Procedure to be carried out: Clinical Assessment of an Existing Patient

Patient details: 31 years, male,

Social habits: no smoking, drinking occasionally,

Medical history: No medical concerns, no allergies of any king

Last visit: 5th September 2023 for Scale and Polish procedure

Clinical area: NHS Dental Practice

Preparation of the clinical area for Clinical Assessment of an existing patient:

I am wearing my scrubs, I have short nails, I am not wearing any jewellery, I washed
my hands in line with HTM 01-05 regulations, as stated in the handwashing poster
found above each handwashing sink and after that I used rinse-free hand
disinfection gel on my hands and wrists. I am wearing Personal Protective
Equipment (PPE) that I put in the following order: first I put on the plastic apron and
tied at the waist, second, I put on the disposable face mask and made sure it covers
my nose, mouth and chin, then I got the visor and lastly the disposable nitrile
powder-free examination gloves.

I made sure that surgery is kept dry and adequately ventilated at all times to
eliminate exposure of airborne materials, toxic hazards and improve the comfort of
dental staff and patients. Temperature, humidity, and ventilations systems are
regularly maintained/checked following HTM 03-01 specialised ventilation for
healthcare premises guidance. Natural light combination with ambient lighting is
used to establish a comfortable environment in a way that helps the patients feel
confident and calm.

I switched on and visually checked all the equipment required for the procedure
according to the manufacturer’s guidelines:

 Air compressor, which is located downstairs, I switched on the power by

pressing the switch button on the wall, and then pulled on the safety valve to
test it which released a hiss of escaping air. After I had done that, I watched
the pressure gauge, waiting for the needle to stop moving. This signifies that
the air inside has reached optimum pressure.
 X-ray Machine, I switched on the power by pressing the red switch button on
the wall, and visually checked if the equipment works within diagnostic
reference levels (DRL), checked if warning lights and alarms functioning
correctly, checked if isolation switch is working, and I checked if the arm is not
loose and moving, and if the head is in good working condition with the
collimator on, recording the findings in the Log in record sheet.
 Dental chair- I switched on the power by pressing the green switch button
from the bottom of the dental chair unit, and I filled a reservoir bottle with
freshly made distilled water and water lines decontamination solution
( tosylchloramide sodium solution), in a concentration of 10ml solution to
990ml distilled water, according to manufacturer guidelines, for preventing the
 biofilm in dental unit waterlines I attached it to the chair securely and flushed
all dental unit water lines (DUWL) like 3 in1 syringe, slow and fast speed hand
pieces and scale and polish, for 2 minutes and flushed again for 30 seconds
between each patient (HTM01-05). This is done to remove stagnant water
and to also reduce the microbiological count within the water lines and to
prevent cross contamination. I am aware that Legionella and Pseudomonas
bacteria can be spread through the handpieces to the patient or staff and can
cause mild to severe illness.
 The Suction line was switched on together with the dental chair, and now
used my finger to completely cover the Regulator Port to check the suction
strength.
 Amalgamator- I switched on the power by pressing the switch button on the
wall, hearing the beep sound confirming that the amalgamator is on.
 Light cure- I switched the power on and checked it was working by removing
the light cure and placing it back on the charging unit watching the charging
light come on.
 switched on the computer from the plug and pressed the on/off button at the
bottom of the screen which then brought power to the computer and logged
into the system.

All the equipment was in good working condition for the day.

All staff in our practice are responsible for checking and setting up the
Decontamination room every morning, by turning all the equipment on - the lights
pressing the swich on, the fun extractor, that is very important because ensures a
good ventilation taking out the air from the room and bringing in fresh air, the
illuminated magnifier by pressing the switcher on, and the Autoclave type N that I
filled with freshly distilled water and I run an autoclave test cycle using TST strip to
test the sterilising conditions. Before the cycle starts, I do the safety checks looking if
the door seal is intact and checking for the door pressure interlock and door closed
interlock. During this cycle the air is sucked out of the vacuum chamber which
creates a steam which allows it to contact all surfaces, including any hollow
instruments. The autoclave heats to 134 degrees Celsius and holds a bar pressure
of 2.25 for 3 minutes. A full cycle length is 15 minutes, and I knew the test was
successful when the yellow circle present on the TST strip had turned to purple once
the cycle had complete. I write down all the findings in the Log sheet, and signed
with my initials, together with the cycle number, the Autoclave model and serial
number. There are no other automatic cleaners in my practice. I scrubbed the dirty
instruments washing sink and the instruments rinsing sink with cream cleaner paste,
the taps as well, making sure there is no limescale deposits, and then I cleaned them
with warm water. I sprayed all the flat work surfaces with disinfectant spray 2 in 1
anti -microbial non- alcoholic surface cleaner and wiped them with paper towels.

Back in surgery room, I sprayed all the flat work surfaces with disinfectant spray 2 in
1 anti -microbial non- alcoholic surface cleaner and wiped them with paper towels.
For the dental chair, dental light, control panels and for the bracket table that holds 3
in 1, slow and faster speed hand pieces and scale and polishing handle, I used anti-
microbial surface cleaning pre-saturated and alcohol-free wipes following
manufactures guidelines (we don’t apply disposable covers to the dental chair
handles and headrest in the surgery room I worked this day, but we do it in other
surgery rooms were the dental chair have any sign of wear or tear, and I am aware
that the best practice according to HTM 01-05 guidelines Best Practice there should
be disposable covers applied to the aspirator tubes, control panels and handles
dental light). Computer keyboard is covered with protective silicone cover. I clean
these areas in between each patient with anti-microbial cleaning wipes following
manufactures instructions. I prepared the dirty instruments box, which is lockable,
rigid and puncture proof by spraying it with disinfectant spray 2 in 1 anti -microbial
non- alcoholic surface cleaner and wiped it with paper towels.

The patient is an existing patient, and I opened hir file records, where I could see
that his last visit was on 5th September 2023, for a Scale and Polish procedure, I
checked if there are any radiograph taken, and I saw that we have two Bite wings
images taken almost 1 year ago, and I opened patient's medical history to check for
any allergies or red flag warnings, to inform the dentist accordingly. The patient’s
habits and medical history was documented, and electronically signed and dated at
the reception, and I can see that the patient is generally healthy, with no allergies,
and no medical concerns. I made sure I have got the consent from the patient as a
trainee dental nurse to use the information about the treatment for my RoE records.
Patients consent was gained for a trainee dental nurse to assist the clinician prior to
treatment.

On the dentist side I placed the tray with mouth mirror, straight probe, BPE probe,
college tweezers, cotton wool rolls, disposable 3 in 1 tip. On the nurse side I placed
a disposable aspirator tube, a cup of fresh mint mouthwash and a box with soft
tissues. I changed my gloves and prepared PPE for the dentist and for the patient,
as follow: for the dentist prepared disposable nitrile powder-free examination gloves,
plastic apron, disposable face mask and visor, and for patient prepared the safety
googles and bib.

I politely invited the patient into the surgery room and asked them to have a seat on
the dental chair. I provided the safety googles and covered her with the bib, always
making sure and asked if the patient is comfortable to start the procedure. When I
saw that the dentist is ready to start the examination, I removed my gloves and
opened a new assessment form, on the patient’s file, ready to record any findings
reported by the dentist. The dentist started by asking the patient about their general
health, and if there are any habits like smoking, drinking alcohol, any cariogenic diet
like sweet intakes, and fizzy drinks and about teeth cleaning habits (how many times
are brushing per day, if they use mouth wash or floss), and the patient answered that
he is brushing twice a day, in the morning and before bed, he is not using dental
floss or interdental brushes, and he is using fluoride mouth wash, low sugar intake,
moderate fizzy drink intake( 2-3/week). The dentist provided the patient with verbal
advice about the risks of having a cariogenic diet, how to properly clean the teeth,
cleaning aids he should use and the benefits of using them, while I was recording the
answer into the assessment form. After the patient gave consent to begin the
examination, the dentist started by visually inspecting the extraoral soft tissue,
checking for skin colour, facial symmetry (could indicate the presence of a swelling,
or problems with the nerve supply or muscular control of that area), the presence of
any blemishes, especially moles and cold sores, the lips (checking for any change in
colour or size, the presence of any blemishes, and palpating for any abnormalities),
and palpating the lymph nodes lying under the mandible and in the neck (these are
palpated to detect any swellings or abnormalities). He asked the patient to open their
mouth, and closing, and repeat this process two – three times to check for any
Temporomandibular Joint disorder, inspecting the joint range of motion or the
presence of joint sounds during mandibular opening movements, and he checked if
the occlusal surfaces are in contact as well ( occlusion).

Next, the dentist asked the patient to open their mouth and using the mouth mirror,
he visually assessed the intraoral soft tissues like labial, buccal, sulcus and palatal
mucosa (both the hard and soft palates, the oropharynx and the tonsils), checking for
colour and textures, the presence of any white patches and the moisture level. He
also checked the tongue by asking the patient to take it out and move it to the left,
then to the right, and the floor of mouth as well, for colour and texture, symmetry of
shape and movement, the level of mobility, the presence of any white or red patches,
and the presence of any swellings, this being referred to as oral cancer screening.

The dentist reported no findings after extraoral and intraoral assessment, and we
both moved to the next stage, the tooth charting. In the dental practice I work, we
use Palmer notation system. The dentist asked the patient to open their moth and,
using the mouth mirror and the straight probe, he checked every tooth surface for
decay, caries, previous restorative procedures, or fixed prosthesis, starting from
lower left eight, and finishing with upper left eight, while I was assisting him by
recording all the findings in the assessment file: lower left and upper left 8 was
missing, lower left 5 has occlusal composite filling, lower right 6 has occlusal and
mesial composite filling, and upper left 7 to be observed further, because the dentist
believes that a cavity might be forming on the hard layer of your tooth. The dentist
also recommended for a radiograph to be taken for this specific tooth, asking the
patient if agrees with that. Using the BPE probe, he asses the health of patient’s
periodontal tissue for signs of disease or recession (in the BPE chart we find these
assessments as gum health, plague control and bone loss), and I was recording the
results using the BPE chart (lower left – 0, lower front – 0, lower right- 1, upper right
– 0, upper front – 0, upper left- 1). After completing the BPE check, the dentist
reports the findings to the patient: the gum’s health is in a good condition, without
signs of inflammation, some plague found on the back side of lower anterior teeth,
and no bone loss recorded, so the dentist recommend to the patient a routine scale
and polish procedure, and ask for consent to take a periapical intraoral radiograph to
detect decay or any changes that occur just below the gum line or inside the tooth,
on upper left 7.

The patient give consent for x ray to be taken, so I equipped with disposable nitrile
powder-free gloves and, after confirming with the dentist what type of intraoral
radiograph to be taken, I took out from the drawer a sterile packed plate holder
periapical with ring, and one digital plate size 2 and handed to the dentist, then I
prepare the x ray machine ready for the dentist to take the necessary radiographs.

When the dentist received the radiograph image, in the computer, he inspected it
and informed the patient that everything looks normal, without major signs of decay
or hidden carries, but to pay more attention to the back teeth when brushing,
especially to that specific tooth, to prevent more decay happening.
The dentist recommended to the patient a routine scale and polish procedure to be
done by our Hygienist, and to come back to him in 6 months for another Routine
Examination. When the examination was done, and the patient left, I escorted him to
the Reception area, where my colleague booked him with the hygienist, on the
following week, for a scale and polish procedure.