DENTAL CHARTING

THE PATIENTS ROLE The Patients Complaint: 1. Preventive Visit once or twice a year; Regular check-up & prophylaxis Px may ask for an appointment simply because he wants to be assured of his oral health is all right & to arrest any starting pathology 2. Curative Frequently the reason for his visits 3. Cosmetics Consultation may be motivated by desire from the px to improve his facial esthetics Facial expression depends, to some degree on oral esthetics

DENTISTS ROLES Pre-treatment Consideration While the dentist is responsible for evaluating, in general, the conditions & symptoms of the case, & it is up to the dentist to make the diagnosis & prognosis & plan treatment, usually there are other factors to be considered before treatment can be started: Pxs available time Individual preferences which should not block the efficiency of the treatment Affect financial stability Cases of Exigency: Where only one plan of treatment is possible, & the denial or delay would destroy the pxs health, it is necessary to perform the operation at once w/o giving much thought to the pxs not too relevant conditions. The px should also be made to understand the gravity of his condition Voluntary Consent No matter how minor or major the planned tx, it is necessary to obtain the pxs VC or that of his guardian As a rule it is not necessary for the px to give his consent categorically. The very request he makes, impliedly or in so many words, when he goes to a clinic & sits down in the dental chair of his own accord, & does not inquire as to what terms of the contract will be before submitting himself to tx, is enough consent. If the case would admit a number of plans of tx each of which would have different requirements as to the pxs & the dentist time, then the px may be allowed to choose among them

PRIORITY DATA 1. Full name of the patient 2. Address House number, Street, town etc. & other designations of regions Enable dentist to communicate with px Unembarassing manner of estimating the community standing & financial bracket to which the px belongs. It is a guide on how he should be charged since dentistry does not always have a fixed rates of fees. Dentistry is not a commercial occupation, it is essentially humanitarian & therefore fees are charged not only on the basis of type of service or product, but also on the paying capacity of the px Gives an idea of what kind of diet the px has, judging from his neighborhood habits Diet is related to oral health. However, more concrete information about his diet should be inquired directly from him Might also explain some phenomena (ex. Mottled enamel) 3. By whom referred, if at all 4. Date of admittance Serves as an index of how long it takes for a process or tx to progress 5. Age of the patient Gauging the physical maturity of the px Knowing whether or not the dentist may enter into a contract with the px Eruptive chronology of teeth 6. Sex Hormonal disturbances & other factors concerned with sex 7. Roentgenograms, pictures of laboratory findings with systemic conditions which may have a bearing upon dental tx 8. Payment or installment of fees, the balance etc.. Together with dates when these were made are noted 9. Conditions of the mouth given attention during routine oral examinations are these: a. Missing teeth (extraction or congenital) b. Supernumerary teeth c. Developmental defects d. Caries e. Attrition, abrasion, erosion f. Deformities of the jaws, teeth, malposition of teeth, condition of occlusion (traumatic or other) g. Firmness of the gums, texture, & also those of other tissue, such as tongue & floor of the mouth h. Inflammation of the visible tissue i. Pain j. Calculus, stains etc.. k. Condition of the bone, alveolar

l. Teeth filled or restored m. Any other deviation from the normal n. Condition of the pulp