(1) adapted from ryanef123: OMFS 1 - OMFS Health Status Evaluation & Principles of Uncomplicated Exodontia (Dr. Stephens)

What is the order of taking a structured medical history?

• Demographic information

• Chief complaint

• History of Present Illness

• Past Medical History

• Past Surgical History

• Family History

• Social History

• Medications

• Allergies

• Review of Systems

What is a one sentence summary in the patients own words?

Chief complaint

Define the following:

Includes information gathered by your questioning of patient regarding their chief complaint

History of Present Illness (HPI)

When recording a History of present illness, what nuemonic can help you gather all important information?

OLD CARTS

- Constitutional symptoms (fever, chills, lethargy, etc) should also be included

The O in OLD CARTS stands for:

Onset

The L in OLD CARTS stands for:

Location/radiation

The D in OLD CARTS stands for:

Duration

The C in OLD CARTS stands for:

Character

The A in OLD CARTS stands for:

Aggravating factors

The R in OLD CARTS stands for:

Relieving factors

The T in OLD CARTS stands for:

Timing

The S in OLD CARTS stands for:

Severity

What has the following characteristics?

• Sequential, comprehensive method of eliciting patient symptoms on an organ system basis

• May reveal undiagnosed medical conditions unknown to the patient

• Should be guided by pertinent answers obtained from the history

Review of systems

If IV sedation or GA is planned, what (three) systems should be reviewed?

• Cardiovascular

• Respiratory

• Nervous systems

Dentists are expected to perform a quick review of what on every patient?

• Head

• Ears

• Eyes

• Nose

• Mouth

• Throat

What are the organ systems that should be reviewed during review of systems?

• Cardiovascular

• Respiratory (Pulmonary)

• Nervous

• Musculoskeletal

• GI

• Endocrine

• Urinary

• Reproductive

• Immune

• Lymphatic

• Integumentary

What information is gathered after the patient history is complete?

Physical exam and Radiographs

ID the ASA status:

mild systemic disease,no functional limitations, well-controlled conditions:

• current smoker, social alc use

• pregnancy

• class I obesity: BMI 30-40

• well controlled DM/HTN

• mild lung disease

aka A Patient with Mild Systemic Disease: Mild Asthma, Controlled Hypertension, Anemia, Controlled Seizure, Early NIDDM

ASA II

ID the ASA status:

severe systemic disease, some functional limitations, poorly controlled:

• poorly controlled DM/HTN, COPD

• Class II morbid obesity: BMI ≥ 40

• active hepatitis

• alc dependence/abuse

• implanted pacemaker

• moderate ↓ ejection fraction (EF 30-50%)

• ESRD: require dialysis or kidney disease

aka A Patient with Severe Systemic Disease Which Limits Activity: Angina Pectoris, Prior MI, COPD, IDDM, Advanced NIDDM

ASA III

ID the ASA status:

which ASA status?

severe systemic disease, constant threat to life

• recent <3mo serious conditions

• ongoing cardiac ischemia

• severe ↓ ejection fraction (EF <30%)

• sepsis

• DIC

• ARDS

• ESRD not on dialysis

aka A Patient with Incapacitating Disease that is a Constant Threat to Life: Congestive Heart Failure, End Stage Renal Disease, Advanced COPD, Hepatic Failure

ASA IV

which ASA status?

moribund pt, not expected to survive w/o operation: ruptured aneurysm, massive trauma, intracranial bleed w mass effect, ischemic bowel, or multiple organ/system dysfunction

V

which ASA status?

declared brain-dead pt, organ donation

VI

What has the following characteristics?

• Energy cost of physical activity (measure the amount of energy your body uses during physical activity compared to when you are resting)

• Defined as the ratio of metabolic rate during activity to reference metabolic rate (3.5ml O2)/(kg x min)

• 1 MET = 1 kcal/(kg x h)

Metabolic Equivalents (METS)

if pt has < 4 METs what needs to be done?

further testing to eval cardio reserve and health before procedure

What vitals information should be gathered during the physical exam?

• Blood pressure

• Pulse

• Respiratory rate

• O2 saturation

• Temperature

What part of the physical exam...

• Notes any asymmetries, swellings, abnormal lesions such as moles or ulcers

• Palpates the face and neck to note any pain on palpation, swellings, etc.

• If maxillary sinus is involved, percussing the maxillary sinus area may be warranted

Head and neck exam

What part of the physical exam...

• Examine the dentition

• Note any swellings, pain on palpation, firmness of the floor of the mouth, deviation of the uvula, etc.

• Note any pathologies including ulcers, pigmentations, or raised lesions

intraoral exam

What type of radiograph should be taken for single teeth (except 3rd molars)?

PA radiograph

What type of radiograph should be taken for...

• Overview of the maxilla and the mandible

• Good for bony pathologies, 3rd molars, dentoalveolar or trauma to the mandible and maxilla

Panoramic radiograph

What type of radiograph should be taken for...

• Detailed 3 dimensional view of the facial skeleton and soft tissue

• Good for maxillofacial trauma, severe infection, maxillofacial pathology, implant planning, etc.

CT scan

What has the following characteristics?

• A summary of your findings

• Differential diagnosis can be included in this section

• E.g. 30 y/o M who presented with pain associated with #3. The patient is being treated for asthma, but is controlled with albuterol

Assessment in SOAP note

What has the following characteristics?

• Stepwise treatment for the patient

• Include type of anesthesia

• E.g. the plan is to extract #3 under local anesthesia

Plan in SOAP note

Do we get clearance from medical doctors to go forward with a treatment?

NO! It is a consult, NOT clearance; we still have skin the game

What type of note?

To be completed at initial visit (150 exam completion in UG clinics) to TUSDM clinics including consultation visits to specialty departments.

New Patient History and Physical Note

What type of note?

To be completed for patients who are new to TUSDM (do not have established providers) and are having a procedure performed. Details of the procedure may be recorded under the section "Record of Procedure". This template includes components of both the New Patient note and the Procedure Note.

Emergency Procedure Note

What type of note?

To be completed when a procedure is performed on an established patient who has already had a New Patient note completed. Details of the procedure may be recorded under the section "Record of Procedure".

Procedure Note

What type of note?

To be completed during follow up visits after a procedure or other situations outside of those outlined in the above templates. This template is in the SOAP format.

Follow Up Note

A ________ is found in either Procedure Note or Emergency Procedure Note. This is where you document what you did during a particular procedure

"Record of Procedure"

What are the five elements of informed consent?

• Disclosure of information

• Patient competency

• Voluntary decision-making

• Reasonable alternatives with risks

• Assessment of understanding

• Consent involves a discussion of the risks, benefits, and alternatives of a procedure

What has the following characteristics?

• To be completed before all irreversible procedures

• The individual signing the time out must see you identify the tooth with an instrument and obtain the patients agreement

Time Out

ID the tool (yellow arrow):

Periapical curette

ID the tool (orange arrow):

No. 9 Molt periosteal elevator

What is typically one of the first instruments used when starting an extraction?

No. 9 Molt Periosteal Elevator

• separate gingiva and periosteum from underlying bone

• sharpey’s fibers: thick bundles of strong type I collagen fibers that anchor the periosteum to underlying bone

What is typically one of the last instruments used after an extraction?

Periapical curette

ID the tool:

Minnesota retractor

ID the tool (orange arrow):

Bone file

ID the tool (yellow arrow):

Root picks

ID the tool (blue arrow):

Seldin Retractor

ID the tool (blue arrow):

Syringe

ID the tool (pink arrow):

Scalpel Handle

What number scalpel blades is most commonly used in dentistry?

#15

What tool should you use to connect a #15 blade to a scalpel handle?

Hemostat

How do you attach a surgical blade?

• Hold blade handle in gloved hand

• Grasp dull side of blade with needle driver

• Align beveled end of blade with beveled edge of handle

• Slide blade onto handle end until it engages with a "click"

ID the tool:

"Sweetheart" tongue retractor

- Common for procedures under anesthesia

ID the tool:

Bishop retractor (cheek and tongue retractor)

ID the tool:

Side cutting rongeur (can cut bone)

ID the tool:

End cutting rongeur (can cut bone/smooth it down)

ID the tool (blue arrow):

Suture Scissors

most common dental anesthesia techniques?

long buccal, IAN, infiltration

ID the tool (pink arrow):

Needle holder

ID the tool:

Tissue forceps

ID the tool:

Small curved hemostat

ID the tool (blue arrow):

Small straight elevator (used 1st and helps make teeth mobile)

ID the tool (pink arrow):

Large straight elevator (helps make teeth mobile)

What are the parts of a straight elevator:

• Blade

• Shank

• Handle

What type of simple machine is the straight elevator?

• As type 1 LEVER and WEDGE

• Wedge first, then lever

What direction of pressure do you apply with the straight elevator?

Apical

which side of the curve of the elevators is the working side (CW and CCW)?

the one closest to you (which ever area of the tooth MD or side of the mouth you are on)

ID the tools:

Cryer Elevators OR East / West Elevators

*Uses a wheel and axel mechanics

ID the tools:

Miller elevators

ID the tool:

Crane pick

ID the tool:

Universal Maxillary Extraction Forceps (#150)

ID the tool:

Universal Mandibular Extraction Forceps (#151)

What are the components of a forceps? (3)

• Beak

• Hinge

• Handle

ID the tool:

Root Tip Forceps (286) /Bayonet forceps

ID the tool:

Straight Maxillary Anterior Forceps (#1)

ID the tool:

Cowhorn Forceps #23

*used for furcation (esp. mandibular molars)

ID the tool:

Ash Forceps (English Style)

*used for bicuspids/anterior teeth

ID the tool:

Proximators

*used to make space for elevator use & retractora

ID the tools:

Proximators

*used to make space for elevator use & retractora

ID the tool:

Hall Drill

*lots of torque, thick bone

What is the benefit of using a Hall drill vs. a traditional handpiece?

Lower risk of air emphysema

What are 3 types of absorbable suture material?

• Plain Gut

• Chromic Gut

• Vicryl

All of the following are types of non-absorbable suture material EXCEPT:

A. Silk

B. Polypropylene

C. Polyester

D. Nylon

E. Gut

E - this is absorbable

What suture material do we use at TUFTS?

Chromic gut

The numbers of a suture material denote the thickness of the

material. A higher numbers mean _________ material

Thinner

What type of suture material?

• Absorbable suture material

• Derived from bovine intestine with chromic salts to slow absorption (vs plain gut)

• 6-10 days of tensile strength

• Most commonly used intraoral suture

Chromic gut

What type of suture material?

• Absorbable braided synthetic material

• Holds tensile strength for ~14 -21 days

Vicryl

Which absorbable suture absorbs the quickest?

• Plain Gut

• Chromic Gut

• Vicryl

Plain Gut

Which absorbable suture absorbs the slowest?

• Plain Gut

• Chromic Gut

• Vicryl

Vicryl

In terms of chair position, you should put the seat higher and a more reclined position when extracting ______ teeth

Maxillary

In terms of chair position, you should put the seat lower and a more upright position when extracting ______ teeth

Mandibular

When doing an extraction, if you are right handed, you should stand to the front and to the _____ side of the patient

Left

When doing an extraction, if you are left handed, you should stand to the front and to the _____ side of the patient

Right

ID the procedure:

- Extraction, erupted tooth or exposed root (elevation, and/or forcep removal)... routine removal of tooth structure, minor smoothing of socket bone and closure as necessary

Simple extraction: D7140

ID the procedure:

- Requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated

Surgical extraction: D7210

For a simple extraction, detach soft tissue off of the tooth ___________

Circumferentially

For a simple extraction, luxate the tooth in the ___________ direction to create space with elevator

Mesio-distal

For a simple extraction, luxate the tooth ___________ with forceps to create space/overcome the undercuts for the tooth to be removed

Bucco-lingually (primarily buccal)

How does aging/degeneration generally affect the mechanical strength of bone?

Decreases strength