Oral diagnosis & treatmeant Flashcards
Amalgam
Shaded in area
Composite
not shaded in
overhang recession
Right triangle on the corner of the tooth , colored in
sealants
red or blue
write S on occlusal surface
abscess
red only
Circle at the tip of the root
root canal
Red or blue
Straight line going from the root
post & core
Red or Blue
arrow starting from the root and going down to the tooth
abrasion
Red
circle cervical edge
write ABR ontop
Attrition
Red
straight line across ontop of tooth
Highlight the whole tooth and write ATTR at the top
Erosion
Red
Circle on the bottom edge of tooth
highlight tooth and write ERO ontop
Recession
Red
Draw a frown if on max or a smiley face if on mand. And write how much its recession is
Mobility
M1- slight
M2- moderate
M3- severe
Under erupted & over erupted
Red
Under erupted arrow going up
over erupted arrow going down
rotation
Red
Draw arrow either mesially or distally
drifting
Red
Draw arrow going either distal or mesial
Partially erupted
Red
Circle the specific area in which is erupted
extraction
red/blue
line going across the entire tooth
missing teeth
Blue
X over the entire tooth
Porcelain
Red and blue
Highlight tooth and write Porc ontop
Porcelain fused to metal crown
Red or blue
outline the tooth and write Pfm
lingual side has horizontal lines
Porcelain jacket crown
red or blue
highlight the tooth and write PJC ontop
Full gold crown
Red or blue
Highlight the tooth and draw diagonal lines across and write FGC ontop
Stainless steel crown
Red or blue
outline the tooth and write SSC on the occlusal surface
veneer
red or blue
Outline only ones that apply and write VEN ontop
Bridge
Red or blue
3 teeth connected together , connected with 2 lines and also diagonal lines across
also missing tooth write X
PFM OR FGB
Inlay
Blue only
Designed to replace a class II cavity
No cusp involved
onlay
designed to replace a class II cavity that includes occlusal, one or more cusp and proximal surfaces
Gold inlay
Red or blue
draw bridge across occlusal surface
no cusps
draw diagonal lines and write FG ontop
porcelain inlay
red or blue
little finger coming out
No cusps
write Porc ontop
porcelain onlay
Red or blue
cusps invloved , include cusp in drawing
outline the tooth and write porc ontop
full gold onlay
red or blue
draw out
cusps involved
horizontal lines and write fg ontop
diastema
Red
2 vertical lines between the teeth
Fracture
Red only
zigzag lines on the edge on the tooth
Complete denture
Red or blue
draw lines around all the teeth either upper or lower denture
CUD /CLD
Partial denture
Draw lines across the teeth that need it , are partial dentures
Implant
Red or blue
Horizontal lines on the root
Fixed lingual retainer
Red or blue
Lingual surfaces only
straight line across
New patient
thorough exam, treatment plan and post op care
emergency patient
for a specific problem
consulting
A specialist ( orthodontics, oral surgery)
Returning/recall
patient ( continued review & care )
if recorded in blue or black it is
3mm or less
if recorded in red it is
4mm or greater or is bleeding
t/f; all entries are to be signed or initialed
true
what may be needed as evidence in a malpractice suit
dental records
how long can an office keep his/her record after leaving
10 years, and 10 years after your turn 18
patient registration form
computer/written
must be filled during 1st appointment and updated regularly
includes patients personal info
medical history
signed and dated by the patient.
includes childhood illness.
includes patient medication history
Shows past/present physical conditions
medical alert stickers are placed
inside of the patient’s chart
soft tissue
gingiva, tongue, oral mucosa
intra oral evaluation includes
soft tissue, hard tissue
extra oral evaluation includes
face, lymph nodes, tmj , neck, lips
appear uniform in color
use mirror, light to detect any imperfections in the enamel
Anything abnormal should be noted
Tooth structure
restoration
silver, gold , or tooth coloured
use fingers/hands to feel the hard/soft tissues for
texture, size , consistency
during extra oral exam following are checked for any swelling & tenderness
TMJ, facial muscles, cervical lymph nodes
used for indirect vision and light reflection
mirror
explorer
detects imperfections in enamel & existing restorations
probe
measures the sulcus for loss of gingival attachement or bone loss
radiography identifies what
decay, defective restoration, abnormalities
intraoral imaging
similar to miniature video camera & used with computer monitor
Easier to access areas that are difficult ( distal & mesial)
provides dentist & pt with the visual means of identifying & understanding specific problems
photography/ visual exam
patient dental chart includes
charting symbols, abbreviations and color coding thats used to indicate diff conditions and existing restorations
Two types of diagrams
anatomic , geometric
Blue
existing
red
needs to be completed
informed consent
form pertains to a specific treatment that has been presented to the patient part of there treatments needs .
Includes outcomes and complications that could occur
alerts dentists to possible medical conditions and medications that could interfere with treatment.
medical history form
dental history form
previous treatment current oral/ dental conditions previous dentist previous treatments ALWAYS SIGN & DATE to verify
purpose of probing
measure how much epithelial attachment has been lost due to disease
medical/dental history
radiographic evaluation
examination
charting
periodontal examination
govern the collection use and disclosure of personal information
PIPA ( personal information protection act)
t/f; the patient record is the dentist’s property and CAN be removed from the office
false
what should you not do for data entry
do not use white out
do not scribble over entry
medical/dental update
review medications
updates must be done at EACH VISIT & signed / dated by the patient
clinical examination
Most detailed document in dental record
Provides past , present , future exam data & charting
Completed for every new patient and updated at EVERY SUCCESSIVE APPOINTMENT
treatment plan form
includes diagnosis , treatment thats needs to be completed .
Fees
Most contain more than one proposed plan
Level 1 - emergency care
not best option , takes care of immediate problem mostly pain
(antibiotics)
Level 2 - standard care
what everyone must get , restores denition to normal function
Level 3- optimum care
highest level of care , restores dentition to max .
how to correct a mistake
make an arrow and make a line through the mistake then initial and date
t/f; only acceptable abbreviations may be used when charting
true
level 1; emergency care
least effective relives immediate pain and discomfort
level 2; standard care
restores dentition to normal function
level 3; optimum care
restores dentition to maximum function and great result (highest level of care)
this legislation applies when submitting personal pt info across provincal boundaries
PIPEDA ( personal information protection and electronic documents act)
what do u write on the medical sticker
the number that corresponds with the indication on the medical history form
most detailed document in the dental record. Provides past,present, future exam data .
Completed for every new patient & updated EVERY SUCCESSIVE APPOINTMENT
clinical examination
includes diagnosis, treatment that needs to be completed & how the dentist plans to proceed with the tx
Has fees
most contain more than one plan
treatment plan form
What happens at the end of tx on treatment records
details about what was accomplished, the progress of treatment planned. Instructions & recall appointment.
DA MUST SIGN AND DATE
