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SOAP Notes Outline

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					                                                                    DDS Class of 2009
                                                                OCP Final Review Sheet
SOAP Notes Outline

S:     ID:    Age, Female or Male, Ethnicity
       CC:    Chief Concern
       MH:    Medical History / Standard Protocol?
       DH:    Last Exam / Standard Protocol?
       SH:    Social History

O:     PE/VS:         BP, HR
       EOE:           Extra-Oral Exam
       IOE:           Intra-Oral Exam
       TMJ:           Test Joint

A:     Comment on the vital signs, EOE, IOE, and TMJ

P:     Create a plan for proceeding.
       No further treatment indicated at this time.
       Continue current treatment.

Oral Pathology
Self Test… blank photos, then a key at the end…
Images taken from our book via: http://www.zhub.com/pathology/listings/25.html
NOTE: The testfiles do not show that we need to identify too many of these structures;
however, I’ve included them as a refresher… just in case.




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                                                               DDS Class of 2009
                                                           OCP Final Review Sheet
   Foliate Papillae
         o Fig 1, 2
   Lymphoid aggregates
         o Fig 3
   Varix
         o Fig4
   Tori
         o Fig 5, 6
   Idiopathic Oeseosclerosis
         o Fig 7, 8
   Bone marrow defect
         o Fig 9, 10
   Fordyce Granules
         o Fig 11
   Apthous stomatitis
         o Fig 13-15
   Herpes virus infection
         o Fig 16-20
   Papillary hyperplasia
         o Fig 21, 22
   Epulis fissuratum (inflammatory fibrous hyperplasia)
         o Fig 23
   Irritation fibroma (traumatic fibroma)
         o Fig 24
   Mucocele
         o Fig 25
   Papilloma
         o Fig 26
   Peripheral fibroma
         o Fig 27
   Pyogenic granuloma
         o Fig 28, 29
   Peripheral giant cell granuloma
         o Fig 30
   Traumatic ulcer
         o Fig 31
   Stomatitis nicotina
         o Fig 32
   Dilantin gingival hyperplasia
         o Fig 33
   Geographic tongue
         o Fig 34, 35
   Lichen planus
         o Fig 36, 37



                                                                    Page 15 of 20
                                                                 DDS Class of 2009
                                                             OCP Final Review Sheet
   Angular chelilosis
        o Fig 38
   Candidosis (Candidiasis, Moniliasis, Thrush)
        o Fig 39
   Pulpitis
        o No Photo
   Dental caries
        o Fig 40-42
   Marginal gingivitis
        o Fig 43, 44
   Necrotizing ulcerative gingivitis, Vincent’s infection, Trench Mouth
        o Fig 45
   Periodontitis
        o Fig 46, 47
   Periapical cyst
        o Fig 48
   Dental granuloma
        o Fig 49
   Condensing osteitis
        o Fig 50
   Pericoronitis
        o Fig 51
   Amalgam tattoo
        o Fig 52
   Hairy tongue
        o Fig 53
   Nasopalatine duct cyst
        o Fig 54
   Dentigerous cyst
        o Fig 55
   Leukoplakia
        o Fig 56
   Erythoplakia
        o Fig 57
   Squamous cell carcinoma
        o Fig 58, 59
   Snuff lesion
        o Fig 60
   Cementoma
        o Fig 61, 62
   Acquired immune deficiency syndrome
        o Fig 63-67




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                                                                    DDS Class of 2009
                                                                OCP Final Review Sheet


Radiographic Interpretation
Prior to seeing your patient, you have to fill out the Radiographic Diagnosis Worksheet.
The form is a white piece of paper. Once you’ve filled it out, you have to have an ODTP
instructor sign the interpretation, check off the appropriate boxes for Step 1, and
hopefully sign your “STEP 1: Completed ODTP STEP 1:” faculty signature line. This
should be completed prior to your patient’s first appointment, if possible.

For the sheet, know how to identify:
   1. Dentition
           a. Adult
           b. Mixed
           c. Primary
           d. Partially Edentulous
           e. Edentulous
   2. Pulpal Status
           a. WNL
           b. Abnormalities (if present, draw them on the diagram)
           c. Root Canal(s) Treated (again, draw them)
   3. Calculus
           a. Absent
           b. Present
                   i. Moderate
                  ii. Heavy
           c. Generalized
           d. Localized
   4. Bone Loss
           a. None
           b. Generalized
           c. Local
           d. Horizontal
           e. Vertical
           f. Circumferential
   5. Other Bone and Antrum (sinus) Abnormalities

QUESTIONS
                         -   What color do you use to “X out” missing teeth?
                         -   What about when you chart root canal fillings
                         -   Caries?
                         -   What color do you use to chart calculus?
                         -   How about Pathology?

ANSWERS
    GREEN: x out missing teeth, chart root canal fillings, caries
    RED: calculus, pathology




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                                                                    DDS Class of 2009
                                                                OCP Final Review Sheet


Treatment Planning and Prioritizing

   1. Emergency / Aesthetics / Potentially acute situations (endo)
   2. Periodontal stuff (difficult to capture margins for crown preps – so fix it… and
      it’s also better for the overall future prognosis.
   3. Operative (get rid of caries, get contacts done quickly)
   4. Fixed (Now you have time to do this, because everything else is healthy)
   5. Removable (because all of your operative, fixed, perio, and emergency
      failed…oops).

Oral Pathology
                              Things to know…
   1. Macule: Flat lesion that can not be wiped off, discolored often
   2. Plaque: Flat lesion
         a. can be wiped off, slightly raised, small, disc shaped growth
   3. Ulcer: Flat lesion
         a. complete loss of surface epithelium, crusted or scabbed sometimes. Ex:
              canker sores / aphthous ulcers
   4. Papule: Swelling (Solid) 1-2mm
         a. Ex: fordyce granules (ectopic sebaceous glands)
   5. Nodule: Swelling (Solid) 1cm or less
         a. may be hyperplasia , or benign malignant neoplasm Ex: pyogenic
              granuloma
   6. Tumor: Swelling (Solid) Greater than 1cm
   7. Vesicle: Swelling (Fluid filled) intraepithelial fluid
   8. Bulla: Swelling (Fluid filled) intraepithelial fluid

   1.   Sessile: attached by a broad base
   2.   Pedunculated: attached by a narrow stalk
   3.   Fluctuant: Compressible, pressure displaces fluid
   4.   Indurated: Hard, usually applies to malignancy
   5.   Bony: Hard, hard as bone




                                                                           Page 18 of 20
                                                                DDS Class of 2009
                                                            OCP Final Review Sheet
ODTP Steps
State what is included in each step, and be sure to mention when you need a
signature…

STEP 1:
      Radiographic interpretation
      Do prior to the first appointment
      Signature required

STEP 2:
      Medical history review
      PE/VS EOE IOE TMJ
      Signature required

STEP 3:
      Periodontal Exam
      Get it signed with OHI (step 4)

STEP 4:
      Oral hygiene instruction
      Signature required

STEP 5:
      Dental / Occlusal exam
      Ortho screening
      Problem List
      CAMBRA
      Signature required

STEP 6:
      Treatment Plan (tentative)
      All consultations
      Signature may be required

STEP 7:
      Treatment Plan (prioritized and approved)
      Signature may be required

STEP 8:
      Treatment Plan (signed)
      Signature required




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                                                                     DDS Class of 2009
                                                                 OCP Final Review Sheet
Periodontal Baseline Clinical Examination and Re-Eval. (“Buff Form”)

For the “Periodontal Diagnoses” section, there are three numbered lines. The following
are guidelines for filling out those lines. However, don’t leave a blank line in the
middle… so if there is no mucogingival problem, don’t fill out line one and line three.
Fill out line one and two, but not three.
    1. Line 1: Inflammatory,
    2. Line 2: mucogingival (attached gingiva),
    3. Line 3: occlusion… primary trauma, secondary, etc.

                             Diagnosis options
Location: Localized or generalized
Category: Mild, Moderate or Severe
Type: Chronic or Acute periodontitis or Gingivitis (and health is an option)


Rx (from Dr. Jacobsen) for premedication

If they are not allergic to penicillin, give them…
                             - 2 grams: 4 tablets of 500mg taken together 1hr before apt.

If they are allergic to penicillin, give them…
                            - 600mg: 4 tablets of 150mg taken together 1hr before


The order of handpieces, saliva ejectors, etc…

Left
        Air / Water
        High Speed Handpiece
        Low Speed Handpiece
        Low Volume Ejector
        High Speed Ejector
Right

               Just remember High, Low, Low, High

The appropriate steps in a treatment plan for initial periodontal therapy:

OHI
Scaling and Root Planing
ITE (Initial Treatment Evaluation) – to see if your scaling and root planing worked
SPT (Supportive Periodontal Therapy)

NOTE: if they ask for three, give them the first three… don’t leave out ITE.




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