9.1 Introduction
Preparation for
patient care is an extremely crucial step towards providing quality dental
services.
The dental assistant must use the
history form to document medical, dental and personal history. Once the
information is recorded, the assistant must inform the dentist in case of any
abnormalities. The dental assistant is also responsible for recording body
temperature, blood pressure and pulse rate.
Preliminary patient care includes
both extra-oral and intra-oral examination. Extra-oral examination includes
gently feeling the floor of the mouth and the side of the cheek bone, in order
to check for abnormalities. You would also observe the condition of the lips.
Intra-oral examination includes a thorough examination of the dentition, gum
tissue and tongue and recording any findings or abnormalities.
Dental charts are created, once a
patient makes their first visit to the dental office. The chart contains the
condition of each tooth, as dictated by the dentist and recorded by the dental
assistant. Notations in red indicate pending treatment, whilst notations in
blue indicate completed treatment.
Modern dental offices use dental
charting software, which allows the assistant to record information with the
use of a light pen, or even voice activation. The assistant needs to be
extremely careful when updating a dental chart, as they are legal records which
may be used for litigation and forensic purposes.
Computerised charting can be done
with the help of a light pen or voice activation. You can also enter
information with the help of a keyboard. All equipment used in the treatment
room should be covered with protective plastic, in order to ensure infection
control.
9.2 Preparation for Patient Care
In
the treatment room, the dental assistant must provide an accurate evaluation of
patient history.
This plays a key role in the
diagnosis and formulation of a treatment plan. Moreover, the medical
information must be reviewed and updated during every subsequent visit. All
surgeries, diseases, treatments, allergies and so on must be listed in
chronological order - and this is particularly relevant if the patient is
suffering from any chronic health conditions. Chronic conditions may cause
long-term changes in the body and such factors may impact treatment. Chronic
conditions may include heart disease, epilepsy and diabetes.
The information should be written
inside a patient record, as well as on the outside of the chart, in order to
bring it to the attention of the dental team. History and information regarding
allergies are extremely important, because the dental team may need to review
the anaesthetics and antibiotics and so on. The information provided by the
patient should be kept confidential and updated at all times, as patient
records are important evidence in cases involving litigation. The patient must
sign and date the form, after the assistant has filled in the information.
Once the medical history and
record has been updated, the assistant must help to seat the patient for
examination prior to treatment. The assistant must observe the patient for any
signs of abnormality, such as slurred speech, drowsy walk, or disorientation.
You must also note down any discolouration of facial skin or any other feature
(such as a drooping eyelid). Whilst the assistant performs the intra-oral and
extra-oral examinations in most clinics, the dentist may perform the first
comprehensive examination along with your assistance. The assistant must also remember
to obtain the consent of the patient, before any clinical procedure (the types
of consent are explained in module 3).
Extra-Oral Examination
The clinical examination may also
include an examination of the lips for cracking, dryness and so on.You must observe the smile line
(the position of the lips when the patient smiles), the commissures (the
corners of the lips), as well as the vermilion line (the line just around the
lip). If you notice any deviation from
the normal, this must be noted down on the charts. You may also consider
offering some recommended lip balm to patients, in order to make them feel more
comfortable.
Next, the assistant must examine
the floor of the mouth, whilst the patient keeps the mouth closed. You can do
this by gently palpating (feeling with fingers and hands) the soft skin under
the mouth and feeling for any abnormalities. The patient is then asked to
gently turn their head from side to side and the assistant checks the lymph
nodes running from the ear to the collar bone.
The last step of the clinical
examination involves sitting behind the patient and palpating in the anterior
area of the ears. The assistant must carefully observe for any swelling,
clicking noises, or tenderness. Ask the patient to open and close the mouth and
touch this area for any abnormality.
Intra-Oral Examination
The first step involves a visual
examination of the oral cavity.
Carefully examine, to look for
signs of discolouration, abscesses and lesions and so on. Now gently support
the mandibular area (the lower dental arch) with your hand and palpate the
areas on the floor of the mouth and pull the lips away to observe the gums. You
can also consider using the mouth mirror to observe the palate, as well as the
posterior areas of the tongue.
Next, using a gauze sponge on the
tip of the tongue, move the tongue from side to side in order to examine the
underside. Ask the patient to say “Ah” or “Aha” and observe the tissue. The
extra-oral examination is now over and the dentist will now examine each tooth
and you must record the findings and observations on the chart area of the
patient record. Depending on the patient's requirement, the dentist may request
you to perform additional diagnostics.
Diagnosis, Treatment Notes and
Vital Signs
The diagnosis is a conclusion or
decision reached by the dentist, with respect to the patient. The treatment
plan will involve various care options that will help to alleviate the problem.
The dental assistant and dentist will update the treatment notes by entering
the date, the tooth number and the specific treatment provided for the tooth.
The treatment notes will contain details of the anaesthetic administered and
any reactions.
At the fundamental level, vital
signs are the basic signs of life. These include blood pressure, temperature,
pulse and respiration rate.The observation and recording of
vital signs is a crucial process, before commencing any dental treatment. The
medical history, health evaluation and recording of vital signs help the
dentist to assess the treatment plan and this is also critical with respect to
emergency treatment.
Normal body temperature: Normal
body temperature should lie in the range of 98.6°F (Fahrenheit) or 37.0°C
(Celsius). The patient may have a fever, if the temperature is above normal, or
be hypothermic, if the temperature is below normal. Tooth or oral infections
may often be accompanied by fever. For children, the assistant may use a
tympanic thermometer to check the temperature. Place the tympanic thermometer
in the ear canal gently and take the temperature.
In order to take the pulse rate,
the assistant must ensure that the patient is positioned with the arm lower
than the level of the heart. Ensure that you take the pulse reading for at
least 30 seconds.
Normal pulse rate for adults is
usually between 60 to 100 beats per minute, whilst for children, it can lie
between 70 to 100 beats per minute.Whilst taking the respiration
rate, count the breaths in and the breaths out during one minute - you can do
this as you take the pulse, so that you are able to take a natural reading
without the patient being aware. Respiration rate and pulse rate are usually faster
in children, compared to adults.
In addition, the dental assistant
must know how to record blood pressure. Nowadays, modern blood pressure devices
help to record blood pressure automatically. If you are using a traditional
sphygmomanometer, then you must fasten the cuff just one inch above the elbow
and tighten it by inflating the device with the handheld pump.
The pulse rate will now be
inaudible. Now release the pressure and listen carefully for the point when you
are able to listen to the pulse rate again. You will be able to hear the pulse
through the stethoscope placed in your ear. This is called the systolic blood
pressure. The point when the pulse rate again stops is called the diastolic
blood pressure. Normal blood pressure for adults is usually between 80-90 and
130-140. Many dental offices do not record
blood pressure nowadays, but it is extremely important to record blood
pressure.
Activity 1
Estimated time: 10 minutes
A non-English speaking patient
visits the dental office. What steps will you take in order to obtain the
correct medical and dental history?
9.3 Dental Charting
The process of
recording the patient's oral cavity conditions using colours, symbols and
numbers is called dental charting. The dental chart is first created
when the patient makes their first visit to the dental office. Each dental
office uses their own preferred system of symbols and numbers and the chart
must be complete and accurate at all times.
Dental charting is extremely
important for the purposes of diagnosis, consultation, treatment and billing.
The dentist will dictate the information to be recorded in the chart, including
teeth that have been treated and those that still require treatment.Dental charts are legal records
that may be required in cases of litigation or in cases involving forensic
dentistry. The individual's dental records may provide important clues
regarding identity, in the event of crimes or homicides, etc.
Here are some important points
regarding dental charts:-
*Although there are several types
of dental charts, the majority of them are divided into two parts: one area is
for charting and the other is for recording treatments.
*The most popular charts show an
anatomical or geometric representation of the teeth, along with numbers.
*Most anatomical charts show
primary, as well as permanent, dentition.
*The anatomical charts show the
crown and the root.
Dental charting includes
information regarding caries, dentition, missing and implanted teeth,
restorations, teeth that require extractions and periodontal problems.
(Children do not have premolars)
Similarly, cavities are
classified into five classes, based on the location of the tooth. Dental charts
are filled with dental terms that have been described in detail in module 6. In general, notations in red
represent work that needs to be completed, whilst notations in blue indicate
dental work that is already complete.
For example
If a tooth is fractured or
chipped, but is not causing any discomfort or pain to the patient, the tooth
may be charted in a different colour, because the dentist has decided to defer
action for the present.
Nowadays, many dental offices use
computerised dental charting that helps to improve standardisation and
efficiency. Many dental charting applications allow the voice systems - the
dental assistant speaks into the software and the application confirms the
information, before recording it.
Alternatively, the assistant can also enter
information using a keyboard or light pen. Please remember to use a protective
covering for the keyboard and a barrier on the light pen, to prevent
cross-contamination. The light pen is used by touching
it to the computer screen, in order to activate commands.
For example
If the assistant wishes to record
a premolar tooth extraction, they will touch the light pen to the correct tooth
on the dental chart - this helps highlight the tooth.
Once the tooth is highlighted,
the assistant should now touch the light pen to the side of the screen on
“extraction” and then either “existing” or “needs to be completed”.
The software will automatically
colour code the tooth in blue, with the relevant information. Dental assistants
can bring excellent value to the dental team, by becoming proficient at dental
charting.
Fact
On an average, dentists
in the UK spend 37 hours working, out of which they are obliged to spend over
seven hours on administrative duties.
Source: British Dental
Association
9.4 The Basic Components of a
Dental Office
Dental offices vary in design, size and comfort, but the underlying objective
is to create a warm and welcoming environment.
Reception Room
Most dental offices will have a
reception room, which dental team staff should keep as neat as possible. You
can also consider placing educational materials, as well as current magazines. Most
dental offices also have a designated children's play area.
Reception Desk
The reception desk consists of
the computer station, pens and telecommunication systems (fax machines, etc).
The counter space allows for privacy when a patient wishes to speak
confidentially, pay bills and schedule appointments.
Sterilising Area
The sterilising area consists of
sterilising equipment, hazardous waste containers, a wash basin, instruments
and trays. The sterilising area should be equipped with excellent air
circulation, as a preventative infection control measure and also, because the
area is associated with the release of fumes and chemicals.
Laboratory
Dental offices may also have a
special area for a laboratory, where dental prosthetics, bridges, crowns,
veneers and dentures may be made. Staff working in laboratories (dental
assistants may often be required to coordinate between sections of the dental
office) should wear protective gear, such as gloves and masks, because fixtures
and prosthetics that arrive in the laboratory for remodelling have already been
worn by patients.
X-Ray/Radiography
In addition, the x-ray processing
room is used for processing x-rays and is often a darkened room with an x-ray
processor. Similarly, there could also be radiography equipment in the
treatment room.Staff and patients should be
adequately protected from ionising radiation in the x-ray room and the
radiography equipment.
Optional rooms include the
dentist's private office (which may be used for private consultation) and a
staff recreational area (usually equipped with chairs, tables, a coffee machine,
a microwave and a refrigerator).
The Dental Chair
The dental chair is at the centre
of all clinical activity and can be adjusted to provide comfort to the patient,
whilst allowing the dentist to perform procedures efficiently. The dental chair
is designed to support the patient's body, either in an upright or supine
position (reclined position where the head is resting lower than the feet). The
head rest is usually narrower, so as to allow the dentist and the assistant to
work close to the patient. Similarly, the arm rests can be moved away or
lifted, in order to allow the patient to sit or leave the chair.
Modern dental chairs also have
controls that allow manipulation of the seat, as well as to recline or
straighten the back as required. Dental chairs usually have the control buttons
on the side or on the floor level and the chair can also be swiveled to the
right and left.
Floor level chairs are becoming
increasingly popular, as they require lower infection control. The controls and
headrest are covered with protective barriers, in order to prevent
cross-contamination. Dental chairs are made of materials that are durable and
can be cleaned easily.
Activity 2
equipment be regularly sterilised?
infection?
9.5 Other Commonly Used Equipment
in Dental Treatment Rooms
Other Commonly Used Equipment in
Dental Treatment Rooms
Mobile Carts
The mobile carts usually contain
air syringes, saliva ejectors, oral evacuators and dental hand pieces. The
mobile carts are portable and are shared between the dental assistant and
operator, with the instruments placed on the appropriate side. Mobile carts are
workspaces that also double as storage units.
Air-Water Syringe
The air-water syringe may be used
to provide a spray of air, water, or a combination of both. The tip of the
air-water is removable and it also comes equipped with tips of several lengths.
The tips may also be angled. It is important to flush the air-water syringe
between patients, as well as once at the beginning and end of the day. The
controls are fairly easy to use and are placed on the handle of the syringe.
Dental assistants should be able to operate the air-water syringe with one
thumb.
Dental Hand-Pieces
These usually come with two
speeds: low and high. The hand-pieces are attached to the dental units by means
of hoses and it is important to ensure that the hoses are not entangled or
crushed during procedures. Dental hand-pieces are used to hold disks, cups, or
burs, in order to clean or polish teeth or perform restorations.
They should be cleaned and
sterilised after each patient, as well as flushed with water at the beginning or
end of the day. It may be a good idea to use distilled water to fill the
reservoir in the hand-piece, to prevent tap water deposits from accumulating in
the water pipeline. Please note that as a dental
assistant, you are responsible for the maintenance and cleanliness of dental
instruments and equipment.
Saliva Ejector
The saliva ejector is used to
suction off saliva and oral fluids during certain dental procedures, such as
fluoride treatments and cleaning, as well as whilst using rubber dams. The
saliva ejector has a tip that is attached to the hose of the dental hand-piece
and also has a trap which must be cleaned after every patient. The saliva
ejector tips must be discarded after every use.
High Volume Evacuator (HVE)
Dental assistants use the high volume
evacuator to suction oral fluids and this must be flushed between patients, as
well as at the beginning and end of the day. The HVE has a trap that collects
debris and this must be cleaned daily or weekly, as needed. HVE's usually come
with metallic or plastic tips. The metallic tips must be sterilised, whilst the
plastic tips are disposable.
Dental Stools
Dental assistants usually sit on
dental stools during procedures and these come in modern, ergonomic designs.
They are equipped with adjustable backrests and heights and come with
comfortable seat material. They come with broad, heavy bases, as well as
multiple castors to prevent tipping. The height and backrest should be
adjustable, in order to adapt to the different physical profiles of assistants
who may be on duty during procedures.
Operating Light
The operating light can be
attached to the ceiling or, more commonly, to the dental chair. The assistant
must know how to adjust the light as required during the procedure. The
operating lights also come equipped with high and low intensities and may be attached
to the arms of the dental chair, for easy manoeuvrability over the patient's
face. Maintenance tasks would include changing the light bulb periodically, as
well as cleaning the heat shield.
Wash Basins/Sinks
Treatment rooms are equipped with
wash basins and sinks, which may be located on either side of the dental chair
or behind it. The dentist, hygienist and the assistant would need to wash their
hands periodically during treatment.
Many modern dental wash basins
come equipped with motion or light sensors, which prevent one's having to
actually touch water controls (this is again linked to infection control and
cross-contamination).
The air compressor provides air
for the air-water syringes, whilst the central vacuum system provides the
required suction for instruments such as the oral evacuator and the saliva
ejector.
Maintenance of Equipment
Dental assistants should make it
a point to follow the manufacturer's instructions in the manuals, for best
results. Regular maintenance will prevent unnecessary breakdowns. It is best to
design a regular maintenance schedule for instruments and equipment.
For example
You may wish to conduct daily,
weekly and monthly assessments, which could include the changing of x-ray
processing solutions, cleaning the insides of sterilisers and making
miscellaneous repairs.
Module Summary
Dental assistants play a crucial
role in preparatory patient care, by recording information related to medical,
dental and personal history. Accurate medical history helps to formulate a
treatment plan that takes into account important factors, such as allergies,
prior surgeries, medications and so on. It also helps to prevent complications
during dental surgery. The assistant should also record body temperature, pulse
rate and blood pressure during every visit. Modern dental offices use automatic
blood pressure machines, to record systolic and diastolic blood pressure.
Once the patient is seated
comfortably, the assistant should also perform an extra-oral and intra-oral
examination, in order to identify any abnormalities in the oral cavity. The
intra-oral check-up will include visual examination of the gums, teeth, tongue
and lips. All of the information, including additional diagnosis and comments
from the dentist, should be recorded on the dental chart. Dental charts must be
accurate and updated, as they are legal medical records and are used as
admissible evidence in cases of litigation and forensic analysis.
Dental charts are created using
colours and symbols and each office may have their own preferred methods of
charting. In general, the colour red indicates pending treatments, whilst the
colour blue is used to denote completed treatments. Dental equipment includes the
dental chair, mobile carts, x-ray processing machines, radiography equipment,
saliva ejectors, oral evacuators and hand-pieces. Assistants should follow the
manufacturer's instructions and conduct regular maintenance tasks, to ensure
that equipment is working at its best.
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