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 Sound dental care begins with a thorough examination of the head, neck, and oral cavity.  For the dentist to make an accurate diagnosis, he or she must  Review the medical and dental history and discuss all health concerns with the patient  Continue with a thorough extraoral and intraoral examination  Evaluate the radiographs and study models  Discuss the plan of treatment Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2

 A new patient will seek dental care for the following reasons:  As a new patient to begin dental care  As an emergency patient when in pain or experiencing discomfort  For consultation with a specialist  As a returning patient, for continued assessment and care Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3

 Specific areas where the dental assistant should be involved include  Assist the patient with completion of patient information forms  Take and record vital signs  Chart and record the dentist’s findings during the extraoral and intraoral examinations  Expose intraoral and extraoral radiographs  Take preliminary impressions and fabricate diagnostic models  Take extraoral and intraoral photographs  Organize the patient record  Prepare for the case presentation Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4

 The examination always begins with a visual evaluation of the patient’s extraoral and intraoral conditions.  This enables the dentist to determine an overall assessment of the type of dental care received previously and reveals any existing conditions that have not been treated. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5

 Specific examination areas include  Face  Lymph nodes  Lips  Soft tissue within the mouth  Tongue  Tooth structure  Restorations  Missing teeth Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6

 The examiner uses his or her fingers and hands to feel for texture, size, and consistency of the hard and soft tissue.  This technique is especially useful for detecting extraoral swelling and is the primary way of detecting swollen lymph nodes. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7

 The use of instruments to examine the teeth and surrounding tissues.  The type of instrument commonly utilized to examine the teeth is the mouth mirror and explorer, and to examine the gingival tissues is the periodontal probe.  Detection – the dentist uses an explorer to detect imperfections in tooth surfaces  Probing – the dentist or dental hygienist will use the periodontal probe to assess the gingiva for the presence of periodontal pockets Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8

 An indispensable tool for identifying  Decay  Defective restorations  Periodontal conditions  Pathology  Developmental conditions  Abnormalities Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9

 Intraoral imaging allows the use of a video system:  To magnify an image for better evaluation  For easier access to difficult areas  For photocopying images for insurance purposes  For case simulation or presentation  For medical and legal documentation Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10

Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11

 A diagnostic tool used for intraoral and extraoral structures  Provide the dentist and patient with a visual means of identifying and understanding specific problems. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12

Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13

 Charting symbols, abbreviations, and color coding can be used in the recording process to indicate various conditions and existing restorations.  Specific criteria that must be known before charting:  Black’s classification of cavities  Tooth diagrams  Tooth-numbering systems  Color coding  Abbreviations Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14

 This standard classification system is universal to all dentists and is used to describe the location of decay and the best method for restoring a tooth.  Black’s original classification included Class I through Class V.  Class VI was added at a later date. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15

Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16

 The clinical exam forms used in charting includes a primary dentition diagram that represents 20 primary teeth and a permanent diagram that represents 32 teeth.  The teeth are presented from the perspective of looking into the patient’s mouth. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17

Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18

 Universal numbering system  Begins with the maxillary right third molar and concludes at the mandibular third molar.  Palmer notation system  Uses a bracket to designate the four quadrants of the mouth Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19

Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20

Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21

 A visual notation to differentiate between treatment that has already been completed and treatment that still needs to be completed.  Black or blue symbols represent dental work that has been completed.  Red symbols indicate treatment that needs to be completed at future dental appointments.  Once this work has been completed, you will mark over the red with a black or blue notation to indicate that the work has been completed. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22

Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23

 For single-surface restorations, charting abbreviations are based on the names of the tooth surfaces.  B – buccal  D – distal  F – facial  I – incisal  L- lingual  M- mesial  O – occlusal Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24

 In multiple-surface restorations, two or more surfaces are involved.  The combined surfaces become one name on which the abbreviation is based.  The rule for combining two surfaces is to substitute the letter “o” for the –al ending of the first surface.  For distal and occlusal, disto-occlusal, or DO.  For mesial, distal, and occlusal, mesio-occlusodistal, or MOD. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25

 Dental charting systems are available in a variety of diagram styles  In the anatomic diagram, the illustrations resemble the actual crown and root of the tooth  In the geometric diagram, a circle represents each tooth  The circle is divided to represent each tooth surface Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26

 The introduction of electronic charting has provided a standardized system where all clinical staff members will chart the same way.  Charting software is providing new directions for the general and specialized dental office  Software programs can standardize digital charting, which can include an intraoral and extraoral examination, charting of dental anatomy, current restorations, pathology, and periodontal conditions. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 27

 Charting symbols are used on the tooth diagram of the dental record to represent the various treatments and types of dental materials used to restore the tooth or teeth.  Each dentist will have individual preferences  It is important to learn the charting symbols for treatment to be completed, as well as for treatment already provided. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 28