3/4: Types of Dental Clinical Examinations Flashcards

1
Q

The foundation of any form of successful treatment is _________________

A

Accurate diagnosis

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2
Q

What is diagnosis the bridge between?

A

The study of disease and the treatment of illness

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3
Q

_______ before you _______

A

Inform; perform

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4
Q

If it isn’t written, it ___________________

A

Didn’t happen

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5
Q

What are types of clinical examinations?

A
  • comprehensive dental diagnosis
  • periodic/recall/recare diagnosis
  • diagnosis of a specific problem
  • emergency diagnosis
  • screening diagnosis
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6
Q

The diagnostic method can be modified to most effectively do what?

A

Address the needs of the patient (Chief complaint)

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7
Q

What does the diagnostic method alter?

A

The amount of diagnostic information collected initially and the scope of diagnostic decisions made by the clinician

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8
Q

What are examples of chief complaints that require immediate attention?

A

Pain, acute infection, bleeding or traumatic injury

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9
Q

What can chief complaints also be a request for?

A

Less urgent care

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10
Q

What do you do if a patient reports several complaints?

A

List in order of priority, AS STATED BY THE PATIENT

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11
Q

What is the most extensive diagnostic assessment?

A

Comprehensive dental diagnosis (initial dx, IOE)

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12
Q

What is comprehensive dental diagnosis appropriate for?

A

The patient who requests total dental care and HAS NOT BEEN EVALUATED PREVIOUSLY

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13
Q

What patients are comprehensive dental diagnosis used for?

A
  • patient of record who has not been seen in several years (3-5)
  • patient of record who has had major change in medical/dental history
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14
Q

What starts the minute you see the patient when performing a comprehensive dental diagnosis?

A

Physical exam and assessment

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15
Q

What does a detailed medical history assess?

A

Systemic diseases
Surgeries
Current medications (both RX and OTC)
Allergies
Establish ASA class

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16
Q

What is included in a comprehensive dental diagnosis?

A

Physical exam and assessment
Detailed medical history
Intra/extra oral evaluation and perioral/periodontal conditions
Dental radiographs
Diagnostic casts

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17
Q

What does comprehensive dental diagnosis data reflect?

A

The patient’s initial status, which serves for comparison later in assessing treatment effectiveness

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18
Q

What requires a considerable time, but provides a sound diagnostic foundation for comprehensive dental care?

A

Comprehensive dental diagnosis

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19
Q

What does comprehensive dental diagnosis protect the clinician by?

A

Documenting the patient’s initial status if treatment complications lead to accusations of sub-standard care

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20
Q

What are medical emergencies typically seen in a dental office?

A

Vasovagal syncope (63%)
Angina (12%)
Epileptic seizures (10%)
Choking (5%)
Asthma (5%)
Vasovagal syncope

21
Q

What is periodic (recall) appropriate for?

A

A patient who requests total dental care when the results of a prior comprehensive dental diagnosis are available

22
Q

What do you assume in a periodic diagnosis?

A

Portion of past information is still accurate but other aspects of the patient’s medical/dental history may have changed

23
Q

What month interval are periodic diagnosis?

A

6 month

24
Q

What is the goal in a periodic diagnosis?

A

Identify the conditions that have changed and supplement the prior database so that it reflects the patient’s current status

25
Q

What is a periodic diagnosis as simple as?

A

Asking patient if there has been changes since the last appointment (always good practice regardless of the time interval)

26
Q

What is a periodic diagnosis as complex as?

A

Repeating most of the comprehensive dental diagnosis

27
Q

What do updates that come from a periodic exam do for a dentist?

A

Refamiliarize the dentist with the patient’s original conditions and provides the new findings for comparison

28
Q

What do you do if a different clinical conducted the original diagnosis?

A

The current dentist must confirm the accuracy of prior data and record current findings prior to diagnosis decisions
(almost like doing a comprehensive exam)

29
Q

What is the dentist frequently asked to provide an opinion regarding?

A

A specific problem
- for a recently evaluated patient (second opinion)

30
Q

What is the soap evaluation an effective approach to?

A

Such situations if the available diagnostic database is current and accurate
- soap form is in axium

31
Q

What is “s” in the SOAP form?

A

S-Subjective information or symptoms of the condition as supplied by the patient. Patient’s chief concern or complaint. It is recorded in the patient’s own words

S- “Toothache on the upper right for the last 2
weeks-getting worse.” Patient reports pain to
cold and hot, duration 5-10 minutes, loss of
sleep and requires Motrin 3-4 x day

32
Q

What is the “O” in the SOAP form?

A

O-Objective or physical findings of the clinician. Includes visual findings,
periodontal assessment, clinical tests (percussion, palpation, vitality tests)

O- # 3Grossly decayed (+) response to percussion & palpation,(-) swelling, mobility. #3 is non-vital to electric pulp testing(EPT), no
apical change interpreted on the periapical radiograph

33
Q

What is the “A” in the SOAP form?

A

A-Analysis or clinical impression of the condition by the clinician This is the diagnosis

A-Caries, necrotic pulp, -tooth is restorable

34
Q

What is the “P” in the SOAP form?

A

P-Plan or recommended management of the problem. May be specific
treatment, referral, or dismissal of the condition as clinically insignificant

P- Discussed treatment options including RCT
and crown vs. extraction. Risk/benefits of each
procedure explained. Patient prefers RCT and
understands that the tooth may need crown
lengthening procedure

35
Q

What are emergency diagnosis designed to manage?

A

A chief complaint such as pain, bleeding, or acute infection that requires immediate attention

36
Q

What is the comprehensive diagnostic evaluation sacrificed in?

A

The interest of providing attention to the urgent problem

37
Q

What is limited in most aspects to the chief complaint?

A

Physical examination

38
Q

What can be demanding because the patient’s concern of the “CC” can interfere with obtaining an adequate patient history?

A

Emergency diagnosis

39
Q

What do screening diagnosis answer?

A

A specific question about the patient

40
Q

What are screening diagnoses evaluation limited to?

A

Obtaining the information needed to answer the question without accepting comprehensive diagnosis or treatment responsibility for the patient

41
Q

Why do institutions rely on screening diagnosis?

A

To determine the patient’s general dental treatment needs
*see this when students are looking for board lesions

42
Q

What is the most common symptom arising in the mouth, face, and neck area?

A

Pain

43
Q

What is the most common reason for emergency appointments?

A

Pain

44
Q

What is pain?

A

Subjective and unlike an ulcer, there may be nothing to assess visually

45
Q

What do you need to be as a dentist?

A

Good listener and have good follow up questions

46
Q

What are questions to ask when diagnosing pain?

A

How would you describe the pain?
- dull/throbbing, sharp/stabbing, burning
- when did you first notice it?
- is the pain continuous or does it go away? How long does it last?
- does it wake you up at night?
- Has it gotten better/worse or stayed the same?
- anything make it worse? anything make it better?
- have you taken anything for the pain?

47
Q

Pain arising from pathology is usually _________

A

Unilateral

48
Q

What may indicate an inefective organ?

A

Swelling, discharge, bad taste, bad breath, elevated temperature, malaise or cervical lymphadenopath