hyperplasia

and prevent angina attack

Timolol, Timoptic To lower blood pressure Xerostomia

ophthalmic: glaucoma

Tizanidine HCl, Zanaflex Muscle relaxant Hypotension

Tobradex, tobramycin, Antibiotic/cortisone None

dexamethasone ophthalmic (eye) drops

Tolterodine, Detrol Medication for overactive Xerostomia

bladder

Topamax, topiramate Medication to prevent Gingival hyperplasia;

seizures and migraine to be taken by pregnan
headaches women as can cause cl
palate birth defect

Toprol-XL, metoprolol BB to lower high blood Hypotension

pressure

Torsemide, Demadex Diuretic for edema Hypotension

Toujeo, insulin glargine Injectable insulin for Hypoglycemia, dizzine

diabetes nausea; if diabetes is
poorly controlled,
increased risk of
periodontitis

Tradjenta, linagliptin Oral medication for type II Headache; joint pain;

diabetes runny or stuffy nose; s
throat

Tramadol, Ultram Narcotic for moderate to Xerostomia

severe pain

Trandolapril, Mavik ACEI to treat high blood Altered taste, persisten

pressure and heart failure cough, dizziness, naus
and for preventing kidney vomiting; minimize us
failure due to high blood epinephrine or
pressure and diabetes levonordefrin in local
anesthetic; angioedem
hypotension

Tranylcypromine, Parnate One of only four available MAOI: last resort whe
 MAOI available for no other antidepressan
treatment of depression effective. Certain food
drugs including
vasoconstrictors can
cause hypertensive cri

Travatan, Travoprost Ophthalmic agent: glaucoma None

Trazodone, Desyrel Treatment for depression Xerostomia

Tretinoin, Retin-A (topical Treatment for acne, wrinkles None

cream)

Triamcinolone acetonide, Corticosteroid: anti- None

Orabase inflammatory for lichen
planus, aphthous, stomatitis;
nasal, oral topical, inhalation

Triamterene/HCTZ, Dyrenium Antihypertensive and Hypotension

diuretic for lowering blood
pressure

Tribenzor, Combination of three drugs Hypotension, xerostom

amlodipine/HCTZ/olmesartan for lowering high blood hypocalcemia
pressure

Tricor, Lipidil, fenofibrate Medication to lower high Muscle pain, tenderne

cholesterol to prevent or weakness with feve
coronary artery disease flu symptoms; or naus
stomach pain, low feve
loss of appetite

Trileptal, oxcarbazepine Medication for prevention of None known

seizures

Trimox, amoxicillin Antibiotic for many Prolonged use:

infections also to prevent candidiasis
 infective endocarditis

Co-trimoxazole, Bactrim Antibiotic for infections of Nausea, vomiting

the urinary tract, ear, lower
respiratory system

TriNessa, norgestimate/ethinyl Birth control (oral Antibiotics taken for

estradiol contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

Triphasil 21, levonorgestrel/ Birth control (oral Antibiotics taken for

ethinyl estradiol contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

TRI-Sprintec, Birth control (oral Antibiotics taken for

estradiol/norgestimate contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

Trivora-28, Birth control (oral Antibiotics taken for

levonorgestrel/ethinyl estradiol contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

Trizivir, Abacavir, lamivudine, Three antiretroviral drugs Headache, joint or mu

zidovudine combined for treatment of pain, nausea, nervousn
HIV+ tiredness, vomiting,
weakness

Truvada, Antiretroviral drug for HIV+ Headache, joint or mu

emtricitabine/tenofovir pain, nausea, nervousn
tiredness, vomiting,
weakness
Tussionex, Antihistamine/antitussive: Xerostomia
hydrocodone/chlorpheniramine cough medicine

Ultram, tramadol Narcotic for moderate to Xerostomia

severe pain

Ursodiol, Actigall Gallstone dissolution agent None

Valacyclovir, Valtrex Antiviral agent: herpes I, II, Xerostomia, headache

herpes zoster (shingles)

Valsartan, Diovan, Valsartan, For lowering high blood Hypotension,

HCTZ pressure hypokalemia

Valturna, aliskiren /valsartan For lowering high blood Hypotension, dizzines

pressure headache, sore throat,
joint pain, runny nose

Veetids, penicillin VK Antibiotic, penicillin—not Oral candidiasis

for prevention of infective
endocarditis

Venlafaxine, Effexor For depression Xerostomia, altered ta

Ventolin HFA, albuterol BRNC medication in inhaler Xerostomia

sulfate for asthma

Verapamil, Calan, Isoptin For lowering blood pressure Gingival hyperplasia

and preventing angina attack

Viagra, sildenafil citrate Erectile dysfunction If chest pain: no

nitroglycerine

Vicoprofen, Narcotic and NSAID Xerostomia, nausea

hydrocodone/ibuprofen combination for pain relief

Victoza Noninsulin injectable Headache, dizziness,

medication for treatment of upset stomach, cold
 diabetes symptoms, back pain,
tired feeling

Vigamox, moxifloxacin Antibiotic eye drops Xerostomia, glossitis,

stomatitis

Viibryd, vilazodone Medication for depression; Dizziness, fast heartbe

adjunct therapy to lithium insomnia, muscle
for bipolar I twitching

Vimovo, Combination of medications Bleeding

naproxen/esomeprazole to treat pain while
preventing gastroesophageal
reflux

Viramune XR, nevirapine Combination of antiviral Liver problems, bleedi

agents for HIV+ nausea, dry cough

Viread, tenofovir Antiretroviral agent for Headache, joint or mu

HIV+ pain, nausea, nervousn
tiredness, vomiting,
weakness

Vivelle-DOT, estradiol Hormone replacement None

transdermal patch therapy (skin patch)

Vytorin, ezetimibe/simvastatin Treatment to lower high Muscle pain, tenderne

cholesterol to prevent or weakness with feve
coronary artery disease flu symptoms; or naus
stomach pain, low feve
loss of appetite

Vyvanse, lisdexamfetamine For treatment of ADHD in Fast pounding, irregul

adolescents heartbeat, tremors,
nervousness, insomnia

Warfarin, Coumadin, Anticoagulant helpful in Ulcerations; increased

Coumarin preventing blood clot bleeding tendency,
formation in patients with medical consult
atrial fibrillation and
artificial heart valves to
reduce the risk of strokes

Welchol, colesevelam Reduces cholesterol levels Constipation, stomach

hydrochloride and helps control glucose upset, flu-like symptom
level in type II diabetes muscle pain

Wellbutrin, bupropion HCl Medication for depression Hypotension, xerostom

Xalatan, latanoprost Ophthalmic agent: glaucoma None

Xeloda, capecitabine Chemotherapy for Stomatitis, abnormal t

colon/breast cancer

Xopenex levalbuterol BRNC inhaler for asthma, Headache, nervousnes

bronchitis, emphysema anxiety, shaking,
dizziness, trouble
insomnia, xerostomia,
sore throat, stomach
upset, diarrhea, muscle
pain, cough, nasal
congestion

Yasmin 28, Birth control (oral Antibiotics taken for

drospirenone/ethinyl estradiol contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.

YAZ, drospirenone/ethinyl Birth control (oral Antibiotics taken for

estradiol contraceptive) dental infections can
decrease the effectiven
of oral contraceptives.
Zafirlukast, Accolate Maintenance therapy for Headache, weakness,
asthma dizziness, diarrhea,
muscle pain

Zegerid OTC, omeprazole and Combination medications Headache; nausea;

sodium bicarbonate for treatment of heartburn stomach pain; vomitin

Zelnorm, tegaserod Medication for treatment of Nausea

constipation in irritable
bowel syndrome

Zestril, Prinivil, Lisinopril Used to treat high blood Altered taste, dizzines
pressure and heart failure nausea, vomiting; use
and for preventing kidney epinephrine or
failure due to high blood levonordefrin in local
pressure and diabetes anesthetic should be
minimized; angioedem
hypotension

Zetia, ezetimibe Medication to lower high Muscle pain, sore thro

cholesterol to prevent headache
coronary artery disease

Zithromax, Z-Pak Antibiotic Nausea, headache

Zocor, simvastatin Treatment to lower high Muscle pain, tenderne

cholesterol to prevent or weakness with feve
coronary artery disease flu symptoms; or naus
stomach pain, low feve
loss of appetite

Zofran, ondansetron Medication for prevention Xerostomia, drowsines

and treatment in nausea
from chemotherapy

Zoloft, sertraline Medication for depression Anxiety, irritability

 Zolpidem, Ambien Sleep aid Xerostomia, sore throa
lightheadedness, dayti
fatigue, weakness,
increased appetite

Zomig, zolmitriptan Medication for migraine Xerostomia, dysphagia

headaches and symptoms

Zonisamide, Zonegran Medication to prevent Xerostomia

seizures

Zyprexa, olanzapine Medication for depression, Xerostomia, tooth

an antipsychotic for disorder, altered taste
depression with bipolar
episodes

Zyrtec, cetirizine HCl (syrup Antihistamine: allergic Xerostomia

or tablet) rhinitis

Zyvox, linezolid Antibiotic, oxazolidinone: Discolored tongue, bad

vancomycin-resistant taste
infections, such as
Methicillin-resistant
Staphylococcus aureus
(MRSA)

Ready Reference 6-2 adapted with permission from Cynthia Biron Leisica, DH Meth-Ed.
 MODULE
7

DENTAL HEALTH
HISTORY
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
The dental health history provides information about the patient’s past and
present dental experiences. The information gathered with the dental history
allows the clinician to determine whether treatment alterations are necessary
for the patient to undergo dental treatment safely. This module reviews the
kinds of information commonly found on dental health history
questionnaires.

MODULE OUTLINE
SECTION 1 Adult Dental Health History
Questionnaire
Questionnaire Format
Reason for Appointment
Previous Dental Experiences
Dental Concerns
Existing Dental Conditions
 Daily Self-care
Dietary Habits
SECTION 2 Children’s Dental History Questionnaire
SECTION 3 Peak Procedure
Procedure 7-1. Review of Dental Health History
Questionnaire
SECTION 4 Sample Dental Questionnaires
SECTION 5 The Human Element
Ethical Dilemma
Communication Scenarios
English-to-Spanish Phrase Lists
SECTION 6 Practical Focus—Fictitious Patient Cases
SECTION 7 Skill Check
KEY TERM
Dental health history

OBJECTIVES
• Explain the importance of the dental health history in planning and
preparing for patient treatment activities.
• Given a dental health history questionnaire, identify those elements
that would be important in modifying the planned treatment.

SECTION 1 • Adult Dental Health History

Questionnaire
A dental health history provides a record of a patient’s previous dental
experiences. Like the medical history, the dental health history is essential in
providing safe dental care for the patient. The dental health history is a quick
and effective way to obtain important information about the patient’s past and
present dental experiences. Most dental practices will utilize a dental health
history questionnaire to obtain relevant information from the patient.
The information requested in a dental health history varies significantly
depending on the type of dental practice. For example, a general dental
practitioner may use a dental history questionnaire that covers a broad range
of dental conditions, whereas an office specializing in pedodontics,
orthodontics, cosmetic dentistry, periodontics, prosthodontics, or oral surgery
may utilize a dental history format that is more narrowly focused to that type
of dental specialty practice. An Internet search on the key words dental
health history will provide literally hundreds of examples of questionnaires
used by various dental practices; all have similarities, but no two forms are
identical.
The dental health questionnaire is a highly effective tool permitting the
dental team to identify the patient’s potential dental needs and risks.
Information gained from the questionnaire can be addressed more carefully
and thoroughly at chairside. In addition, the questionnaire can provide
opportunities for enriched communication opportunities for the dental team
related to addressing potential dental anxiety, daily self-care, preventive
therapy regimens, dietary counseling, esthetic considerations, as well as
treatment alternatives.
It is always assumed that the dental health history provides supplemental
information important to the dental practice team and is always used in the
context of having first taken a complete medical history. The dental health
history is never used independent of the medical health history.

Questionnaire Format
There is no standardized format for a dental health questionnaire. Common
formats include fill-in-the-blank type questions, checkmarks, boxes, and
circling the correct response (Fig. 7-1).
Reason for Appointment
For a new patient, the dental health questionnaire very likely includes some
of the elements indicated in Figure 7-2.

Previous Dental Experiences

Many dental questionnaires attempt to identify whether or not the patient has
had any previous negative dental experiences that might require special
considerations. Examples of special considerations are antianxiety
premedication, intravenous sedation, or nitrous oxide sedation. Some
examples of questions used to elicit information about previous dental
experiences are listed in Figures 7-3 and 7-4.
Dental Concerns
The next section of the dental health questionnaire generally involves
identifying specific dental concerns that the patient may have regarding
possible treatment options. These questions can be used to focus the dental
team on issues that the patient feels are important. Examples of typical
questions are shown in Figure 7-5.
Existing Dental Conditions
The above elements of the dental health questionnaire not only provide an
overview of the patient’s past dental experiences but also help prompt a
patient to identify issues that he or she wants addressed by the dental team.
These types of questions provide the clinician with a potential “heads up”
regarding whether or not this patient has had prior positive or negative dental
experiences and alerts the clinician to any potential problems with local
anesthesia, the need for anxiety premedication and other important treatment
considerations. The preceding questions, however, do not provide an
opportunity for the dental health team to focus on specific, common dental
problems and symptoms.
The next section of the dental health questionnaire will vary from one
office to the next depending on the focus of the practice and represents an
opportunity for the dental team to identify existing dental conditions that may
require consideration. Examples of the types of questions are provided in
Figure 7-6 and are typically presented in a check the line/box type of format.
Daily Self-care
Other helpful elements in a dental health questionnaire may relate to
identifying the patient’s daily self-care routine. Examples of typical questions
are shown in Figure 7-7.

Dietary Habits
Some dental health questionnaires specifically address dietary activities that
might potentially have a significant negative impact on dental health (Fig. 7-
8). For example, a history of consuming sugary drinks may increase the risk
of dental decay.
 SECTION 2 • Children’s Dental History Questionnaire
For offices that treat young children, a special children’s dental health
questionnaire is required. A typical children’s dental history would include
some of the elements illustrated in Figure 7-9.
SECTION 3 • Peak Procedure

Procedure 7.1 Review of Dental Health History

Questionnaire

Action Rationale

1. Read through every line and • Complete information is

check box. Are all the important to protect the
questions answered? patient’s health.

2. Can you understand what is • Make a note to ask the

written? patient about anything that
is not clear.
 3. Did the patient, parent, or • The dental history must be
guardian sign and date the signed and dated.
form?

4. Read through the form. • Discuss concerns during the

Circle concerns in red pencil patient interview.
—such as problems that the
patient has experienced in the
past with dental treatment.

5. Read through handwritten • Discuss concerns during the

responses made by the patient interview.
patient. Circle concerns in
red pencil.

6. Identify any dental treatment • Examples of treatment

alterations that might be alterations include
necessary for treatment of antianxiety medication prior
this patient. to appointment or use of
latex-free gloves for a
patient who has
experienced an adverse
reaction to latex gloves
during previous dental
treatment.

SECTION 4 • Sample Dental Questionnaires

Figures 7-10A to 7-13B are examples of dental health questionnaires.
SECTION 5 • The Human Element

Ethical Dilemma
PATIENT TREATMENT PREFERENCES

Your next patient is Emily F., a 25-year-old yoga instructor. She was
previously treated in Dr. Harley’s practice, but has since left because she
says that they could not accommodate her “lifestyle.” This is the first time
that she is being seen in your office and is very excited, as she has heard
that you have all the latest interventions for optimal patient care. Her chief
complaint is discomfort around the area of the maxillary right first molar.
In conversation, Emily tells you that she is a vegan, strives to live a
“green” lifestyle, and absolutely refuses to ingest anything “unnatural” into
her body. In reviewing her dental health history, Emily states that she
refuses all radiographs due to the poisonous radiation. She also refuses
sealants, as they are composed of toxic materials. She refuses all forms of
fluoride.
1. What is the best way to address/discuss Emily’s treatment plan with her?
2. Do you have an ethical obligation to treat this patient?
3. Is it appropriate for you to call Dr. Harley to discuss Emily’s past dental
health history?
4. What, if any alternatives, can you offer Emily in terms of her treatment
plan?
Communication Scenarios

LISTENING

Directions: For role-play scenarios 1 and 2, work in pairs. One person is

the speaker, and the other is the listener. After completing scenarios 1 and
2, participate in a class discussion about these two role-plays.

Scenario 1:
• The speaker plays the role of a disgruntled patient who is unhappy
about something that happened at his or her last appointment in your
dental office.
• The listener plays the role of the dental hygienist who is blatantly
disrespectful. For example, the hygienist pays little attention to the
patient’s concerns and demonstrates rude behavior by reading the
chart, typing on a keyboard while making no eye contact, or
terminating the conversation abruptly.
• After 4 minutes, stop the role-play and switch roles (the speaker
becomes the listener).

Scenario 2:
• In scenario 2, the speaker once again plays the role of an unhappy
patient.
• For this scenario, the listener plays the role of a dental hygienist who
shows respect for the patient and his or her concerns throughout the
 conversation.
• After 4 minutes, stop the role-play and switch roles (the speaker
becomes the listener).

Discussion Points for Scenarios 1 and 2:

• As the patient, what were the effects of disrespect? How did it feel to
receive respectful communication with the hygienist?
• Discuss what participating in these role-play scenarios has taught you
about interpersonal relationships in the professional dental setting?

English-to-Spanish Phrase List

SECTION 6 • Practical Focus—Fictitious Patient Cases

DIRECTIONS
• This section contains completed dental health questionnaires for
patients A to E.
• In a clinical setting, you will gather additional information about your
patient with each assessment procedure that you perform. When
determining treatment considerations and modifications for patients A
to E, you should take into account the health history and over-the-
counter/prescription drug information that was revealed for each
patient in Module 5: Medical History.
• Review the completed dental health questionnaires for patients A to E
in Figures 7-14A to 7-18B. For each patient, make a list of any
concerns, problems, or treatment modifications that will be necessary
based on the information on the dental health history.
SECTION 7 • Skill Check

Technique Skill Checklist: Dental Health Questionnaire

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as
S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E

Reads through every line on the completed dental

health questionnaire. Identifies any unanswered
questions on the form and follows up to obtain
complete information.
Makes notes about any information that is not clear
or difficult to read. Confirms that the patient has
signed and dated the form.
Circles concerns in red pencil. Reads through all
handwritten responses and circles concerns in red.
Formulates a list of follow-up questions to review
with the patient.

Formulates a preliminary opinion regarding any

treatment alterations that may be needed based on
the information gathered during the dental health
history assessment. Discusses possible treatment
alterations with the clinical instructor.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.
 MODULE
8

VITAL SIGNS:
TEMPERATURE
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
This is the first of three modules covering the assessment of vital signs that
provide essential information about a patient’s health status. The four vital
signs are temperature, pulse, respiration, and blood pressure. This module
covers the technique for measuring oral temperature. Pulse and respiration
are discussed in Module 9. The technique for blood pressure assessment is
described in Module 10.
This module covers oral temperature taking, including:
• Taking an oral temperature
• Preparing the patient for the procedure
• Step-by-step peak procedures for taking an oral temperature

MODULE OUTLINE
SECTION 1 Introduction to Vital Signs Assessment
Vital Signs Overview
Why Are Vital Signs Important?
 When an Oral Temperature Should Not Be Taken
Understanding Temperature Scales
Equipment Selection
SECTION 2 Peak Procedures
Temperature Assessment with a Glass Thermometer
Procedure 8-1. Reading a Glass Thermometer
Preparing a Glass Thermometer for Use
Procedure 8-2. Shaking Down a Glass Thermometer
Positioning the Thermometer in the Mouth
Procedure for Temperature Taking
Procedure 8-3. Assessing Oral Temperature with a Glass
Thermometer
SECTION 3 Ready References
Body Temperature Ranges
Back and Forth—From Fahrenheit to Celsius
Variables that Commonly Affect Temperature
Impact of Temperature Readings on Dental Treatment
SECTION 4 The Human Element
Through the Eyes of a Student
English-to-Spanish Phrase List
SECTION 5 Skill Check
KEY TERMS
Vital signs • Temperature • Pulse • Respiration • Blood pressure •
Celsius/Centigrade • Fahrenheit • Thermometer • Heat pockets

OBJECTIVES
• Define the term vital signs and discuss how vital signs reflect changes
in a person’s health status.
• Discuss the dental health care provider’s responsibilities in assessing
 temperature.
• Describe factors that can affect a person’s body temperature.
• State the variables that can affect accurate temperature assessment.
• Prior to assessing temperature, explain to the patient why an accurate
body temperature is needed.
• Describe the equipment to the patient and explain what to expect
during the procedure.
• Answer any questions regarding the procedure that the patient might
have.
• Accurately assess, interpret, and document body temperature.
• Provide information to the patient about the readings that you obtain.
• Properly use and care for the equipment used for measuring oral
temperature.
• Recognize oral temperature findings that have implications in
planning dental treatment.
• Provide appropriate referral to a physician when findings indicate the
need for further evaluation.
• Compare temperature findings in the fictitious patient cases A to E (in
Module 10) to the normal temperature range.
• Demonstrate knowledge of temperature assessment by applying
concepts from this module to the fictitious patient cases A to E in
Module 10, Vital Signs: Blood Pressure.

NOTE TO COURSE INSTRUCTOR: Fictitious patient cases A to E for all

the vital signs modules are located in Module 10, Vital Signs: Blood
Pressure.

SECTION 1 • Introduction to Vital Signs Assessment

Vital Signs Overview

1. Origin of Terminology. The word vital means necessary to life. For this
 reason, key measurements that provide essential information about a
person’s health are referred to as vital signs.
2. Definition. Vital signs are a person’s temperature, pulse, respiration,
and blood pressure.
3. Fifth Vital Sign. In addition to these standard vital signs, tobacco use
has been suggested as the fifth vital sign since tobacco use is a factor in
many medical conditions as well as periodontal disease.
4. Homeostasis. The body tries to maintain a state of balance
(homeostasis) by making adjustments as necessary to keep the body’s
vital signs within the range of normal.
5. Assessment. Vital signs can be observed, measured, and monitored to
provide critical information about a person’s state of health.
a. Temperature is the measurement of the degree of heat in a living
body.
b. Pulse is the measurement of the heart rate in beats per minute. The
pulse is a throbbing caused by the contraction and expansion of an
artery as blood passes through it.
c. Respiration is the breathing rate of an individual, stated in breaths
per minute.
d. Blood pressure is the force exerted against the walls of the blood
vessels as the blood flows through them.

Why Are Vital Signs Important?

• Changes in a vital sign may indicate that something is out of balance in
the body and the body is trying to get that balance back.
• Vital signs tell the dental health care provider about changes in a
person’s body such as illness, infection, stress, or internal body damage.
• For patient safety, vital signs should be measured before the start of any
dental treatment.

BOX How Are Vital Signs Measured?

8-1
 • Oral temperature is measured in the mouth with a thermometer placed
under the tongue. A glass, digital, or disposable thermometer may be
used.
• Pulse rate is measured by touch. In the dental setting, the pulse rate is
felt at the wrist.
• Breathing rate is measured by watching the rise and fall of the chest
wall.
• Blood pressure is measured using a stethoscope and a blood pressure
cuff. Digital blood pressure cuffs are an alternative to the traditional
stethoscope and blood pressure cuff; digital measurement may not be
as accurate as the traditional method of assessment.

When an Oral Temperature Should Not Be Taken

Do not measure a patient’s temperature orally if one or more of the following
contraindications are present:
• The patient has recently had oral surgery.
• The patient is a child under 5 years of age. (A child under 5 years cannot
be relied upon to follow a “don’t bite down” request.)
• The patient is confused, heavily sedated, or has some condition that
makes it likely that he or she might bite down on a glass thermometer.
• The patient is receiving oxygen by nose.

Understanding Temperature Scales

Three terms—Fahrenheit, Celsius, and centigrade—are encountered when
reading or discussing the measurement of body temperature. These terms can
be confusing to the novice health care provider. All three terms refer to
temperature scales used in both medicine and dentistry.
• The terms Celsius and centigrade can be used interchangeably in a
medical or dental setting, but the term Celsius is the one preferred in
most countries.
 • The Celsius temperature scale is used in most countries except for the
United States. Even in the United States, most of the scientific and
engineering communities use the Celsius scale.
• Most Americans remain more accustomed to the Fahrenheit
temperature scale, which is the scale that U.S. broadcasters use in
weather forecasting. In the United States, the Fahrenheit scale is also
used for measuring body temperatures in most dental settings. It is
common for hospitals in the United States to use the Celsius scale.
• In Canada, due to its close relationship with the United States, kitchen
devices, literature, and packaging may include both Fahrenheit and
Celsius temperatures.
• In this textbook, temperature measurements are reported in both the
Fahrenheit and Celsius scales. Ready Reference 8-2 in this textbook
explains how to convert temperatures between the Fahrenheit and
Celsius temperature scales.

Equipment Selection
1. Glass Thermometers. Glass thermometers provide an inexpensive
means for obtaining an accurate oral temperature. Modern glass
thermometers are mercury-free and contain most commonly either
galinstan or alcohol. The galinstan thermometer is more accurate than
digital for the measurement of body temperature in children.1
2. Accuracy of Equipment. Oral and temporal artery measurements are
most accurate.2–4 Oral temperature is the standard in health care
settings.3 Ear (tympanic) measurements are the least accurate and
precise.2–4
3. Automatic Temperature Equipment. Automatic temperature
equipment—also called digital temperature equipment—ranges from the
highly calibrated types used in hospital settings to less advanced
equipment designed for home use.
a. All automatic equipment should be verified using a traditional fluid-
 filled thermometer.
b. An abnormally high or low temperature reading obtained with an
automatic device should be verified by retaking the temperature in a
few minutes using a traditional fluid-filled thermometer.

SECTION 2 • Peak Procedures

Temperature Assessment with a Glass Thermometer

A common method of taking an oral temperature is with a glass
thermometer.5 Reading a glass thermometer accurately requires training, so
it is helpful to practice the technique before attempting temperature
assessment on a patient (Fig. 8-1).

Procedure 8-1. Reading a Glass Thermometer

Action
1. Hold the stem—the end of the thermometer opposite the bulb
—firmly between the thumb and index finger.

2. Hold the thermometer horizontally at eye level with the

degree lines visible.
Roll the thermometer slowly back and forth between the
fingers until the liquid column is visible.

3. The point where the liquid column ends marks the

temperature.
• The division between the long lines is 1° Fahrenheit (F) or
Celsius (C).
• Each small line in between the long lines equals 0.2° F or
0.1° C.
Preparing a Glass Thermometer for Use
Liquid-in-glass thermometers can be used to measure body temperature
because the liquid inside the thermometer expands when exposed to the
warmth of the oral cavity. The liquid column should be at a level below 94° F
(34.4° C) at the start of the temperature assessment procedure (Fig. 8-2).
Shaking down the liquid column requires a rapid snapping motion with the
wrist, so practicing this technique is helpful.

Procedure 8-2. Shaking Down a Glass Thermometer

Action Rationale
1. Grasp the stem—the end • Grasping the bulb may
of the thermometer warm the liquid and cause
opposite the bulb—firmly it to rise in the
between the thumb and thermometer.
index finger.

2. Shake the thermometer • The snapping motion

several times using a quick moves liquid back into the
downward snap of the bulb below 94° F or 34.4°
wrist. Glass thermometers C.
break easily, so shake the
 thermometer away from
counters or objects.

3. Shake the thermometer • If not shaken down, the

until the liquid level is liquid level could result in
below 94° F or 34.4° C. an inaccurate temperature
reading. For example, the
liquid level is at 100° F;
however, the patient’s
temperature is 98°.
Forgetting to shake down
the liquid level results in
an incorrect temperature
finding of 100° F.

Positioning the Thermometer in the Mouth

To obtain an accurate reading, it is important to locate the thermometer or
temperature probe correctly in the oral cavity.
• Ask the patient to open his or her mouth. If the patient’s tongue is not
raised, give the patient additional instructions to lift the tongue.
• Place the bulb of the thermometer or temperature probe on a heat pocket.
The mouth has two heat pockets located on either side of the floor of
the mouth between the base of the tongue and the molar teeth.
• Place the thermometer so that the bulb rests in one of the heat pockets
with the stem on the anterior teeth on the opposite side of the mouth.
 Crossing the midline of the mouth helps to keep the thermometer in
place.
• Figure 8-3 illustrates correct placement of the thermometer in the mouth.

Procedure for Temperature Taking

Procedure 8-3. Assessing Oral Temperature with a Glass

Thermometer
EQUIPMENT
Mercury-free glass fever thermometer, stored at room temperature
Tissue
Disposable thermometer sheath
Clock or watch with a second hand
Pen (or computer keyboard)
Action Rationale
1. Confirm that the patient • The temperature of the oral
has not had alcohol, mucosa affects the
tobacco, caffeine, or accuracy of the
performed vigorous thermometer reading.
exercise within 30 minutes • Alcohol, caffeine, or
of the vital signs vigorous exercise can alter
assessment. pulse and respiration; these
vital signs usually are
 assessed in conjunction
with temperature.

2. Wash hands. • Reduces likelihood of

transmitting
microorganisms

3. Explain the procedure to • Informs the patient of the

the patient (Fig. 8-4). clinician’s intent
• Reduces patient
apprehension and
encourages patient
cooperation

4. Shake the liquid level • If not shaken down, the

below 94° F (34.4° C). liquid level could result in
an inaccurate temperature
reading.

5. Place a disposable sheath • Reduces likelihood of

on the thermometer (Fig. cross-contamination
8-5).
6. Place the thermometer bulb • The heat from the lingual
under the patient’s tongue arteries under the tongue
in a heat pocket—on the causes the liquid column to
right or left side—toward rise. Positioning the bulb
the back of the mouth (Fig. in this manner places it in
8-6). close contact with blood
• Ask the patient to hold vessels lying near to the
the thermometer in surface.
place. • Closing the lips helps to
• The patient should keep the bulb in position.
breathe through the nose, • Glass thermometers are
keeping the lips closed. easily broken.
• Caution the patient
against biting down on
the thermometer.
7. Leave the thermometer in • Three full minutes is the
place according to clinic minimum amount of time
protocol, usually 3–5 required to obtain an
minutes. accurate oral temperature
using a standard glass
thermometer.

8. Take the thermometer from • The liquid column is

the patient’s mouth. harder to see with the
Remove the thermometer sheath in place.
sheath and discard it in a
receptacle for
contaminated items.

9. Read the temperature at • The liquid column may be

eye level to the nearest between the calibration
tenth (Fig. 8-7). lines.
10. After reading, place the • Deters transmission of
thermometer on a barrier in microorganisms to the
a safe location. Wash and paper chart or computer
dry your hands. Record keyboard6
today’s date and time and • Recording the reading
the temperature reading in promptly facilitates
the chart or computer accurate documentation.
record. Discuss findings
with the patient.
11. Upon completion of the • If the temperature reading
vital signs assessment, is elevated, elective dental
report all abnormal treatment should be
findings to a clinical postponed and the patient
instructor or supervising referred to a primary care
clinician. physician for evaluation.
12. Wash the thermometer in • Thermometer sheaths can
lukewarm, soapy water. easily tear allowing oral
Rinse in cold water and microorganisms to
dry.Disinfect the contaminate the
thermometer, dry, and thermometer.
place in a storage • Hot water can cause the
container. liquid column to expand,
 potentially breaking the
thermometer.
• Proper containers prevent
contamination and protect
the delicate thermometer.

SECTION 3 • Ready References

NOTE: The Ready References in this book may be removed from the book
by tearing along the perforated lines on each page. Laminating or placing
these pages in plastic protector sheets will allow them to be disinfected for
use in a clinical setting.

Ready Reference 8-1. Body Temperature Ranges

NORMAL BODY TEMPERATURE

• The normal adult oral temperature ranges from 96° to 99.6° F

(35.5° to 37.5° C).

• The average normal oral temperature is 98.6° F (37° C);

however, “normal” varies from person to person.

ELEVATION IN BODY TEMPERATURE

• Fever (pyrexia) is a reading over 99.5° F or 37.5° C.

Ready Reference 8-2. Back and Forth—From Fahrenheit to

Celsius
Ready Reference 8-3. Variables that Commonly Affect
Temperature

• Time of day—temperature varies throughout the day, usually

being lowest in the early morning and rising by 0.5° to 1.0° F
(0.3° to 0.6° C) in the early evening.

• Exercise—temperature may rise by 1.0° F (0.6° C) or more

after strenuous physical exertion on a hot day.

• Age—the average normal oral temperature for persons over

70 years of age is 96.8° F (36.0° C).

• Environment—a cold or hot environment can alter

temperature.

• Stress—a stressful situation can cause body temperature to

rise.

• Hormones—a woman’s body temperature typically varies by

1.0° F (0.6° C) or more throughout her menstrual cycle.

• Hot liquids—increase oral temperature for approximately 15

minutes7
 • Cold liquids—decrease oral temperature for approximately 15
minutes7

• Smoking—increases oral temperature for approximately 30

minutes7

• Tachypnea (rapid breathing)—decreases oral temperature8

• Infection or inflammation—increases body temperature

Ready Reference 8-4. Impact of Temperature Readings on

Dental Treatment

1. An elevated temperature reading should be reassessed to

determine if the initial reading is accurate. Before taking a
second temperature reading, reconfirm that the patient has not
smoked or consumed a hot beverage for at least 30 minutes.
An elevated temperature could also result from spending time
in a hot environment, such as driving for an hour in a vehicle
with no air conditioning on a hot day.

2. Temperatures in excess of 101° F (38.3° C) usually indicate

the presence of an active disease process.

3. In most cases, dental treatment is contraindicated for a patient

with an elevated temperature. The patient should be referred
to his or her primary care physician for evaluation.

4. If an elevated temperature is due to a dental infection,

immediate dental treatment and antibiotic therapy may be
indicated.

5. If the temperature is 104° F (40° C) or higher, a consultation

 with the patient’s primary care physician is indicated.

6. A temperature of 105.8° F (41° C) constitutes a medical

emergency. Contact emergency medical services (EMS) to
request transport to the hospital.

SECTION 4 • The Human Element

Through the Eyes of a Student

MAKING ASSUMPTIONS ABOUT A PATIENT’S

VALUES

As a student, I learned an important lesson about people at Mrs. B.’s initial

appointment. Mrs. B. was 65 years old, and when she sat down in my
chair, she started telling me about her career as a model. She had been a
catalog model for a large department store in Toronto for over 40 years.
Mrs. B. was dressed meticulously in a three-piece suit. Her shoes were
polished and perfectly matched her suit. Her makeup and hair was perfect.
Then I began to ask her questions. When was her last dental visit?
What was done at that visit? The patient answered my questions, and it
became obvious that she had neglected her dental health. I took her vital
signs. When she opened her mouth for the thermometer, I saw red swollen
gingiva and heavy calculus deposits on her lower anterior teeth.
I talked to my instructor in the supply room where the patient would
not be able to hear me. I told my instructor how surprised I was that Mrs.
B. was neglecting her dental health when “she looked so PERFECT on the
outside.” My instructor helped me to understand that I should not make
assumptions about a patient’s values. And even more important, not to
expect a patient to have the same health values that I have. My instructor
helped me to see that my next task was to talk to my patient without being
judgmental. I needed to learn what her values are at the present time. Of
course, most important, I learned that I must see each patient as a unique
individual with his or her own needs and values.
Anonymous graduate,
George Brown College of Applied Arts and Technology
Toronto, Canada

English-to-Spanish Phrase List

 NOTE: The Practical Focus—Fictitious Patient Cases section for all of
the vital signs modules is located in Module 10, Vital Signs: Blood
Pressure.

SECTION 5 • Skill Check

Technique Skill Checklist: Oral Temperature Procedure

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Seats the patient in a comfortable upright position.
Confirms that the patient has not had a hot or cold
beverage or smoked within the previous 30 minutes.
Washes hands.

Shakes down the thermometer so that the liquid

level is below 94° F or 34.4° C.
Covers the thermometer with a disposable sheath.
Asks the patient to open the mouth. Positions the
bulb under the tongue on one side toward the back
of the mouth.
Maintains the thermometer in the patient’s mouth
for 3 to 5 minutes.
Removes the thermometer from the patient’s mouth.
Removes and discards the sheath in an appropriate
receptacle.

Holds the thermometer in a horizontal position.

Reads the position of the liquid column to the
nearest tenth.
Places the thermometer on a barrier in a safe
location. Washes and dries hands. Records today’s
date, time, and the oral temperature reading in the
patient chart or computer record.
Upon completion of the vital signs assessment,
washes the thermometer in lukewarm, soapy water.
 Rinses it in cold water and dries. Disinfects and
dries thermometer; places it in an appropriate
container.

OPTIONAL GRADE PERCENTAGE

CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

Communication Skill Checklist: Role-Play for Temperature

ROLES:
• Student 1 = Plays the role of the patient.
• Student 2 = Plays the role of the clinician.
• Student 3 or instructor = Plays the role of the clinic instructor near
the end of the role-play.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, each U equals 0 point.

CRITERIA: S E
Explains what is to be done in terminology that is
easily understood by the patient.
Reports the temperature reading to the patient and
 explains if the reading is normal or outside the
normal range and the significance of the finding.

Encourages patient questions before and after the

temperature assessment procedure.
Answers the patient’s questions fully and
accurately.
Communicates with the patient at an appropriate
level avoiding dental/medical terminology or
jargon.
Accurately communicates the findings to the
clinical instructor. Discusses the implications for
dental treatment using correct medical and dental
terminology.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

NOTE TO COURSE INSTRUCTOR: A series of role-play

scenarios for the modules in this textbook can be found at
http://thepoint.lww.com/GehrigPAT4e.

References
1. Schreiber S, Minute M, Tornese G, et al. Galinstan thermometer is more accurate than
digital for the measurement of body temperature in children. Pediatr Emerg Care.
2013;29(2):197–199.
2. Farnell S, Maxwell L, Tan S, Rhodes A, Philips B. Temperature measurement:
comparison of non-invasive methods used in adult critical care. J Clin Nurs.
 2005;14(5):632–639.
3. Lawson L, Bridges EJ, Ballou I, et al. Accuracy and precision of noninvasive
temperature measurement in adult intensive care patients. Am J Crit Care.
2007;16(5):485–496.
4. Lu SH, Dai YT, Yen CJ. The effects of measurement site and ambient temperature on
body temperature values in healthy older adults: a cross-sectional comparative study.
Int J Nurs Stud. 2009;46(11):1415–1422.
5. Bickley LS, Szilagyi PG, Bates B. Bates’ Guide to Physical Examination and History
Taking. 11th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2012.
6. Hübner NO, Hübner C, Kramer A, Assadian O. Survival of bacterial pathogens on
paper and bacterial retrieval from paper to hands: preliminary results. Am J Nurs.
2011;111(12):30–34.
7. Terndrup TE, Allegra JR, Kealy JA. A comparison of oral, rectal, and tympanic
membrane-derived temperature changes after ingestion of liquids and smoking. Am J
Emerg Med. 1989;7(2):150–154.
8. Tandberg D, Sklar D. Effect of tachypnea on the estimation of body temperature by an
oral thermometer. N Engl J Med. 1983;308(16):945–946.
 MODULE
9

VITAL SIGNS: PULSE

AND RESPIRATION
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
This is the second of three modules covering the assessment of vital signs.
Vital signs are key measurements that provide essential information about a
person’s state of health. Vital signs include a person’s temperature, pulse,
respiration, and blood pressure.
This module describes assessment of pulse and respiratory rates,
including:
• The anatomy of the brachial and radial arteries
• Palpating the radial pulse point
• Determining the pulse rate
• Measuring respiratory rate

MODULE OUTLINE
SECTION 1 Peak Procedure for Pulse Assessment
Pulse Rate
Pulse Points
 Assessing Pulse Rate
Procedure 9-1. Practice Locating the Radial Artery
Procedure 9-2. Determining Pulse Rate
SECTION 2 Peak Procedure for Assessing Respiration
Respiratory Rate
Control of Respiration
Assessing Respiration
Procedure 9-3. Count Your Own Respiratory Rate
Procedure 9-4. Assessing the Respiratory Rate
SECTION 3 Ready References
Ready Reference 9-1. Normal Pulse Rates per Minute at
Various Ages
Ready Reference 9-2. Factors Affecting Pulse Rate
Ready Reference 9-3. Pulse Patterns
Ready Reference 9-4. Pulse Amplitude Assessment
Ready Reference 9-5. Pulse Pressure
Ready Reference 9-6. Normal Respiratory Rates per
Minute at Various Ages
Ready Reference 9-7. Factors Affecting Respiration Rate
Ready Reference 9-8. Evaluation of Respiration
Ready Reference 9-9. Types of Respiration
SECTION 4 The Human Element
Through the Eyes of a Student
Through the Eyes of a Patient
English-to-Spanish Phrase List
SECTION 5 Skill Check
KEY TERMS
Pulse rate • Pulse • Pulse points • Brachial artery • Radial artery •
Respiratory rate • Voluntary control
OBJECTIVES
• Define the term pulse and describe factors that may affect a person’s
pulse.
• Describe the different qualities of the pulse that a clinician should be
aware of when taking a pulse.
• Demonstrate the correct technique for locating and assessing the
radial pulse.
• Explain why the patient should not be told beforehand that the
clinician is assessing his or her respiratory rate.
• Describe the factors that may affect a person’s respirations.
• Explain the terms used to describe a person’s respirations.
• Demonstrate the correct technique for assessing respiration.
• Provide information to the patient about the pulse and respiration
assessment procedure and the readings that you obtain.
• Recognize findings that have implications in planning dental
treatment.
• Provide appropriate referral to a physician when findings indicate the
need for further evaluation.
• Compare findings in the fictitious patient cases A to E (Module 10) to
the normal ranges for pulse and respiration.
• Demonstrate knowledge of the pulse and respiration assessment by
applying concepts from this module to the fictitious patient cases A to
E in Module 10, Vital Signs: Blood Pressure.

NOTE TO COURSE INSTRUCTOR: Fictitious patient cases A to E for

the vital signs modules are located in Module 10, Vital Signs: Blood
Pressure.

SECTION 1 • Peak Procedure for Pulse Assessment

Pulse Rate
The pulse rate is an indication of an individual’s heart rate. Pulse rate is
measured by counting the number of rhythmic beats that can be felt over an
artery in 1 minute. The normal adult heart rate is between 60 and 100 beats
per minute. Rapid or slow pulse rates are not necessarily abnormal. Athletes
tend to have slow pulses at rest. Increased pulse rates may be a normal
response to stress, exercise, or pain. Ready Reference 9-1 outlines normal
pulse rates at various ages, and Ready Reference 9-2 shows some factors that
can affect the pulse rate. Ready References 9-3, 9-4, and 9-5 provide details
of pulse patterns, pulse amplitude, and pulse pressure.

Pulse Points
As the heart beats and forces blood through the body, a throbbing sensation—
the pulse—can be felt by putting the fingers over one of the arteries that are
close to the surface of the skin. Pulse points are the sites on the surface of the
body where rhythmic beats of an artery can be easily felt.1 In the dental
setting, the most commonly used pulse point is over the radial artery in the
wrist. Before practicing the techniques for assessing the pulse rate and blood
pressure, it is helpful to locate and palpate the brachial and radial pulse points
on the underside of the arm (Fig. 9-1).
Assessing Pulse Rate

Procedure 9-1. Practice Locating the Radial Artery

Action Rationale

1. Sit or stand facing the • This position makes it easy

patient. Position the to locate the radial pulse
patient’s arm in a palm-up point.
position with his or her
arm resting comfortably
on a countertop or chair
armrest.

2. Use the finger pads of • The sensitive finger pads

your index, middle, and can feel the pulsation of
ring fingers to locate the the artery.
 radial artery on the wrist at • The thumb has a pulse of
the base of the thumb (Fig. its own that might be
9-2). confused with the patient’s
Feel the throbbing pulse pulse.
by pressing lightly in the • Too much pressure will
shallow groove at the base make it difficult to detect
of the thumb. the pulsations under your
fingers.

Procedure 9-2. Determining Pulse Rate

EQUIPMENT
Clock or watch with second hand or digital readout

Action Rationale
1. It takes time to obtain an • Assessing the other vital
 accurate oral temperature signs while the
using a glass thermometer. thermometer registers the
For this reason, pulse, patient’s temperature
respiration, and blood makes efficient use of
pressure are assessed appointment time.
during the time needed to
determine the oral
temperature.

2. Explain the pulse • Informs the patient of the

assessment procedure to clinician’s intent
the patient. • Reduces patient
apprehension and
encourages cooperation
3. The patient’s arm should • There is no reason for the
be resting comfortably on patient’s arm to be in an
the chair armrest or other awkward position.
support, such as a
countertop (Fig. 9-3).
4. Sit or stand facing the • This position is
patient. Grasp the patient’s comfortable for the patient
wrist with the fingers of and convenient for the
your free (non–watch- clinician.
bearing) hand.

5. Using the finger pads of • The thumb is never used to

your first three fingers, assess the pulse. The
locate the radial pulse point thumb has a pulse; this
on the thumb side of the pulse could be confused
patient’s wrist (Fig. 9-4). with the patient’s pulse.
Apply only enough • Moderate pressure
pressure so that the radial facilitates palpation of the
artery can be distinctly felt. beats. The pulse is
imperceptible with too
little pressure, whereas too
much pressure obscures
the pulse.

6. Look at a watch or clock • Starting with the second

and wait until the second hand at the “12” or “6”
 hand gets to the “12” or makes it easy to determine
“6.” When the second hand when 30 seconds has
reaches the “12” or “6,” passed.
begin counting the pulse • Sufficient time is needed to
beats. assess the rate and
Count for a minimum of characteristics of the pulse.
30 seconds. Multiply this • With an irregular pulse, the
number by 2 to calculate beats counted in a 30-
the pulse rate for 1 minute. second period may not
If the pulse is irregular represent the overall rate.
in any way or if your The longer you measure,
patient has a pacemaker, the more these variations
count the beats for 1 are averaged out.
minute.

7. Make a mental note of the • The patient may alter the

pulse rate and without rate of respirations if aware
letting go of the patient’s that breathing is being
wrist, begin to observe the monitored.
patient’s breathing.
Assessment of the
respiration should begin
immediately after taking
the patient’s pulse.

SECTION 2 • Peak Procedure for Assessing Respiration

Respiratory Rate
Respiration is the process that brings oxygen into the body and removes
carbon dioxide. With each normal breath, a person inhales 500 ml of air and
exhales the same amount. Ready References 9-8 and 9-9 outline terms used
when evaluating the respiratory rate and types of respiration.
• The respiratory rate is determined by counting the number of
respirations in 1 minute—one inhalation and one exhalation = one
respiration.
• The normal adult respiratory rate is between 14 and 20 breaths per
minute. Elderly patients typically have higher resting respiratory rates; it
is not unusual for an elderly patient to have a resting respiratory rate of
20 to 22 minutes.2 Ready Reference 9-6 outlines normal respiration
rates at various ages.
• Excitement, exercise, pain, and fever increase respiratory rate. Any
patient who is working hard at breathing is in trouble.
• Rapid respiration is characteristic of lung diseases such as emphysema.
Heart disease also increases the rate of respiration, as do some drugs.
Ready Reference 9-7 provides a list of factors that can affect respiration
rate.

Control of Respiration
Respiration is mostly unconscious; people breathe without thinking about it.
Unlike pulse rate, however, respiration is easily brought under voluntary
control. Breath-holding, panting, use of expiratory air to speak, singing, or
sighing at will are all examples of this voluntary control. Just thinking about
respiration causes most individuals to alter their breathing rate. Telling
someone to “breathe normally” almost certainly will cause that person to
begin to breathe more slowly or rapidly.3,4 For this reason, the respiratory
rate should be measured immediately after taking a pulse. Counting the
respirations while appearing to count the pulse helps to keep the patient
from becoming conscious of his or her breathing and possibly altering the
usual rate.

Assessing Respiration
Procedure 9-3. Count Your Own Respiratory Rate

Action Rationale
1. Place a hand on your own • One inspiration and
chest and feel your chest expiration comprises one
rise. One breath in and out respiration.
is counted as one
respiration.

2. Count the number of times • Sufficient time is needed

your chest rises for 30 to observe the breathing
seconds and multiply by 2 rate and characteristics.
to obtain your respiratory
rate.

3. Note if your breathing is • Abnormal respirations

irregular. Listen for may be irregular, rapid,
unusual breath sounds. labored, weak, or noisy.
Note how much effort is
needed for you to breathe.
Normal breathing should
be quiet and effortless.

Procedure 9-4 Assessing the Respiratory Rate

EQUIPMENT
Clock or watch with second hand or digital readout
Pen (or computer keyboard)

Action Rationale
1. This assessment is best • Respiratory rate is under
 done immediately after voluntary control. If the
taking the patient’s pulse. patient knows that you are
Do not announce that you counting the breaths, he or
are measuring the she may change breathing
respirations. pattern.

2. After determining the • The patient will assume

pulse rate, keep your that you are still counting
fingers resting on the the pulse rate.
patient’s wrist and begin to • Breathing rate can be
assess the respiration (Fig. controlled voluntarily.
9-5).
Observe respirations
inconspicuously; use
peripheral vision to
observe the chest rise and
fall. Young children use
their diaphragms when
breathing; the respiratory
rate of a young child is
measured by observing the
abdomen rise and fall.

3. Look at a watch or clock • Sufficient time is needed

and wait until the second to observe the breathing
hand gets to the “12” or rate and characteristics.
“6.” When the second
hand reaches the “12” or
“6,” use your peripheral
vision to watch the chest
and begin counting each
rise of the chest as one
breath.
 Count the number of
breaths for a minimum of
30 seconds. In adults with
irregular rates, count for 1
full minute.

4. Pay attention to the depth • Increased time allows

and rhythm of the patient’s detection of abnormal
respirations by watching characteristics.
the chest rise and fall.4
• Normal breathing is
easy, quiet, and regular.
• Abnormal respirations
may be irregular, rapid,
labored, weak, or noisy.
• If breathing is abnormal
in any way, count the
respirations for at least 1
full minute.

5. Record the pulse and • Recording findings

 respiratory rates in the immediately in the chart
patient chart or computer facilitates accurate
record. documentation and
Discuss the findings reporting.5
with the patient. • Elective dental treatment
Upon completion of the may be postponed due to
vital signs assessment, abnormal findings. For
report all abnormal example, a patient with
findings to a clinical labored breathing should
instructor or supervising be referred to his or her
clinician. physician for evaluation.

SECTION 3 • Ready References

NOTE: The Ready References in this book may be removed from the book
by tearing along the perforated lines on each page. Laminating or placing
these pages in plastic protector sheets will allow them to be disinfected for
use in a clinical setting.

Ready Reference 9-1. Normal Pulse Rates per Minute at

Various Ages

Approximate
Age Range Approximate Average

2–6 years 75–120 100

6–12 years 75–110 95

Adolescent to 60–100 80
adult
Ready Reference 9-2. Factors Affecting Pulse Rate

Age
Medications
Stress
Exercise

Ready Reference 9-3. Pulse Patterns

Regular—evenly spaced beats; may vary slightly with respiration

Regularly irregular—regular pattern overall with ``skipped''

beats

Irregularly irregular—no real pattern, difficult to measure

accurately

Normal amplitude—full, strong pulse that is easily felt

Abnormal amplitude—weak pulse that is not easily felt

Ready Reference 9-4. Pulse Amplitude Assessment

To assess the amplitude of a pulse, use a numerical scale to characterize
the strength.
0—absent pulse, not palpable
+1—weak or thready pulse, hard to feel; the beat easily eliminated by
slight finger pressure
+2—normal pulse, easily felt; the beat is eliminated by forceful finger
pressure
+3—bounding, forceful pulse that is readily felt; the beat not easily
eliminated by pressure from the fingers
Ready Reference 9-5. Pulse Pressure

Normal
The pulse pressure
is smooth (Fig. 9-
6A–C).

Weak
The pulse pressure
is diminished; the
pulse feels weak
and small.

Bounding
The pulse pressure
is increased and
the pulse feels
strong and
bouncing.

Ready Reference 9-6. Normal Respiratory Rates per

Minute at Various Ages

Age Approximate Range

Preschooler (3–6 years) 22–34

School age (6–12 years) 18–30

Adolescent (12–18 years) 12–16

Adult 14–20
Ready Reference 9-7. Factors Affecting Respiration Rate

Age Altitude
Medications Gender
Body position Stress
Exercise Fever

Ready Reference 9-8. Evaluation of Respiration

Rhythm—regularity of respirations
Ease—easy, labored, or painful?
Depth—deep or shallow?
Noise—slight, wheezing, gurgling?
Abnormal odor—fruity odor, alcohol on
breath?

Ready Reference 9-9. Types of Respiration

Normal
The respiratory rate
is about 14–20
per minute in
adults (Fig. 9-
7A–E).

Rapid shallow
breathing
(Tachypnea)
The respiratory rate
is >20 per
minute; causes
include restrictive
 lung disease and
inflammation of
the lungs.

Rapid deep
breathing
(Hyperpnea,
hyperventilation)
Breathing with
increased rate and
depth; causes
include exercise,
anxiety, and
metabolic
acidosis.

Slow breathing
(Bradypnea)
Breathing with
decreased rate
and depth; one
common cause is
diabetic coma.

Obstructive
breathing
The expiration is
prolonged
because of
narrowed
airways; causes
include asthma,
chronic
bronchitis, and
 chronic
obstructive
pulmonary
disease (COPD).

SECTION 4 • The Human Element

Through the Eyes of a Student

A MEDICAL EMERGENCY

It was my first appointment with Mr. J. As I prepared for his appointment,

I noted that he was 70 years of age and has a history of congestive heart
failure. When I assessed Mr. J.’s respiration, he seemed breathless and to
be having some difficulty in breathing. He seemed to be tired even though
this was a morning appointment. I reclined the dental chair so that he could
rest while I took his blood pressure. Once he was in a supine position, Mr.
J. seemed to have even more difficulty breathing and he asked to sit
upright again.
I wanted to get on with the appointment because I was worried about
completing all my clinic requirements. Something in the back of my mind,
however, kept telling me that I should be concerned about Mr. J.’s labored
breathing. I decided to report my observations to my clinic instructor.
My instructor called an ambulance, and the paramedics transported
Mr. J. to the hospital. Later, I received a telephone call from Mrs. J. telling
me that her husband was hospitalized and saying that my actions might
have saved his life. I learned that day that even seemly small things like a
patient’s respiratory rate could be significant. Now, I take the vital signs
assessment procedures more seriously and never rush through them.

George, student,
Tallahassee Community College

Through the Eyes of a Patient

INCLUDING THE PATIENT DURING

ASSESSMENT AND CARE PLANNING

Patient-centered care is a fundamental concept in the provision of excellent

dental care. Engaging with each patient as you complete the various
assessment procedures can help to improve care outcomes.
As you gather information during the patient assessment process, you
increasingly assemble information about the patient that you will use to
individualize the treatment care plan recommendations.
As you plan care for your patient, consider this method for patient-
centered care based on respect for the patient’s preferences:
• Clear your mind of your own concerns and focus on the patient as a
unique individual with values and health beliefs.
• What is the essential information you need to know to plan effective
care for a patient? Hint: In addition to clinical findings gathered
during the patient assessment process, what information will be
helpful to ensure that the patient is included in the care planning
process?
Applying evidence-based standards helps improve the quality of
care.
• Discuss instances when it is appropriate to make exceptions to the
standard of care in order to accommodate a patient’s wishes.
• Discuss instances when it would not be appropriate.

English-to-Spanish Phrase List

 NOTE: The Practical Focus— Fictitious Patient Cases section for all of
the vital signs modules is located in Module 10, Vital Signs: Blood
Pressure.

SECTION 5 • Skill Check

Technique Skill Checklist: Pulse and Respiration

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Positions the patient with the arm resting
comfortably on the armrest or other support.

Faces the patient. Grasps the patient’s wrist with the

fingers of the free (non–watch-bearing) hand.
Using the finger pads, locates the radial pulse point
on the thumb side of the patient’s wrist. Applies
only enough pressure so that the radial artery can be
distinctly felt.
Notes whether the pulse is regular or irregular.
Using a watch with a second hand, counts the beats
for a minimum of 30 seconds if the pulse is regular.
Counts the pulse for 1 minute if the pulse is
irregular. Calculates the pulse rate.

Makes a mental note of the pulse rate and without

letting go of the patient’s wrist, begins to observe
the patient’s breathing. Does not inform the patient
that the respirations are being assessed.
When one complete cycle of inspiration and
expiration has been observed, looks at watch in
preparation for determining the respiratory rate.
Counts the number of breaths for a minimum of 30
seconds. If breathing is abnormal in any way, counts
 the respirations for one minute. Calculates the
respiratory rate.

Records today’s date, time, and the pulse and

respiratory rates in the patient chart or computer
record.
Reports pulse rate within +/−2 beats of the
evaluator’s rate.
Reports respiratory rate within +/−2 breaths of the
evaluator’s rate.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

Communication Skill Checklist: Role-Play for Pulse and

Respiration

ROLES:
• Student 1 = Plays the role of the patient.
• Student 2 = Plays the role of the clinician.
• Student 3 or instructor = Plays the role of the clinic instructor near
the end of the role-play.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).
DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S
(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Explains what is to be done at the start of the pulse
assessment procedure.
At the conclusion of the pulse assessment, does not
announce that respiration will be assessed next.
Upon completion of the procedures, reports the
pulse and respiration findings to the patient and
explains if the readings are normal or outside the
normal range and the significance of these findings.
Encourages patient questions before and after the
assessment procedure.
Answers the patient’s questions fully and
accurately.
Communicates with the patient at an appropriate
level and avoids dental/medical terminology or
jargon.
Accurately communicates the findings to the
clinical instructor. Discusses the implications for
dental treatment using correct medical and dental
terminology.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
 and divide by the total points possible to calculate a
percentage grade.

NOTE TO COURSE INSTRUCTOR: A series of role-play

scenarios for the modules in this textbook can be found at
http://thepoint.lww.com/GehrigPAT4e.

References
1. Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking.
11th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2012.
2. Mistovich JJ, Krost WS, Limmer DD. Beyond the basics: interpreting vital signs.
Emerg Med Serv. 2006;35(12):194–199.
3. Hatlestad D. The anatomy and physiology of respiration. Emerg Med Serv.
2002;31(1):56–65.
4. Limmer DD, Mistovich JJ, Krost WS. Beyond the basics: putting the vital back in
vital signs. EMS Mag. 2008;37(9):71–75.
5. Fieler VK, Jaglowski T, Richards K. Eliminating errors in vital signs documentation.
Comput Inform Nurs. 2013;31(9):422–427.
 MODULE
10

VITAL SIGNS: BLOOD

PRESSURE
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
This is the third of three modules on vital signs assessment. Vital signs are a
person’s temperature, pulse, respiration, and blood pressure. In addition to
these standard vital signs, tobacco use has been suggested as the fifth vital
sign. Tobacco use—smoking cigarettes, cigars, or pipes—is a contributing
factor in many medical conditions and, in addition, increases the risk of
periodontal disease.

MODULE OUTLINE
SECTION 1 Blood Pressure Assessment in the Dental
Setting
SECTION 2 Equipment for Blood Pressure
Measurement
The Sphygmomanometer
The Manometer Pressure Gauge
 The Stethoscope
Automatic Blood Pressure Equipment
SECTION 3 Measurement and Documentation of
Korotkoff Sounds
Blood Pressure Measurements
The Korotkoff Sounds
Auscultatory Phases
The Silent Auscultatory Gap
Fluctuations in Blood Pressure
SECTION 4 Critical Technique Elements
Cuff Size
Correct Sizing of Bladder
Arm Position during Blood Pressure Assessment
Palpatory Estimation of Blood Pressure
SECTION 5 Peak Procedure
Procedure 10-1. Blood Pressure Determination
Procedure 10-2. If Korotkoff Sounds Are Difficult to Hear
SECTION 6 Ready References
Ready Reference 10-1. Recommended Bladder Dimensions
Ready Reference 10-2. Classification of Blood Pressure for
Adults Aged 18 Years or Older
Ready Reference 10-3. Blood Pressure Values for Children
and Adolescents
Ready Reference 10-4. Dental Management of
Hypertensive Adults
Ready Reference 10-5. Assessing Pediatric Patients
Ready Reference 10-6. Factors Affecting the Accuracy of
Blood Pressure Measurement
Ready Reference 10-7. Causes of Inaccuracies in Blood
Pressure Measurement
 Ready Reference 10-8. Equipment Maintenance
Ready Reference 10-9. Internet Resources: Blood Pressure
Ready Reference 10-10. Summary Reports Related to
Interpreting Blood Pressures

SECTION 7 The Human Element

The Man Behind Manual Blood Pressure Technique
Through the Eyes of a Student
Ethical Dilemmas
English-to-Spanish Phrase List
SECTION 8 Practical Focus—Fictitious Patient Cases
for Vital Signs Modules
SECTION 9 Skill Check
KEY TERMS
Blood pressure • Systolic pressure • Diastolic pressure • Hypertensive •
Hypotensive • Hypertension • Asymptomatic • Silent killer • Auscultatory
method • Sphygmomanometer • Cuff • Manometer • Aneroid
manometers • Mercury manometer • Earpieces • Brace • Binaurals •
Amplifying device • Diaphragm endpiece • Bell endpiece • Systolic
reading • Diastolic reading • Millimeters of mercury • Korotkoff sounds •
Auscultatory gap • White-coat hypertension • Antecubital fossa •
Estimated systolic pressure

OBJECTIVES
• Define the term blood pressure and describe factors that may affect a
person’s blood pressure.
• Define systolic and diastolic blood pressure and give their normal
values.
• Explain how a sphygmomanometer works and demonstrate how to
use this tool to measure blood pressure.
 • Identify the bladder width and length of a cuff. Check to see if the
length, width, and center of the bladder are correctly marked; if not,
correctly mark the cuff.
• Explain why the blood pressure cuff is kept at heart level while
measuring blood pressure.
• List and describe the Korotkoff sounds that are heard while taking a
person’s blood pressure.
• Define and discuss the significance of the auscultatory gap.
• Locate and palpate the brachial pulse point in the antecubital fossa.
• Demonstrate correct technique for accurately assessing the blood
pressure.
• Provide information to the patient about the blood pressure
assessment procedure and the readings that you obtain.
• Describe blood pressure findings that have implications in planning
dental treatment.
• Provide appropriate referral to a physician when findings indicate the
need for further evaluation.
• Compare findings for the fictitious patient cases found in Section 8 to
the normal range for blood pressure.
• Demonstrate knowledge of blood pressure assessment by applying
concepts from this module to the fictitious patient cases found in
Section 8.

SECTION 1 • Blood Pressure Assessment in the Dental

Setting
The National Heart, Lung, and Blood Institute (NHLBI) estimates that 65
million Americans have high blood pressure (hypertension). Of those 65
million, nearly 20 million are not aware they have the condition. There is a
high prevalence of undiagnosed hypertension and prehypertension.1 As the
population ages, the prevalence of hypertension will increase even further
unless broad-based measures are implemented for blood pressure screening.
Dental health care providers can play an important role in improving the
current levels of detection for hypertension by implementing routine blood
pressure screening (Boxes 10-1 and 10-2).1

BOX Standard of Care for Blood Pressure

10-1 Assessment
• The American Dental Association (ADA) recommends that blood
pressure assessment should be a routine part of the initial appointment
for all new dental patients—including children—as a screening tool for
undiagnosed high blood pressure.2
• In addition, the ADA suggests that a blood pressure assessment should
be performed routinely during continuing care appointments (3-, 4-, 6-,
or 12-month recall appointments).
• The ADA, the American Academy of Pediatrics, and the American
Heart Association recommend that blood pressure measurements be
taken at all pediatric health care visits—including dental appointments
—for patients 3 to 18 years of age.3

BOX High Blood Pressure Facts

10-2

HYPERTENSION IN ADULTS
• According to the American Heart Association (AHA), nearly 1 in 3
U.S. adults has high blood pressure.
• Because there are frequently no symptoms from high blood pressure,
nearly one-third of the people with this condition do not know they
have it.
• 69% of Americans who have a first heart attack have blood pressure
over 140/90 mm Hg.
• 77% of Americans treated for a first stroke have blood pressure over
140/90 mm Hg.
• 74% of Americans with congestive heart failure have blood pressure
 over 140/90 mm Hg.
• More men than women have high blood pressure.
• Pregnant women are a high-risk group for high blood pressure whether
they had hypertension before becoming pregnant or not.
HYPERTENSION IN CHILDREN AND ADOLESCENTS
• Children and adolescents are at risk for high blood pressure.
• Studies indicate that 2% to 4% of the pediatric population have
hypertension.7–11
• Studies indicate that between 15% and 30% of obese children have
hypertension,7–11 which can lead to cardiovascular disease, type 2
diabetes mellitus, and fatty liver disease.3,12–15
• The American Dental Association (ADA), Academy of Pediatrics, and
AHA recommend that children over 3 years of age who are seen in
health care settings should have their blood pressure measured at least
once during every health care episode.3,14

1. Blood Pressure Overview. Arterial blood pressure is the pressure

exerted against blood vessel walls as blood flows through them. Every
time the heart contracts in an adult, it forces 6 qt of blood beyond the
torso and out to the head, hands, and feet. With each heart contraction,
the blood not only pushes through the vessels but also presses outward
against the vessel walls.
a. The highest pressure occurs when blood is propelled through the
arteries by the contraction of the heart. During each heart
contraction, the pressure created by the blood as it presses through
and against blood vessel walls is known as the systolic pressure.
b. When the heart relaxes between contractions, the pressure exerted on
the vessels lessens but only to a point. That lower pressure is known
as the diastolic pressure.
c. Blood pressure is one important clue to the health of the heart and
blood vessels; therefore, blood pressure measurement is an important
part of the patient assessment.
 d. Although both systolic and diastolic pressures are clinically
significant, the latest evidence from research indicates that the systolic
blood pressure is the more important of the two in the management of
high blood pressure.4–6
2. Hypertension and Hypotension
a. Blood pressure measurements indicate if a person is hypertensive
(has abnormally high blood pressure) or hypotensive (has abnormally
low blood pressure).
b. High blood pressure—hypertension—is blood pressure that stays at
or above 140/90 mm Hg.
c. Blood pressure can increase when larger blood vessels begin to lose
their elasticity and the smaller vessels start to constrict, causing the
heart to try to pump the same volume of blood through vessels with
smaller internal diameter.
3. Symptoms, Diagnosis, and Treatment of Hypertension
a. Hypertension commonly has no obvious symptoms (i.e., is
asymptomatic). For this reason, high blood pressure is often called
the “silent killer.”
b. The only way for an individual to know if he or she has hypertension
is to have a blood pressure screening.
c. Fortunately, hypertension is easy and painless to detect in a few
minutes using a blood pressure cuff and a stethoscope.
4. Complications of Uncontrolled Hypertension
a. Uncontrolled hypertension is a serious condition that can lead to
stroke, heart attack, heart failure, or kidney failure.
b. In pregnant women, hypertension can lead to seizures or death as well
as premature births or stillbirths.
5. Treatment of Hypertension and Patient Compliance with Treatment
a. Simple treatments including weight loss, lifestyle changes, and
medication can be effective in lowering blood pressure.
b. Blood pressure medications are very effective at lowering blood
pressure; however, many of the medications can have mild side
 effects such as fatigue or dry cough.
c. For the blood pressure medications to work, patients must actually
take them. Unfortunately, it is estimated that within a year of
receiving a prescription, 50% of patients stop taking their blood
pressure medication.

SECTION 2 • Equipment for Blood Pressure

Measurement
The gold standard for clinical blood pressure measurement is the
auscultatory method, where a trained health care provider uses a
sphygmomanometer and a stethoscope to listen for arterial sounds in the
brachial artery. This is called the “auscultatory method” because the detection
of sound is called “auscultation.”

The Sphygmomanometer
A sphygmomanometer (sss-image-mo-ma-nom-eter) consists of (1) a cuff
with an inflatable bladder, (2) a hand bulb with a valve used to inflate and
deflate the bladder, and (3) a pressure gauge. A sphygmomanometer is
illustrated in Figure 10-1. Figure 10-2 shows different sizes of blood pressure
cuffs.
The Manometer Pressure Gauge
A manometer is the device that measures the air pressure present in the
inflatable pouch. The two traditional types of manometers are aneroid gauges
and mercury column gauges (Fig. 10-3).

1. Aneroid manometers use a round dial-type gauge to indicate the

pressure reading.
a. The aneroid gauge is the most commonly used type of manometer in a
dental office setting.
b. Aneroid devices are believed to be less accurate than mercury
columns because they can be difficult to keep in calibration.16
1) Aneroid manometers require regular checks for common defects
 such as non-zeroed gauges, cracked faceplates, or defective rubber
tubing.17
2) These gauges should be validated for accuracy against a standard
mercury manometer at 6-month intervals.18,19 Refer to Ready
Reference 10-8 in the “Ready References” section for information
on calibration.
3) To ensure regular maintenance, the calibration due date should be
clearly marked on each gauge.
1. A mercury manometer is a device with a column of mercury to
indicate the pressure reading.
a. Mercury manometers are considered the gold standard measuring
devices for blood pressure determination. This type may be placed on
a table or mounted on the wall.
b. It should be noted that mercury manometers pose a health threat if the
manometer is broken causing the mercury to spill.

The Stethoscope
A stethoscope is a device that makes sound louder and transfers it to the
clinician’s ears. The parts of a stethoscope are illustrated in Figure 10-4 and
are outlined below.
 1. Earpieces, which are placed in the clinician’s ears
2. A brace and binaurals, which connect the earpieces to the tubing that
conducts the sound
3. An amplifying device, which makes the sound louder; it may be two-
sided with a diaphragm and bell or one-sided with only a diaphragm.
a. The diaphragm endpiece has a large, flat surface that is used to hear
loud sounds like the blood rushing through the arteries. The
diaphragm endpiece covers a greater area and is easier to hold than a
bell endpiece and is recommended for routine measurement of blood
pressure in adults.20
b. The bell endpiece has a small, rounded surface that is designed to
hear faint sounds like heart murmurs. Some authors recommend the
bell endpiece for measurement of blood pressure in children because
it provides better sound reproduction.3

Automatic Blood Pressure Equipment

Automatic blood pressure equipment—also called digital or electronic blood
pressure equipment—ranges from the highly calibrated types used in hospital
settings to less advanced equipment designed for home use.
1. Electronic Battery-Powered Devices. The most common types of
automatic blood pressure equipment found in the dental setting are
electronic battery-powered devices (Fig. 10-5).
• These devices use a microphone instead of a stethoscope to detect the
blood pulsing in the artery.
• The cuff connects to an electronic monitor that automatically inflates
and deflates the cuff when the start button is pressed. There are two
types of cuffs, arm, and wrist cuffs.
• A monitor displays the blood pressure reading as a digital display.
2. Pros and Cons of Electronic Equipment
• Pro: These devices are easiest to use.
• Con: These devices can be expensive.
• Con: Many automatic devices do not provide accurate readings.
3. Types of Automated Devices. Three categories of automated devices
are available: devices that measure blood pressure on the upper arm, the
wrist, and the finger.
• Devices that measure blood pressure at the finger are not
recommended.20
• Devices that measure blood pressure at the wrist are more accurate
than finger devices but are still not recommended for use in the dental
setting.20
• Devices that measure blood pressure in the upper arm have been
shown to be the most reliable of the three, both in clinical practice and
in the major hypertension trials.
4. Precautions for Use of Automated Equipment
• The main source of error with automatic devices is that the cuff has
not been positioned at the level of the heart when the reading is taken.
 • Automatic devices are convenient, but they do not provide
measurements that always are a close match to measurements
obtained a standard sphygmomanometer and stethoscope.3,21,22 The
preferred method of blood pressure measurement is a traditional
sphygmomanometer and a stethoscope (auscultation).
• All automatic equipment should be verified using a traditional
sphygmomanometer and a stethoscope before its use in a dental
setting. An automated device that does not provide readings that are
within 1 mm Hg of those obtained with a traditional
sphygmomanometer and a stethoscope should not be used in the
dental setting. Furthermore, the automatic device must be checked
monthly for continued accuracy.
• An abnormally high or low reading obtained with an automatic
device should be verified by retaking the blood pressure in a few
minutes using a traditional sphygmomanometer and a stethoscope.3

SECTION 3 • Measurement and Documentation of

Korotkoff Sounds

Blood Pressure Measurements

1. Systolic and Diastolic Readings. Two readings are recorded for blood
pressure.
a. The systolic reading is the pressure of the blood flow when the heart
beats—the pressure when the first sound is heard. During this stage,
the heart is pumping blood through the arteries to the parts of the
body (Table 10-1).
 b. The diastolic reading is the pressure between heartbeats—the
pressure when the last sound is heard. During this stage, the heart is
relaxed and refills with blood before its next contraction.
2. Millimeters of Mercury. Blood pressure readings are recorded in
millimeters of mercury (mm Hg) because the original mercury
manometer devices used a column of mercury.
 a. The pressure is measured by how high a pulsing artery can push a
column of mercury in a manometer (Fig. 10-6A).

b. Measurements made with an aneroid manometer also are recorded in

mm Hg, despite the fact that these gauges contain no mercury (Fig.
10-6B).
c. The two blood pressure readings are recorded as a fraction (Box 10-
3).

BOX Blood Pressure Measurements

10-3

Blood pressure measurements are recorded as a fraction with the systolic

reading as the top number and the diastolic reading as the lower number in
the fraction. A typical blood pressure reading for an adult might be 118/78
mm Hg. For example, if an individual’s systolic blood pressure is 118 mm
Hg and the diastolic blood pressure is 78 mm Hg, the blood pressure reading
is recorded and read as “118 over 78.”

To remember that the diastolic number is the lower number, think

“diastolic = down.”

The Korotkoff Sounds

Blood pressure is most often measured by auscultation, using a
sphygmomanometer and stethoscope. Auscultation is the act of listening for
sounds within the body to evaluate the condition of the heart, blood vessels,
lungs, or other organs. During blood pressure determination, a stethoscope is
used to listen to sounds created by the blood as it pushes its way through the
constricted brachial artery.
The Korotkoff (ko-rot-kov) sounds are the series of sounds that are
heard as the pressure in the sphygmomanometer cuff is released during the
measurement of arterial blood pressure (Boxes 10-4 and 10-5).
• Systolic pressure is defined as “the onset of the tapping Korotkoff
sounds.”
• The diastolic pressure is defined as “the disappearance of Korotkoff
sounds.”3,20,23

BOX Korotkoff Sounds

10-4

Phase Sounds and Characteristics

1 The first appearance of repetitive, clear tapping sounds that
gradually increase in intensity
• The first tapping sound is recorded as the systolic pressure.
2 A brief period of softer and longer swishing sounds
Gap Auscultatory gap—in some patients, sounds may disappear
altogether for a short time
3 The return of sharper sounds, which become crisper and louder
thudding sounds
4 The distinct, abrupt muffling of sounds, which become soft and
blowing in quality
5 The point at which all sounds finally disappear completely
• Silence occurs as the blood flow returns to normal.
• The point when the last sound is heard is recorded as the
diastolic pressure.
 BOX Hear the Korotkoff Sounds on Online Video
10-5

“Korotkoff Blood Pressure Sights and Sounds,” is an excellent video clip

from the Medical Committee of the Virginia Healthy Pathways Coalition.
The video clip allows the viewer to hear examples of actual Korotkoff
sounds.

Video link: http://vimeo.com/26580985

Auscultatory Phases
There are five phases of Korotkoff sounds.
• Each phase is characterized by the volume and quality of sound heard
through the stethoscope. Figure 10-7 below illustrates these phases.
• These phases were first described by Nicolai Korotkoff and later
elaborated by Witold Ettinger.24–26

The Silent Auscultatory Gap

Failure to detect a gap in the Korotkoff sounds is a potential source of error in
blood pressure measurement. The auscultatory gap is a period of abnormal
silence that can occur between the Korotkoff phases (Fig. 10-8). Failure to
recognize the presence of an auscultatory gap will result in an inaccurate
blood pressure reading in which the systolic pressure is underestimated. Box
10-6 provides an example of how failure to recognize the auscultatory gap
can result in inaccurate readings.

BOX The Impact of an Unrecognized Auscultatory

10-6 Gap
TECHNIQUE ERROR: GAP MISTAKEN FOR THE SILENT
PERIOD BEFORE PHASE 1
1. If the cuff is not inflated high enough, the clinician will mistake the gap
in sounds as the silent period before the phase 1 sounds begin.
2. In the example shown below, if the clinician only inflates the cuff to 116
mm Hg:
• The auscultatory gap is unrecognized. Because the clinician only starts
listening at 116 mm Hg (within the gap in sounds), he mistakes the
sounds he or she hears at 106 mm Hg as the start of the Korotkoff
sounds.
• The systolic pressure is significantly underestimated as 106 mm Hg and
interpreted as being within the normal range. Instead, the true systolic
reading of 166 mm Hg is above the recommended range.
 DETECTION OF AUSCULTATORY GAP
Palpation of the brachial or radial pulse during cuff inflation ensures that
an auscultatory gap is not mistaken for the start of Phase I sounds.27

Fluctuations in Blood Pressure

Blood pressure varies from moment to moment and can be influenced by
many factors such as body position, respiration, emotion, anxiety, exercise,
meals, tobacco, alcohol, temperature, and pain. Blood pressure also is
influenced by age and race and is usually at its lowest during sleep. These
influences on blood pressure can be significant, often accounting for rises in
systolic blood pressure greater than 20 mm Hg. These factors have to be
carefully considered in all circumstances of blood pressure measurement.
Insofar as is practical, the patient should be relaxed in a quiet room for a
short period of time before measurement.
White-coat hypertension refers to blood pressure that rises above its
usual level when it is measured in a health care setting (such as a medical or
dental office, where a health care provider may be wearing a white lab
coat).3,28–31 White-coat hypertension is more common in people who have
high blood pressure, and in the dental setting, their blood pressure is
remarkably higher than normal. This increase in blood pressure tends to
subside once the patient becomes more relaxed as the dental appointment
progresses. In many cases, continuing with the extraoral examination and
then retaking the blood pressure measurement will yield a lower blood
pressure reading.

SECTION 4 • Critical Technique Elements

The procedure for the measurement of arterial blood pressure using a
sphygmomanometer is well established, and consensus recommendations
have been produced by the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure (United States),
Canadian Hypertension Education Program, British Hypertension Society,
and the European Society of Hypertension in the interest of
standardization.20,32,33,34–38
• Every person who performs blood pressure assessments should undergo
careful training and be aware of common errors in technique.
• Four of the most critical technique elements for accurate blood pressure
determination are the ability to (1) select the proper cuff size, (2) place
the cuff, (3) position the patient’s arm, and (4) obtain a palpatory
estimate of the blood pressure.16,35,36,39

Cuff Size
In the case of blood pressure cuffs, one size does not fit all. Improper bladder
width or length is one of the primary sources of error in accurately assessing
blood pressure. Proper technique includes selecting the correct cuff size for
the patient’s upper arm.40–42 Each dental office or clinic should have a set of
three to four cuffs to properly fit a variety of arm sizes (Fig. 10-2).
• Cuffs are usually labeled as child, adult small, adult standard, adult
large, and adult thigh. Unfortunately, at the current time, there is no
universal standardization among manufacturers. For this reason, the
bladder dimensions may vary in length and width.
• The American Heart Association (AHA) Guidelines for cuff selection
are summarized in Ready Reference 10-1 in the “Ready References”
section of this module.
• Ideally, every cuff should be labeled with the dimensions of the enclosed
 bladder, and a line should mark the center of the bladder. The user
should mark unlabeled cuffs by outlining the bladder and indicating its
midpoint.
• It is the length and width of the inflatable bladder—not its cloth sheath
—that affects the accuracy of blood pressure measurement.43 Figure 10-
9 (see Box 10-7) illustrates the bladder length and width.

BOX Cuff Size

10-7

Correct Sizing of Bladder

To select the correct cuff size, both the bladder length and width need to be
sized correctly for each individual patient.
• When placed on the midpoint of the upper arm on an adult patient, the
bladder length should encircle at least 80% of the midpoint of the
upper arm (Fig. 10-10).
 • When placed on the midpoint of the arm on an adult patient, the width
of the bladder should encircle at least 40% of the arm (Fig. 10-11).

• A bladder that is too small causes overestimation of the blood pressure

—false high readings—because the pressure is not evenly transmitted to
the brachial artery. A bladder that is too large may cause
underdiagnosing of hypertension—false low readings—because the
pressure of the cuff is dispersed over too large a surface of the arm.

Arm Position during Blood Pressure Assessment

1. Correct Arm Position for Blood Pressure Assessment in the Dental
Setting. Proper positioning of the patient’s arm is key to obtaining an
accurate blood pressure reading. Blood pressure readings go up or down
depending on where the arm is positioned. Recommendations of the
AHA, Canadian Hypertension Education Program, and the British
Hypertension Society (BHS) are all in agreement on the
recommendation for arm position (Box 10-8).20,37,38,44–46
a. Seated Position. The patient should be seated comfortably with his
or her back supported.
b. Arm Supported by Clinician.
1) The clinician should support the patient’s arm by holding it
under the elbow.
2) The phrase “passively supported arm” indicates that the weight of
the patient’s arm should be supported by the clinician rather than
held in position by the patient.
3) A rise in blood pressure and heart rate occurs if the patient must
tense his or her muscles to support the weight of the arm.
c. Antecubital Fossa at Mid-sternum Level. The arm should be
horizontal with the antecubital fossa at the level of the patient’s
heart (about mid-sternum). The patient’s arm and hand should be
relaxed and the elbow slightly flexed.
1) The antecubital fossa is the hollow or depressed area in the
underside of the arm at the bend of the elbow (Fig. 10-12).

2) During blood pressure determination, the antecubital fossa is used

as a: (1) landmark for locating the brachial pulse point, (2)
reference point for cuff placement, and (3) reference point for
correct arm position.
a) The cuff is placed around the upper arm with the lower edge of
the cuff about 1 in (2.5 cm) above the antecubital fossa.
 b) The patient’s arm is positioned with the antecubital fossa level
with the heart. Figure 10-13 in Box 10-8 demonstrates correct
arm and cuff position.

BOX Correct Arm and Cuff Position for Blood

10-8 Pressure Assessment

d. Differences between Arms. Some studies have demonstrated

significant differences between the blood pressure reading obtained
from the right versus the left arm of an individual.20 For this reason,
the clinician should document the arm used at the initial assessment in
the patient record and use the same arm at subsequent visits.
2. Effect of Level of Antecubital Fossa during Blood Pressure
Assessment
a. Antecubital Fossa Positioned Too Low
1) Allowing the patient’s arm to hang by the patient’s side or lay on
the dental chair’s armrest can result in false high readings.
 2) Overestimating the blood pressure in a medical setting might result
in overtreatment, for example, prescribing blood pressure
medication for a patient who does not really need treatment.
3) Overestimating the blood pressure in a dental setting might
needlessly delay dental treatment due to concern that the patient is
hypertensive.
b. Antecubital Fossa Positioned Too High
1) Positioning the patient’s arm so that the antecubital fossa is above
mid-sternum level can result in false low readings.
2) Underestimating the blood pressure in a medical setting, in the
worst case, could lead to heart attack or stroke.
3) Underestimating the blood pressure in a dental setting is a missed
opportunity to identify hypertension and refer the patient to a
primary care physician. In addition, it could result in a medical
emergency during dental treatment.

Palpatory Estimation of Blood Pressure

To avoid falsely low systolic pressure readings, the systolic pressure can be
estimated before the clinician uses the stethoscope by palpating the brachial
artery pulse and inflating the cuff until the pulsation disappears. The point at
which the pulsation disappears is the estimated systolic pressure.
• This palpatory estimation is important, because phase 1 sounds
sometimes disappear as pressure is reduced and reappear at a lower level
—auscultatory gap—resulting in the systolic pressure being
underestimated unless already determined by palpation.20
• If the systolic pressure is not first estimated by palpation, insufficient
inflation of the cuff may cause the clinician to mistake the lower end of
the gap as the systolic pressure.
• Measuring palpable pressure first avoids the risk of seriously
underestimating blood pressure because of the auscultatory gap.
• The radial artery also is used for palpatory estimation of the systolic
pressure, but by using the brachial artery, the clinician also establishes
 its location. Later in the procedure, the stethoscope-amplifying device is
placed over the brachial artery to listen for the Korotkoff sounds.
• The brachial pulse point is located just above the antecubital fossa
toward the inner aspect of the arm (Fig. 10-14).

SECTION 5 • Peak Procedure

Procedure 10-1. Blood Pressure Determination

EQUIPMENT
Stethoscope
Sphygmomanometer known to be accurate
Blood pressure cuff of the appropriate size
A watch or clock displaying seconds
Pen (or computer keyboard)
Patient chart or computer record

GENERAL CONSIDERATIONS
• The patient should not have had alcohol, tobacco, caffeine, or
performed vigorous exercise within 30 minutes of the blood
pressure assessment.
• After escorting the patient to the treatment room, allow him or
her to relax for at least 5 minutes before beginning the vital
signs assessment. If a glass thermometer is used for
temperature determination, the pulse, respiration, and blood
pressure may be assessed while the thermometer is registering
the patient’s temperature.
• Delay obtaining the blood pressure if the patient is anxious or
in pain.
• The patient should be sitting in an upright position with his
or her back supported and legs uncrossed.47 The patient
should not be moving or speaking during the procedure.

Action Rationale
1. Briefly explain the • Reduces patient
procedure to the patient. If apprehension and
the patient has never had a encourages patient
blood pressure assessment, cooperation
explain that some minor
discomfort can be caused
by the inflation of the
cuff.20
2. Select an appropriate arm • Measurement of blood
—no breast cancer surgery pressure may temporarily
involving lymph node impair circulation to the
removal on that side, cast, compromised arm.
 injured limb, or other
compromising factor.
3. Choose a cuff with an • Using a cuff with the
appropriate bladder width wrong size bladder may
and length matched to the result in inaccurate
size of the patient’s upper readings.
arm. • Air remaining in the
Squeeze the bladder to bladder makes it difficult
completely deflate the cuff. to wrap the cuff around the
arm.
4. The patient’s upper arm • Clothing over the artery
should be bare. interferes with the ability
The sleeve should not be to hear sounds.
rolled up if doing so • Tight clothing on the arm
creates a tight roll of cloth causes congestion of blood
around the upper arm. in the arm and can result in
inaccurate readings.
Remove arm from sleeve,
if sleeve cannot be rolled
up without creating a tight
roll of cloth.
5. Ask the patient to assume • There is no need for the
a comfortable position with patient’s arm to be in an
the palm of the hand uncomfortable position.
upward.
6. Position the cuff so that • Allows sufficient space
the lower edge is 1–2 in below the cuff so that the
(2–3 cm) above the elbow amplifying device of the
crease.20,36 stethoscope can be placed
Place the cuff so that the on the brachial pulse point
midline of the bladder is in the antecubital fossa
 centered over the brachial • Centering the bladder over
artery (Fig. 10-15). Wrap the brachial artery assures
the cuff smoothly and equal compression of the
snugly around the arm. artery by the bladder
Fasten it securely. pressure.
The tubing from the cuff • Loose application of the
should not cross the cuff results in
auscultatory area. overestimation of the
pressure.
• Contact of the amplifying
device of the stethoscope
with the tubing creates
noises that make it difficult
to hear the Korotkoff
sounds.

7. Place the manometer so • Improper positioning of the

the mercury column or gauge can lead to errors in
aneroid dial is easily reading the measurements.
visible to the clinician and • Instruct the patient not to
the tubing from the cuff is talk during the blood
unobstructed. pressure procedure.
8. Place the earpieces of the • This forward angle directs
stethoscope into the ear the earpieces into the canal
canals with the earpieces and not against the ear
angled forward (Fig. 10- itself.
16).

9. Grasp the patient’s elbow • A lower arm position will

with your hand and raise result in erroneously high
the arm. Support the readings.
patient’s arm so that the • A higher arm position will
antecubital fossa is at mid- result in erroneously low
sternum level. The readings.
patient’s arm should • If the patient does the work
remain somewhat bent and of holding up the arm, the
completely relaxed (Fig. readings will be elevated.
10-17).
10. Palpate the brachial pulse • Palpation allows for
by gently pressing with the estimation of the systolic
fingertips. Use your free pressure.
hand to tighten the valve • The bladder will not inflate
on the air pump. unless the valve is
Inflate the cuff rapidly to completely closed.
70 mm Hg and then • The palpatory method is
increase by increments of used to avoid
10 mm Hg. Note the underinflation of the cuff
pressure at which the pulse in patients with an
disappears. This is a rough auscultatory gap or over
estimate of the systolic inflation in those with very
pressure. low blood pressure.
11. Open the valve, deflate the • Allowing a brief pause
cuff rapidly leaving it in before continuing permits
place on the arm, and wait the blood to refill and
15 seconds. circulate through the arm.
12. Gently place the • Wedging the amplifying
amplifying endpiece of the device under the edge of
stethoscope over the pulse the cuff creates extraneous
—just above the noise that will distract
antecubital fossa toward from the sounds made by
the inner aspect of the arm the blood flowing through
—but below the lower the artery.
edge of the cuff. • Heavy pressure on the
Hold the amplifying brachial artery distorts the
device in place with your shape of the artery and the
fingers, making sure that it sound.20
makes contact with the • Moving the amplifying
skin around its entire device produces noise that
circumference (Fig. 10-18). can obscure the Korotkoff
 sounds.

13. Hold the air pump bulb so • Having the valve within
that it is easy to reach the easy reach is important
valve at the top (Fig. 10- because the other hand is
19). Close the valve at the used to hold the amplifying
top of the bulb. device against the arm.

14. Using brisk squeezes of the • Rapid inflation of the

bulb, rapidly inflate the bladder cuts off the blood
bladder to a pressure 30 flow quickly and
mm Hg above the level intensifies the sounds
previously determined by heard later as the air is
 palpation. slowly released.
At 30 mm Hg above the • Increasing the pressure
systolic estimate, slightly above that of the palpated
open the valve and release pressure assures a silent
the pressure slowly so that period before hearing the
the pressure gauge drops first sound.
no faster than 2 mm Hg • A slow cuff deflation rate
per second.20 of 2 mm per second is
necessary for accurate
readings.

15. Pay careful attention to • Systolic pressure is the

sounds heard through the point at which the blood in
stethoscope as the needle the artery is first able to
on the gauge falls. Listen force its way through the
for the first clear tapping vessel. The first clear,
sound (the systolic tapping sound is the
pressure). Make a mental systolic pressure.
note of this pressure (Fig.
10-20).

16. Do not reinflate the cuff • Reinflating a partially

once the air has been inflated cuff causes
released to recheck the congestion in the lower
systolic reading. arm, which lessens the
 If you are uncertain of loudness of the Korotkoff
the systolic reading, sounds.
continue releasing air and • Obtain the diastolic
listen carefully for the pressure, wait 30 seconds,
diastolic pressure. and repeat the procedure to
obtain the systolic reading.

17. Continue releasing • Diastolic pressure occurs

pressure slowly at a rate of when the blood is able to
2 mm per second. The resume normal flow
sounds should become through the vessel. This
louder in intensity, then smooth flow of blood is
muffle, and then disappear. silent.
Listen carefully and note
the point at which the
sounds disappear (the
diastolic pressure).
Note the diastolic
pressure (Fig. 10-21).

18. After the last Korotkoff • Slow deflation for 10 mm

sound is heard, the cuff Hg ensures that no further
should be deflated slowly sounds are audible.
for at least another 10 mm • Once all sounds have
 Hg. Then, allow the disappeared, the cuff is
remaining air to escape deflated rapidly to prevent
rapidly. venous congestion of the
If the Korotkoff sounds arm.20
persist as the pressure level • The American Heart
approaches 0 mm Hg, then Association recommends
phase 4 is used to indicate using the muffling of
the diastolic pressure. sound as the diastolic
pressure when recording
blood pressure in children.
19. Immediately record the • Recording the pressures
two numbers as a fraction promptly helps to ensure
in whole, even numbers. accuracy.20
Also record the arm and • Do not round off the
the patient’s position. An reading to the nearest 5- or
auscultatory gap should 10-mm Hg digit.
always be noted (112/76,
mm Hg, right arm, seated).
20. Blood pressure may be • It is common to have a 5-
taken in both arms on the to 10-mm Hg difference in
patient’s initial visit to the the systolic reading
dental office or clinic. If between the arms. Use the
there is more than a 10-mm arm with the higher
Hg difference between the reading for subsequent
two arms, the arm with the pressures.
higher readings should be
used at future
appointments.
21. Repeat any reading that is • Repeat reading to confirm
outside the expected range the accuracy of the original
but wait 30 to 60 seconds measurement.
 between readings to allow • False readings are likely to
normal circulation to return occur if there is congestion
to the arm. of blood in the arm when
• Be sure to deflate the obtaining repeat readings.
bladder completely
between attempts to check
the blood pressure.
22. Inform the patient and • The patient is interested in
explain the significance of the results. This is an
the blood pressure readings opportunity to educate the
(Fig. 10-22). patient about hypertension.

23. Remove the cuff and clean • Equipment should be left

and store the equipment. in a manner so that it is
ready for use.

Procedure 10-2. If Korotkoff Sounds Are Difficult to Hear

If the Korotkoff sounds are difficult to hear, the following

techniques are recommended:
1. Raise the patient’s arm—with cuff in place—over his or her
head for 15 seconds before rechecking the blood pressure.
Raising the arm over the head helps relieve the congestion of
 blood in the arm, increases pressure differences, and makes
the sounds louder and more distinct when blood enters the
lower arm.
Reposition any clothing that might be rubbing against the
stethoscope tubing (causing extraneous noises).
2. Confirm that the stethoscope earpieces are angled forward
and snuggly in ear canals.
3. Hold your hands and tubing as still as possible.
4. Confirm the amplifying device is over the brachial pulse
point and the entire circumference is in contact with the skin.
5. Inflate the cuff rapidly.
6. Inflate the cuff with the antecubital fossa elevated above heart
level and then gently lower the arm while continuing to
support it.
7. Deflate the cuff at a steady rate of 2 mm Hg per second while
listening for the Korotkoff sounds.

SECTION 6 • Ready References

NOTE: The Ready References in this book may be removed from the book
by tearing along the perforated lines on each page. Laminating or placing
these pages in plastic protector sheets will allow them to be disinfected for
use in a clinical setting.

Ready Reference 10-1. Recommended Bladder

Dimensionsa
Ready Reference 10-2. Classification of Blood Pressure for
Adults Aged 18 Years or Older

Ready Reference 10-3. Blood Pressure Values for Children

and Adolescentsa
Ready Reference 10-4. Dental Management of
Hypertensive Adults

Systolic/Diastolic Blood Dental Management

Pressure Recommendations

<140/90 1. Routine dental treatment can

be provided; recommend
lifestyle modifications (i.e.,
diet, exercise, quit smoking).
2. Retake blood pressure at
continuing care appointment
as a screening strategy for
hypertension.
140–159/90–99 1. If the initial reading is in this
range, retake blood pressure
after 5 minutes and patient
has rested. Retaking the
blood pressure determines
the accuracy of the initial
readings.
2. Inform patient of blood
pressure status; recommend
lifestyle modifications.
3. Routine treatment can be
provided. Employ stress
reduction strategies. Refer to
Box 5-5 in Module 5 to
review Strategies for Stress
Reduction.
4. Measure prior to any
appointment. If patient has
measurements above normal
range on three separate
appointments—and is not
under the care of a physician
for hypertension—refer for
medical evaluation.

160–179/100–109 1. Retake blood pressure after 5

minutes and patient has
rested.
2. If still elevated, inform
patient of readings.
3. Refer for medical evaluation
within 1 month; delay
 treatment if patient is unable
to handle stress or if dental
procedure is stressful. If
local anesthesia is required,
use 1:100,000
vasoconstrictor.
4. Routine treatment can be
provided. Employ stress
reduction strategies during
dental treatment.

≥180/≥110 1. Retake blood pressure after 5

minutes and patient has
rested.
2. Delay dental treatment until
blood pressure is controlled.
3. Refer to physician for
immediate medical
evaluation. Require a
medical release form from
the patient’s physician prior
to dental treatment.
4. If emergency dental care is
needed, it should be done in
a setting in which emergency
life support equipment is
available, such as a hospital
dental clinic.

KEY: <, less than; ≥, greater than or equal to. The patient’s blood
pressure is determined by the higher value for either the systolic or
diastolic blood pressure.48
Modified from Pickett FA, Gurenlian JR. The Medical History: Clinical Implications and
Emergency Prevention in Dental Settings. Baltimore, MD: Lippincott & Wilkins, 2005, p.
9.

Ready Reference 10-5. Assessing Pediatric Patients

Keys to Successful
Age Interaction Characteristics

Preschooler (3–6 • Explain actions • Normally alert,

years) using simple active
language. • Can sit still on
• Tell child what request
will happen next. • Can cooperate
• Tell child if with the
something will assessment
hurt. • Understands
• Distract child speech
with a story. • Will make up
• Praise good explanations for
behavior. anything not
understood

School-age child • Explain actions • Will cooperate if

(6–12 years) using simple trust is
language. established
• Explain • Wants to
procedure participate and
immediately retain some
before control
performing.
• Let child make
treatment choices
when possible.
 • Allow child to
participate in
exam.

Adolescent (12–17 • Explain the • Able to make

years) process as to an decisions about
adult. care
• Treat the • Has clear
adolescent with concepts of future
respect.
• Encourage
questions.

Ready Reference 10-6. Factors Affecting the Accuracy of

Blood Pressure Measurement

• Time of day—blood pressure readings are usually lowest in

the morning and can increase by as much as 10 mm Hg later
in the day.

• Position—blood pressure generally is lower when a person is

lying down, as compared to when sitting or standing.

• Arm—there are pressure differences of more than 10 mm Hg

between the arms in 6% of hypertensive patients.

• Eating—blood pressure readings usually are slightly higher

after a meal, especially if the meal is high in salt content.

• Exercise—strenuous activity will temporarily increase the

systolic blood pressure.

• Stress—anxiety, fear, or pain will temporarily raise a

person’s blood pressure.
Ready Reference 10-7. Causes of Inaccuracies in Blood
Pressure Measurement

Problem Result Solution

Equipment

Stethoscope Difficulty hearing Clean earpieces

earpieces plugged sounds

Earpieces fit poorly Distorted sounds Angle earpieces

forward

Aneroid needle not Inaccurate reading Recalibrate gauge

at zero

Bladder too narrow Inaccurate high Bladder 80% of

for arm reading circumference

Bladder too wide Inaccurate low Use appropriate cuff

for arm reading size

Faulty valve Difficulty inflating Replace equipment

cuff

Leaky tubing or Inaccurate reading Replace equipment

bulb

Patient position

Patient arm not at Inaccurate readings Position patient

heart level with the antecubital
fossa at mid-
sternum

Patient legs Inaccurate high Legs supported

dangling reading

Back unsupported Inaccurate high Support back

reading

Cuff placement

Cuff wrapped too Reading too high Rewrap more

loosely snugly

Applied over Inaccurate reading Remove arm from

clothing sleeve

Amplifying device

Amplifying device Extraneous noise Place amplifying

not in contact with device correctly
skin

Amplifying device Diastolic reading Place amplifying

applied too firmly too low device correctly

Amplifying device Sounds difficult to Place amplifying

not over artery hear device over
palpated artery

Amplifying device Extraneous noise Place below edge of

touching tubing or cuff
cuff

Failure to palpate Underestimation of Routinely check

brachial pulse systolic pressure systolic pressure by
palpation first

Pressure/inflation

Inflation level too Patient discomfort Inflate to 30 mm Hg

high above palpatory
 blood pressure

Inflation level too Underestimation of Inflate to 30 mm Hg

low systolic pressure above palpatory
blood pressure

Inflating cuff too Patient discomfort; Inflate the cuff as

slowly overestimation of rapidly as possible
diastolic pressure

Cuff pressure Underestimation of Release pressure no

released too fast systolic pressure; faster than 2 mm Hg
overestimation of per second
diastolic pressure

Cuff pressure Congestion of blood Remove cuff; ask

released too slowly in forearm; sounds patient to elevate
difficult to hear the arm and then
open and close the
fist several times

Readings

Rounding off Inaccurate readings Record to nearest 2

readings to 0 or 5 mm Hg

Intra-arm difference Pressure differences Initially, measure

of more than 10 mm BP in both arms;
Hg between arms use arm with higher
reading at
subsequent
appointments

Ready Reference 10-8. Equipment Maintenance

GENERAL MAINTENANCE

• Check the cuff for any breaks in stitching or tears in fabric.

• Check the tubing for cracks or leaks, especially at connections.

• Look to see that the aneroid needle on the gauge is at zero.

MARKING THE CUFF

Unfortunately, not all manufacturers are using the same guidelines

to mark blood pressure cuffs. Many cuffs are marked incorrectly;
therefore, you will have to correctly mark each cuff.
• The center of the bladder should be positioned over the brachial
artery. Locate the center by folding the bladder in half.

• Mark the middle with an “x.”

• This is where the cuff should cross the brachial pulse.

CALIBRATING AN ANEROID MANOMETER

The aneroid manometer—because of its design—is prone to

mechanical problems that can affect its accuracy. Jolts and bumps
that occur during everyday use affect accuracy over time, usually
resulting to false low readings.20 Aneroid gauges require regular
calibration and checks for common defects such as non-zeroed
gauges, cracked faceplates, or defective rubber tubing.16 The
needle of the aneroid gauge should rest at the zero point before the
cuff is inflated and return to zero when the cuff is deflated.
Aneroid manometers should be handled gently to avoid
decalibration and require routine maintenance. Every 6 months,
the accuracy of the aneroid gauge should be checked at different
pressure levels by connecting it with a Y-piece (Fig. 10-23) to the
tubing of a standardized mercury column manometer.18,20
Ready Reference 10-9. Internet Resources: Blood Pressure

• http://jama.jamanetwork.com/article.aspx?articleid=1791497
This link provides access to the 2014 Evidence-Based Guideline
for the Management of High Blood Pressure in Adults Report: From
the Panel Members Appointed to the Eighth Joint National
Committee (JNC 8).

• http://www.nhlbi.nih.gov/files/docs/resources/heart/hbp_ped.pdf
The Fourth Report on the Diagnosis, Evaluation, and Treatment
of High Blood Pressure in Children and Adolescents on the National
Heart, Lung, and Blood Institute’s website

• http://www.abdn.ac.uk/medical/bhs
Recommendations on blood pressure measurement on the
British Hypertension Society website

• http://www.ash-us.org/documents/ASH_ISH-
Guidelines_2013.pdf
This link provides access to the Clinical Practice Guidelines for
 the Management of Hypertension in the Community: A Statement by
the American Society of Hypertension and the International Society
of Hypertension

• http://www.bhf.org.uk/heart-health/conditions/high-blood-
pressure.aspx
The British Heart Foundation website has information for
patients on what blood pressure reading numbers mean and what
causes high blood pressure.

Ready Reference 10-10. Summary Reports Related to

Interpreting Blood Pressures

The interpretation of blood pressures and the need for treatment of

patients with high blood pressures is under constant scrutiny
because of the high level of importance of this topic to both
patients and clinicians and because of the continuing research
related to this topic. Over the last several years, there have been
reports published in the United States and in Europe, which
attempt to make clinical sense of available evidence related to this
critical topic.
There are three primary summary reports that have been
published since 2013:
1. The Eighth Joint National Committee guideline published in the
United States and referred to as the JNC 8 Guideline49
2. Clinical Practice Guidelines for the Management of
Hypertension in the Community: A Statement by the American
Society of Hypertension and the International Society of
Hypertension50
3. The European Society of Hypertension (ESH) and the European
 Society of Cardiology (ESC) guidelines for the management of
hypertension (referred to as ESH/ESC Guidelines for the
Management of Arterial Hypertension)51
These published guidelines differ in certain respects such as
how to interpret blood pressures in elderly patients and what blood
pressure goals should be used for the treatment of elderly patients.
These summary reports have been drawn from somewhat different
data sets, so these differences may be understandable. In spite of
any differences, there appears to be agreement that for the majority
of patients, the upper limits of systolic/diastolic pressures that
should trigger further diagnostic thought remain at 140/90 mm Hg.
Because these reports have received some criticism, the careful
clinician should expect more publications and clarifications related
to these critical topics over the next several years.

SECTION 7 • The Human Element

The Man Behind Manual Blood Pressure Technique

RUSSIAN PHYSIOLOGIST NIKOLAI

KOROTKOFF
With the following words, spoken to in an address to the Imperial Military
Academy in 1905, Russian physiologist Nikolai Korotkoff introduced the
classic technique of obtaining systolic and diastolic blood pressure with the
use of a sphygmomanometer and stethoscope.
“The sleeve of Riva-Rocci is put on the middle third of the arm; the
pressure in this sleeve rises rapidly until the circulation below this sleeve
stops completely. At first, there are no sounds whatsoever. As the mercury
in the manometer drops to a certain height, there appear the first short or
faint tones, the appearance of which indicates that part of the pulse wave of
the blood stream has passed under the sleeve. Consequently, the reading on
the manometer when the first sound appears corresponds to the maximum
blood pressure; with the further fall of the mercury in the manometer, there
are heard systolic pressure murmurs which become again sounds
(secondary). Finally, all sounds disappear. The time of the disappearance
of the sounds indicates the free passage or flow of the blood stream; in
other words, at the moment of the disappearance or fading out of the
sounds, the minimum blood pressure in the artery has surpassed the
pressure in the sleeve. Consequently, the reading of the manometer at this
time corresponds to the minimum blood pressure.” Lewis WH. The
evolution of clinical sphygmomanometry. Bull N Y Acad Med.
1941;17(11):871–881.

Through the Eyes of a Student

THE IMPORTANCE OF VITAL SIGN

ASSESSMENT
Just a few weeks ago, I saw Mrs. P., an 81-year-old patient for her fourth
appointment. Mrs. P. is under the care of a physician for blood pressure
control and reported taking Toporol 25 mg/day and Prevacid. She had
recently been taken off of potassium and had a recent history of low blood
pressure. Her blood pressure was 132/92 mm Hg. I double checked the
blood pressure reading to make sure it was accurate. I was a bit concerned
about these readings since her blood pressure had ranged from 118/80 mm
Hg to 122/78 mm Hg on her other three visits. I asked Mrs. P. how she has
been feeling and she said that she was having a feeling of pressure in her
chest. I discussed the blood pressure reading and her symptoms with the
dentist. The dentist consulted with her physician who requested that EMS
transport her to the hospital.
On the way to the hospital, Mrs. P. fainted in the ambulance. Medical
tests showed that she had a 96% blockage in one carotid artery and 60%
blockage in the other. This experience taught me that it really is important
to take vital signs seriously. It is also important to check today’s readings
with prior readings to look for changes.
Charles, student,
Catawba Valley Community College

Ethical Dilemmas
PATIENT STARTING A NEW JOB

Mr. Lester Evans, one of your favorite patients, is scheduled with you at
11:00 for his 4-month recall appointment. Mr. Evans has been a patient in
the practice for approximately 10 years. As you seat him in your chair, he
tells you that he is leaving his present job and will be starting new
employment next week. He wants to make sure that you can complete all
of his treatments today, as he will not have any time off in the near future.
You take Mr. Evans’ vital signs prior to beginning treatment and
record his blood pressure as 195/110 mm Hg. His other vital signs are
within normal limits. You ask him how he is feeling, and he states that he
feels fine. You wait 5 minutes, chatting casually with him, before you
repeat his blood pressure assessment. His second reading is 190/110 mm
Hg.
1. How should you proceed with Mr. Evans’s appointment today?
2. What recommendations can you suggest for Mr. Evans?
3. What treatment modifications can you employ for Mr. Evans’ future
dental treatment?
4. Because Mr. Evans’ schedule is tight, is it appropriate to treat him today
and address his blood pressure issue at his next visit? Why or why not?

TENSION VERSUS HYPERTENSION

Mrs. Edwina Carl is a 73-year-old patient who first came to your dental
practice 5 years ago when she moved to a retirement community near your
office. At that time, you noted that Mrs. Carl’s blood pressure was quite
elevated, and your dental team referred her to a physician for a medical
exam. She was diagnosed with hypertension and was placed on a blood
pressure medication by the physician. Since that time, her blood pressure
has remained normal as measured at each of her biannual dental
appointments.
Today, Mrs. Carl is back for a routine preventive dental appointment,
but you again note that her blood pressure is quite elevated. During your
discussion with Mrs. Carl, she tells you that she has been feeling a lot of
“tension” lately because of the many changes being made in her retirement
community. She decided to stop taking her blood pressure medication for
her hypertension and instead started managing her hypertension through
relaxation techniques that she has recently studied.
Vital Signs

Case Question for Mrs. Carl

1. What could have prompted Mrs. Carl’s mistake in equating her
diagnosis of “hypertension” with increased levels of tension or stress
from changes in her retirement living community?
2. What changes in biomedical communications from health and dental
care professionals might have resulted in a better understanding of her
medical condition and a more favorable health outcome for Mrs. Carl?

English-to-Spanish Phrase List

SECTION 8 • Practical Focus—Fictitious Patient Cases
for Vital Signs Modules

DIRECTIONS
• The fictitious patient cases in this module involve patients A to E. In a
clinical setting, you will gather additional information about your patient
with each assessment procedure that you perform. In a similar manner,
 you will learn additional assessment findings for patients A to E in
upcoming Modules 11 to 15.
• In answering the case questions in this module, you should take into
account the health history and over-the-counter/prescription drug
information that was revealed for each patient in Module 5, Medical
History.

FICTITIOUS PATIENT CASE A: MR. ALAN

ASCARI
Synopsis of Information about Mr. Ascari
Mr. Ascari is a new patient in the dental office. You notice that Mr. Ascari
seems to be slightly impatient. As you count his pulse rate, he suddenly
removes the thermometer from his mouth and says, “I have had enough of
this! First, you ask me all those questions about my health and now, this. I
just came in to have my teeth checked, not for a medical exam! Can’t you
just check my teeth and get it over with?”

Case Questions for Mr. Ascari

1. How do you think Mr. Ascari is feeling or thinking concerning the
health history and vital signs assessment? Why might he feel this way?
2. How would you respond to Mr. Ascari’s comments? How would you
 phrase your response to him?
3. Do you think that it is important to complete the vital signs assessment
on Mr. Ascari before proceeding with treatment? Or, could you skip this
procedure just this once since he is a new patient in the office?

FICTITIOUS PATIENT CASE B: BETHANY

BIDDLE
Synopsis of Information about Bethany Biddle
Bethany Biddle is a physically active 9-year-old who has been a patient in
the dental office since she was 3 years old. Bethany enjoys coming to have
her teeth cleaned. She is interested in dental hygiene and always asks a lot
of questions about the care that dental hygienists provide.
Bethany hurried into the office 10 minutes late for her appointment.
She tells you that her mother was late picking her up at school. Concerned
about being late, she ran from the parking lot to the dental office.
Remembering that it is 90° F outside, you can understand why she is
perspiring and slightly out of breath. Worried about falling behind
schedule, you quickly take Bethany’s vital signs.

Case Questions for Bethany Biddle

1. At her last four appointments, Bethany’s vital signs were all within
 normal ranges. Identify possible interpretations of Bethany’s vital signs
at today’s appointment. Are you concerned about these findings, and
what if any action would you take?
2. Is there anything about the way in which the vital signs assessment was
conducted that could have had an impact on the findings?
3. How would you determine if dental treatment is contraindicated for
Bethany? If so, what words would you use to explain the
contraindications to Bethany?
4. What will you do next?

FICTITIOUS PATIENT CASE C: MR. CARLOS

CHAVEZ
Synopsis of Information about Mr. Chavez

Case Questions for Mr. Chavez

1. Does Mr. Chavez have any contraindications for dental treatment? If so,
what are your concerns?
2. What information would you provide to Mr. Chavez about his vital signs
readings? How would you phrase your explanation?
3. After discussing his vital signs, what would you do next?
FICTITIOUS PATIENT CASE D: MRS. DONNA
DOI
Synopsis of Information about Mrs. Doi
As you seat Mrs. Doi in the dental chair, she tells you that she is grateful
for an excuse to get out of the house today. Her 6-year-old daughter,
Melanie, has been home sick with a high fever and “strep throat” for the
last several days.

Case Questions for Mrs. Doi

1. Are Mrs. Doi’s vital signs within normal ranges?
2. What information would you give Mrs. Doi about her vital signs? How
would you phrase your explanation?
3. You note that Mrs. Doi’s temperature has been 97.7° F at her last three
visits. When you inquire how she is feeling today, she replies, “I was
very tired this morning and my throat feels dry and scratchy.” Are you
concerned about Mrs. Doi’s elevated temperature reading? Can you
think of any possible causes for her elevated temperature?
4. What will you do next?
5. Does Mrs. Doi have any contraindications for dental treatment? If so,
what words would you use to explain these contraindications to Mrs.
Doi?
FICTITIOUS PATIENT CASE E: MS. ESTHER
EADS
Synopsis of Information about Ms. Eads
Ms. Eads has been a patient in the dental practice for 30 years; she is 79
years of age. Ms. Eads is a retired teacher and is still very active for her
age. She enjoys taking day trips with the seniors group at her church. Ms.
Eads is here today for a routine checkup.

Case Questions for Ms. Eads

1. Are all of Ms. Eads’ vital signs within normal range? What information
would you use in determining if her findings today are normal for her?
2. Does Ms. Eads have any contraindications for dental treatment? If so,
what words would you use in explaining the contraindications to Ms.
Eads?

SECTION 9 • Skill Check

Technique Skill Checklist: Blood Pressure Assessment

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as
S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Determines that the patient has not had alcohol,
tobacco, caffeine, or performed vigorous exercise
within 30 minutes of the blood pressure assessment.
After seating patient, allows the patient to relax for
at least 5 minutes prior to assessment.
Selects an appropriate arm—no breast cancer
surgery involving lymph node removal, cast, injured
limb, or other compromising factor.
Squeezes the bladder to completely deflate the cuff.
Selects a cuff with an appropriate bladder width and
length matched to the size of the patient’s upper
arm.
Asks patient to roll up sleeve. Determines that
rolling up the sleeve does not create a tight roll of
cloth around the upper arm.
Asks patient to position arm with the palm of the
hand upward.
Positions the cuff with the lower edge 1–2 in (2–3
cm) above the elbow with the midline of the bladder
centered over the brachial artery. Wraps the cuff
smoothly and snugly around the arm and fastens it
securely.
Places the manometer so that the mercury column or
aneroid dial is easily visible and the tubing from the
cuff is unobstructed.
Places the stethoscope earpieces into the ear canals
with the earpieces angled forward.
Supports the patient’s arm by holding it at the elbow
so that the antecubital fossa is level with the
patient’s mid-sternum. The patient’s arm should
remain somewhat bent and completely relaxed.
Palpates the brachial pulse with the fingertips.
Closes the valve. Inflates the cuff rapidly to 70 mm
Hg and then increases the pressure by increments of
10 mm Hg until the pulse disappears. Notes the
pressure reading where the pulse disappears.
Opens the valve, deflates the cuff rapidly, leaving it
in place on the arm, and waits 15 seconds.
Gently places the amplifying device over the pulse
—just above the antecubital fossa toward the inner
aspect of the arm. Holds the device in place, making
sure that it makes contact with the skin around its
entire circumference.
Closes the valve and holds the bulb so that it is easy
to reach the valve at the top. Briskly squeezes the
bulb to rapidly inflate the bladder to a pressure 30
mm Hg above the palpatory estimate.
Opens the valve so that the pressure drops no faster
than 2 mm Hg per second.
Pays careful attention to sounds heard through the
 stethoscope. Notes the point at which the first clear
tapping sound occurs.

Continues releasing the pressure slowly at a rate of

2 mm Hg per second. Notes the point at which the
sounds disappear.
Continues releasing the pressure slowly at a rate of
2 mm Hg per second for at least another 10 mm Hg.
Then allows the remaining air to escape rapidly.

Records the two numbers as a fraction—systolic

over diastolic—to the closest 2 mm Hg. Records the
arm and the patient’s position. Records the
auscultatory gap, if present.
Obtains a systolic reading within +/−2 mm Hg of
the evaluator’s reading. Obtains a diastolic reading
within +/−2 mm Hg of the evaluator’s reading.
Removes the cuff. Cleans and stores the equipment
so that it is ready for use.
OPTIONAL GRADE PERCENTAGE
CALCULATION

Using the E column, assign a point value of 1 for

each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

Communication Skill Checklist: Role-Play for Blood

Pressure
 Roles:
• Student 1 = Plays the role of the patient.
• Student 2 = Plays the role of the clinician.
• Student 3 or instructor = Plays the role of the clinic instructor near
the end of the role-play.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point and each U equals 0 point.

CRITERIA: S E
Explains the blood pressure procedure. If the patient
has never had a blood pressure assessment, explains
that some minor discomfort is caused by the
inflation of the cuff.
Upon completion of the procedure, reports the
findings to the patient and explains whether the
readings are normal or outside the normal range and
the significance of these readings.
Encourages patient questions before and after the
blood pressure assessment.
Answers the patient’s questions fully and
accurately.
Gains the patient’s trust and cooperation.
Communicates with the patient at an appropriate
 level and avoids dental/medical terminology or
jargon.

Accurately communicates the findings to the

clinical instructor. Discusses the implications for
dental treatment. Uses correct medical and dental
terminology.
OPTIONAL GRADE PERCENTAGE
CALCULATION

Using the E column, assign a point value of 1 for

each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

NOTE TO COURSE INSTRUCTOR: A series of role-play scenarios can be

found at http://thepoint.lww.com/GehrigPAT4e.

References
1. Al-Zahrani MS. Prehypertension and undiagnosed hypertension in a sample of dental
school female patients. Int J Dent Hyg. 2011;9(1):74–78.
2. Herman WW, Konzelman JL Jr, Prisant LM; for the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. New
national guidelines on hypertension: a summary for dentistry. J Am Dent Assoc.
2004;135(5):576–584.
3. National High Blood Pressure Education Program Working Group on High Blood
Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation,
and treatment of high blood pressure in children and adolescents. Pediatrics.
2004;114(2 suppl 4):555–576.
4. Williams B, Poulter NR, Brown MJ, et al. British Hypertension Society guidelines for
hypertension management 2004 (BHS-IV): summary. BMJ. 2004;328(7440):634–640.
5. Ramsay L, Williams B, Johnston GD, et al. Guidelines for management of
hypertension: report of the third working party of the British Hypertension Society. J
Hum Hypertens. 1999;13(9):569–592.
 6. Ramsay LE, Williams B, Johnston GD, et al. British Hypertension Society guidelines
for hypertension management 1999: summary. BMJ. 1999;319(7210):630–635.
7. Angelopoulos PD, Milionis HJ, Moschonis G, Manios Y. Relations between obesity
and hypertension: preliminary data from a cross-sectional study in primary
schoolchildren: the children study. Eur J Clin Nutr. 2006;60(10):1226–1234.
8. Boyd GS, Koenigsberg J, Falkner B, Gidding S, Hassink S. Effect of obesity and high
blood pressure on plasma lipid levels in children and adolescents. Pediatrics.
2005;116(2):442–446.
9. Falkner B, Gidding SS, Ramirez-Garnica G, Wiltrout SA, West D, Rappaport EB. The
relationship of body mass index and blood pressure in primary care pediatric patients.
J Pediatr. 2006;148(2):195–200.
10. Manzoli L, Ripari P, Rotolo S, et al. Prevalence of obesity, overweight and
hypertension in children and adolescents from Abruzzo, Italy [in Italian]. Ann Ig.
2005;17(5):419–431.
11. Sorof JM, Turner J, Martin DS, et al. Cardiovascular risk factors and sequelae in
hypertensive children identified by referral versus school-based screening.
Hypertension. 2004;43(2):214–218.
12. Denney-Wilson E, Hardy LL, Dobbins T, Okely AD, Baur LA. Body mass index,
waist circumference, and chronic disease risk factors in Australian adolescents. Arch
Pediatr Adolesc Med. 2008;162(6):566–573.
13. Urbina EM, Kimball TR, McCoy CE, Khoury PR, Daniels SR, Dolan LM. Youth with
obesity and obesity-related type 2 diabetes mellitus demonstrate abnormalities in
carotid structure and function. Circulation. 2009;119(22):2913–2919.
14. Levey AS, Rocco MV, Anderson S, et al. Kidney Disease Outcomes Quality Initiative
(K/DOQI) clinical practice guidelines on hypertension and antihypertensive agents in
chronic kidney disease. Am J Kidney Dis. 2004;43(5, suppl 1):S1–S290.
15. Muntner P, He J, Cutler JA, Wildman RP, Whelton PK. Trends in blood pressure
among children and adolescents. JAMA. 2004;291(17):2107–2113.
16. Perloff D, Grim C, Flack J, et al. Human blood pressure determination by
sphygmomanometry. Circulation. 1993;88(5, pt 1):2460–2470.
17. McAlister FA, Straus SE. Evidence based treatment of hypertension. Measurement of
blood pressure: an evidence based review. BMJ. 2001;322(7291):908–911.
18. Canzanello VJ, Jensen PL, Schwartz GL. Are aneroid sphygmomanometers accurate
in hospital and clinic settings? Arch Intern Med. 2001;161(5):729–731.
19. Waugh JJ, Gupta M, Rushbrook J, Halligan A, Shennan AH. Hidden errors of aneroid
sphygmomanometers. Blood Press Monit. 2002;7(6):309–312.
20. O’Brien E, Asmar R, Beilin L, et al. European Society of Hypertension
recommendations for conventional, ambulatory and home blood pressure
measurement. J Hypertens. 2003;21(5):821–848.
21. Gourdeau M, Martin R, Lamarche Y, Tétreault L. Oscillometry and direct blood
pressure: a comparative clinical study during deliberate hypotension. Can Anaesth Soc
J. 1986;33(3, pt 1):300–307.
22. Kaufmann MA, Pargger H, Drop LJ. Oscillometric blood pressure measurements by
different devices are not interchangeable. Anesth Analg. 1996;82(2):377–381.
23. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R; for the Prospective Studies
Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a
meta-analysis of individual data for one million adults in 61 prospective studies.
Lancet. 2002;360(9349):1903–1913.
24. O’Brien E, Fitzgerald D. The history of blood pressure measurement. J Hum
Hypertens. 1994;8(2):73–84.
25. Mancia G, Zanchetti A. One hundred years of auscultatory blood pressure:
commemorating N. S. Korotkoff. J Hypertens. 2005;23(1):1–2.
26. Multanovsky MP. The Korotkov’s method. History of its discovery and clinical and
experimental interpretation, and contemporary appraisal of its merits. Cor Vasa.
1970;12(1):1–7.
27. Askey JM. The auscultatory gap in sphygmomanometry. Ann Intern Med.
1974;80(1):94–97.
28. Gerin W, Ogedegbe G, Schwartz JE, et al. Assessment of the white-coat effect. J
Hypertens. 2006;24(1):67–74.
29. Pickering TG, Gerin W, Schwartz AR. What is the white-coat effect and how should it
be measured? Blood Press Monit. 2002;7(6):293–300.
30. Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH. How
common is white coat hypertension? JAMA. 1988;259(2):225–228.
31. Verdecchia P, O’Brien E, Pickering T, et al; for the European Society of Hypertension
Working Group on Blood Pressure Monitoring. When can the practicing physician
suspect white coat hypertension? Statement from the Working Group on Blood
Pressure Monitoring of the European Society of Hypertension. Am J Hypertens.
2003;16(1):87–91.
32. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure. Hypertension. 2003;42(6):1206–1252.
33. Cuddy ML. Treatment of hypertension: guidelines from JNC 7 (the Seventh Report of
the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure 1). J Pract Nurs. 2005;55(4):17–21.
34. National Clinical Guideline Centre. Hypertension: The Clinical Management of
Primary Hypertension in Adults. London, United Kingdom: National Clinical
Guideline Centre; 2011.
35. Beevers G, Lip GY, O’Brien E. ABC of hypertension: blood pressure measurement.
 Part II—conventional sphygmomanometry: technique of auscultatory blood pressure
measurement. BMJ. 2001;322(7293):1043–1047.
36. Beevers G, Lip GY, O’Brien E. ABC of hypertension. Blood pressure measurement.
Part I—sphygmomanometry: factors common to all techniques. BMJ.
2001;322(7292):981–985.
37. Hackam DG, Khan NA, Hemmelgarn BR, et al; for the Canadian Hypertension
Education Program. The 2010 Canadian Hypertension Education Program
recommendations for the management of hypertension: part 2—therapy. Can J
Cardiol. 2010;26(5):249–258.
38. Hemmelgarn BR, Zarnke KB, Campbell NR, et al; for the Canadian Hypertension
Education Program, Evidence-Based Recommendations Task Force. The 2004
Canadian Hypertension Education Program recommendations for the management of
hypertension: part I—blood pressure measurement, diagnosis and assessment of risk.
Can J Cardiol. 2004;20(1):31–40.
39. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure: the JNC 7 report. JAMA. 2003;289(19): 2560–2572.
40. Gómez-Marín O, Prineas RJ, Råstam L. Cuff bladder width and blood pressure
measurement in children and adolescents. J Hypertens. 1992;10(10):1235–1241.
41. Prineas RJ. Measurement of blood pressure in the obese. Ann Epidemiol.
1991;1(4):321–336.
42. Sprafka JM, Strickland D, Gómez-Marín O, Prineas RJ. The effect of cuff size on
blood pressure measurement in adults. Epidemiology. 1991;2(3):214–217.
43. O’Brien E. Review: a century of confusion; which bladder for accurate blood pressure
measurement? J Hum Hypertens. 1996;10(9):565–572.
44. Mourad A, Carney S. Arm position and blood pressure: an audit. Intern Med J.
2004;34(5):290–291.
45. Netea RT, Lenders JW, Smits P, Thien T. Both body and arm position significantly
influence blood pressure measurement. J Hum Hypertens. 2003;17(7):459–462.
46. Netea RT, Lenders JW, Smits P, Thien T. Influence of body and arm position on
blood pressure readings: an overview. J Hypertens. 2003;21(2):237–241.
47. Keele-Smith R, Price-Daniel C. Effects of crossing legs on blood pressure
measurement. Clin Nurs Res. 2001;10(2):202–213.
48. Glick M. The new blood pressure guidelines: a digest. J Am Dent Assoc.
2004;135(5):585–586.
49. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the
management of high blood pressure in adults: report from the panel members
appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–
520.
50. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the
management of hypertension in the community: a statement by the American Society
of Hypertension and the International Society of Hypertension. J Hypertens.
2014;32(1):3–15.
51. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the
management of arterial hypertension: the Task Force for the Management of Arterial
Hypertension of the European Society of Hypertension (ESH) and of the European
Society of Cardiology (ESC). Eur Heart J. 2013;34(28):2159–2219.
 MODULE
11

TOBACCO CESSATION
COUNSELING
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
Consumer survey data collected by the American Dental Association (ADA)
shows that half of all smokers visit the dentist annually. A full 75% of these
smokers indicate a willingness to hear advice on quitting from dental health
care providers. In a 1992 policy statement, the ADA urges dental health care
providers to become fully informed about tobacco cessation intervention
techniques and educate their patients in methods for overcoming tobacco
addiction.
This module is designed to assist dental health care providers in
improving their knowledge of tobacco cessation techniques and resources,
including:
• Understanding the health risks of tobacco use
• Understanding the health benefits of not using tobacco
• Providing tobacco cessation counseling

MODULE OUTLINE
SECTION 1 Health Effects of Tobacco Use
Smoking: The Leading Preventable Cause of Illness and
Death
Smoking as a Risk Factor for Systemic Disease
It’s Never Too Late to Quit
Medical Health Risks of Secondhand Smoke
Medical Health Risks of Thirdhand Smoke
Electronic Cigarettes
Hookah Water Pipes
Smokeless Tobacco
SECTION 2 Harmful Properties of Tobacco
Chemical Components of Tobacco Products
Addictive Properties of Nicotine
Tobacco Addiction
SECTION 3 Why Should Dental Health Care Providers
Intervene?
Smoking and the Periodontium
SECTION 4 Guidelines for Tobacco Cessation
Counseling
The Clinical Practice Guideline
One-on-One Education Is Needed
Tobacco Cessation Counseling Works
The Five A’s Model
Quitlines
Withdrawal Symptoms
Quit Rates and Implications
SECTION 5 Peak Procedure: Tobacco Cessation
Procedure 11-1. Tobacco Cessation Counseling
SECTION 6 Patient Education Resources
 SECTION 7 The Human Element
Through the Eyes of a Clinician
Ethical Dilemma
Through the Eyes of a Patient

SECTION 8 Practical Focus—Fictitious Patient Case

for Tobacco Cessation
SECTION 9 Skill Check
KEY TERMS
Risk factors • Perioral rhytides • Secondhand smoke • Thirdhand smoke
• Electronic cigarettes • Vaping • Hookah • Smokeless tobacco • Chewing
tobacco • Snuff • Carcinogen • Addiction • Five A’s Model • Quitlines •
Withdrawal symptoms

OBJECTIVES
• Explain why tobacco cessation counseling is a valuable part of patient
care in the dental setting.
• Value the importance of providing tobacco cessation counseling as a
routine part of the dental hygiene appointment.
• Explain a strategy for providing tobacco cessation counseling as a
routine part of the dental hygiene appointment.
• Give examples of diseases associated with or linked to tobacco use.
• Give examples of oral diseases and conditions associated with tobacco
use.
• Differentiate which components of tobacco/cigarette smoke are (1)
addicting and (2) carcinogenic.
• Discuss the hazards of secondhand and thirdhand smoke.
• Demonstrate knowledge of tobacco cessation counseling by applying
information from this module to the fictitious patient case and the
communication skills role-play at the end of this module.
 SECTION 1 • Health Effects of Tobacco Use
In addition to the standard vital signs—temperature, pulse, respiration, and
blood pressure—tobacco use has been suggested as the fifth vital sign.
• Tobacco use is a contributing factor in many medical conditions and, in
addition, increases the risk of periodontal disease. All oral health care
professionals should be concerned with their patients’ use of tobacco
products.
• About 30% of patients in any given dental practice are current smokers.
• The regularly scheduled dental hygiene visit provides a unique
opportunity to document tobacco use, relate oral health findings to a
patient’s use of tobacco, and provide cessation support.

Smoking: The Leading Preventable Cause of Illness and

Death
Scientific knowledge about the health effects of tobacco use has increased
greatly since the first Surgeon General’s report published in 1964. Smoking
increases the risks of numerous diseases and associated illness and death. In
general, smokers have a mortality rate approximately twice that of
nonsmokers. Extensive evidence links smoking to cancer, cardiopulmonary
disease, and complications of pregnancy.
Tobacco use has long been identified as the leading preventable cause
of illness and death; a fact established by the most substantial body of
scientific knowledge ever amassed linking a product to disease.
• Tobacco claims one life every 8 seconds and kills 1 of 10 adults
globally.
• Cigarette smoking is responsible for more than 480,000 deaths per year
in the United States, including nearly 42,000 deaths resulting from
secondhand smoke exposure. This is about 1 in 5 deaths annually, or
1,300 deaths every day (Fig. 11-1).1
 • Smoking causes more deaths alone than AIDS, alcohol, accidents,
suicides, homicides, fires, and drugs combined.
• Worldwide, tobacco use causes nearly 6 million deaths per year, and
current trends show that tobacco use will cause more than 8 million
deaths annually by 2030.2

Smoking as a Risk Factor for Systemic Disease

Risk factors are conditions that increase a person’s chances of getting a
disease (such as cancer). There is no doubt that the risk for smoking-related
disease increases with the amount a person smokes. However, smoking one
to four cigarettes per day is associated with a significantly higher risk of
prematurely dying.3 Cigar use causes cancer of the larynx, mouth, esophagus,
and lung; emphysema; and heart disease. The bottom line is that smoking any
amount harms nearly every organ of the body, damaging a smoker’s overall
health even when it does not cause a specific illness.
CANCER
Smoking is a known cause of multiple cancers, accounting for at least 30% of
all cases of cancer and approximately 163,700 cancer deaths every year in the
United States.4
• The types of cancer associated with tobacco use include those that affect
the lung, mouth, nasal passages/nose, larynx, pharynx, breast,
 esophagus, stomach, pancreas, bladder, kidney, cervix, and possibly the
colon and rectum, in addition to acute myelogenous leukemia.
• In particular, smoking has been linked to 90% of cases of lung cancer in
males and 78% in females.5
CARDIOVASCULAR AND LUNG DISEASE
In addition, smoking is a known cause of at least 25% of all heart disease and
strokes and no less than 90% of all chronic obstructive pulmonary disease.
Smoking is a major cause of coronary artery disease, cerebrovascular disease
(stroke), peripheral vascular disease, and abdominal aortic aneurysm.
• Smoker’s cough is the chronic cough experienced by smokers because
smoking impairs the lung’s ability to clean out harmful material.
Coughing is the body’s way of trying to get rid of the harmful material
in the lungs.
• Chronic obstructive pulmonary disease is a lung disease in which the
airways in the lungs produce excess mucus resulting in frequent
coughing. Smoking accounts for 80% to 90% of the risk for developing
chronic obstructive pulmonary disease. Only 5% to 10% of patients with
chronic obstructive pulmonary disease have never smoked.
• Coronary artery disease—a thickening of the coronary arteries—is the
most common type of heart disease. Coronary artery disease results in a
narrowing of the arteries so that the supply of blood and oxygen to the
heart is restricted or blocked. Smoking is the major risk factor for
coronary artery disease.
• Peripheral vascular disease occurs when fat and cholesterol build up
on the walls of the arteries blocking the supply blood to the arms and
legs.
• Abdominal aortic aneurysm occurs when part of the aorta—the main
artery of the body—becomes weakened. If left untreated, the aorta can
burst. Once thought of as an “old man’s disease,” this disorder has
become a major killer in women as well. The disease kills 120,000
Americans a year, is the fourth leading cause of death, and is expected to
be third leading cause of death by 2020.5
HEALTH RISKS FOR FEMALE SMOKERS
Smoking during pregnancy causes spontaneous miscarriages, low birth
weight, placental abruption, fetal heart defects, and sudden infant death
syndrome. Babies born to women who smoke are more likely to be
premature. Women, particularly those older than 35 years of age who smoke
and use birth control pills, face an increased risk for heart attack, stroke, and
venous thromboembolism.
HEAD AND NECK CANCER
Smoking also significantly increases the risk of head and neck cancers (more
than 500,000 people are diagnosed with these cancers every year). In general,
individuals who smoke one pack per day increase their head and neck cancer
risk by 11-fold and individuals who smoke two packs per day increase their
risk to 25 times that of a nonsmoker.4
SKIN
More than 7,000 chemicals in tobacco smoke trigger the destruction of
collagen and elastin in the skin—the fibers that give skin its strength and
elasticity. Cigarette smoke causes unfavorable skin changes or intensifies
many skin diseases including skin cancer.6–8 Tobacco smoke additionally
quickens the natural process of skin aging.9 Even being around secondhand
smoke degrades the building blocks of the skin.8 The consequences of this
destruction include sagging skin and deeper wrinkles, making a smoker look
older than a nonsmoker of the same age.8 Wrinkles develop sooner in the
skin around the eyes and lips of smokers. Skin damage due to tobacco smoke
is irreversible; however, further damage can be avoided by stopping
smoking.8
Smoking delivers a one-two punch to the skin around the mouth. First,
smokers use certain muscles around their lips that cause them to have deep
wrinkles that nonsmokers do not (Fig. 11-2). Second, the loss of skin
elasticity can lead to deep lines around the lips, perioral rhytides (Fig. 11-3).
OTHER CONDITIONS
Other conditions that affect smokers more than nonsmokers include cataracts,
macular degeneration, poor dental health, low bone density, early menopause,
gastroesophageal reflux, high blood pressure, type 2 diabetes, psoriasis,
erectile dysfunction, infertility, and fire-related injury or death.

It’s Never Too Late to Quit

For patients who use tobacco, one of the most important messages is that it is
never too late to quit.
• Even for long-term smokers, quitting smoking carries major and
immediate health benefits for men and women of all ages (Fig. 11-4).
Benefits apply to healthy smokers and to smokers already suffering from
smoking-related disease.
 • Smoking cessation represents the single most important step that
smokers can take to enhance the length and quality of their lives.
• Smokers who quit—even after age 63 years—start repairing their bodies
right away. After only 2 weeks, lung function increases by up to 30% in
most persons.

Medical Health Risks of Secondhand Smoke

Secondhand smoke is the term for tobacco smoke that is exhaled by smokers
or is produced by a lighted cigarette, pipe, or cigar. Secondhand smoke
contains the same harmful chemicals that smokers inhale and presents a
substantial health risk to nonsmokers (Fig. 11-5). A 2006 report of the U.S.
Surgeon General states that
“There is no risk-free level of exposure to secondhand smoke.
Nonsmokers exposed to secondhand smoke at home or work increase
their risk of developing heart disease by 25 to 30 percent and lung cancer
by 20 to 30 percent. The finding is of major public health concern due to
the fact that nearly half of all nonsmoking Americans are still regularly
 exposed to secondhand smoke.”10

1. Adult Nonsmokers. Secondhand smoke exposure is linked to an

increase in certain types of cancer among nonsmokers.
a. There are clear associations between secondhand smoke and cancers
of the nasal sinus, cervix, breast, and bladder.
b. Those exposed to secondhand smoke are at increased risk for
cardiopulmonary problems, including decreased lung function,
chronic cough, and ischemic heart disease.
c. As many as 60,000 annual heart disease deaths in adult nonsmokers
result from secondhand smoke in the United States. Approximately
3,400 lung cancer deaths per year among adult nonsmokers in the
United States are linked to secondhand smoke.1
2. Children and Infants
a. Exposed children are more likely to have reduced lung capacity,
 serious lower respiratory tract infections, severe asthma, and middle
ear infections.11
b. The risk for sudden infant death syndrome is higher among babies
exposed to smoke, and babies born to women exposed to secondhand
smoke are more likely to have low birth weight and to be premature.
c. There is a clear link between childhood tooth decay and parental
smoking.12
3. Companion Animals
a. Cigarette smoke can cause cancer in dogs, cats, and other pets. Pets
don’t just inhale smoke; the smoke particles get trapped in their fur
and ingested when they groom themselves.
b. Dogs living in smoking households have a 60% greater risk of lung
cancer and longer nosed dogs are twice as likely to develop nasal
cancer.
c. Cats living in smoking households are 3 times more likely to develop
lymphoma, the most common type of feline cancer.
d. In addition, secondhand smoke has been associated lung cancer in pet
birds.

Medical Health Risks of Thirdhand Smoke

Thirdhand smoke—a serious and mounting health concern—is generally
considered to be residual nicotine and other chemicals left on a variety of
indoor surfaces by tobacco smoke.13
• This residue is thought to react with common indoor pollutants to create
a toxic mix. This toxic mix of thirdhand smoke contains cancer-causing
substances, posing a potential health hazard to nonsmokers who are
exposed to it, especially children.
• Studies show that thirdhand smoke clings to hair, skin, clothes, furniture,
drapes, walls, bedding, carpets, dust, vehicles, and other surfaces, even
long after smoking has stopped.
• Infants, children, and nonsmoking adults may be at risk of tobacco-
 related health problems when they inhale, ingest, or touch substances
containing thirdhand smoke.
• Thirdhand smoke residue builds up on surfaces over time and resists
normal cleaning. Thirdhand smoke cannot be eliminated by airing out
rooms, opening windows, using fans or air conditioners, or confining
smoking to only certain areas of a home.
• The only way to protect nonsmokers from thirdhand smoke is to create a
completely smoke-free environment.

Electronic Cigarettes
Electronic cigarettes, or e-cigarettes, are battery-powered devices that
provide doses of nicotine and other additives to the user in an aerosol (Fig.
11-6). They are currently unregulated by the U.S. Food and Drug
Administration (FDA). While the FDA has announced that it intends to
expand its jurisdiction over tobacco products to include e-cigarettes, it has
not yet issued regulatory rules. Because e-cigarettes are unregulated, the
agency does not have good information about them, such as the amounts and
types of components and potentially harmful constituents.

1. Current Research14
• A 2009 FDA analysis of e-cigarettes from two leading brands found that
the samples contained carcinogens and other hazardous chemicals,
including diethylene glycol, which is found in antifreeze.
• A report from Greek researchers found that using e-cigarettes caused
breathing difficulties in both smokers and nonsmokers. A French-based
 research group found that e-cigarettes contain “potentially carcinogenic
elements.”
• The British Medical Association and the World Health Organization
have each issued warnings about the dangers that may be associated with
the smoking devices.
• Many countries have already banned sale—including Canada, New
Zealand, and Australia. All of the U.S. airline companies ban use in-
flight.
2. Use. E-cigarette use, or vaping, in the United States and worldwide is
increasing.15,16
• Current use of e-cigarettes increased among middle and high school
students from 2011 to 2014. Nearly 4 of every 100 middle school
students (3.9%) reported in 2014 that they used e-cigarettes in the past
30 days—an increase from 0.6% in 2011.
• More than 13 of every 100 high school students (13.4%) reported in
2014 that they used e-cigarettes in the past 30 days—an increase from
1.5% in 2011.
• Almost 13% of adults reported in 2014 that they had tried an e-cigarette,
and about 3.7% of adults currently use e-cigarettes. Among current
cigarette smokers who had tried to quit smoking in the past year, more
than one-half tried an e-cigarette and 20.3% were current e-cigarette
users.

Hookah Water Pipes

A hookah is a large water pipe with a hose used to smoke flavored tobacco
(Fig. 11-7). A common misconception is that the water in the hookah
removes the harmful chemicals from the tobacco smoke. Current research
indicates, however, that even after passing through the water, the tobacco
smoke still produces high levels of toxins including carbon monoxide and
carcinogens.17
Smokeless Tobacco
1. Smokeless Tobacco Products. Smokeless tobacco is tobacco that is
not smoked but used in another form. Smokeless tobacco was formally
classified as a “known human carcinogen” by the U.S. government in
2000. Smokeless tobacco contains more nicotine than cigarettes. Snuff
and chewing tobacco are the two main forms of smokeless tobacco in
use in the United States and Canada.
a. Chewing tobacco—also known as spit tobacco, chew, dip, and
chaw—is tobacco cut for chewing.
b. Snuff is a smokeless tobacco in the form of a powder that is placed
between the gingiva and the lip or cheek or inhaled into the nose.
2. Medical/Dental Risks of Smokeless Tobacco. Many people who use
smokeless tobacco think it’s safer than smoking. However, smokeless
tobacco carries many health risks.
a. Recent research shows the dangers of smokeless tobacco might
play a role in cancers of the pancreas, heart disease, and stroke.
b. Regular use of smokeless tobacco can cause oral cancers and dental
problems, so it should not be used as a substitute for smoking
cigarettes.
c. Gingival recession and decay of exposed root surfaces frequently
occurs adjacent the site of placement of the smokeless tobacco (Fig.
11-8).
 d. White patches or red sores on the buccal mucosa occur at the site of
placement of the smokeless tobacco (Figs. 11-8 and 11-9).

e. Cancers of the oral cavity (i.e., the mouth, lip, and tongue) have
been associated with the use of chewing tobacco as well as snuff.
Studies indicate that the tumors often arise at the site of
placement of the tobacco.

SECTION 2 • Harmful Properties of Tobacco

Chemical Components of Tobacco Products

As illustrated in Figure 11-10, all tobacco products emit over 7,000
chemicals, 70 of which have been identified as carcinogens.18 A carcinogen
is a chemical or other substance that causes cancer.

• The act of burning a cigarette creates the majority of these chemical

compounds, many of which are toxic and/or carcinogenic.1 For example,
formaldehyde, benzene, arsenic, ammonia, carbon monoxide, nitrogen
oxides, hydrogen cyanide, and ammonia are all present in cigarette
smoke.
• Ironically, low-tar cigarettes often produce higher levels of chemicals
like carbon monoxide than regular cigarettes. Also, when smoking a
low-tar cigarette, the smoker may inhale more deeply and more often to
get the usual amount of nicotine. This is very important because even
 though nicotine is not a carcinogen, it is the chemical that causes
addiction.

Addictive Properties of Nicotine

Addiction is a chronic dependence on a substance—such as smoking—
despite adverse consequences. The dependence on the substance makes
stopping very difficult. All tobacco products contain nicotine. Nicotine is
found naturally in tobacco; however, it is classified as an additive since all
the tobacco companies increase the amount of nicotine in all tobacco
products to ensure continual use.17
• Nicotine is powerful, fast acting, and one of the most addictive
substances known to humankind (Fig. 11-11).

• Even though nicotine is not a carcinogen, it is the chemical that causes

addiction.
• On a milligram-per-milligram basis, it is 10 times more addictive than
heroin or cocaine and 6 to 8 times more addictive than alcohol.
• It is therefore imperative that dental hygienists encourage each and
every patient who uses tobacco to follow sound advice when making a
quit attempt and consider incorporating one of the cessation medications
 as part of the quit plan.

Tobacco Addiction
It is a testament to the power of tobacco addiction that 16.8% of U.S. adults
(about 40 million)11 and 15% of Canadians (about 4.2 million people) are
current smokers.19 Smoking rates in the United States and Canada have
decreased since the 1964 Surgeon General’s report linked lung cancer and
cigarette use. At that time, an estimated 42% of the American population was
smokers. However, the current prevalence has not significantly decreased
since 2004, demonstrating a stall in the previous 7-year decline (Fig. 11-
12).19

• Unfortunately, the incidence is highest in the most vulnerable

populations. Those living below poverty line are 31.1% more likely to
 smoke than those living above the poverty line.20
• The most powerless populations—the young, indigent, depressed,
uninsured, less educated, blue-collar, and minorities—have the highest
percentages of smokers in the United States and in Canada.
• Tragically, tobacco use must be considered a pediatric disease. Tobacco
use is started and established primarily during adolescence. Nearly 9 out
of 10 cigarette smokers first tried smoking by age 18 years, and 99%
first tried smoking by age 26 years. Each day in the United States, more
than 3,800 youth aged 18 years or younger smoke their first cigarette,
and an additional 2,100 youth and young adults become daily cigarette
smokers. If smoking continues at the current rate among youth in this
country, 5.6 million of today’s Americans younger than 18 years will die
early from a smoking-related illness which is about 1 of every 13
Americans aged 17 years or younger alive today.1

SECTION 3 • Why Should Dental Health Care

Providers Intervene?
As one of the most accessible health care professionals, dental hygienists are
in an ideal position to provide tobacco cessation services. The more intensive
the intervention, the higher the quit rates, but even minimal tobacco
interventions—less than 3 minutes—increase the proportion of tobacco users
who quit and have a considerable public health impact.
All dental health care professionals should be concerned with their
patients’ use of tobacco products. Smoking may be responsible for more than
half of the cases of periodontal disease among adults in this country.21,22
Tobacco use is therefore one of the most significant risk factors in the
development and progression and successful treatment of periodontitis.
Current smokers are about 4 times more likely than people who have never
smoked to have periodontal disease.21,22 Even in adult smokers with
generally high oral hygiene standards and regular dental care habits, smoking
accelerates periodontal disease.
Smoking and the Periodontium
1. Smoking and Periodontitis
a. Smoking appears to be one of the most important risk factors in the
development and progression of periodontal disease. Smoking may be
responsible for more than half of the cases of periodontal disease
among adults in the United States.22–26
b. Smokers are 2.6 to 6 times more likely to exhibit periodontal
destruction than nonsmokers.12 Tobacco use is therefore one of the
most significant risk factors in the development and progression and
successful treatment of periodontitis.
c. Smokers are 12 to 14 times more likely than nonsmokers to have
severe bone loss.12
d. Tobacco smoking may play an important role in the development of
forms of periodontitis that does not respond to treatment (Fig. 11-13)
despite excellent patient compliance and appropriate periodontal
therapy.27

e. Smokers loose more teeth than nonsmokers. Only about 20% of

people older than 65 years of age who have never smoked are
toothless, whereas 41.3% of daily smokers older than 65 years are
toothless.
f. Current smokers are about 4 times more likely than people who have
never smoked to develop advanced periodontal disease.22–26 Even in
adult smokers with generally high oral hygiene standards and regular
 dental care habits, smoking accelerates periodontal disease.
g. The extent of periodontal disease is directly related to the number of
cigarettes smoked and the number of years of smoking. The more a
person smokes and the longer a person smokes, the more periodontal
disease that individual will have.
h. Gingival inflammation and gingival bleeding, two of the cardinal
signs of periodontal disease, are often reduced or absent in smokers.
For this reason, great care should be taken in performing
periodontal screening and examination of smokers. In smokers, the
lack of bleeding on probing does not indicate healthy tissue as it
does in nonsmokers.22–26
i. Cigarette smoking may be a cofactor in the relationship between
periodontal disease and chronic obstructive pulmonary disease and in
the relationship between periodontal disease and coronary heart
disease.22–26
2. Effects of Smoking Cessation on the Periodontium
a. The past effects of smoking on the periodontium, such as bone loss,
cannot be reversed; however, smoking cessation is beneficial to the
periodontium.
b. Several years after quitting, former smokers are no more likely to
have periodontal disease than persons who have never smoked. This
indicates that quitting seems to gradually erase the harmful effects of
tobacco use on periodontal health.
c. Evidence that periodontal health does improve with smoking
cessation has led the American Academy of Periodontology to
recommend tobacco cessation counseling as an important
component of periodontal therapy.
d. Dental hygienists should advise patients of tobacco’s negative effects
on the periodontium and the benefits of quitting tobacco use. (“As
your clinician, I want you to know that quitting smoking is the most
important thing you can do to protect your current and future dental
health.”)
 SECTION 4 • Guidelines for Tobacco Cessation
Counseling

The Clinical Practice Guideline

The Clinical Practice Guideline for Treating Tobacco Use and Dependence,
published by the U.S. Department of Health and Human Services, is
considered the benchmark for cessation techniques and treatment delivery
strategies. The Clinical Practice Guideline may be downloaded at
http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-
providers/guidelines-
recommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf. The
updated 2008 Guideline reflects the scientific cessation literature published
from 1975 to 2007. The guideline contains strategies and recommendations
designed to assist clinicians in delivering and supporting effective treatments
for tobacco use and dependence. Several key recommendations of the
updated guideline are as follows:
• Tobacco dependence is a chronic condition that often requires repeated
intervention. However, effective treatments exist that can produce long-
term or even permanent abstinence.
• Because effective tobacco dependence treatments are available, every
patient who uses tobacco should be offered at least one of these
treatments:
• Patients willing to try to quit tobacco use should be provided with
treatments identified as effective in this guideline.
• Patients unwilling to try to quit tobacco use should be provided
with a brief intervention designed to increase their motivation to
quit.
• It is essential that clinicians consistently identify, document, and counsel
every tobacco user seen in a health care setting. Dental health care
providers who ask all patients whether they use tobacco and advise
quitting can have a profound impact on patient health. Figure 11-14
 outlines a systematic approach to cessation counseling.

One-on-One Education Is Needed

Despite major efforts to educate the public on the dangers of smoking over
the past 50 years, the general populace seriously underestimates the
magnitude of the harm that tobacco causes. Perhaps even more alarming is
that major knowledge gaps exist in what smokers themselves believe to be
true about the risks associated with smoking compared to the actual realities
of tobacco-related disease and death.
• Although many smokers are aware that smoking can lead to serious
health problems including lung cancer, many underestimate the risk of
getting the disease from smoking.
• As many as a third of smokers think that certain activities such as
exercise and taking vitamins “undo” most of the detrimental effects of
smoking.
• Experts believe these misperceptions may prevent smokers from trying
to quit and successfully utilizing proven smoking cessation treatments.
• A century from now, when historians reflect on the account of tobacco
in the 20th century, it will surely be looked upon as one of the most
intriguing and tragic developments of the period.
Tobacco Cessation Counseling Works
The effectiveness of even brief tobacco dependence counseling has been well
established and is also extremely cost-effective relative to other medical and
disease-prevention interventions.
• Smokers cite a health professional’s advice to quit as an important
motivator for attempting to stop smoking.
• With effective education, counseling, and support—rather than
condemnations and warnings about dangers of smoking—dental health
care providers can provide an invaluable service.
• Helping someone overcome a tobacco addiction may be the most broad-
reaching health care intervention a dental hygienist can achieve.

The Five A’s Model

The Clinical Practice Guideline for Treating Tobacco Use and Dependence
recommends the Five A’s Model (Ask, Advise, Assess, Assist, and Arrange)
as the key components of comprehensive tobacco cessation counseling (Fig.
11-15). Table 11-1 outlines strategies for implementing the Five A’s.
Quitlines
Quitlines are toll-free telephone centers staffed by trained smoking cessation
experts. It takes as little as 30 seconds to refer a patient to a quitline or
website (Fig. 11-16). A list of quitlines is provided in the “Ready Reference”
section of this module.
• Evidence suggests quitline use more than triples success in quitting.
• By referring their patients to a quitline, dental hygienists are
incorporating all Five A’s (Ask, Advise, Assess, Assist, Arrange) of the
Smoking Cessation Clinical Practice Guidelines.
• Quitlines have proven to be one of the more effective methods of
promoting smoking cessation. Canada and the United States have each
established publicly financed quitline services.
• Quitline services have the potential to reach large numbers of tobacco
users including low income, rural, elderly, uninsured, and racial/ethnic
populations who may not otherwise have access to cessation programs.
• Dental hygienists are natural partners for quitlines and can play a major
role in increasing utilization of quitline.
• Table 11-2 lists common misconceptions and facts about tobacco
cessation counseling.
Withdrawal Symptoms
Tobacco use is a complex behavior involving the interplay of physiologic,
psychological, and habitual factors that continuously reinforce one another to
promote dependence (Fig. 11-17). Two hallmarks of dependency include
smoking within 30 minutes of arising from sleep and experiencing
withdrawal symptoms if regular pattern of use is disrupted. The cardinal
withdrawal symptoms include a variety of unpleasant symptoms such as
craving for nicotine, irritability, anger, anxiety, fatigue, depressed mood,
difficulty concentrating, restlessness, and sleep disturbance.
Quit Rates and Implications
• The majority of smokers try to quit on their own. For most, relapse
occurs quickly. Only half succeed for 2 days and only a third last 1
week. Most relapses occur in the first few months. Overall, self-quitters
have a success rate of 4% to 6%.1
• Most smokers make 11 quit attempts before finally succeeding.
• Half of all smokers eventually quit. In the United States, there are now
as many former smokers as current smokers.
• An important implication of the quit rate statistics is that dental health
care providers need to understand the importance of helping the
tobacco user through not just one quit attempt but rather through
several attempts before a final successful one.
• Another implication is that dental professionals need to prompt and
reprompt tobacco users to make efforts to quit. Offering consistent
smoking cessation counseling can motivate smokers to try to quit.

SECTION 5 • Peak Procedure: Tobacco Cessation

Procedure 11-1. Tobacco Cessation Counseling

1. Ask. Ask if your patient • Many smokers want to quit

smokes or uses and appreciate the
smokeless tobacco encouragement of health
products. professionals.

2. Advise. Advise the • Smokers are more likely to

patient to quit. quit if advised to do so by
The benefits of quitting health professionals.
include: • The oral examination provides
• Decreased risk of a the perfect opportunity to
heart attack, stroke, discuss smoking cessation
coronary heart disease; with your patient.
lung, oral, and • Tobacco use is a major risk
pharyngeal cancer factor in oral and pharyngeal
• Improved sense of cancer as well as periodontal
taste and smell disease.
• Improved circulation • Tobacco use is a risk factor for
and lung function coronary heart disease, heart
• Improved health of attack, and lung cancer.
family members Secondhand smoke is
unhealthy for family
members.

3. Refer. Tell the patient • Evidence suggests quitline use

that help is a free phone can more than triple success in
call away. Provide patient quitting.
with quitline numbers. • Quitlines provide an easy, fast,
A list of quitlines for and effective way to help
the United States and smokers quit.
Canada is located in the • By simply identifying
“Ready References” smokers, advising them to
 section of this module. quit, and sending them to a
free telephone service,
clinicians can save thousands
of lives.

SECTION 6 • Patient Education Resources

Figures 11-18 to 11-24 provide resources for use with patients.
SECTION 7 • The Human Element

Through the Eyes of a Clinician

ONE COUNSELING EXPERIENCE

Mr. R. is a 60-year-old male who started smoking at age 14 years. By 17
years, he was smoking daily—as much as one to three packs a day. Mr.
R.’s current daily consumption was two packs a day. Typically, Mr. R.
smoked immediately upon waking and if he woke in the middle of the
night. This information indicated to me that Mr. R. had a strong physical
addiction.
Mr. R. told me that a year ago, he met a wonderful woman, Helen,
and that they were going to be married in 7 months. He was very defensive
about his smoking and said that Helen really wanted him to quit before
their wedding. Mr. R. confided that he finds the pressure from his fiancée
about quitting decidedly unhelpful! He felt that he did not have the “will
power” to quit. He also expressed concern that since he had been smoking
for so long, it was probably pointless to quit at his age.
I encouraged Mr. R. to just listen to the cessation options available to
him. I assured him it wasn’t nearly as necessary to want to quit as it was to
decide to quit, and I could help by offering him tools to assist in the
quitting process. I spoke to Mr. R. about nicotine addiction and explained
through no fault of his own, he most likely had a genetic predisposition to
nicotine addiction. I told him that even though taking control of a nicotine
addiction was more difficult than heroin, cocaine, or alcohol, it was very
possible. Although quitting may be the most difficult thing he would ever
do, it would also be the most worthwhile.
In speaking with Mr. R., I stressed the health benefits of quitting
rather than talking about health risks from smoking. I explained the goal of
quitting was not to stop wanting to smoke but to stop the behavior of
smoking. He may want a cigarette the rest of his life—not to the degree
upon first quitting—but, that doesn’t mean he has to smoke the rest of his
life! Quitting isn’t about will power—it is about taking control over an
addiction that now controls his life.
Six months after our meeting, Mr. R. e-mailed me from Paris. He and
Helen were enjoying a very happy honeymoon; Mr. R. was not smoking
and very confident he would remain tobacco free. He did gain a bit of
weight but felt with exercise, he would soon lose those extra pounds. He
felt “tremendous” and was so glad that Helen had encouraged him to quit.
Carol Southard, RN, MSN, project consultant,
ADHA Smoking Cessation Initiative

Ethical Dilemma

TEEN SMOKER

As you enter the waiting room to call your next patient, Jeremy Reemy, the
scent of smoke surrounds you. Jeremy, who is 13 years old, attends the
local middle school. His mother has dropped him off for his prophylaxis
appointment. You review Jeremy’s medical history and are anxious to hear
his response to your questions about smoking. At first, he denies the use of
tobacco, but upon further pressing, he states, “Yep, I smoke . . . what’s the
big deal. Both my parents smoke, too.” You are disturbed by his response
but grateful for his honesty.
1. What do you do to educate Jeremy about the dangers of tobacco use?
2. Is it ethical to share this information with his parents?
3. How can you intervene to make Jeremy aware of the necessity of
tobacco cessation?
4. How can you help Jeremy quit smoking?

Through the Eyes of a Patient

LEAVING THE DOOR OPEN

Danielle Rothchild is the dental hygienist in a periodontal practice. She is

caring for a new patient, Mr. Marston, who is a heavy smoker. Mr.
Marston states that he plans to continue smoking cigarettes despite the
likelihood that smoking is a risk factor in his periodontitis and general
health.
Danielle does not agree with Mr. Marston’s decision, although she
believes it to be an informed decision (i.e., he fully understands the
implications for both his oral and general health).
• Discuss how Danielle can demonstrate her respect for Mr. Marston’s
right to make his own decision.
• Is there a way that Danielle could “leave the door open” to future
discussions about smoking cessation with Mr. Marston (without
 “pushing” her opinions on the patient and without sounding like she is
“harping” on the issue)?

SECTION 8 • Practical Focus—Fictitious Patient Case

for Tobacco Cessation

DIRECTIONS
FICTITIOUS PATIENT CASE A: MR. ALAN ASCARI
• The fictitious patient case in this module involves patient A, Mr. Alan
Ascari.
• While completing the “Practical Focus” section in this module, you
should take into account the health history and over-the-
counter/prescription drug information that was revealed for Mr. Ascari
in Module 5, Medical History, and Module 10, Vital Signs: Blood
Pressure.
• Review Mr. Ascari’s Smoking History form in Figure 11-25 located on
the next page of this module.
• Using Peak Procedure 11-1 for guidance, role-play tobacco cessation
counseling with a classmate portraying Mr. Ascari. Remember to use the
patient resource handouts from section during the role-play.
SECTION 9 • Skill Check

Skill Checklist: Role-Play Tobacco Cessation Counseling

 ROLES:
• Student 1 = Plays the role of the patient.
• Student 2 = Plays the role of the clinician.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point and each U equals 0 point.

CRITERIA: S E
Asks the patient if he or she uses tobacco.
Advises the patient that quitting is important for
wellness and longevity. Asks the patient if he or she
is interested in learning about tobacco cessation.
Encourages patient questions about the health risks
of tobacco use and the tools for tobacco cessation.

Answers the patient’s questions fully and

accurately.
Communicates with the patient at an appropriate
level avoiding dental/medical terminology or
jargon.
Provides the patient with quitline telephone
numbers or websites and patient education materials
on tobacco cessation.
OPTIONAL GRADE PERCENTAGE
 CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

References
1. U.S. Public Health Service. Office of the Surgeon General, National Center for
Chronic Disease Prevention and Health Promotion. Office on Smoking and Health.
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon
General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health; 2014.
2. WHO urges more countries to require large, graphic health warnings on tobacco
packaging: the WHO report on the global tobacco epidemic, 2011 examines anti-
tobacco mass-media campaigns. Cent Eur J Public Health. 2011;19(3):133, 151.
3. Bjartveit K, Tverdal A. Health consequences of smoking 1-4 cigarettes per day. Tob
Control. 2005;14(5): 315–320.
4. The 2004 United States Surgeon General’s report: the health consequences of
smoking. N S W Public Health Bull. 2004;15(5–6):107.
5. Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health. 2010 Surgeon
General’s Report—How Tobacco Smoke Causes Disease: The Biology and Behavioral
Basis for Smoking-Attributable Disease. Atlanta, GA: Centers for Disease Control and
Prevention; 2010.
6. Ortiz A, Grando SA. Smoking and the skin. Int J Dermatol. 2012;51(3):250–262.
7. Rossi M, Pistelli F, Pesce M, et al. Impact of long-term exposure to cigarette smoking
on skin microvascular function. Microvasc Res. 2014;93:46–51.
8. Urbańska M, Nowak G, Florek E. Cigarette smoking and its influence on skin aging
[in Polish]. Przegl Lek. 2012;69(10):1111–1114.
9. Urbańska M, Ratajczak L, Witkowska-Nagiewicz A. Analysis of knowledge about
tobacco smoking influence on skin condition [in Polish]. Przegl Lek.
2012;69(10):1055–1059.
10. U.S. Department of Health and Human Services. The Health Consequences of
Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta,
GA: U.S. Department of Health and Human Services, Centers for Disease Control and
 Prevention, Office of Smoking and Health; 2006.
11. U.S. Department of Health and Human Services. Children and Smoke Exposure:
Excerpts from the Health Consequences of Involuntary Exposure to Tobacco Smoke:
A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and
Human Services, Public Health Service, Office of the Surgeon General; 2007.
http://www.surgeongeneral.gov/library/reports/smokeexposure/fullreport.pdf.
Accessed August 3, 2016.
12. Stoltenberg JL, Osborn JB, Pihlstrom BL, et al. Association between cigarette
smoking, bacterial pathogens, and periodontal status. J Periodontol.
1993;64(12):1225–1230.
13. Tuma RS. Thirdhand smoke: studies multiply, catchy name raises awareness. J Natl
Cancer Inst. 2010; 102(14):1004–1005.
14. Palazzolo DL. Electronic cigarettes and vaping: a new challenge in clinical medicine
and public health. A literature review. Front Public Health. 2013;1:56.
15. Arrazola RA, Neff LJ, Kennedy SM, Holder-Hayes E, Jones CD; for the Centers for
Disease Control and Prevention. Tobacco use among middle and high school students
—United States, 2013. MMWR Morb Mortal Wkly Rep. 2014;63(45):1021–1026.
16. Proescholdbell S. Tobacco Use among Middle and High School Students: Results
from the North Carolina Youth Tobacco Survey, 1999–2007. Raleigh, NC: State
Center for Health Statistics; 2008.
17. Jacob P III, Abu Raddaha AH, Dempsey D, et al. Nicotine, carbon monoxide, and
carcinogen exposure after a single use of a water pipe. Cancer Epidemiol Biomarkers
Prev. 2011;20(11):2345–2353.
18. National Institutes of Health State-of-the-Science Panel. National Institutes of Health
State-of-the-Science conference statement: tobacco use: prevention, cessation, and
control. Ann Intern Med. 2006;145(11):839–844.
19. Jamal A, Homa DM, O’Connor E, et al. Current cigarette smoking among adults—
United States, 2005–2014. MMWR Morb Mortal Wkly Rep. 2015;64(44):1233–1240.
20. National Institute on Drug Abuse. Nicotine Addiction. Rockville, MD: National
Institute on Drug Abuse; 2012.
21. Centers for Disease Control and Prevention. Cigarette smoking among adults—United
States, 2003. MMWR Morb Mortal Wkly Rep. 2004;54:509–513.
22. Haber J, Wattles J, Crowley M, Mandell R, Joshipura K, Kent RL. Evidence for
cigarette smoking as a major risk factor for periodontitis. J Periodontol.
1993;64(1):16–23.
23. Fiorini T, Musskopf ML, Oppermann RV, Susin C. Is there a positive effect of
smoking cessation on periodontal health? A systematic review. J Periodontol.
2014;85(1):83–91.
24. Gelskey SC. Cigarette smoking and periodontitis: methodology to assess the strength
 of evidence in support of a causal association. Community Dent Oral Epidemiol.
1999;27(1):16–24.
25. Johannsen A, Susin C, Gustafsson A. Smoking and inflammation: evidence for a
synergistic role in chronic disease. Periodontol 2000. 2014;64(1):111–126.
26. Johnson GK, Guthmiller JM. The impact of cigarette smoking on periodontal disease
and treatment. Periodontol 2000. 2007;44:178–194.
27. MacFarlane GD, Herzberg MC, Wolff LF, Hardie NA. Refractory periodontitis
associated with abnormal polymorphonuclear leukocyte phagocytosis and cigarette
smoking. J Periodontol. 1992;63(11):908–913.
 MODULE
12

SOFT TISSUE LESIONS

For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
This module discusses recognition of soft tissue lesions of the skin and oral
mucosa. It presents a systematic approach to describing pertinent
characteristics of soft tissue lesions. The ability to formultate a concise,
accurate verbal and written description of any lesion is a necessary skill when
communicating and documenting findings from the extraoral and intraoral
examination.
This module covers:
• Recognizing the primary types of soft tissue lesions
• Formulating a written description of a soft tissue lesion
• Prevention of skin and oral cancers

MODULE OUTLINE
SECTION 1 Learning to Look at Lesions
Why Look for Lesions?
Cancer Facts and Statistics
What Is a Soft Tissue Lesion?
Characteristics of Soft Tissue Lesions
 Basic Types of Soft Tissue Lesions
The ABCD-T Mnemonic for Formulating Lesion
Descriptions
SECTION 2 Peak Procedure: Describing Lesions
Procedure 12-1. Determining and Describing Lesion
Characteristics
SECTION 3 Detection Tools
SECTION 4 Ready References
Lesion Descriptor Worksheet
Ready Reference 12-1. Characteristics of Common
Cancerous Lesions
SECTION 5 The Human Element
Through the Eyes of a Student
Communication Scenario
SECTION 6 Practical Focus—Describing and
Documenting Lesions
KEY TERMS
Soft tissue lesion • Regular • Irregular • Smooth • Raised • Discrete •
Grouped • Confluent • Linear • Macule • Patch • Papule • Plaque •
Nodule • Wheal • Vesicle • Bulla • Pustule • Erosion • Ulcer • Fissure •
ABCD-T

OBJECTIVES
• Explain the importance of inspecting the head, neck, and oral cavity
for the presence of soft tissue lesions.
• Given an image of a lesion, use the Lesion Descriptor Worksheet
(located in this module) to identify the location and characteristics of
the lesion and to develop a written description of the lesion.
 • Demonstrate knowledge of soft tissue lesions by applying information
from this module to the fictitious patient cases A to E found in
Modules 13 and 14.

NOTE TO COURSE INSTRUCTOR: Skill checklists and fictitious patient

cases A to E for this topic are located in Modules 13 (Head and Neck
Examination) and 14 (Oral Examination).

SECTION 1 • Learning to Look at Lesions

Inspection of the skin and oral mucosa for soft tissue lesions is an important
part of every head and neck examination and intraoral examination. By
performing routine screenings, dental health care providers can reduce deaths
from skin, oral, and pharyngeal cancers.

Why Look for Lesions?

The most effective approach to decreasing the number of deaths associated
with soft tissue cancers is through early detection and appropriate treatment
and referral.1–5 In June 2003, the American Dental Association (ADA)
launched a campaign urging dental professionals to examine patients for
signs of early soft tissue lesions. Most Americans visit a dental office or
clinic at least once a year. For this reason, dental health care providers have a
unique opportunity to help decrease skin and oral cancer rates by routinely
performing head, neck, and intraoral examinations. Early detection of skin
and oral cancers is critical in the prevention of cancer deaths. When detected
at its earliest stage, skin and oral cancers are more easily treated and cured.

Cancer Facts and Statistics

1. Skin Cancer
a. Skin cancer is the most common of all cancer types.
b. More than 1 million skin cancers are diagnosed each year in the
 United States. The number of skin cancers has been on the rise
steadily for the past 30 years.
c. There are two main types of skin cancers—melanomas and
nonmelanomas.
d. Melanomas are much more likely to spread to other parts of the body
and account for over 60% of skin cancer deaths. Melanoma is almost
always curable in its early stages.
e. Nonmelanomas—such as basal cell and squamous cell cancers—are
the most common cancers of the skin. Nonmelanomas rarely spread
elsewhere in the body and are less likely than melanomas to be fatal.
2. Oral and Pharyngeal Cancer
a. The Surveillance, Epidemiology, and End Results (SEER) Program of
the National Cancer Institute (NCI) is an authoritative source of
information on cancer incidence and survival in the United States. In
2013, there were an estimated 300,682 people living with oral cavity
and pharynx cancer in the United States.
b. More than 1 in 4 people affected with oral cancer will die—about one
person each hour. According to the American Cancer Society, oral
cancer claims almost as many lives as melanoma cancer.

What Is a Soft Tissue Lesion?

A soft tissue lesion is an area of abnormal-appearing skin or mucosa that
does not resemble the soft tissue surrounding it. Lesions are variations in
color, texture, or form of an area of skin or mucosa. A soft tissue lesion may
be:
• Present at birth—such as a mole or birthmark
• Associated with an infection—such as warts or acne
• Associated with an allergic reaction—such as hives
• Associated with an injury—such as a blister from a burn or scar from a
cut
Characteristics of Soft Tissue Lesions
LESION BORDER TRAITS

LESION MARGIN TRAITS

LESION COLOR
Lesions can be red, white, red and white, blue, yellow, brown, or black. Some
examples are shown here.6–9

COMMON LESION CONFIGURATIONS

Configuration refers to the way that multiple lesions are arranged.
Basic Types of Soft Tissue Lesions
FLAT LESIONS
ELEVATED LESIONS
FLUID-FILLED LESIONS
DEPRESSED LESIONS

LINEAR CRACKS
The ABCD-T Mnemonic for Formulating Lesion
Descriptions
The description a soft tissue lesion has two components: (1) characteristics
of the lesion and (2) type of lesion. A lesion’s characteristics include its
anatomic location, border traits, color, configuration, and diameter or
dimensions. Primary types of lesions are flat, elevated, fluid-filled, and
depressed lesions.
Because each lesion has so many characteristics, it is common for
clinicians to feel overwhelmed when trying to create a verbal description of a
lesion. To assist clinicians in remembering the characteristics to document, it
is helpful to use the letters ABCD-T as a memory device (Box 12-1).

BOX Remembering What to Look For

12-1

Use the letters A, B, C, D, and T as a memory device to remember the

characteristics to look for on a lesion.
A—Anatomic location
B—Border
C—Color and configuration
D—Diameter or dimensions
T—Type

SECTION 2 • Peak Procedure: Describing Lesions

Procedure 12-1. Determining and Describing Lesion

Characteristics

Action Rationale
1. Determine lesion • The Lesion Descriptor
characteristics. Use the Worksheet makes it easy to
Lesion Descriptor identify the characteristics of
Worksheet (Fig. 12-31A– a particular lesion.
B) from the “Ready
References” section of this
module. Circle or highlight
the words that describe the
lesion.
A—Anatomic location. • This allows other clinicians
Describe the anatomic to locate the lesion from your
location of the lesion. written description.
B—Border. Examine the • An asymmetrical lesion with
lesion to see if the an irregular border may
border is symmetrical indicate a malignant lesion.
(having balanced
proportions, equal
halves from the center
 dividing line) or
asymmetrical (unequal
halves). Examine the
border to see if it is
well demarcated,
regular, or irregular.
C—Color and • Lesions can change color
configuration. Note over time. A color change
the color of the lesion. may indicate a malignant
Record the lesion.
configuration of the • Many skin diseases have
lesion(s). Is this a lesions in a typical
single lesion? Are the configuration.
lesions separate,
clustered together,
grouped, confluent, or
linear?
D—Diameter or • Over time, a change in size
dimensions. Measure may indicate a malignant
the size of the lesion lesion.
using a plastic
millimeter ruler if the
lesion is on the skin.
Use a periodontal
probe for intraoral
lesions.
T—Type. Identify the • The type of lesion is an
type of lesion such as important component of the
macule, vesicle, etc. description of a lesion.

2. Document lesion • The rationale for drawing the

location. Indicate the lesion is NOT to create an
artistic likeness of it.
 location of lesion on the • Drawing the lesion on an
appropriate illustration on anatomical illustration assists
the Lesion Descriptor other clinicians in quickly
Worksheet. locating the lesion now and
at future appointments, if
applicable.

3. Develop a written description. After circling or highlighting

the words on the Lesion Descriptor Worksheet that pertain
to the lesion, you are ready to formulate a description for the
lesion.
For example:
A—Anatomic location: left buccal mucosa near tooth #14
B—Border: well-demarcated
C—Color and configuration: blue; single lesion
D—Diameter or dimensions: 4 mm × 2mm
T—Type: macule

4. Finalize the description. Next, use the outline to create a

description and enter it at the bottom of page 2 of the Lesion
Descriptor Worksheet.
For example using the words outlined above, the description
might be: On the left buccal mucosa near tooth #14, a single,
well-demarcated, blue, 4 mm × 2 mm macule.

5. Document the lesion. Enter the lesion description and date in

the patient’s chart or computerized record.

SECTION 3 • Detection Tools

In the dental setting, the three primary tools for the detection of soft tissue
lesions on the head and neck or oral cavity are the head and neck
examination, oral examination, and patient history. Medical history
questionnaires should include questions that elicit information about tobacco
and alcohol use as well as interest in smoking cessation programs. Box 12-2
outlines the role of a dental professional in cancer detection.

BOX Dental Professional’s Role in Cancer Detection

12-2

A thorough examination of the head, neck, and oral cavity should be a

routine part of each dental visit. Clinicians should be particularly vigilant
with patients who use tobacco and alcohol.
• EXAMINE the patient at each visit using a systematic visual inspection
of the head, neck, and oral cavity.
• ENSURE the health history questionnaire elicits information about
tobacco and alcohol use.
• EDUCATE the patient that tobacco and alcohol use dramatically
increases the risk of oral cancer.
• IDENTIFY and document any suspicious soft tissue lesions.
• REFER to a dermatologist—for skin lesions—or an oral maxillofacial
surgeon—for oral lesions—to obtain a definitive diagnosis of the
suspicious lesion.
• FOLLOW UP to make sure that a definitive diagnosis was obtained.

SECTION 4 • Ready References

Lesion Descriptor Worksheet

Ready Reference 12-1. Characteristics of Common
Cancerous Lesions

Type Appearance
Basal cell carcinoma
60% of skin cancers
A—face
B—round at first, later irregular
C—skin-colored, pink, dark
brown, black

Squamous cell carcinoma

20% of skin cancers
A—areas exposed to sunlight;
lip
B—poorly demarcated raised
border; raised border with
central ulceration 17,18
C—skin-colored, reddened;
new lesions may appear
near old ones

Malignant melanoma
Accounts for over 60% of
skin cancer deaths
A—areas exposed to sunlight
B—becomes irregular as it
grows
C—may have pink or red halo

Kaposi’s sarcoma
A—skin; mucous membranes
B—raised border; well
demarcated
C—intense red, blue, or brown:
color does not blanch
SECTION 5 • The Human Element

Through the Eyes of a Student

TOBACCO USE AND THE ORAL EXAM

Our school had just switched to a new medical history form, and the new
form has two columns of information. Even after using this new form for
some time, I think that it is easy to miss some of the questions when
reviewing the patient’s answers.
Today, I was seeing a new patient, Mr. U. I had forgotten to look at
the tobacco use question. So, I did not read that my patient had been
chewing tobacco for over 10 years. If I had read this information, I would
not have made my next mistake.
I did a quick oral exam and accidentally overlooked some suspicious
tissue changes on the lower anterior mucolabial fold. I did not notice until
my instructor came to assist me. She showed me where Mr. U. held his
tobacco in his mouth and how the tissue looked different. He had what
would be considered precancerous tissue changes. I explained to Mr. U.
the risk of developing cancer, and he seemed ready to change this habit. I
may have helped to save my patient’s life or at least decreased his risk of
developing oral cancer. You can bet that I will never take the oral exam
lightly ever again.
 Kimberly, student,
Tallahassee Community College

Communication Scenario

QUESTIONING SKILLS

This scenario focuses on your question-asking and problem-solving skills.

You are a dental hygienist working with an elderly female client, Mrs.
Nguyen, who has been diagnosed with advanced Alzheimer disease. The
oral exam reveals that she has a severe burn on the roof of her mouth. Mrs.
Nguyen was accompanied to her appointment by her elderly husband and
her daughter. It is your responsibility to determine how the patient burned
the roof of her mouth.
Working on your own, write down what your first three questions
would be. Be able to defend your questions by describing the following:
• What exactly would you ask? Exactly how would you word your
questions?
• Why would these be your first three questions?
• Whom would you ask?
• Where—what location in the dental office—would you ask your
questions?
 Compare your questions with those of your classmates. This scenario
focuses on your question-asking and problem-solving skills.

SECTION 6 • Practical Focus—Describing and

Documenting Lesions

DIRECTIONS
• Use the steps outlined in Procedures 12-1 and the Lesion Descriptor
Worksheet to develop descriptions for the four lesions in this section.
• An example is provided as a guide for completing this section of the
module.
• The pages in this section may be removed from the book for easier
use by tearing along the perforated lines on each page.

EXAMPLE
Location: mucosa of left cheek

EXAMPLE: Worksheet page 1

EXAMPLE: Worksheet page 2
LESION 1
Location: palate, right side of midline
LESION 1
LESION 1
LESION 2
Location: mucosa of right cheek
LESION 2
LESION 2
LESION 3
Location: palate
LESION 3
LESION 3
LESION 4
Location: gingiva and alveolar mucosa, right side of oral cavity
LESION 4
LESION 4
LESION 5
Location: gingiva, maxillary left posterior sextant, facial aspect
LESION 5
LESION 5
Sources of Clinical Photographs
The authors gratefully acknowledge the sources of the following clinical
photographs in this module.
• Figure 12-1. Dr. John S. Dozier, Tallahassee, FL.
• Figure 12-2. Dr. Michaell A. Huber, University of Texas Health Science
Center at San Antonio, TX.
• Figure 12-3. Dr. Michaell A. Huber, University of Texas Health Science
Center at San Antonio, TX.
• Figure 12-4. Centers for Disease Control and Prevention Public Health
Image Library.
• Figure 12-5. From Langlais RP, Miller CS, Nield-Gehrig JS. Color Atlas
of Common Oral Diseases. 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2009.
• Figure 12-6. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 12-7. Dr. Charles Goldberg, University of California San Diego
School of Medicine, CA.
• Figure 12-8. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 12-9. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 12-10. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 12-11. Courtesy of Dr. Michaell A. Huber, University of Texas
Health Science Center at San Antonio, TX.
• Figure 12-12. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 12-14. From Goodheart HP. Goodheart’s Photoguide of Common
Skin Disorders. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2003.
• Figure 12-16. From Langlais RP, Miller CS, Nield-Gehrig JS. Color
Atlas of Common Oral Diseases. 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2009.
• Figure 12-18. From Goodheart HP. Goodheart’s Photoguide of Common
Skin Disorders. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2003.
• Figure 12-19. From Goodheart HP. Goodheart’s Photoguide of Common
 Skin Disorders. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2003.
• Figure 12-20. Dr. Michaell A. Huber, University of Texas Health
Science Center at San Antonio, TX.
• Figure 12-21. From Goodheart HP. Goodheart’s Photoguide of Common
Skin Disorders. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2003.
• Figure 12-23. From Langlais RP, Miller CS, Nield-Gehrig JS. Color
Atlas of Common Oral Diseases. 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2009.
• Figure 12-24. From Langlais RP, Miller CS, Nield-Gehrig JS. Color
Atlas of Common Oral Diseases. 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2009.
• Figure 12-25. From Goodheart HP. Goodheart’s Photoguide of Common
Skin Disorders. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2003.
• Figure 12-27. From Langlais RP, Miller CS, Nield-Gehrig JS. Color
Atlas of Common Oral Diseases. 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2009.
• Figure 12-28. From the National Cancer Institute, Bethesda, MA.
• Figure 12-30. From Neville B, Damm DD, White DK. Color Atlas of
Clinical Oral Pathology. Philadelphia, PA: Lea & Febiger; 1991.
• Figure 12-32A. From the National Cancer Institute, Bethesda, MA.
• Figure 12-32B. From Goodheart HP. Goodheart’s Photoguide of
Common Skin Disorders. 2nd ed. Philadelphia, PA: Lippincott Williams
& Wilkins; 2003.
• Figure 12-32C. From the National Cancer Institute, Bethesda, MA.
• Figure 12-32D. From Weber J, Kelley J. Health Assessment in Nursing.
2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.
• Figure 12-32. From Goodheart HP. Goodheart’s Photoguide of Common
Skin Disorders. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2003.
• Figure 12-34. Dr. Richard Foster, Guilford Technical Community
 College, Jamestown, NC.
• Figure 12-36. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 12-38. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 12-40. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 12-42. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.

References
1. Petti S, Scully C. The role of the dental team in preventing and diagnosing cancer: 5.
Alcohol and the role of the dentist in alcohol cessation. Dent Update. 2005;32(8):454–
455.
2. Scully C, Boyle P. The role of the dental team in preventing and diagnosing cancer: 1.
cancer in general. Dent Update. 2005;32(4):204–206.
3. Scully C, Newman L, Bagan JV. The role of the dental team in preventing and
diagnosing cancer: 3. oral cancer diagnosis and screening. Dent Update.
2005;32(6):326–328.
4. Scully C, Newman L, Bagan JV. The role of the dental team in preventing and
diagnosing cancer: 2. Oral cancer risk factors. Dent Update. 2005;32(5):261–262.
5. Scully C, Warnakulasuriya S. The role of the dental team in preventing and
diagnosing cancer: 4. Risk factor reduction: tobacco cessation. Dent Update.
2005;32(7):394–396.
6. Felix DH, Luker J, Scully C. Oral medicine: 7. Red and pigmented lesions. Dent
Update. 2013;40(3):231–234.
7. Felix DH, Luker J, Scully C. Oral medicine: 6. White lesions. Dent Update.
2013;40(2):146–148.
8. Scully C, Felix DH. Oral medicine—update for the dental practitioner: red and
pigmented lesions. Br Dent J. 2005;199(10):639–645.
9. Scully C, Felix DH. Oral medicine—update for the dental practitioner: oral white
patches. Br Dent J. 2005;199(9):565–572.
10. Felix DH, Luker J, Scully C. Oral medicine: 11. Lumps and swellings: mouth. Dent
Update. 2013;40(8):683–687.
11. Scully C, Felix DH. Oral medicine—update for the dental practitioner: aphthous and
other common ulcers. Br Dent J. 2005;199(5):259–264.
12. Felix DH, Luker J, Scully C. Oral medicine: 3. Ulcers: cancer. Dent Update.
2012;39(9):664–668.
13. Felix DH, Luker J, Scully C. Oral medicine: 2. Ulcers: serious ulcers. Dent Update.
2012;39(8):594–598.
14. Felix DH, Luker J, Scully C. Oral medicine: 1. Ulcers: aphthous and other common
ulcers. Dent Update. 2012;39(7):513–516.
15. Scully C. Oral ulceration. Br Dent J. 2002;192(11):607.
16. Scully C, Felix DH. Oral medicine—update for the dental practitioner lumps and
swellings. Br Dent J. 2005;199(12):763–770.
17. Scully C, Bagan J. Oral squamous cell carcinoma: overview of current understanding
of aetiopathogenesis and clinical implications. Oral Dis. 2009;15(6):388–399.
18. Scully C, Bagan J. Oral squamous cell carcinoma overview. Oral Oncol. 2009;45(4–
5):301–308.
 MODULE
13

HEAD AND NECK

EXAMINATION
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
This module describes the head and neck examination. The head and neck
examination is a physical examination technique consisting of a systematic
visual inspection and palpation of the structures of the head and neck. A
thorough head and neck examination should be a routine part of each
patient’s dental visit.
This module describes the head and neck examination including:
• Review of anatomic structures of the head and neck
• Examination and palpation techniques
• Peak procedure for a systematic head and neck examination

MODULE OUTLINE
SECTION 1 Examination Overview
Overall Appraisal of the Head and Neck
Anatomy Review
Eyes, Ears, and Nose
 Sternomastoid Muscle
Lymph Nodes of the Head and Neck
Salivary Glands
Thyroid Gland
Temporomandibular Joint
SECTION 2 Methods for Examination
Examination Techniques
Compression Techniques
Palpation Expectations
SECTION 3 Peak Procedure
Procedure 13-1. Head and Neck Examination
Subgroup 1: Overall Appraisal of Head, Neck, Face,
and Skin
Subgroup 2: Lymph Nodes of the Head and Neck
Subgroup 3: Salivary and Thyroid Glands
Subgroup 4: Temporomandibular Joint (TMJ)
SECTION 4 The Human Element
Through the Eyes of a Cancer Survivor
Ethical Dilemma
English-to-Spanish Phrase List
SECTION 5 Practical Focus—Fictitious Patient Cases
Fictitious Patient Case A: Mr. Alan Ascari
Fictitious Patient Case B: Bethany Biddle
Fictitious Patient Case C: Mr. Carlos Chavez
Fictitious Patient Case D: Mrs. Donna Doi
Fictitious Patient Case E: Ms. Esther Eads
SECTION 6 Skill Check
KEY TERMS
Head and neck examination • Sternomastoid muscle • Lymphatic system
• Lymph • Lymph nodes • Enlarged • Lymphadenopathy • Metastasis •
Salivary glands • Parotid glands • Submandibular glands • Sublingual
glands • Thyroid gland • Nodules • Goiter • Temporomandibular joint
(TMJ) • Inspection • Palpation • Antegonial notch

OBJECTIVES
• Describe the normal anatomy of the structures of the head and neck.
• Identify deviations from normal of the skin, lymph nodes, salivary
and thyroid glands.
• Position the patient correctly for the head and neck examination.
• Demonstrate the use of communication strategies to provide
information to the patient about the head and neck examination and
any notable findings.
• Locate the (1) lymph nodes of the head and neck, (2) salivary and
thyroid glands, and (3) temporomandibular joint.
• Demonstrate the head and neck examination using correct technique
and a systematic sequence of examination.
• Document notable findings in the patient chart or computerized
record.
• Identify findings that have implications in planning dental treatment.
• Provide referral to an appropriate specialist when findings indicate the
need for further evaluation.
• Demonstrate knowledge of the head and neck exam by applying
concepts from this module to the fictitious patient cases A to E found
in Section 5.

SECTION 1 • Examination Overview

The head and neck examination is a physical examination technique
consisting of a systematic visual inspection of the skin of the head and neck
combined with palpation of the lymph nodes, salivary glands, thyroid gland,
and temporomandibular joint. This procedure takes only minutes and allows
the clinician to gather general information on the health of a patient, note
early indications of some diseases, and detect abnormalities and potentially
life-threatening malignancies at an early stage.1–8 The head and neck and
oral examinations are two of the most important clinical procedures that a
clinician will ever master, as these examinations can literally save a
patient’s life. The oral examination is presented in Module 14.
There are many structures to be assessed during the head and neck
examination. To assist the clinician in performing a systematic examination,
the structures are organized into four subgroups: (1) the overall appraisal of
the head and neck, face, ears, and skin; (2) lymph nodes of the head and
neck; (3) salivary and thyroid glands; and (4) temporomandibular joint.

Overall Appraisal of the Head and Neck

The head and neck examination begins while greeting and seating the patient.
While chatting with the patient, unobtrusively examine the head and neck
area including assessment of facial form and symmetry and inspection of the
skin (Fig. 13-1).
Anatomy Review
To perform an accurate head and neck examination, the clinician needs to
know the anatomy of the eyes, ears, nose, and neck and recognize the clinical
appearance of normal structures.
EYES, EARS, AND NOSE
Knowledge of the landmarks of the eyes, ears, and nose is useful when
recording the location of a soft tissue lesion or other notable findings (Figs.
13-2 and 13-3).
STERNOMASTOID MUSCLE
The sternomastoid muscle—also known as the sternocleidomastoid muscle
—is a long, thick superficial muscle on each side of the head with its origin
on the mastoid process and insertion on the sternum and clavicle (Fig. 13-4).
• This muscle acts to bend, rotate, and flex head.
• The ability to locate the sternomastoid muscle is significant because the
cervical lymph nodes lie above, beneath, and posterior to this muscle.
LYMPH NODES OF THE HEAD AND NECK
The lymphatic system is a network of lymph nodes connected by lymphatic
vessels that plays an important part in the body’s defense against infection.
This system transports lymph—a clear fluid that carries nutrients and waste
materials between the body tissues and the bloodstream. Lymph nodes
(pronounced “limf”) are small, bean-shaped structures that filter out and trap
bacteria, fungi, viruses, and other unwanted substances to safely eliminate
them from the body (Fig. 13-5). All substances transported by the lymphatic
system pass through at least one lymph node, where foreign substances can
be filtered out and destroyed before fluids are returned to the bloodstream.
 There are 400 to 700 lymph nodes in the body, 170 to 200 of which are
located in the neck.9 The major lymph node groups are located along the
anterior and posterior aspects of the neck and on the underside of the jaw
(Fig. 13-5).
1. Normal lymph nodes can be as small as the head of a pin or the size of a
pea or baked bean.
2. Lymph nodes can become enlarged due to infection, inflammatory
conditions, an abscess, or cancer.
a. Lymphadenopathy (lymph•ade•nop•a•thy) is the term for enlarged
 lymph nodes.
b. If the nodes are quite big, they may be visible bulging under the skin
(Fig. 13-6) particularly if the enlargement is asymmetric (i.e., it will
be more obvious if one side of the neck is larger than the other).

3. By far, the most common cause of lymph node enlargement is infection.

In general, when swelling appears suddenly and is tender to the touch, it
is usually caused by injury or infection.
a. When a part of the body is infected, the nearby lymph nodes become
swollen as they collect and destroy the infecting organisms. For
example, if a person has a throat infection, the lymph nodes in the
neck may swell and become tender to the touch.
b. Nodes with a viral infection are usually 1/2 to 1 in across.
c. Nodes with a bacterial infection usually are larger than 1 in across,
about the size of a quarter.
4. Node enlargement that comes on gradually and painlessly may result
from cancer.
a. An enlarged lymph node might be a sign that the cancer has spread to
a lymph node.
b. Metastasis is the spread of cancer from the original tumor site to
other parts of the body by tiny clumps of cells transported by the
 blood or lymphatic system.
c. When oral cancer metastasizes, it most commonly spreads through the
lymphatic system to the cervical chain of lymph nodes in the neck.
d. Lymph nodes can play a role in the spread of cancer, as the lymphatic
system can transport cancer cells throughout the body.
SALIVARY GLANDS
Salivary glands produce saliva and have ducts that release saliva into the
mouth (Fig. 13-7). Problems of the salivary glands include obstruction of the
flow of saliva, inflammation, infection, and salivary gland tumors.

There are three main pairs of salivary glands:

 • The parotid glands are the largest of the salivary glands. Each gland is
located on the surface of the masseter muscle between the ear and the
jaw.
• The submandibular glands sit below the jaw toward the back of the
mouth.
• The sublingual glands are located under the tongue, beneath the
mucous membrane of the floor of the mouth.
THYROID GLAND
The thyroid gland (THIGH-royd), one of the endocrine glands, secretes
thyroid hormone that controls the body’s metabolic rate. The thyroid gland is
located in the middle of the lower neck and is covered by layers of skin and
muscles (Fig. 13-8). It is situated below the larynx (voice box), over the
trachea and just above the clavicles (collarbones). The small 2-inch gland has
a right and left lobe joined by a narrow isthmus, giving the gland the shape of
a bow tie.
 Disorders of the thyroid gland are very common, affecting millions of
Americans.10 The most common disorders of the thyroid are an over- or
underactive gland. Examination of the thyroid is done to look at the size of
the gland as well as for nodules (lumps or masses). Normally, the thyroid
gland cannot be seen and can barely be felt, but if it becomes enlarged, it can
be felt and it may appear as a bulge below or to the side of the Adam’s apple
(Figs. 13-9 and 13-10).
TEMPOROMANDIBULAR JOINT
The temporomandibular joint (TMJ) is the joint that connects the mandible
to the temporal bone at the side of the head (Figs. 13-11 and 13-12). It is one
of the most complicated joints in the body, allowing the jaw to open and
close, move forward and backward, and from side to side. The joint contains
a piece of cartilage called a disk that keeps the skull and the mandible from
rubbing against each other. Temporomandibular disorders include problems
with the joints, the muscles surrounding them, or both.
SECTION 2 • Methods for Examination

Examination Techniques
1. Examination Techniques. The two primary examination techniques are
inspection and palpation.
a. Inspection is a systematic visual examination of a patient’s general
appearance, skin, or a part of the body to observe its condition.
 b. Palpation is the examination of a part of the body by using the
fingertips to move or compress a structure against the underlying
tissue. The most sensitive part of the hand—the fingertips—should be
used for palpation.
2. Keys to Effective Examination Technique
a. Consistent sequence. The sequence for examination of the head and
neck must be followed consistently with every patient so as not to
accidentally skip an area or structure. The specific order can vary
from clinician to clinician. It is most important, however, that once a
clinician chooses a particular sequence that he or she keeps the same
sequence of examination every time to ensure thoroughness.
b. Good palpation technique. Correct palpation technique is critical to
the success of a head and neck examination. Suggestions for effective
palpation technique are listed in Box 13-1.
c. Careful documentation. All findings should be documented on the
patient chart or computerized record. Documentation of unusual or
abnormal findings with a camera is extremely helpful.

BOX Technique for Effective Palpation

13-1

1. To detect abnormalities such as swelling, tumors, or enlarged lymph

nodes, the structure being examined must be compressed against a
firm, underlying structure or between the examiner’s fingers.
2. To compress a structure against an underlying structure, use the
fingertips to depress the structure being examined about 1/2 inch
against the underlying tissue.
3. Depress the structure, applying consistent light pressure and a circular
motion.
4. When ready to palpate another area, lift the fingers, move to the next
area, and repeat the process applying light, consistent pressure against
the underlying tissue.
 5. Incorrect palpation technique involves lightly “walking” or
“dancing” the fingertips over a structure. This light dancing
technique usually is unsuccessful in detecting nodules, tumors,
swelling, or enlarged lymph nodes.
6. Rather than dancing your fingertips over a structure, use the fingertips
to compress the structure against the underlying tissues using a circular
motion.

Compression Techniques
To detect abnormalities such as swelling, tumors, or enlarged lymph nodes,
the structure being examined must be compressed against a firm structure or
between the examiner’s fingers (Table 13-1). The fingertips are used during
palpation by placing the sensitive palmar surfaces of the fingertips against the
tissues (Fig. 13-17).
 Two basic compression techniques are employed during palpation:
1. Compressing the soft tissue between the examiner’s fingertips and
2. Compressing the soft tissue against underlying structures or tissues of
the head or neck.

Palpation Expectations
In health, the lymph nodes, salivary glands, and thyroid rarely are detectible
by palpation. For this reason, many beginning clinicians express concern
saying, “But I don’t feel anything.” Table 13-2 outlines findings that can be
detected by palpation.
• Palpating the structures of the head and neck can be likened to our
observations in everyday life.
• Think about the skin of the arm. When touched, the skin on an arm is
smooth, even, soft, and intact. This is the normal finding.
• If the arm is stung by a bee, however, there will be a red, raised welt on
the skin. The area of the sting is swollen, tender, and warm to the touch.
The welt is an example of an abnormal finding.
• Thus, an infected, injured, or diseased structure—like a lymph node—
may be palpable when normally it is not detectible.
 SECTION 3 • Peak Procedure
The head and neck examination involves the inspection and palpation of the
structures of the head and neck. It is helpful to organize the structures to be
examined into four subgroups:
1. Overall appraisal, head, neck, face, and skin
2. Lymph nodes of the head and neck
3. Salivary and thyroid glands
4. The temporomandibular joint (TMJ)

Procedure 13-1. Head and Neck Examination

SUBGROUP 1: OVERALL APPRAISAL OF HEAD, NECK, FACE,
AND SKIN
Table 13-3 presents an overview of normal and notable findings for the head
and neck examination.
SUBGROUP 2: LYMPH NODES OF THE HEAD AND NECK
Table 13-4 presents an overview of normal and notable findings for the the
lymph nodes of the head and neck region.

SUBGROUP 3: SALIVARY AND THYROID GLANDS

Table 13-5 presents normal and notable findings for the salivary and thyroid
glands.
SUBGROUP 4: TEMPOROMANDIBULAR JOINT (TMJ)
Table 13-6 presents normal and notable findings for the TMJ.

Procedure 13.1. Head and Neck Examination

EQUIPMENT
Gloves and optional overgloves
Small cup of water for patient use during thyroid exam

SUBGROUP 1: OVERALL APPRAISAL OF

HEAD, NECK, FACE, AND SKIN

Action Rationale
1. General appraisal. While
seating and chatting with the
 patient, unobtrusively inspect
the skin and facial symmetry
of the face and neck.
If problems are detected,
question the patient about the
onset, duration, and possible
causes of any surface
variations of the skin, such as
lesions or scars.
2. Preparation and • An upright head position
positioning. Position the makes the structures of the
patient in an upright seated neck standout for easier
position. The patient should examination.
support his or her head in an • The height of the patient
upright position rather than chair should be positioned
resting it against the headrest. so that the clinician can
Ask the patient to remove easily reach all the
eyeglasses and loosen structures to be examined.
clothing that limits • Gloves prevent direct
examination of the neck. contact with open wounds,
Wash and dry hands, don cuts, sores, or contagious
gloves. skin conditions.
Donning overgloves at this • Donning overgloves at this
time is optional. time facilitates moving
directly from the head and
neck examination to the
intraoral examination. The
overgloves are removed
before proceeding to the
intraoral examination.
3. Provide Information. • Reduces patient
Briefly explain the apprehension and
 examination procedure to the encourages patient
patient. cooperation.
4. Head, scalp, and ears. • Lesions and head lice are
Change your position so that common conditions that
you are standing directly may be detected on the
behind the patient. Visually skin and scalp of the head.
inspect the head and scalp for • The ears are common sites
any abnormalities. Inspect the for lesions, such as basal
ears. cell carcinoma.

SUBGROUP 2: LYMPH NODES OF THE

HEAD AND NECK
1. Occipital lymph nodes. The occipital nodes are located at the
base of the skull.
 1. Your position. Stand behind the patient.
2. Patient’s position. Ask the patient to tip the head forward
slightly. If applicable, the patient can assist by holding up
long hair so that the neck is fully visible to the examiner.
3. Palpation technique
• Position your fingertips at the base of the skull.
• Begin at the midline of the neck, working outward along the
hairline until the sternomastoid muscle is reached.
• Use circular motions with your fingertips to compress the
tissues against the base of the underlying bone.
• Cover the area slightly above and below the hairline
because the location of lymph nodes varies among patients.

2. Posterior auricular lymph nodes. The posterior auricular

nodes are located behind each ear.
1. Your position. Stand behind the patient.
2. Patient’s position. Head in an upright position. If applicable,
the patient can assist by holding up long hair so that the neck
is fully visible to the examiner.
3. Palpation technique
• Inspect each ear separately, beginning with the right ear.
• Displace the right ear forward to visually inspect the back
of the ear and the skin behind the ear. The ears are common
sites for lesions, such as basal cell carcinoma.
 • Palpate the posterior auricular nodes using steady, gentle
circular motions with your fingertips to compress the
tissues against the bone of the patient’s skull.
• Repeat this procedure to examine the back of the left ear
and the skin behind it.

3. Preauricular lymph nodes. The preauricular nodes are located

in front of the ears.

1. Your position. Stand behind the patient.

 2. Patient’s position. Head in an upright position.
3. Palpation technique
• Palpate the preauricular nodes using steady, gentle circular
motions with your fingertips against the underlying bone.
• Note tender or enlarged lymph nodes.

4. Submental lymph nodes. The submental nodes are located

under the jaw on either side of the midline of the mandible.

1. Your position. Stand behind or to the side of the patient.

 2. Patient’s position. Head in upright position.
3. Palpation technique
• Use your thumb and index finger to compress the area
behind and beneath the symphysis (midline area) of the
mandible.
• Note tender or enlarged nodes.

5. Submandibular lymph nodes. The submandibular nodes are

under the jaw, along the side of the mandible.

1. Your position. Stand behind the patient.

 2. Patient’s position. Head in upright position.
3. Palpation technique
• Begin with the submandibular nodes on the right side of the
head
• To facilitate palpation, use your left hand as a stabilizing
hand to move the tissue under the chin toward the right side
of the neck. Moving the tissue toward the right side assists
the examiner in rolling the tissue over the right side of the
mandible.
• Your right hand is used for palpation. Cup your fingers
under the chin; roll the tissue up and over the inferior
border of the mandible. Keeping the fingertips in place,
allow the tissue to slowly slide down over the mandible,
back into normal position. As the tissue moves over the
mandible, you can detect enlarged nodes.
• Examine the submandibular nodes on the left side of the
jaw, using a similar procedure.

6. Cervical lymph nodes medial to muscle. The anterior chain of

cervical lymph nodes lie above the sternomastoid muscle.
 1. Your position. Stand behind the patient.
2. Patient’s position. Ask the patient to tip the chin down
slightly and turn the head to the left. This position makes the
sternomastoid muscle stand out. Support the patient’s chin
with your left hand.
3. Palpation technique.
• Palpate the cervical nodes medial to the sternomastoid
muscle, beginning with those on the right side of the neck.
• With your right hand, grasp the body of the muscle between
your fingertips and thumb.
• Rotate your fingertips back and forth over the muscle,
covering its entire length from behind the ear to the
clavicle.

7. Cervical lymph nodes posterior to muscle. The posterior chain

of cervical lymph nodes lie beneath and posterior to the
sternomastoid muscle.
1. Your position. Stand behind the patient.
2. Patient’s position. Ask the patient to maintain the same head
position as when palpating the lymph nodes medial to the
muscle.
3. Palpation technique
• Begin by palpating the nodes on the right side of the neck.
• Palpate the nodes by positioning the fingertips of your index
and middle fingers under (behind) the muscle and applying
gentle compression against the underlying tissues along the
 entire length of the muscle from behind the ear to the
clavicle.
• Repeat this procedure to examine the cervical nodes medial
and posterior to the sternomastoid muscle on the left side of
the neck.

8. Supraclavicular lymph nodes. The supraclavicular nodes are

located in the angle formed between the sternomastoid muscle
and the clavicle.

1. Your position. Stand to the side or behind the patient.

 2. Patient’s position. Ask the patient to face forward with the
chin tipped slightly downward. This position facilitates
palpation by relaxing the muscles in the neck.
3. Palpation technique
• Place your index and middle fingers above the clavicle on
the right side of the neck and apply circular compression.
• Palpate the supraclavicular nodes on the left side using the
same technique.

SUBGROUP 3: SALIVARY AND THYROID

GLANDS
1. Parotid glands. The parotid gland is located between the ear
and the jaw.
 1. Your position. Stand behind or slightly to the side of the
patient.
2. Patient’s position. Head in upright position.
3. Palpation technique
• Place the palms of your hands in front of the ears with your
fingers extending the full length of the cheek so that you
can palpate the entire gland.
• Use circular compression to compress the tissue against the
cheekbones.
• A normal parotid gland is difficult to detect by palpation;
however, an enlarged gland or nodules in the gland are
palpable.
• Pain or tenderness may be related to salivary stones,
inflammation, or cancer.

2. Submandibular glands—locate. The submandibular gland sits

below the jaw toward the back of the mouth.
1. Your position. Stand behind the patient.
2. Patient’s position. Head in upright position.
3. Locate the submandibular gland.
• Locate the submandibular salivary glands by placing your
index fingers near the angle of the mandible and then
moving forward along the mandible to locate the slight
depression in the inferior border of the mandible—the
antegonial notch.
• Continue to the next page for the palpation technique for
 the submandibular glands.

3. Submandibular glands—palpate.

1. Your position. Stand behind the patient.

2. Patient’s position. Head in upright position.
3. Palpation technique
• Move your fingers under the chin to locate the gland on
both sides of the head.
• Ask the patient to press the tip of his or her tongue against
 the roof of her mouth. This causes the mylohyoid and
tongue muscles to tense, making it easier to palpate the
submandibular gland.
• Bilaterally compress the glands upward against the tensed
muscles.

4. Thyroid gland—locate. The thyroid gland is located in the

middle of the lower neck. It is situated below the larynx, over
the trachea, and just above the clavicles.

1. Your position. Stand behind the patient.

 2. Patient’s position. Head in upright position.
3. Locate the thyroid gland.
• Find the thyroid cartilage (the Adam’s apple) at the midline
of the neck. The thyroid gland lies approximately 2–3 cm
below the thyroid cartilage.
• Give the patient a cup of water and ask him or her to
swallow as you watch this region. The thyroid gland, along
with the adjacent structures, will move up and down with
swallowing.
• The normal thyroid is not visible, so observing the neck
during swallowing is helpful in locating the gland. Once
you have located the gland, you are ready to palpate it.10
• Continue to the next page for the palpation technique for
the thyroid gland.

5. Thyroid gland—palpate right lobe.

1. Your position. Stand behind the patient and position your
hands with thumbs on the nape of the neck.
2. Patient’s position. Ask the patient to flex the neck forward
and tilt the head slightly to the right. This relaxes the neck
muscles for easier palpation.
3. Palpation technique. Begin with the right lobe of the gland.
• Use your left hand as a stabilizing hand to displace the
trachea slightly to the right.
• Use your right hand for palpation. Position your fingers
between the Adam’s apple and the sternomastoid muscle.
Rest your fingers lightly in a stationary position.
• Ask the patient to take a sip of water and swallow, as the
fingers of your right hand rest lightly on the neck. The
gland slides beneath your fingers as it moves up and down
during swallowing. Repeat this process several times.
• A normal gland is undetectable or barely detectable. Do not
be disappointed if you do not identify the gland. If the gland
is detectable, this is a notable finding.
• Repeat a similar maneuver to examine the left lobe of the
thyroid gland.
SUBGROUP 4: TEMPOROMANDIBULAR
JOINT (TMJ)
1. (TMJ)—locate.

1. Your position. Stand behind the patient.

2. Patient’s position. Head in upright position.
3. Locate the TMJ.
• Locate the joints by placing your index fingers just in front
of the tragus of each ear.
• Ask the patient to open and close the mouth. As the mouth
is opened and closed, your fingertips should drop into the
joint spaces.
• Continue to the next page for directions on palpating the
TMJ.

2. TMJ—palpate.
 1. Your position. Stand behind the patient.
2. Patient’s position. Head in upright position.
3. Palpation technique
• Place your fingertips over the joints. Palpate the joints as
the patient slowly opens and closes several times.
• Note any deviations during opening.
• Continue to the next page for directions on palpation
during lateral excursions.

3. TMJ—lateral excursions (side to side movements of the jaw).

1. Your position. Stand behind the patient.
2. Patient’s position. Head in upright position.
3. Palpation technique
• Maintaining your hands in the same position, ask the patient
to open slightly and move the lower jaw laterally to the
right.
• Repeat this maneuver, with the patient moving the lower
jaw to the left.
• Finally, ask the patient to protrude the lower jaw forward.
 • Listen for abnormal sounds such as popping or clicking.

4. Optional examination: TMJ—range of motion.

Assessment of the range of motion is optional, based on notable

findings from the TMJ assessment.
• Assess normal range of motion by asking the patient to place the
index, middle, and ring fingers between the incisal edges of the
upper and lower incisors. The patient’s own fingers are
proportional to his or her jaw and are a good indication of
adequate range of motion.
5. Document. Document all notable findings in the patient chart or
computerized record.

SECTION 4 • The Human Element

Through the Eyes of a Cancer Survivor

JUST A “BEAUTY MARK”

About 10 years ago, while I was pregnant with my first child, my mother
urged me to go and have the small brown spot above my upper lip checked
by a doctor. At the time, I was excited and busy getting ready for my first
child, and I decided that the brown spot was just like a beauty mark. I
knew that it had only appeared about a year ago, but I did not want to
worry about it. After all, I saw my obstetrician each month, and I had just
had a dental exam last month. Surely, my doctor or my dentist would have
noticed the brown spot above my lip and told me if it was a problem.
Wouldn’t they?
Well, finally, because my mother just insisted, I went to see my
regular doctor to ask about the brown “beauty” mark. I was shocked when
he wanted to remove the spot and send it off to the lab. The test results
showed that the brown spot was cancer, and I had to have additional
surgery to make sure that all the cancer cells had been removed.
 Six years ago, I went back to school and became a dental hygienist.
Today, as a dental hygienist, I stress the importance of a yearly head, neck,
and oral cancer examination to all my patients. My experience made me so
aware that many health professionals have tunnel vision. My obstetrician
concentrated on my pregnancy. My dentist looked at my teeth but did not
look up an inch to notice the brown spot above my upper lip. As future
dental health care providers, I strongly urge you to remember that doing a
cancer exam and following up on any changes could save a patient’s life.
Cathy, RDH,
Cancer Survivor

Ethical Dilemma

THE HEAD AND NECK EXAM

Utsava is in her last semester of dental hygiene school, and her patient for
the day just cancelled. Desperate, she calls any relative that she can think
of who may be available. Her brother-in-law, Paresh, a 32-year-old
engineer, agrees to be her patient for the day.
Paresh’s medical history assessment indicates that he has not seen a
physician or dentist for over 10 years. Utsava performs a head and neck
examination and asks her instructor, Professor Miller, to check it so she
can progress with the appointment.
 Utsava reports to her instructor that all areas of the head and neck
examination were all “within normal limits.” Professor Miller asks Paresh
to tip his head forward so she can both observe and palpate his occipital
lymph nodes. As soon as she does, Professor Miller both notices and
palpates an enlargement in Paresh’s occipital area, which extends from the
nape of his neck all the way under his hairline. Professor Miller points out
the enlargement to Utsava, who states that she just thought that it was part
of Paresh’s normal anatomy. Utsava states that as long as she has known
Paresh, his occipital area has looked like this. Utsava does admit that
looking closely at it now the area appears to have enlarged over the last
few years. Professor Miller is very concerned about the finding, as she
feels that it is outside the limits of normal.
1. What ethical principles are involved in this scenario?
2. How should Utsava address Paresh’s treatment?
3. What should Utsava do when treating future patients?

English-to-Spanish Phrase List

SECTION 5 • Practical Focus—Fictitious Patient Cases

DIRECTIONS
• The photographs in this section show the findings from the head and
neck examination of five fictitious patients, patients A to E. Refer to
previous modules to refresh your memory regarding each patient’s
health history and vital signs because there may be a connection
between the patient’s systemic health status or habits and the findings
from the head and neck examination.
• Use the Lesion Descriptor Worksheet to develop descriptions for the
 notable findings of fictitious patients A to E.
• The pages in this section may be removed from the book for easier use
by tearing along the perforated lines on each page.

Sources of Clinical Photographs in this Section

The author gratefully acknowledges the sources of the following clinical
photographs in the “Practical Focus” section of this module.
• Figure 13-52. From Goodheart HP. Goodheart’s Photoguide of Common
Skin Disorders. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2003.
• Figure 13-54. From Langlais RP, Miller CS, Nield-Gehrig JS. Color
Atlas of Common Oral Diseases. 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2009.
• Figure 13-58. Dr. Richard Foster, Guildford Technical Community
College, Jamestown, NC.
• Figure 13-60. Image provided by Stedman’s Medical Dictionary.

Fictitious Patient Case A: Mr. Alan Ascari

Fictitious Patient Case B: Bethany Biddle
Fictitious Patient Case C: Mr. Carlos Chavez
Fictitious Patient Case D: Mrs. Donna Doi
Fictitious Patient Case E: Ms. Esther Eads
SECTION 6 • Skill Check

Technique Skill Checklist: Head and Neck Examination

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as
S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E

Subgroup 1: Overall Appraisal of the Head,

Neck, Face, and Skin
Unobtrusively inspects the skin and facial symmetry
of the face and neck.
Positions the patient in an upright-seated position.
Asks patient to remove eyeglasses and loosen
clothing that limits examination of the neck.
Requests that the patient not lean the head against
the headrest.
Visually inspects the head, scalp, and ears.
Washes and dries hands. Follows clinic protocol
regarding gloves.
Subgroup 2: Lymph Nodes of the Head and Neck
Palpates the occipital nodes.
Palpates the posterior auricular lymph nodes by
applying circular compression with the fingertips.
Palpates the preauricular lymph nodes by applying
circular compression with the fingertips.
Palpates the submental nodes using digital
compression with the thumb and index fingers.
Palpates the submandibular nodes by rolling the
tissue over the mandible.
Palpates the cervical nodes medial to the muscle by
grasping the muscle and rotating the fingertips back
and forth over the muscle. Covers the entire length
of the muscle from the ear to the clavicle.
Palpates the cervical lymph nodes posterior to the
muscle by applying gentle compression under the
muscle against the underlying tissues along the
entire length of the muscle.
Palpates the supraclavicular lymph nodes using
circular compression.
Subgroup 3: Salivary and Thyroid Glands
Palpates the parotid glands using circular
compression.
Locates submandibular glands by finding the
antegonial notch. Asks the patient to press the tip of
the tongue against the roof of the mouth while
compressing the glands upward against the tensed
muscles.
Locates the thyroid gland below the thyroid
cartilage. Asks patient to swallow a sip of water, if
necessary, to facilitate locating the gland. Keeping
the hand in a stationary position, palpates the gland
as the patient swallows sips of water.
Subgroup 4: Temporomandibular Joint
Locates the joints near the tragus of each ear and
 palpates as the patient slowly opens and closes the
mouth.

Palpates the TMJ as the patient makes lateral

excursions to the right and then to the left.
OPTIONAL: Assesses the range of motion by
asking the patient to place the index, middle, and
ring fingers between the incisal edges of the upper
and lower incisors.

Documents notable findings in the patient chart or

computerized record.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

Communication Skill Checklist: Head and Neck

Examination

ROLES:
• Student 1 = Plays the role of a fictitious patient.
• Student 2 = Plays the role of the clinician.
• Student 3 or instructors = Plays the role of the clinic instructor near
the end of the role-play.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Explains what is to be done.
Reports notable findings to the patient. As needed,
makes referrals to a physician or dental specialist.
Encourages patient questions before and during the
head and neck examination.
Answers the patient’s questions fully and
accurately.
Communicates with the patient at an appropriate
level avoiding dental/medical terminology or
jargon.
Accurately communicates the findings to the
clinical instructor. Discusses the implications for
dental treatment using correct medical and dental
terminology.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

NOTE TO COURSE INSTRUCTOR: A series of role-play

scenarios for the modules in this textbook can be found at
http://thepoint.lww.com/GehrigPAT4e.

References
1. Alho OP, Teppo H, Mäntyselkä P, Kantola S. Head and neck cancer in primary care:
presenting symptoms and the effect of delayed diagnosis of cancer cases. CMAJ.
2006;174(6):779–784.
2. Anand N, Chaudhary N, Mittal MK, Prasad R. Comparison of the efficacy of clinical
examination, ultrasound neck and computed tomography in detection and staging of
cervical lymph node metastasis in head and neck cancers. Indian J Otolaryngol Head
Neck Surg. 2007;59(1):19–23.
3. de Visscher JG. Examination of the head and neck region: a part of the routine mouth
examination [in Dutch]. Ned Tijdschr Tandheelkd. 2012;119(3):107.
4. Georgopoulos R, Liu JC. Examination of the patient with head and neck cancer. Surg
Oncol Clin N Am. 2015;24(3):409–421.
5. Gogarty DS, Shuman A, O’Sullivan EM, et al. Conceiving a national head and neck
cancer screening programme. J Laryngol Otol. 2016;130(1):8–14.
6. Kemper M, Zahnert T, Graupner A, Neudert M. Operationalization of the clinical
head and neck examination [in German]. Laryngorhinootologie. 2011;90(9):537–542.
7. Louis PJ, Williams MA. Problems and abnormalities found on routine clinical head
and neck examination. Semin Orthod. 1998;4(2):99–112.
8. Hapner ER, Bauer KL, Wise JC. The impact of a community-based oral, head and
neck cancer screening for reducing tobacco consumption. Otolaryngol Head Neck
Surg. 2011;145(5):778–782.
9. Sharawy M. Knowledge of the lymphatics of the head & neck is essential to the
accurate examination of lymph nodes. J Okla Dent Assoc. 2002;92(3):48–49.
10. Slater S. Palpation of the thyroid gland. South Med J. 1993;86(9):1001–1003.
 MODULE
14

ORAL EXAMINATION
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
This module describes the oral examination. The oral examination is a
physical examination technique that consists of a systematic visual inspection
and/or palpation of the structures of the oral cavity and oropharynx. This
examination should be a routine part of each patient’s dental visit.
This module describes the oral examination including:
• An anatomy review of oral structures
• Peak procedure for a systematic oral examination

MODULE OUTLINE
SECTION 1 Examination Overview
Oral Cancer
Information to Improve Patient Understanding
Risk Factors, Signs, and Symptoms of Oral Cancer
Anatomy Review
Landmarks of the Lips
Salivary Glands
Ventral Surface of the Tongue and Anterior Floor of
 Mouth
Dorsal Surface of the Tongue
Palate, Tonsils, and Oropharynx
SECTION 2 Peak Procedure
Procedure 14-1. Oral Examination
Subgroup 1: Lips and Vermillion Border
Subgroup 2: Oral Cavity and Mucosal Surfaces
Subgroup 3: Underlying Structures of the Lips and
Cheeks
Subgroup 4: Floor of the Mouth
Subgroup 5: Salivary Gland Function
Subgroup 6: The Tongue
Subgroup 7: Palate, Tonsils, and Oropharynx
SECTION 3 The Human Element
Through the Eyes of a Student
Ethical Dilemmas
English-to-Spanish Phrase List
SECTION 4 Practical Focus—Fictitious Patient Cases
Fictitious Patient Case A: Mr. Alan Ascari
Fictitious Patient Case B: Bethany Biddle
Fictitious Patient Case C: Mr. Carlos Chavez
Fictitious Patient Case D: Mrs. Donna Doi
Fictitious Patient Case E: Ms. Esther Eads
SECTION 5 Skill Check
KEY TERMS
Oral examination • Oral cancer • Vermillion border • Commissures •
Parotid glands • Submandibular glands • Sublingual glands • Sublingual
caruncles • Lingual frenum • Sublingual fold • Sublingual veins • Papillae
(of the tongue) • Filiform papillae • Fungiform papillae • Foliate papillae
• Circumvallate papillae • Oropharynx

OBJECTIVES
• Recognize the normal anatomy of the oral cavity.
• Locate the following oral structures: parotid ducts, sublingual fold,
sublingual caruncles, papillae, anterior and posterior pillars, and the
tonsils.
• Recognize and describe deviations from normal in the oral cavity.
• Position the patient correctly for the oral examination.
• Demonstrate the use of communication strategies to provide
information to the patient about the oral examination and any notable
findings.
• Demonstrate the oral examination using correct technique and a
systematic sequence of examination.
• Document notable findings in the patient chart or computerized
record.
• Identify findings that have implications in planning dental treatment.
• Provide referral to a physician or dental specialist when findings
indicate the need for further evaluation.
• Demonstrate knowledge of the soft tissue findings by applying
concepts from this module to the fictitious patient cases A to E found
in Section 4.

SECTION 1 • Examination Overview

A comprehensive oral examination is a physical examination technique
consisting of a systematic inspection of the oral structures. Like the head and
neck examination, this procedure takes only minutes. The oral examination
allows the clinician to gather general information on the health of a patient,
note early indications of some diseases, and detect abnormalities and
potentially life-threatening malignancies at an early stage.1–19
The American Dental Association (ADA) recommends that a
comprehensive oral examination should be a routine part of each patient’s
dental visit.18 Teaching patients about oral cancer screenings and performing
oral cancer examinations at every appointment is part of the dental hygiene
process of care and policy of the American Dental Hygienists’
Association.20,21

Oral Cancer
The British Dental Association has adopted a definition of oral cancer as
malignancies of the lip, tongue, gingiva, all of the oral mucosa, oropharynx,
and pharynx.17 Figure 14-1 depicts the oral cancer process.

Tissue changes in the mouth that signal the beginnings of cancer often
can be seen and felt easily. With early detection and timely treatment, deaths
from oral cancer could be dramatically reduced.3,5,6,8,15,22 When detected at
the earliest stages, oral cancer has an 80% survival rate. At present, only one-
third of oral cancers are diagnosed in the early stage. Only 13% of Americans
recall having an oral examination performed in the past year.23 Healthy
People 2020 targets the goal of increasing this statistic to 20% so that more
individuals receive an annual oral examination.24
In the United States in 2013, there were an estimated 300,682 people
living with cancer of the oral cavity and pharynx.25 Close to 48,250
Americans will be diagnosed with oral or pharyngeal cancer in 2016. It will
cause over 9,575 deaths, killing roughly 1 person per hour, 24 hours per day.
Of those 48,250 newly diagnosed individuals, only slightly more than half
will be alive in 5 years.25 Worldwide, the problem is much greater. The
World Health Organization (WHO) estimates over 450,000 new cases being
found each year. Of the oral structures, the tongue is the site with the highest
incidence rate.25

Information to Improve Patient Understanding

Although a detailed explanation of oral cancer screening is not necessary,
patients should normally be told that an oral cancer check is being carried
out. There is plenty of evidence to show that patient satisfaction with
clinicians is increased if patients are given this information.26–29 All dental
team members must be prepared to answer patient questions. Box 14-1
provides examples of simple language that can be used to answer patient
questions.28–30

BOX Answering Patient Questions

14-1

Why Haven’t I Had This (Cancer Screening) Done Before?

Evidence shows that cases of oral cancer are increasing. We believe we
should be taking a more active role by extending the scope of health care
provided at this clinic/dental practice. Remember, I can see parts of your
mouth that you cannot easily see yourself.
What Is Cancer of the Mouth?
Oral cancer is a serious growth that can occur in any part of the mouth.
How Can I Tell if I Have Mouth Cancer?
Most cancers appear as a painless ulcer that does not heal normally.
Less often, a white or red patch in the mouth may develop into a cancer.
 Am I at Risk for Mouth Cancer?
Anyone can be affected by mouth cancer, whether they have teeth or not.
Smoking greatly increases your risk of mouth cancer. Heavy drinking is
also a risk.
How Can Mouth Cancer Be Detected Early?
Mouth cancer can often be spotted early by the dentist or dental
hygienist.
What Is Involved In Checking the Mouth for Cancer?
I will examine the inside of your mouth with the help of a small mirror.

Risk Factors, Signs, and Symptoms of Oral Cancer

The public domain publications of the U.S. Department of Health and Human
Services, National Institutes of Health, and National Institutes of Dental and
Craniofacial Research contain information about risk factors, prevention,
signs, and symptoms of oral cancer. A summary of this information is found
below. Box 14-2 summarizes common signs and symptoms of oral cancer.

BOX Common Signs and Symptoms of Oral Cancer

14-2

LESIONS THAT MIGHT SIGNAL ORAL CANCER

• Leukoplakia (white lesions): possible precursor to cancer
• Erythroplakia (red lesions): less common than leukoplakia but with
greater potential for becoming cancerous
SYMPTOMS THAT YOUR PATIENT MIGHT REPORT
• Soreness
• A lump or thickening
• Numbness in the tongue or other areas of the mouth
• Feeling that something is caught in the throat, hoarseness
• Difficulty chewing or swallowing
• Ear pain
 • Difficulty moving the jaw or tongue
• Swelling of the jaw that causes dentures to fit poorly
MANAGEMENT OF SUSPICIOUS LESIONS
• White or red lesions should be reevaluated in 2 weeks.
• Any white or red lesion that does not resolve itself in 2 weeks should
be biopsied to obtain a definitive diagnosis.
• Any symptom listed previously that persists for more than 2 weeks
indicates the need for referral to an appropriate specialist for definitive
diagnosis.

RISK FACTORS FOR ORAL CANCER

1. Age
• The incidence of oral cancer rises steadily with age, usually because
older persons have had a longer exposure to risk factors, such as
exposure to sunlight.
• Incidence peaks between ages 55 and 74 years.
2. Gender. Men are 2 times more likely to develop oral cancer than are
women.
3. Sunlight. Exposure to sunlight is a risk factor for lip cancer.
4. Tobacco and Alcohol Use
• Tobacco and excessive alcohol use increases the risk of oral cancer.
• Using tobacco and alcohol in combination poses a much higher risk than
using either substance alone. Those who both smoke and drink alcohol
have a 15 times greater risk of developing oral cancer than others.4,31

Anatomy Review
LANDMARKS OF THE LIPS
Two important landmarks of the lips are the vermillion border and the
commissure (Fig. 14-2). Both of these landmarks are useful when recording
the location of a soft tissue lesion or other notable finding. Figures 14-3 and
14-4 illustrate some conditions that can cause an alteration in the normal
appearance of the lip.

SALIVARY GLANDS
The major salivary glands are three pairs of glands that produce saliva (Fig.
14-5).
1. The parotid glands are the largest of the salivary glands. Each gland is
located on the surface of the masseter muscle between the ear and the jaw.
• Each parotid gland has a duct that opens into the oral cavity opposite the
maxillary first molar (Fig. 14-6).

2. The submandibular glands sit below the jaw toward the back of the
mouth.
• Each submandibular gland has a duct that extends forward in the floor of
the mouth to open into the sublingual caruncles.
• Refer to Figure 14-7 for the anatomy of the anterior floor of the mouth.
3. The sublingual glands are located in the anterior floor of the mouth next
to the mandibular canines.
• Each has one major duct that opens—along with the submandibular
glands—into the sublingual caruncles.
• In addition, the sublingual gland has several minor ducts, which open in
a line along the fold of tissue beneath the tongue, known as the
sublingual fold.
VENTRAL SURFACE OF THE TONGUE AND ANTERIOR FLOOR
OF MOUTH
Landmarks of the ventral surface of the tongue and anterior floor of the
mouth include the sublingual caruncles, the lingual frenum, the sublingual
fold, and the sublingual veins. Some of these landmarks are shown in Figure
14-8.
DORSAL SURFACE OF THE TONGUE
The dorsal surface of the tongue has a complex arrangement of papillae that
serve as taste sensitive structures. Figure 14-9 illustrates this arrangement of
papillae. Figures 14-11 and 14-12 show variations in the appearance
(pigmentation) and anatomy (ankyloglossia) of the tongue, respectively.
PALATE, TONSILS, AND OROPHARYNX
Figure 14-13 illustrates the normal anatomy of the palate, tonsils, and
oropharynx (the part of the throat at the back of the mouth, including the
soft palate, the base of the tongue, and the tonsils). Figures 14-14 and 14-15
show conditions that can alter the appearance of the anatomy of the palate,
tonsils, and oropharynx.
 SECTION 2 • Peak Procedure
Evidence-based clinical recommendations developed by a panel convened by
the ADA Council on Scientific Affairs advocate the comprehensive oral
examination as the “gold standard” for early oral cancer detection.7
The oral examination involves the inspection and/or palpation of the
structures of the oral cavity and oropharynx. To assist the examiner, it is
helpful to organize the structures to be examined into seven subgroups:
• Subgroup 1: Lips and Vermillion Border
• Subgroup 2: Oral Cavity and Mucosal Surfaces
• Subgroup 3: Underlying Structures of the Lips and Cheeks
• Subgroup 4: Floor of the Mouth
• Subgroup 5: Salivary Gland Function
• Subgroup 6: The Tongue
• Subgroup 7: Palate, Tonsils, and Oropharynx

Peak Procedure 14–1. Oral Examination

SUBGROUP 1: LIPS AND VERMILLION BORDER
Table 14-1 presents an overview of normal and notable findings for the lips
and vermillion border.

SUBGROUP 2: ORAL CAVITY AND MUCOSAL SURFACES

Table 14-2 presents an overview of normal and notable findings for the
mucosal surfaces.
SUBGROUP 3: UNDERLYING STRUCTURES OF THE LIPS AND
CHEEKS
Table 14-3 presents an overview of normal and notable findings for the
underlying structures of the lips and cheeks.

SUBGROUP 4: FLOOR OF THE MOUTH

Table 14-4 presents an overview of normal and notable findings for the floor
of the mouth.
SUBGROUP 5: SALIVARY GLAND FUNCTION
Table 14-5 presents an overview of normal and notable findings for the
salivary glands.

SUBGROUP 6: THE TONGUE

Table 14-6 presents an overview of normal and notable findings for the
tongue.
SUBGROUP 7: PALATE, TONSILS, AND OROPHARYNX
Table 14-7 presents an overview of normal and notable findings for the
palate, tonsils, and oropharynx.
Procedure 14-1. Oral Examination
EQUIPMENT
Gloves and protective gear for the clinician
Safety glasses for the patient
2 in × 2 in gauze squares, cotton-tipped applicators, and a dental
mirror

SUBGROUP 1: VISUAL INSPECTION OF

LIPS AND VERMILLION BORDER
1. Preparation for the examination.
 • After briefly explaining the procedure to the patient, ask him
or her to remove partial or complete dentures, if applicable.
Give female patients a tissue to remove lipstick.
• Provide the patient with safety glasses.
• Wash your hands and don gloves.
• Place the patient in a supine position.
• Position yourself in a seated position.

2. Lips and vermillion border—visual inspection.

• Visually inspect the lips and vermillion border.

SUBGROUP 2: INSPECTION OF THE ORAL

CAVITY AND MUCOSAL SURFACES
1. Oral cavity—preliminary visual inspection.
 • Visually inspect the entire oral cavity and oropharynx.
• Adjust the dental unit light so that the oral cavity is well
illuminated.
• Use a dental mirror to look for any conditions that would
cause the examination procedure to be modified or postponed.
Examples include herpetic lesions or a red, inflamed throat.

2. Labial mucosa of the lower lip—visual inspection.

• Visually inspect the labial mucosa of the lower lip. Place the
index fingers of both hands on the inside with your thumbs
on the outside of the lower lip.
• Tip: Keep your index finger(s) inside the mouth and the
thumb(s) outside the mouth while completing all the steps
for examining the mucosal surfaces. This technique keeps
your wet fingers inside the mouth while your dry fingers
 come in contact with the patient’s face. Your patient will
appreciate this courtesy.
• Evert and retract the lip fully away from the teeth and alveolar
ridge. Retract the lip completely so that you have a clear view
of the entire labial mucosal surface and vestibule of the lower
lip.

3. Labial mucosa of the upper lip—visual inspection.

• Examine the labial mucosa of the upper lip in a similar

manner. Slide both index fingers upward to position them
between the maxillary arch and the labial mucosa of the upper
lip.
• Use your thumbs to evert and retract the upper lip.
• Stretch the tissue away from the dental arches. Visually
examine the entire mucosal surface adjacent to the maxillary
teeth as well as the tissue between the dental arches.

4. Buccal mucosa—visual inspection.

 • Begin with the buccal mucosa on the right side of the mouth,
near the maxillary arch.
• Place the index fingers of both hands on the inside with the
thumbs on the outside of the cheek. One hand and a mirror
can also be used, taking care not to press the mirror rim
against the soft tissue.
• Evert the cheek and stretch the tissue of the right cheek up and
away from the maxillary teeth. Extend the tissue completely
away from the teeth so that no folds remain to conceal a lesion
or abnormality. Proceed to Step 5 to examine the buccal
mucosa adjacent to the mandibular arch on the right side of
the mouth.

5. Buccal mucosa—visual inspection.

• Next, inspect the buccal mucosa on the right side of the

 mouth, near the mandibular arch.
• Stretch the cheek down and away from the mandibular arch on
the right side of the mouth.
• Extend the tissue completely away from the teeth so that no
folds remain to conceal a lesion or abnormality.
• Visually inspect the buccal mucosa. Repeat this process to
examine the buccal mucosa on the left side of the mouth.

SUBGROUP 3: UNDERLYING STRUCTURES

OF THE LIPS AND CHEEKS
1. Lower lip—palpate.

• Palpate the lower lip by compressing the tissues between your

index fingers and thumbs.

2. Right cheek—palpate.
 • Reposition your left hand with middle and ring fingers
extraorally on the right cheek. These fingers are not wet with
saliva; your patient will appreciate this courtesy.
• Reposition the index finger of your right hand so that it is
opposite the fingers of your left hand.
• Compress the tissues on the right cheek between your fingers.
• Palpate the entire length of the buccal mucosa.
• Continue with Step 3 to palpate the left buccal mucosa.

3. Upper lip—palpate.

• Compress the tissues of the upper lip between the index

fingers and thumbs.
• Palpate from the right commissure of the mouth to the left.

SUBGROUP 4: FLOOR OF THE MOUTH

1. Anterior region of the floor of the mouth—visual inspection.

• Ask the patient to touch the tip of the tongue to the roof of the
mouth.
• Inspect the floor of the mouth. The inspection will be easier if
the patient is in a chin-down position.
• With the floor of the mouth well illuminated, visually inspect
the anterior portion.
• A mouth mirror may be helpful in providing indirect
illumination.

2. Posterior region of the floor of the mouth—visual inspection.

• Instruct your patient to relax the tongue and protrude it

slightly. Fold a damp gauze square in half and grasp the tip of
the tongue between the sides of the gauze square.
 • Use your right hand to pull the tongue gently to the left
commissure of the lip.
• Using your left hand to apply gentle pressure upward against
the submandibular gland will make it easier see the right
posterior region of the floor of the mouth.
• Visually inspect the floor of the mouth. Repeat this procedure
on the left side of the mouth

3. Floor of the mouth—palpation.

• Place your right index finger on the floor of the mouth.

• Place the middle and ring fingers of the left hand under the
patient’s chin on the right side of the head. Ask the patient to
relax the tongue and close the mouth slightly. This maneuver
relaxes the muscles in the floor of the mouth.
• Gently move the tongue out of the way with your index finger
and touch the floor of the mouth. Palpate the floor of the
mouth by pressing upward with your extraoral fingers and
downward with your index finger as if you are “trying to
make your fingers meet.”
• Palpate from the right posterior region forward to the anterior
region and then back to the left posterior region of the floor of
the mouth.

SUBGROUP 5: SALIVARY GLAND

FUNCTION
1. Submandibular and sublingual ducts—examine.

• Ask the patient to raise his or her tongue toward the roof of
the mouth.
• Use a gauze square to gently dry the area around the
sublingual caruncles and sublingual fold.
• Press down gently with a cotton-tipped applicator in the
region of the caruncles. A drop or stream of saliva should be
evident.

2. Parotid salivary ducts—examine.

• Ask your patient to open the mouth half way so that the cheek
is easy to retract.
• The purpose of this examination is to evaluate the functioning
 of the right parotid gland.
• Retract the right cheek and locate the parotid papilla on the
buccal mucosa opposite to the maxillary right molars.
• Dry the papilla with a gauze square; it will be difficult to
detect saliva flowing out of the papilla if the area is wet.
• Using the tip of a cotton-tipped applicator, press the area
slightly above the parotid papilla. It may be helpful to roll the
cotton-tipped applicator from an area slightly above the
papilla down to the papilla while applying pressure. Repeat
this rolling action several times, as necessary.
• If the duct is functioning properly, a drop of saliva will be
expressed from the papilla.
• Evaluate the parotid gland on the left side using the same
procedure.

SUBGROUP 6: THE TONGUE

1. Ventral surface of the tongue—visual inspection.

• Ask the patient to open wide and touch the tip of the tongue to
the roof of the mouth.
• Closely inspect the ventral surface of the tongue.
• Keep in mind that the tongue is a frequent site of oral cancer.

2. Dorsal Surface of the tongue—visual inspection.

 • Ask the patient to relax the tongue and protrude it slightly
from the mouth.
• Grasp the tongue with a damp gauze square. Technique tip:
Dry gauze may stick to the tongue so use the air/water syringe
to wet the gauze before use.
• Gently pull the tongue forward being careful not to injure the
lingual frenum on the incisal edges of the mandibular anterior
teeth.
• Visually inspect the dorsal surface of the tongue. Use a mouth
mirror, if it is helpful.
• Keep in mind that the tongue is a frequent site of oral cancer.

3. Lateral borders of the tongue—visual inspection.

• Gently pull the tongue to the left commissure and evert it

slightly to obtain a clear view of the lateral surface and foliate
 papillae.
• Visually inspect the lateral surface of the tongue.
• Use a mirror to view the posterior portion of the lateral
surface.
• Repeat this procedure to inspect the left border of the tongue.

4. Tongue—palpation.

• Palpate the body of the tongue between your index finger and
thumb.
• Be alert for swellings or nodules.

SUBGROUP 7: PALATE, TONSILS, AND

OROPHARYNX
1. Palate—preliminary visual inspection.
 • Visually inspect the hard and soft palate, uvula, oropharynx,
and tonsils.

2. Hard and soft palate—palpate.

• Use intermittent pressure with your index finger to palpate the

hard and soft palate.
• Technique tip: Avoid sliding your finger across the palate, as
this technique may cause the patient to gag. Instead, lift your
index finger away from the palate to reposition it. This
technique facilitates palpation.

3. Tonsils and oropharynx—visual inspection.

• You will need a mirror to move the tongue out of your line of
vision.
• Position the mouth mirror with the reflecting surface down.
 • Ask the patient to say “ah” as you depress the back of the
tongue downward and forward. Firm forward and downward
pressure is needed to keep the tongue out of your line of
vision.
• Visually inspect the tonsils and oropharynx.

4. Document. Document all notable findings from the oral

examination in the patient chart or computerized record.

SECTION 3 • The Human Element

Through the Eyes of a Student

MY FIRST ORAL EXAM

I so clearly remember the very first time that I did an intraoral exam. It was
on my very first patient. Seeing my first patient was a day that I had
dreamed about, but now that it was here, I was very nervous. The first part
of the appointment went well, but then it was here—the time to do the oral
examination. There seemed to be so much to check, and I was worried that
I would forget to check an area. Fortunately, my patient must have realized
how nervous I was because he said, “Take your time, I am retired. I am in
no hurry.”
I started the exam and heard my instructor’s voice in my mind saying
that the key to any procedure is to work through it one step at a time. I
concentrated on going step-by-step, and before I knew it, I had completed
the exam. I remember my relief when I finished the exam. Suddenly it was
over—the procedure that I had worried about all last night—and I felt like
yelling, “I did it!” To this day, I don’t think that I ever do an oral exam
without remembering the first time I did this examination.
Joanne, RDH,
Graduate, University of North Carolina at Chapel Hill

Ethical Dilemmas

“CREAM OF WHEAT”

You have been a dental hygienist for approximately 20 years and just
started a new job as a nursing home hygienist. You provide dental hygiene
services to the residents in a variety of care facilities. Today, you are
working with the founder of the company, Dr. Ari, and are seeing the
patients on an Alzheimer floor. You complete the intraoral examination for
your next patient, Florence, who is unresponsive and makes no eye
contact. You notice three large white lesions in the back of Florence’s
throat. You check Florence’s throat two additional times as best as you
can, as she is not very cooperative. Dr. Ari is very busy providing
restorative care, but you ask him to check Florence’s throat at his
convenience. He states that you are probably mistaking the white lesions
for “Cream of Wheat” that was served for breakfast. You examine
Florence again, and confirm that the lesions are not from a food source and
again ask for Dr. Ari to examine Florence.
1. What ethical principles come into play here?
2. Why are you concerned about the white lesions in Florence’s throat?
3. How would you proceed in this situation?

ADOLESCENT PATIENT WITH AN ORAL

LESION

As a first-year dental hygiene student in your second semester, you have

just started treating patients. Today, a group of patients from a local
adolescent correctional facility will be the patients in the clinic. You will
be treating Grace, a 16-year-old female who has an uneventful medical
history assessment, which you have reviewed with the social worker
accompanying the group.
You begin treatment and perform an extraoral examination on Grace.
As everything is within normal limits, you proceed to the intraoral
examination. You retract the right cheek of the buccal mucosa and find a
large red and white lesion in the mucobuccal fold that extends the entire
length of the cheek. Since this is the first soft tissue lesion that you have
ever found on a patient, you are not sure what to do next.
1. Is it ethical to share this information with your instructor/social worker?
2. How do you inform/educate Grace about the lesion?
3. How do you document the lesion in Grace’s chart or computerized
record?
4. What do you teach Grace about her own oral health?

English-to-Spanish Phrase List

SECTION 4 • Practical Focus—Fictitious Patient Cases

DIRECTIONS
• The photographs in this section show the findings from the oral
examination of fictitious patients A to E. Refer to previous modules to
refresh your memory regarding each patient’s health history and vital
signs because there may be a connection between the patient’s
systemic health status or habits and the findings from the head and
neck examination.
• If appropriate, use the Lesion Descriptor Worksheet to develop
descriptions for the findings in this section.
• The pages in this section may be removed from the book for easier
use by tearing along the perforated lines on each page.
• Note: The clinical photographs in a fictitious patient case are for
illustrative purposes but are not necessarily from the same individual.
The fictitious patient cases are designed to enhance the learning
experiences associated with each case.

Sources of Clinical Photographs

The author gratefully acknowledges the sources of the following clinical
photographs in the “Practical Focus” section of this module.
• Figure 14-39. Dr. Richard Foster, Guilford Technical Community
College.
• Figure 14-41. From Fleisher GR, Ludwig L, Baskin MN. Atlas of
Pediatric Emergency Medicine. Philadelphia, PA: Lippincott Williams
& Wilkins; 2004.
• Figure 14-43. Dr. Richard Foster, Guilford Technical Community
College.
• Figure 14-44. Dr. Richard Foster, Guilford Technical Community
College.
• Figure 14-46. Dr. Richard Foster, Guilford Technical Community
College.
• Figure 14-48. Dr. John S. Dozier, Tallahassee, FL.

Fictitious Patient Case A: Mr. Alan Ascari

Fictitious Patient Case B: Bethany Biddle
Fictitious Patient Case C: Mr. Carlos Chavez
Fictitious Patient Case D: Mrs. Donna Doi
Fictitious Patient Case E: Ms. Esther Eads
SECTION 5 • Skill Check

Technique Skill Checklist: Oral Examination

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as
S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, each U equals 0 point.

CRITERIA: S E

Subgroup 1: Visual Inspection of Lips and

Vermillion Border
Provides patient with safety glasses and positions
patient in the supine position.
Dons gloves.
Visually inspects the lips and vermillion border.
Subgroup 2: Inspection of the Oral Cavity and
Mucosal Surfaces
Adjusts the dental unit light so that the oral cavity is
well illuminated.
Visually inspects the oral cavity and oropharynx.
Identifies any condition that would cause the oral
examination to be modified or postponed.
Visually inspects the upper and lower lips.
Visually inspects the buccal mucosa of both cheeks.
Subgroup 3: Palpation of the Lips and Cheeks
Palpates the upper and lower lips.
Palpates the buccal mucosa of both cheeks.
Subgroup 4: Floor of the Mouth

Inspects the anterior region of the mouth.

Retracts the tongue and inspects the posterior region
of the floor of the mouth.
Palpates the floor of the mouth.

Subgroup 5: Salivary Gland Function

Examines the parotid salivary ducts in both sides of
the mouth.
Examines the submandibular and sublingual ducts.
Subgroup 6: The Tongue
Inspects the ventral surface of the tongue.
Inspects the dorsal surface of the tongue.
Inspects the lateral surfaces of the tongue.
Palpates the tongue.

Subgroup 7: Palate, Tonsils, and Oropharynx

Visually inspects the palate.
Palpates the hard and soft palate.
Inspects the tonsils and oropharynx.
Documents notable findings in the patient chart or
computerized record.
OPTIONAL GRADE PERCENTAGE
CALCULATION
 Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

Communication Skill Checklist: Oral Examination

ROLES:
• Student 1 = Plays the role of a fictitious patient.
• Student 2 = Plays the role of the clinician.
• Student 3 or instructor = Plays the role of the clinic instructor near
the end of the role-play.

DIRECTIONS FOR STUDENT CLINICIAN: Use Column S; evaluate your

skill level as S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Explains what is to be done.
Reports notable findings to the patient. As needed,
makes referrals to a physician or dental specialist.
Encourages patient questions before and during the
oral examination.
Answers the patient’s questions fully and
 accurately.
Communicates with the patient at an appropriate
level avoiding dental/medical terminology or
jargon.
Accurately communicates the findings to the
clinical instructor. Discusses the implications for
dental treatment using correct medical and dental
terminology.

OPTIONAL GRADE PERCENTAGE

CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

References
1. National Cancer Institute. Oral Cavity and Oropharyngeal Cancer Prevention
(PDQ®)—Health Professional Version. Bethesda, MD: National Cancer Institute;
2002.
2. British Dental Association. Opportunistic Oral Cancer Screening: A Management
Strategy for Dental Practice. London, United Kingdom: British Dental Association;
2000.
3. Brocklehurst P, Kujan O, O’Malley LA, Ogden G, Shepherd S, Glenny AM.
Screening programmes for the early detection and prevention of oral cancer. Cochrane
Database Syst Rev. 2013;(11):CD004150.
4. Joshi V, Scully C. Oral cancer: comprehending the condition, causes, controversies,
control and consequences. 18. Dental management. Dent Update. 2012;39(6):442–
443.
5. Lim K, Moles DR, Downer MC, Speight PM. Opportunistic screening for oral cancer
and precancer in general dental practice: results of a demonstration study. Br Dent J.
2003;194(9):497–502.
6. Macpherson LM, McCann MF, Gibson J, Binnie VI, Stephen KW. The role of
 primary healthcare professionals in oral cancer prevention and detection. Br Dent J.
2003;195(5):277–281.
7. McCann MF, Macpherson LM, Gibson J. The role of the general dental practitioner in
detection and prevention of oral cancer: a review of the literature. Dent Update.
2000;27(8):404–408.
8. Mighell AJ, Gallagher JE. Oral cancer—improving early detection and promoting
prevention. Are you up to date? Br Dent J. 2012;213(6):297–299.
9. Mignogna MD, Fedele S. Oral cancer screening: 5 minutes to save a life. Lancet.
2005;365(9475):1905–1906.
10. Mignogna MD, Fedele S, Lo Russo L, Ruoppo E, Lo Muzio L. Oral and pharyngeal
cancer: lack of prevention and early detection by health care providers. Eur J Cancer
Prev. 2001;10(4):381–383.
11. Petersen PE. Strengthening the prevention of oral cancer: the WHO perspective.
Community Dent Oral Epidemiol. 2005;33(6):397–399.
12. Poh CF, Williams PM, Zhang L, Rosin MP. Heads up!—a call for dentists to screen
for oral cancer. J Can Dent Assoc. 2006;72(5):413–416.
13. Rethman MP, Carpenter W, Cohen EE, et al. Evidence-based clinical
recommendations regarding screening for oral squamous cell carcinomas. J Am Dent
Assoc. 2010;141(5):509–520.
14. Rosin MP, Poh CF, Elwood JM, et al. New hope for an oral cancer solution: together
we can make a difference. J Can Dent Assoc. 2008;74(3):261–266.
15. Sankaranarayanan R, Ramadas K, Thara S, et al. Long term effect of visual screening
on oral cancer incidence and mortality in a randomized trial in Kerala, India. Oral
Oncol. 2013;49(4):314–321.
16. Sankaranarayanan R, Ramadas K, Thomas G, et al; for Trivandrum Oral Cancer
Screening Study Group. Effect of screening on oral cancer mortality in Kerala, India:
a cluster-randomised controlled trial. Lancet. 2005;365(9475):1927–1933.
17. Scully C, Felix DH. Oral medicine—update for the dental practitioner oral cancer. Br
Dent J. 2006;200(1):13–17.
18. Stahl S, Meskin LH, Brown LJ. The American Dental Association’s oral cancer
campaign: the impact on consumers and dentists. J Am Dent Assoc.
2004;135(9):1261–1267.
19. Walsh T, Liu JL, Brocklehurst P, et al. Clinical assessment to screen for the detection
of oral cavity cancer and potentially malignant disorders in apparently healthy adults.
Cochrane Database Syst Rev. 2013;(11):CD010173.
20. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene
Practice. Chicago, IL: American Dental Hygienists’ Association; 2008.
https://dcp.psc.gov/osg/hso/documents/2015-adha_standards08_3.pdf. Accessed
September 6, 2016.
21. American Dental Hygienists’ Association. American Dental Hygienists’ Association
Policy Manual. Chicago, IL: American Dental Hygienists’ Association; 2015.
https://www.adha.org/sites/default/files/7614_Policy_Manual.pdf. Accessed
September 6, 2016.
22. International Dental Federation, Commission on Dental Research. Early Detection of
Oral Cancer. Geneva, Switzerland: Fédération Dentaire Internationale; 1971.
23. U.S. Department. of Health and Human Services. Healthy People 2010, Midcourse
Review. Washington, DC: U.S. Department of Health and Human Services; 2006.
24. Parks CI, Chikotas NE, Olszewski K. A comprehensive review of the Healthy People
2020 Occupational Safety and Health Objectives: part 1. Tools for the occupational
health nurse in goal attainment. Workplace Health Saf. 2012;60(1):33–42.
25. Howlader N, Noone AM, Krapcho M, et al, eds. SEER Cancer Statistics Review,
1975–2013. Bethesda, MD: National Cancer Institute; 2016.
26. Awojobi O, Scott SE, Newton T. Patients’ perceptions of oral cancer screening in
dental practice: a cross-sectional study. BMC Oral Health. 2012;12:55.
27. Biggar H, Poh CF, Rosin M, Williams PM. Voices from the community—the voice of
an oral cancer patient. J Can Dent Assoc. 2008;74(3):237–238.
28. Currie BL, Williams PM, Poh CF. Is the message clear? Talking with your patient
about oral cancer screening. J Can Dent Assoc. 2008;74(3):255–256.
29. Laronde DM, Bottorff JL, Hislop TG, et al. Voices from the community—experiences
from the dental office: initiating oral cancer screening. J Can Dent Assoc.
2008;74(3):239–241.
30. Humphris GM, Duncalf M, Holt D, Field EA. The experimental evaluation of an oral
cancer information leaflet. Oral Oncol. 1999;35(6):575–582.
31. Blot WJ. Alcohol and cancer. Cancer Res. 1992;52(suppl 7):2119s–2123s.
 MODULE
15

GINGIVAL
DESCRIPTION
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
This module presents a systematic approach to describing the characteristics
of the gingiva. The ability to formulate a concise, accurate written or verbal
description of the gingiva is an important component of patient assessment.
This module covers the gingival description, including:
• Characteristics of the gingiva in health
• Changes in gingival characteristics in disease
• Formulating a description of gingival characteristics

MODULE OUTLINE
SECTION 1 Learning to Look at the Gingiva
Characteristics of the Gingiva in Health
Changes in Disease
SECTION 2 Peak Procedure
Procedure 15-1. Determining Gingival Characteristics
 SECTION 3 Ready References
Gingival Descriptor Worksheet
Gingival Characteristics Chart: Maxillary Arch
Gingival Characteristics Chart: Mandibular Arch
SECTION 4 The Human Element
Through the Eyes of a Student
Ethical Dilemma
English-to-Spanish Phrase List
SECTION 5 Practical Focus—Fictitious Patient Cases
Fictitious Patient Case A: Mr. Alan Ascari
Fictitious Patient Case B: Bethany Biddle
Fictitious Patient Case C: Mr. Carlos Chavez
Fictitious Patient Case D: Mrs. Donna Doi
Fictitious Patient Case E: Ms. Esther Eads
SECTION 6 Skill Check
KEY TERMS
Exudate • Enlarged • Coronal to CEJ • Apical to CEJ • Bulbous •
Blunted • Cratered • Nodular • Marginal • Papillary • Diffuse

OBJECTIVES
• Describe gingival characteristics that are indicative of health and
disease.
• Demonstrate the use of communication strategies to provide
information to the patient about gingival characteristics and any
notable findings.
• Accurately communicate gingival characteristics to a clinical
instructor. Discuss the implications of notable findings.
• Given an image of a sextant of the mouth, use the Gingival Descriptor
Worksheet to identify characteristics of the gingiva.
• Demonstrate knowledge of gingival characteristics by applying
 information from this module to the fictitious patient cases A to E in
this module.

SECTION 1 • Learning to Look at the Gingiva

The ability to formulate a concise, accurate written or verbal description of
the gingiva is an important component of the patient assessment process. The
following characteristics of the gingiva should be assessed:
1. Color
2. Size
3. Position of margin
4. Shape of margins and papillae
5. Texture and consistency
6. Bleeding and/or exudate

Characteristics of the Gingiva in Health

Changes in Disease
SECTION 2 • Peak Procedure
Procedure 15-1. Determining Gingival Characteristics

Action Rationale
1. Choose one sextant and • Focusing your attention on
aspect. Select one sextant a specific aspect (facial or
of the mouth for lingual) of one sextant is
assessment; if applicable, more efficient than trying
choose the sextant that to examine the entire
shows the most tissue mouth at one time.
changes. Select either the
facial or lingual aspect of
this sextant for
examination.

2. Worksheet. Use the • The Gingival Descriptor

Gingival Descriptor Worksheet is helpful in
Worksheet from the identifying the gingival
“Ready References” characteristics present in
section of this module. the sextant.
Circle or highlight the • Changes in gingival
words that describe the characteristics may be
facial or lingual aspect of indicators of disease.
the sextant.
a. Assess the color of the
tissue. Changes in color
may involve only the
margin (marginal) or
the papilla (papillary).
Changes that involve
both the marginal and
papillary tissue are
indicated as diffuse
 color changes.
b. Assess the size of the
tissue.
c. Assess the position of
the gingival margin.
d. Assess the shape of the
margins and papillae in
the sextant.

3. Examine. Use compressed • The texture and

air and a periodontal probe consistency of the tissue
to assess the texture and provides important clues
consistency and enter your about the health of the
findings on the worksheet. tissue. Normal tissue is
a. Healthy tissue is very resilient. Soft spongy
resilient when pressed tissue may be an indicator
lightly with the side of gingivitis. Leathery,
(length) of a periodontal nodular tissue may be an
probe. indicator of periodontitis.
b. Soft, spongy tissue will
retain the shape of the
probe for several
seconds.
c. Leathery, nodular tissue
is very firm and not
resilient when the tissue
is pressed lightly with
the probe.

4. Observe. Observe the • Bleeding and/or exudate

sextant to check for any are important indicators of
areas of spontaneous inflammation.
bleeding. Use a
periodontal probe to check
 for bleeding upon probing
and/or exudate.

5. Chart. Complete a • The Gingival

Gingival Characteristics Characteristics Chart is
Chart from the “Ready helpful in identifying the
References” section of this gingival characteristics
module. You will need a present in the sextant.
red/blue pencil and a • Changes in gingival
yellow highlighter to characteristics may be
complete this chart. You indicators of disease.
will be entering
information for the same
sextant and aspect selected
for the Gingival Descriptor
Worksheet.
a. Draw the location of the
gingival margin on the
chart.
b. Indicate areas of
gingival recession with
the yellow highlighter.
c. Enter gingival margin
findings in red pencil at
the root apices.
d. Enter papillae findings
in blue pencil between
the teeth near the root
area.

SECTION 3 • Ready References

SECTION 4 • The Human Element

Through the Eyes of a Student

GINGIVAL DESCRIPTION: PAINTING AN
ACCURATE DESCRIPTION

I was seeing, Mr. L., a patient who I had seen 6 months ago. Before
starting to write up a gingival description, I looked at the one I had done 6
months ago. Since the last time, we have covered gingival descriptors more
in class. I realized that I now knew many more gingival descriptors and
what they meant and how to use them.
The gingival description from 6 months ago did not paint a very
accurate picture of Mr. L.’s gingiva. I realized my description from last
time would not be of any help today. Using the correct gingival
descriptors, I wrote a description that really put into words what the
gingival tissue looks like. At this moment, I realized for the first time how
much I learned in 6 months and how much better I understood the
appearance of the gingiva. I really felt proud of myself at that moment.
Kim, student,
South Florida Community College

EXPRESSING YOUR OPINION

Think about a time when you expressed your opinion and were glad you
did.
Think about a time when you expressed your opinion and regretted it.
Think about a time when you did not share your opinion and regretted it.

Participate in a class discussion on what you learned from these

experiences that can apply to your professional interactions with patients.

Ethical Dilemma

COLLEAGUE WITH POOR INFECTION

CONTROL PRACTICES

For the past 6 months, you have been working as a part-time dental
hygienist for a dental group practice. Unfortunately, you have developed
concerns about the quality of some of the dental care being delivered by
the periodontist who is a member of the group practice. Your specific
concerns about the quality of care center around apparent poor infection
control procedures.
You have just finished seeing a new patient in the group practice,
Mrs. Eliza Stuart. Mrs. Stuart is a 35-year-old homemaker who smokes
one pack of cigarettes a day and has recently been diagnosed with type 2
diabetes. Mrs. Stuart has a 22-month-old daughter and has just found out
that she is 8 weeks pregnant with her second child.
Although Mrs. Stuart denies any oral discomfort, her dental
examination reveals many oral problems such as probing depths up to 7
mm, generalized alveolar bone loss on her posterior teeth, severe dental
caries on several molar teeth, and multiple sites of moderate-to-severe
gingival inflammation along with other signs of gingival inflammation
including bleeding on probing. Based on your clinical observations, you
suspect that Mrs. Stuart has chronic periodontitis.
Routine office policy dictates that Mrs. Stuart should be scheduled
with the group practice periodontist. However, you are uncomfortable
making the referral based on your concerns about infection control
practices by the periodontist. You are conflicted about how to proceed with
Eliza’s treatment.
1. What ethical principles are in conflict in this dilemma?
2. How do you inform/educate Eliza about her oral/general health?
3. How should you handle future referrals to the periodontist in your
office?

English-to-Spanish Phrase List

SECTION 5 • Practical Focus—Fictitious Patient Cases

DIRECTIONS
• Use the steps outlined in Procedure 15-1, the Gingival Descriptor
Worksheet, and Gingival Characteristics Chart to develop descriptions
for each of the patient cases. Examples of completed forms are shown
on the following pages.
• In thinking about the health status of the gingival tissues in this module,
you should take into account the health history and over-the-
counter/prescription drug information that were revealed for each patient
in previous modules. For each patient, answer the question, “Is there any
 connection between the gingival characteristics observed and the
patient’s health history or drug information?”
• The pages in this section may be removed from the book for easier use
by tearing along the perforated lines on each page.
• Note: The clinical photographs in a fictitious patient case are for
illustrative purposes but are not necessarily from the same individual.
The fictitious patient cases are designed to enhance the learning
experiences associated with each case.

Sources of Clinical Photographs

The author gratefully acknowledges the sources of the following clinical
photographs in the “Practical Focus” sections of this module.
• Figure 15-31. Courtesy of Dr. Don Rolfs, Wenatchee, WA.
• Figure 15-34. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 15-37. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 15-40. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 15-43. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
Fictitious Patient Case A: Mr. Alan Ascari
Indicate any connection between the gingival characteristics observed and the
patient’s health history or drug information:
Fictitious Patient Case B: Bethany Biddle
Indicate any connection between the gingival characteristics observed and the
patient’s health history or drug information:
DIRECTIONS: To use the Gingival Characteristics Chart for a patient
with a mixed dentition, enter the letter of the primary tooth on the crown of
the permanent tooth and cross out any missing teeth.
Fictitious Patient Case C: Mr. Carlos Chavez
Indicate any connection between the gingival characteristics observed and the
patient’s health history or drug information:
Fictitious Patient Case D: Mrs. Donna Doi
Indicate any connection between the gingival characteristics observed and the
patient’s health history or drug information:
Fictitious Patient Case E: Ms. Esther Eads
Indicate any connection between the gingival characteristics observed and the
patient’s health history or drug information:
SECTION 6 • Skill Check

Technique Skill Checklist: Gingival Description

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as
S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E

Selects the facial or lingual aspect of a sextant that

shows the most tissue changes and assesses this
area.
For the selected area, accurately records the color of
the gingival tissue on Gingival Descriptor
Worksheet.
Accurately records the size of the gingival tissue on
the Gingival Descriptor Worksheet.
Accurately records the position of the gingival
margin on the Gingival Descriptor Worksheet.

Accurately records the shape of the gingival margin

on the Gingival Descriptor Worksheet.
Accurately records the shape of the papillae on the
Gingival Descriptor Worksheet.
Accurately records the texture of the gingival tissue
on the Gingival Descriptor Worksheet.
Accurately records the consistency of the tissue on
the Gingival Descriptor Worksheet.
 Checks for the presence or absence of bleeding
and/or exudate. Notes bleeding and/or exudate, if
applicable.

Accurately draws the position of the gingival

margin in the selected area on the Gingival
Characteristics Chart.
Indicates areas of recession with a yellow
highlighter on the Gingival Characteristics Chart.

Enters gingival margin findings in red pencil at the

root apices on the Gingival Characteristics Chart.
Enters findings for the papillae in blue pencil
between the teeth on the Gingival Characteristics
Chart.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

Communication Skill Checklist: Gingival Description

ROLES:
• Student 1 = Plays the role of a fictitious patient.
• Student 2 = Plays the role of the clinician.
• Student 3 or instructor = Plays the role of the clinic instructor near
the end of the role-play.
DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as
S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Explains what is to be done.

Points out changes in gingival characteristics and

explains their significance to the patient.
Encourages patient questions.
Answers the patient’s questions fully and
accurately.
Communicates with the patient at an appropriate
level avoiding dental/medical terminology or
jargon.
Accurately communicates the findings to the
clinical instructor. Discusses the implications for
dental treatment using correct dental terminology.

OPTIONAL GRADE PERCENTAGE

CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.
 MODULE
16

MIXED DENTITION
AND OCCLUSION
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
This module presents a systematic approach to identifying the teeth present in
a mixed dentition and for classifying the occlusion.
This module covers:
• Mixed dentitions and how to recognize primary and permanent teeth in
the mouth
• Angle’s classification of occlusion and how to classify a patient’s
occlusion
• Additional characteristics of malocclusion and malpositions of
individual teeth
Before beginning this module, you should have completed the chapters
on the primary and permanent dentitions and Angle’s classification of
occlusion in a dental anatomy textbook.

MODULE OUTLINE
SECTION 1 Sorting Out a Mixed Dentition
 Stages in Eruption of the Primary and Secondary
Dentitions
SECTION 2 Learning to Look at the Occlusion
The Relationship of the Maxillary and Mandibular Teeth
Angle’s Classification
Class I: Groove in the Normal Position
Class II, Division 1: Groove Posterior to the Normal
Position
Class II, Division 2: Groove Posterior to the Normal
Position
Class III: Groove Anterior to the Normal Position
Other Characteristics of Malocclusion
Malpositions of Individual Teeth
SECTION 3 Peak Procedures
Procedure 16-1. Identifying Teeth in a Mixed Dentition
Procedure 16-2. Occlusion Classification and
Characteristics
SECTION 4 Ready References: Mixed Dentition
Ready Reference 16-1. Eruption Times: Primary Teeth
Ready Reference 16-2. Eruption Times: Permanent Teeth
Ready Reference 16-3. Stages in Eruption
SECTION 5 Ready References: Occlusion
Ready Reference 16-4. Occlusion Classification: Molar
Relationship
Ready Reference 16-5. Occlusion Worksheet
SECTION 6 The Human Element
Through the Eyes of a Student
Through the Eyes of a Young Patient
English-to-Spanish Phrase List
 SECTION 7 Practical Focus—Mixed Dentition
Fictitious Patient Case B: Bethany Biddle
Fictitious Patient Case: Lulu Lowe
Fictitious Patient Case: Kenneth Kole

SECTION 8 Practical Focus—Occlusion

SECTION 9 Skill Check
KEY TERMS
Mixed dentition • Occlusion • Malocclusion • Overbite • Overjet •
Angle’s classification • End-to-end bite • Anterior/posterior crossbite

OBJECTIVES
• List the order of eruption of the permanent teeth.
• List the time ranges for permanent tooth eruption.
• In a clinical setting, distinguish the primary and permanent teeth in a
mixed dentition.
• In a clinical setting, identify Angle’s Class I, Class II, and Class III
relationships.
• List and describe types of tooth malocclusions.
• Provide information to a pediatric patient and his or her parent about
the tooth eruption sequence.
• Provide information to a pediatric patient—and his or her parent—
about the teeth present in (this patient’s) mouth. Discuss the
implications of notable findings.
• Provide information to the patient about occlusion, malocclusion, and
any notable findings.
• Accurately communicate the findings to the clinical instructor/dentist.
Discuss the implications of notable findings.
• Demonstrate knowledge of mixed dentitions by applying information
from this module to the fictitious patient cases in this module.
• Given a patient case, establish the expected age of the individual by
 studying the mixed dentition.
• Demonstrate knowledge of occlusion and malocclusion by applying
information from this module to the fictitious patient cases in this
module.

SECTION 1 • Sorting Out a Mixed Dentition

The patient assessment includes examination of the dentition. As a child ages,
the maxilla and mandible grow, making room for the eruption of the
permanent teeth. For a period of several years, a child will have a mixed
dentition. That is, the child will have a combination of some primary teeth
and some permanent teeth. Determining which teeth are primary and which
are permanent in a mixed dentition can be challenging. This section presents
a review of tooth eruption patterns. Guides to these stages can be found in the
“Ready References” section of this module.

Stages in Eruption of the Primary and Secondary Dentitions

AGE 5 YEARS
The primary teeth usually erupt between ages 2½ and 5½ years of age; no
permanent teeth are visible in the mouth (Fig. 16-1).
AGE 6 TO 7 YEARS
As the maxilla and mandible grow, there is room for more teeth. From age 6
to 7 years, the permanent first molars erupt just distal to the second primary
molars. No primary teeth are exfoliated to make room for these permanent
molars. Eruption of the first molars is followed closely by the loss of the
mandibular primary central incisors, which are quickly replaced by the
permanent central incisors (Fig. 16-2).
AGE 7 TO 8 YEARS
By age 7 to 8 years, the permanent incisors have replaced the primary
incisors (Fig. 16-3).

AGE 10 TO 12 YEARS
All four mandibular premolars erupt into place replacing the mandibular
primary first molars and canines. On the maxillary arch, the permanent first
premolars erupt and replace the primary first molars (Fig. 16-4).

AGE 11 TO 13 YEARS
The primary canines and the primary second molars are the last to exfoliate.
Normally, all primary teeth are exfoliated by age 13 years (Fig. 16-5).
 SECTION 2 • Learning to Look at the Occlusion

The Relationship of the Maxillary and Mandibular Teeth

The patient assessment includes an examination of the occlusion, the
relationship of the teeth to each other when the incisal and occlusal surfaces
of the mandibular arch contact those of the maxillary arch. The way that the
teeth occlude during chewing and speaking is important for the appearance,
comfort, and health of an individual.
The American Academy of Pediatric Dentistry defines malocclusion as
the improper positioning of the teeth and jaws. Malocclusion is a variation of
normal growth and development that can affect the bite, ability to maintain
adequate plaque control, speech development, and appearance. A healthy
occlusion normally exhibits overbite and overjet (Figs. 16-6 and 16-7). In
addition, in a healthy occlusion, the maxillary teeth are positioned facial to
the mandibular teeth (Fig. 16-8).
Angle’s Classification
In 1887, Dr. Edward H. Angle developed a system for classifying the
relationship of the mandibular teeth to the maxillary teeth. Angle’s
classification is still in widespread use today.
• Angle’s classification system is based primarily on the relationship of
the mandibular first molar to the maxillary first molar.
• According to Angle, there are three relationships that can exist between
the first molars: Class I, Class II, or Class III.
• If the first molars are missing or malaligned, the relationship of the
mandibular canine to the maxillary canine is used in determining the
classification.
• The key to understanding Angle’s classification is the position of the
buccal groove of the mandibular permanent first molar in relation to
the maxillary teeth (Fig. 16-9).
Class I: Groove in the Normal Position
• Molar relation: The buccal groove of the mandibular first molar is
directly in line with the mesiobuccal cusp of maxillary first molar (Fig.
16-10).

• Canine relation: The maxillary permanent canine occludes with the

distal half of the mandibular canine and the mesial half of the
mandibular permanent premolar.

Class II, Division 1: Groove Posterior to the Normal

Position
• Molar relation: The buccal groove of the mandibular first molar is
distal to the mesiobuccal cusp of maxillary first molar by at least the
width of a premolar (Fig. 16-11).

• Canine relation: The distal surface of the mandibular canine is distal to

the mesial surface of the maxillary canine by at least the width of a
 premolar.
• In Class II, Division 1, all four of the maxillary incisors are protruded.

Class II, Division 2: Groove Posterior to the Normal

Position
• Molar relation: The buccal groove of the mandibular first molar is
distal to the mesiobuccal cusp of maxillary first molar by at least the
width of a premolar (Fig. 16-12).

• Canine relation: The distal surface of the mandibular canine is distal to

the mesial surface of the maxillary canine by at least the width of a
premolar.
• In Class II, Division 2, both maxillary lateral incisors protrude while
both central incisors retrude.

Class III: Groove Anterior to the Normal Position

• Molar relation: The buccal groove of the mandibular first molar is
mesial to the mesiobuccal cusp of maxillary first molar by at least the
width of a premolar (Fig. 16-13).
 • Canine relation: The distal surface of the mandibular canine is mesial to
the mesial surface of the maxillary canine by at least the width of a
premolar.

Other Characteristics of Malocclusion

Malocclusions may have many variations. Some of these variations are
depicted in Figures 16-14 through 16-21.
Malpositions of Individual Teeth
SECTION 3 • Peak Procedures

Procedure 16-1. Identifying Teeth in a Mixed Dentition

Action Rationale
 1. Assemble resources. Use • These references will assist
the Eruption Times and you in recognizing primary
the Stages in Eruption and permanent teeth.
references from Section 4
of this module.

2. Identify the primary • Focusing your attention on

teeth. Circle the primary identifying the primary teeth
teeth present in red pencil will help you to sort out the
on the Mixed Dentition mixture of primary and
Worksheet provided for permanent teeth.
each patient case.

3. Identify the permanent • Once you have identified the

teeth. Circle the primary teeth, focus your
permanent teeth present in attention on recognizing the
blue pencil on the Mixed permanent teeth present in
Dentition Worksheet. the mouth.

4. Record. Transfer the • Referring to the information

information from the entered on the Mixed
Mixed Dentition Dentition Worksheet will
Worksheet to the patient’s facilitate the dental charting
chart or computerized process.
record.

Procedure 16-2. Occlusion Classification and

Characteristics

Action Rationale
1. Assemble resources. Use • This reference will assist you
the Occlusion in assessing the molar
 Classification: Molar relationship.
Relationship reference • Note: If either the maxillary
from Section 5 of this or mandibular molars are
module. missing, the canines are used
to classify the dentition.

2. Determine the molar • The items listed on the

relationship. Enter your worksheet will help you
findings on the Occlusion remember to check for all
Worksheet from Section 5 characteristics of
of this module. malocclusion and tooth
malpositions.

3. Record. Transfer the • Referring to the information

information from the entered on the Occlusion
Occlusion Worksheet to Worksheet will facilitate the
the patient’s chart or documentation process.
computerized record.

SECTION 4 • Ready References: Mixed Dentition

NOTE: The Ready References in this book may be removed from the book
by tearing along the perforated lines on each page. Laminating or placing
these pages in plastic protector sheets will allow them to be disinfected for
use in a clinical setting.

Ready Reference 16-1. Eruption Times: Primary Teeth

Ready Reference 16-2. Eruption Times: Permanent Teeth
Ready Reference 16-3. Stages in Eruption
 SECTION 5 • Ready References: Occlusion
The Ready References may be removed from the book by tearing along the
perforated lines on each page. Laminating or placing these pages in plastic
protector sheets will allow them to be disinfected for use in a clinical setting.
Ready Reference 16-4. Occlusion Classification: Molar
Relationship

Ready Reference 16-5. Occlusion Worksheet

SECTION 6 • The Human Element

Through the Eyes of a Student

PRIMARY OR PERMANENT TOOTH?

I had gotten pretty confident about charting a patient’s teeth. I had seen
several adult patients and one 16-year-old. But then it happened. Sitting in
my chair was my first patient with a mixed dentition. My palms began to
sweat. As I looked in the mouth, I could not tell which teeth were
permanent and which ones were primary. I really started to panic.
Then, I got out an eruption chart that I had laminated for clinic. I
studied the chart to see which teeth were likely to be present in a child’s
mouth at age 10 years. I calmed down and thought about which primary
teeth were likely to be present and which permanent teeth probably would
have erupted by age 10 years.
I looked in the patient’s mouth again and began marking the primary
teeth that were present. Next, I crossed out the permanent teeth that were
not present in the mouth. Before I knew it, I had prepared a chart of teeth
present in my patient’s mouth.
When my instructor reviewed my charting, she smiled and said,
“Bravo, Skip!” I felt really proud of myself, but most important, I learned
that I could handle new things when I just stay calm and stop to remember
all the pieces of information in the puzzle (like primary dentition, adult
dentition, and eruption patterns).
Skip, student,
South Florida Community College

Through the Eyes of a Young Patient

EDUCATING PEDIATRIC PATIENTS

Use an Internet browser, such as Google, to locate creative websites to

educate your pediatric patients. For example, play some of the games at
http://www.kidshealth.org/kid/closet, a website to help children explore
their health.
• As a class project, compile a list of educational dental and medical
health websites that would be fun and interesting for children.
• How might you incorporate similar websites into the dental office?

English-to-Spanish Phrase List

SECTION 7 • Practical Focus—Mixed Dentition

DIRECTIONS
• Use the steps outlined in Procedure 16-1 and the Mixed Dentition
Worksheet to determine the primary and permanent teeth present for
the three fictitious patient cases in this section. Bethany Biddle is a
fictitious patient that you are familiar with from other modules in the
book. The other two fictitious patients are unique to this module.
• Determine the expected age of each patient by studying his or her mixed
dentition.
• The pages in this section may be removed from the book for easier use
by tearing along the perforated lines on each page.
Fictitious Patient Case B: Bethany Biddle

Directions Case B:
• View the three photographs of Bethany’s mouth on this and the
following pages.
• Remove the Mixed Dentition Worksheet that follows the three photos
of Bethany’s mouth and indicate the primary and permanent teeth
present.
• Indicate Bethany’s expected age based on the primary and permanent
teeth present in her mouth at this time: ___________
Fictitious Patient Case: Lulu Lowe
Patient Case L is a pediatric patient with fixed orthodontic appliances and a
mixed dentition.
Directions for Case L:
• View the photograph of Lulu’s mouth shown in Figure 16-30.
• Remove the Mixed Dentition Worksheet that follows and indicate the
primary and permanent teeth present in Lulu’s mouth.
• Indicate Lulu’s expected age based on the primary and permanent teeth
present in her mouth at this time: _______________
Fictitious Patient Case: Kenneth Kole
Directions for Case K:
• View the photograph of Ken’s mouth shown in Figure 16-32.

• Remove the Mixed Dentition Worksheet that follows and indicate the
primary and permanent teeth present in Ken’s mouth.
• Indicate Ken’s expected age based the primary and permanent teeth
present in her mouth at this time: _______________
SECTION 8 • Practical Focus—Occlusion

DIRECTIONS
• Locate Ready Reference 16-5, the Occlusion Worksheet, in Section 5
of this module. Photocopy the Occlusion Worksheet or duplicate it on
notebook paper so that you have a worksheet for each of Figure 16-34 to
 16-47.
• Follow the steps outlined in Procedure 16-2 to describe the occlusal
characteristics for the fictitious patient cases shown in Figure 16-34 to
16-47.
• The pages in this section may be removed from the book for easier use
by tearing along the perforated lines on each page.
 SECTION 9 • Skill Check

Technique Skill Checklist: Mixed Dentition

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).
DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S
(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Accurately identifies the primary teeth present in
the dentition on the Mixed Dentition Worksheet.
Accurately identifies the permanent teeth present in
the dentition on the Mixed Dentition Worksheet.
Accurately transfers the information to the patient
chart or computerized record.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

Technique Skill Checklist: Occlusion

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
 Accurately classifies the occlusion on the Occlusion
Worksheet.

Accurately notes other characteristics of

malocclusion or malpositions of individual teeth on
the Occlusal Worksheet.
Accurately transfers the information to the patient
chart or computerized record.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

Communication Skill Checklist: Mixed Dentition

ROLES:
• Student 1 = Plays the role of the patient.
• Student 2 = Plays the role of the clinician.
• Student 3 or instructor = Plays the role of the clinic instructor near
the end of the role-play.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.
 CRITERIA: S E
Explains the eruption sequence of permanent teeth
to the patient and/or parent.
Relates the eruption sequence to the teeth present in
the patient’s mouth.
Encourages patient questions.
Answers the patient’s questions fully and
accurately.
Communicates with the patient at an appropriate
level avoiding dental/medical terminology or
jargon.
Accurately communicates the findings to the
clinical instructor. Discusses the implications for
dental treatment using correct dental terminology.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.

Communication Skill Checklist: Occlusion

ROLES:
• Student 1 = Plays the role of the patient.
• Student 2 = Plays the role of the clinician.
 • Student 3 or instructor = Plays the role of the clinic instructor near
the end of the role-play.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Explains the role of occlusion in the health and
appearance of the dentition.
Explains findings such as malocclusion or
malpositions of individual teeth to the patient.
Encourages patient questions.
Answers the patient’s questions fully and
accurately.
Communicates with the patient at an appropriate
level avoiding dental/medical terminology or
jargon.
Accurately communicates the findings to the
clinical instructor. Discusses the implications for
dental treatment using correct dental terminology.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
 percentage grade.

Sources of Clinical Photographs

The author gratefully acknowledges the sources of the following clinical
photographs in the “Practical Focus” sections of this module.
• Figure 16-26. Dr. Marci Marano Beck, Tallahassee, FL.
• Figure 16-27. Dr. Marci Marano Beck, Tallahassee, FL.
• Figure 16-28. Dr. Marci Marano Beck, Tallahassee, FL.
• Figure 16-30. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 16-32. Dr. Don Rolfs, Wenatchee, WA.
• Figure 16-34. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 16-35. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 16-36. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 16-37. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 16-38. Dr. Don Rolfs, Wenatchee, WA.
• Figure 16-39. Dr. Don Rolfs, Wenatchee, WA.
• Figure 16-40. Dr. Don Rolfs, Wenatchee, WA.
• Figure 16-41. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 16-42. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 16-43. Dr. Don Rolfs, Wenatchee, WA.
• Figure 16-44. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 16-45. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 16-46. Dr. Richard Foster, Guilford Technical Community
 College, Jamestown, NC.
• Figure 16-47. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
 MODULE
17

DENTAL
RADIOGRAPHS
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
Radiographic examination of patients provides valuable information related
to the presence or absence of dentally related disease. However, radiographs
should never be used as the sole source for diagnosis. It is only when the
information derived from the radiographic assessment is combined with a
careful review of the health history and periodontal charting of soft tissue
findings that radiographic information becomes a powerful diagnostic aid.
This module covers the evaluation and assessment of radiographic
information involving the recognition of normal anatomic structures and
evaluation of the teeth and their supporting structures. It will require
recognition and discernment of differences between normal and abnormal
conditions especially those relating to the assessment of the alveolar bone and
periodontal structures.
If necessary, the normal radiographic anatomy and the radiographic
manifestations of common dental diseases can be reviewed by referring to a
dental radiology theory textbook before beginning this module.
MODULE OUTLINE
SECTION Review of Radiographic Anatomy
1
SECTION Interpreting Radiographs
2 What to Look for and How to Look for It
Four-Step Assessment
Radiographic Features of Normal Alveolar Bone
Recognizing Early Evidence of Alveolar Bone Loss
SECTION Peak Procedure
3 Procedure 17-1. Assessing Radiographs
SECTION Cone Beam Computed Tomography
4
SECTION Ready References
5 Ready Reference 17-1. Helpful Concepts in Radiology
Ready Reference 17-2. Radiographic Evidence of Bone
Loss
SECTION The Human Element
6 Through the Eyes of an Experienced Clinician
Through the Eyes of a Student
English-to-Spanish Phrase List
SECTION Practical Focus—Fictitious Patient Cases
7 Example: Fictitious Patient Case D: Mrs. Donna Doi
Example: Radiographic Evaluation for Patient Case D
Fictitious Patient Case A: Mr. Alan Ascari
Fictitious Patient Case C: Mr. Carlos Chavez
Fictitious Patient Case E: Ms. Esther Eads
SECTION Practical Focus—Panoramic Radiographs
8 Panoramic Radiograph 1
 Panoramic Radiograph 2
Panoramic Radiograph 3
Panoramic Radiograph 4
Panoramic Radiograph 5
Panoramic Radiograph 6
SECTION Skill Check
9

KEY TERMS
Triangulation • Cone beam computed tomography • Cone beam volume
tomography • Minimally diagnostically acceptable • Significant overlap •
Rule of symmetry • Thorough assessment

OBJECTIVES
• Identify the anatomic structures commonly visible on panoramic
radiographs for fictitious patients.
• Explain radiographic technique and processing errors that could affect
radiographic assessment.
• Given a set of radiographs, recognize and localize the location of each
radiographically visible normal anatomic landmark.
• Describe the radiographic characteristics of normal and abnormal
alveolar bone.
• Recognize and describe early radiographic evidence of periodontal
disease.
• Classify the degree of alveolar bone loss as “localized” or
“generalized,” “slight,” “moderate,” or “severe/advanced.”
• Explain the difference between vertical and horizontal alveolar bone
loss and identify each type of bone loss on radiographs of simulated
patients.
• Recognize potential etiologic agents for periodontal disease
radiographically.
• Briefly and succinctly summarize radiographic findings on
 radiographs of simulated patients and relate them to pertinent
elements from the health history, clinical charting, periodontal
probing, etc.
• Gain practical experience in radiographic assessment by applying
information from this module to the fictitious patient cases in this
module.

SECTION 1 • Review of Radiographic Anatomy

Before attempting to interpret a set of radiographs, it is important to have an
understanding of the anatomic structures visible on radiographs. This section
presents a quick review of the anatomic structures readily and commonly
visible on a panoramic radiograph (Figs. 17-1 and 17-2).
 SECTION 2 • Interpreting Radiographs

What to Look for and How to Look for It

When evaluating any radiograph—whether a single periapical, bitewing, or a
complete mouth radiographic survey (CMRS)/full mouth x-ray (FMX)—
perform the radiographic evaluation in a consistent, routine fashion from one
time to the next. When working with digital radiographs, remember that
the information present and the interpretation process is the same as
that for a conventional radiograph. The order in which the evaluation is
performed is not necessarily as critical as the consistency with which the
clinician performs the task.

Four-Step Assessment
For convenience, the radiographic interpretative process can be divided into a
series of steps:
• Step 1: Determine diagnostic value. Ask the question, “Do these
radiographs exhibit the criteria for meeting minimal diagnostic
acceptability?” Refer to the “Ready References” section of this module
for a brief definition of diagnostic acceptability.
• Step 2: Recognize any significant technique or processing errors that
will deter a clinician’s ability to correctly evaluate all of the relevant
dental structures.
• Step 3: Recognize the “normal” anatomic structures observable on the
radiographs. It is important to be able to distinguish normal structures
from variations or deviations from normal. For example, the clinician
should recognize the mental foramen as “normal anatomy” rather than
“periapical pathology,” especially if the foramen is anatomically close to
the apex of the mandibular first or second premolar.
• Step 4: Conduct a systematic and careful assessment of the teeth and
their supporting tissues. The clinician must be careful not to focus on
only a single condition or deviation. For example, a dental hygienist will
be naturally inclined to look at the alveolar bone first. Focusing on the
alveolar bone early in the search process may distract the hygienist and
cause him or her to stop searching for other dentally relevant deviations
and variations from normal such as calcified pulps, dens in dente, or
periapical pathosis. To avoid this tendency to focus on the alveolar bone,
 he or she should look at the bone last.
Regardless of his or her role in the dental team, the clinician should
consistently examine radiographs for dental caries, periapical pathology,
calcified pulps (indicators of possible prior trauma), asymmetry in pulps of
similar teeth (an early loss of pulp vitality will produce a pulp that doesn’t
mature with age by getting smaller), changes in alveolar bone pattern from
one area to another, alveolar bone height, and etiologic agents promoting
dental disease, such as overhanging margins on restorations and crowns,
calculus, or open contacts.

Radiographic Features of Normal Alveolar Bone

Normal alveolar bone height will vary slightly depending on the age of the
patient. In general, “normal alveolar bone height” is 1.5 to 2 mm below and
parallel to the cementoenamel junction (CEJ) of adjacent teeth (Fig. 17-3).

• The bone forming the alveolar crest should be smooth and intact with
the radiolucent space adjacent to the root surface no wider than the
width of the periodontal ligament space (PDLS).
• Many times, as in Figure 17-3, a distinct “crestal lamina dura” will be
visible; in other words, the alveolar crest appears as a dense radiopaque
line similar in density to the lamina dura surrounding the root of the
tooth. The most important radiographic feature of the alveolar crest,
however, is that it forms a smooth intact surface between adjacent teeth
with only the width of the periodontal ligament (PDL) separating it from
the adjacent tooth surface.

The most important radiographic feature of the alveolar crest is that it

forms a smooth intact surface between adjacent teeth with only the width
 of the PDL separating it from the adjacent root surface.

Recognizing Early Evidence of Alveolar Bone Loss

Early evidence of interproximal alveolar bone loss begins as a progressively
increasing area of radiolucency where the alveolar crest and PDL meet.
1. Widening of periodontal ligament space. Look for the earliest
evidence of bone loss as a progressive widening of the PDLS as it
approaches the alveolar crest (Fig. 17-4). This increasing area of
radiolucency produces a triangular shape and is referred to as
triangulation.

• Triangulation is the widening of the PDLS caused by the resorption

of bone along either the mesial or distal aspect of the interdental
(interseptal) crestal bone (Fig. 17-4).
• Depending on the patient’s self-care (oral hygiene) and other factors,
this increased widening of the PDLS may be seen on the mesial or
distal of a single tooth or on multiple teeth.
2. Loss of integrity of crestal lamina dura. An additional early
radiographic sign of alveolar bone loss is a loss of the integrity of the
crestal lamina dura between adjacent teeth.

SECTION 3 • Peak Procedure

Procedure 17-1. Assessing Radiographs

Action Rationale
1. Determine if the • A complete mouth
radiographs are radiographic survey/full
diagnostically acceptable. mouth x-ray
Ask the question, “Do (CMRS/FMX) should
these radiographs exhibit exhibit sufficient
the criteria for meeting radiographic information
minimal diagnostic to provide the dentist with
acceptability?” an adequate amount of
information to determine
the patient’s specific
treatment needs.
• Usually, this means that
the CMRS/FMX should
show each interproximal
space at least once without
overlap and each root apex
at least once.

2. Look for technique or • Any significant technique

processing errors. Ask the and/or processing errors
questions: will negatively impact the
• “Are there any clinician’s ability to
significant technique or evaluate all of the relevant
processing errors that dental structures.
will influence my ability
to correctly evaluate all
of the relevant dental
structures?”
• “What would I do to
correct these errors next
time?”

3. Recognize normal • It is important to

structures. distinguish normal
 anatomic structures from
variations or deviations
from normal.

4. Conduct a systematic • Conducting the assessment

assessment of the teeth and in a consistent and
their supporting tissues. thorough manner will
assure that all aspects of
the CMRS/FMX are
evaluated.
• A systematic assessment
should include
identification of:
• Teeth present/absent in
the dentition
• Dental caries
• Periapical pathology or
calcified pulps
• Asymmetry in pulps of
similar teeth
• Changes in alveolar
bone pattern from one
area to another
• Alveolar bone height
• Etiologic agents
promoting dental
disease, such as
overhanging margins on
restorations and crowns,
calculus deposits, open
contacts

5. Place radiographs in the • At the start of each

 patient chart or appointment, place the
computerized record for radiographs on a chairside
use at all appointments. view box or display them
on a computer screen.
• Radiographs provide
useful information during
treatment and patient
education.

SECTION 4 • Cone Beam Computed Tomography

One amazing new dental radiographic technology is called cone beam
computed tomography (CBCT) or cone beam volume tomography
(CBVT). These very sophisticated imaging systems ultimately may
completely replace the need for intraoral, panoramic, or other extraoral
radiographic imaging techniques. With this technology, or advances in this
current technology, individuals reading this paragraph will witness a time in
the not-too-distant future when all that will be necessary to diagnostically
image a patient will be to have him or her sit in a chair, stabilize his or her
head in some minimal way, and activate the unit similar to exposing a
panoramic radiograph today. Image capture will take less than 20 seconds
and show up on our computer screen within 2 to 4 minutes. The software will
automatically create a three-dimensional view of the patient from any desired
angle. The details of the images will surpass any of our current extraoral
imaging systems and be approximately equivalent to our better than our
intraoral radiographs.
Space does not permit a detailed explanation of CBCT principles, but in
its simplest form, the CBCT unit produces an adjustable beam of radiation
and exposes an area of the patient’s head as small as 4 cm × 4 cm up to 15 cm
× 15 cm (essentially the whole head). In less than 20 seconds, the unit uses a
pulsed radiation exposure to expose the patient’s head in a 360-degree circle.
During its rotation around the patient’s head, the unit will expose more than
500 individual images of the patient’s head; these individual images are
called “basis images.” Computer software takes these 500+ images and
creates small discrete image volumes, called “voxels,” that the software can
reassemble into sagittal, coronal, and axial images of the patient’s head. The
voxels vary in size from 0.09 to 0.45 mm and will determine the overall
resolution of the image we are viewing.
Currently, CBCT units designed specifically for dental purposes may
seem expensive; however, when compared to the cost of medical CBCT and
CT units, they are relatively inexpensive and provide truly amazing detail not
available in any other dental imaging system. Examples of CBCT volumes
are shown in Figures 17-5 to 17-10.
Figures 17-5A–E represent the detail associated with a “small-volume”
CBCT unit with a voxel size of 0.125 mm. Observe the exquisite bony detail
depicted in this case of cementifying fibroma. Even though these are
motionless images, the software permits moving the section we view in
increments of 0.25 to 1 mm (Figs. 17-5C–E) or more in any direction within
three-dimensional space in real time. The thicknesses of the section below are
1 mm thick.
 One of the major benefits of CBCT is their use in precisely identifying
the quality and thickness of bone in prospective implant sites as well as
clearly identifying and delineating areas of pathology. The technology also
provides uncompromised detail for evaluating potential root fractures;
potential complications associated with symptomatic endodontically treated
teeth; or presurgical evaluation of impacted third molars and their
relationship to adjacent teeth, maxillary sinus, or mandibular canal.
The sections shown below in Figures 17-6A–C illustrate a small
odontoma located between and lingual to the canine and first premolar.

Figures 17-7A and B are example of an acute maxillary sinusitis; note

the small bubbles in the fluid filling the sinus.
 Figures 17-8A and B show how clearly endodontic problems are
depicted in the CBCT images; note the resorption of the root apex of the
second premolar.

Figure 17-9 shows a recent extraction with bone graft material in the
extraction socket. Distal to the extraction socket is a well-circumscribed
“mixed” lesion (combination of radiolucent and radiopaque features)
indicative of some type of residual pathology; the inferior portion of the
lesion has eroded the superior border of the mandibular canal.

Figure 17-10A–C illustrate an example of a “large-volume” CBCT unit

that can be used to evaluate the entire oral–maxillofacial complex. Large-
volume CBCT images may be used in three-dimensional analysis of the
maxillofacial complex in pretreatment and posttreatment planning for
orthognathic surgery and orthodontic treatment as well as multiple implant
site planning.
SECTION 5 • Ready References

Ready Reference 17-1. Helpful Concepts in Radiology

Minimally diagnostically acceptable—with reference to a
CMRS/FMX, at the very least, each interproximal space should be
visible somewhere without significant overlap and each root apex
should be visible. Significant overlap is an overlap that is more
than one-half the width of the enamel or obscures the
dentinoenamel junction (DEJ).

Rule of symmetry—or right side/left side check—is based upon

the principle that most human beings are symmetrical in
appearance; that is, the right side looks like the left side.
• EXAMPLE: Assessing for periapical pathology:
• When assessing for the presence of periapical pathology, the
clinician should first look at the apex of the right first molar
and then immediately compare it to the apex of the left first
molar.
• When evaluating symmetry, the question the clinician should
ask is, “Does the right root look like the left?”
• If the answer is “yes, they both look alike,” then the roots are
probably normal.
• If the answer is “no,” then the question becomes “why not?”
The clinician’s task is to identify what makes one root apex
different from the one on the opposite side of the mouth.
• Continue assessing the right and left sides in this manner. For
example, if you see caries on the mesial surface of the right
maxillary second premolar, immediately look at the mesial
surface of the left maxillary second premolar. This technique
really works, and you will be amazed at how many deviations
and variations you will find if you persist in using this strategy.
Thorough assessment—a thorough assessment involves looking
for more than caries and periodontal disease.
• A quick glance at any pathology textbook or the relevant
sections of your radiology textbook will reveal a vast array of
 conditions that can manifest in the oral cavity in a many subtle
and not-so-subtle ways.
• It is appropriate that your radiographic assessment be
sufficiently sensitive and thorough such that you can identify
deviations and variations from normal.
• The rule of symmetry method of evaluating individual teeth
and/or areas of the jaw is a highly effective strategy.
Ready Reference 17-2. Radiographic Evidence of Bone
Loss

Radiographic Evidence of the Extent of Bone Loss

• Slight—the crest of the alveolar bone is approximately 3–4 mm
apical to the CEJ.
• Moderate—crest of the alveolar bone is approximately 4–5 mm
apical to the CEJ.
• Severe/advanced—crest of the alveolar bone is more than 5
mm apical to the CEJ or the bone covers less than one-half of
the anatomic root length as measured from the CEJ to the root
apex.

Radiographic Evidence of the Distribution of Bone Loss

• Generalized—bone loss involving more than 50% of the
erupted teeth in one arch
• Localized—bone loss involving fewer than 50% of the erupted
teeth in one arch
• When noting such conditions in the patient’s record, it is
appropriate to identify where the localized lesions occur—such
as “mandibular R & L central and lateral incisor region.”

Radiographic Evidence of the Patterns of Bone Loss

• Horizontal pattern of bone loss—is a fairly uniform reduction
in the height of the bone radiographically throughout an arch or
 quadrant.
• Vertical pattern of bone loss—is an uneven pattern of bone
loss that typically involves a single tooth: This uneven pattern
of bone loss leaves a trench-like area of missing bone alongside
the root.

SECTION 6 • The Human Element

Through the Eyes of an Experienced Clinician

HELPFUL TIPS
Limitations of Radiographs
Keep in mind the fact that periapical and interproximal/bitewing
radiographs are two-dimensional representations of a three-dimensional
object and the changes in alveolar bone facial or lingual to the tooth may
be obscured by the superimposition of the tooth and the overlying alveolar
bone. In addition, alveolar bone height will vary depending upon the
radiographic technique used to capture the image; in general, bisecting-
angle radiographs will produce more distortion of the tooth and alveolar
bone compared to radiographs obtained using the paralleling principle.

Key Features of Radiographic Accuracy

Key features of radiographic accuracy to look for prior to attempting any
interpretation, especially of alveolar bone height are:
• Radiographic superimposition of the buccal and lingual cusp tips on
posterior teeth
• Absence of interproximal overlap potentially obscuring the
cementoenamel junction (CEJ)
• Radiographs of sufficient density (darkness) to permit identification of
the CEJ

Using Radiographs in Patient Education

Note: The radiographs on patient A can be extremely useful in educating
the patient regarding the extent and severity of his or her existing disease.
For example, the big easily discerned chunks of calculus on the
interproximal spaces can be useful in explaining the “inflammatory” nature
of the periodontal disease process—if you have patients, consider the
relationship of a splinter in their finger with the subsequent reddening and
potential infection should the splinter not be removed in a timely fashion.
Similarly, calculus can be portrayed as causing a similar effect in the gum
tissues as that of a splinter. The patient should be able to recognize bone
loss in the posterior areas of the maxilla if you identify the CEJ as the level
where the bone level should be “normally.”

Mastering Radiographic Interpretation

As a beginning student of radiographic interpretation, it is easy to feel
overwhelmed by the importance of recognizing sometimes very subtle
changes in bony architecture that can have important consequences in
terms of patient care and treatment. As with any skill development, it will
take time and patience. Develop a systematic approach to analyzing your
radiographs so that you know you are covering all of the essential
elements. You may wish to start by developing a “checklist” of normal
anatomic structures and another list of deviations and variations from
normal that have clinical implications: caries, calculus, calcified pulps,
dens in dente, periapical radiolucencies/radiopacities, etc., simply as a
reminder to look for each of these things. With repetition and
implementation of the rule of symmetry, you will find your radiographic
assessment skills will increase significantly.

Through the Eyes of a Student

TEAM SPIRIT

Effective dental teams work together to provide excellent care.

This includes helping other team members when necessary. As a
dental hygienist, you need to be aware of your own limitations as
well as knowing the strengths and limitations of other team
members. Mutual support and cooperation is an important
behavior for the dental team. In the school setting, instructors and
students are a source of cooperation and support.
• Identify instances in which you felt you needed assistance in
completing a task, such as completing an assignment in a
chemistry or dental materials lab.
• Who did you ask to assist you?
• What influenced your decision to ask this person?
• What is your response when you notice another student needs
assistance?
• Discuss how dentists, assistants, hygienists, and office managers
can work together to improve patient care.

English-to-Spanish Phrase List

SECTION 7 • Practical Focus—Fictitious Patient Cases

DIRECTIONS
• This section shows the radiographs for four fictitious patients A,
C, D, and E.
• The first patient, Donna Doi’s radiographs provide an example
of a thorough evaluation using the steps outlined in Procedure
17-1 in this module. Use Procedure 17-1 and the Radiograph
Evaluation Worksheet to assess the radiographs for the
remaining fictitious patient cases, patients A, C, and E.
• The pages in this section may be removed from the book for
easier use by tearing along the perforated lines on each page.
• Note: The clinical photographs and radiographs in a fictitious
patient case are for illustrative purposes but not necessarily from
the same individual. The fictitious patient cases are designed to
enhance the learning experiences associated with each case.
Example: Fictitious Patient Case D: Mrs. Donna Doi

Example: Radiographic Evaluation for Patient Case D

1. Diagnostic Acceptability. Ask the question, “Do these radiographs
exhibit the criteria for meeting minimal diagnostic acceptability?” If not,
why not?
• This series of radiographs consists of 14 periapical radiographs. There
 are no interproximal/bitewing radiographs available.
• The paralleling principle was used, and there is good superimposition
of the cusp tips suggesting minimal image distortion.
• Each interproximal space may be seen at least once—somewhere.
However, each root apex is not visible at least once; the distal root of
the right mandibular second molar is not visible.
• Conclusion: No, the set of radiographs does not exhibit minimal
diagnostic acceptability. We would need to retake the mandibular
right molar periapical radiograph. Note: Several of the individual
radiographs exhibit rather severe horizontal overlapping of
interproximal spaces; you might feel that the interproximal space of
the maxillary left first and second molar is not adequately open, but
the chapter author considers this to be “minimally” acceptable but not
ideal.
2. Technique. Ask the question, “Are there any significant technique or
processing errors that will influence my ability to correctly evaluate all
of the relevant dental structures?”
• There are no obvious processing errors, but several of the periapical
radiographs exhibit less than optimal film placement: For example,
the maxillary and mandibular right and left canine regions do not
center the canines well; the maxillary central incisor radiograph is
slightly off center, but this doesn’t affect the diagnostic value, only the
“esthetic” value of the radiograph.
• The mandibular right molar periapical is tipped cutting off the apices
of the premolars; however, these apices are visible on the premolar
radiograph.
• The maxillary left molar periapical exhibits severe overlap of all
interproximal spaces.
Problem Solving: Is the overlap of the maxillary left molar
radiograph due to excessive horizontal angulation from the mesial or
distal? How can you tell? (Hint: Look up “Clark’s technique/shift-
shot/buccal-object rule” in your textbook if you don’t know.)
3. Normal Anatomic Structures. Recognize the “normal” anatomic
structures observable on the radiographs. Radiographically visible
“normal” anatomic structures on each of the radiographs include:
• Maxillary right molar: maxillary sinus, lower border of the maxillary
sinus, tuberosity of the maxilla
• Maxillary right premolar: maxillary sinus, anterior, and lower border
of the maxillary sinus
• Maxillary right canine: Large portion of the maxillary sinus and
anterior border of the maxillary sinus, a small portion of the lower
border of the nasal fossa may be seen along the upper mesial corner of
the radiograph.
• Maxillary central incisor: Incisive foramen is easily seen between the
two central incisors, tiny bit of the anterior nasal spine; the nasal fossa
and the lower border of the nasal fossa are not easily discerned; a faint
radiopacity corresponding to the tip of the nose may also be seen. The
lip line is discernible along the central and lateral incisal edges.
• Maxillary left canine: anterior portion and border of the maxillary
sinus
• Maxillary left premolar: maxillary sinus, lower and anterior border of
the maxillary sinus
• Maxillary left molar: maxillary sinus, lower border of the maxillary
sinus, tuberosity of the maxilla, coronoid process of the mandible
• Mandibular right molar: external oblique line (distal to second molar);
a small portion of the submandibular fossa is visible along the lower
distal corner of the radiograph.
• Mandibular right premolar: none noted
• Mandibular right canine: The submandibular fossa may be slightly
visible due to angulation at the lower distal edge of the radiograph; no
other anatomic structures noted.
• Mandibular central incisor: Genial tubercles are barely visible at the
bottom of the radiograph. Nutrient canals are visible as thin vertical
radiolucent lines.
• Mandibular left canine: The mental foramen is visible between the
 apex of the second premolar and first molar.
• Mandibular left premolar: none noted, possibly the submandibular
fossa along the lower distal edge of the film
• Mandibular left molar: external oblique line, mandibular canal
4. Systematic Assessment. Conduct a thorough assessment of the teeth
and supporting structures and provide a written summary of your
findings.
There were no significant deviations or variations in the symmetry of
pulp chambers, no periapical radiolucencies were noted, restorations
appear to be clinically acceptable, and no open contacts or significantly
rotated teeth. Heavy calculus deposits were noted in all four quadrants,
and there is generalized moderate-to-severe alveolar bone loss
throughout the mandible and maxilla. Bone loss is especially severe
around the distal buccal roots of the maxillary right and left first molars.
Increased radiolucency in the trifurcations of the maxillary first molars
and maxillary right second molar; the bifurcation of the mandibular right
second molar exhibits an increased radiolucency and the PDL in the
bifurcation area is radiographically more prominent when compared to
the other mandibular molar teeth (rule of symmetry).

Problem Solving Answer: If you identified the excessive horizontal overlap

of the interproximal spaces as due to excessive horizontal angulation due to
positioning the central ray of the x-ray unit too far from the distal, you are
correct. According to Clark’s rule, objects on the lingual move in the
direction of tube shift. If you look closely at the position of the first molar
root apices, the lingual and distal-buccal roots are superimposed. Excessive
angulation from the mesial would cause the mesial-buccal and lingual roots
to overlap.

Fictitious Patient Case A: Mr. Alan Ascari

Fictitious Patient Case C: Mr. Carlos Chavez
Fictitious Patient Case E: Ms. Esther Eads
SECTION 8 • Practical Focus—Panoramic Radiographs

DIRECTIONS
• This section has six panoramic radiographs for interpretation.
 • Please provide a brief description of the radiographic findings to
include, but not limited to, the following, if present, for each
panoramic radiograph:
• Missing teeth
• General description of alveolar bone height in each arch
• Presence or absence of calculus, caries, periapical pathology
(if any)
• Dental restorative materials
• Any radiographic “deviations” from normal
• The pages in this section may be removed from the book for
easier use by tearing along the perforated lines on each page.

Panoramic Radiograph 1
Panoramic Radiograph 2
Panoramic Radiograph 3
Panoramic Radiograph 4
Panoramic Radiograph 5
Panoramic Radiograph 6
 SECTION 9 • Skill Check

Technique Skill Checklist: Dental Radiographs

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).
DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S
(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Defines the term minimal diagnostic acceptability.
Given a set of CMRS/FMX, determines if the
radiographs exhibit the criteria for meeting minimal
diagnostic acceptability.
Recognizes and lists in writing any significant
technique or processing errors that would influence
a clinician’s ability to correctly evaluate all the
relevant dental structures on the radiographs.
Lists in writing the “normal” anatomic structures
observable on the radiographs.
Conducts a thorough assessment of the teeth and
supporting structures and provides a written
summary of his or her findings
OPTIONAL: SATISFACTORY PERFORMANCE
CRITERIA
Student written assessment is in 80% agreement
with the evaluator’s assessment.

Communication Skill Checklist: Dental Radiographs

ROLES:
• Student 1 = Plays the role of the patient.
 • Student 2 = Plays the role of the clinician.
• Student 3 or instructor = Plays the role of the clinic instructor near
the end of the role-play.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Explains to the patient how radiographs help
clinicians to better understand a patient’s dental
needs.
Points out and explains findings on the radiographs
to the patient.
Encourages patient questions.
Answers the patient’s questions fully and
accurately.

Communicates with the patient at an appropriate

level avoiding dental/medical terminology or
jargon.
Accurately communicates the findings to the
clinical instructor. Discusses the implications for
dental treatment using correct medical and dental
terminology.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.
 PART 3
Comprehensive Patient
Cases
 MODULE
18

COMPREHENSIVE
PATIENT CASES F TO K
For additional ancillary materials related to this chapter, please
visit thePoint.

MODULE OVERVIEW
This module presents six fictitious patient cases, patients F to K. The
fictitious patient cases in this module provide opportunities to practice
interpreting and communicating assessment information.

MODULE OUTLINE
SECTION Fictitious Patient F, Frasier Fairhall
1
SECTION Fictitious Patient G, Gumercindo de la
2 Garza
SECTION Fictitious Patient H, Harry Haversmith
3
SECTION Fictitious Patient I, Ida Iannuzzi
4
 SECTION Fictitious Patient J, John Jolioceur
5
SECTION Fictitious Patient K, Kwan Kang
6
SECTION The Human Element
7 Ethical Dilemma
SECTION Skill Check
8

OBJECTIVES
• Demonstrate knowledge of information gathering and evaluation by
applying concepts from the modules in this book to fictitious
comprehensive patient cases F to K.
• During a role-play, demonstrate the use of communication strategies
to provide information to each patient about his or her assessment
findings.
• During a role-play, accurately communicate the assessment findings
to a clinical instructor.
• Discuss the implications for dental treatment using correct medical
and dental terminology.

Sources of Clinical Photographs

The authors gratefully acknowledge the sources of the clinical photographs in
this module:

CASE F
• Figure 18-4. Image provided by Stedman’s Medical Dictionary.
• Figure 18-5. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-6. Dr. Richard Foster, Guilford Technical Community
 College, Jamestown, NC.
• Figure 18-7. Dr. Don Rolfs, Wenatchee, WA.
• Figure 18-8. Dr. Don Rolfs, Wenatchee, WA.

CASE G
• Figure 18-12. From Langlais RP, Miller CS, Nield-Gehrig JS. Color
Atlas of Common Oral Diseases. 4th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2009.
• Figure 18-13. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-14. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-15. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.

CASE H
• Figure 18-19. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-20. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-21. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-22. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.

CASE I
• Figure 18-26. Centers for Disease Control and Prevention, Public Health
Image Library (PHIL).
• Figure 18-27. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-28. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-29. Dr. Richard Foster, Guilford Technical Community
 College, Jamestown, NC.

CASE J
• Figure 18-33. Dr. Charles Goldberg, University of California San Diego
School of Medicine.
• Figure 18-34. Image provided by Stedman’s Medical Dictionary.
• Figure 18-35. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-36. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-37. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-38. Catherine Ranson, George Brown College, Toronto.
• Figure 18-39. Catherine Ranson, George Brown College, Toronto.

CASE K
• Figure 18-42. From Goodheart HP. Goodheart’s Photoguide of Common
Skin Disorders. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2003.
• Figure 18-43. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-44. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.
• Figure 18-45. Dr. Don Rolfs, Wenatchee, WA.
• Figure 18-46. Dr. Richard Foster, Guilford Technical Community
College, Jamestown, NC.

DIRECTIONS FOR COMPLETING THE

FICTITIOUS PATIENT CASES
1. Compile and analyze findings. Follow the Peak Procedures outlined
in Modules 4 to 16 to assess the patient findings.
2. Create a summary statement. Use notebook paper to create a
 summary worksheet for each patient. List the significant findings for
each assessment category and explain how each finding will impact
the dental hygiene care plan.
3. Complete the communication role-play in Section 8 of this
module. Clearly and accurately communicate assessment findings to
each patient. Present assessment findings to your clinical instructor
and discuss the implications of these findings for patient care.

NOTE: The clinical photographs and radiographs in this module are for
illustrative purposes but are not necessarily from the same individual.
The components of a fictitious patient case were selected to enhance the
learning experiences associated with the case.

SECTION 1 • Fictitious Patient F, Frasier Fairhall

Finding:
Location: left side of face
Size: two raised lesions; each lesion is 1 cm in diameter

Finding:
Location: floor of the mouth
Size: 1 cm in anterior-posterior length; 0.5 cm in superior-inferior width
SECTION 2 • Fictitious Patient G, Gumercindo de la
Garza
Finding:
Location: lower lip
Size: 0.5 cm in diameter

Finding:
Location: ventral surface of tongue
Size: 2.5 cm in anterior-posterior length; 1.5 cm in width
SECTION 3 • Fictitious Patient H, Harry Haversmith
Finding:
Location: left side of neck below border of the mandible
Size:
8 cm in superior-inferior length;
4 cm in width
Finding:
Location: raised lesion on dorsal surface of tongue
Size: 0.5 mm in diameter
SECTION 4 • Fictitious Patient I, Ida Iannuzzi
Finding:
Location: corners of the lips

Finding:
Location: right buccal mucosa
Size: 1 cm in superior-inferior length; 5 mm in anterior-posterior width
SECTION 5 • Fictitious Patient J, John Jolioceur
Finding:
Location: right side of neck
Size: 5 cm in diameter

Finding:
Location: left side of nose
Size: 6 mm in superior-inferior height at midline of lesion; 17 mm in width
Finding:
Location: right, lateral border of tongue
Size: irregular border, approximately 1 cm in diameter
SECTION 6 • Fictitious Patient K, Kwan Kang
Finding:
Location: left temporal region
Size: 1 cm in diameter

Finding:
Location: ventral surface of tongue, to right of midline
Size: 6 mm in diameter
SECTION 7 • The Human Element

Ethical Dilemma

THE NEW PATIENT

You have just seated Frasier Fairhall, who is a new patient in your group
practice. Mr. Fairhall is a 57-year-old male with a chief complaint of
“bleeding gums.” He states that his last dental visit was approximately 5
years ago to repair a broken filling.
The first thing you notice as you review Mr. Fairhall’s medical
history responses is the apparent strong smell of alcohol on his breath. As
you observe the patient during the discussion, you note that his face is red,
his breathing is heavy, and he seems a bit disoriented.
Mr. Fairhall’s last physical examination was approximately 10 years
ago, although he states that he was treated for hepatitis 2 years ago.
Although he answered “no” to question 61 on the written health history
form, he admits to the occasional use of recreational drugs during your
verbal review of his medical history.
Something doesn’t seem right to you, as you are questioning his
cognitive recall for accurate dates. He states that he smokes three packs of
cigarettes per day, but his answers to your questions seem somewhat
evasive. You are concerned about his blood pressure reading of 158/100 as
well as extraoral lesions on his face and an intraoral lesion in the floor of
his mouth. However, you are most concerned about his sobriety, treating
him in his present condition, and are fearful of his getting into a car and
driving following the appointment.
1. Should you treat Mr. Fairhall today?
2. What ethical principles are involved in this scenario?
3. How do you inform/educate Mr. Fairhall about his oral/general health?
4. How can you help Mr. Fairhall quit smoking?

SECTION 8 • Skill Check

Communication Skill Checklist: Communication Role-

Plays
DIRECTIONS:
Play the role of the clinician in one or more role-plays selected by your
instructor.
ROLES:
• Student 1 = Plays the role of the patient.
• Student 2 = Plays the role of the clinician.
• Student 3 or instructor = Plays the role of the clinic instructor near
the end of the role-play.

DIRECTIONS FOR STUDENT: Use Column S; evaluate your skill level as

S (satisfactory) or U (unsatisfactory).

DIRECTIONS FOR EVALUATOR: Use Column E. Indicate S

(satisfactory) or U (unsatisfactory). In the optional grade percentage
calculation, each S equals 1 point, and each U equals 0 point.

CRITERIA: S E
Uses appropriate nonverbal behavior such as
maintaining eye contact, sitting at the same level as
the patient, nodding head when listening to patient,
etc.

Interacts with the patient as a peer, avoids a

condescending approach. Collaborates with the
patient and provides advice. Gains the patient’s trust
and cooperation.
Reports all notable findings to the patient and
explains whether the findings are normal or outside
the normal range and the significance of these
findings. Communicates using common, everyday
words. Avoids dental terminology.
Listens attentively to the patient’s comments.
Respects the patient’s point of view.
Listens attentively to the patient’s questions.
Encourages patient questions. Clarifies for
understanding, when necessary.
Answers the patient’s questions fully and
accurately. Checks for understanding by the patient.
Clarifies information.
Accurately communicates the findings to the
clinical instructor. Discusses the implications for
dental treatment. Uses correct medical and dental
terminology.
OPTIONAL GRADE PERCENTAGE
CALCULATION
Using the E column, assign a point value of 1 for
each S and 0 for each U. Total the sum of the “S”s
and divide by the total points possible to calculate a
percentage grade.
 GLOSSARY

A
Abdominal aortic aneurysm—occurs when part of the aorta—the main
artery of the body—becomes weakened. If left untreated, the aorta can
burst.
Addiction—a chronic dependence on a substance, such as smoking, despite
adverse consequences.
Aneroid manometer—a round dial-type gauge to indicate pressure readings.
Angle’s classification—a system for classifying the relationship of the
mandibular teeth to the maxillary teeth.
Antecubital fossa—the hollow or depressed area in the underside of the arm
at the bend of the elbow.
Aphasia—a disorder that results from damage to language centers of the
brain. It can result in a reduced ability to understand what others are
saying, to express ideas, or to be understood.
Asymptomatic—a condition or disease that has no symptoms that are
detectable to the patient; an example of an asymptomatic condition is
hypertension.
Attention deficit hyperactivity disorder (ADHD)—a developmental
disorder believed to be caused primarily by genetic factors. Patients with
ADHD may experience problems such as difficulty with sustained
attention, excessive activity, and increased distractibility.
Auscultation—the act of listening for sounds within the body to evaluate the
condition of the heart, blood vessels, lungs, or other organs.
Auscultatory gap—a period of abnormal silence that occurs between the
 Korotkoff phases that are heard during the measurement of blood pressure.

B
Blood pressure—pressure exerted against the blood vessel walls as blood
flows through them. Also see systolic pressure and diastolic pressure.
Blood pressure cuff—an airtight, flat, inflatable bladder covered by a cloth
sheath that is used when measuring blood pressure.
Brachial artery—the main artery of the upper arm; it divides into the radial
and ulnar arteries at the elbow. The brachial artery is used when taking
blood pressure.
Bulla—a large blister filled with clear fluid; usually over 1 cm in diameter;
commonly seen in burns.

C
Cancer—a term for diseases in which abnormal cells divide without control.
Cancer cells can invade nearby tissues and spread through the bloodstream
and lymphatic system to other parts of the body. Also see head and neck
cancer.
Capacity for consent—the ability of a patient to fully understand the
proposed treatment, possible risks, unanticipated outcomes, and alternative
treatments—takes into account the patient’s age, mental capacity, and
language comprehension.
Carcinogen—a chemical or other substance that causes cancer.
Celsius temperature scale—the temperature scale used in most countries for
measuring body temperature. Also see Fahrenheit temperature scale.
Chewing tobacco—also known as spit tobacco, chew, dip, and chaw—is
tobacco cut for chewing. Also see smokeless tobacco and snuff.
Chronic obstructive pulmonary disease (COPD)—a lung disease in which
the airways in the lungs produce excess mucus resulting in frequent
coughing. Smoking accounts for 80% to 90% of the risk for developing
COPD.
Circumvallate papillae—the 8 to 12 large papillae that form a V-shaped row
 on the tongue.
Clinical Practice Guideline for Treating Tobacco Use and Dependence
—guidelines published by the U.S. Department of Health and Human
Services are considered the benchmark for cessation techniques and
treatment delivery strategies. The Clinical Practice Guideline may be
downloaded at
http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf.
Closed questions—questions that can be answered with a yes or no, or a
one- or two-word response, and do not provide an opportunity for the
patient to elaborate.
Communication—the exchange of information between individuals.
Coronary artery disease (CAD)—a thickening of the coronary arteries—is
the most common type of heart disease. CAD results in a narrowing of the
arteries so that the supply of blood and oxygen to the heart is restricted or
blocked. Smoking is the major risk factor for CAD.
Cuff—see blood pressure cuff.
Cultural awareness—the development of sensitivity and cross-cultural
understanding.
Cultural competency—the application of cultural knowledge, behaviors,
and interpersonal and clinical skills to enhance a dental health care
provider’s effectiveness in managing patient care.
Culture—a pattern of learned behavior, values, and beliefs exhibited by a
group that shares history and geographic proximity. Culture determines
health attitudes, roles, and behaviors of providers and patients.
Culture, high-contact—cultures that prefer 1 in to 4 ft of body space during
personal interaction and much contact between people.
Culture, low-contact—cultures that prefer 4 to 12 ft of body space during
personal interaction and little, if any, physical contact.

D
Dental health history—a record of the patient’s past and present dental
experiences.
Diaphragm endpiece—the amplifying device of a stethoscope that is used to
 hear loud sounds like the blood rushing through the arteries.
Diastolic pressure—the pressure exerted against the vessel walls when the
heart relaxes.
Diplomacy—the art of treating people with tact and genuine concern.
Dysarthria—speech problems that are caused by the muscles involved with
speaking or the nerves controlling them. Individuals with dysarthria have
difficulty expressing certain words or sounds.

E
Empathy—identifying with the feelings or thoughts of another person; an
essential factor in effective communication.
Environmental tobacco smoke (ETS)—occurs when nonsmokers inhale a
mixture of smoke from a burning cigarette, pipe, or cigar and the smoke
exhaled by the smoker. Also known as secondhand smoke or passive
smoking.
Estimated systolic pressure—an estimation of the actual systolic blood
pressure that is determined by palpating the brachial artery pulse and
inflating the cuff until the pulsation disappears. This point at which the
pulsation disappears is the estimated systolic pressure.
Extraoral examination—See head and neck examination.

F
Fahrenheit temperature scale—the temperature scale used in most
countries for measuring body temperature. Also see Celsius temperature
scale.
Filiform papillae—the long, thin, gray, hairlike papillae that cover the
anterior two-thirds of the dorsal surface of the tongue.
Fissure—a linear crack in the top two layers of the skin or mucosa.
Foliate papillae—the three to five large, red, leaflike projections on the
lateral border of the posterior third of the tongue.
Fungiform papillae—the broad, round, red, mushroom-shaped papillae of
the tongue.
G
Galinstan—the most common alternative to a mercury thermometer.
Glass thermometer—a small glass tube with a bulb at the end containing
mercury that is used to take an oral temperature. When the thermometer
bulb is warmed, the mercury moves up the glass tube.
Goiter—an enlarged thyroid gland.

H
Head and neck cancer—cancer that arises in the head or neck region (in the
nasal cavity, sinuses, lip, mouth, salivary glands, throat, or larynx [voice
box]).
Head and neck examination—a physical examination technique consisting
of a systematic visual inspection of the skin of the head and neck combined
with palpation of the lymph nodes, salivary glands, thyroid gland, and
temporomandibular joint.
Health literacy—the ability of an individual to understand and act on health
information and advice.
Hookah—a large water pipe with a hose used to smoke flavored tobacco.
Hypertension—high blood pressure; blood pressure that stays at or above
140/90 mm Hg.
Hypertensive—an individual with abnormally high blood pressure.
Hypotensive—an individual with abnormally low blood pressure.

I
Idiom—a distinctive, often colorful expression in which the meaning cannot
be understood from the combined of its individual words (e.g., the phrase
“to kill two birds with one stone”).
Informed consent—involves providing complete and comprehensive
information about patient assessment procedures and planned dental
hygiene treatments so that the patient can make a well-informed decision
about either accepting or rejecting the proposed treatment. Informed
consent involves not only informing the patient about the expected
 successful outcomes of assessment procedures but also the possible risks,
unanticipated outcomes, and alternative treatments as well. The patient
also should be made aware of the costs for each of the options involved,
which may influence the patient’s ultimate decision. Also see capacity for
consent and informed refusal.
Informed refusal—the patient’s right to refuse one or more of the
recommended assessment or treatment procedures.
Inspection—the systematic visual examination of a patient’s general
appearance, skin, or a part of the body to observe its condition.
Intraoral examination—see oral examination.

K
Korotkoff sounds—the series of sounds that is heard as the pressure in the
sphygmomanometer cuff is released during the measurement of arterial
blood pressure.

L
Laryngectomy—the surgical removal of the voice box due to cancer; affects
approximately 9,000 individuals each year, most are older adults.
Lesion of the soft tissue—an area of abnormal-appearing skin or mucosa
that does not resemble the soft tissue surrounding it; such as a variation in
color, texture, or form of an area of skin or mucosa.
Literacy—See health literacy.
Lymph—a clear fluid that carries nutrients and waste materials between the
body tissues and the bloodstream.
Lymphadenopathy—the term for enlarged lymph nodes.
Lymphatic system—a network of lymph nodes connected by lymphatic
vessels that plays an important part in the body’s defense against infection.
Lymph nodes—small, bean-shaped structures that filter out bacteria, fungi,
viruses, and other unwanted substances to eliminate them from the body.

M
Macule—a small, flat, discolored spot on the skin or mucosa that does not
include a change in skin texture or thickness; less than 1 cm in size; the
discoloration can be brown, black, red, or lighter than the surrounding skin.
Malocclusion—the improper positioning of the teeth and jaws.
Manometer—a gauge that measures the air pressure in millimeters used
when measuring blood pressure. Also see aneroid manometer and mercury
manometer.
Medical alert box—a specified area (such as a box) on the patient chart or
computerized record in which medical conditions/diseases or medications
that necessitate modifications or special precautions for treatment are
clearly marked.
Mercury manometer—a device with a column of mercury to indicate
pressure readings.
Metastasis—the spread of cancer from the original tumor site to other parts
of the body by tiny clumps of cells transported by the blood or lymphatic
system.
Mixed dentition—a combination of primary and permanent teeth in a
dentition.
Multi-Language Health History Project—an initiative of the University of
the Pacific Dental School (UOP) to address the needs of patients and
dental health care providers who do not speak the same language.

N
Nodule—a raised, marblelike lesion detectable by touch, usually 1 cm or
more in diameter; it can be felt as a hard mass distinct from the tissue
surrounding it.
Nonverbal communication—the transfer of information between persons
without using spoken, written, or sign language.

O
Occlusion—the relationship of the teeth to each other when the incisal and
occlusal surfaces of the mandibular arch contact those of the maxillary
 arch.
Open-ended questions—questions that require more than a one-word
response and allow the patient to express ideas, feelings, and opinions.
Oral examination—a physical examination technique consisting of the
systemic inspection of the oral structures.
Overbite—the amount of vertical overlap that occurs when the maxillary
incisors vertically overlap the mandibular incisors.
Overjet—the horizontal distance between the incisal edges of the maxillary
teeth and the mandibular teeth.

P
Palpation—the examination of a part of the body by using the fingertips to
move or compress a structure against the underlying tissue. The most
sensitive part of the hand—the fingertips—should be used for palpation.
Papillae—the taste sensitive structures of the tongue. Also see filiform
papillae, fungiform papillae, foliate papillae, and circumvallate papillae.
Papule—a solid, raised lesion that is usually less than 1 cm in diameter; may
be any color.
Parotid glands—the largest of the salivary glands; each gland is located
between the ear and the jaw.
Passive smoking—see environmental tobacco smoke.
Patch—a flat, discolored spot on the skin or mucosa; larger than 1 cm in
size.
Patient-centered care—an approach to health care that emphasizes
respecting the patient as a whole, unique individual. A patient-centered
approach to patient care recognizes that there are two experts present
during the interaction between a health care provider and patient. One
expert is the health care provider who has clinical knowledge. The second
expert is the patient who brings experience, beliefs, and values to the
dental treatment planning process.
Peripheral vascular disease (PVD)—a vascular disease that occurs when fat
and cholesterol build up on the walls of the arteries blocking the supply
blood to the arms and legs.
Personal filters—when involved in the act of communication, factors in a
person’s life, such as his or her life experiences, age, gender, and cultural
diversity, that act as filters to incoming information. For this reason, the
message received may not be the message sent. Normal human biases or
personalized filters create major barriers to effective communication.
Personal space—the physical distance maintained between persons; a
powerful concept that we use in determining the meaning of messages
conveyed by another person.
Plaque—a superficial raised lesion often formed by the coalescence (joining)
of closely grouped papules; more than 1 cm in diameter; a plaque differs
from a nodule in its height; a plaque is flattened and a nodule is a bump.
Presbycusis—the loss of hearing that gradually occurs in most individuals as
they grow old.
Proxemics—the study of the distance an individual maintains from other
persons and how this separation relates to environmental and cultural
factors.
Pulse points—the sites on the surface of the body where rhythmic beats of an
artery can be easily felt.
Pulse rate—an indication of an individual’s heart rate. Pulse rate is measured
by counting the number of rhythmic beats that can be felt over an artery in
1 minute.
Pustule—a small, raised lesion filled with pus.

Q
Quitlines—toll-free telephone centers staffed by trained smoking cessation
experts.

R
Racial group—a group of people who share socially constructed differences
based on visible characteristics or regional linkages.
Radial artery—a branch of the brachial artery beginning below the elbow
and extending down the forearm on the thumb side of the wrist and into the
 hand.
Reflection—the act of repeating something that someone has just said.
Respiratory rate—measured by counting the number of times that a
patient’s chest rises in 1 minute.
Risk factors—conditions that increase a person’s chances of getting a
disease (such as cancer).

S
Secondhand smoke—occurs when nonsmokers inhale a mixture of smoke
from a burning cigarette, pipe, or cigar and the smoke exhaled by the
smoker. Also see environmental tobacco smoke.
Service animal—any guide dog or other animal that is trained to provide
assistance to a person with a disability.
Smokeless tobacco—tobacco that is not smoked but used in another form.
Snuff and chewing tobacco are the two main forms of smokeless tobacco
in use in the United States and Canada. Also see chewing tobacco and
snuff.
Smoker’s cough—the chronic cough experienced by smokers because
smoking impairs the lung’s ability to clean out harmful material. Coughing
is the body’s way of trying to get rid of the harmful material in the lungs.
Snuff—a smokeless tobacco in the form of a powder that is placed between
the gingiva and the lip or cheek or inhaled into the nose. Also see chewing
tobacco and smokeless tobacco.
Soft tissue lesion—see lesion of the soft tissue.
Sphygmomanometer—a device used to measure blood pressure consisting
of a cuff with an inflatable bladder, a hand bulb with a valve used to inflate
and deflate the bladder, and a pressure gauge.
Sphygmomanometer cuff—see blood pressure cuff.
Stereotype—an oversimplified, standardized image that one individual uses
to categorize other individuals or groups.
Sternomastoid muscle—a long, thick, superficial muscle on each side of the
head with its origin on the mastoid process and insertion on the sternum
and clavicle (also called the sternocleidomastoid muscle).
Stethoscope—a device that makes sound louder and transfers it to the
clinician’s ears.
Sublingual glands—the smallest of the three salivary glands; located in the
anterior floor of the mouth next to the mandibular canines.
Submandibular glands—the salivary glands located below the jaw toward
the back of the mouth.
Systolic pressure—the pressure created by the blood as it presses through
and against the vessel walls. Also see estimated systolic pressure.

T
Temperature—the measurement of the degree of heat in a living body.
Temporomandibular joint (TMJ)—the joint that connects the mandible to
the temporal bone at the side of the head. One of the most complicated
joints in the body; it allows the jaw to open and close, move forward and
backward, and from side to side.
Territory—the space we consider as belonging to us. The way that people
handle space is largely determined by their culture. Also see culture, low-
contact, and culture, high-culture.
Thermometer—see glass thermometer.
Thyroid gland—one of the endocrine glands, secretes thyroid hormone that
controls the body’s metabolic rate; located in the middle of the lower neck.
Triangulation—the widening of the periodontal ligament space (PDLS)
caused by the resorption of bone along either the mesial or distal aspect of
the interdental (interseptal) crestal bone as observed on a radiograph.

U
Ulcer—a craterlike lesion of the skin or mucosa where the top two layers of
the skin are lost.

V
Verbal communication—the use of spoken, written, or sign language to
exchange information between individuals.
Vesicle—a small blister filled with a clear fluid; usually 1 cm or less in
diameter.
Vital signs—a person’s temperature, pulse, respiration, and blood pressure.

W
Wheal—a raised, somewhat irregular area of localized edema; often itchy,
lasting 24 hours or less; usually due to an allergic reaction, such as to a
drug or insect bite.
White-coat hypertension—blood pressure that rises above its usual level
when it is measured in a health care setting (such as a medical or dental
office, where a health care provider may be wearing a white laboratory
coat).
Withdrawal symptoms—the unpleasant symptoms experienced by a smoker
when trying to quit smoking, such as craving for nicotine, irritability,
anger, anxiety, fatigue, depressed mood, difficulty concentrating,
restlessness, and sleep disturbance.
 INDEX

Note: Page references followed by b, f, or t indicate boxes, figures, or tables,

respectively.

A
ABCD-T mnemonic, for lesions, 394, 394b, 395
Addiction, 354–355, 354f
Addison disease, 158
ADHD, 75, 75b
Adolescents
communicating with, 63, 64b
consent from, 124
Adrenal crisis, 164, 168
Adrenal insufficiency, 158, 166
Adult dental health history questionnaire. See Dental health history
questionnaire, adult
Advocacy, patient, 35
Affirmations, 88, 92
Age, as communication barrier, 63–64, 80
AIDS, 163
Alcoholism, 158
Allergy, 158
Allergy, latex, 163
Alveolar bone
loss, evidence of, 631, 631f, 641, 641f
 normal, radiographic features of, 630–631, 631f
Alzheimer disease, 158
American Society of Anesthesiologists Physical Status Classification (ASA-
PS), 111, 111t
Americans with Disabilities Act (ADA), 66
Amplifying device, of stethoscope, 294, 294f
Amyotrophic lateral sclerosis (ALS), 164
Anaphylaxis, 158
Anemia, 158
Aneroid manometer, 293, 293f, 296f, 320, 320f
Angina, 158
Anginal attack, 158, 160
Angioedema, 491f
Angle, Edward H., 590
Angle’s classification, of occlusion, 590–592, 590f–592f, 600f
Ankyloglossia, 494, 495f
Antecubital fossa, 303–305, 303f, 304f
Antegonial notch, 453
Anterior crossbite, 593f
Anticoagulant therapy, 158
Anxious patient, stress reduction protocol for, 119, 119b
Aphasia, 68
Apical to CEJ, 545t, 548f
Arthritis, 159
Arthritis, rheumatoid, 168
Asking permission, 89, 92
Aspirin/antiplatelet therapy, 159
Assessment. See also specific anatomy and approaches
communication styles in, 87, 87f
dental health history for, 214–247
informed consent for, 116–117
medical history for, 102–155
motivational interviewing for, 84–99
Assumptions about patients, 263
Asthma, 159
Asthma attack, 159
Asymptomatic, 291
Attention deficit hyperactivity disorder (ADHD), 75, 75b
Auricular lymph nodes, posterior, 444, 444f
Auscultation, 292–294, 295, 296–301
Auscultatory gap, 299, 299f, 300b, 312
Auscultatory method, 292
Auscultatory phases, 299, 299f
Autism/autism spectrum disorder, 76, 76b, 159
Automatic blood pressure equipment, 294–295, 295f
Automatic temperature equipment, 253

B
Bad news, sharing, 31, 32t–33t
Basal cell carcinoma, 386, 401
Behavioral change, 86
Bell endpiece, of stethoscope, 294, 294f
Bell palsy, 159
Bifid uvula, 496f
Binaurals, 293, 294f
Bipolar affective disorder, 159
Bladder, of blood pressure cuff, 301–302, 301f, 302f, 315
Blindness, 65–66, 65b
Blood glucose levels, 112b
Blood pressure, 252, 288–341
accuracy of, factors affecting, 318
arm position for taking, 303–304, 303f, 304f, 308, 308f
assessment, pediatric, 318
assessment in dental setting, 290–291
classification, adult, 316
classification, children and adolescent, 316
 communication tasks in assessment, 27, 28b
critical technique elements for, 301–305
English-to-Spanish phrase list for, 327t–328t
equipment for measuring, 292–295
equipment for measuring, maintaining, 320
fluctuations in, 300
high (hypertension), 163, 290–291, 291b, 300, 317
high, dental management of, 317
human element in, 323–328
inaccuracies in, causes of, 319
informing patient of, 312, 312f
Internet resources on, 321
interpreting, summary reports on, 321
low (hypotension), 290
measurement of, 252, 296–301, 296b
palpatory estimation of, 305, 305f, 309
peak procedure for, 306–312
practical focus (cases) on, 329–333
ready references for, 315–321
skill check, role-play, 337
skill check, technique, 335–336
standard of care, 290b
Blunted gingiva, 545t
Bone loss, 631, 631f, 641, 641f
Border, of soft tissue lesions, 387f
Brace, of stethoscope, 293, 294f
Brachial artery, 270, 270f, 305, 305f, 309
Bradypnea, 279, 279f
Breathing. See Respiration
Bronchitis, chronic, 160
Buccal mucosa, 501, 501f
Bulbous gingiva, 545t
Bulimia nervosa, 159
Bulla, 392f

C
Cancer
characteristics of common lesions in, 401
dental professional’s role in detecting, 397b
head and neck, 166, 346
human element in, 461
metastasis of, 432
oral, 166, 386, 488–490, 488f, 489b, 490b
pharyngeal, 386
skin, 386, 401, 461
soft tissue lesions in, 386, 397b, 401
tobacco use and, 345, 353, 403
Capacity for consent, 116
Carcinogen, 353
Cardiovascular disease, smoking and, 345
Cases, 668–707
blood pressure, 329–333
dental health history, 235, 236f–245f
gingiva, 563, 564f–580f
head and neck examination, 465, 466f–480f
medical history, 127, 128f–152f
mixed dentition, 607–612, 607f–613f
occlusion, 615, 615f–619f
oral examination, 519, 520f–534f
radiographs, 647–650, 648f, 651f–656f, 657, 658f–663f
soft tissue lesions, 405, 405f–422f
tobacco cessation, 377, 378f
CBCT. See Cone beam computed tomography
Celsius, 253, 261
Centigrade, 253, 261
Cerebral palsy, 77, 77b, 159
Cerebrovascular accident (CVA), 160, 163
Cervical lymph nodes, 430, 431f, 432, 432f, 448–449, 448f–449f
Cheeks, underlying structures of, 502–503, 502f, 502t, 503f
Chemotherapy, 160
Chewing tobacco, 351
Children. See also Dental health history questionnaire, children’s; Dentition
communicating with, 63, 63b
Chinese, health history form in, 108f
Chronic bronchitis, 160
Circumvallate papillae, 494, 494f
Clinical Practice Guideline for Treating Tobacco Use and Dependence, 358
Closed questions, 26b
Code of Ethics, 116
Cognitive disability, 74, 74b
Collaboration, interprofessional, 112
Color
of gingiva, 546f–547f
of soft tissue lesions, 388f
Commissure of lips, 491, 491f
Communication
clear, accurate, and understandable, 41–54, 42b
cross-cultural, 61–62, 62f
dental health history, 232
difficult conversations in, 31, 31b, 32t–33t
effective, 5, 5f
electronic records and, 29–30, 29b
empathy in, 11
first impressions, 8, 8f
good, benefits of, 6
human element in, 34–36, 48–49, 78–80
Internet resources for, 47, 47t, 49
motivational interviewing for, 84–99
nonverbal, 7–10, 7f
 patient-centered, 17–28, 17b, 18f
poor, impact of, 5
questioning skills in, 26, 26b
right words in, 11, 12t
self-assessment of, 19t
skill check, gingival description, 581
skill check, head and neck examination, 483
skill check, mixed dentition, 623
skill check, occlusion, 624
skill check, oral examination, 537
skill check, radiographs, 666
skill check, role-play, 37, 51, 81, 97, 154, 266, 286, 337, 379, 707
skill check, temperature, 266
standardized nomenclature for, 30
tasks during patient assessment, 27, 28b
techniques hindering, 24, 24t–25t
temperature-taking, 266
terminology and, 42, 44, 44t–46t, 48–49
verbal, 7
Communication barriers, 56–83
age, 63–64, 80
filters, 6, 6f
hearing impairments, 67, 67b, 80
human element in, 78–80
language, 58–62
special health needs, 71–77
speech problems, 68–70, 69b
vision impairments, 65–66, 65b
Communication filters, 6, 6f
Communication styles, 87, 87f
Compression techniques, 438, 438f
Computed tomography, cone beam, 633–637, 633f–638f
Computerized records, impact on communication, 29–30, 29b
Concept words, and communication, 44, 45t
Cone beam computed tomography (CBCT), 633–637, 633f–638f
Cone beam volume tomography (CBVT), 633
Confluent configuration, of lesion, 389f
Congenital heart defects, 160
Congestive heart failure (CHF), 160
Consent
adolescent, 124
informed, 116–117
for medical consult, 113
Consultation with physician, 112–113, 114f–115f, 127, 132f, 137f, 142f, 147f,
152f
Coronal to CEJ, 545t, 548f
Coronary artery disease (CAD), 160
Corticosteroid therapy, 160
Crack, 394f
Cratered gingiva, 545t
Crohn disease, 160
Crossbite, 593f
Cross-cultural communication, 61–62, 62f
Cuff, blood pressure, 292, 292f, 297t, 301–302, 301f, 302f, 304f, 315
Cultural competency, 60, 61b
Cultural differences, 61
Culture(s). See also Spanish language
health history and, 104, 124, 125t
language barriers and, 58–62
low-contact vs. high-contact, 9–10
Cushing syndrome, 161
Cystic fibrosis (CF), 161

D
Daily self-care, 219, 219f
Dental concerns, 218, 218f
Dental conditions, existing, adult, 218–219, 219f
Dental experiences, previous, 217, 217f, 218f
Dental health history, 214–247
communication scenarios, 232
English-to-Spanish phrase list for, 233t
human element in, 231–233
practical focus (cases) on, 235, 236f–245f
skill check, 247
Dental health history questionnaire, adult, 216–220
daily self-care, 219, 219f
dental concerns, 218, 218f
dietary habits, 220, 220f
existing dental conditions, 218–219, 219f
format of, 216, 216f
information requested in, 216
practical focus (cases) on, 235, 236f–245f
previous dental experiences, 217, 217f, 218f
reason for appointment, 217, 217f
review (peak procedure), 222
samples of, 223f–226f
skill check, 247
Spanish, 225f–226f
Dental health history questionnaire, children’s, 221, 221f
English, 227f–228f
Spanish, 229f–230f
Dental radiographs. See Radiographs
Dental terminology, 42, 44, 46t, 48–49
Dentition
age 5 years (primary), 586, 586f, 597f, 599f
age 6 to 7 years, 587, 587f, 599f
age 7 to 8 years, 587, 587f, 599f
age 10 to 12 years, 588, 588f, 599f
age 11 to 13 years, 588, 588f, 599f
 English-to-Spanish phrase list for, 605t
human element in, 603–604
mixed, 586–588
practical focus (cases) on, 607–612, 607f–613f
ready references for, 597, 597f–599f
skill check, communication, 623
skill check, technique, 621
stages of, 586–588, 597f–599f
Depressed lesion, 393f
Diabetes (Type I), 161
Diabetes (Type II), 161
Diagnostic acceptability, 639, 649
Dialysis, 163
Diaphragm endpiece, of stethoscope, 294, 294f
Diastolic pressure, 290, 298b, 311, 311f
Diastolic reading, 296
Dietary habits, 220, 220f
Difficult conversations, 31, 31b, 32t–33t
Diffuse changes, in gingiva, 552
Digital radiographs, 630
Digital temperature equipment, 253
Diplomacy, 11
Directing communication style, 87, 87f, 91
Disability awareness and etiquette, 71–72, 72b
Discrete configuration, of lesion, 389f
Diseases, 158–169. See also specific diseases
Down syndrome, 161
Drugs, 170–211
Dysarthria, 68

E
Ear(s), 429, 429f
Earpieces, of stethoscope, 293, 294f
Ear (tympanic) temperature, 253
Education, 16, 16f
Elaboration, 91
Electronic blood pressure equipment, 294–295, 295f
Electronic cigarettes, 350, 350f
Electronic dental record, impact on communication, 29–30, 29b
Elevated lesion, 391f
Elicit–provide–elicit model, 89, 89f, 92
Embarrassment, patient, 42
Empathy, 11, 16, 16f
Emphysema, 161
Endocarditis, 161
End-to-end bite, 592f
Engagement, 16, 16f
English-to-Spanish phrase lists
blood pressure, 327t–328t
dental health history, 233t
gingival description, 561t
head and neck examination, 463t–464t
medical history, 124, 125t
mixed dentition and occlusion, 605t
oral examination, 517t–518t
pulse and respiration, 283t
radiographs, 645t
temperature, 264t
Enlarged gingiva, 545t, 547f
Enlarged lymph nodes, 432, 432f
Enlistment, 16, 16f
Epilepsy, 161
Erosion, 393f
Estimated systolic pressure, 305, 305f
Ethical dilemmas, 124, 231, 325, 462, 515, 560, 706
Ethics, code of, 116
Exudate, 544
Eye(s), 429, 429f
Eye contact, 89, 90f

F
Facioversion, 593f
Fahrenheit, 253, 261
Farsi, health history form in, 109f
Female smokers, health risks for, 346
Fibromyalgia, 162
Filiform papillae, 494, 494f
Finding the problem, 16
First impressions, 8, 8f
Fissure, 394f
Five A’s Model, of tobacco use cessation, 359, 359f, 360t
Fixing the problem, 16
Flat lesion, 390f
Fluid-filled lesions, 392f–393f
Foliate papillae, 494, 494f
Following communication style, 87, 87f
French, health history form in, 107f
Fungiform papillae, 494, 494f

G
Galinstan thermometer, 253
Gastroesophageal reflux disease (GERD), 162
Gingiva, 542–582
changes in disease, 545t, 546f–551f
color of, 546f–547f
English-to-Spanish phrase list for, 561t
healthy, 544f, 545t, 546f
human element in description, 559–560
 looking at, 544, 544f, 545t, 546f–551f
margin of, 547f–549f
papillae of, 549f–550f
peak procedure for, 552–553
practical focus (cases) on, 563, 564f–580f
ready references for, 555f–557f
skill check, communication, 582
skill check, technique, 581
texture and consistency of, 550f–551f
Gingival Characteristics Chart, 553, 556f–557f, 565f, 568f, 571f, 574f, 577f,
580f
Gingival Descriptor Worksheet, 555f, 564f, 567f, 570f, 573f, 576f, 579f
Glass thermometers. See Thermometers, glass
Glaucoma, 162
Glomerulonephritis, 162
Glucose levels, blood, 112b
Goiter, 435f
Graves disease, 162
Grouped configuration, of lesion, 389f
Guiding communication style, 87, 87f

H
Hard palate, 496, 496f, 512, 512f
Head and neck cancer, 166, 346
Head and neck examination, 426–485. See also specific anatomy
compression techniques in, 438, 438f
English-to-Spanish phrase list for, 463t–464t
human element in, 461–462
importance of, 428
methods of, 437–439
overall appraisal in, 428, 428f, 440t, 441, 441f
overview of, 428–436
palpation in, 428, 437–439, 437b, 439t, 440
 peak procedure for, 440–460
practical focus (cases) on, 465, 466f–480f
skill check, communication, 483
skill check, technique, 481–482
Health
dental practices as screening, 110–111
relationship between systemic and oral, 110
Health history. See Medical (health) history
Health literacy, 42
Heart attack, 160, 163, 166
Heart failure, congestive, 160
Heart rate, 270
Heat pockets, 256, 256f, 258, 259f
Helping relationship, 13–14
Hemophilia, 162
Hemorrhage, 162
Hepatitis B, 162
Hepatitis C, 162
Herpes simplex, recurrent, 491f
Heslin, Richard, 10–11
Heslin’s categories of touching behavior, 10, 11b
High blood pressure. See Hypertension
High-contact cultures, 9–10
Hispanic population, 60, 60f. See also Spanish language
History. See Medical (health) history
HIV/AIDS, 163
Homeostasis, 252
Hookah, 351, 351f
Human element. See also English-to-Spanish phrase lists
in assumptions about patients, 263
in blood pressure, 323–328
in communication, 34–36, 48–49, 78–80
in dental health history, 231–233
 in gingival description, 559–560
in head and neck examination, 461–462
in medical history, 122–124
in mixed dentition and occlusion, 603–604
in motivational interviewing, 94–95
in new patient assessment, 706
in oral examination, 514–516
in pulse and respiration, 281–282
in radiographs, 643–644
in soft tissue lesions, 403–404
in tobacco cessation, 374–375
Hyperpnea, 279, 279f
Hypertension, 163, 290–291, 291b, 317
Hypertension, white-coat, 300
Hypertensive, 290
Hyperthyroidism, 163
Hyperventilation, 279, 279f
Hypotension, 290
Hypotensive, 290
Hypothyroidism, 163

I
Implantable cardioverter defibrillator, 163
Information gathering
Internet for, 47, 47t, 49
medical history for, 118
motivational interviewing for, 84–99
Informed consent, 116–117
Informed refusal, 116
Inspection, 437
Insulin reaction, 161
Intellectual/cognitive disability, 74, 74b
Internet
 blood pressure resources on, 321
and communication skills, 47, 47t, 49
Interprofessional collaboration, 112
Interview(s)
job, for deaf hygienist, 80
motivational, 84–99
Irregular border, of lesion, 387f

J
Job interview, for deaf hygienist, 80

K
Kaposi’s sarcoma, 401
Kidney dialysis, 163
Kidney disease, chronic, 163
Korotkoff, Nikolai, 323
Korotkoff sounds, 297, 298–299, 298b, 299f, 313

L
Language. See also Spanish language
multi-language health history forms, 104–105, 105b, 106f–109f
words for communication, 42–49
Language barriers, 58–62
Laryngectomy, communicating with person with, 70, 70b
Larynx, 434, 434f
Latex allergy, 163
Lesion Descriptor Worksheet, 399f–400f, 405, 405f–422f
head and neck, 466f–480f
oral, 520f–534f
Leukemia, 164
Linear configuration, of lesion, 389f
Linear cracks, 394f
Lingual frenum, 493, 493f, 495f
Linguoversion, 594f
Lips, 491, 491f, 497t, 498, 498f
labial mucosa of, 500, 500f
underlying structures of, 502–503, 502f, 503f
Liver disorder, 164
Lou Gehrig disease, 164
Low-contact cultures, 9–10
Low vision, 65–66, 65b
Lung disease, smoking and, 345
Lupus erythematosus, 164
Lymph, 431
Lymphadenopathy, 432, 432f
Lymphatic system, 431
Lymph nodes, 431–432, 431f, 442t, 443–450, 443f–450f

M
Macule, 390f
Malocclusion, 589. See also Occlusion
Mandibular arch, 501, 557f, 571f, 574f, 580f
Mandibular groove, 590–592, 590f–592f
Manometer, 293, 293f, 296f, 308, 320, 320f
Marginal gingiva, 545t, 552
Margins
of gingiva, 547f–549f
of soft tissue lesions, 387f
Maxillary arch, 501, 556f, 568f, 577f
Medical alert box, 118, 118b
Medical conditions, 158–169. See also specific conditions
Medical consult, 112–113, 114f–115f, 127, 132f, 137f, 142f, 147f, 152f
Medical (health) history, 102–155, 104–117
complicated, 122
conducting, 118–119
 dental, 214–247
English-to-Spanish phrase lists for, 124, 125t
goal of, 118
human element in, 122–124
importance of, explanation of, 117b
informed consent for, 116–117
medical conditions and diseases, 158–169
multiculturalism and, 104, 124, 125t
peak procedure for, 120–121
practical focus (cases) on, 127, 128f–152f
review of questionnaire and interview, 120–121
risk assessment in, 111
sensitive information in, 123
skill check, questionnaire, 153
skill check, role-play, 154
Medical risk, 111
Medical words, and communication, 44, 44t
Medication(s), 170–211
Medication review/list, 127, 129f, 134f, 139f, 144f, 149f
Mehrabian, Albert, 7
Melanoma, 386, 401
Ménière disease, 164
Mental disorder, 164
Mercury manometer, 293, 293f, 296f
Metabolic syndrome, 164
Metastasis, 432
Millimeters of mercury, 296
Minimally diagnostically acceptable, 639
Minority populations, 59–60, 59f, 60f
Mitral valve prolapse, 165
Mitral valve stenosis, 165
Mixed dentition
age 6 to 7 years, 587, 587f, 599f
 age 7 to 8 years, 587, 587f, 599f
age 10 to 12 years, 588, 588f, 599f
age 11 to 13 years, 588, 588f, 599f
definition of, 586
English-to-Spanish phrase list for, 605t
human element in, 603–604
peak procedure for, 595
practical focus (cases) on, 607–612, 607f–613f
ready references for, 597, 597f–599f
skill check, communication, 623
skill check, technique, 621
sorting out, 586–588
Mixed Dentition Worksheet, 607–612, 609f, 611f, 613f
Mononucleosis, 165
Motivational interviewing, 84–99
behavioral change fostered by, 86
benefits of, 93
communication styles in, 87, 87f
core skills in, 88–89, 88f
definition of, 86
elicit–provide–elicit model in, 89, 89f, 92
human element in, 94–95
potential concerns in, 93
skill check, 97
using tools in, 89–92
Mouth, floor, 493, 493f, 504–505, 504f–505f, 504t
Mucosal surfaces, inspection of, 499–501, 499f–501f
Multiculturalism, 58, 59t, 104
Multi-Language Health History Project, 104–105, 105b, 106f–109f
Multiple myeloma, 165
Multiple sclerosis (MS), 165
Muscular dystrophy (MD), 165
Myasthenia gravis, 166
Myocardial infarction (MI), 160, 163, 166
Myxedema coma, 163

N
Narcolepsy, 166
Nicotine, 354
Nodular gingiva, 545t
Nodule, 391f
Nodules, thyroid, 434
Non-English-speaking communities, 58. See also Spanish language
Non-Hodgkin lymphoma, 166
Nonverbal communication, 7–10, 7b, 7f
Nose, 429, 429f

O
Obstructive breathing, 279, 279f
Occipital lymph nodes, 431f, 443, 443f
Occlusion
Angle’s classification of, 590–592, 590f–592f, 600f
definition of, 589
English-to-Spanish phrase list for, 605t
human element in, 603–604
looking at, 589–594
malocclusion characteristics, 592, 592f–593f
malposition of individual teeth, 593f–594f
peak procedure for, 595
practical focus (cases) on, 615, 615f–619f
ready references for, 600, 600f–601f
relationship of maxillary and mandibular teeth, 589, 589f
skill check, communication, 624
skill check, technique, 622
Occlusion Worksheet, 595, 601f, 615
Older adults, communicating with, 64, 64b, 80
Open bite, 592f
Open (open-ended) questions, 26b, 88, 89–90
Oral cancer, 166, 386, 488–490, 488f
patient questions about, 489b
risk factors for, 489–490
signs and symptoms of, 490b
Oral cavity, inspection of, 499–501, 499f–501f
Oral examination, 486–540. See also specific anatomy
English-to-Spanish phrase list for, 517t–518t
human element in, 514–516
overview of, 488–496
peak procedure for, 497–513
practical focus (cases) of, 519, 520f–534f
skill check, communication, 537
skill check, technique, 535–536
Oral health, relationship with systemic health, 110
Oral temperature, 253–260
assessing with glass thermometer, 257–260, 257f, 258f, 259f
contraindications to, 253
English-to-Spanish phrase list for, 264t
equipment for taking, 253
measurement of, 252
peak procedures for, 254–260
positioning thermometer in mouth, 256, 256f, 258, 259f
preparing glass thermometer for use, 255, 255f
reading glass thermometer, 254, 254f, 259, 259f
skill check, communication, 266
skill check, technique, 265
as standard, 253
Organ transplant, 166
Oropharynx, 496, 496f, 511t, 513, 513f
Osteonecrosis of the jaw, 167
Overbite, 589, 589f, 593f
Overjet, 589, 589f
Overlap, significant, 639

P
Pacemaker, 167
Palate, 496, 496f, 511t, 512, 512f
Palpation, 437
cheek, 503, 503f
floor of mouth, 505, 505f
head and neck, 428, 437–439, 437b, 439t, 440
lip, 502, 502f, 503, 503f
lymph node, 443–450, 443f–450f
oral, 510, 510f, 512, 512f
oral examination, 498
palate, 512, 512f
parotid gland, 452, 452f
pulse, 270–271, 270f–271f, 273, 273f
submandibular gland, 454, 454f
temporomandibular joint, 458–459, 458f–459f
thyroid gland, 456, 456f
tongue, 510, 510f
Palpatory estimation, of blood pressure, 305, 305f, 309
Panic disorder, 167
Panoramic radiographs, 628, 628f–629f, 657, 658f–663f
Papillae
of gingiva, 549f–550f
of tongue, 494, 494f
Papillary gingiva, 545t, 552
Papule, 391f
Parkinson disease, 167
Parotid duct, 492, 492f, 507, 507f
Parotid glands, 433, 433f, 452, 452f, 492, 492f, 507, 507f
Patch, 390f
Paternalism, 14–15, 15t
Patient advocacy, 35
Patient-centered care, 14–15, 15t, 282
Patient-centered communication, 17–28, 17b
barriers to. See Communication barriers
clear, accurate, and understandable, 41–54, 42b
difficult conversations in, 31, 31b, 32t–33t
electronic records and, 29–30, 29b
framework for, 18, 18f
human element, 34–36, 48–49
as key clinical skill, 18
questioning skills in, 26, 26b
skill check, role-play, 37, 51, 81
standardized nomenclature for, 30
techniques hindering, 24, 24t–25t
techniques of, 19, 20t–23t
Patient consent
adolescent, 124
informed, 116–117
for medical consult, 113
Patient–hygienist relationship, 13–16
Patient responsibilities, 116–117
Patient’s rights, 14, 14b
Patients with special needs. See Special needs, patients with
“People-first” language, 71, 72t
Periodontitis, smoking and, 356
Periodontium, smoking and, 356–357, 357f
Perioral rhytides, 346, 347f
Peripheral arterial disease (PAD), 167
Permission, asking, 89, 92
Person who are deaf, communicating with, 67, 67b, 80
Person with hearing impairment, communicating with, 67, 67b, 80
Person with visual impairment
communicating with, 65–66, 65b
service animal for, 66
sighted guide for, 66, 66b
Personal filters, 6, 6f
Personal space, 9–10
Pharyngeal cancer, 386
Physical status, 111, 111t
Physician, consultation with, 112–113, 114f–115f, 127, 132f, 137f, 142f,
147f, 152f
Picture boards, 62, 62f
Pigmented tongue, 495f
Plaque (lesion), 391f
Polymyalgia rheumatica, 167
Postauricular lymph nodes, 431f
Posterior auricular lymph nodes, 444, 444f
Posterior crossbite, 593f
Practical focus. See Cases
Preauricular lymph nodes, 431f, 445, 445f
Presbycusis, 67
Prescription medications, 170–211
Proxemics, 9
Pulse, 252, 268–287
amplitude assessment, 278
English-to-Spanish phrase list for, 283t
human element in, 282
patterns of, 277
peak procedure for assessing, 270–274
ready references for, 277–278
skill checklist, role-play, 286
skill checklist, technique, 285
Pulse points, 270, 270f
brachial artery, 270, 270f, 305, 305f, 309
 radial artery, 270–271, 270f, 271f, 273, 273f, 305, 305f
Pulse pressure, 278, 278f
Pulse rate, 270, 272–273, 272f, 273f
factors affecting, 277
normal per minute, by age, 277
Pustule, 393f

Q
Question(s)
closed, 26b
open (open-ended), 26b, 88, 89–90
Questioning skills, 26, 26b
Questionnaire, dental health history
adult, 216–220, 216f–219f, 222, 223f–226f
children’s, 221, 221f, 227f–230f
practical focus (cases) on, 235, 236f–245f
review (peak procedure), 222
skill check, 247
Questionnaire, medical history, 120–121
Quitlines, 361, 361f

R
Radial artery, 270–271, 270f, 271f, 273, 273f, 305, 305f
Radiographic Evaluation Worksheet, 640f, 652f, 654f, 656f
Radiographs, 626–666
anatomy review, 628, 628f–629f
digital, 630
English-to-Spanish phrase list for, 645t
four-step assessment, 630
helpful concepts in, 639
human element in, 643–644
interpreting, 630–631
 panoramic, 628, 628f–629f, 657, 658f–663f
peak procedure for, 632
practical focus (cases) on, 647–650, 648f, 651f–656f, 657, 658f–663f
ready references of, 639–641
skill check, communication, 666
skill check, technique, 665
Raised margin, of lesion, 387f
Rapid deep breathing, 279, 279f
Rapid shallow breathing, 279, 279f
Reading ability, patient, 43, 43b
Reason for appointment, 217, 217f
Redirecting, 91
Reflections, 88–91, 91t
Refusal, informed, 116
Regular border, of lesion, 387f
Relationship, patient–hygienist, 13–16
Repetitive and stereotypical behaviors, 76
Respiration, 252, 268–287
assessing, 274–276, 275f
control of, 274
English-to-Spanish phrase list for, 283t
evaluation of, 279
human element in, 281–282
peak procedure for assessing, 274–276
ready references for, 278–279
skill checklist, role-play, 286
skill checklist, technique, 285
types of, 279, 279f
Respiration rate, 252
Respiratory difficulty, 160, 279, 279f
Respiratory rate, 274–276
assessing, 275–276, 275f
counting own, 274–275
 factors affecting, 279
normal per minute, by age, 278
Responsibilities, patient, 116–117
Rheumatic fever, 168
Rheumatic heart disease, 168
Rheumatoid arthritis, 168
Risk assessment, in health history, 111
Rule of symmetry, 639

S
Salivary ducts, 492, 493f, 506–507, 506f, 507f
Salivary glands, 433, 433f, 451t, 452–454, 452f–454f, 492, 492f–493f, 506–
507, 506f, 507f
Satisfaction with care, 123
Schizophrenia, 168
Scleroderma, 168
Screening, in dental practices, 110–111
Secondhand smoke, 348, 349f
Seizures, 161
Self-care, daily, 219, 219f
Service animal, 66
Sexually transmitted diseases (STDs), 168
Sickle cell anemia, 169
Sighted guide, 66, 66b
Significant overlap, 639
Silent killer, 291
Sjögren syndrome, 169
Skin cancer, 386, 401, 461
Skin damage, from smoking, 346, 346f, 347f
Slow breathing, 279, 279f
Smokeless tobacco, 351, 352f, 403
Smoking. See Tobacco cessation; Tobacco use
Smoking history, 365f–366f
Smooth margin, of lesion, 387f
Snuff, 351
Soft palate, 496, 496f, 512, 512f
Soft tissue lesions, 384–424. See also specific lesions
ABCD-T mnemonic for, 394, 394b, 395
basic types of, 390f–394f
border traits of, 387f
characteristics of, 387f–394f
color of, 388f
configuration of, 389f
definition of, 386
detection tools for, 397
human element in, 403–404
Lesion Descriptor Worksheet, 399f–400f, 405, 405f–422f
looking for, 386–394
margins of, 387f
peak procedure for describing, 395–396
practical focus (cases) on, 405, 405f–422f
ready references for, 399f–400f, 401
Space, use of, 9–10
Spanish language
blood pressure, 327t–328t
dental health history, 233t
dental health history questionnaire, adult, 225f–226f
dental health history questionnaire, children’s, 229f–230f
gingival description, 561t
head and neck examination, 463t–464t
medical history, 124, 125t
mixed dentition and occlusion, 605t
oral examination, 517t–518t
pulse and respiration, 283t
radiographs, 645t
temperature, 264t
 tobacco cessation, 366f, 372f–373f
Special needs, patients with, 71–77
being different, 79
definition of, 71
disability cultural awareness and etiquette for, 71–72, 72b
helping, 78
“People-first” language for, 71, 72t
perceptions of, 73f
potential barriers to dental care, 72–73
Speech problems, 68–70, 69b
Sphygmomanometer, 292, 292f, 295
SPIKES model, for delivering bad news, 31, 32t–33t
Splenectomy, 169
Squamous cell carcinoma, 386, 401
Stereotypes, 8
Stereotypical behaviors, 76
Sternomastoid muscle, 430, 430f
Stethoscope, 292, 293–294, 294f, 295
Stress reduction protocol, 119, 119b
Stroke (CVA), 160, 163
Sublingual caruncles, 492–493, 493f
Sublingual ducts, 506, 506f
Sublingual fold, 493
Sublingual glands, 433, 433f
Sublingual veins, 493
Submandibular ducts, 506, 506f
Submandibular glands, 433, 433f, 453–454, 453f, 454f, 506, 506f
Submandibular lymph nodes, 431f, 447, 447f
Submental lymph nodes, 431f, 446, 446f
Summaries, 89, 92
Supraclavicular lymph nodes, 431f, 450, 450f
Supraversion, 594f
Symmetry, rule of, 639
Systematized Nomenclature of Dentistry (SNODENT), 30
Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT),
30
Systolic pressure, 290, 298b, 310–311, 310f
Systolic pressure, estimated, 305, 305f
Systolic reading, 296, 296f, 310–311, 310f

T
Tachypnea, 279, 279f
Temperature, 250–267
digital, 253
ear (tympanic), 253
English-to-Spanish phrase list for, 264t
equipment for taking, 253
impact of readings on dental treatment, 262
oral, 253–260
oral, assessing with glass thermometer, 257–260, 257f, 258f
oral, as standard, 253
oral, contraindications to, 253
oral, measurement of, 252
peak procedures, 254–260
positioning thermometer in mouth, 256, 256f, 258, 259f
preparing glass thermometer for use, 255, 255f
ranges of, 261
reading glass thermometer, 254, 254f, 259, 259f
ready references for, 261–262
scales of, understanding, 253, 261
skill check, communication, 266
skill check, technique, 265
variables affecting, 262
Temporomandibular joint (TMJ), 436, 436f, 457–460, 457f–460f, 457t
Terminology, and communication, 42, 44, 44t–46t, 48–49
Territory, 9
Thermometers, glass, 253, 254–260
assessing oral temperature with, 257–260, 257f, 258f, 259f
positioning in mouth, 256, 256f, 258, 259f
preparing for use, 255, 255f
reading, 254, 254f, 259, 259f
shaking down, 255f
sheath for, 258, 258f
Thirdhand smoke, 349
Thorough assessment, 639
Thrombophlebitis, 169
Thyroid gland, 434, 434f–435f, 451t, 455–456, 455f–456f
Thyroid storm, 162, 163
Tinnitus, 169
Tobacco addiction, 354–355
Tobacco cessation
addiction vs. free will, 363f
Five A’s Model of, 359, 359f
guidelines for counseling, 358–363
health benefits of, 347, 347f
human element in, 374–375
intervention by dental health providers, 356–357
myths vs. facts, 362t
peak procedure for, 364
practical focus (case) on, 377, 378f
quit rates and implications, 363
skill check, role-play, 379
systematic approach to, 358f
withdrawal symptoms in, 363
Tobacco use, 342–382
chemical components of products, 353, 353f
current trends in, 355, 355f
deaths attributed to smoking, 344, 344f
harmful properties of tobacco, 353–355
 health effects of, 344–351, 403
patient education resources on, 365f–373f
as risk factor for systemic disease, 345–346
Tongue, 508t, 509–510
dorsal surface of, 494, 494f, 509, 509f
lateral borders of, 510, 510f
palpation of, 510, 510f
pigmented, 495f
ventral surface of, 493, 493f, 509, 509f
Tonsillitis, 496f
Tonsils, 496, 496f, 511t, 513, 513f
Torsiversion, 594f
Touch, 10, 11b, 11f
Tourette syndrome, 169
Traditional model of care, 15–16, 15t
Triangulation, 631, 631f
Tuberculosis (TB), 169
Tympanic temperature, 253

U
Ulcer, 393f
University of the Pacific (UOP) multi-language forms, 104–105, 105b, 106f–
109f
Uvula, 511t
Uvula, bifid, 496f

V
Value judgment words, 44, 45t
Vaping, 350
Verbal communication, 7
Vermillion border, 491, 491f, 497t, 498, 498f
Vesicle, 392f
Vital signs. See also specific signs
blood pressure, 288–341
definition of, 252
importance of, 252
measurement of, 252
overview of, 252
pulse and respiration, 268–287
temperature, 250–267
Voluntary control, 274

W
Wheal, 392f
White-coat hypertension, 300
Withdrawal symptoms, 363