Dental Hygiene Assessment

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Patient appointment information was accessed through Axium where the student was able to view her assigned patient. The student was supposed to confirm her patient’s appointment and medical history via telephone before the day of the appointment. Over the phone she discussed any new changes on medications, filled out the blue sheet and made sure that pre-medications were taken if any were needed before they came to the appointment. Also, prior to the appointment, the student had a head-start on the patient’s dental charting because radiographs were available on Axium.
Once the patient checked in at the front desk and was seated, the student updates the patient’s medical and social history. The patient was a 19-year-old male. His only medication …show more content…
The patient rinsed to reduce the amount of bacteria that could be spread in the air. She examined the exterior of his head and neck by palpating the cheeks, neck, and throat to check for any bumps or abnormalities with the lymph nodes. She then changed pair of gloves and started the intraoral examination and noticed the patient had fluorosis on anterior maxillary teeth, linea alba inside his left cheek and the tissue around #32 was inflamed. While examining inside his oral cavity she made sure that his restorations were charted correctly. The patient mentioned having food impaction on two temporary crowns he had. The student made note to ask Dr. Collins if the patient was ready for permanent crowns to prevent food impaction. She began to explore for any calculus or decay. She found decay mainly on the mesial and distal surfaces of his mandibular central and lateral incisors. She followed by taking periodontal probing measurements. There were some 4mm pockets but he was classified as having gingivitis, periodontitis class 1, and as a difficulty A patient. She made note of all of this in the DH assessment form and on her restoration and calculus chart. After finishing all of her hygiene assessment, she asked him a set of questions to calculate his caries risk. The patient was at a low caries risk. The student accidentally disclosed the patient
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