12 Questions
What type of information should be included in the identification data of an oral health record?
Patient full name, address, and telephone number, age, sex, and occupation
What is the primary purpose of the diagnosis stage in the oral health process?
To make a judgment of variations from normal
Why is it essential to determine the patient's chief complaint?
To understand the problem that initiated the patient's visit
What is the primary goal of infection control measures in oral healthcare?
To prevent the transmission of infections
What is the purpose of the barrier technique in oral healthcare?
To prevent the transmission of infections
What should a recording chart in oral healthcare be?
Uncomplicated, comprehensive, accessible, and current
What is the primary purpose of discussing the patient's current problem, including onset, duration, symptoms, and related factors?
To identify the need for specific diagnostic tools or tests
What type of condition may be identified during a medical review, requiring special precautions to prevent cross infection?
Communicable disease, such as hepatitis
What is the primary purpose of a dental history, including past and present dental history?
To understand the patient's current problem and anticipate future behavior
What is the first step in examining the oro-facial soft tissue during a clinical examination?
Examination of the submandibular glands and cervical lymph nodes
What is caries risk assessment defined as?
The probability that a specific number of new lesions will develop and/or existing lesions will progress over a specified period of time
What is the purpose of a clinical examination in a clean, dry, well-illuminated mouth?
To examine the patient's oro-facial soft tissue and other oral structures
Study Notes
Oral Health Record
- Includes identification data, medical history, dental history, clinical examination, diagnosis, treatment planning, and documentation of informed consent, progress notes, and completion notes.
Recording Chart
- Should be uncomplicated, comprehensive, accessible, and current.
- Uncomplicated: easily understood by the patient.
- Comprehensive: notes all conditions, both normal and abnormal.
- Accessible: can be easily reached for treatment or real appointments.
- Current: can accept any changes in treatment.
Examination and Diagnosis
- Examination: observing both normal and abnormal conditions.
- Diagnosis: determination and judgment of variations from normal.
Patient Assessment
- Infection control: instituted before, during, and after patient visits, including barrier technique and proper use of disinfectants and instrument sterilization.
- Chief complaint: determining the patient's primary problem, including onset, duration, symptoms, and related factors.
- Medical review: identifying conditions that may complicate or contraindicate dental procedures, including:
- Communicable diseases (e.g., hepatitis)
- Allergies (e.g., to penicillin or local anesthesia)
- Medications (e.g., anticoagulants)
- Systemic diseases and cardiac abnormalities
- Physiologic changes associated with aging
- Dental history: including past and present dental history, indicating patient motivation and future behavior.
Clinical Examination
- Performed in a clean, dry, well-illuminated mouth using diagnostic instruments (e.g., mirror, explorer, periodontal probe).
- Includes examination of:
- Oro-facial soft tissue
- Caries lesions
- Non-carious lesions
- Existing restorations
- Periodontium
- Occlusion
- Examination of patient in pain
Examination of Oro-Facial Soft Tissue
- Begins with examination of:
- Submandibular glands and cervical lymph nodes for abnormalities
- Masticatory muscles for pain or tenderness
- Visual examination and palpation of cheeks, vestibules, mucosa, lips, lingual and facial alveolar mucosa, palate, tonsillar areas, tongue, and floor of the mouth
Diagnosis of Dental Caries
- Caries risk assessment: probability of new lesions developing or existing lesions progressing over time.
- Identification of caries: diagnosed using traditional examination modalities, including:
- Visual examination using a mirror
- Examination of tooth surface texture or color changes
This quiz covers the essential information to be included in an oral health record, including patient identification data, medical and dental history, clinical examination, and treatment planning. It also outlines the proper format for recording charts.
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