Charting Flashcards

1
Q

Abrasion

A

(ABR)

Pathological wearing away of tooth structure by friction.

Ex. Brushing too aggressively

Most common site: cervical thirds

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2
Q

Attrition

A

(ATTR)

Loss of tooth structure as a result of occlusal wear due to grinding/clenching/bruxism

Most common site: incisal (anterior) and occlusal (posterior)

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3
Q

Erosion

A

(ERO)

Wearing away of tooth structure due to chemical action. (Bulimia/purging)

Most common site: maxillary lingual surface

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4
Q

Abscess

A

Localized area of pus accumulation; formed at the apex of the root tip.

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5
Q

Amalgam

A

An alloy, which is mixed with mercury to form a restorative material.
AKA silver filling

Tooth colored = composite

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6
Q

Bifurcation

A

Area between two root branches

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7
Q

Trifurcation

A

Area between three tooth branches

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8
Q

Furcation involvement

A

Area between two or more branches (furcation) is visible or noted during probing.

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9
Q

Crown

A

A cast restoration that covers the entire anatomical crown of a tooth

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10
Q

Bridge

A

A fixed prosthetic device consisting of artificial teeth (Pontic) that are supported by attaching them to an existing tooth/implant (abutment)

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11
Q

Abutment

A

A tooth, a tooth or an implant used for retention of a fixed or a removable prosthesis

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12
Q

Pontic

A

An artificial tooth that replaces a missing natural tooth.

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13
Q

Decay

A

Caries

An infectious disease that progressively destroys the tooth structure

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14
Q

Recurrent decay

A

Tooth decay that has reoccurred after a restoration is in place.

“Leakage”

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15
Q

Eruption

A

Migration of a tooth into functional position in the oral cavity ( over/under-erupted)

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16
Q

Under erupted

A

A tooth / teeth that are not fully erupted in the oral cavity

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17
Q

Over erupted

A

A tooth that is erupted more than its normal position in the oral cavity.

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18
Q

Extraction

A

Removal of a tooth from the alveolar socket (simple/surgical)

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19
Q

Fracture

A

A break in continuity (cracked tooth)

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20
Q

Hypoplasia

A

An incomplete or deficient development of enamel

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21
Q

Hyperplasia

A

An abnormal overgrowth of tissue / an organ (gums)

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22
Q

Impaction

A

An un-erupted tooth in the alveolus (socket) beyond the time at which it should normally be erupted

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23
Q

Inlay

A

A cast restoration designed to restore one, two, or three surfaces of a prepared tooth (doesn’t include any cusps)

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24
Q

Onlay

A

A cast restoration designed to restore the occlusal and some proximal surfaces of a posterior tooth (includes up to 3 cusps of a tooth)

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25
Q

Mobility

A

Gum recession, loss of bone

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26
Q

Overhang

A

A projection of restorative material on mesial or distal surface of a tooth.

Sloppy filling work

Class like object used to support shape of tooth

27
Q

Periodontal pocket

A

Created when the depth of the gingival sulcus exceeds 3 mm.

3 mm average
Anything deeper = bone loss

28
Q

Porcelain

A

A highly polished tooth colored restorative material made in a lab.

Most commonly used ceramic in dentistry

29
Q

Recession

A

Loss of a part or all of gingiva over the root of the tooth.

30
Q

Rotation

A

Moving of a tooth to it’s left or right in the pocket

31
Q

Tipped tooth

A

A tooth that is not upright or has moved in a certain direction (M, D, L, F)

32
Q

Veneer

A

A very thin, custom-made shells of tooth-colored materials designed to cover the front surface of teeth to improve its appearance

33
Q

Porcelain jacket crown

A

(PJC)

A crown made of porcelain over a thin layer of metal shell

Mostly used for anterior teeth

Covers the facial and proximal surfaces of a tooth

34
Q

Stainless steel crown

A

A crown made of stainless steel, mostly used for primary teeth

35
Q

Post and core

A

A type of dental restoration used either to stabilize a weakened/broken tooth or provide an anchor for a crown.

36
Q

Partial denture

A

Some teeth need to be present

PUD ( partial upper denture)
PLD ( partial lower denture)

37
Q

Complete denture

A

Replaces all teeth in an arch

CUD ( complete upper denture )
CLD ( complete lower denture )

38
Q

Implant

A

An artificial root made of titanium that is inserted into the jawbone to replace the root of a missing natural tooth.

Implants act as an anchor to hold the replacement tooth ( crown ) in place

39
Q

Diastema / open contact

A

An abnormal space between teeth in permanent dentition

40
Q

Odontogram

A

Part of a patients dental chart with the whole dentition illustrated on it.

Used to document a patients existing dental conditions and also record planned treatment.

41
Q

Geometric odontogram

A

Each tooth is represented by a circle

Each circle is further divided into 5 sections representing all surfaces of the tooth

42
Q

An atomic odontogram

A

Illustrates and resembles the anatomical crown and root of a tooth.

43
Q

Purpose of the dental chart

A

To gather all relevant information that is needed by the dentist to make accurate diagnosis and tx plans

44
Q

What do charts need to contain?

A
Personal information 
Complete medical history
Dental history 
Clinical observations
Intra/extra oral photographs 
Radiographs
45
Q

Purpose of PHIPA

A
  1. Provides the public with right to access their personal health information
  2. Provides independent reviews of complaints with respect to personal health information.
  3. Provides penalties for breach of the Act
46
Q

What is personal health information?

A

About and individual: includes identifying information that is not necessarily personal health information but is contained in a record.

Ex. The clients chart, medical history, medical information.

47
Q

Who does PHIPA apply to?

A

A health information custodian is anyone who collects, uses and discloses personal health information.

Ex. Doctors, dentists, hospitals etc.

48
Q

What must a health information custodian do?

A

Notice of loss- a health information custodian shall notify the individual at the first reasonable opportunity if the information is lost, stolen, or accessed by unauthorized persons.

49
Q

Retention of records

A

Records for which the most recent entry was created on or after June 1, 2013 must be kept for 16 years from the date of last entry

Records for which the most recent entry was created before June 1,2013 must be kept for 31 years

50
Q

Privacy policy and procedures

A

It is the responsibility of the health care provider to protect the personal information contained in the charts

Should a client have questions or concerns about the privacy of their information, they shall be directed to the Privacy Officer.

51
Q

What does the Privacy Officer do?

A

Ensures that copies of the Privacy Code are available upon request.

Ensure any inquiries, complaints and concerns are responded to in a prompt and appropriate manner.

52
Q

Privacy Officer procedure

A

Will prepare an immediate written response to the complaint.

An investigation will be commenced.

Depending on the nature of the inquiry, this may result in a change of procedure, change to the clients record, or no action may be required.

Upon completion, an appropriate response will be given to the patient.

53
Q

“Respondeat superior”

A

Let the master answer,

which essentially refers to the dentist being held responsible for the action of their employees

54
Q

PIPEDA

A

Personal Information Protection and Electronic Documents Act

An act that protects personal information in the hands of a private sector.

55
Q

Under PIPEDA, personal information must…?

A

Be collected with consent and for a reasonable purpose.

Be Used and disclosed for the limited purpose for which it was collected.

Be accurate.

Be accessible for inspection and correction.

Be stored securely.

56
Q

An explanation is presented to each patient:

A

Overall treatment plan

Tx alternatives

Any possible risks of tx

Estimate cost

57
Q

Patient chart release

A

Client signed consent must be obtained before any information is given to a referral dentist, the clients family physician or authorized representative.

58
Q

Sample dental history questions.

A

When was your last dental visit?

When did you last have dental X-rays?

How often do you brush/floss your teeth?

Have you been seeing a dentist regularly?

Do your teeth ache?

59
Q

Each visit should include:

A
  • description of services completed
  • date of tx
  • identify the dental provider
  • type and amount of anesthetic used
  • materials used
  • any other drugs administered or prescribed
  • post op instructions
  • any advice given / discussed with client
60
Q

Referral documentation

A

If we send a patient to a specialist office:

Notations of referral to a specialist, & copies of ANY report to and from specialists must be kept on file.

61
Q

Computerized records keeping

A

Records may be kept electronically only if:

  1. Provides an accurate visual display of the recorded information and is capable of retrieving and printing.
  2. Maintains an audit trail which indicates any changes that have been made in the recorded information
  3. Preserves the original content of the recorded information when changed or updated.
62
Q

Benefits of computer records

A

Records the dates of all entries for each patient.

Access to the clinical and financial records of each patient quickly.

Can visually display and print the recorded clinical and financial information for each patient in chronological order.

Includes a password and provides security.

Backs up files on a removable hard drive and allows for data recovery

63
Q

Transfer of charts and personal health information

A
  • all personal information that is contained within the chart is affected by the Personal Health Information Regulations.
  • when charts are transferred or passed along to another department, student or staff, the chart shall be tracked be recording the location of the chart.
  • each chart shall be tracked either manually, requiring the signature of the health information custodian, or electronically
64
Q

When submitting a predeterminación for a bridge:

A
  • ask the patient when the tooth or teeth were extracted
  • since many patients will have difficulty remembering the exact date, an approx. date or year will be acceptable.
  • the insurance company will require that info to see if the claim is elegible for the missing tooth.