EVALUATION VISIT

Armamentarium

1. Obtain your patient's chart from the instructor. The chart should include: continuation sheet, medical history form, general consent form, and Medicaid reimbursement form (if applicable).

2. Briefly review the chart.

Determine if the chart is complete. The pink medical history and the white pediatric dental consent and policy form should be signed.
All forms must be signed by a parent or legal guardian (not by the patient or another relative).

Review the medical history form to determine if there are any medical problems listed.

Determine if radiographs have been taken previously and if they are in the chart.

3. Obtain necessary forms: yellow treatment plan form and continuation sheet. Also request a slip for a toothbrush and dental floss from an instructor.

4. Greet the patient and parent in the reception area and escort them to your operatory. At subsequent visits the patient should be encouraged to come to the chair alone.

NOTE: At the evaluation visit, no child may be treated without a parent or legal guardian present.. All younger patients must be accompanied by an adult over the age of 18 at every visit. If the parent or legal guardian is unable to accompany the younger patient at every visit, the section designating another specific adult to accompany and consent for the patient must be appropriately signed.

5. Explain to the accompanying adult that the evaluation visit is devoted to examination, toothbrush prophylaxis, fluoride treatment and oral hygiene instruction. This prevents misunderstandings as to the treatment planned for this visit. An exception will be made if an emergency exists. Ask the parent if there is an emergency (pain, swelling or bleeding) or if they have a specific question or concern (chief complaint).

The Role of Prophylaxis in Pediatric Dentistry
Reviewed and Reaffirmed May 1996, From AAPD Reference Manual 1999-2000

There are several indications for a dental prophylaxis, including:

1. Removal of plaque from teeth
2. Removal of extrinsic stains from teeth
3. Polishing teeth after removal of calculus
4. Facilitation of a thorough clinical oral examination
5. Education and introduction of the child to dental procedures

Traditionally, the dental prophylaxis has included tooth polishing with a rubber cup. This is a procedure whereby a dental polishing paste is applied to tooth surfaces with a rotary rubber cup or rotary bristle brush. Based on research findings regarding the potential of a rubber cup/pumice prophylaxis to remove fluoride-rich enamel, the toothbrush prophylaxis has gained acceptance for use during initial or recall examination visits. In this procedure, plaque is removed from tooth surfaces using a toothbrush and dental floss. Part of the rationale for the toothbrush prophylaxis is to conserve the fluoride-rich enamel surface while enhancing the uptake of fluoride.

Recommendations:

1. The dental prophylaxis should be used as part of a comprehensive preventive program designed to improve children's ability to maintain their personal oral health. The use of dental prophylaxis should be considered as an educational tool to allay patient fears regarding the manipulation of oral tissues.
2. A patient-appropriate dental prophylaxis should be performed when indicated, in conjunction with oral hygiene instruction, periodic oral examination visits, and other indicated preventive care.

6. Before any examination or treatment is rendered, review the medical history with the parent or guardian. If the parent does not speak English, an appropriate interpreter e.g. instructor, staff member or fellow student (not a child) should be asked to translate.

7. If the patient has a significant health problem or allergy discuss it with your instructor prior to touching the patient. If necessary the medical chart or physician should be consulted. The medical chart can be requested via the 9th floor Pediatric Dental Clinic. Medical history must be noted on the yellow treatment plan form. If the medical history is non-contributory to oral conditions and will not have a significant effect on dental care the following note must be written: "patient is in good health; no contraindications to routine dental treatment". If a medical problem exists they must be listed along with any medication including dosage and frequency. A one or two word medical alert note should be written in red in the designated area on the top of the yellow form.

NOTE: If for any reason, the medical history can not be completed, a notation should be made in the chart and all invasive procedures should be deferred until the history can be completed.

8. Ask the parent about the patient's past dental history. This should include:

a.Past accidents to teeth, jaws and soft tissue.
b.Previous dental treatment and the patients behavior at that time (the age of the patient at
the time of the previous treatment is important in evaluating the significance of the
previous behavior).
c.Previous orthodontic treatment.
d.Any habits that may affect oral development or caries rate, e.g. nursing bottle habits,
long-term breast feeding on demand.

9. Explain the preliminary consent (top part of white consent form) to the parent or guardian and have them sign it. This includes prophylaxis, fluoride treatment, radiographs and any emergency treatment, which is specified.

10. The next step is the extraoral and intraoral examination in the order given on the yellow treatment plan form. If findings are normal this should be indicated with the abbreviation "WNL" (within normal limits). Any abnormalities should be described. Infection control procedures must be strictly followed. One way to maintain proper infection control while charting is to have a classmate complete the form. Another method is to have a headrest cover nearby to cover your gloved hand while writing in the chart. Under no circumstances should you hold the chart, pen or radiographs with contaminated gloves.

11. Instruction in oral hygiene should be given with the parent present to educate the parent and encourage follow through at home.

First, disclose the entire mouth for plaque and do the plaque index. The results of the index should be recorded on the yellow treatment plan form. Discuss the results with the patient and parent in terms they can understand. Remember to compare results at subsequent appointments to encourage good oral hygiene. An instructor should check the plaque analysis.

Demonstrate and explain tooth brushing technique. Use tell, show, do. Use the mirrors above the clinic sinks (they tilt to the patient's eye level). Flossing instruction should be given to children over 10 years old; parents can be shown how to floss for younger children.

12. Oral health education material including a brief discussion of cavities, carbohydrates and sugars in the diet, plaque and the relationship to good oral hygiene should be presented at this time. It is important that the patients know why they are brushing their teeth in order to motivate them to achieve good dental health.

13. At this point it can be suggested that the parent wait in the reception area.

14. If there are no problems requiring emergency care, scaling and oral pumice prophylaxis done sparingly (as needed) are done. After the prophy rinse the patient's mouth thoroughly to remove excess prophy paste.

15. Then, a brief yet thorough assessment of the patient's dental status is done in order to
determine radiographic needs. Some important factors are:

a. The presence and size of carious lesions.
b. Missing or impacted teeth.
c. Over-retained primary teeth.
d. Dental age.
e. Dental anomalies.
f. Soft tissue lesions
g. Time since the last radiographs were taken

Prior to taking radiographs an instructor must be consulted to determine the appropriateness of the selected views. The radiographs are then taken and developed.

16. At this point the detailed examination of the teeth and related structures is resumed using
tell, show, do. This examination begins with the orthodontic considerations. This section of the chart is designed to be completed with brief answers. A plus sign (+) indicates a positive answer; a minus sign (-) indicates a negative answer. A number or brief answer can be use when indicated. Any additional comments concerning the patient's orthodontic status may be added at the bottom of the page, e.g. "deep curve of Spee" or "multiplane occlusion".

17. With the radiographs as an adjunct the individual teeth should now be examined. It is
preferable that a blue and red pencil be used to complete this section of the chart. The numbers or letters of the teeth present are circled in blue. The charting code should be use as a guide to identify unerupted, mobile, impacted, extracted, or fractured teeth, etc.

Carious lesions are indicated in red pencil, and existing restorations in blue. If an existing restoration is defective, the blue mark is outlined in red.

A sealed tooth can be marked with a blue "S". If the existing restoration is a preventive resin restoration (PRR) or glass ionomer (GI) this should be noted next to the tooth.

18. If special management is indicated for the patient (because of behavior, pain response, medical condition or treatment plan) the appropriate box is checked after consultation with an instructor.

19. Each time radiographs are taken, the date and an abbreviated interpretation must be written.
Examples of appropriate notations would be:- "WNL", "caries", "pulp stones", etc.

20. A problem list should then be written. e.g.:-

a. Multiple caries.
b. Thumb habit.
c. Open bite.

21. Using the information which has been charted a tentative sequential treatment plan can then
be written lightly in pencil on the chart or it can be written on a spare piece of paper.

22. If the patient requires treatment, which must be deferred until a more appropriate time, this may be noted under Future Considerations.

23. The final section is the Preventive Program. It should be noted whether the patient has more or less than two smooth surface or pit and fissure carious lesions. The current fluoride status and any supplementation, whether prescription or over the counter, is then noted. If indicated a Diet History Form is given to the parent. When it is returned it will be useful in caries prevention counseling.

24. At this point an instructor must check the treatment plan and preventive program. After any corrections the blue and red pencil marks are colored over in blue and red ink.

25. The four minute fluoride treatment is done using disposable fluoride trays or using cotton roll isolation if the patient will not tolerate the trays. If trays are used the maxillary and mandibular arch should be done at the same time. About 5ml of APF fluoride gel is placed in each tray. With cotton roll isolation using the roll holder, one half of the mouth is done at a time. The fluoride gel is applied with cotton tipped applicators for four minutes. For either method the saliva ejector is in place throughout the application and the patient is in an upright position. Care should be taken to prevent excessive fluoride ingestion. The patient can not be left unattended with the fluoride tray in place; and if the four minutes of waiting time is used to write up the chart, the patient must be within the field of vision of the operator throughout the treatment.

After four minutes have elapsed, the interproximal areas are flossed and the excess fluoride gel is removed with suction. No water is given to the patient to rinse. The patient is advised not to eat, drink or rinse for half an hour.

26. A note is then made in the dental chart using the appropriate format, including the procedures that were done. The patient's behavior during the visit should be noted using the Frankl scale (B=1 through 4) an explanation shall be given of specific behavioral occurrences. The abbreviation PICPF should be used to indicate that "proper infection control procedures were followed". The grade form is completed and these forms checked by the instructor.

27. The parent is then requested to rejoin the patient and a summary of the visit is given and the treatment plan is explained. The parent must then sign an informed consent to treatment (see forms).

28. The patient is then given the next appointment. This appointment MUST be written in the appointment book.