DOH Dental Hygienist oral exam prep

Knowledge: Under the 2017 classification, bone loss into the middle third, probing depths of 6 mm or more, Class II furcations and tooth loss of up to four teeth to periodontitis put him in Stage III. Grade uses the ratio of percentage bone loss to age: 55 divided by 46 is above 1.0, which is Grade C. Smoking at least 10 cigarettes a day and an HbA1c of 7 percent or more are also Grade C modifiers. Diabetes and periodontitis affect each other. The EFP S3 guideline sets out four steps: risk factor control and plaque control, subgingival instrumentation, treatment of residual pockets, then supportive care.

Management: I would record a full chart and share my staging with the dentist, who confirms the diagnosis and plan. Step 1 is tailored oral hygiene instruction with interdental brushes, supragingival plaque and calculus removal, and brief smoking cessation advice. With consent I would inform his physician. Step 2 is subgingival instrumentation with hand and ultrasonic instruments, with local anaesthesia as the dentist and facility scope allow. The guideline does not support routine systemic antibiotics, and prescribing them is not my role. I would re-evaluate after a healing period of several weeks; residual pockets of 6 mm or more, or 5 mm with bleeding, go back to the dentist or periodontist for step 3. He then needs supportive care at short intervals set by his risk.

Ethics and communication: I would explain his diagnosis and its links with smoking and diabetes without blame, and gain consent for each stage. I work to the dentist's prescription and report findings back rather than change the plan myself. For a fasting patient with diabetes, I would time appointments to avoid hypoglycaemia. I would document charts, advice and consent.

Reference: Tonetti, Greenwell and Kornman, Staging and grading of periodontitis: framework and proposal of a new classification (J Periodontol 2018); EFP S3 level clinical practice guideline: treatment of stage I to III periodontitis (Sanz et al, J Clin Periodontol 2020)

Knowledge: This is anaphylaxis: sudden airway, breathing and circulation problems with skin changes after exposure to a likely trigger. Chlorhexidine is a recognised cause in dental and surgical settings. The first-line treatment is intramuscular adrenaline, 500 micrograms (0.5 mL of 1 mg/mL) for an adult, into the anterolateral thigh, repeated after 5 minutes if there is no improvement. Antihistamines and steroids are not first-line and must not delay adrenaline. If she is hypotensive she should lie flat with legs raised, or sit up if breathing is the main difficulty. Reactions can recur, so she needs hospital observation even if she improves.

Management: I would stop treatment, remove the exposure and call loudly for the dentist and the emergency kit. I would ask a colleague to call an ambulance and give a clear message about anaphylaxis. Adrenaline 500 micrograms IM goes into the outer thigh at once, by the dentist or by me if I am trained and the practice protocol allows. I would give high-flow oxygen, position her as her breathing and blood pressure allow, and monitor pulse, breathing and saturation. If there is no improvement after 5 minutes, adrenaline is repeated. If she becomes unresponsive and stops breathing normally, we start CPR and use the defibrillator. I would record the times of each drug and observation and hand over to the ambulance crew. Afterwards, the dentist documents a chlorhexidine allergy prominently, refers her to an allergy clinic and reports the event.

Ethics and communication: In an emergency we treat in her best interests without waiting for formal consent, which UAE law allows when a patient cannot decide. Afterwards she deserves an honest explanation that chlorhexidine was the probable cause. I would report the incident and check that the emergency kit and team training are up to date.

Reference: Resuscitation Council UK, Emergency treatment of anaphylaxis: guidelines for healthcare providers (2021); World Allergy Organization Anaphylaxis Guidance (2020)

Knowledge: A blood-filled hollow needle is the highest-risk sharps injury. My documented hepatitis B response means hepatitis B risk is negligible. Treated hepatitis C may be cured, but his current status is unknown, and there is no post-exposure prophylaxis for hepatitis C, so the plan is follow-up testing and early treatment if infection occurs; CDC advises HCV RNA testing at 3 to 6 weeks and antibody testing at 4 to 6 months. HIV post-exposure prophylaxis works best when started within hours and is not recommended after 72 hours, so the source patient's HIV status matters urgently. Uncapped needles left on trays are a recognised system cause of injury.

Management: Immediately I would let the wound bleed freely, wash it with soap and running water without scrubbing or sucking, and cover it. I would tell the dentist and report to occupational health or the emergency department straight away, not at the end of the session. The dentist or designated clinician would ask the patient for consent to test for HIV, hepatitis B and hepatitis C RNA. I would give baseline blood samples. A physician decides on HIV prophylaxis based on the source result and risk, ideally within hours. I would attend follow-up testing as advised. I would complete an incident report. The review should look at safety syringes, single-handed resheathing and the rule that the operator disposes of their own sharps.

Ethics and communication: The source patient's tests need his informed consent, and his results and mine stay confidential. If a new notifiable infection is found, reporting under Federal Law No. 14 of 2014 on the Prevention of Communicable Diseases is handled by the treating physician. He should continue to receive care with standard precautions and no stigma. I would report the system failure without blaming the dentist.

Reference: Kuhar et al, Updated US Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis (Infect Control Hosp Epidemiol 2013); Moorman et al, Testing and clinical management of health care personnel potentially exposed to hepatitis C virus (MMWR Recomm Rep 2020); Federal Law No. 14 of 2014 on the Prevention of Communicable Diseases (UAE)

Knowledge: A non-healing ulcer present for more than 3 weeks, with induration, rolled edges, a site on the lateral tongue and a firm neck node, is suspicious for oral squamous cell carcinoma. Areca nut and smokeless tobacco are both classified by IARC as carcinogenic to humans, and the white patch may be a potentially malignant disorder such as leukoplakia. A traumatic ulcer from a sharp tooth is a differential, but it should heal within 2 to 3 weeks once the cause is removed and would not explain the node. NICE NG12 advises urgent referral for an unexplained oral ulcer lasting more than 3 weeks or a persistent unexplained neck lump. Diagnosis needs biopsy by a specialist.

Management: I would pause routine treatment near the lesion and ask the supervising dentist to examine him the same day. I would record the site, size and features, chart the node, and take clinical photographs with consent. The dentist makes an urgent referral to oral and maxillofacial surgery or head and neck services for biopsy. I would explain to him, without stating a diagnosis, that the sore needs specialist tests before he travels. If he still travels, he needs a copy of the referral and clear advice to be seen promptly where he is going. The practice should follow up to confirm he attended. I would offer advice and support to stop chewing betel quid and tobacco.

Ethics and communication: I must be honest that the lesion is worrying without frightening him with a diagnosis I cannot make. He has the right to decide about travel, but I would document the advice and his decision. Betel quid use is common in some communities in the UAE, so I would advise without judgement and offer an interpreter if needed.

Reference: NICE NG12 Suspected cancer: recognition and referral (2015, with later updates); Warnakulasuriya et al, Oral potentially malignant disorders: a consensus report from an international seminar (Oral Dis 2021); IARC Monographs Volume 85: Betel-quid and areca-nut chewing (2004)

Knowledge: As a dental hygienist I work under a dentist's prescription and supervision; diagnosis and the treatment plan belong to the dentist, who should examine new patients first and review their medical history. BPE codes 1 and 2 indicate bleeding and calculus without pockets, which need oral hygiene instruction and supragingival scaling, not subgingival root surface debridement, which is for deeper pockets. Billing for treatment not done is fraud: it harms the insurer, creates a false clinical record and can affect the patient's future cover. Clinical records are legal documents and must reflect what was done. Practising beyond scope exposes the patient to risk.

Management: I would politely tell the manager that I can treat new patients only after the dentist's examination and a written prescription. For today's patient, I would ask the dentist for a brief examination or rebook her once that is done. I would record and code only the treatment I actually provide. I would put my concerns in writing to the clinical director and suggest practical solutions, such as dentist screening slots before hygiene visits. If the pressure continued, I would use the facility compliance route and, if needed, report to the regulator. I would keep a factual note of the requests and my responses. I would not treat outside the prescription or sign a false claim, whatever the pressure.

Ethics and communication: Patients trust that their treatment is needed and their records are true. Practising without a prescription and false billing both breach professional standards, and medical liability under Federal Decree-Law No. 4 of 2016 rests on accurate records and acting within one's licence. Consent is not valid if the patient is told she needs treatment she does not. I can refuse respectfully and still support the clinic's real problem with access.

Reference: British Society of Periodontology, The Basic Periodontal Examination (BPE) (2019); Federal Decree-Law No. 4 of 2016 on Medical Liability (UAE)

Knowledge: The 2017 classification defines peri-implantitis as bleeding or suppuration on probing with increased probing depth compared with earlier records and progressive bone loss beyond initial remodelling; she meets all three. Peri-implant mucositis has inflammation without bone loss. Risk factors include a history of periodontitis, poor plaque control, lack of maintenance and smoking, and excess cement or a crown that cannot be cleaned can contribute. The EFP S3 guideline recommends non-surgical treatment first, re-evaluation, and surgery if the disease does not resolve, and it does not support routine adjunctive systemic antibiotics. Instruments should not damage the implant surface: plastic, carbon-fibre or titanium curettes, ultrasonic tips designed for implants, and glycine or erythritol air polishing are suitable.

Management: I would tell the dentist that my findings meet the criteria for peri-implantitis and ask for diagnosis and a treatment plan. Under that prescription I would carry out non-surgical debridement with implant-safe instruments and air polishing. I would give oral hygiene instruction using interdental brushes and a single-tufted brush around the implant. The dentist should check the radiograph for excess cement and assess whether the crown allows cleaning. I would chart the remaining teeth for periodontitis. I would re-evaluate with the dentist after healing; persistent bleeding, suppuration or deep pockets mean referral for surgical treatment. She then needs short maintenance intervals. I would not use stainless steel scalers on the implant surface or reassure her that this is gum irritation.

Ethics and communication: I would explain honestly that maintenance visits matter for implants without blaming her for missing them. If the implant was placed elsewhere, I would ask her consent to request earlier records and radiographs. She should understand the costs and options before further treatment, and I would document the baseline and today's findings carefully.

Reference: Berglundh et al, Peri-implant diseases and conditions: consensus report of workgroup 4 of the 2017 World Workshop (J Clin Periodontol 2018); EFP S3 level clinical practice guideline: prevention and treatment of peri-implant diseases (Herrera et al, J Clin Periodontol 2023)