Dental assisting notes dental assistant's chairside pocket guide, 1 e (2015) [pdf][unitedvrg]

Always at your side...
• F. A. Davis Company

Dental Assisting
Notes
Dental Assisting
NotesDental Assistant’s Chairside Pocket Guide
Minas Sarakinakis
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MS; Cynthia S. Cronick, CDA, AAS, BS; DeAnna Davis, CDA, RDA, MEd; Danielle
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INDEXRESOURCEINSTRRADIOL
INFECT
CONTROL
CHAIR-
SIDE
MEDSEMERG
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Contacts • Phone/E-Mail
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Name
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EMERG
1
Emergency Preparedness
ASA Classifications
The American Society of Anesthesiologists (ASA) has introduced
a classification system to determine a patient’s physical status.
ASA I
■ Patient is healthy.
■ Patient can either climb two flights of stairs or walk for two
city blocks without experiencing any shortness of breath.
ASA II
■ Evidence of some mild systemic disease present.
■ Patient can climb one flight of stairs or walk two city blocks
but may experience some shortness of breath.
■ Examples: Epilepsy, asthma, allergies, pregnancy.
ASA III
■ Severe systemic disease that interferes with but does not
inhibit daily life.
■ Individual may be able to climb one flight of stairs or walk
one city block but more than likely would have to stop
because of shortness of breath.
■ Examples: Type I diabetes, heart failure, hypertension.
ASA IV
■ Severe systemic disease that inhibits daily activities and can
be fatal.
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EMERG
2
■ Individual is unable to climb a flight of stairs or walk one
city block and may even experience shortness of breath
at rest.
■ Examples: Uncontrolled, diabetes, heart failure, angina, type
two hypertension.
ASA V
■ Patient is rapidly deteriorating and will not survive.
Emergency Kit
Every dental office should maintain a custom designed emer-
gency kit ready for use that is easily accessible and portable.
Each emergency kit in a dental office should contain at least the
following components:
■ Portable oxygen: Used in every medical emergency EXCEPT
hyperventilation.
■ Epinephrine: Used in anaphylactic emergencies.
■ Nitroglycerin: Used in angina, myocardial infarction (MI),
and congestive heart failure emergencies.
■ Diphenhydramine: Used to manage allergic reactions.
■ Albuterol: Used in asthma attacks.
■ Glucose: Used in patients who are conscious and have
hypoglycemia (low blood sugar).
■ Glucagon: Used in unconscious patients with hypoglycemia.
It is administered intramuscularly.
■ Lorazepam: Used in emergencies involving seizures
or hyperventilation. It is usually administered
intramuscularly.
■ Atropine: Used in low blood pressure emergencies.
■ Aspirin: Extremely beneficial drug in patients with signs
of MI.
■ Steroids: Although considered an essential drug due to the
slow onset (1 hour), steroids such as hydrocortisone can be
used in managing allergic reactions.

EMERG
3
Besides the afore mentioned substances, a few items should be
included in the emergency kit, such as:
■ One-way valve pocket mask
■ Syringes for administering the intramuscular drugs
■ Sterile gauze and bandages
■ Ice pack
■ Automated external defibrillator (AED)
Premedication Guidelines
The American Dental Association (ADA) notes that some indi-
viduals may require antibiotic prophylaxis before certain dental
procedures. These dental procedures involve manipulation of the
gingival tissue, the periapical region of a tooth, or perforation of
the oral mucosa.
Only dentists and physicians can prescribe antibiotic
prophylaxis.
The two groups of patients for whom antibiotic prophylaxis is
recommended are:
■ Individuals with certain heart conditions that predispose
them to infective endocarditis (IE)
■ Artificial heart valves
■ History of having previously contracted IE
■ Heart transplant that had complications and valve
problems
■ Certain congenital heart conditions such as:
• Unrepaired or incompletely repaired cyanotic congenital
heart disease, including those with palliative shunts or
conduits
• A completely repaired congenital defect of the heart with
prosthetic material or device, whether placed by surgery
or by catheter intervention, during the first 6 months
after the procedure
• Any repaired congenital heart defect with residual defect
at the site or adjacent to the site of a prosthetic patch or
a prosthetic device

EMERG
4
Patients should check with their cardiologists if they have any
questions about whether they fall into one of these categories.
The recommendations for antibiotic prophylaxis for IE state
that the antibiotic should be taken 30 to 60 minutes before the
procedure for it to reach adequate levels in the blood. However,
if the antibiotic is inadvertently not administered before the pro-
cedure, the dosage may be administered up to 2 hours after the
procedure.
If a patient who is required to have antibiotic prophylaxis is
already taking antibiotics for a separate condition, the dentist
must prescribe a different class of antibiotic from the one the
patient is already taking.
■ Individuals who have a total joint replacement and run the
risk of developing infection at the prosthetic site.
Even though the American Academy of Orthopedic Surgeons
(AAOS) recommends antibiotic prophylaxis for all patients with
total joint replacement, the ADA and AAOS are in the process of
developing evidence-based guidelines to help determine when
antibiotic prophylaxis is recommended before a dental proce-
dure for patients with orthopedic implants.

EMERG
5
Antibiotic Prophylaxis Regimen
Route of
Administration Drug
Dose: One Dose 30–60 Min
Before Appointment
Adult Children
Oral Amoxicillin 2 g 50 mg/kg
Unable to take
oral meds
Ampicillin
Cefazolin
2 g IV or IM
1 g IV* or IM
50 mg/kg IV or IM
50 mg/kg IV or IM
Unable to take
oral meds or
allergic to
penicillins
Cephalexin
Clindamycin
Azithromycin
2 g
600 mg
500 mg
50 mg/kg
20 mg/kg
15 mg/kg
Unable to take
oral meds or
allergic to
penicillins
Cefazolin
Clindamycin
1 g IV or IM
600 mg IV or
IM
50 mg/kg IV or IM
20 mg/kg IV or IM
*IM, intramuscular; IV, intravenous.
Vital Signs
In dentistry, pulse, respiration, and blood pressure are routinely
taken to assess the patient’s health before treatment.

EMERG
6
Blood Pressure
Reprinted with permission from: Kantz, S. (Forthcoming).
Dental Assisting: A Comprehensive Guide to Current Practice,
ed 1. Philadelphia: F.A. Davis Company.
The blood pressure is recorded as a fraction of the systolic blood
pressure over the diastolic blood pressure. The force of blood
against the blood vessel walls during ventricular contraction is
called systolic pressure, and the force of blood against the blood
vessel walls during ventricular relaxation is called diastolic
pressure.

EMERG
7
Blood Pressure Types In Adults
Systolic (mm Hg) Diastolic (mm Hg)
Normal <120 <80
Prehypertension 120–139 80–89
Hypertension stage 1 140–159 90–99
Hypertension stage 2 ≥160 ≥100
Pulse Rate
A pulse is the rhythmic dilation of an artery caused by the con-
traction and expansion of the arterial wall as blood is pushed out
of the heart. It is commonly used to measure one’s heart rate. A
person’s pulse can be measured in various areas but is usually
felt in the carotid artery in the neck, the brachial artery in the
arm, or the radial artery in the wrist. When measuring pulse, one
should also assess rhythm and strength. Pulse should be
recorded for 1 minute. (In dentistry, it is common to measure the
pulse rate for 30 seconds and then multiply by 2.)
Normal Pulse Rates
Pulse Category Heart Rate (bpm)
Adults and children 10 years old and older 60–100
Children younger than 10 years but older
than 1 year
60–140
Babies 1 year old and younger 100–160
Adult marathon runners 40–60
bpm, beats per minute.
Respiration
During respiration, oxygen and carbon dioxide are exchanged in
the human body. It is measured by the respiration rate (RR). In
an adult at rest, the normal RR is between 12 and 20 breaths/min.

EMERG
8
Normal Respiration Rates
Age Category Respiratory Rate (breaths/min)
Adults 12–20
Children 15–25
Newborns 40–50
Chain of Survival (AHA)
■ Early access: Immediate recognition of cardiac arrest and
activate emergency response system (EMS) CALL 911.
■ Begin early CPR: Chest compressions and ventilations.
■ Early deﬁbrillation: Use the AED.
■ Early advanced care: Provided by EMS personnel.
CPR
Sequence of Steps for CPR: CAB
Begin the CAB sequence if the person is unresponsive, is not
breathing, or has no pulse within 10 seconds.
■ Chest compressions: Perform 30 compressions of the
sternum to a depth of at least 2 in. for adults, about 2 in. for
children, and about 1½ in. for infants at a rate of 100/min.
Allow complete recoil of chest wall.
■ Airway: Ensure that the ability of the victim to breathe is not
obstructed by performing a head tilt and chin lift.
■ Breathing: Perform two ventilations.
Reassess CABs after 2 min.

EMERG
9
Automated External Defibrillator
External defibrillators are becoming vital pieces of equipment in
dental offices as part of a protocol for managing medical emer-
gencies. Early defibrillation saves lives.
■ Turn machine on.
■ Follow audio and visual instructions.
■ Place pads as directed.
■ Follow instructions; stay clear for shock if indicated.
■ If machine indicates, continue with CPR.
Obstructed Airway Management
(Heimlich Maneuver)
Obstructed airways may occur anywhere at any time. A foreign
object can become lodged, not allowing the victim to breathe.
If a victim shows the universal sign of choking (grasping the
throat with both hands), do the following:
■ Ask whether the person is choking. If she responds, avoid
physical contact and encourage her to cough. If she cannot
respond, be ready to perform abdominal thrusts.
■ Stand behind the victim, wrap your hands around her waist,
and place your fist, thumb first, above the navel but below
the breast bone.

EMERG
10
■ Perform abdominal thrusts using quick upward motions.
■ Continue until the foreign object is expelled or until the
victim becomes unconscious due to lack of oxygen in the
brain.
■ If the patient becomes unconscious, call 911 and begin CPR.
If, because of pregnancy or the size of the victim, one cannot
perform abdominal thrusts, chest thrusts are the best
alternative.
Medical Emergencies
Most medical emergencies can be prevented from happening in
a dental office by being aware of the patient’s medical health
history. Regardless of the precautions taken by the dental staff,
however, medical emergencies do happen. Therefore, all dental
assistants should have up-to-date credentials on CPR, obstructed
airway management, and obtaining vital signs.
Medical emergencies in a dental office are best dealt with
as a team. The entire dental team (dentist, assistant, hygienist,
and front desk personnel) should practice medical emergency
scenarios, so that individual roles are preassigned and duties
predetermined.
Angina Pectoris
Lack of oxygen to the heart muscle will lead to myocardial is-
chemia with severe chest pain. It has been reported that angina
is one of the most frequently encountered medical emergencies
in a dental office.
Symptoms & Signs
■ Chest pain
■ High blood pressure
■ High pulse
■ Nausea
■ Pain radiating to shoulder or even to lower jaw

EMERG
11
Management
■ Administer 100% oxygen.
■ Administer nitroglycerin.
■ If pain has not subsided 10 minutes after nitroglycerin
administration, call EMS.
■ If patient has no known angina condition, call EMS
immediately and follow the first two steps above.
Broken Instrument
By maintaining instruments in good working condition and dis-
carding instruments that have become oversharpened and thin,
one can prevent broken tips in a patient’s mouth.
In the event that a tip is broken in a patient’s mouth, without
alarming the patient, ask him or her not to swallow. Do not rinse
because you may dislodge the tip unknowingly. Try to isolate the
area, gently dry it out, and locate the tip. If the tip is visible, use
a curette or cotton pliers to gently retrieve it. If the tip is not
visible, take a radiograph to determine its location. If the tip is
deeply lodged, the patient may need to be referred to an oral
surgeon for surgical removal.
Diabetic Emergency
Obtaining an accurate medical history in the dental office is
extremely important, especially for patients with metabolic dis-
orders, such as diabetes. There are three types of diabetes. Type
1 diabetes occurs when the body makes too little or no insulin,
also called insulin-dependent diabetes. Type 2 diabetes occurs
when the body cannot use the insulin it makes, also called non–
insulin-dependent diabetes. Gestational diabetes occurs in preg-
nant women.
Hypoglycemia
Hypoglycemia or insulin shock occurs when blood glucose levels
drop significantly.
Symptoms & Signs
■ Fast onset
■ Irritability

EMERG
12
■ Clammy skin
■ Rapid breathing
Management
■ Stop all dental procedures and remove all objects from the
mouth.
■ If the patient is conscious, give oral glucose.
■ Fully recline the patient’s chair.
■ If the patient is unconscious, administer glucose
intravenously or glucagon intramuscularly.
■ Call EMS.
Hyperglycemia
Hyperglycemia is less likely to occur in a dental office and is
triggered by low insulin levels in the blood.
Symptoms & Signs
■ Slow onset
■ Dry skin
■ Deep breathing
■ Nausea
■ Vomiting
■ Drowsiness
Management
■ Determine what type of diabetic emergency is at hand.
■ Administration of glucose will not harm a patient with
hyperglycemia, but it will significantly help a hypoglycemic
one.
■ Managing hyperglycemia requires administration of
precisely the right amount of insulin. Thus, a physician must
administer it, so that the patient’s condition will not turn to
hypoglycemia because of an overdose of insulin.
■ Call EMS.
Fainting (Syncope or Vasovagal Episode)
Syncope, more commonly known as fainting, is perhaps the
most common cause of loss of consciousness in a dental office.
It is usually triggered by fear, anxiety, pain, or fasting.

EMERG
13
Symptoms & Signs
■ Lightheadedness
■ Nausea or vertigo (dizziness)
■ Pupil dilation
■ Perspiration
■ Pallor (paleness)
■ Bradycardia (low pulse)
■ Loss of consciousness
Management
■ Stop all dental procedures and remove all objects from the
mouth.
■ Place patient in supine position with head below heart level
to facilitate blood return.
■ Administer oxygen (4 L/min).
■ Loosen tight clothing.
■ Monitor vital signs.
■ Keep patient in supine position even after recovery until
ready to be elevated to a seated position.
■ If patient is not recovering, call EMS.
Foreign Object Aspiration
Foreign body aspirations in dentistry can be prevented by the
use of screens, gauze, or rubber dams. Fixed prostheses should
also be secured with ﬂoss before trying them intraorally. Aspira-
tion of a foreign object is a serious, potentially life-threatening
situation. If the aspiration leads to the patient choking while in
the dental ofﬁce, follow the instructions for obstructed airway
management as described earlier. If the patient becomes uncon-
scious, call 911 and begin CPR, as described previously.
Hyperventilation
During hyperventilation, the patient breathes at a much faster
rate, consuming more carbon dioxide than is produced, resulting
in changes in the pH of the blood. Hyperventilation is triggered
by many conditions, including anxiety and fear.

EMERG
14
Symptoms & Signs
■ Very fast breathing
■ Dizziness
■ Heart palpitations
■ Muscle spasms
■ Tingling of the extremities
Management
■ Position the patient in a position in which he or she feels
comfortable (preferably upright).
■ Assist in trying to control the patient’s breathing.
■ Check vital signs.
■ Consider administering lorazepam intramuscularly.
■ If condition does not improve, contact EMS.
Seizures
Seizures result from abnormal electrical activity in the brain.
Risk factors include genetic predisposition and systemic imbal-
ances caused by metabolic disorders, use of certain drugs, infec-
tions, cancer, and trauma.
Symptoms & Signs
Because of the various types of seizures, the symptoms may vary
slightly. However, common symptoms include the following:
■ Convulsions
■ Heavy breathing
■ Muscle contraction
■ Loss of consciousness
■ Frothy mouth
Management
■ Stop treatment immediately and make sure you remove all
objects from the patient’s mouth to avoid injury.
■ Place the patient in a supine position on his or her left side
to avoid aspiration.
■ Loosen tight clothing.
■ Protect the patient from injury by gentle restraint and do not
attempt to move to the ﬂoor.

EMERG
15
■ Administer oxygen.
■ If the patient becomes unconscious, call EMS and begin CPR.
Dental Emergencies
Management procedures described in the following are to be
performed only by licensed dentists or, in some cases, by dental
hygienists.
Abscess
Periodontal
Symptoms & Signs
■ Pain
■ Swelling
■ Pus
■ Bleeding gums
Management
■ Débridement of the periodontal pocket, root planing, and
scaling if indicated and clinically possible
■ Local delivery of antimicrobial solutions and placement of
antibiotics
■ If pocket is deep (>6–7 mm), referral to periodontist may be
appropriate for surgical resolution and reduction of the
pocket depth.
Tooth Related
Symptoms & Signs
■ Pain (can be severe).
■ Swelling.
■ Pus.
■ Bad taste and odor.
■ Pain on tapping.
■ No temperature sensitivity.
■ Many times a parulis is visible on the gingival margin apical
to the abscessed tooth.
■ Fever.

EMERG
16
Management
■ Drain the abscess to relieve the pressure.
■ Prescribe systemic antibiotics.
■ Prescribe mild pain control medication.
■ Perform root canal or extraction depending on tooth
condition and patient preference.
Alveolar Osteitis (Dry Socket)
Symptoms & Signs
■ Radiating pain (can be severe)
■ Visible bone
■ Bad breath
■ Foul taste
■ Bleeding from the extraction site
■ Gray tissue surrounding the extraction site
Management
■ Administer local anesthesia.
■ Clean and irrigate socket.
■ Place medicaments in the socket.
■ Stress postoperative instructions.
■ Prescribe antibiotics and perhaps pain medication.
■ Replace medicaments if necessary.
■ Evaluate in a few days.
Avulsed Tooth
Symptoms & Signs
■ Tooth completely out of the socket
■ Pain
■ Swelling
Management
■ Obtain a radiograph of the area to rule out bone fragments
in the socket or socket fracture and collapse.
■ If the tooth is temporary (deciduous), do nothing; let the
permanent tooth erupt.
■ If the tooth is permanent (succedaneous) and is preserved
without excessive manipulation, attempt to reinsert it back
to the socket and splint it to adjacent teeth.

EMERG
17
■ If reimplantation is successful, root canal treatment and
crown restoration will be necessary.
■ If reimplantation fails, discuss alternative restorative options
with the patient.
Broken Tooth
Symptoms & Signs
■ Caused by trauma or decay
■ Temperature sensitivity
Management
■ Obtain a radiograph to evaluate root integrity.
■ Restore (restorations will vary depending on the amount of
the broken tooth and the condition of the remaining tooth
structure).
■ Root canal or extraction may be necessary.
■ Discuss alternative restorative options.
Cracked Tooth Syndrome (CTS)
Symptoms & Signs
■ Caused by trauma or decay
■ Temperature sensitivity
Management
■ Obtain a radiograph to evaluate root integrity.
■ Conﬁrm CTS with bite stick (bite and release test).
■ Restore (restorations will vary depending on the amount of
the broken tooth and the condition of the remaining tooth
structure).
■ Root canal or extraction may be necessary.
■ Discuss alternative restorative options.

18
MEDS
CommonlyPrescribedMedicationsThatAffecttheMouth
andTeeth
TradeNameGenericNameDentalEffects/Management
AccuprilQuinaprilHypotension/Monitorvitalsigns,allowpatientto
situpforacoupleofminutes
AciphexRabeprazoleDrymouth,potentiallygingivitis
AdderallAmphetamine/dextro-
amphetamine
Drymouth/Monitorvitalsigns,keep
appointmentsshort
AdvilIbuprofenPotentialpostoperativebleeding
AggrenoxDipyridamole–ASAContactphysicianbeforeperformingaprocedure
inwhichbleedingisexpected
AldactoneSpironolactoneDrymouth
AllegraFexofenadineHClDrymouth
AmbienZolpidemtartrateDrymouth
AmoxilAmoxicillinCompromisedcontraception
AtivanLorazepamDrymouth
AugmentinPenicillin–clavulanateCandida,compromisedcontraception

MEDS
19
andTeeth—cont’d
AZTZidovudineBleedingofthegums
BonivaIbandronatePotentialnecrosisofjawbone
BusparBuspironeDrymouth
CalanVerapamilHClDrymouth/Monitorvitalsigns,providea
stress-freeappointment
CarduraDoxazosinmesylateDrymouth/Monitorvitalsigns,providea
stress-freeappointment
CelebrexCelecoxibDrymouth
CelexaCitalopramDrymouth,posturalhypotension
CialisTadalaﬁlDrymouth
ClaritinLoratadineDrymouth
ClozarilClozapineDrymouth
Continued

20
MEDS
andTeeth—cont’d
CombiventAlbuterol–ipratropiumDrymouth,teethmayappeardiscolored
ConcertaMethylphenidateHClDrymouth/Usevasoconstrictorswithcaution
CortefHydrocortisoneCandida
CoumadinWarfarinContactphysicianbeforeperformingaprocedure
DarvocetPropoxyphene–
acetaminophen
Stomatitis
DeltasonePrednisoneDelayedhealing,Candida
DemerolMeperidineHypotension(postural)
DenavirPenciclovirAffectstaste
DepakoteValproicAcidDrymouth
DesyrelTrazodoneDrymouth,hypotension
DetrolTolterodineDrymouth
DiﬂucanFluconazoleAffectstastebuds

MEDS
21
andTeeth—cont’d
DilantinPhenytoinsodiumGingivalhyperplasia
DilaudidHydromorphoneDrymouth
DuragesicFentanyl(transdermal)Hypotension,drymouth
EffexorVenlafaxineHClDrymouth
ElavilAmitriptylineHCLDrymouth,hypotension/Donotuse
vasoconstrictors
EnbrelEtanerceptAlterstaste
EndocetOxycodone–acetaminophenDrymouth
FosamaxAlendronatesodiumRarecasesofosteonecrosis
HalcionTriazolamDrymouth,stomatitis
HaldolHaloperidolDrymouth
HyzaarLosartan–hydrochlorothiazideDrymouth
ImitrexSumatriptanDrymouth
InderalPropranololHCLDrymouth
Continued

22
MEDS
andTeeth—cont’d
IsordilIsosorbidedinitrateHypotension
LamictalLamotrigineDrymouth
LasixFurosemideDrymouth,hypotension
LibriumChlordiazepoxideDrymouth,sometimescoatedtongueisnoted
LodineEtodolacDrymouth
LopressorMetoprololDrymouth
LorabidLoracarbefCandida,affectscontraceptivemeasures
LotrelAmlodipine–benazeprilDrymouth,gingivalhyperplasia
LovenoxEnoxaparinsodiumContactphysicianbeforeperformingaprocedure
LunestaEszopicloneDrymouth
LuvoxFluvoxaminemaleateDrymouth
LyricaPregabalinDrymouth
MedrolMethylprednisoloneCandida,delayedhealing

MEDS
23
andTeeth—cont’d
MevacorLovastatinDrymouth,hypotension
MirapexPramipexoledihydrochlorideDrymouth
MircetteEthinylestradiol–desogestrelGingivalchanges
NeconEthinylestradiol–
norethindrone
Gingivalchanges
NeurontinGabapentinDrymouth
NorvascAmlodipineDrymouth,gingivalhyperplasia
NorvirRitonavirCandida
Ortho-novumNorethindrone–ethinyl
estradiol
Gingivalchanges
OxyContinOxycodoneDrymouth,hypotension
PamelorNortriptylineHClHypotension/Donotusevasoconstrictors
PatanolOlopatadineHClDrymouth
PaxilParoxetineDrymouth
PepcidFamotidineDrymouth
Continued

24
MEDS
andTeeth—cont’d
PenicillinVKPenicillinCandida,hairytongue,reducescontraceptive
action
PlavixClopidogrelContactphysicianbeforeperformingaprocedure
ProtonixPantoprazoleExcessivesalivation
ProventilAlbuterolDrymouth,teethdiscoloration
ProzacFluoxetineDrymouth,hypotension
RequipRopiniroleDrymouth,hypotension
RestorilTemazepamDrymouth,tastealterations
SeraxOxazepamDrymouth,coatedtongue
SereventSalmeterolCandida
SeroquelQuetiapineDrymouth
TegretolCarbamazepineDrymouth,stomatitis
TenorminAtenololDrymouth,affectstaste
TimopticTimololmalateDrymouth

MEDS
25
andTeeth—cont’d
Trivora-28Levonorgestrel–ethinyl
estradiol
Gingivalchanges
TofranilImipramineHCLDrymouth,hypotension/Donotuse
vasoconstrictors
TopamaxTopiramateDrymouth
TrileptalOxcarbazepineDrymouth
UltramTramadolDrymouth,hypotension
ValiumDiazepamDrymouth
VersedMidazolamIncreasedsalivation
WellbutrinBupropionHCLDrymouth
XanaxAlprazolamDrymouth
ZithromaxAzithromycinCandida,hairytongue,reducescontraceptive
action
ZomigZolmitriptanAffectstaste
ZyprexaOlanzapineDrymouth,hypotension
Themedicationsingreenarethoseoftenprescribedbydentists.Textinredindicatesimplicationsforthedentalvisit.

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Dentition
Tooth Eruption Tables
Deciduous (Primary) Dentition
Teeth Age of Eruption (months)
Central incisors 6–8
Lateral incisors 7–9
Canines 15–20
First molars 12–16
Second molars 20–30

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Permanent (Adult) Dentition
Arch Teeth
Age of Eruption
(years)
Maxillary Central incisors 7–9
Canines 11–13
First premolars 10–11
Second premolars 10–13
First molars 6
Third molars (wisdom teeth) 17–21
Mandibular Central incisors 6–7
Canines 8–9
First premolars 10–12
Second premolars 11–13
First molars 6
Third molars (wisdom teeth) 17–21

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Tooth Numbering
Tooth numbering systems provide a consistent method for iden-
tifying teeth for charting and descriptive purposes.
Universal System
1
Permanent dentition
Permanent dentition
Maxillary
Maxillary
Mandibular
Mandibular
Primary
dentition
A B C D E F G H I J
T S R Q P O N M L K
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Reprinted with permission from: Prajer, R., & Grosso, G.
(2011). DH Notes: Dental Hygienist’s Chairside Pocket Guide,
ed 1. Philadelphia: F.A. Davis Company; p. 28.

29
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Universal System
(Permanent Dentition)
Tooth Number Tooth Name
1 Maxillary right third molar
2 Maxillary right second molar
3 Maxillary right first molar
4 Maxillary right second premolar
5 Maxillary right first premolar
6 Maxillary right canine
7 Maxillary right lateral incisor
8 Maxillary right central incisor
9 Maxillary left central incisor
10 Maxillary left lateral incisor
11 Maxillary left canine
12 Maxillary left first premolar
13 Maxillary left second premolar
14 Maxillary left first molar
15 Maxillary left second molar
16 Maxillary left third molar
17 Mandibular left third molar
18 Mandibular left second molar
19 Mandibular left first molar
20 Mandibular left second premolar
21 Mandibular left first premolar
22 Mandibular left canine
23 Mandibular left lateral incisor
24 Mandibular left central incisor

30
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Universal System
(Permanent Dentition)—cont’d
25 Mandibular right central incisor
26 Mandibular right lateral incisor
27 Mandibular right canine
28 Mandibular right first premolar
29 Mandibular right second premolar
30 Mandibular right first molar
31 Mandibular right second molar
32 Mandibular right third molar
Begin counting from the upper right third molar as #1 to the upper left third molar
as #16, then move to the lower left third molar as #17, and finish at the lower
right third molar as #32.

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Universal System (Primary Dentition)
A Primary maxillary right second molar
B Primary maxillary right first molar
C Primary maxillary right canine
D Primary maxillary right lateral incisor
E Primary maxillary right central incisor
F Primary maxillary left central incisor
G Primary maxillary left lateral incisor
H Primary maxillary left canine
I Primary maxillary left first molar
J Primary maxillary left second molar
K Primary mandibular left second molar
L Primary mandibular left first molar
M Primary mandibular left canine
N Primary mandibular left lateral incisor
O Primary mandibular left central incisor
P Primary mandibular right central incisor
Q Primary mandibular right lateral incisor
R Primary mandibular right canine
S Primary mandibular right first molar
T Primary mandibular right second molar
Begin counting from the upper right second molar as #A to the upper left second
molar as #J, then move to the lower left second molar as #K, and finish at the
lower right second molar as #T.

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Palmer Notation System
In the Palmer notation system, all quadrants are given their own
bracket. Teeth are noted within each bracket based on their rela-
tion to the midline. The orientation of the bracket notes the
quadrant. Letters are used for deciduous teeth.
Permanent Teeth
Upper Right
8┘ 7┘ 6┘ 5┘ 4┘ 3┘ 2┘ 1┘
8┐ 7┐ 6┐ 5┐ 4┐ 3┐ 2┐ 1┐
Lower Right
Upper Left
└1 └2 └3 └4 └5 └6 └7 └8
┌1 ┌2 ┌3 ┌4 ┌5 ┌6 ┌7 ┌8
Lower Left
Deciduous Teeth (Baby Teeth)
Upper Right Upper Left
E┘ D┘ C┘ B┘ A┘ └A └B └C └D └E
E┐ D┐ C┐ B┐ A┐ ┌A ┌B ┌C ┌D ┌E
Lower Right Lower Left

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Cavity (Caries) Classification
Cavities (caries) are perhaps the most common dental disease.
Caries is defined as an infectious bacterial disease that affects
the tooth and the surrounding structures. G.V. Black has intro-
duced a system classifying the various types of caries found on
teeth based on location and tooth surfaces affected.
Class I
■ Pit and fissure caries
Class II
■ Interproximal caries in posterior teeth (mesial, distal)

34
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Class III
■ Interproximal caries in anterior teeth with no incisal edge
involvement
Class IV
■ Interproximal caries in anterior teeth with incisal edge
involvement

35
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Class V
■ Caries in the gingival third of anterior and posterior teeth
Class VI
■ Caries on incisal edge of anterior teeth or cusps of posterior
teeth due to defects

36
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Charting
Charting of existing and diagnosed procedures is important to
maintain an accurate record of the patient’s oral status.
Color Coding
Color Meaning
Red Treatment pending
Blue or black Existing restorations
Tooth Surface Abbreviations
Abbreviation Meaning
M Mesial
D Distal
La Labial
B Buccal
L Lingual
I Incisal
O Occlusal
DO Disto-occlusal
MO Mesio-occlusal
MOD Mesio-occlusal-distal

37
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Dental Abbreviations
Abs Abscess
ADA American Dental Association
ADAA American Dental Assistant Association
Adj Adjustments
AM or Amal Amalgam
Anes Anesthesia
Ant Anterior
BOP Bleeding on probing
Br Bridge
BWX Bitewing radiograph
C or Com Composite
Cem Cement
CLD or FLD Complete lower denture or full lower denture
Consult Consultation
CPR Cardiopulmonary resuscitation
CRN or Cr Crown
CUD or FUD Complete upper denture or full upper denture
Deci Deciduous
Del Delay
Dent Denture
Dx or Diag Diagnosis
Epi Epinephrine
Ex or Exam Examination
EXT Extraction
Continued

38
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Dental Abbreviations—cont’d
FGC Full gold crown
Fl Fluoride
FMX Full mouth radiographic series
FPD Fixed partial denture (i.e., bridge)
FX Fracture
Fx Function
HIPAA Health Insurance Portability and
Accountability Act
Hist History
HP Handpiece
I & D or I/D Incise and drain
MSDS Manufacturer’s safety data sheet
NKA No known allergies
NKDA No known drug allergies
NSAIDS Nonsteroidal anti-inﬂammatory drugs
PA Periapical radiograph
PANO Panoramic radiograph
Perm Permanent
PFM Porcelain fused to metal crown
PFS Pits and ﬁssure sealants
PLD Partial lower denture
Pre-Med Premedication
PRN As needed
PSR Periodontal Screening Record
PUD Partial upper denture
Px Prognosis

39
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Dental Abbreviations—cont’d
PX or P Prophylaxis
RCT Root canal therapy
RPD Removable partial denture
Rx Prescription
TMJ Temporomandibular joint
Tx Treatment
Tx Pl Treatment plan
UCR Usual, customary, and reasonable
Xylo Xylocaine
ZOE Zinc oxide eugenol
Occlusion
The relationship of the maxillary teeth with the mandibular teeth
when they come together is described as occlusion.
The ideal occlusion occurs when maxillary and mandibular
teeth contact at maximum level.
Class I Occlusion Molar Relationship
Class I occlusion molar relationship is defined as the type of
occlusion in which the mesiobuccal cusp of the maxillary first
molar contacts the buccal grove of the mandibular first molar.
Class I Occlusion Canine Relationship
Class I occlusion canine relationship is defined as the type of
occlusion in which the maxillary canine contacts the distal half
of the mandibular canine and the mesial half of the mandibular
first premolar.

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Class II Occlusion Molar Relationship
Class II occlusion molar relationship is defined as the type of
occlusion in which the mesiobuccal cusp of the maxillary first
molar occludes in the space between the mandibular second
premolar and the mandibular first molar.
Class II Occlusion Canine Relationship
Class II occlusion canine relationship is defined as the type of
occlusion in which the distal surface of the maxillary canine is
located mesially to the distal surface of the mandibular canine.
Class II Division 1
The molar relationships are like that of Class II, and the anterior
teeth are protruded.

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Class II Division 2
The molar relationships are Class II, but the central teeth are
retroclined, and the lateral teeth are seen overlapping the
centrals.
Class III Occlusion Molar Relationship
Class III occlusion molar relationship is defined as the type of
occlusion in which the buccal groove of the mandibular first
molar occludes mesial to the mesiobuccal cusp of the maxillary
first molar.
Class III Occlusion Canine Relationship
Class III occlusion canine relationship is defined as the type of
occlusion in which the distal surface of the mandibular canine
occludes mesially from the mesial surface of the maxillary
canine.

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Misalignment or Malocclusion
Teeth and arches can be positioned in such a way that can cause
problems with occlusion, aesthetics, and function. Some exam-
ples of misaligned teeth are described.
Crossbite
Ideally, the maxillary teeth should occlude facially or buccally to
the mandibular teeth. Deviations from this norm, such as the
maxillary incisors being lingual to mandibular incisors or maxil-
lary or mandibular posterior teeth being excessively lingual or
buccal to the norm, will result in what is called crossbite.

43
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End to End
Cusp-to-cusp or incisal edge-to-incisal edge contact.

44
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Overbite
An excessive overlap in a vertical direction between maxillary
and mandibular incisors.
Overbite
Overjet
An excessively buccal positioning of the maxillary incisors in
relation to mandibular incisors.
Overjet

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Open Bite
Anterior teeth do not occlude when the posterior teeth are in
occlusion.
Anesthesia
One of the primary responsibilities of a dentist is to eliminate
dental disease as painlessly as possible. Science and chemistry
have provided the dental profession with several agents to
achieve topical, local, and general anesthesia so the patient can
be as comfortable and pain free as possible during dental
procedures.
Topical Anesthetics
Topical anesthetics are administered to achieve terminal nerve
ending anesthesia. It is short lasting and can be used for a variety
of reasons:
■ Before local anesthetics
■ To manage patient’s gag reﬂex
■ Before suture removal or removal of loosely attached
primary teeth

46
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Most Common Topical Anesthetics
Benzocaine 20% Concentration
Cetacaine 14% Benzocaine
2% Tetracaine
Lidocaine 5% In liquid form
Oraqix (mostly used in dental hygiene
procedures)
2.5% Prilocaine
2.5% Lidocaine
Local Anesthetics
Local anesthetics are used before treatment to provide tempo-
rary anesthesia (no feeling) to the teeth and soft tissue. The mode
of action is to block nerves that identify pain from sending
impulses to the brain. Local anesthetics vary in the duration of
their effect:
■ Short acting (30 minutes)
■ Intermediate acting (60 minutes)
■ Long acting (90 minutes)

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Most Common Local Anesthetics
Generic Name Trade Name
Vaso-
constrictor
Vasoconstrictor
Concentration
2% Lidocaine with
epinephrine
Xylocaine
Octocaine
Yes 1:100,000
2% Mepivicaine
with
levonordefrin
Carbocaine Yes 1:20,000
3% Mepivicaine
plain
Carbocaine No N/A
4% Articaine Septocaine Yes 1:100,000
1:200,000
Prilocaine Citanest Forte Yes 1:100,000
Bupivacaine Marcaine Yes 1:200,000
2% Lidocaine Xylocaine No N/A

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Anesthesia Color Coding
Anesthetic Color
2% Lidocaine with epinephrine
1:100,000
2% Lidocaine with epinephrine
1:50,000
Lidocaine plain
Mepivacaine 2% with
levonordefrin 1:20,000
Mepivacaine 3%
Prilocaine 4% with epinephrine
1:200,000
Prilocaine 4%
Bupivacaine 4% with
epinephrine
Articaine 4% with epinephrine
Preparation for Injection
■ Review medical history.
■ Wipe injection site with 2 × 2 gauze to remove excess saliva.
■ Apply topical anesthetic and let it remain for 2 to 3 minutes.
■ Assemble and hand anesthetic syringe to doctor for
injection.
■ Most commonly used needles:
■ 30-gauge short (blue cap) for inﬁltrations and maxillary
blocks
■ 27-gauge long (yellow cup) for mandibular blocks

49
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Injection Types
Maxillary Injections
Maxillary
nerve
Ophthalmic
nerve
Mandibular
nerve
Anterior superior
alveolar nerve
Middle
superior
alveolar
nerve
Posterior
superior
alveolar
nerve
Greater and lesser
palatine nerves
Dental plexus
Trigeminal
ganglion

50
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Posterior Superior Alveolar (PSA)
■ Inﬁltration injection is used for maxillary posterior molars.
■ Use a 27-gauge short needle.

51
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Middle Superior Alveolar (MSA)
■ Inﬁltration injection is used for maxillary premolars.

52
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Anterior Superior Alveolar (ASA)
■ Inﬁltration injection is used for maxillary anterior teeth.

53
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Greater Palatine Block
■ Block injection.
■ Anesthetizes posterior portion of hard palate.

54
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Nasopalatine Block
■ Anterior portion of hard palate between canines.

55
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Mandibular Injections
Inferior alveolar nerve
Lingual nerve
Mylohyoid nerve

56
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Inferior Alveolar Nerve Block
■ Unilateral effect to the midline.
■ Use a 30-gauge long needle.

57
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Buccal Nerve Block
■ Soft tissue buccal to ﬁrst molars.

58
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Mental Nerve Block
■ Premolars, canines, incisors.
Nitrous Oxide Sedation
Nitrous oxide is the most commonly used sedative in dentistry.
It is commonly used in oral and periodontal surgery, in patients
with high levels of apprehension and anxiety, in children, and in
patients with developmental and behavioral conditions.

59
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Indications
■ To reduce fear and anxiety
■ Used in children to eliminate negative experience of
restraining
■ Used in patients with special needs
■ Used in patients with high gag reflex
■ Used in patients who have difficulty reaching profound local
anesthesia
■ To enhance the action of local anesthesia
■ To prevent triggering other medical conditions (e.g., stress
may increase blood pressure, trigger angina incidents)
Contraindications
■ Patients unable to breathe adequately through their nose
due to respiratory infections, blocked sinuses
■ Patients who have undergone eye or ear surgery
■ Patients with hypoxia or chronic obstructive pulmonary
disease (COPD)
■ Patients with history of drug addiction
■ Patients taking sleep medications or antidepressants
■ Pregnant women during first trimester even though their
physicians should be contacted if N2O-O2 is considered for
their treatment
■ Patients treated with bleomycin sulfate treatment for
neoplasm in which fibrosis of the lungs is often found
■ Patients with sickle cell anemia
■ Patients who have congestive heart failure (CHF)
Medical Assessment of the Patient
Before Administration
Patients who are considered candidates for N2O-O2 inhalation
sedation should complete a detailed medical history form to be
reviewed by the dentist. If at any moment there is a doubt about
their suitability for nitrous oxide, the physician should be con-
sulted, and if necessary, the appointment should be rescheduled.

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Upon verifying the patient’s suitability, an informed consent
should be signed and all details, and potential side effects should
be explained to the patient. Before the actual administration of
the gas, the patient’s vital signs must be measured and recorded
and an examination of the airway should take place. The patient
or the parent (if a minor) must also have been informed before
the appointment to eat light to avoid vomiting. In children,
special attention should also be paid for enlarged adenoids and
tonsils. After the procedure, detailed records of the time, ﬂow,
and oxygenation procedures should be recorded.
Pharmacological and Physiological Effects of
Nitrous Oxide
When ammonium nitrate is heated to high temperatures, it yields
nitrous oxide and water. Nitrous oxide is a colorless, “sweet”-
tasting gas, and it is the only inorganic gas that is used for seda-
tion in humans. Nitrous oxide affects the central nervous system
(CNS) by dulling the perception of painful stimuli and creating a
more relaxed, carefree attitude in the patient. The exact mecha-
nism is not completely known; it is believed, however, that this
drug increases the release of endorphins in the body, which in
turn block opioid receptors in the CNS, thus elevating the pain
threshold. It is a relatively safe drug and has no effect on the
cardiovascular system except minor vasodilatation. The pulse
and heart rate remain unaffected, and there is no effect on the
skeletal muscle system.
Nitrous oxide has an onset time of 2 to 5 minutes and is
metabolized and excreted by the lungs. Because of its high dif-
fusion rate (34 times higher than nitrogen), it is contraindicated
for patients with medical conditions listed earlier, and it should
never be administered without a scavenging system because it
can accumulate, displacing oxygen, and overcome health care
personnel. When inhaled, nitrous oxide reaches the lungs and
travels via the circulatory system to the brain (limbic system) and
the rest of the body. The patient experiences the following
symptoms:

61
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■ A tingling sensation, especially in the extremities
■ A warm feeling
■ A feeling of well-being and euphoria
■ In deeper sedation states, inability to keep the eyes open
■ Nausea and vomiting (only if oversedated)
Notable: Nitrous oxide/oxygen has a fast onset and recovery.
Management of Complications and
Medical Emergencies
Even though nitrous oxide has a great safety record, medical
emergencies may occur while the patient is under its inﬂuence.
The best way to manage such emergencies is to prevent them.
Perform a thorough examination of the prospective recipient’s
medical history to not only ensure that the patient is a “good”
candidate, but also to learn of any medical condition.
Oversedation can lead to nausea and vomiting during the pro-
cedure. If such an event occurs, do the following:
1. Turn the patient to his or her side to avoid aspiration.
2. Stop administering nitrous oxide immediately.
3. Give the patient 100% oxygen.
4. When the risk of vomiting has subsided, move the patient to
a contamination-free area where he or she can breathe fresh
air. Measure the patient’s vital signs.
High concentrations of the gas can lead to dizziness, deep breath-
ing, and eventually unconsciousness because of a lack of oxygen.
In such cases, do the following:
1. Immediately stop the gas supply.
2. Give the patient 100% oxygen.
3. Measure and record vital signs.
4. Evaluate voluntary breathing and pulse.
5. Initiate cardiopulmonary resuscitation while informing the
emergency services.
REMEMBER: Nitrous oxide does not kill brain cells, but lack of
oxygen does.

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Chairside Concepts
Four-Handed Dentistry
■ Minimizes stress and fatigue for dentist and assistant.
■ Provides efﬁcient care to the patient.
Seating zones: Visualize the patient as a clock with his head on
12 o’clock and his feet on 6 o’clock and use the zones shown in
the following chart to determine the appropriate seating for the
dentist and the assistant.

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12
1
2
3
4
5
6
7
8
9
10
Operator’s
zone
Right-handed dentist
Left-handed dentist
Operator’s
zone
Static zone
Static zone
Assistant’s
zone
Assistant’s
zone
Transfer zone
Transfer zone
11
12
1
2
3
4
5
6
7
8
9
10
11

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Right-Handed Dentist
Dentist’s zone 7–12
Assistant’s zone 2–4
Transfer zone 4–7
Static zone 122
Positioning
■ Sit all the way back on the stool.
■ Rest your feet on the stool base.
■ Keep your legs parallel to the patient’s dental chair.
■ Keep your eye level about 6 inches above the operator.

65
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Motions
■ Class I: Movement of the ﬁngers only
■ Class II: Movement of the wrist and ﬁngers

66
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■ Class III: Movement of the wrist, ﬁngers, and elbow
■ Class IV: Movement of the arm and shoulder

67
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■ Class V: Movement of the entire torso
Basic Principles
■ The operator is able to maintain vision on the operative
ﬁeld, thus reducing eyestrain.
■ The team conserves time and motion during instrument
transfers.
■ There is a reduction in stress and strain on the operating
team because of the uninterrupted ﬂow of the procedure
without the delays associated with locating and delivering
instruments.
■ When instrument transfer is used in conjunction with the
oral evacuator and the air/water syringe, the operative site
will always be clean and the next instrument will be ready
for use.
■ Percutaneous injuries associated with use of dental
instruments can be minimized using a prescribed transfer
technique.

68
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Instrument Transfer
■ Pen grasp: The position commonly used to hold a pen or
pencil and is widely used for most operative instruments.
■ Modiﬁed pen grasp: Similar to the pen grasp except the
operator uses the pad of the middle ﬁnger on the handle
of the instrument. Adds stability to the transfer.
■ Palm grasp: Hold the instrument on the palm. Used for
bulky instruments such as forceps.

69
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■ Palm/thumb grasp: Hold the instrument in the palm and
guide with the thumb. Used in holding the high volume
evacuation (HVE), it provides more vertical freedom in the
movement of the instrument.

70
INFECT
CONTROL
Infection Control and Instruments
Instrument Classiﬁcation Based on Need
for Infection Control
Critical
■ Touch bone and/or penetrate soft tissue.
■ Heat sterilize between uses or use sterile single-use,
disposable devices.
■ Examples: surgical instruments, scalpel blades, periodontal
scalers, and surgical dental burs.
Semicritical
■ Touch mucous membranes.
■ Heat sterilize or high-level disinfect.
■ Examples: Dental mouth mirrors, amalgam condensers, and
dental handpieces.
Noncritical
■ Contact with intact skin.
■ Clean and disinfect using a low- to intermediate-level
disinfectant.
■ Examples: X-ray head, pulse oximeter, blood pressure cuff.
Instrument Processing
■ Transport
■ Transport contaminated instruments to processing and
sterilization area.
■ Use a designated processing area to control quality and
ensure safety.
■ Divide processing area into work areas.
■ Cleaning: Use an ultrasonic cleaner.
■ Packaging
■ Wrap or package instruments for sterilization.
■ Wrap or place critical and semicritical items that will be
stored in containers before heat sterilization.
■ Open and unlock hinged instruments.

71
INFECT
CONTROL
■ Place a chemical indicator inside the pack.
■ Wear heavy-duty, puncture-resistant utility gloves.
■ Sterilization: Load and operate sterilizer according to the
manufacturer’s guidelines.
■ Storage: Store instruments in such a way as to maintain
integrity of the package.
■ Delivery to procedure site: Deliver instruments to procedure
site maintaining integrity and opening before procedure.
■ Quality control: Implement quality control test to assure
sterilization efﬁciency.
Instrument Sterilization
Sterilization Methods
■ Steam Autoclave (steam under pressure)

INFECT
CONTROL
72
■ Four cycles (heat up, sterilization, depressurization,
drying).
■ Short time.
■ Corrosive (may rust non–stainless steel instruments).
■ Use distilled water ONLY.
■ Chemical Vapor
■ Special chemical compound
■ Short time
■ Rapid Heat Transfer
■ Very short time
■ Noncorrosive
■ Dry Heat
■ Long time
■ Noncorrosive
■ Liquid Chemical Sterilant/Disinfectants
■ Only for heat-sensitive critical and semicritical devices.
■ Powerful, toxic chemicals raise safety concerns.
■ Heat-tolerant and disposable alternatives are available.
Sterilization Monitoring: Types of Indicators
■ Mechanical: Measure time, temperature, pressure
■ Chemical: Change in color when physical parameter is
reached

73
INFECT
CONTROL
Reprinted with permission from: Henry, R., & Perno, M.G.
(Forthcoming). Dental Hygiene: Applications to Clinical
Practice, ed 1. Philadelphia: F.A. Davis Company.
■ Biological (spore tests): Use biological spores to assess the
sterilization process directly

INFECT
CONTROL
74
CDC Guidelines for Infection Control
Chain of Infection
CDC Guidelines for Infection Control
Chain of
InfectionHost Source
Pathogen
Entry
For an infection to occur, four conditions must be present:
■ A germ must be present (e.g., bacteria, virus, parasite).
■ The germ must have a place to live and multiply such as
human, food, soil, or water.
■ A susceptible host must be present.
■ There must be a way for the germ to enter the host, such as
direct contact or air droplets.
Standard Precautions
Application
■ Apply to all patients
■ Integrate and expand Universal Precautions to include
organisms spread by blood and the following:
■ Body ﬂuids, secretions, and excretions except sweat,
whether or not they contain blood
■ Nonintact (broken) skin
■ Mucous membranes

75
INFECT
CONTROL
Elements
■ Hand washing
■ Use of personal protective equipment (PPE) (gloves, masks,
eye protection, gowns)
■ Patient care equipment
■ Environmental surfaces
■ Injury prevention
Bloodborne Pathogens
Examples
■ Hepatitis B virus (HBV)
■ Hepatitis C virus (HCV)
■ Human immunodeﬁciency virus (HIV)
Characteristics
■ Are transmissible in health care settings
■ Can produce chronic infection
■ Are often carried by persons unaware of their infection
Exposure Prevention Strategies
■ Engineering controls: Isolate or remove the hazard
■ Work practice controls: Change the manner of performing
tasks
■ Administrative controls: Policies, procedures, and
enforcement measures
Postexposure Management Program
■ Clear policies and procedures
■ Education of dental health care personnel (DHCP)
■ Rapid access to clinical care
■ Postexposure prophylaxis (PEP)
■ Testing of source patients and health-care personnel (HCP)
■ Wound management
■ Exposure reporting
■ Assessment of infection risk
■ Type and severity of exposure

INFECT
CONTROL
76
■ Bloodborne status of source person
■ Susceptibility of exposed person
Hand Hygiene
■ Hands are the most common mode of pathogen
transmission.
■ Reduce spread of antimicrobial resistance.
■ Prevent health care–associated infection.

77
INFECT
CONTROL
Terms and Definitions
■ Hand washing: Washing hands with plain soap and water
■ Antiseptic hand wash: Washing hands with water and soap
or other detergents containing an antiseptic agent
■ Alcohol-based hand rub: Rubbing hands with an alcohol-
containing preparation
■ Surgical antisepsis: Washing hands with an antiseptic soap
or an alcohol-based hand rub before operations by surgical
personnel
Guidelines
■ Use hand lotions to prevent skin dryness.
■ Consider compatibility of hand care products with gloves.
■ Keep fingernails short.
■ Avoid artificial nails.
■ Avoid hand jewelry that may tear gloves.

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CONTROL
78
Personal Protective Equipment
■ A major component of Standard Precautions
■ Protects the skin and mucous membranes from exposure to
infectious materials in spray or spatter
■ Should be removed when leaving treatment areas
Masks and Face Shield
■ Wear a surgical mask and either eye protection with solid
side shields or a face shield to protect mucous membranes
of the eyes, nose, and mouth.
■ Change masks between patients.
■ Use clean, reusable face protection between patients; if
visibly soiled, clean and disinfect.

79
INFECT
CONTROL
Clothing
■ Wear gowns, lab coats, and uniforms that cover skin and
personal clothing likely to become soiled with blood, saliva,
or infectious material.
■ Change if visibly soiled.
■ Remove all barriers before leaving the work area.
Gloves
■ Minimize the risk of HCP acquiring infections from patients.
■ Prevent microbial flora from being transmitted from HCP to
patients.
■ Reduce contamination of the hands of HCP by microbial
flora that can be transmitted from one patient to another.
■ Are not a substitute for hand washing.
Sterile Glove Donning Technique
Peel open the outer pack from the corners. The inner pack is
sterile.
■ Pick up the cuff of the right glove with your left hand. Slide
your right hand into the glove until you have a snug fit over
the thumb joint and knuckles. Your bare left hand should
only touch the folded cuff; the rest of the glove remains
sterile.

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CONTROL
80

81
INFECT
CONTROL
■ Slide your right fingertips into the folded cuff of the left
glove. Pull out the glove and fit your left hand into it.
■ Unfold the cuffs down over your gown sleeves. Make sure
your gloved fingertips do not touch your bare forearms or
wrists.

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CONTROL
82
All photos in the gloving sequence are reprinted with
permission from: Johansson, C., & Chinworth, S. A. (2012).
Mobility in Context: Principles of Patient Care Skills, ed 1.
Philadelphia: F.A. Davis Company; pp. 102–103, Fig. 4-12.
Environmental Surfaces
■ May become contaminated
■ Do not require as stringent decontamination procedures
Categories
■ Clinical contact surfaces
■ High potential for direct contamination from spray or
splatter or by contact with DHCP’s gloved hand
■ Housekeeping surfaces
■ Do not come into contact with patients or devices
■ Limited risk of disease transmission
Recommendations
■ Use barrier precautions (e.g., heavy-duty utility gloves,
masks, protective eyewear) when cleaning and disinfecting
environmental surfaces.

83
INFECT
CONTROL
■ Physical removal of microorganisms by cleaning is as
important as the disinfection process.
■ Follow manufacturer’s instructions for proper use of
Environmental Protection Agency (EPA)–registered hospital
disinfectants.
■ Do not use sterilants or high-level disinfectants on
environmental surfaces.
Clinical Contact Surfaces
■ Risk of transmitting infections is greater than for
housekeeping surfaces.
■ Surface barriers can be used and changed between patients.
OR
■ Clean and then disinfect using an EPA-registered low-
(HIV/HBV claim) to intermediate-level (tuberculocidal claim)
hospital disinfectant.
Water Lines
Problem: Contamination of Water Supply
■ Microbial biofilms form in small-bore tubing of dental units.
■ Biofilms serve as a microbial reservoir.
■ Primary source of microorganisms is municipal water
supply.
Solutions to the Problem
■ Independent reservoir.
■ Chemical treatment.
■ Filtration.
■ Combinations.
■ Sterile water delivery systems.
■ Use sterile saline or sterile water as a coolant or irrigator
when performing surgical procedures.
■ Use devices designed for the delivery of sterile irrigating
fluids.
■ Clean and heat sterilize intraoral devices that can be
removed from air and waterlines.
■ Follow manufacturer’s instructions for cleaning, lubrication,
and sterilization.
■ Do not use liquid germicides or ethylene oxide.
■ Use barriers and change between uses.

INFECT
CONTROL
84
■ Clean and disinfect at an intermediate level the surface of
devices if visibly contaminated.
■ Do not advise patients to close their lips tightly around the
tip of the saliva ejector.
Medical Waste Management
■ Properly label containment to prevent injuries and leakage.
■ Medical wastes are “treated” in accordance with state and
local EPA regulations.
■ Processes for regulated waste include autoclaving and
incineration.
Program Evaluation
■ Develop standard operating procedures.
■ Evaluate infection control practices.
■ Document adverse outcomes.
■ Document work-related illnesses.
■ Monitor health care–associated infections.

RADIOL
85
Introduction to Radiology
Dental radiology is one of the most important factors contribut-
ing to quality and reliable diagnosis and treatment of patients.
Dental assistants must understand the concepts behind the
physics of radiology and must be competent in exposing accu-
rate, diagnostic, and quality radiographs and images.
Brief History
In 1895, Wilhelm C. Roentgen discovered x-rays by accident
while he was experimenting with the production of cathode rays.
Many other scientists continued to research these new rays, and
in 1896, Edmund Kells, a dentist, recorded the first practical
use of x-rays in dentistry. Throughout the years, several devel-
opments and improvements have been implemented in dental
radiology, such as the panoramic concept, high-speed films
(F-speed), digital radiography, and 3-D cone imaging.
Uses of Dental Radiology
■ Diagnostic: Identify disease in the teeth and the surrounding
hard tissue.
■ Qualitative: Evaluate quality and clinical functionality of
placed restorations.
■ Legal: Document and record conditions at a specific time
frame.
■ Forensic: Help identify deceased individuals.
Types of Dental Radiology
■ Intraoral: Procedures in which the film or digital devices that
record images are placed inside the patient’s mouth.
Examples of intraoral x-rays are periapical (PA) x-rays and
bitewing (BW) x-rays.

RADIOL
86
■ Extraoral: Procedures in which the ﬁlm or digital devices
that record images are located outside the patient’s mouth.
Examples of extraoral x-rays are panoramic, cephalometric,
and lateral skull.

RADIOL
87
Dental Radiology Equipment
Intraoral X-Ray Unit
Components
■ Control panel: Contains all setting adjustments buttons,
master switch, indicator light, and exposure button. It can be
located in the x-ray area only if a remote exposure button is
available to limit the operator’s exposure to radiation or
outside the x-ray area.
■ Exposure button: Controls the ﬂow of electricity to
generate x-rays.
■ Kilovoltage selector (kVp): Controls the penetrating power
of the x-ray beam. Normal kVp range is between 70 and
90 kVp.
■ Milliamperage selector (mA): Controls the number of
electrons produced. Higher mA increases the number of
electrons.
■ Extension arm: Positions the tubehead during x-ray
procedures and contains wiring that connects the tubehead
and the control panel. It is easily adjustable and folds for
efﬁcient storage.

RADIOL
88
Reprinted with permission from: Henry, R., & Perno, M. G.
■ Tubehead: Metal housing of the x-ray tube. It also contains
transformers, oil that prevents overheating for the
production of x-rays, and aluminum or lead glass.
■ Important components in the tubehead are the collimator,
aluminum disc (which restricts the size of the x-ray beam
before exiting the tubehead), and aluminum ﬁlters (which
ﬁlter out low-wavelength x-rays).

RADIOL
89
Reprinted with permission from: Henry, R., & Perno, M. G.
■ X-ray tube: Located inside the tubehead and is the device
where the x-rays are produced. It contains the following:
■ Anode: A positive electrode composed of the tungsten
target embedded in a copper housing. The tungsten target
acts as a focal spot and transforms the electron waves
into x-rays.
■ Cathode: A negative electrode made of a tungsten
ﬁlament embedded in molybdenum housing. The tungsten
ﬁlament is where electrons are produced.
The x-ray tube is in a vacuum state (no air is present).

RADIOL
90
Extraoral X-Ray Unit
Panoramic machines have similar components and produce
x-rays under the same principles as the intraoral units.
X-Ray Processor
■ Manual: Rarely used today because of extended period of
time to develop and process radiographs.
■ Automatic: Faster and more efﬁcient with controlled
temperature and time.
Automatic processors house a roller transport system that
carries radiographs through the developer and ﬁxer solutions
and through a rinse and air dry cycle.

RADIOL
91
Processing Solutions
■ Developing solution: Reacts with exposed silver halide
crystals forming black metallic silver and softens emulsion
of the film.
■ Fixer solution: Removes all unexposed silver halide crystals
and hardens emulsion.
Both of these solutions are available in powder, liquid concen-
trate, and ready-to-use liquid forms.
Duplicating
Duplication of radiographs must occur in a dark room.
Procedure for duplication:
■ Open duplicating machine.
■ Place duplicating film on the glass top of the machine with
the emulsion facing up.
■ Place films to be duplicated on the top and close the lid.
■ Turn on exposing light of the duplicating machine for the
manufacturer’s recommended time.
■ Remove duplicating film and process as normal.

RADIOL
92
Dental Radiology Film Types
Dental radiology film is made of a semiflexible acetate film base
that is coated with an emulsion of silver halide, silver bromide,
and silver iodide crystals.
Intraoral Film
Speed
■ D speed
■ E speed
■ F speed (the fastest film available, which means it requires
less amount of radiation)

RADIOL
93
Size
■ #0, smallest ﬁlm used in pediatric patients
■ #1, used in pediatric patients and often for lower anterior
PAs
■ #2, most commonly used for adult BW and PA x-rays
■ #4, used in occlusal exposures
Extraoral Film
■ Is placed outside the mouth.
■ Requires a cassette to protect it.
■ Requires intensifying screens.
■ Green sensitive (rare earth–intensifying screens).
■ Blue sensitive (calcium tungstate–intensifying screens).
Duplicating Film
■ Sensitive to light.
■ Emulsion only in one side.
■ Side with emulsion appears dull.
■ Available in all sizes, including 8-in x 10-in sheets.
Characteristics of Radiographic Beam
Contrast
■ Radiographic images appear in a range of shades from black
to white with several shades of gray in between.
■ Higher kVp produces lower contrast.

RADIOL
94
Density
■ Density is the overall darkness or blackness of the ﬁlm.
■ Density is controlled by mAs (milliampere seconds).
Factors Inﬂuencing Contrast and Density
Factor Effect
Milliamperage (mA)
Decreased Decreased density
Increased Increased density
Kilovoltage (kVp)
Increased Increased density, low contrast
Decreased Decreased density, high contrast
Time (sec)
Decreased Decreased density
Increased Increased density
Radiation Effects
X-rays are a type of ionizing radiation that is harmful and causes
biologic changes in living tissue.
Exposure to radiation has a cumulative effect, meaning that
tissue undergoes damage and changes over a period of time.
Acute Radiation Exposure
Acute radiation exposure occurs when large amounts of radia-
tion are absorbed by tissue over a short period of time (i.e.,
exposure to nuclear fallout).

RADIOL
95
Chronic Radiation Exposure
Chronic radiation exposure occurs when small amounts of radia-
tion are absorbed by tissue over an extended period of time.
During chronic exposure, symptoms of damage may not be
noticeable until years after the original exposure.
Critical Organs
Organs that are more susceptible to radiation exposure during
dental procedures are:
■ Skin
■ Thyroid gland
■ Bone marrow
■ Lens of the eye
Maximum Permissible Dose
According to the National Council on Radiation Protection and
Measurements (NCRP), the maximum permissible dose (MPD) is
the highest amount of radiation that the human body can receive
without enduring any injury.
■ MPD for occupational exposure: 5.0 rem/year.
■ MPD for non-occupational exposure: 0.1 rem/year.
Patient Protection
■ Lead apron and thyroid collar.
■ High-speed ﬁlm or use of digital systems.
■ Proper technique that minimizes the number of retakes.
■ Exposure factors such as kVp and mA to minimum levels,
allowing diagnostic quality radiographs.
■ Use of aiming devices to avoid patient holding the ﬁlm or
digital sensors.

RADIOL
96
Operator Protection
■ Monitoring: use of monitoring devices such as badges.
■ Proper equipment operation.
■ Knowledge of safety regulation.
■ ADA and FDA guidelines state that pregnant operators must
use a lead apron during exposure of dental radiographs. The
embryo or fetus will not receive detectable amounts of
radiation if a lead apron is used.
ALERT: Keep radiation exposure to as low as reasonably
achievable.
Errors Due to Temperature, Solutions,
Contamination, and Film Handling
■ Underdeveloped film: Appears light; indicates not enough
developing time.
■ Overdeveloped film: Appears dark; indicates excessive
developing time.
■ Fixer spots: White spots; indicate fixer came into contact
with film prior to developing.
■ Developer spots: Dark spots; indicate developer came into
contact with film prior to developing.
■ Brown or yellow stains: Indicate inadequate chemicals.
■ Fingerprint: Indicates film touched by fingers.
■ Overlapping: Indicates films are in contact during
processing.
■ Developer/fixer cutoff: Indicates inadequate chemical levels.
■ Light lean in the dark room: Film appears black.
■ Fogged film: Indicates inappropriate safe light.

RADIOL
97
Most Common Types of Dental
Radiographs
Intraoral
Periapical (PA)
A PA radiograph captures the entire tooth and its surrounding
structures. It is used primarily to identify periapical pathology.
Exposure techniques include the paralleling (aiming devices) and
bisecting the angle techniques. PA radiographs are taken in both
the anterior and posterior teeth.
Bitewing (BW)
A BW radiograph captures the posterior upper and lower teeth,
mainly the crown portion. There are two types of BW radio-
graphs. Premolar BWs include the first and second premolars
and mesially extend up to and distal to the canines. Molar BWs
include the first and second molars. Exposure techniques include
BW tabs or the use of aiming devices.
Intraoral Series
A full-mouth survey (FMX) is a series of usually 18 films: 14 PA
and 4 BW x-rays. An FMX survey is necessary to perform a
comprehensive dental examination.

RADIOL
98
Exposing Techniques
Paralleling Technique
■ Place the film/sensor parallel to the long axis of the tooth of
interest.
■ Direct the central x-ray beam perpendicular to the long axis
of the tooth and the film.
■ Direct the central x-ray beam through the contact areas
between the teeth.
■ Use film size #1 or #2.
Film
X-rays
Tube
The use of XCP (extension cone paralleling) devices is recom-
mended for the paralleling technique for more accurate and
operator-free errors.

RADIOL
99
Bisecting Technique
■ Bisecting technique is not an ideal technique but is useful in
special situations, such as in children and patients with
shallow, narrow mouths or flat palates.
■ Place the film against the tooth of interest.
■ Aim the central beam perpendicular to the imaginary
bisector of the angle formed between the long axis of the
tooth and the film.
■ Use film size #1 or #2.
Plastic bite blocks, aiming rings, and Eezee-Grip (Rinn) holders
can be used with the bisecting techniques.
Film
X-rays
Tube
Imaginary
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