Charting Flashcards
Abrasion
(ABR)
Pathological wearing away of tooth structure by friction.
Ex. Brushing too aggressively
Most common site: cervical thirds
Attrition
(ATTR)
Loss of tooth structure as a result of occlusal wear due to grinding/clenching/bruxism
Most common site: incisal (anterior) and occlusal (posterior)
Erosion
(ERO)
Wearing away of tooth structure due to chemical action. (Bulimia/purging)
Most common site: maxillary lingual surface
Abscess
Localized area of pus accumulation; formed at the apex of the root tip.
Amalgam
An alloy, which is mixed with mercury to form a restorative material.
AKA silver filling
Tooth colored = composite
Bifurcation
Area between two root branches
Trifurcation
Area between three tooth branches
Furcation involvement
Area between two or more branches (furcation) is visible or noted during probing.
Crown
A cast restoration that covers the entire anatomical crown of a tooth
Bridge
A fixed prosthetic device consisting of artificial teeth (Pontic) that are supported by attaching them to an existing tooth/implant (abutment)
Abutment
A tooth, a tooth or an implant used for retention of a fixed or a removable prosthesis
Pontic
An artificial tooth that replaces a missing natural tooth.
Decay
Caries
An infectious disease that progressively destroys the tooth structure
Recurrent decay
Tooth decay that has reoccurred after a restoration is in place.
“Leakage”
Eruption
Migration of a tooth into functional position in the oral cavity ( over/under-erupted)
Under erupted
A tooth / teeth that are not fully erupted in the oral cavity
Over erupted
A tooth that is erupted more than its normal position in the oral cavity.
Extraction
Removal of a tooth from the alveolar socket (simple/surgical)
Fracture
A break in continuity (cracked tooth)
Hypoplasia
An incomplete or deficient development of enamel
Hyperplasia
An abnormal overgrowth of tissue / an organ (gums)
Impaction
An un-erupted tooth in the alveolus (socket) beyond the time at which it should normally be erupted
Inlay
A cast restoration designed to restore one, two, or three surfaces of a prepared tooth (doesn’t include any cusps)
Onlay
A cast restoration designed to restore the occlusal and some proximal surfaces of a posterior tooth (includes up to 3 cusps of a tooth)
Mobility
Gum recession, loss of bone
Overhang
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
Periodontal pocket
Created when the depth of the gingival sulcus exceeds 3 mm.
3 mm average
Anything deeper = bone loss
Porcelain
A highly polished tooth colored restorative material made in a lab.
Most commonly used ceramic in dentistry
Recession
Loss of a part or all of gingiva over the root of the tooth.
Rotation
Moving of a tooth to it’s left or right in the pocket
Tipped tooth
A tooth that is not upright or has moved in a certain direction (M, D, L, F)
Veneer
A very thin, custom-made shells of tooth-colored materials designed to cover the front surface of teeth to improve its appearance
Porcelain jacket crown
(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
Stainless steel crown
A crown made of stainless steel, mostly used for primary teeth
Post and core
A type of dental restoration used either to stabilize a weakened/broken tooth or provide an anchor for a crown.
Partial denture
Some teeth need to be present
PUD ( partial upper denture)
PLD ( partial lower denture)
Complete denture
Replaces all teeth in an arch
CUD ( complete upper denture )
CLD ( complete lower denture )
Implant
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
Diastema / open contact
An abnormal space between teeth in permanent dentition
Odontogram
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.
Geometric odontogram
Each tooth is represented by a circle
Each circle is further divided into 5 sections representing all surfaces of the tooth
An atomic odontogram
Illustrates and resembles the anatomical crown and root of a tooth.
Purpose of the dental chart
To gather all relevant information that is needed by the dentist to make accurate diagnosis and tx plans
What do charts need to contain?
Personal information Complete medical history Dental history Clinical observations Intra/extra oral photographs Radiographs
Purpose of PHIPA
- Provides the public with right to access their personal health information
- Provides independent reviews of complaints with respect to personal health information.
- Provides penalties for breach of the Act
What is personal health information?
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.
Who does PHIPA apply to?
A health information custodian is anyone who collects, uses and discloses personal health information.
Ex. Doctors, dentists, hospitals etc.
What must a health information custodian do?
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.
Retention of records
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
Privacy policy and procedures
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.
What does the Privacy Officer do?
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.
Privacy Officer procedure
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.
“Respondeat superior”
Let the master answer,
which essentially refers to the dentist being held responsible for the action of their employees
PIPEDA
Personal Information Protection and Electronic Documents Act
An act that protects personal information in the hands of a private sector.
Under PIPEDA, personal information must…?
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.
An explanation is presented to each patient:
Overall treatment plan
Tx alternatives
Any possible risks of tx
Estimate cost
Patient chart release
Client signed consent must be obtained before any information is given to a referral dentist, the clients family physician or authorized representative.
Sample dental history questions.
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?
Each visit should include:
- 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
Referral documentation
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.
Computerized records keeping
Records may be kept electronically only if:
- Provides an accurate visual display of the recorded information and is capable of retrieving and printing.
- Maintains an audit trail which indicates any changes that have been made in the recorded information
- Preserves the original content of the recorded information when changed or updated.
Benefits of computer records
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
Transfer of charts and personal health information
- 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
When submitting a predeterminación for a bridge:
- 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.
