ORAL DIAGNOSIS

1. ORAL DIAGNOSIS Dena 320 Deborah Bell

2. Diagnosis • To identify or determine the nature and cause of a disease or injury through evaluation of the medical and dental history. • The dentist only can diagnosis

3. Assessment • Assess is to evaluate or conclude

4. Assistant’s Responsibility • Data gathering to bring together all of the information required by the dentist to make and accurate diagnosis of the patient’s condition • accomplished by asking the new patient to complete printed forms - reviewing these forms with the patient in interview form to clarify and gain more information.

5. Patient Record • Result of overall process of delivering patient care • permanent document which reflects the patient • primary source of information to assess the quality of care given a patient • source of data for research purposes

6. Provides documentation regarding the patients • condition • diagnosis • treatment • responses to treatment • risk management for team

8. Components of the Patient Record • Patient information • demographics • financial responsibility • medical history • alerts to possible medical conditions • medications • special treatments needs to avoid emergencies • patients signature

9. Make sure there is a signatured release form to allow release of information • consultations with physician if needed

10. Continue Medical History • Update history at each visit • patient and assistant reviews • patients signs and dates • health changes/ no changes • surgery • conditions • Medications • Medical alert information

11. Vital Signs • Pulse • respiration rate • body temperature • blood pressure

12. Pulse • Expansion of the artery as the heartbeats • slight finger pressure used to identify • normal pulse rate in resting adults • 60 - 100 beats per minute • normal pulse rate in resting child • 70 - 110 beats per minute

15. Recording technique • radial artery • count for 30 seconds and multiply by 2 • Or count for 1 minute • IMMEDIATELY RECORD ON RECORD • Note any arrhythmia's

16. Respirations • Normal respiration rate for relaxed adults • 10 - 20 breaths • Normal respiration rate for relaxed child • 20 - 26 • observe patients chest rise and fall for30 seconds and multiply by 2

17. Body Temperature • Average normal 98.6 degrees • normal range 96.4 - 99.1 degrees Fahrenheit

19. Blood Pressure • The amount of labor the heart has to exert to pump blood throughout the body • Systolic pressure • first recording (higher number) • pressure it takes for left ventricle to push oxygenated blood out into the blood vessels

20. Diastolic pressure • second number (lower number) • reflects the hear muscle at rest • both pressures are measured in millimeters of mercury (mm HG)

21. BP classifications for adults • Normal • 120/80 • range less than 130/less that 85 • high normal • 130 - 139/ 85 - 90

22. Hypertension • stage 1(mild) • 140-159/91-99 • stage 2 (moderate) • 160-179/100-109 • stage 3 (severe) • 180-209/110-119 • stage 4 (very severe) • 210 & above/120 & above

23. Types of BP Meters • Automated electronic blood pressure device • sphygmomanometer & Stethoscope

26. BP technique Guidelines • Extend the patients arm at same level as heart • cuff approximately 1 inch above the antecubital space • secure cuff around arm with all air expelled • Korotkoff sounds phases

29. Phase I • first distinct thumping sound and becomes louder • SYSTOLIC READING • Phase II • sound softens • Phase III • becomes crisper and intensifies

30. Phase IV • distinct abrupt muffling • Phase V • artery is fully open and sound disappears • DIASTOLIC READING • Record immediately and verbalize your reading results to the patient

31. guidelines • If more than one reading needed allow 10 minutes between ideally • If somewhat high before procedure take again at end of appointment • If reading is extremely high • choose not to begin procedure • refer to physician

32. Components of a Dental Examination

33. Oral Examination • Takes place after the patient has completed the medical history and vital signs have been recorded

34. Components • General overall appearance • facial area • temporomandibular joint • oral mucosa • lips • tongue • floor of mouth

35. Palate • gingival tissue • occlusion • teeth • structures maintaining the teeth in position

36. Techniques for examination • Visual examination • whole patient not just oral area • palpation • feeling for abnormal changes • instrumentation • caries detection • intraoral/extraoral radiography

37. Intraoral imaging • provide better visibility • better evaluation • case presentations • risk management • photocopy for insurance purposes

38. Intraoral/extraoral photography • treatment planning • case presentation • Oral Cancer exam • neck • facial areas • intraoral tissues • by touching and visual evaluation

39. Remember • Check for crepitus (popping of TMJ at tragus of the ear) when you complete the oral cancer exam • Note Bruxism habit (grinding)

49. Oral Hygiene IndiciesEvaluation and Recording • A systematic assessment of plaque debris and calculus • Use of 6 tooth surfaces: 4 post / 2 ant. • Division of tooth into thirds used as principle

50. Scoring of Indicies • 0 – no plaque • 1 – no more than 1/3 of surface • 2 - 2/3 or more that 1/3 but not more than 2/3 • 3 – more that 2/3 covered • Total points each category and divide by number of surfaces ( 6 or both 12)