Clinic Orientation

1. Clinic Orientation Aka “Everything we learned the hard way”

2. Clinic protocol • Huddle Rules: • Starts at 8am • Variances for tardiness • You must be in huddle unless you are on rotation • If you are on rotation in the morning but have a patient in the afternoon you must put a check next to your name that you have verified that what you are doing on the schedule is correct

3. Center Lab NO STONE ZONE

4. Clinic protocol • Infection Control Protocol • After seeing patient clean operatory and spray wipe spray • Put chair to upward position with rheostat on chair on paper towel • Do NOT leave the operatory with gloves on • Do NOT enter supply room with gown on • Have red bag taped to assistant table and for items soiled with blood (red bag goes in red biohazard boxes) • All sharps go in sharps container • Wash hands properly when you enter the operatory before you put gloves on

5. Clean operatory

6. Operatory Set-up

7. Clinic protocol • Have your name plate at your station for the duration of the appointment • Always have a napkin on your patient even if you’re just looking real quick • Always have goggles on your patient • Do not bring a patient into the clinic without faculty present

8. Clinic protocol • If you are in your station with a patient you are required to be wearing a gown even if you are only at the computer taking a medical history • Be done with procedure by 11am and 4pm to have time for chart notes, making follow-up appointments and end checks • Know the procedures to follow should there be an emergency with your patient • Know where the aid kits, the AED, and the oxygen are in our clinic

9. Some tips: • Use the plastic boxes at your stations to gather supplies before the appointment and only take out what you need to avoid wasting supplies • Become familiar with the different products we use in the clinic (for example types of composites and when to use each)(Don’t be afraid to ask for the instructions the product comes with) • When you put the patient in the chair make sure the headrest is adjusted properly • Assist each other whenever possible • Do NOT schedule a patient if they have not paid their bill

10. sterilization tips: • If something in your kit is missing or broken, tell sterilization • Extra 330 burs can be found in our supply room (the ones in the kits are often dull) • Ask for an “operative setup” as opposed to tray • Don’t check out more than one handpiece • Leaving scalpel, needle, glass or other sharps on trays given to sterilization can result in a variance

11. Coe: comprehensive oral evaluation • Medical Dental History Form • Physical Exam (old blue form) • Hard Tissue Charting • Perio Charting • Diagnostic Impressions/FB/Bite record • Phase I Treatment Plan

12. Before the appointment • Have reviewed the radiographs and completed an interp (the FINDINGS HANDOUT is good) • Have your station set up (obviously) • Have what you will need for the appointment ready (exam kit, bite fork, goggles, gown, mask, facebow) • Check under TRANSACTIONS to make sure the patient does not have a balance before you sit them!

13. Coe: comprehensive oral evaluation • Once faculty is in clinic • Check your messages to see if your patient has checked in (it may just pop up on your screen) • Bring patient up • Take BP • Chart add COE and Diagnostic casts as planned treatment • Under COE add HEADERtx note and fill it out

14. Blood pressure • BP > 160/94 we cannot treat (let patient relax and take again in 5 min) • diastolic > 110 refer to doctor • Diastolic > 120 refer to ER • Even if you are using an electronic BP cuff you must check pulse for RRR

15. Get START CHECK from team leader Have team leader approve planned treatment: COE DIAGNOSTIC CASTS HEADER

16. 1. Medical dental history • Under FORMS add the MEDICAL DENTAL HISTORY FORM • Complete forms and summarize • Make sure to look up medications • Know why the patient is taking each medication • Know when to get a MEDICAL CONSULT(paper form)

17. Medical consults • Handout • When to get medical consult • Pre-medication for total joint replacement: • Much controversy • < 2 years premedicate • > 2 years discuss with team leader if you should get a medical consult with patients physician • Medical consult should request that patients physician provide patient with script if they deem premedication necessary *If patient needs premedication or premed consult you cannot probe that day

18. 2. Physical exam (old blue form) • Under FORMS add PHYSICAL EXAM (old blue form) • Complete extraoral and intraoral analysis • Learn how to do a good oral cancer screening  • handout • Summarize findings (unless there really is nothing at all significant)

19. Check • Summarize patient medical history and significant findings • Have TEAM LEADER check and approve medical history and physical exam form • Get the OK to continue COE!

20. 3. Hard tissue charting • Chart: (can use FINDINGS HANDOUT) • Missing teeth • Existing restorations (use xrays for RCT) • Findings (primary decay, recurrent decay, fractures…) • In Axium: • Chart missing teeth (click on teeth, right click and scroll to missing) • Under CHART ADD add as FINDINGS: • Existing restorations • Findings

21. 3. Hard tissue charting check • Have team leader or operative faculty check and approveexisting restorations and findings • Discuss possible restorative treatment options… add to third column of FINDINGS HANDOUT

22. 4. Perio charting (soft tissue) • Under PERIO CHARTING chart pocket depths, furcations, bleeding, GM, and gingival defects • If you don’t have an assistant to input directly into axium we have dry erase boards to chart and them copy the info into axium • Make sure to press SAVE or your data will be lost!

23. 4. Perio charting check • Get information checked and COMPLETED/APPROVED by PERIO FACULTY • Discuss treatment options with faculty • Diagnosis MUST be in general note for that day • Review your periodontal disease diagnosis criteria!

24. 5. Diagnostic casts/facebow/bite record • THIS SHOULD BE DONE AT THE FIRST APPOINTMENT REGARDLESS OF WHERE YOU STOP IN YOUR DATA COLLECTION • Take alginate impressions • Take facebow with bite fork and blue mousse • Take bite record with blue mousse or aluwax • If your patient doesn’t have posterior support or vertical dimension is in question: take impressions and fabricate wax rims to take an accurate bite and facebow upon next visit

25. End Check • Write GENERAL NOTE with that days findings and procedures and FOOTER TEMPLATE NOTE • Have TEAM LEADER: • Check impressions • Approve chart notes • Approve COE as IN PROGESS and DIAGNOSTIC IMPRESSIONS(1st step) as COMPLETED (the status is changed by right clicking and choosing)

26. Your patient • Schedule an appointment for next visit with team coordinator • Give patient yellow payment slip of $105for COE and DIAGNOSTIC IMPRESSIONS • Bring patient to cashier to pay (if your patient does not pay make sure not to see him or her again until they have paid)

27. phase I treatment plan • Based on the mounted diagnostic models, radiographs, and information from the COE create a phase I treatment plan (keeping in mind your possible phase II treatment plan)

28. Phase I treatment plan Under treatment plan: Add PROBLEMS Add DIAGNOSIS Add DETAILED PLAN (each item must have a dx)

29. Perio Flow Chart Health/ Gingivitis Prophylaxis 3 or 6 month prophy recalls Perio exam periodontitis 4-6 wks No improvement Phase 1 (simple or complex) SRP SRP Improvement/maintenance SPT (Periodontal Maintenance)

30. AHA Premedication Guidelines • artificial heart valves • a history of having had IE • certain specific, serious congenital (present from birth) heart conditions, including: • unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits • a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter interventions, during the first six months after the procedure • any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or prosthetic device • a cardiac transplant which develops a problem in a heart valve

31. Medical Consult Example 1 Dear Dr. Valdez: Jane Smith, an 84 yo female who is a patient of your practice, came to my dental office in need of dental extractions of teeth #19, 20 due to severe bone loss due to periodontal disease. She has a medical history significant for atrial fibrillation for which she takes coumadin, diabetes for which she takes glucophage and metformin, and congestive heart failure. I anticipate the dental extractions to be simple with minimal blood loss and plan to place one suture to help with closure and hemostasis. I plan to check her INR the day before the scheduled extractions and will proceed with extractions if the INR is less than 3. Please advise within the next week if you have other recommendations in the management of her medical conditions in light of the planned dental extractions, most specifically her cardiovascular status. Sincerely, Tom Johnson, D.M.D.

32. Medical Consult Example 2 Patient presented with:         Hypertension, back pain,  bipolar disorder, schizophrenia and    COPD.  Reports being on Methylprednisolone 80 mg and a   lidoderm patch. The patient requires the following dental treatment:         Full mouth extractions, aveolplasty, and Denture placement.      This will involve the use of lidocaine and all extractions and aveoloplasty will be preformed simultaneously. Please evaluate the patient for:         Does the patient need to be put on an increased steroid dosage   due to current methylprednisolone use?  Is there any     complications due to methylprenisolone or lidoderm patch use     that prohibit this dental treatment.?  Is the patient’s  hypertension, biploar disorder, schizophrenia, and COPD well     controlled with medication?  Is there any other information      that we should be aware of before treating this patient?  Please         respond below with comments, sign, and return.