Student Name
Date:
SECTION I
Instrumentat
ion
Skill
Evaluation
CH 3 Explorer
Possibl Minimum
e
Possible
80%
16
13
32
26
16
13
16
13
14
11
40
32
24
19
40
32
40
32
Y
N
Y
N
Pg. 11
13/14 Universal
Curet
Y
N
Pg. 10
204SD Sickle
Y
N
Pg. 9
6/7 Sickle
Y
N
Pg. 8
11/12 Explorer
Y
N
Pg. 7
Hand Piece
Y
N
Pg. 6
Piezo
Y
N
Pg. 5
Ultrasonic
Remediat Remediati
ion
on
Required Complete
d (enter date
and faculty
initials)
Pg. 4
Probe
Points
Achieve
d
Y
N
Pg. 12
32
26
11/12 Gracey
Curet
Y
N
Pg. 13
32
26
Y
N
Pg. 14
13/14 Gracey
Curet
32
26
Y
N
Pg. 15
FH 3/7, 5/11
Files
16
13
Y
N
Pg. 16
SECTION I
Total Points
Possible
350
Total Points
Achieved:_________
SECTION II
PATIENT
EVALUATION
AND
PROCEDURES
Blood Pressure
and faculty
initials)
Y
N
Pg. 17
Pulse and
Respiration
Remediat Remediati
ion
on
Required Complete
d (enter date
Y
N
Pg. 18
16
13
Y
N
Pg. 19
Oral Examination
11
Fluoride Tray
16
13
12
10
Y
N
Pg. 22
Fluoride Varnish
Y
N
Pg. 21
Fluoride Rinse
Y
N
Pg. 20
12
10
SECTION II
Total Points
Possible
79
Points SECTION I
Y
N
Pg. 23
Total Points
Achieved:_________
+ Points SECTION II
429
FINAL PERCENTAGE=
PASS
FAIL
ADA Accreditation Standard 2-19 states Graduates must be competent in providing the
dental hygiene process of care which includes; assessmentperiodontal and dental
examination.
Max
3/4 O
1 pt
Mand
19/20 O/B
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
Wrist
1 pt
1 pt
0 pt
0 pt
Adaptation/Angulatio
n
1 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
-Retraction/Reflection
-Grasp
0 pt
0 pt
Ergonomics/Lighting/
Location -Posture
1 pt
1 pt
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
0 pt
0 pt
Professionalism
1 pt
1 pt
0 pt
0 pt
Grasp
-Modified Pen Grasp
Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas
Exploring Technique
-Uses a light exploring technique
-OSHA
-Infection Control
Instructor
Comments
5
Total Points Possible
16
Minimum Points 13
_____yes_____no
Remediate
O=Occlusal B=Buccal
B
3/4/5
F
8/9/10
L
19/20/21
L
23/24/25/
26
1 pt
1 pt
1 pt
1 pt
Fulcrum
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
0 pt
0 pt
Wrist
1 pt
Grasp
-Modified Pen Grasp
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
Adaptation/Angulatio
n
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
Exploring Stroke
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
Instructo
r
Commen
ts
6
Proper
-Retraction/Reflection
-Grasp
0 pt
0 pt
0 pt
0 pt
Ergonomics/Lighting/
Location -Posture
1 pt
1 pt
1 pt
1 pt
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
0 pt
0 pt
0 pt
0 pt
Professionalism
1pt
0pt
1pt
0pt
1pt
0pt
1pt
0pt
-OSHA
-Infection Control
Remediate
F=Facial
L=Lingual B=Buccal
Tuning
-Tunes for plaque removal(mist
and drip)
-Tunes for calculus removal(fine
mist)
-Verbalizes correct insert use
-Demonstrates foot pedal
controls
-Gives saliva ejector to patient
-Provides patient paper towels
Grasp
-Modified Pen Grasp
Fulcrum
7/8/9/10 F
23/24/25/26 L
(Completed
Correctly)
1 pt
0 pt
(Completed
Correctly)
1 pt
0 pt
1 pt
0 pt
1 pt
1 pt
0 pt
1 pt
Instructor
Comments
7
-Close to area being treated
-Intra or Extra Oral
0 pt
0 pt
Wrist
1 pt
1 pt
0 pt
0 pt
Adaptation/Angulatio
n
1 pt
1 pt
0 pt
0 pt
Dental Mirror
Uses Proper
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
0 pt
0 pt
-Retraction/Reflection
-Grasp
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
Professionalism
-OSHA
-Infection Control
F=Facial
L=Lingual
7/8/9/10 F
(Completed
Correctly)
1 pt
23/24/25/26 L
Instructor
Comments
8
-Attaches tip to handpiece using
wrench
and rotates clockwise until a
click is
heard
-Selects appropriate operation
mode
-Selects appropriate water mode
-Selects appropriate power range
setting
Tuning
-Adjusts water flow
-Tunes for plaque removal(mist
and drip)
-Tunes for calculus removal(fine
mist)
-Gives saliva ejector to patient
-Provides patient paper towels
Grasp
-Modified Pen Grasp
Fulcrum
-Close to area being treated
-Intra or Extra Oral
Wrist
0 pt
(Completed
Correctly)
1 pt
0 pt
1
0
1
0
pt
pt
pt
pt
1
0
1
0
pt
pt
pt
pt
1 pt
0 pt
1 pt
0 pt
Adaptation/Angulatio
n
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
0 pt
0 pt
Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
Professionalism
-OSHA
-Infection Control
F=Facial
L=Lingual
7/8/9/10
F
1 pt
28/29/30
L
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
Wrist
1 pt
1 pt
0 pt
0 pt
Adaptation/Polishing
Technique
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
Grasp
Instructor
Comments
Fulcrum
-Hard tissue fulcrum
-Close to area being treated
-Pivots on fulcrum finger
-Retraction/Reflection
-Grasp
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
Professionalism
-OSHA
-Infection Control
0 pt
0 pt
Remediate
F=Facial
L-Lingual
10
Additional Instructor Comments:
3/4/5
B
7/8/9
F-ST
19/20/2
1L
23/24/2
5 F-ST
23/24/2
5 L-ST
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
Wrist
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
Adaptation/Angulatio
n
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
Grasp
-Modified Pen Grasp
-Light Grasp
Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas
Exploring Stroke
-Uses digital action
-Uses a light lateral pressure
-Uses short overlapping strokes
-Rolls and pivots and keeps tip
on tooth
-Side of tip is in the sulcus and
finishes
under contact
Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
Instruct
or
Comme
nts
11
-Uses loupes
Professionalism
-OSHA
-Infection Control
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
Remediate
B-Buccal
F=Facial
L=Lingual
8/9/10
F-ST, F-SA
1 pt
25/26/27
F-SA, L-SA
1 pt
23/24/25
F-ST, L-ST
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
0 pt
Exploratory/Working
Strokes
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
Grasp
-Modified Pen Grasp
Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas
Wrist
-Keeps straight with forearm
-Positions palm toward incisal
Adaptation/Angulatio
n
Instructor
Comments
12
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
Professionalism
-OSHA
-Infection Control
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
Total Points 24
Minimum Points=19
_____yes_____no
Remediate
F=Facial
L=Lingual
ST=Surfaces Toward
3/4/5
B
12/13/
14
L
19/20/
21
L
30/29/
28
B
1 pt
1 pt
1 pt
1 pt
23/24/
25 FST LST
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
Wrist
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
Grasp
-Modified Pen Grasp
Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas
Adaptation/Angulatio
n
-Uses correct working end
-Keeps terminal shank parallel
to long axis of tooth in posterior
-Terminal shank wraps to the
Instruct
or
Comme
nts
13
surface in
the anterior
-Repositions at line angles and
advances
toward proximal
-Rotates to adapt proximally
Exploratory/Working
Stroke
-Uses light exploratory stroke
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
initially
-Finishes with working stroke,
cutting
edge engaged 60-80
-Uses short overlapping strokes
-Rolls and pivots keeping
cutting edge
engaged on tooth
Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
Professionalism
-OSHA
-Infection Control
Remediate
B=Buccal
L=Lingual
F=Facial
ST=
3/4/5
B
12/13/
14
L
19/20/
21
L
30/29/
28
B
23/24/
25 FST, LST
Instruct
or
Comme
nts
14
Grasp
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
Wrist
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
Adaptation/Angulatio
n
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
Exploratory/Working
Stroke
-Uses light exploratory stroke
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas
initially
-Finishes with working stroke,
cutting
edge engaged 60-80
-Uses short overlapping strokes
-Rolls and pivots keeping
cutting edge
engaged on tooth
Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
Professionalism
-OSHA
-Infection Control
Remediate
B=Buccal
L=Lingual
F=Facial
ST=
15
Additional Instructor Comments:
7/8/9
F-ST
10/11
L-SA
25/26/2
7
F-ST
22/23/2
4
L-SA
1 pt
1 pt
1 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
0 pt
0 pt
Exploratory/Working
Stroke
-Uses light exploratory stroke
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
Grasp
-Modified Pen Grasp
Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas
Wrist
-Keeps straight with forearm
-Positions palm toward incisal
Adaptation/Angulatio
n
initially
-Finishes with working stroke,
cutting
edge engaged 60-80
-Uses short overlapping strokes
-Rolls and pivots keeping
cutting edge
engaged on tooth
Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
Instruct
or
Comme
nts
16
Professionalism
1 pt
0 pt
-OSHA
-Infection Control
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
Remediate
F=Facial
L=Lingual
ST=Surfaces Toward
4/5
B
13/14
L
19/20
L
28/29
B
1 pt
1 pt
1 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
0 pt
0 pt
Wrist
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
Adaptation/Angulatio
n
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
Exploratory/Working
Stroke
-Uses light exploratory stroke
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
Grasp
-Modified Pen Grasp
Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas
Instruct
or
Comme
nts
17
initially
-Finishes with working stroke,
cutting
edge engaged 60-80
-Uses short overlapping strokes
-Rolls and pivots keeping
cutting edge
engaged on tooth
Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
Professionalism
-OSHA
-Infection Control
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
Remediate
B=Buccal
L=Lingual
Grasp
4/5
B
13/14
L
19/20
L
28/29
B
1 pt
1 pt
1 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas
Wrist
-Keeps straight with forearm
-Positions palm toward
Instruct
or
Comme
nts
18
occlusal/incisal
Adaptation/Angulatio
n
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
Exploratory/Working
Stroke
-Uses light exploratory stroke
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
1 pt
1 pt
1 pt
1 pt
0 pt
0 pt
0 pt
0 pt
1pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
initially
-Finishes with working stroke,
cutting
edge engaged 60-80
-Uses short overlapping strokes
-Rolls and pivots keeping
cutting edge
engaged on tooth
-Rotates to adapt proximally
Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
Professionalism
-OSHA
-Infection Control
Remediate
B=Buccal
L=Lingual
19
Activity
1 pt
FH 5/11
14DL,
30MB
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
0 pt
Wrist
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
0 pt
0 pt
Exploratory/Working
Strokes
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
0 pt
0 pt
1 pt
1 pt
0 pt
0 pt
Grasp
FH 3/7
3B, 19L
Instructor Comments
Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas
Adaptation/Angulatio
n
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes
Professionalism
-OSHA
-Infection Control
Total Points 16
Minimum Points=13
_____yes_____no
Total Points Earned______
Remediate
B=Buccal
DL=Distolingual
L=Lingual
MB=Mesiobuccal
20
Interview
-Determines patient has not had alcohol, tobacco,
caffeine or vigorous exercise within previous 30
minutes
Selection
-Selects an appropriate arm
-Selects appropriate size cuff
Instructor Comments
1
0
1
0
pt
pt
pt
pt
1 pt
0 pt
Cuff Placement
1 pt
0 pt
Manometer, Stethoscope,
Amplifying Device
-Places manometer so dial is clearly visible
-Places stethoscope earpieces into the ear canals
with earpieces angled forward
-Places amplifying device above antecubital fossa
-Supports patients arm so antecubital fossa is at
mid-sternum
Valve/Pressure
-Opens valve and rapidly inflates
-Opens valve so pressure drops no faster than 2
mm per second
-Notes point at which sounds appear
-Notes point at which sounds disappear
-Continues releasing pressure slowly for at least 10
mm Hg beyond last sound heard then rapidly
deflates
Professionalism
-OSHA
-Infection control
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
Total Points 7
Minimum Points=6
_____yes_____no
Total Points Earned______
Additional Instructor Comments:
Remediate
21
Preparation
-Grasps the patients wrist with the fingers of the
free hand (non-watch bearing)
-Using finger pads, locates radial pulse using
appropriate pressure
Respiration Technique
-without letting go of the wrist, student begins to
observe the patients breathing
-Does not inform the patient respirations are being
assessed
-Counts number of respirations for a minimum of 30
seconds
-Respiration rate within two breaths of the
evaluators rate
Professionalism
-OSHA
-Infection control
Instructor Comments
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
Total Points 5
Minimum Points=4
_____yes_____no
Total Points Earned______
Additional Instructor Comments:
Remediate
22
PPE/Lighting
-Using infection control protocol, student dons
eyewear, masks and patient care gloves
-Lighting used for visualization
Visually inspects:
-General appraisal
-Head, scalp and ears
Palpation:
-Occipital nodes
-Avoids walking fingers
-Posterior auricular nodes using circular
compression with fingertips
-Avoids walking fingers
-Pre-auricular nodes using circular compression
with fingertips
-Avoids walking fingers
Instructor Comments
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
23
-Maxillary and frontal sinuses using circular
compression with fingertips
-Avoids walking fingers
-TMJ using circular compression
-Has patient slowly open and close mouth
-Has patient make lateral excursions to the right
and left
-Thyroid gland, locates below thyroid cartilage
-Asks patient to swallow, provides water if
necessary
-Palpates the gland and inspects visually as patient
swallows
1 pt
0 pt
Professionalism
1 pt
0 pt
-OSHA
-Infection Control
1 pt
0 pt
1 pt
0 pt
Total Points 16
Minimum Points=13
_____yes_____no
Remediate
Oral Examination
Activity
Patient Position
-Places patient in supine position
-Provides patient eyewear
Instructor Comments
1 pt
0 pt
PPE/Lighting
1 pt
0 pt
Visually inspect:
-Lips and vermillion border
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
24
compression
Professionalism
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
-OSHA
-Infection Control
Total Points 11
Minimum Points=9
_____yes_____no
Remediate
Instructor
comments:
1 pt
0 pt
1
0
1
0
1
0
1
0
1
0
1
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
25
0 pt
1 pt
0 pt
1
0
1
0
pt
pt
pt
pt
1
0
1
0
1
0
1
0
pt
pt
pt
pt
pt
pt
pt
pt
1 pt
0 pt
1 pt
0 pt
Total points: 16
Minimum Points=13
_____yes_____no
Remediate
Instructor
comments:
1 pt
0 pt
1
0
1
0
pt
pt
pt
pt
26
4. Instructs the patient on the proper way to
swish the solution around the mouth but not to
swallow
5. Instructs the patient on the amount of time to
swish (30 seconds)
6. Continuously monitors patient and instructs
the patient not to swallow
7. Provides evacuation (saliva ejector) to patient
and instructs them to expectorate in the saliva
ejector and to avoid pursing lips around the
ejector tip
8. Repeats the swish with the second half
following the same instructions reminding the
patient on the proper way to swish the solution
around the mouth
9. Instructs the patient on the amount of time to
swish (30 seconds)
10. Continuously monitors patient and instructs
the patient not to swallow
11. Provides evacuation (saliva ejector) to patient
and instructs them to expectorate in the saliva
ejector and to avoid pursing lips around the
ejector tip
12. Gives appropriate post-operative instructions
including avoiding eating, rinsing, drinking,
and smoking for 30 minutes
1 pt
0 pt
1
0
1
0
1
0
pt
pt
pt
pt
pt
pt
1 pt
0 pt
1
0
1
0
1
0
pt
pt
pt
pt
pt
pt
1 pt
0 pt
Total points: 12
Minimum Points=10
_____yes_____no
Remediate
Instructor
comments:
27
1. Provides the patient the proper rationale for
the use of fluoride varnish treatment followed
by informed consent
2. Seats patient in an upright position and offers
patient a drink of water
3. Grasps varnish cup between fingers and peels
off foil lid
4. Mixes varnish thoroughly with applicator brush
5. Using compressed air thoroughly dries
mandibular teeth
6. Paints a thin layer of fluoride varnish directly
on all surfaces of the mandibular teeth
7. Using compressed air thoroughly dries all
maxillary teeth
8. Paints a thin layer of fluoride varnish directly
on all surfaces of the maxillary teeth
9. Allows all surfaces to become wet either by
gentle rinsing or natural salivary flow
10. Instructs patient to expectorate using the
saliva ejector reminding the patient to avoid
pursing the lips around the ejector tip
11. Instructs patient to remain on a soft-food diet,
avoid mouth rinses containing fluoride or
alcohol, and avoid brushing or flossing treated
area for a minimum of four hours
12. Advises patient the varnish may begin to
gradually slough off from the tooth surface
after treatment and remaining varnish can be
removed by brushing and flossing after a
minimum of four hours
1 pt
0 pt
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
1 pt
0 pt
1 pt
0 pt
Remediate