ORAL DIAGNOSIS Dena 320 Deborah Bell

Diagnosis n To identify or determine the nature and cause of a disease or injury through evaluation of the medical and dental history. n The dentist only can diagnosis

Assessment n Assess is to evaluate or conclude

Assistant’s Responsibility n Data gathering to bring together all of the information required by the dentist to make and accurate diagnosis of the patient’s condition n accomplished by asking the new patient to complete printed forms - reviewing these forms with the patient in interview form to clarify and gain more information.

Patient Record n Result of overall process of delivering patient care n permanent document which reflects the patient n primary source of information to assess the quality of care given a patient n source of data for research purposes

n Provides documentation regarding the patients –condition –diagnosis –treatment –responses to treatment n risk management for team

Components of the Patient Record n Patient information –demographics –financial responsibility n medical history –alerts to possible medical conditions –medications –special treatments needs to avoid emergencies –patients signature

n Make sure there is a signatured release form to allow release of information –consultations with physician if needed

Continue Medical History n Update history at each visit –patient and assistant reviews –patients signs and dates n health changes/ no changes n surgery n conditions n Medications n Medical alert information

Vital Signs n Pulse n respiration rate n body temperature n blood pressure

Pulse n Expansion of the artery as the heartbeats n slight finger pressure used to identify n normal pulse rate in resting adults – beats per minute n normal pulse rate in resting child – beats per minute

n Recording technique –radial artery –count for 30 seconds and multiply by 2 –Or count for 1 minute –IMMEDIATELY RECORD ON RECORD –Note any arrhythmia's

Respirations n Normal respiration rate for relaxed adults – breaths n Normal respiration rate for relaxed child – n observe patients chest rise and fall for30 seconds and multiply by 2

Body Temperature n Average normal 98.6 degrees n normal range degrees Fahrenheit

Blood Pressure n The amount of labor the heart has to exert to pump blood throughout the body n Systolic pressure –first recording (higher number) –pressure it takes for left ventricle to push oxygenated blood out into the blood vessels

n Diastolic pressure –second number (lower number) –reflects the hear muscle at rest n both pressures are measured in millimeters of mercury (mm HG)

BP classifications for adults n Normal –120/80 –range less than 130/less that 85 n high normal n /

n Hypertension –stage 1(mild) n /91-99 –stage 2 (moderate) n / –stage 3 (severe) n / –stage 4 (very severe) n 210 & above/120 & above

Types of BP Meters n Automated electronic blood pressure device n sphygmomanometer & Stethoscope

BP technique Guidelines n Extend the patients arm at same level as heart n cuff approximately 1 inch above the antecubital space n secure cuff around arm with all air expelled n Korotkoff sounds phases

n Phase I –first distinct thumping sound and becomes louder n SYSTOLIC READING n Phase II –sound softens n Phase III –becomes crisper and intensifies

n Phase IV –distinct abrupt muffling n Phase V –artery is fully open and sound disappears –DIASTOLIC READING n Record immediately and verbalize your reading results to the patient

guidelines n If more than one reading needed allow 10 minutes between ideally n If somewhat high before procedure take again at end of appointment n If reading is extremely high –choose not to begin procedure –refer to physician

Components of a Dental Examination

Oral Examination n Takes place after the patient has completed the medical history and vital signs have been recorded

Components n General overall appearance n facial area n temporomandibular joint n oral mucosa n lips n tongue n floor of mouth

n Palate n gingival tissue n occlusion n teeth n structures maintaining the teeth in position

Techniques for examination n Visual examination –whole patient not just oral area n palpation –feeling for abnormal changes n instrumentation –caries detection n intraoral/extraoral radiography

n Intraoral imaging –provide better visibility –better evaluation –case presentations –risk management –photocopy for insurance purposes

n Intraoral/extraoral photography –treatment planning –case presentation n Oral Cancer exam –neck –facial areas –intraoral tissues –by touching and visual evaluation

Remember n Check for crepitus (popping of TMJ at tragus of the ear) when you complete the oral cancer exam n Note Bruxism habit (grinding)

Oral Hygiene Indicies Evaluation and Recording n A systematic assessment of plaque debris and calculus n Use of 6 tooth surfaces: 4 post / 2 ant. n Division of tooth into thirds used as principle

Scoring of Indicies n 0 – no plaque n 1 – no more than 1/3 of surface n 2 - 2/3 or more that 1/3 but not more than 2/3 n 3 – more that 2/3 covered n Total points each category and divide by number of surfaces ( 6 or both 12)

Perio Charting n Each tooth has 6 readings –Mf –M –Df –Ml –Li –dl

Results of Scoring n.6 – good n.7 to 1.8 – fair n 1.9 to 3.0 – poor n Higher score – BAD!

Assistants Role n Acquiring diagnostic aids n interviewing the patient n accurate charting and recording

Treatment Plan n A written treatment plan is presented to the patient after the dentist has reviewed and evaluated all patient information gathered.

Types of Treatment Plans n Level I –emergency care –relieves immediate discomfort n Level II –Standard care –restores dentition to normal function

Charting The Dentition

Charting components n Charting abbreviations –BO MO –DIMOD –DLMODBL –DO –LOConnect by adding “o” –MIexception: buccal-occlusal

n charting symbols n choose charting system for tooth identification n Measuring tissue levels

Procedures Sample

Bonding

Bridge

Maryland Bridge

Caries

Restoration

Implant

Inlays and Onlays

Sealants

Veneers

Let’s chart!