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29 Cards in this Set
- Front
- Back
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What is the usual sequencing of events for a patient assessment?
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- History taking
- Extra-oral exam - Intra oral exam - To allow for Diagnosis/prognosis/treatment plan/ref - Treatment - Reassment/recall made |
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Does the clinician make decsions or provide advice?
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Advice
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Who chooses to accpet of decline the clinicians advice?
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- The patient, children over the age of 16 are also aloud to make decisions if unaccompanied
- Parent - Guardian is also aloud in WA to make decisions when accompanying a minor to the clinic |
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What elements of consent do you need to consider?
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- That you get informed consent before commencing
- Procedure is legal - Patient must be competent to give concent - Patient or concent giver should have a good compreension of info ... mental capacity/age etc. |
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Patient info needed for records...
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Name
Address Contact details Date of Birth Gender School name, year Parents details |
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What are 2 important qs you need to ask in your initial consult?
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> Why has the patient attended?
> What does the patient expect? |
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What do we need to ask regarding patients presenting issue?
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- Commencement
- Location - Type - Incidence, Duration - Initiating factors, relieving factors |
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What should we consider in th emedical history?
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> Heart disease
> Allergies > Abnormal bleeding > Jaundice > Medication - current present past > Hospital admissions |
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What should we consider regarding patients past dental history?
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> Current treatment
> Regularity of visits > Treatment recieved > Any difficulty with past treatment > Advice on prevention > Attitude and motivation > Flouride exposure |
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What should we consider with social history for patient assessment?
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- Family background
- Availability |
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What habits should we be identifying?
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- OH
- Diet - Smoking - Drugs and alcohol - Bruxing, Clenching |
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What general appearance/demenour observations can often identisy the type of patient we are about to treat?
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- nervous/relaxed
- well/unwell - tidy/dishevelled |
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What are we looking for when looking at extraoral findings?
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Any devaitions from normal
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What are we looking for assessing the patient intra-oraly?
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Soft tissue assessment - any devaitions from normal
e.g. colour change, swellings, ulcers etc. |
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What are paraafunction assessments?
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Any TMJ/myofacial probles
- Pain, limited opening, clicking Tooth Wear - Bruxing, abrasion, corrosion/erosion |
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What ortho findings are we looking at intraoraly?
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> Molar relationship (classification)
> Skeletal (Jaw) relationship (classificiation) > Overbite/overjet > Crossbite, crowind, spacing, rotation |
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From OH perceptive what are we looking for?
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Plaque distribution/ Plaque retentive factors ie. calculus
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In the initial perio assessment what do we look for?
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Gingival tissue appearance
Pockets/recession Mobility |
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What is the DIC index?
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D ebris
I infalmmation C alculus used in sextants |
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What do we note in tooth charting?
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> Teeth present
> Teeth missing > Caries/fractures > Restorations > Fissure sealants > Other features of note |
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What special tests can we consider?
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- Radiographs
- Vitality - Study models - Diet analysis |
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Information gathered from hisstory taking and initial exma is used for what?
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Diagnosis/prognosis/treatment
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List sequencing we should consider when planning treatment.
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- Urgent treatment
- Stabalising treament - Initial prevention - Reassement - Initiate definitive treatment - reassess - Finalise definitive treatment - Reassess, maintain and reinforce prevention |
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What are additional sequencing consideraions for planning patient treatment?
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> Patient introduction/ familiarise, cooperation
> Patient availablity > LA consideration |
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What are the legal requirements according to the health act in confirming/communicating the proposed treatment plan?
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- Intial treatment plan must be evident
- There needs to be subsequent treatemnt plans - How this was communicated to patient/guardian - How consent was obtained for treatment - Who it was obtained from |
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Does every new patient need to see a dentist before they can see the oral health therpaist?
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Yes they must see a DO on their initial visit and every 4 years following
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According to our patient risk assessment and dental care needs how far apart should our recall appointments be?
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> Poor OH/Rampant caries = Tailored to Px
> Caries present and treated = 12/12 > No active caries = 15/12 > Clear caries free after 1+ examination = 18/12 |
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According the Dental Board Guidlines on dental records - records/details entered sshould be...?
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. Confidential
. Legible . Detailed but concise, relevant, accurate . Objective, unemotional . Chronological . In pen for hard copy . Error correction method |
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What documentation of treament details should we include in our records/details entered?
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> Date
> Treatment(s) provided > Unusual ssequelae > Advice provided > Medicines/drugs prescribed, administere, applied or an therapeutic agenst used (name, quantity, dose and instructions) > Operator ID |
