A 10-Step Occlusion Checklist for the Hygiene Room

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A 10-Step Occlusion Checklist for the Hygiene Room

The hygiene visit is a cornerstone in a busy general dental practice. It is where patients not only receive education and treatment, but also receive an examination of the oral soft tissue structures, the dentition status and the periodontal health. Each status is documented in detail and a history is created so it can be followed over time. Often an initial diagnosis and additional treatment recommendations also begin in the hygiene room appointment.


To achieve all of that in one very full appointment requires streamlined systems to maximize the productivity. The periodontal and dentition documentation are well established for the hygiene appointment. Probing depths and bleeding indexes, tooth numbers and restorative tracking are ingrained early in education and in clinical practice. What is less systematized is tracking the developing occlusion.

An important aspect of treatment decisions is using the patient history to understand the progress or severity of problems, using that to guide recommendations. Equally valuable is monitoring the patterns that are expressed in dental, jaw and facial development. Using a checklist system will help to identify issues we don’t always see if we don’t look for them. When it comes time to make a treatment referral it is beneficial to know when the cross bite developed. Or that the open bite has reduced with each six-month exam. Your treatment decisions may alter if the airway has not improved for the last two visits. Or if the midline is now off by another millimeter. With good documentation you are able to inform patients and families of issues that may need additional evaluation in the future. It will not be a surprise when you make a referral for an issue that you have already identified for them.

Using this “top 10” checklist can organize your documentation into an easy system to follow and update with future visits. As with any new system, it will take several times to become efficient, but once practiced can be completed in a few minutes.

Some considerations are listed below for each measurement.

The Checklist

1. Overbite:  A deep bite can be associated with incisor wear. An open bite may have a habit or airway component.

2. Overjet:  An excess can indicate a developing Class II growth pattern, dental protrusion or narrow arch width.

3. Upper midline: With lips at rest and slightly apart, midline should be within the philtrum (cupids bow). Off-center midline can indicate crowding, a developing crossbite with palatal incisor eruption, or early primary tooth loss.

4. Lower midline: This can be an indication of a lower jaw growth asymmetry, crossbite, early loss of primary teeth or crowding

5. Cross bite: Posterior can indicate a lower jaw growth asymmetry or a narrow upper arch; anterior can indicate a developing Class III pattern or crowding with palatal eruption and a functional shift.

6. Crowding: Mild is in the range of up to 4 mm of crowding, moderate range 6-8 mm or more, and severe is 8 mm of crowding or more.      

7. Palate width: 36-38 mm is the range of normal with normal range tooth size. Less than 31 mm and there is a high risk for severe crowding.

8. Canine position: Screening for canine position by age 10 can increase the potential to successfully improve an ectopic (impacted) eruption pathway. Comparing the angle of the canine crown to the distal contour of the lateral incisor from crown to root tip can indicate if active treatment is indicated.

9. Missing teeth: Noting this early can assist with awareness and planning discussions for replacement.

10. Airway: Easy breathing through the nose with lips resting together is ideal. Stuffiness, tonsils and adenoids, allergies, lip strain and snoring can be indicators for referral to an ENT for evaluation.

Donna J. Stenberg D.D.S., M.S., P.A., Spear Visiting Faculty and Contributing Author. djstenbergdds@gmail.com


McNamara JA, Brudon WL, Kokich VG. Orthodontics and Dentofacial Orthopedics. Ann Arbor, MI: Needham Press; 2001.

Schindel RH, Sheinis MR. Prediction of maxillary lateral-incisor root resorption using sector analysis of potentially impacted canines. Journal of Clinical Orthodontics. 2013;47(8):490-493.

Turning My Restorative WREB "Failure" into a "Success"

Thank you Nancy Huckvale for writing and being honest about your WREB experience! Nancy is an amazing dental hygienist who is dedicated to her patients and her family.

To my dental hygiene lovelies, 

After graduating dental hygiene school and spending my first year in my home state of Utah, I moved up to the beautiful area near Vancouver, Washington. This move started me on a confusing process of applying for my WA license where somehow I ended up with an incorrect understanding that it would be REQUIRED for me to have a restorative license, along with a general dental hygiene license, if I wanted to work in WA. So I signed up for an expanded functions restorative class and the fun began! *Insert a waa-haa-haaaaaa sound in the background here*   

The truth was, however, because I already had my hours built up from my time working in Utah, I didn't need any additional classes or tests beyond what I'd needed to get my UT license.  I didn't learn this until after I had failed the restorative WREB test three times. I didn't learn this until after I had spent over $6,000 (yes, six-freakin'-thousand dollars) invested into taking necessary classes, books, hotel/gas fees to travel to take the tests, remediation classes, etc later.   I didn't learn this until I had shed many heart-broken tears of feeling like I myself was a failure to match the word "FAIL" that came back on each of those test results.

After learning that I didn't actually NEED to take that horrible, awful test again, I had a choice.   I got to make the choice of keeping my 'limited hygiene license' forever  (easier, less expensive, 'safer' choice) or paying another $600 and giving myself one last chance just for the heck of it.  Taking this test simply to prove to myself I could do it. (exciting, more expensive, challenging, Ninja choice.) You can guess what choice I made! 

Learning how to do fillings came so un-naturally to me. It felt so... awkward. The physical piece of dentistry in general seemed to come un-naturally to me. In dental hygiene school I struggled to feel the calculus with the explorer, let alone remove it with scalers. I didn't feel like "I've got the hang of this teeth- cleaning thing!" till probably about six years after graduating and working in the field.  I love people, and I love science. So the social/human interaction and relationship piece of dentistry comes natural, and understanding the biology and chemistry behind dentistry makes sense in my mind. But the ARTISTIC piece I've had to invest much energy into developing. That part of being able to see the anatomy of the teeth as ART while you're creating, seeing angles while giving injections, building a detailed filling, or removing stains during a prophy-- that cool creative, art-sy piece!  This would be confirmed in the example of what I see vs. what my art-sy, creative (hunk-y) husband sees when we each looked at a big blank wall in our home.  I simply saw a big blank wall complete with crickets chirping in the background, while he was looking at a canvas to work magic on and already had 10 ideas of different ways we could create in that space!

I spent hours and hours learning and practicing fillings by watching YouTube videos, reading and highlighting books, observing hygienists and dentists in the operatory doing fillings, asking questions, sitting at home in bed with a fake tooth and playdoh practicing anatomy. HOURS. MONTHS. I was determined that if I didn't pass the test, it wasn't because I didn't know how to do fillings. I had done EVERYTHING in my power to pass and it was out of my hands.  Don't get me wrong, I had studied and practiced for the first three times I took the test as well, but this time I kicked it up a notch to go from "good" to "GREAT." 

One night before taking the test my final time, I had an "a-ha!" moment and that art piece finally CLICKED for me.  It all made sense.  The angles of the margins, the anatomy of the teeth, the way I needed to hold my instrument to make it look like how I finally could properly see it in my mind… it finally clicked and it was like the heavens opened up and angels sang around me!!  I wondered if this is how it is for some clinicians where this piece DOES come naturally-  the ones in the clinic who pick up their clinical skills quickly and what appears to be so effortlessly.  And now here I was thinking that all of this restorative stuff is actually kind of fun, and not just struggily?!   I knew right then and there I was going to not just pass, but I was going to kick that restorative test's butt! (Not that tests have butts, BUT(t) you get the point.)

I passed it on my FOURTH TRY, my final chance I was allowed to take it.

This final chance taking the test, I went into it calmly and felt at peace. I actually looked forward to it in a way because I was confident in myself and my abilities after all that preparation, not just praying I'd pass out of luck. And two weeks later (isn't that the longest two weeks of your life waiting to hear back your results?) when my phone buzzed that I had a new email from WREB, my heart stopped for a moment. I was out driving around with my sister and she was going on talking about something I couldn't even hear anymore after seeing those four letters pop up in my email.  I couldn't wait, and yet, I couldn't open it at the same time!!  Finally I opened it up and saw the best four letter word:  PASS. Ahhhhhhhhh!!!!!!!!!!! I cried happy, victorious, relieved tears and felt so PROUD of myself.  Genuine pride in myself that I'd worked so hard and been so dedicated to developing this "weakness" of myself into becoming a "strength."  Proud that I didn't give up. Proud that I'd learned so much more by experiencing it THIS way instead of just passing it the first time. (by the way, 2/3 times I took it previously, I didn't pass by ONE point. If I had one single mark better, I would have passed! For some reason, that feels worse in a way than just totally bombing the test. Like.. Are you kidding me?!  ONE POINT!!) THIS incredible feeling of accomplishment was worth all the heartache, frustration, sadness, and money I'd spent from before.  This feeling was amazing. And I reached a place of acceptance beforehand of knowing if I hadn't passed, I would genuinely have been okay with that too. The journey itself was worth it and I'd already learned what I'd needed to learn, whether I passed this test or not.

To this day, passing that restorative test is one of my huge life-defining moments, right up there with delivering my two baby boys, and running a marathon. Like.. HUMUNGO MOMENT! My arch-nemesis test defeated by moi.   I put SO MUCH into that test.  And it paid off. I DID IT. I learned that day that I can do hard things. I can do ANYTHING. And YOU can too! I'm so glad I didn't let my FEAR of NOT PASSING get in the way of me trying. I could have dragged that guilt of 'what if?' my whole life, and instead I punched it in the face. (Again, not that tests have butts OR faces. And I promise I don't usually try to kick or punch so much stuff! Apparently I've still got some PTSD left behind from it--- I know you guys know what I'm talking about!  ) I worked at an amazing pediatric office (Adventure Dental) putting that restorative license into action, which was quite a fun change of pace to my dental hygiene career

As humans we have a tendency to move AWAY from things that are uncomfortable, unfamiliar.  We naturally stick to a place where it is safer, more secure, and predictable.  I didn't HAVE to take this test again and put myself through torture, but I CRAVED seeing what I COULD do, seeing what I WAS able to accomplish, discovering what I was capable of. And when you get that burning desire inside you to try something different, and you're scared because you don't know what you're doing, DO IT! Go for it! Seriously!  You have five seconds to take action following an idea before you'll talk yourself out of doing it. So whatever you just thought of right now as you read this, it is worth exploring, it is worth trying.  

Why are we so afraid to try?  Often we aren't afraid to try, but we're afraid to FAIL.  I firmly believe this quote by R. Buckminster Fuller that "There is no such thing as failure, just outcomes."  It's true. And the less afraid I am of "failure" whether it is in the form of passing a dental test or quitting an addiction, or answering something calling me from inside, and instead I choose to get CURIOUS and dig in and dive deeper, the more I learn, grow, and understand myself, life, and our world in general. 

I'll leave you with a couple more inspirational quotes to lovingly pull you out of your comfort zone:

"Lean into the discomfort of the work." -Brene Brown

"If it excites you and scares you at the same time, it might be a good thing to try." -Seth Godin

What are some ways you've felt you've turned your "failures" into "successes?" I'd love to hear you share your experiences!

Nancy Huckvale, RDH graduated from the Utah College of Dental Hygiene in 2010. Since then, she’s practiced dental hygiene in Utah, Washington, and Oregon. Currently, she’s living in Logan, UT working at Logan Peak Dental and LOVING life. Nancy genuinely loves people, learning, connection, ducks, running, zumba/dancing, nature, trying new things to learn about different cultures, and kids. For any questions, she can be contacted by email: Nanhuck@Live.com.

Winners of Our Recent Giveaways for the XP Sharpen-Free Technology

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