Form - Pit & Fissure

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PIT AND FISSURE SEALANT CLINICAL PATIENT WORKSHEET

Student Name – Please add your name in the form below exactly as it appears on your ID

Date

Faculty Name

Patient Name

Use this worksheet to identify errors in procedures. Place a check mark in the box each time a step in the procedure is incorrectly
performed or omitted.
*In some cases, a specific procedural step that is identified by an asterisk will require that this step must be correctly performed as improper performance would cause harm to the patient and/or cause failure to the sealant.

Infection Control/ Patient Safety

Apply barriers to chair, unit, light, air/water syringe, hoses, HYE, saliva ejector,

Don PPE: gloves, mask, gown, scrubs, eye wear, patient safety glasses*

Check medical health history

Assemble Armamentaria

Basic set-up: mirror, explorer, cotton pliers

Air-water syringe tip, HYE tip, saliva ejector

Low-speed handpiece with disposable prophy angle

Non-fluoridated/flavored prophy paste

Isolator cotton roll holder, Dri-aids, Dri-tips, Lingua-fix

Etchant, sealant material, applicator tips and brushes

Curing light, tinted safety glasses or shield.

Articulating paper, composite finishing stone, floss

Tooth Preparation

Remove plaque/pellicle from tooth/teeth with non-fluoridated/flavored prophy paste and rubber cup.*

Rinse surface and suction. Check surface with explorer for complete pumice removal. Rinse again and thoroughly dry.

Use articulating paper and determine the occlusal stops.

Isolate quadrant area with appropriate cotton rolls, holder, Dri-Aid, Dri-angle etc.

Completely dry teeth.

Etchant Placement

Place etchant onto enamel surfaces to be sealed; extending beyond the anticipated sealant area with etchant, but not extending onto the inclines or ridges.

Allow etchant solution to remain for 15 seconds.

Thoroughly rinse removing etchant, while keeping teeth isolated. If teeth become contaminated, re-etch for 10 seconds, and rinse again

Thoroughly rinse tooth surfaces for at least 20-30 seconds followed by dyeing for 20 seconds. Etchant pattern will not appear on typodont tooth.

Sealant Placement and Curing Etchant pattern will not appear on typodont tooth.

Express small drop of UltraSeal XT plus at the end

Express another small drop; lightly paint on until desired amount is reached. Sealant materials appear thin. Once in place sealant will thicken.

Polymerized sealant by curing light. Hold light as close to surface as possible without touching materials (1-2mm). Standard curing light-cure for 20 seconds; high energy curing light-cure for 10 seconds.

Check the void area, bubbles, etc. with explorer. If sealant needs to be added and surface is still not contaminated, add sealant and cure. If surface is contaminated, repeat etchant for 10 seconds, rinse, dry.

Using a dampened cotton roll, gently remove the inhibition layer from the sealant surface

Remove isolation materials, rinse and dry.

Check contact with floss.

Check occlusion with articulating paper

Reduce any high areas on the sealant with composite stone.

Patient Education (not provided during laboratory experiences)

Infection Control-Patient Safety Clean-Up

Remove barriers on the chair, unit, light, air/water syringe, hose, HVE, saliva ejector, headpiece.

Surface disinfect areas that are not covered with barriers

Prepare and institute sterilization procedures

Manage PPE: gloves, mask, scrubs, eyewear, patient safety glasses.

PIT AND FISSURE PLACEMENT PRODUCT EVALUATION

First Name

Last Name

Date Of Birth

The following areas reflect the errors made that indicate a reduction in the grade.

PREPARATION AND ETCHANT

Tooth #1

Teeth are free of stains/plaque

Coronal polish/teeth precleaning

Isolation of selected area

Etching solution application

Etching solution removal

Add score and comments for another tooth?

Yes

Teeth are free of stains/plaque

Coronal polish/teethprecleaning

Isolation of selected area

Etching solution application

Etching solution removal

Add score and comments for another tooth?

Yes

Teeth are free of stains/plaque

Coronal polish/teethprecleaning

Isolation of selected area

Etching solution application

Etching solution removal

The following areas reflect the errors made that indicate a reduction in the grade.
SEALANT PLACEMENT
Tooth #1

Mixing/ preparation of sealant dispensing procedure

Application

Occlusal coverage

Occlusal thickness

Polymerization time

Occlusal adjustment

Add score and comments for another tooth?

Yes

Mixing/ preparation of sealant dispensing procedure

Application

Occlusal coverage

Occlusal thickness

Polymerization time

Occlusal adjustment

Add score and comments for another tooth?

Yes

Mixing/ preparation of sealant dispensing procedure

Application

Occlusal coverage

Occlusal thickness

Polymerization time

Occlusal adjustment

KEY FOR GRADING USING PRODUCT EVALUATION
NUMERICAL SCORE PERCENTAGE

10 Pass – Excellent
7.5 Pass
5 Fail – Critical Errors
3 Fail – Critical Errors No Concept
A 7.5 must be received for each of the four teeth per patient in order to pass the clinical experience and/or examination.

UPDATED MEDICAL HEALTH HISTORY FORM

Name

Your Physician’s Name

Date of Birth

Your Physician’s Address

Briefly describe your general health

Checkbox Field

Measles

Jaundice

Epilepsy

Venereal disease

Diabetes

Rheumatic fever

Tuberculosis

Chicken Pox

Heart Attack

Hepatitis

Mumps

Stroke

Ulcers

Asthma

Thyroid Disease

Anemia

Liver Disease

Emotional disease

Have you been examined by a physician in the last year?

Yes

Hasthere been any change in your health in the last year?

Yes

Have you ever had surgery? (An operation)

Yes

Please specify

Have you gained or lost much weight recently?

Yes

Have you ever been treated for ear or eye trouble, other than corrective glasses?

Yes

Do you bleed for a long time when you cut yourself?

Yes

Have you ever had hives or a skin rash?

Yes

Have you ever been told you have heart trouble?

Yes

Do you get out of breath easily?

Yes

Do you have spells of dizziness?

Yes

Do your ankles ever become badly swollen?

Yes

Do you have high blood pressure?

Yes

Have you ever been told that you have a heart murmur?

Yes

Do you have any blood disorder?

Yes

Do you have asthma, hay fever, sinusitis or frequent sore throat?

Yes

Have you ever had tuberculosis, emphysema or other lung disease?

Yes

Do you have stomach trouble, frequent diarrhea or constipation?

Yes

Have you ever been told you have kidney or bladder trouble?

Yes

Have you ever had syphilis or gonorrhea?

Yes

Do you ever have fits, convulsions or seizures?

Yes

Do you have arthritis or joint trouble?

Yes

Are your joints often painfully swollen?

Yes

Have you had a general or local anesthetic?

Yes

Have you often had toothaches?

Yes

Do your gums bleed when you brush your teeth?

Yes

Do your gums itch when you brush your teeth?

Yes

Does it hurt when you chew?

Yes

Do you have any problems with your jaws?

Yes

Do you clench or grind your teeth?

Yes

Have you ever had an injury to your face, neck or jaw?

Yes

Do you suffer from frequent or severe headaches, neck or back pain?

Yes

Have you ever received x-ray or radiation therapy to the head or neck?

Yes

Do you have ear pain or pain in front of the ears?

Yes

Does your jaw feel tired after a big meal?

Yes

Must you chew on one side exclusively?

Yes

Is your sleep disturbed by pain of the head and neck region?

Yes

Are your daily activities or routine disturbed by pain of the head and neck region?

Yes

Do you consider yourself a nervous person?

Yes

Do you fee unhappy or depressed?

Yes

Are you easily upset?

Yes

Are you sensitive or allergic to any medicine

Yes

Are you sensitive or allergic to any of the following?

Penicillin

Novocain

Aspirin

Iodine

Codeine

Sleeping pills

Other

Please specify

Do you smoke or use tobacco?

Yes

Do you drink alcohol daily?

Yes

WOMEN – Are you pregnant?

Yes

WOMEN – Are you in or have passed through menopause (change of life)?

Yes

When did you last have radiographs (Full Mouth X-rays – 18-20 images) taken?

List all Prescription and Non-Prescription drugs taken or used in the past 3 months:

List all hospitalizations for any reason:

PATIENT MEDICAL HISTORY

Patient’s Name

Patient’s Last Name

Address: City: State: Zip:

Phone

Physician Name

Dentist Name

Age

Physician Phone

Dentist Phone

Date Of Birth

Physician Address

Dentist Address

Name Of Student

MEDICAL HEALTH STATEMENT

I, hereby declare that to the best of my knowledge and belief, I do not have or have not had in the past any systemic condition that can affect the pit and fissure sealant procedure. The disclosures of any of these conditions have been included in my medical health history. These systemic conditions include but are not limited to:
heart and/or kidney disease, herpes simplex, hepatitis, diabetes, epilepsy, positive HIV, AIDS, organic heart murmur and heart valve replacement. Disclosures of these conditions have been forthcoming on my signed and dated medical health history.
I also acknowledge that Fullerton Dental Assistant School or any participant in the pit and fissure sealant certification course will maintain and keep all course related documents confidential.

PATIENT RELEASE FORM

I hereby give my permission for a pit and fissure sealant to be performed on me as part of a clinical requirement for pit and fissure sealant certification.
I understand that no charge will be made for the service performed. In consideration thereof, I hereby agree to waive, release, hold harmless, defend and indemnify, as against any and all claims I or my heirs may have now or in the future against its principals and/or agents, arising out of or resulting from my voluntary participation as a patient in the dental trainee program.

Pit and Fissure Sealant Patient Criteria Form

Date / Time

Patient Name

The patient named above has been examined by the faculty member and meets the following criteria:
• Patient must be 18 years of age or older.
• Patient must be in good health. (A medical history form will be completed prior to
treatment and approved by the instructor.)
• Each patient will have a minimum of four (4) virgin, non-restored, natural teeth,
sufficiently erupted so that a dry field can be maintained. In addition, each patient will
have a minimum of one tooth in all four quadrants.
• Patients with another 4 qualifying teeth (1 tooth per quadrant) can serve as an additional patient.
• Third molars (#1, 16, 17, and 32) cannot be used to be sealed

Signature

Sign Here

I the student, confirm that all the procedures are performed correctly.

Call Us: 714-882-5518

Form - Pit & Fissure

PIT AND FISSURE PLACEMENT PRODUCT EVALUATION

UPDATED MEDICAL HEALTH HISTORY FORM

PATIENT MEDICAL HISTORY

MEDICAL HEALTH STATEMENT

PATIENT RELEASE FORM

Pit and Fissure Sealant Patient Criteria Form

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