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Guidance and Training manual to accompany the Full Standard Clinical Survey Form

European Non Carious Cervical Lesions – Dentine

Hypersensitivity Development Programme

November 2010

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Dental Practitioner Guidance

Introduction

The ESCARCEL Full Standard Clinical Survey Assessment has been designed for use in the dental

surgery environment. There are four main sections to the form:

1. Identification and General Information;

2. Periodontal Health and Disease Severity Assessments;

3. Non Carious Cervical Lesions Assessment

4. Dentine Hypersensitivity Assessment;

Within each section there may be more than one related question. It is recommended that the

examination follows the order of questions on the form.

It should be noted that all questions are applicable to all participants. A symbol next to each question

will provide a reminder when a section of the clinical assessment applies to restricted age groups.

Figure 1: Symbols indicating applicable participant age groups: Adults 18-35 years old

It is important that all appropriate parts of the clinical assessment are completed accurately. The dental

practitioner and the chosen scribe should co-operate to ensure this is done.

Section 1: Identification and General Information Before you begin the clinical assessment make sure the Identification and general information section

of the ESCARCEL. Full Standard Clinical Survey Assessment has been properly completed. Make sure

you leave no data entry area blank.

For the purpose of this pilot study, the participating countries have been allocated codes which should

be entered into box 1. Then, enter the date when the examination is carried out (box 2), the patient’s 3-

digit identity number (box3) and the examiners’ 2-digit identity number (box 4).

Boxes 5 and 6 are used for the participant’s age and sex respectively. For adult patients, box 7 should be used to indicate their highest grade of education according to the

key.

Please indicate the current or recent employment status (box 8). Examiners should use their judgement

when asking potentially embarrassing questions.

Adults only 18-35 years old

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Pre-Clinical Assessment Protocol

For the ESCARCEL Full Standard Clinical Survey Assessment you will need a dental light and the

following equipment:

Dental mirror

Dental probe – PDT Sensor CPI probe Type U.S. (Williams) 2.3.4.5.7.9

Three in-one air syringe, cotton wool rolls

Section 2: Periodontal Health and Disease Severity Assessment

Quick View Summary

o Participants aged 18 to 34 years only

o Full mouth charting

Introduction

The Periodontal Health Assessment and Periodontal Disease severity assessment can be found on

“Periodontal condition” section of the form. This section is made up of 3 indicators: Probing

depth, where you will be asked to record the Periodontal Pocket index; Indicator “Gingival

Bleeding” and “Loss of Attachment”, which deals with measuring the loss of attachment around

the mouth. It should be noted that these questions are applicable to all participants. The most

reliable way of measuring loss of attachment is immediately after recording bleeding and the

depth score for that tooth. Therefore you should record three measures in a teeth before moving

on to the next, remembering that third molar teeth are not counted.

Pre-Periodontal Assessments Protocol

Check Health Status

Before you begin, assess the participant’s health status. Note special precautions should be taken

for those participants with:

o Bleeding disorders (e.g. those taking anticoagulant medications and haemophiliacs)

o Antibiotic cover requirements e.g. those who have had infective endocarditis, with valve

replacements and those with indwelling conduits (British Society for Antimicrobial

Chemotherapy guidelines, 2006)

Equipment Periodontal probes are used for this examination which have circumferential

markings to help assess pocket depth and loss of attachment.

The sequence to collect the indexes is: Gingival Bleeding Index, Periodontal Pocket Index,

Loss of Attachment Index.

Measuring Gingival Bleeding

During the probing depth assessment, the bleeding on probing index (Yes/No) is sufficient to

highlight the bleeding condition. Score are: 0: No; 1: Yes; 9: Cannot be determined; X: Excluded.

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Bleeding observed, directly or by using a mouth mirror, after probing. The sensing force used

should be no more than 20 grams

Using the Periodontal Probing Depth Index

The following indicators of periodontal status are used for this assessment:

(0) Health gingival; 1 = Pocket 2 -3] mm; 2 = Pocket 3-4] mm; 3 = Pocket 4 or 5mm, 4 = Pocket

5-7] mm; 5 = Pocket 7-9] mm; 6= Pocket 9mm and more and 9 = Cannot be determined; X =

Excluded teeth

A specially designed lightweight probe with 0.5mm ball tip is used, The PDT Sensor CPI probe

Type U.S. (Williams) 2.3.4.5.7.9 is recommended.

Figure 1: Showing an example of a PDT Sensor CPI probe Type U.S. (Williams) 2.3.4.5.7.9. This probe

should be used for measurement of the extent of attachment loss.

Sensing gingival pockets Sensing gingival pockets: An index tooth should be probed, using the probe as a ‘sensing’

instrument to:

Determine pocket depth

The sensing force used should be no more than 20 grams. A practical test for establishing this

force is to place the probe point under the thumb nail and press until blanching occurs. When the

probe is inserted, the tip should follow the anatomical configuration of the surface of the tooth

root. If the patient feels pain during probing, this is indicative of the use of too much force. The

probe tip should be inserted gently into the gingival sulcus or pocket and the total extent of the

sulcus or pocket explored. For example, the probe is placed in the pocket at the disto-buccal

surface of the second molar, as close as possible to the contact point with the third molar, keeping

the probe parallel to the long axis of the tooth. The probe is then swept gently along the bottom of

the pocket, with short upward and downward movements, along the gingival sulcus or pocket to

the mesial surface of the second molar, and from the disto-buccal surface of the first molar

towards the contact area with the premolar. A similar procedure is carried out for the lingual

surfaces, starting disto-lingually/palatally to the second molar. The pocket depth is measured from

the base of the pocket to the tip of the gingival crest.

Examination and recording

The index teeth should be probed and the highest score recorded in the Probing Depth box on the

clinical form. The depth codes are:

0 = Healthy (1 black band on the probe visible)

1 = Pocket 2 -3] mm (1 black band on the probe not visible)

2 = Pocket 3-4] mm (1with and 1 black bands on the probe not visible gingival)

3 = Pocket 4 or 5] mm (1with and 2 black bands on the probe not visible gingival)

4 = Pocket 5-7] mm (2 with and 2 black bands on the probe not visible)

5 = Pocket 7-9] mm (3 with and 1 black bands on the probe not visible)

6= Pocket 9mm and more

9 = Cannot be determined

X = Excluded tooth

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Code 9 is placed in the appropriate box when it is not possible to make a reliable recording (e.g.

large accumulations of calculus prohibiting proper probing of pockets).

Examples of Coding according to Periodontal Depth Index criteria

PDI Code 0: Healthy, no bleeding observed, but all of the lower dark band of the probe is visible,

no pocket 4 or 5mm, no pocket 6mm or more

PDI Code 1: Bleeding observed, but all of the lower (2mm to 3mm) white band of the probe is

visible, no pocket 4 or 5 mm, no pocket 6mm or more

PDI Code 3: Pocket 4 or 5mm (in photo pocket extends to top of second dark band at 4mm), no

pocket 6mm or more

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PDI Code 4: Pocket 5-7 mm

Measuring Attachment Loss Loss of attachment will be recorded on the appropriate index tooth in addition to the PDI score, in

order to obtain an estimate of the life-time accumulated destruction of the periodontal attachment.

Probing pockets depths give some indication of attachment loss. However, this measurement

becomes inadequate when recession of the gingiva becomes apparent (the CEJ becomes visible).

When shallow pocketing of 4-5mm (PDI score 3) is recorded at the highest score for a tooth and

no recession is visible, the estimated maximum attachment loss for that sextant is, apart from

exceptional cases, no more than 3mm and no separate record of attachment loss is made. When

deep pockets (6mm or more, equal to PDI score 4 or more) are recorded or when recession of the

gingiva is apparent (the CEJ is visible); the examiner will access and record the maximum

attachment loss at the index teeth in the same sextant with the same probe.

Definition of important terms

Clinical attachment level is the point (point C on the diagram) at which the gingival attaches to a

root surface.

Loss of attachment (point B – point C on the diagram) is measured by clinical probing.

Lifetime cumulative attachment loss is the measurement (in mm) from the cemento-enamel

junction (point B) to the clinical attachment level at a given point in time.

Pocket depth and loss of attachment (Glavind & Löe 1967)

Cemento-Enamel Junction (point B) is the anatomical point where the root and crown of a tooth

meet. For convenience (and reproducibility), it is used as a fixed point from which to measure

attachment loss. However, even at healthy sites the attaching fibres are rarely found at this point.

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Hence the threshold for attachment loss is usually set at 1 or 2 mm as measurements of less than

these figures do not represent true clinical attachment loss.

Measurement of loss of attachment health

Periodontal examination employs a sterile, disposable US Williams PDT Sensor probe, at a

pressure of 20 g. Clinical attachment level is defined as the distance from the cement-enamel

junction to the tip of the probe. Attachment loss is measured (to the nearest mm) by simple

probing by identifying the cemento–enamel junction and measuring the distance to the base of the

pocket. Probing depth is defined as the distance from the soft tissues margin to the tip of the

probe. All teeth are examined excepted third molars which are excluded from analysis.

Variables are assessed for two sites per tooth: median-vestibular (mid-buccal); median-

lingual/palatine.

Periodontal indices are recorded in the following order: probing depth; and probing attachment

loss. The recording sequence is as follows: first, median-vestibular 17 for the LA indices; second,

median-palatine 17. The recording sequence for the four quadrants is quadrant 1, quadrant 2,

quadrant 3, and then quadrant 4.

Examination and recording

The index teeth should be probed and the highest score recorded in the Loss of Attachment box

on the clinical form. The depth codes are:

0 = Healthy 0 mm

1 = Slight 1-2] mm

2 = Moderate 3-4] mm

3 = Severe 5 mm or more

9 = Cannot be determined

X = Excluded tooth

Examples of Coding according to loss of attachment

LA Code 0: Health: Periodontal attachment loss 0 mm

LA Code 0: Health: Periodontalchment loss 0 mm

LA Code 1: Slight: Periodontal attachment loss 1 or 2 mm

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LA Code 2: Moderate: Periodontal attachment loss 3 or 4 mm

LA Code 3: Severe: Periodontal attachment 5mm or more

Photographs: Denis Bourgeois

Section 3: Non Carious Cervical Lesions

The Basic Erosive Wear Examination (BEWE) has been designed to provide a simple scoring

system that can be used with the diagnostic criteria of all existing criteria of all existing indices

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aiming to transfer their results into one unit which is the BEWE score sum. This Index has been

adapted to measure in this study every tooth and cover the buccal and lingual surfaces only in

order to comply with the primary objective of the study aiming to evaluate the prevalence of

NCCl in 18 to 35 years old (inclusive) of European subjects.

Non Carious Cervical Lesions Assessment Protocol

Remove any removable denture

Ask the participant to remove any removable oral prosthesis prior to completing the dental

assessment.

Clean and dry the teeth Prior to the NCCL assessment make sure the participant’s natural teeth are clean. You

should aim, at the very least; to clean the participant’s teeth with a dry toothbrush to remove

plaque and flossing may be required in some cases. It may still be necessary during the

examination to further remove plaque deposits in order to visualise all tooth surfaces clearly.

Using the BEWE Codes

To use the BEWE codes correctly, the participant’s teeth must be clean and dry prior to

assessment. Each tooth surface should be visually assessed and allocated an appropriate 2 digit

BEWE code. This is constructed from the individual numerical codes see Table 1. The four level

score grades appearance or severity of wear on the teeth from no surface loss (0), initial loss of

enamel surface texture (1), distinct defect, hard tissue loss (dentine) less than 50% of the surface

area(2) or hard tissue loss more than 50% of the surface area.

Buccal/facial and lingual/palatal surfaces are examined with the highest score recorded.

Table 1: BEWE Codes

BEWE Codes [Lussi, 2008]

Localisation Codes

0 = No erosive wear 0 = Anatomic crown and over cervical localization

1 = Initial loss of surface texture 1 = Anatomic crown in cervical localization

2 = Distinct defect, hard tissue loss minor than 50% of the surface area 2 = Anatomic root in cervical localization

3 = Hard tissue loss more or equal than 50% of the surface area 3 = Anatomic crown and root cervical localization

9= No recorded (tarter, suppuration) Missing Teeth = X

you could have as result to note 0 or 10, 11, 12 or 20, 21, 22 or 30, 31, 32 depend the loss of surface (clinical crown) and the localization and 9 (no recorded).

For each tooth, the index grades 2 individual surfaces

o Buccal- assessment includes the cervical buccal portion

o Buccal cervical = cervical 1/3rd of tooth

Figure 2: Example of BEWE code allocation

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BEWE Codes [Lussi, 2008] Localisation Codes 0 = over cervical

0 = No erosive wear 1 = anatomic crown cervical 1 = Initial loss of surface texture 2 = anatomic root cervical 2 = Distinct defect, hard tissue loss minor than 50% of the surface area 3 = Hard tissue loss more or equal than 50% of the surface area 3 = Anatomic crown and root cervical localization 9= No recorded (tarter, suppuration) :

you could have as result to note 0 or 10, 11, 12 or 20, 21, 22 or 30, 31, 32 depend the loss of surface (clinical crown) and the localization and 9 (no recorded).

In cases where a tooth or teeth are missing you should use the ‘Missing Teeth’ two digit BEWE

codes instead. There are three missing teeth codes: 97 (for a tooth extracted due to caries), 98 (for

a tooth missing for another reason other than caries) and 99 for a tooth still to erupt, and code P

where a tooth is missing but has been replaced by a fixed prosthesis such as a bridge pontic or

implant.

There are two charts in the dental disease assessment section of this form. The first chart is for

upper teeth while the second chart is for lower teeth. Each chart is made up of individual tooth

surfaces (Buccal and Lingual/Palatal) corresponding to each tooth in the arch.

For example, a sound tooth would be coded 00 in the bottom box. A two-digit code should be

used to indicate each tooth surface’s condition. Sound surfaces may be left blank but care must be

taken to ensure that codes are recorded in the correct space of the chart.

Figure 3: Example of Completed Upper Arch Chart

Upper Left 17 16 15 14 13 12 11 21 22 23 24 25 26 27

B 0 23 11

P 11 13 STAGE ONE: Coding Restorations

There are 4 erosion codes (0-3) that you can select from when coding the presence or absence

of a NCCL on individual tooth surfaces. For each surface you should select one of the four

codes as appropriate and record it as the first digit of the two digit BEWE code.

BEWE Code: 22

First digit = Erosion code

Second digit = Location code

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Figure 4: Coding Restorations

BEWE Codes (Lussi, 2008)

0= No erosive wear

1=Initial loss of surface texture

2= Distinct defect, hard tissue loss than 50% of the surface area

3= Hard tissue loss more or equal than 50% of the surface area

If an initial loss of surface texture is present you should use code 1 as the first digit.

CODE 2: NCCL

If a distinct defect, hard tissue loss minor

than 50% of the surface area is present

you should use 2 as the first digit

Select from five

restoration codes

and record as first

digit of BEWE

code

CODE 1: NCCL

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Photographs: A. Lussi (2);

STAGE TWO: Coding Location

There are three location codes (0, 1, 2) that you can select from when coding the presence or

absence of NCL on individual tooth surfaces. For each surface you should select one of the

three codes as appropriate and record it as the second digit of the two digit BEWE code.

Figure 5: Coding location

Location Codes)

0= Anatomic crown and over cervical localization

1=Anatomic crown in cervical localization

2= Anatomic root in cervical localization

3= Anatomic crown and root cervical localization

Each Caries code will now be considered in more detail:

CODE 3: NCCL

If hard tissue loss more or equal than 50% of

the surface area, then code it as a 3.

Location CODE 1: Anatomic crown cervical

Select from three

location codes and

record as second

digit of BEWE

code

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STAGE THREE: Coding Missing Teeth

There are 4 codes that you can select from for coding the absence of teeth and one which

allows you to code if a fixed prosthesis has been placed. This is a two digit code and is

summarized at the bottom of the second column of the adapted table of BEWE codes. (It

should be noted that bridge pontics and implants, if present, are coded as missing teeth, using

code P).

Section 4: Dentine Hypersensitivity Assessment

Introduction

Short, sharp pain arising from exposed dentin in response to stimuli, typically thermal,

evaporative, tactile, osmotic or chemical which cannot be ascribed to any other form of dental

defect or pathology (Holland 1997)

Pre-Hypersensitivity Assessment Protocol

Location CODE 2: Anatomic root cervical

Location CODE 3: Crown and root cervical

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Dentine Hypersensitivity indices are recorded in the following order: Hypersensitivity and Schiff

cold index.

Measuring Hypersensitivity

Hypersensitivity Index

A simple answer following the sec airblast on the buccal surface of every tooth (except the 2nd

molars) (Yes/No) is sufficient to highlight the bleeding condition. Score are: 0: No; 1: Yes; 9:

Cannot be determined; X: Excluded.

Examiner assessment of pain – Schiff cold air sensitivity scale

Following the evaporative air blast, sensitivity will be recorded by the examiner using the Schiff

Cold Air Sensitivity Scale [Schiff, 1994].

The scale is as follows:

0 = Subject does not respond to air stimulus

1 = Subject responds to air stimulus but does not request discontinuation of stimulus

2 = Subject responds to air stimulus and requests discontinuation or moves from stimulus

3 = Subject responds to air stimulus, considers stimulus to be painful, and requests

discontinuation of the stimulus

Exclusion criteria for testing teeth for sensitivity:

1. Teeth with exposed dentine but with deep, defective or facial restorations, teeth used as

abutments for fixed or removable partial dentures, teeth with full crowns, orthodontic

bands, extensive caries or cracked enamel.

2. Sensitive teeth with contributing aetiologies other than erosion, abrasion or recession of

exposed dentine.

The identified teeth - recession and or NCCL presence- are tested for sensitivity with a

cold air blast and each tooth identified has a Schiff score associated with it, recorded on

one line and another a HD score recorded on line. Exclude 7's and 8's.

The examiner will assess the evaporative (air) sensitivity on the teeth (incisors, canines, premolars

and 1st molars) identified at baseline. This assessment is made by directing a one-second

application of air from a triple air dental syringe at 60 psi (± 5 psi) and operating temperature

range 19°C (±5°C) to the exposed dentine surface from a distance of approximately 1 cm for 1

second. Use fingers of non-dominant hand to mask the teeth either side. Observe the body and

eyes of the subject during the application of the stimulus.

Variables are assessed for one site per tooth: buccal. The recording sequence is as follows: buccal

17; second buccal 16, etc. The recording sequence for the four quadrants is quadrant 1, quadrant

2, quadrant 3, and then quadrant 4.

Suggested guidelines

If no response (0) check with the volunteer “did you feel anything?” if yes then 1

Vocal response with no movement away from the stimulus = 1

Vocal response with head and neck movement = 2

Vocal response with limb movement and yes to “was that painful?”=3

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Important: Examiner will need to first score the Schiff value by communicating discreetly to his

scribe and then ask the question to the subject in order to complete the Hypersensitivity Y/N

assessment

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