Dental Terminology and Record Keeping Flashcards
Why are dental terminology and record keeping important?
Medico-legal requirements
Professionalism and reputation
Safety
Continuing care
Forensics
What are some subheadings that can be used for dental history?
P/C: Presenting complaint
Hx of P/C: History of Presenting Complaint
MHx: Medical History
Dent Hx: Dental History
SHx: Social History
Natal Hx
OH: Oral Health (habits)
Diet
EOE: ExtraOral Exam
IOE: IntraOralExam
Diagnoses
Tx options
Informed consent
Tx Plan
Tx
Post-op
Should you make diagnoses in an examination?
No, just describe the appearance (eg generalised enamel opacities and mottling)
What are the types of non-carious tooth surface loss?
Erosion
Attrition
Abrasion
Abfraction
These are often multifactorial (this is important for record keeping)
What dental terminology describes cracks in the tooth?
Fractures, chips, and infractions
Enamel infraction
Enamel fracture (chip)
What is the difference between a complicated and uncomplicated fracture?
Uncomplicated fracture does not involve the pulp and a complicated fracture involves the pulp.
How are restorations described?
Material: Composite resin, if unsure describe tooth coloured / adhesive.
Whether or not they are satisfactory and if not why not.
How should lesions be described?
Location
Size
Shape
Colour
Texture
Margins
Eg: “Ulceration affecting right lateral border of the tongue, well defined erythematous margins, irregular in shape, 3mm x 2mm, central area of grey slough.”
