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  • periodic oral evaluation — established patient
  • limited oral evaluation — problem focused
  • oral evaluation for a patient under three years of age and counseling with primary caregiver
  • comprehensive oral evaluation — new or established patient
  • detailed and extensive oral evaluation — problem focused,by report
  • re-evaluation — limited, problem focused (established patient;not post operative visit)
  • comprehensive periodontal evaluation — new or established patient

Pre-diagnostic Services - screening of a patient - assessment of a patient

Models(odontograms) - pre treatment=> diagnostic - Treatment planning - During treatment - post treatment - again pre treatment

Patient record

  • chief complaint
  • background information
  • history of present illness Demographic information
  • Name
  • History
    • personal history
    • Medical history
    • persent illness history
      • dental history

Consultant • Clinical assessment (provisional diagnosis method) - General examination - psychological - physiological - local examination - Extraoral - Head(⅓) - Face(⅔) - shape/structure - symmetry - profile - Devergence - jaw-relations - proportions - Intraoral - Lip - Tongue - Gingiva - colour - size - Texture - contour - consistency - Bleeding on probe - position

    - Teeth
        - Type of dentition 
        - Tooth Presence
            - Number
                - ==Missing (= present)
                - ==supernumerary==
                - ==impacted==
            - Position
        - Tooth structure 
            - Segment 
                - flurosis
                - hypoplasia
                - stains
                - wasting
                - Bridge
            - Single
                - Decayed
                    - class
                    - Depth
                    - Type
                - Filled
                - Fractured
                - inclined
                - crown
        - Occlusal trauma
        - Occlusion
        - periodontal status
            - gingivitis
            - pockets
            - mobility
            - furcution
- Functional
  • Provisional Diagnosis
  • History centered diagnosis
  • Investigation Diagnosis
  • Diagnosis
  • prophylaxis
  • prognosis
  • Treatment plan

Referral - Treatment progress

Principles of treatment

Date

Examiner name

Patient ID

Name

For Identification

Date

Questioning technique

Rapport

Types of questions

Open=Tell me about the pain. Closed=What does the pain feel like? Leading= Does the pain feel like an electric shock?

Pros

Cons

When

Step -1 A detailed history

Personal history/Demographic details

The age, gender, ethnic group and occupation of the patient should be noted routinely; even though apparently trivial, such information is occasionally critical.

For Age related diseases or conditions Gender related Ethic groups habit related Occupational related

Dental history

Medical history

A medical history is important because it aids the diagnosis of oral manifestations of systemic disease. Some medical conditions they have there don't know or aware of it

These are specific evaluation so Last is better

History of the present complaint

It is the reason to visit the doctor which is in a symptoms of patient for treatment and suggests the diagnosis and

It is patient own words so hints patient's psychology

Types of symptoms or complaints - pain - Burning sensation - Bleeding - Loose teeth - occlusal problem - Halitosis - swelling - xerostomia - Bad taste - Repair

History of Present Illness of present complaint

Pain and it's chronology,causes,functions Character,severity,duration❗

It is imperative to obtain patients’ consent for any procedure, including examination. Requirements for consent

CLINICAL EXAMINATION(odontogram)

First, look at the patient, before looking into the patient’s mouth.

Extral Oral

Intra Oral

Examination of Nondental Structures(Soft tissues)

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Oral hygiene Lips Gingiva Floor of the mouth Buccal mucosa Tongue Palate Tonsils and adenoids

Examination of Dental Structures(hard tissues)
Teeth

Difference between deciduous and permanent teeth Stains and calculus Percussion test Mobility and depressibility test Dental arch irregularities Occlusion Presence of periodontal pocket Furcation involvement Pulp testing or vitality testing Thermal testing Heat testing

  • Enamel opacities/hypoplasia are assessed on index teeth(14, 13, 12, 11, 21, 23, 24, 36, 46) using DDE index (43-52) while dental fluorosis is assessed using Dean's criteria (53).
  • CPI (54-59) and loss of attachment (60-65) are assessed on index teeth (17/16, 11, 26/27, 36/37, 31,
  • Dentition status (crown and root) and treatment needs are recorded for maxillary teeth (66-113) and mandibular teeth (114-161). In maxillary and mandibular teeth, status of crown and root are recorded separately followed by treatment needs.
  • Prosthetic status for upper and lower arches are entered while prosthetic need in 164 and 165.
  • Dentofacial anomalies are assessed using dental aesthetic index (DAI) with boxes for entering number missing incisors, canines and premolars in the dentition category (166-167), crowding (168), spacing (169), diastema (170), largest anterior maxillary (171) and mandibular irregularities ( 172) in the space category and anterior maxillary (173) and mandibular overjet (174), vertical anterior open bite (175) and anteroposterior molar relation (176) in occlusion category.

Need for immediate care and referral such as life treatening conditions (177), pain or infection ( 178), other conditions (179) and referral ( 180) are entered as the case may be. Space at the bottom is earmarked for notes to enter any patient's information which .is important.

The fifth edition of WHO Oral Health Surveys - Basic Methods makes the following recommendations for oral health surveys.

• Dentition status should be recorded in compliance with Lhe recommendations given in previous editions of this manual. Recording of specific dental treau11ent needs for india,dual teeth is no longer recommended. 161 • Recording of periodontal status by sextants or index teeth has been modified to include assessment of gingival bleeding and recording of pocket scores for all teeth present. Presence of calculus is not recorded. The recommendation not to probe pocket depth in children less than 15 years of age remains unchanged. Loss of attachment should be recorded using index teeth except in children under 15 years of age, • Recording presence of enamel fluorosis is recommended. Calculation of tJ1e community fluorosis index. • Loss of tooth substance due to erosion as well as the number of teeth involved. • Orodental trauma includes injury to the mouth, including tJ,e teetJ,, lips, gingivae and tongue, and jaw bones. • Recording of presence of fixed or removable dentures has been included in tJ,e adult assessment form. • Examination of the oral mucosa and recording of extraoral conditions and their location using standardized coding are included. Most common oral lesions occurring in human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are also recorded. • The section on intervention urgency specifies the recommended level of treatment in response to acute oral problems and the need for immediate referral to special care. This may also include preventive care or routine dental care required for large carious lesions witJ, or witJ1out accompanying pa.in or evident infection. Urgent intervention may also be needed in cases of reported pain and obvious signs of severe infection.

Gingiva

Jaw swelling Asthetics

The soft tissues of the mouth should usually be inspected first. Examination should be systematic to include all areas of the mouth

Again present illness if you see mouth

Medical examination

Provisional diagnosis /Tentative diagnosis

Investigation

Final Diagnosis

Treatment plan

Consultation form

  • List the availabilities of following examination(tests)=> diagnosis(diseases)=>prognosis=>treatment(procedures)

Examination

Parts -All parts -Thier type -Thier manifestations -complaints(clinical features) - Differentiation diagnosis - group of individual changes = disease (confrimed) -disease(diagnosis) -Treatment plan -Treatment

Manifestations - Systemic - Local

Never trust what patient or others say because thier don't know about it and draws false conclusion.Believe the fact what is present meanwhile Patient also never trust what a doctor say by that principle.

Chief complaint

I.urgent phase II. control phase III. re-evaluation phase IV. definitive phase V.maintenance phase

Promotive Emergency Etiotropic/Preventive Sugrical/Curative Restorative/Rehabilitation Recall/Maintenance