Adult Patient Sequence

1. Medical History (MH) (calculate pt.’s age, note allergies to meds, ask follow up ?s to med conditions, ask abt x-rays (last x-rays
taken& if willing to take x-rays today, look up meds
2. Vitals Signs (VS) (pulse, respiration, BP)
3. Present to Faculty (don’t say patient’s name) (tell: race, sex, age, med allergies, med conditions, last prophy, meds, vitals x-rays)
4. Radiographs as indicated (authorization from dentist, inform patient of cost before taking, document if patient refuses x-rays)
5. Antimicrobial Mouthwash (ask patient to rinse w/ antimicrobial mouthwash to decrease amount of pathogenic bacteria)
6. Extraoral Exam (lymph nodes, SCM, TMJ, Swallow)
7. Intraoral Exam (occlusion, over jet, overbite, midline, habits) (Make sure patient has glasses & napkin before reclining!!)
8. Dentition Charting (DC) (current/ needed restorations, over jet, over bite, habits, occlusion class, explore for calc, WSCC class)
9. Periodontal Charting (PC) probe, note BOP, mobility, furcations,
10. Gingival Index (GI) (0: Pink, firm, full papilla, 1: Red, swollen, NO bleeding, 2: Red & BOP, 3: Red, swollen, bleeds easily)
 Typically after GI, you sit your patient up, remove your PPEs and complete the following paperwork:
11. Dental Hygiene Diagnosis-in letter expert, go over with patient as part of patient education
12. Patient Treatment Plan
13. Complete Top of Grade Sheet!!! (Fill in # of Teeth, WSCC Class, AAP & ASA Class) (This is also easy to forget!!)
14. Sign in for Assessment Check
 Have mirror, probe, SH explorer, 11/12 explorer, recline patient
 remember to introduce patient & instructor
 (While waiting for assessment check address recall card)
15. Get a Patient Bag (Get products that best meet your patient’s needs, ex. biotene rinse, sensodyne toothpaste, a denture brush)
16. Disclose Patient (assessment check first)
17. Plaque Index (PI) (0: No plaque, 1: plaque only visible after disclosing 2: light-moderate plaque visible 3: heavy plaque/ debris)
18. Oral Hygiene Instruction (OHI) (Tell, Show, Do: You MUST open toothbrush & have patient demonstrate proper brushing)
19. Scale (Max Right, Mand Right, Max Left, Mand Left) (In each quad start at posterior and move to anterior, do buccal then lingual)
20. Polish (It is best to disclose the patient after polishing to ensure all plaque has been removed)
21. Floss (Rinse patient’s mouth after flossing)
22. Sign in for Final Faculty Check (recline patient, have clean explorer, mouth mirror & cotton tip applicator)
 Have grade sheet on clipboard and use red & blue pencils to record any calculus or plaque that you missed
23. Caries Exam from Dentist (Have referral form ready!! Clean mouth mirror & explorer, Raise Chair)
 Discuss any suspicious areas or other reasons for referral w/ Dentist, document OC- or OC+ in clinical notes
24. Fluoride Treatment (place trays on silver tray (not counter), dry mouth, place mand 1st then max, check for allergic rxn at end)
25. Walk Patient to Front Desk
 Schedule another appointment if necessary, have patient complete patient questionnaire, Thank patient for coming
 Fill out recall postcard for patient and file in box at Ms. Kim’s desk!!
26. Complete Clinical Notes
 Document what treatment was provided that day (End w/ SPT or PTR)
 Document if patient refused x-rays, type of prophy paste used, type of fluoride used, & teeth #s if sealants were placed
 Record any referrals made by dentist, if the cancer screening was OC- or OC+, & any anesthesia administered
 Have hygiene faculty and dentist check clinical notes

Remember: Always remove patient glasses and napkin before he/she goes to the bathroom
AND never leave your operatory w/ your PPEs on