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  • Record Keeping

    Clinical Records The clinical records we keep should include – • Up to date case history • Attendance • Findings • Treatment • Medical history • Payments Recorded Details • Name, address, Date of Birth, phone numbers • Doctor • Next of kin • Medical history • Dental history • Attendance • Charting – tooth and periodontal • Soft tissue assessment • Present condition • Treatment • Appointments with other team members • All legally required paperwork • Consent forms • Radiographs (identified correctly and mounted) • Referral letters or copies • Laboratory prescriptions • Payments (estimates, accounts) • Correspondence Why are Records Important? • They are a legally valid document • They can be used for identification • To ensure correct treatment planning • To be able to accurately calculate fees • Attitude to dental health can be assessed • Allow practice to run efficiently Maintaining Records • Must record information accurately, legibly and comprehensively at the time of the appointment • They must be filed properly away from unauthorised persons • Easily accessible • Patient records must be available at every appointment • Signed when necessary by the dentist or patient • Retained for 11 years after completion of treatment or until the patient is 25 for children Data Protection Act 1998 and GDPR 2018 • These apply to living, identifiable people. • Law designed to protect personal data stored on a computer or organised paper filing system • Controls how information is handled • Give legal rights to people who have information stored about them which covers both patients and staff • Must be register with Information Commissioner Access to Health Records • Patients have right to see own health records under the data protection act 98 – ‘right of access’ – physical or mental Health • Deceased patients records can be obtained through the access to health records act 1990 • NHS and Private • The freedom of information act is different and does not cover the release of patient details • Third parties are excluded from access to patient records unless the patient has previously signed a mandate to authorise the release of their records either to a solicitor or relative To release dental records written since November 1991 they must have - • Approval from Dentist or record holder • Request has to be in writing • Response has to be within 1 month • Identity must be checked before release and the records can only be released to the patient or their legal representative • Amendments of inaccuracies can be requested • Availability of explanations of terminology and jargon Refusal to Access The dentist or record holder can refuse access to patients records if : • Disclosure would cause serious harm to the patient • Another person other than a health care member has been mentioned by name and has not given consent • Access to a deceased patients records is not to be granted if prior notification has been included Information Must Be • True • Accurate • Factual • Free of judgement • Contemporaneous (happens at the same time) • Contain no derogatory comments Freedom of Information Act 2000 • Allows the public access to information held by public authorities • Public authorities are obliged to publish certain information about their activities and members of the public are entitled to request information from public authorities

  • Module 1 Lesson

    Learning Outcomes By the end of this section, you will be able to: • Identify the different sections of the oral cavity • Clarify the anatomy that is relevant to dentistry • Describe what does what *Please use the recommended reading book alongside this module Cranium • (skull) encloses brain protects Face • supports eyes & nose Jaws • supports teeth & tongue • provides openings for Respiratory & digestive tracts Cranium • At birth and during early childhood the plates making up the cranium are kept separate from each other by natural membrane covered spaces called fontanelles • Fontanelles allow the brain to grow without any restrictions • Around 18 months the fontanelles should have closed completely and the bony plates fuse togethers at the coronoid sutures • All sensory nerves running to all areas of the body have to pass through this bony cavity and they do so through natural foramina at the base of the cranium • Blood vessels pass through the same foramina to the body or run along natural naturals spaces in the bone called Fissures • The largest foramen in the cranium is on the underside of the cranium and is called the foramen magnum (think of the ice cream!) • The foramen magnum allows the exit of the spinal cord from the base of the brain into the spine Cranium Bones • Frontal bone – single plate of bone at the front of the cranium forming the forehead • 2 Parietal bones – forming the top and side of the skull on either side • 2 Temporal bones – fan shaped bones in the temporal region in front of the ears • Occipital bone – single plate at the back and partial underside of the cranium • Sphenoid bone – single plate forming the majority of the base of the cranium • Ethmoid bone – single plate at the front base section of the cranium, immediately behind the nose Facial Bones • The face is composed of 11 bones, which are separated from each other by sutures which act as immovable joints. The main bones include – • Vomer- single bone behind the nasal cavity that connects the cranial and facial areas of the skull together • Lacrimal bone – Pair of fragile bones forming the inner wall of the orbital cavities – eye sockets • Nasal bones – pair of bones forming the bridge of the nose • Nasal turbine – pair of curled bones projecting into the nasal cavity which aid in the removal of debris in the inhaled oxygen • Palatine bones – Pair of bony plates forming the posterior area of the palate • Zygomatic bones – pair of facial bones that extend anteriorly into the zygomatic arch – cheek bones • Maxilla – Pair of bones forming the upper jaw • Mandible – a single horse shaped bone forming the lower jaw • Forms the middle third of the face • 2 bones – Right & Left maxillae which join together below the nose as the front section of the hard palate • Outer layer of compact bone much thinner than in mandible • Fixed to skull - immovable • Floor of orbit • Front of cheekbone • Supports Alveolar process for upper dentition • Ends at back of maxilla in rounded bulge called the maxillary tuberosity • Separates oral & nasal cavities • Malformation at birth – cleft palate Maxilla Foramen– • Infraorbital foramen – beneath the eye sockets which the nerve supply for the upper teeth passes through • Greater and lesser palatine foramina – at the back of the hard palate where the nerve supply enters for the palatal soft tissues of the upper posterior teeth. • Incisive foramen – at the front centre of the palate where the nerve supply enters for the palatal soft tissues of the upper anterior teeth Maxillary sinus or antrum • Hollow on either side of nasal cavities • Lies immediately above premolar & molar teeth • Oro-antral fistula – perforation can occur during extraction Zygomatic Bones Formed by 3 bones of skull • Zygomatic bone – Front, part of maxilla • Zygomatic arch - Side • Extension of temporal bone - Back Nasal Bones • Joined to frontal bone to form the bridge of nose • Nasal septum – separates the nasal cavity Base of Skull and Maxilla Mandible • Body of mandible is made up of two bones that join together in the centre at theMental symphysis to create the horseshoe shape • The mandible had the alveolar process running around it which is the support for the lower teeth. • Below the Alveolar process on the inside of the body of the mandible lies a ridge of bone called the Mylohyoid ridge/line, which is where the mylohyoid muscle attaches to form the floor of the mouth. • The vertical section of the mandible is called the Ramus of the mandible. Ramus has 2 projections: • coronoid process - In front • condyle - Behind • Sigmoid notch - Between • The horizontal section is called the body of the mandible • The point in which the ramus and the body of the mandible meet is called the angle of the mandible • The mandibles only connection with the skull is the Tempero mandibular Joints (TMJ) • The point at which the mandible connects to the temporal bone is head of theCondyle • Ends at back of mandible in rounded bulge called the Retro Molar Pad • A bony ridge also lies around the outer surface of the ramus of the mandible called theexternal oblique ridge/line which marks the base of the alveolar process in this area. • The foramina of the mandible that are of interest to a dental nurse are - • Mandibular foramen – Halfway up the inner surface of the ramus. This is where the nerve supply enters for the lower teeth and some of the surrounding tissues • Mental foramen – On the outer surface of the mandible, between the positions of the premolar teeth is where the same nerve exits Temporo-Mandibular Joint • Also known as the TMJ • Only moving joint in the skull (hinge) • Formed between condyle of mandible & temporal bone at base of skull • When the mouth is shut the condyle rests in the hollow region of the temporal bone • Glenoid fossa - Hollow in temporal bone • Articular eminence –Formed at the edge front of glenoid fossa • Meniscus - pad of cartilage between the temporal bone and the condyle, in the glenoid fossa • The meniscus prevents the temporal bone and condyle from grating against each other. When the meniscus moves from its normal position it causes jaw clicking on opening and closing • The disarrangement of the joint and the meniscus is called subluxation The TMJ allows three basic style movements of the mandible – • Gliding movement – occurs when the disc and condyle slide up and down the articulate eminence. This allows the mandible to move forwards and backwards. • Rotational movement – occurs when the condyle rotates either anteriorly or posteriorly over the meniscus. This allows the mandible to move up and down. • Lateral movement – This occurs when one joint moves on its own, so the condyle rotates sideways over the disk. Which enables the mandible to swing from side to side. The mandible will swing to the opposite side from the gliding action. • When the jaw opens it opens likes a hinge, The condyle will follow the curve of the articulate eminence until it reaches the crest. Once the crest has been reached the mouth is fully open. • If the condyle slips over the articulate eminence and gets stuck this is said to be dislocated and the treatment for this would be to press down on the lower molar to force the condyle backwards and downwards back over the articulate eminence and back into the glenoid fossa. This may need to be done under sedation or GA to enable the muscles of mastication to relax enough to be able to close the mandible. • Bruxism is caused by clenching or grinding of the teeth, patients may not be aware they’re doing it just that their jaw or teeth hurt. • Trismus is caused by muscle spasms which can result in the inability to open the mouth fully. Trismus can also be caused by pericoronitis • Subluxation – dislocation • Naturally occurring hole in the bone • Mandibular foramen • Mental foramen • Greater palatine foramen • Incisive foramen • Infra-orbital foramen • Foramen magnum • Found only in jaws • Specialised to support teeth • Horse-shoe shaped • Alveolar process – ridge of bone with tooth sockets – alveolus • Resorption occurs after extraction • Compact bone – lamina dura – outer layer • Cancellous bone – spongy inner layer • Hard palate has Rugae which are a series of ridges that help move food backwards • Soft Palate - flap of soft tissue at back of hard palate • Extending tissue behind is called the uvula - made up of connective tissues • The soft tissues of the mouth are Known as mucous membrane • The mucous membrane between teeth & cheek is known as the buccal sulcus • The mucous membrane between teeth and lips is labial sulcus • Attached by fibrous tissue upper - frenum • Attached to floor of mouth by lingual frenum • Mobile muscular organ - thick layer mucous membrane on top, thinner below • Rapidly absorbs drugs placed underneath tongue • Rough surface • Taste buds Functions: • Aids Eating and Swallowing • Speech • Taste • Cleansing mouth Soreness can occur with some conditions: • Anaemia • Vitamin B deficiency • Hormonal disturbances Will have: • Thin, smooth glazed appearance ( Glossitis inflammation of tongue) • Cold sores caused by the Herpes simplex virus • Very common Signs and symptoms – • Tingling • Blotch – blister • Weeping • Scab • very Infectious treatment should be postponed • Treatment -Antiviral cream or Antiviral drugs Can be caused or triggered by: • Illness • Stress • Menstruation • Sunlight • Extreme cold weather • Fatigue • Injury • Cracks in lips • Older people • Denture wearers • Angles of lips • Sore, reddened • No healing or continuous reoccurrence • Replace ill fitting dentures • Antifungal ointment • Apthous Ulceration • Breach in oral mucosa • Not contagious • Painful open sore • Occur on their own or in clusters • Last approximately 7 – 14 days Cause: • Not fully understood • Trauma • Susceptibility • Reaction • Vitamin deficiency • Hormonal • Gastrointestinal Disease • Stress • Immune deficiency Candida albicans Includes: • Oral thrush • Denture stomatitis • Angular cheilitis Can affect: • Very young • Old people • Terminally ill • Asthma sufferers • Thick, White deposits • Tongue, Cheeks ,Lips or Palate • Red raw patches • Antifungal drugs • Nystatin™ • Pastilles or Oral suspension • Denture wearers • Inflammation of mucosa • Red, Shiny, Sore patches • Remove and sterilise dentures • Avoid antibiotics • Antifungal drugs • Gentle brushing of areas affected Saliva Saliva is made up of 99.5% water and 0.5% dissolved substances. The main functions of saliva are - • To aid mastication • Oral hygiene – saliva bathes the mouth and helps wash debris from the mouth. It also has an antibacterial action that helps control disease • Speech – saliva is a lubricant. For example is you think of the last time you were nervous you most likely got a dry mouth which is caused by the adrenaline in your body reducing the saliva flow, it becomes harder to speak with a dry mouth • Taste – saliva dissolves substances and allows the taste bud to recognise the taste of things • Helps maintain hydration – Saliva reduction is one of the first signs we notice of dehydration which encourages you to have a drink and rehydrate • Excretion – Saliva contains trace amounts of urea and uric acid • Digestion – Salivary amylase begins the breakdown of foodstuffs especially starch (important when we get to oral hygiene later on) • Buffering agent – Saliva helps to maintain the neutral Ph of the mouth (which is important when we get to caries) the resting Ph of the mouth is 6.8-7PH this is neutral so neither acidic nor alkaline Composition of saliva Facts about Saliva • People who produce more watery saliva with a low mineral content tend to develop less calculus but have a higher caries risk. People who have thicker saliva, with a higher mineral content, tend to have a lower caries risk but produce more calculus • More is secreted when required (gag reflex or before vomiting) • Composition changes according to what is eaten (more mucous with a diet high in meat) • The average adult will produce between 0.5-1L of saliva daily • Saliva flow almost ceases during sleep • Saliva is sterile until in enters the mouth • Saliva can be used to solve crimes as saliva contains DNA! Reduced Salivary Flow • Xerostomia or dry mouth • Increases the risk of caries & periodontal disease • Causes difficulty in swallowing & speaking • Affects taste • Will leave food debris – halitosis • Hinder natural retention of dentures Reduced salivary flow -causes • Normal age-related changes to salivary glands • Dehydration • Autoimmune disorders – e.g. Sjögren’s syndrome • Cancer treatments • Diuretics, some antidepressants & beta blockers • Parotid Salivary gland • Submandibular Salivary gland • Sublingual Salivary gland Parotid Salivary Gland • Lies partly over the outside and partly behind the ramus of mandible in front of the ear • an be affected by mumps • Tube connecting to the oral cavity is Stensens’ duct – passes forwards across the masseter muscle and inwards through the cheek to open into the buccal sulcus opposite the upper second molar • Commonest salivary gland to be associated with benign and malignant tumours Sublingual Gland • Lies in floor of mouth, above mylohyoid line but much further forward than submandibular gland • Several sublingual ducts which open into the floor of the mouth behind the orifice of the submandibular duct Submandibular Salivary Gland • Lies in posterior region of the floor of the mouth - near the angle • Wharton’s duct passes forwards in the floor of the mouth to open at the midline, beside the fraenum • Longest of ducts • Likeliest to become blocked by salivary stones (calculi) Salivary glands • There are two main types of cells found within the salivary glands – • Mucous secretory cells – Produce a thick, mucus like secretion which aids lubrication and contains minerals and enzymes • Serous secretory cells – produce a thin, serum like substance containing antibodies and electrolytes Muscles of Mastication • Clench your teeth together • Put a hand to the side of your head & face • You can feel the temporal & masseter muscles • There are four sets of muscles connected between the mandible and the cranium. They allow chewing movements and mouth closing. • Temporalis – Its point of origin is the temporal bone. Its point of insertion is the coronoid process of the mandible, passing under the zygomatic arch. This muscle pulls the mandible backwards and closed • Masseter - Its point of origin is the outer surface or the zygomatic arch. Its point of insertion is the outer surface of mandibular ramus and angle. The purpose of the Masseter is to close the mandible. • Lateral Pterygoid (silent “p”) – Its point of origin is at the lateral pterygoid plate at the base of the cranium, just behind the maxillary tuberosity. Its point of insertion is the head of the mandibular condyle and the TMJ meniscus. The Lateral pterygoid works to pull the mandible to one side if one is contracting, if both lateral pterygoids are contracting it brings the mandible forward so the anterior teeth touch. • Medial Pterygoid – Its point of origin is the medial pterygoid plate at the base of the cranium just behind the tuberosity and closer to the midline. Its point of insertion is the inner surface of the mandibular ramus and angle. The medial pterygoid works to close the mandible. Masseter •Closes mandible •Origin - zygomatic arch •Insertion - angle and ramus of mandible Temporalis •Closes mandible & pulls backward •Origin - Temporal bone •Insertion – Coronoid process Medial Pterygoid • Closes mandible • Origin – medial surface of the pterygoid bone • Insertion – Inner surface of mandible near angle Lateral Pterygoid • Both muscles together pull jaw forward • Act alone swing jaw to opposite side • Origin – Lateral Pterygoid Plate • Insertion - Condyle Suprahyoid muscles • This muscles all have one end attached to the horse- shoe shaped hyoid bone which lies suspended in soft tissues beneath the mandible • The hyoid bone is the only bone in the body not connected to any other bone • They all lie above the hyoid bone as the ones below are called the infrahyoid muscles • The suprahyoid muscles are responsible for the opening of the mouth and swallowing The three you need to remember are: • Anterior digastric, its point of origin is the hyoid bone and its point of insertion is the inner surface of the mental symphysis of the mandible. It is responsible for helping to lift the hyoid bone and larynx during swallowing it also pulls the mandible down to open the mouth • Mylohyoid, its point of origin mylohyoid line, fusing in the midline to form the floor of the mouth, its point of insertion is the hyoid bone. The mylohyoid is responsible lifting the hyoid bone and larynx for swallowing and opening the mouth • Geniohyoid, Its point of origin is the genial tubercles on the inner surface of the mandible and its point of insertion is the hyoid bone. This is also responsible for lifting the hyoid bone and larynx during swallowing and for opening the mouth Muscles of Facial Expression Orbicularis Oculi • Ring of muscle around eyes • Thin muscle radiates away to produce movement Orbicularis Oris • Ring of muscle around mouth • Thin muscle radiates away to produce movement Buccinator • Innermost muscle – attached above & below to the buccal surface of alveolar processes • It assists with mastication Digastric Muscle Home Study • Please complete the Homework I’ve emailed out which is a supplementary outcome. If you have your PebblePad login now the supplementary outcome is unit 2 I • Also is you have your PebblePad login now might be a good time to fill in the ones you’ve completed to date.

  • Patient Confidentiality

    GDC Standards • Treat information about patients as confidential and only use it for the purpose it has been given • Prevent information from being accidentally revealed and prevent unauthorised access by keeping information secure at all times • In exceptional circumstances, it may be justified to make confidential patient information known without consent if it is in the public interest or the patient interest Within your role as a dental nurse you have both a legal and ethical duty to keep patient information confidential Duty of Confidentiality • Patients are Entitled to confidentiality • All team members must maintain confidentiality • Covers all information, records and treatment • Patient are entitled to confidentiality even after death As a Dental nurse/trainee you must – • Work within legislation guidelines • Work for the best interest of patient • Once registered you are liable to prosecution or legal action • You must report inappropriate behaviour also known as whistleblowing • You must keep up to date with your CPD • Whole team are bound by the duty of care with regards to a patient's confidentiality • Breach of confidentiality could lead to dismissal for misconduct Releasing Information • The patient has the opportunity to withhold permission • Must gain patient consent (written)to release information The patient, in order to give informed consent must - • Understand what agreeing to • Why we are sharing information • Who sharing with • What is being shared • The consequences • Only the minimum information is to be released • Justify decision and actions behind sharing this information • All party's information is shared with understands information is confidential • Ensure patient cannot be identified if unnecessary • Caldicott regulations (NHS guidelines on the next slide) Caldicott Regulations The NHS guidelines for releasing records The six principles are: 1. Justify the purpose 2. Don’t use patient identifiable information unless necessary 3. Only use minimum information necessary 4. Information is on a strict need to know basis 5. Be aware of responsibilities 6. Understand and comply with the law Safeguarding Information We must ensure these steps are followed- • Secure storage of information – either in locked filing cabinets or on a password protected computer • Received securely by a member of staff • Sent securely (sealed envelopes) • If necessary to dispose of any records they must be disposed of securely either by shredding or collected by an authorised carrier for correct disposal. • Do not leave where they may be accessed by unauthorised persons, anything that can lead back to a patient shouldn’t be left in sight. I know when I worked in surgery(a fair few years ago…ok maybe more than a few!) we used to print off a day list of the patients and leave it on the side, big no no! If you do have day lists printed off they should be out of sight and destroyed correctly at the end of the day. • Ensure you cannot be overheard if discussing information. Keep all confidential conversations in a room with the door closed. • Discuss personal matters with patients in private • Do not reveal attendance (not even to a spouse), you don’t know their circumstances and you could be putting them in danger if they're fleeing domestic abuse for an example. • Records kept for correct period of time which is 11 years or until a child patient reaches the age of 25 Statutory Obligation Sometimes we have a obligation to release records without the patients prior consent but only in the following circumstances - • Road Traffic Act 1988 – to identify a driver or passenger involved in a road traffic accident if facial trauma prevents other identification • If requested to do so by the Dental Practice Division of the Business Services Authority formally the DPB • When providing information to a parent or legal guardian regarding a child • When in the ‘Public interest’, suspected or known criminals ( if you see a patient is a wanted criminal you are able to give information to the police) • When requested to do so by a court order. • When requested without a court order under the prevention of Terrorism Act 1989, or Police and Criminal Evidence Act 1984 Other Types of Records There are other types of records we keep within the dental practice such as - • Staff personnel • Invoices (equipment, materials, etc) • Laboratory slips • Study models • Referrals • Radiographs • Health and safety • Appointment book Home Study I will be emailing out some charting for you to do this week. Again this is a supplementary outcome so will need to be copied over once you’ve got your login. Please also do some research on study models… as they are also classed as confidential how long should we keep them and how should they be disposed?

  • Record Keeping

    Clinical Records The clinical records we keep should include – • Up to date case history • Attendance • Findings • Treatment • Medical history • Payments Recorded Details • Name, address, Date of Birth, phone numbers • Doctor • Next of kin • Medical history • Dental history • Attendance • Charting – tooth and periodontal • Soft tissue assessment • Present condition • Treatment • Appointments with other team members • All legally required paperwork • Consent forms • Radiographs (identified correctly and mounted) • Referral letters or copies • Laboratory prescriptions • Payments (estimates, accounts) • Correspondence Why are Records Important? • They are a legally valid document • They can be used for identification • To ensure correct treatment planning • To be able to accurately calculate fees • Attitude to dental health can be assessed • Allow practice to run efficiently Maintaining Records • Must record information accurately, legibly and comprehensively at the time of the appointment • They must be filed properly away from unauthorised persons • Easily accessible • Patient records must be available at every appointment • Signed when necessary by the dentist or patient • Retained for 11 years after completion of treatment or until the patient is 25 for children Data Protection Act 1998 and GDPR 2018 • These apply to living, identifiable people. • Law designed to protect personal data stored on a computer or organised paper filing system • Controls how information is handled • Give legal rights to people who have information stored about them which covers both patients and staff • Must be register with Information Commissioner Access to Health Records • Patients have right to see own health records under the data protection act 98 – ‘right of access’ – physical or mental Health • Deceased patients records can be obtained through the access to health records act 1990 • NHS and Private • The freedom of information act is different and does not cover the release of patient details • Third parties are excluded from access to patient records unless the patient has previously signed a mandate to authorise the release of their records either to a solicitor or relative To release dental records written since November 1991 they must have - • Approval from Dentist or record holder • Request has to be in writing • Response has to be within 1 month • Identity must be checked before release and the records can only be released to the patient or their legal representative • Amendments of inaccuracies can be requested • Availability of explanations of terminology and jargon Refusal to Access The dentist or record holder can refuse access to patients records if : • Disclosure would cause serious harm to the patient • Another person other than a health care member has been mentioned by name and has not given consent • Access to a deceased patients records is not to be granted if prior notification has been included Information Must Be • True • Accurate • Factual • Free of judgement • Contemporaneous (happens at the same time) • Contain no derogatory comments Freedom of Information Act 2000 • Allows the public access to information held by public authorities • Public authorities are obliged to publish certain information about their activities and members of the public are entitled to request information from public authorities

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