ORAL DIAGNOSIS AND RADIOLOGY
From the Clinic Manual
Contents |
Associated Links
ASA (American Society of Anesthesiologists Classification system)
ASA Linked Guidelines For Medical Consultations
Guidelines For Prescribing Dental Radiographs (table)
Guidelines For Prescribing Dental Radiographs (full text)
Introduction
A. Oral Diagnosis is that part of dentistry that deals with the recognition of the abnormal, the collection of diagnostic data and the synthesis of that data to establish a differential diagnosis leading to a final diagnosis and the establishment of a treatment plan.
B. Oral Medicine is that branch of dentistry concerned with the oral health care of the medically compromised patient and with the diagnosis and non-surgical management of medically related disorders or conditions affecting the oral and maxillofacial region.
C. Oral and Maxillofacial Radiology utilizes ionizing radiation in the diagnosis of the pathology or oral and maxillofacial structures. Its foundation is based upon the understanding of radiation physics, biology, protection, radiographic
technique, and interpretation.
Patient Evaluation and Clinical Oral and Head and Neck Examination
A. Procedure:
- The purpose of the clinical examination is to observe and record pertinent information regarding the physical condition of the patient. The examination includes evaluation of the patient’s general health, systems review, appearance of the head, neck, exposed skin surfaces, lips, gingival, oral mucosal membranes, tongue, pharynx, and teeth. Dental examination should include evaluation of missing teeth, impacted teeth, caries, fractures, condition of existing restoration and prostheses, periodontal and pulpal status, occlusion, attrition, erosion, and harmful habits. Abnormal oral and perioral masses, growth, ulcers, vesiculobullous lesions, discolorations, sinus tracts, fistulae, radiolucencies, and radiopacities should receive special attention. All significant findings should be properly documented in the patient’s dental records.
- All patients must be classified in accordance with The American Society of Anesthesiologists (ASA) Classification system. The student of record is responsible for entering the ASA classification in SOE and updating it when and if the patient's classification changes.
- All treatment planning and recall competencies must be performed on "special needs" patients, defined as having an ASA classification of P2 or higher.
B. Criteria:
- A medical and dental history form is completed on all patients (new and readmits) according to criteria in physical evaluation (DEND 225).
- Vital signs shall be recorded for all patients at initial visit and subsequently as dictated by patient medical profile.
- All patients shall undergo a complete head and neck examination at initial visit and at every recall visit (6 months).
- The admitting procedure takes place in strict adherence to infection protocol which includes:
- The use of sterilized instruments.
- The use of gloves, masks, and eye protection (universal precautions).
- The disinfection of radiographs or the use of disposable barrier packets.
- The use of plastic barriers placed over the x-ray tube head and control panel, examination light handles and switch, chair and door handles.
- The use of sterilized instruments.
Medical and Dental History
A. Procedure:
- The medical and dental history consists of gathering and recording significant information concerning the chief complaint; history of the present illness; previous treatment; past medical and dental problems; allergies; systemic diseases, hospitalizations, psychiatric and drug treatment. The history should allow a thorough evaluation of the patient’s physical and emotional ability to tolerate dental procedures safely. The history should also identify potential systemic problems that require further evaluation before regular dental treatment.
B. Criteria:
- At each visit, the medical and dental history should be updated. HHR shall note change or no change.
- If, as a result of the medical history and based on the school’s Medical Consult Policy, specific areas of concern occur, a consultation form is faxed (or mailed) to the patient’s attending physician.
- Medical concerns must be recorded on the Medical Alert Sticker and placed on the outside of the patient file and on the health history form.
- Each time a patient is seen, a progress note documenting the appointment must be completed in the accepted format.
Dental and Maxillofacial Radiographs
A. Procedure:
- Radiographs should be ordered during the evaluation of tooth or bony disease. Radiographs should not be used as a standard disease screen process every 6 months or every year, particularly when there is no evidence of pathology. Radiographs should be ordered by the dentist based on the individual needs of the patient, presenting problem, and review of the patient’s medical history, not based on some arbitrary schedule. The appropriate radiographs shall include any that would aid the diagnosis and treatment or oral and maxillofacial disease and may include both intraoral and extraoral films. Radiographs should be kept in the patient’s dental record at all times for review and evaluation. All radiographic procedures must be performed with the strictest concern for minimizing radiation exposure to the patient and clinical personnel. In all cases, infection control should be strictly observed. The radiographs produced should be of satisfactory quality to provide the necessary information for diagnosis. No radiographs shall be taken solely for administration purposes and/or licensure.
B. Criteria:
- ADA and FDA guidelines for prescribing radiographs are to be followed.
- Attempts shall be made to obtain any previous radiographs.
- A lead apron and a thyroid collar should be used for all radiographic procedures.
- Radiographs shall be undistorted and clearly show all appropriate anatomy and any pathology.
- Double films shall be used for administrative purposes.
- Each radiograph shall have patient identification and date of exposure.
Oral Diagnosis
A. Procedure:
- Diagnosis consists of the determination of the cause of the patient’s dental or oral problem and its classification into a category of disease or dysfunction. The diagnosis is based on the findings of the history and clinical examination. Diagnosis aids may include: radiographs; electrical or thermal pulp testers; percussion; palpation; transillumination; analysis of saliva, blood, or urine; biopsy and study casts, as necessary. Medical laboratory screening tests are used when suggested by the dental and medical history or physical examination. The diagnostic findings must be appropriately documented in the patient’s record.
- The patient’s physician shall be consulted when the patient’s physical or mental status is fragile and/or when information is necessary to determine a potential modification of dental therapy. Please refer to the Medical Consult Policies which follow this section.
B. Criteria:
- Written diagnostic notations and progress notes shall be made in the dental record, including dental charting.
- The results of all such tests shall be maintained in the patient’s record.
