4: Occlusal Examination
Medical History
Blood pressure: 115/70 mmHg; Pulse: 70 beats/min; Respiration: 12 breaths/min.
Review of Systems
All systems were within normal limits.
Social History
Miranda participates in school team sports five days per week. However, she reports being unhappy that members of her sixth‐grade class tease her about the gaps between her teeth and her prominent incisors. The bullying impacts attendance and her ability to concentrate in class.
Dental History
The patient has an established dental home and has received comprehensive dental hygiene care under parental supervision.
Head and Neck Examination
Extraoral Exam
The temporomandibular joints and surrounding extraoral structures were within normal limits. A facial profile photograph shows a retrognathic or convex skeletal profile (Figure 1.4.1).
Figure 1.4.1: Patient profile image.
Intraoral Exam
There were no biofilm accumulations or calculus deposits. The patient’s gingiva was pink with normal pigmentation for her ethnicity. The maxillary anterior interdental papillae were blunted due to lack of proximal contacts. The gingiva exhibited normal contour and the amount of textural stippling and consistency expected in a patient in phase four of arch development (time in which the permanent canines emerge). The intraoral photographs show delayed eruption of maxillary first and second premolars (see Figures 1.4.2 and 1.4.3).
Figure 1.4.2: Patient intraoral palate.
Figure 1.4.3: Patient intraoral floor of mouth.
Occlusion
Class II Division I malocclusion with a severe overbite and excessive overjet (9 mm) (see Figures 1.4.4–1.4.6). No occlusal habits or other parafunctional occlusal habits noted.
Figure 1.4.4: Malocclusion right.
Figure 1.4.5: Malocclusion left.
Figure 1.4.6: Malocclusion facial.
Radiographic Examination
Delayed eruption of maxillary first and second premolars (see Figures 1.4.7 and 1.4.8).
Figure 1.4.7: Radiographic image.
Figure 1.4.8: Relative mandibular retrognathia.
Dental Hygiene Diagnosis
| Problems | Related to Risks and Etiology |
| Class II Division I malocclusion | Permanent molar and anteriorteeth relationships:
|
| Negative oral health‐related Quality‐of‐Life (OHRQoL) | Teasing and bullying about malocclusion |
| Increased risk of sports‐related mouth injury | Patient age and participation in sporting activities |
Planned Interventions
| Planned Interventions(to arrest or control disease and regenerate, restore or maintain health) | ||
| Clinical | Education/Counseling | Oral Hygiene Instruction |
| Initial exam, intraoral photographs, alginate impressions, study models radiographs, and adult prophylaxisFabrication of mouth guardReferral to an orthodontic/orthopedic specialistReferral to primary care physician and school officials to implement appropriate services and support for bullyingSix‐month recall | Features of malocclusion and the importance of orthodontic intervention to OHRQoL.Proper use of a mouth guard during contact sports activities and risks of not wearing or altering protective equipment (Ranalli 2002). | OTC fluoride‐containing toothpaste twice daily, after breakfast and at bedtime.Oral hygiene, flossing, and brushing.Wear mouth guard during sports activities |
Progress Notes
Miranda arrived for her appointment 15 minutes late. I reminded Miranda and her mother of the office policy regarding missed and late appointments. A complete medical, social, and dental history was taken. Head and neck and dental exams including occlusal assessment were performed. Panoramic and lateral cephalogram radiographs, and alginate impressions were taken. Study models were made for fabrication of a mouth guard. The patient had a mild to moderate gag response to the alginate impressions and was managed well by using a distraction technique: the patient was given a small puzzle to complete (For information on managing patients who gag during dental treatment, see Figures 1.4.9A and B). Oral hygiene instructions were given regarding protective factors to maintain current caries status. Correct use of mouth guard was explained to the patient. The patient was referred to an orthodontist for malocclusion and advised to speak to her guidance counselor for in‐school bullying. The hygienist will make follow‐up calls to Miranda’s parents and her school guidance counselor regarding bullying. Six‐month recall recommended.
Figure 1.4.9: (A) Managing patients who gag during dental treatment. (B) Transformer puzzle toy.
Discussion
The occlusal examination is critical to the assessment of the patient’s dentition and facial symmetry. It includes:
- Classification of occlusion,
- Identification of any teeth malrelationships,
- Examination of the temporomandibular joints, muscles of mastication and range of movements (ROM),
- Record of parafunctional habits such as bruxism and clenching.
Diagnostic records such as intraoral photographs, study casts, and panoramic radiographs and cephalograms assist in the evaluation of the patient’s condition and provide a baseline growth record and database for changes during treatment. Disease development such as caries, noncaries cervical lesions (abfractions), periodontal disease and temporomandibular joint disorder (TMD) are related to occlusal disharmony. When teeth are malaligned they lose their ability to self‐cleanse; also, parafunctional habit patterns (movements that are not within the normal range) may appear. Malocclusion has physical and psychological ramifications and interferes with children’s Oral Health‐Related Quality‐of‐Life (OHRQoL) regarding school attendance, performance, and psychosocial wellbeing (Jokovic et al. 2002; da Rosa et al. 2016). OHRQoL is a construct based on the World Health Organization’s definition of health and is used to measure people’s oral health status. OHRQoL looks at physical, mental, and social wellbeing as a determinant of oral health and not just the absence of oral disease and related ailments.
Ideal occlusion, although rare, is used as a standard for determining the need for orthodontic treatment in patients. In centric occlusion or maximum intercuspation (MI), each tooth has a particular relationship with teeth in the same arch (intraarch) and opposing arches (interarch). Centric relation (CR), the relationship of the mandible to the maxilla, should coincide with MI (when teeth are entirely interposed). When the MI and CR differ occlusal disharmony is the result. (For a list of risk factors for malocclusion, see Figure 1.4.10.)
Figure 1.4.10: Risk factors for malocclusion.
Analysis of the permanent occlusion uses the first molars and canines to classify or confirm occlusion while the primary occlusal assessment is performed using the second molars. Analysis of the primary dentition is important because it determines the arch space required to provide room for the secondary teeth. Additionally, the identification of a distal terminal plane relationship between the primary maxillary and mandibular second molars predicts permanent molar relationships and provides valuable information for early orthodontic intervention (For an illustration of flush, mesial, and distal steps, see Figure 1.4.11).
Figure 1.4.11: Distal terminal plane in determining primary occlusion. (A) mesial and (B) flush steps predict class I, (C) distal step predicts class II, extreme mesial step predicts class III.
All patients should have an orthodontic evaluation to determine the health of the masticatory system and to provide early therapy to manage the developing dentition and occlusion. The American Association of Orthodontists (AAO) recommends that an evaluation by an orthodontist should be performed no later than age seven because the first molars establish posterior occlusion and the incisors alert clinicians to crowding and poor anterior overlap relationships (American Association of Orthodontists mylifemysmile.org 2013).
Malocclusion can have an adverse effect on self‐esteem, self‐concept, happiness, and social development; also, it increases the risk of teasing (Seehra et al. 2011; da Rosa et al. 2016). Bullying among schoolchildren has a global prevalence rate of 5–58% and is as high as 47% in 11–12‐year‐old children (Al‐Omari et al. 2014). The most commonly reported targets by bullies are dentofacial features; for example, children with spaces between teeth, malformed and discolored teeth, and prominent maxillary anteriors are likely to be victims of bullying (Al‐Bitar et al. 2013). If a child admits to being bullied, clinicians should inform parents of the possible consequences that include psychological distress, anxiety, and depression. Also, parents should be asked to contact the school and teachers regarding the situation. The US Department of Health and Human Services website, Stopbullying.gov (U.S. Department of Health and Human Service, n.d.) provides parents, teachers, communities, and students with tools that support victims of unwanted aggressive behavior. Noting occlusal problems early, identifying possible victims of bullying, and referring patients for treatment have physical and psychosocial benefits for children with poor dentofacial features (Al‐Omari et al. 2014).
Take‐Home Hints
- As seen in this case, the age group that is most vulnerable to sports‐related injuries is children between the ages of 7 and 11 (Tesini and Soporowski 2000).
- According Lyznicki et al. (2004) the clinician’s role in bullying involves identifying the children at risk, counseling families, screening for psychiatric comorbidities, and providing preventive surgeries.
- The dental arches go through five phases of development as the bony structures mature to accommodate the permanent teeth:
- Phase one is characterized by the eruption of the permanent first molars;
- Phase two is marked by the eruption of the permanent anterior teeth;
- Phase three consists of the eruption of the premolars anterior to the permanent molars;
- Phase four occurs when the permanent canines erupt; and finally,
- Phase five occurs when the third molars erupt (Fehrenbach and Popowics 2016).
- Flush and mesial steps in primary occlusal findings predict Class I and distal steps predict Class II in the permanent dentition. An excessive mesial step predicts Class III malocclusion (Figure 1.4.11).
- Hygienists can reduce student bullying and its effects by collaborating with the patient’s parents, school officials, and primary care physician on implementing appropriate responsive services and support.
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