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1
Preventive Dental Sciences Department Pediatric Dentistry Division
(PDS 615)
Clinical Evaluation Manual-Part 1
Student name: ………………………………… Computer #: ………………………………..
2
Preventive Dental Sciences Department Pediatric Dentistry Division
Table of Contents 1. MPE Forms
1.1. MPE Point System
1.2. MPE Student Copy
1.3. Assisting form
2. Finished Case Evaluation
2.1. Finish Case Form
3. Competency Exam Forms
3.1. Clinical Competency Exam Form for Examination & Treatment
Planning
3.2. Clinical Competency Exam for Diet Evaluation
3.3. Clinical Competency Exam for Formocresol Pulpotomy
3.4. Clinical Competency Exam for Stainless Steel Crown Restoration
3.5. Clinical Competency Exam for Local Anesthesia
3.6. CCE Student’s copy
4. MPE Evaluation Forms
4.1. MPE Evaluation for Examination & Treatment Planning
4.2. MPE Evaluation for Oral Hygiene Instruction
4.3. MPE Evaluation for Prophylaxis & Topical Fluoride Application
4.4. MPE Evaluation for Rubber Dam Isolation
4.5. MPE Evaluation for Local Anesthesia
4.6. MPE Evaluation for Fissure Sealant
4.7. MPE Evaluation for Preventive Resin Restorations
4.8. MPE Evaluation for Cavity Preparation and Restoration
4.9. MPE Evaluation for Stainless Steel Crown/Strip Crown/Class IV Permanent
4.10. MPE Evaluation for Formocresol Pulpotomy
4.11. MPE Evaluation for Extraction of Primary Teeth
4.12. MPE Evaluation for Diet Evaluation
4.13. MPE Evaluation for Space Analysis
4.14. MPE Evaluation for Space Maintainer I (Band’s Selection and Impression)
4.15. MPE Evaluation for Space Maintainer II (Appliance Fitting and Cementation)
5. Other Forms
5.1. Arabic Consent
3
1. MPE Forms
4
Department of Preventive Dental Sciences
Pediatric Dentistry (PDS 615)
MINIMAL PROCEDURE EXPERIENCES
The student is required to collect a minimum of 80 points. Maximum point to be graded – 130.
The points are distributed as: Points Points
Exam and T.P. 5 Class III 3 OHI First 2 Pulpotomy 4 Extra 1 Extraction (Exfoliating) 1 Prophy/fluoride First 2 “ (Normal) 2 Extra 1 Space Maintainers (Band Selection) 1 Pit and Fissure sealant 2 “ (Impression) 1 Class I /PRR 3 “ (Cementation) 1 Partial Impression (RPD Impression) 1 ” (RPD delivery) 2 Class II 4 Pulpectomy 5 SSC 4 Space analysis 3
Class V 3 Diet evaluation (basic food group + plaque forming sweet) 4
Buccal or lingual pit 1 Direct pulp capping in Permanent 3 CSC/Composite build up 4 Indirect pulp capping in Permanent 3
Excavation & Temporization (rampant caries)
1/quadrant
Each student should do at least:(Mandatory) 2 Exam and T.P. 1 Class III or V or build up 2 OHI 1 Space Analysis 2 SSC 1 Space Maintainer 2 Pulpotomy 1 Diet Evaluation 2 Extraction
Each student should not exceed more than: 4 Exam and T.P., 4 Prophy / Fl. , 8 Fissure sealant, 2 space analysis, 2 diet analysis ( extra work from the above categories will be accepted but not given grades)
NOTE: Supervisor will mark the procedures considering time, infection control, file, behavior management. Failing to do any mandatory procedure will be recorded as minus ½ of the grades of that procedure (e.g.
missing SSC will be -20).
ssssss
Form 1.1
5 Extra points above the 80 points 4 the grades of this procedure will be added to the total grades.
6
Department of Preventive Dental Sciences Pediatric Dentistry (PDS 615)
MINIMAL PROCEDURE EXPERIENCES (Minimum of 80 points is required)
Student Name : Computer No. :
Clinical Procedures Pts. File No. Faculty
Signature Date Extra Clinical Work
Procedures Pts. File no. Faculty Signature Date
Exam and T.P. 5 Diet evaluation 4
Exam and T.P. 5
OHI 2
OHI 1
Stainless Steel Crown 4
Stainless Steel Crown 4
Pulpotomy 4
Pulpotomy 4
Extraction
Extraction
Class 3/V/CSC/Build up
Space analysis 3
Space maintainer
Form 1.2
7
Clinical Procedures Pts. File No. Faculty
Signature Date
Extra Clinical Work
Procedures Pts. File no. Faculty Signature Date
8
Department of Preventive Dental Science Pediatric Dentistry Comprehensive Care Clinic (PDS 615)
6th Year Assisting Requirement - Minimal of 5 sessions is required
Student’s Name:___________________________
Date Assigned
Cubicle no.
Pedo session
Faculty Signature
Form 1.3
9
2. Finished Case Evaluation
10
Department of Preventive Dental Sciences
Pediatric Dentistry (PDS 615)
Finished Case Evaluation Form
Students’ Name: _______________________________________ Patients Name: ___________________________________ File No.: ____________________ Instructor’s Name: ________________________________ Date: ____________________
Case No.: 1 2 3 Case Type: Short Long A. Case is satisfactory completed: Yes No B. For long case 2 quadrants are completed at midyear: Yes No C. Record fulfillment evaluation: (only for finished cases) 1. Pre-operative photo Yes No 2. Pre-operative radiograph Yes No 3. Pre-operative casts Yes No 4. General Health Inspection Yes No 5. Dental Charting Yes No 6. Signed Treatment Plan Yes No 7. Signed consent for treatment planning Yes No 8. Signed Detailed Progress Notes Yes No 9. Post-operative photos Yes No 10. Post-operative radiographs Yes No 11. Finish case referral Yes No D. Final clinical competency evaluation: Accepted Rejected
Form 2.1
11 N.B. Progress Report should document (1) Anesthesia, (2) Procedure Done, (3) Patient Behavior (4) Next Visit N.B. Long case is for (4 SSC + 2 pulpotomy) or equivalent.
3. Competency Exam
Forms
12
Pediatric Dentistry Division Clinical Competency Examination Evaluation Form
Examination & Treatment Planning
Steps and procedures Instructor Evaluation
Weight Mark 0
Not Competent 1
Competent 2
Proficient 1. History and Personal Data - Patient's complete personal data recorded - All questions on the medical history answered.* - All questions on the dental history answered. - Caries risk assessment *
Mistake in one or more of the critical steps(*)
Complete only Critical steps*
Complete all the steps including
critical steps*,
2
2. Examination: a. Extra oral/Intra oral
Head and neck Soft Tissue Evaluation: Gingiva, mucosa,
etc. Oral hygiene
b. Occlusion and Orthodontic Evaluation / Referral c. Dental Charting:
Teeth present or absent* Existing restorations Presence of dental decay * Fractures and developmental anomalies
Mistake in one or more of the critical steps(*) misdiagnosed
cavitated caries
Complete Critical steps*
but misdiagnosed non cavitated
carious lesions.
Complete all the steps including
critical steps*,
4
3. Radiographic Diagnosis: 1. Indicated radiographs were taken* 2. Examine quality of bone, tooth structure
and development 3. Identify proximal caries in bite wing*
Missed more than 2 proximal caries in dentin
in bite wing radiograph
Missed 1 or 2 proximal
carious lesion in dentin in bite wing
Did not missed any proximal
caries in dentin in bite wing
2
4. Treatment Planning 1. Prevention of caries is emphasized in
initial appointments.* 2. QUADRANT dentistry is one of the main
emphasis points. 3. Accurate plan for restoration* 4. Appliances will be left until after all
operative has been completed in that arch.
5. The recall period of 3 to 6 months.*
Mistake in one or more of the critical steps(*)
or wrongly planned
restoration for 4 teeth or more
Complete all critical steps (*)
but wrongly planned
restoration for not more than
3 teeth
Complete all critical steps (*) and non critical and currently
planned all restorations
6
5.Behavior guidance: TSD, distraction, positive reinforcement, voice control
Uses none Uses 1 or 2 Uses 3 or more 1
6. Presenting the case to Parents (*) - Disclosing sufficient informative using radiographs, photographs, study casts.* - Suggest treatment for the problems with benefits and risks.* - Alternative treatment with benefits and risks* - Cost - How many visits and lengths - Preventive meaning and anticipating guidelines - Signed consent form*
Mistake in one or more of the critical steps(*)
Complete only critical steps (*)
Complete all the steps including
critical steps*,
3
7. Time * > 180 min 60– 180 min < 60 min 2
Form 3.1
13
Pediatric Dentistry Division
Clinical Competency Examination Evaluation Form
Total Mark /40
Steps and procedures
Instructor Evaluation
Weight Mark 0
Not Competent
I
Competent
2
Proficient
1. Diet Evaluation
Information from the parent is accurately taken
Quality of food intake by patient was identified and described to the patient / parent. *
Cariogenic potential of the patient’s diet was
One or more Critical mistakes
(*)
Critical steps are completed
(*)
Critical steps (*) and all other
steps are completed
3
Form 3.2
14
Diet Evaluation
identified and described to the patient /parent. *
2. Recommendation to patient and parents
5 food groups was explained using the pyramid *
Recommended amounts for the child to improve nutrition
Cariogenecity of the diet was explained * Instruction about sweetened or fuzz beverages
was given Instruction about sticky solid CHO including
fruits was given * Safe snacks was suggested properly * Time for sweets intake was suggested * Encourage brushing after sweets *
One or more Critical mistakes
(*) recommendation
is given only to the parents
Critical steps are completed
(*)
Critical steps (*) and all other
steps are completed ,
used pictures and supplied the parents
with the guide to good eating
4
3. Behavior guidance
TSD, positive reinforcement Uses none Uses 1 Uses 2 1
4. Time * < 10 minutes 10-20 minutes > 20 minutes 2
Total Mark /20
15
Pediatric Dentistry Division Clinical Competency Examination Evaluation Form
Formocresol Pulpotomy
Steps and procedures Instructor Evaluation
Weight Mark 0
Not Competent 1
Competent 2
Proficient
1. Rubber Dam One quadrant is exposed Floss tight to clamp Allow patient breathing
Only 3 teeth are exposed, seepage
of fluids, clamp unstable
A quadrant is exposed, follow
all criteria
All criteria plus: Rubber dam is reverted and frame is not
deviated
1
2. Access and deroofing a. Complete removal of caries* b. Proper opening for access. All pulp
horns are uncovered and are readily accessible.
c. Complete removal of the coronal pulp tissue *
d. No perforation* e. Hemorrhage control *
One or more of the Critical
mistakes (*) present
Excessive bleeding
Complete removal of caries and
pulp tissue but with over
extension or sharp edges.
Slight Bleeding on removal of the wet cotton
pelete.
Complete removal of caries pulp tissue with
proper access and extension.
No signs of
Hemorrhage
4
3. Formocresol fixation and temporary restoration
Slightly damped 5 minutes Pellet removal Placement of ZOE temporary
Cotton pelete do not cover the
pulp stumps or use peletes soaked with
formocresol or without fixation
or improper consistency for
ZOE
Follow the steps but
slight bleeding on removal of the pelete, or slight soft ZOE
mix.
Follow the steps with fixation and firm consistency
of ZOE
2
4. Behavior Guidance TSD, distraction, positive reinforcement, voice control
Uses none Uses 1 or 2 Uses 3 or more 1
5.Time * More than 120
min 30 min – 120
min Less than 30 min 2
Total Mark /20
Form 3.3
16
Pediatric Dentistry Division Clinical Competency Examination Evaluation Form
Stainless Steel Crown
Steps and procedures Instructor Evaluation
Weight Mark 0
Not Competent 1
Competent 2
Proficient
1. Rubber Dam One quadrant is exposed Floss tight to clamp Allow patient breathing
Only 3 teeth are exposed, seepage
of fluids, clamp unstable
A quadrant is exposed, follow all criteria
All criteria plus: Rubber dam is reverted and frame is not
deviated
1
2. Tooth Preparation and caries removal a. Occlusal Reduction*
1-1.5mm compared to adjacent teeth Follows original anatomy
b. Proximal Reduction:* Break contacts Are covergent to occlusal/incisal End in feather-edge margin No Ledges *
c. Buccal Lingual Surfaces Bevel Removes sharp cusp tips and
roundation of line angles Bevel occlusal 1/3 of buccal and
lingual d. Complete Caries Removal* e. Avoid Damage to Adjacent Teeth *
Mistake in one or more of the
critical steps (*)
Complete only the critical
steps(*) but not all other
steps
Complete all critical (*) and
other steps 3
3. SSC Adaptation* Crown leveled with adjacent teeth * Original Contacts restored * No extensive blanching Margins 1mm subgingivally and
form smooth curve* Difficult to seat and remove No gaps at margins* Proper occlusion *
One or more Critical mistakes
(*) e.g. under extended
margins, the bite is opened
Only critical steps are
completed (*) but with
slight blanching
All critical steps (*) and other
steps are completed
without blanching
3
4. Cementation/Restoration: Crown seated in correct position
bucco lingually Properly remove remaining cement Adequately produced
proper contact* Proper occlusion*
One or more Critical mistakes (*) e.g. open bite
All critical steps are
completed (*) SSC: but
some cements on the crown
All critical steps (*) are
completed 1
5.Behavior guidance: TSD, distraction, positive reinforcement, voice control
Uses none Uses 1 or 2 Uses 3 or more 1
6.Time * > 120 min 80 – 120 min < 80 min 1
Total Mark /20
Form 3.4
17
Pediatric Dentistry Division Clinical Competency Examination Evaluation Form
Local Anesthesia
Steps and procedures
Instructor Evaluation
Weight Mark 0
Not Competent
1
Competent
2
Proficient
1. Behavior
TSD, positive reinforcement, voice control, distraction
Explain the procedure * Did not instruct the patient to close his
eyes Describe the feeling *
One or more Critical mistakes
(*)
All critical steps are completed (*)
All critical steps (*) and other
steps are completed
1
2. Pre-operative procedure
Proper positioning of the patient (supine)* The child head is stabilized between the
body and arm of the dentist. Dry the site of injection and apply topical
anesthesia * Select the proper gauge and length (short
in maxilla and 3 mm long in mandible) for the needle*
One or more Critical mistakes
(*)
All critical steps are completed (*)
All critical steps (*) and other
steps are completed
1
3. Procedure & Effectiveness
Establish a firm hand rest during the injection
Keep syringe out of the patient vision block the patient vision by hands *
Slowly advance needle through the mucosa, deposit the LA (1ml/min) and withdraw the syringe *
Correct landmarks* Patient experiences, no pain or discomfort
during different procedures*
One or more Critical mistakes
(*)
All critical steps are completed (*)
All critical steps (*) and other
steps are completed
3
Total /10
Form 3.5
18
Department of Preventive Dental Sciences Pediatric Dentistry (PDS 615)
Student name ……………………….…….……..………….…………………………………………….
Pre-requisite - 1Treatment Planning ______ yes ______ no
Clinical competency exam for Treatment Planning
Patient name …………………………………………. File # ……………………………… date ……………………. Instructor name & signature ………………………………………….……
Pre-requisite - 1Diet Evaluation ______ yes ______ no Clinical competency exam for Diet Evaluation
Patient name …………………………………………. File # ……………………………… date ……………………. Instructor #1 name & signature …………………..……………………………………………………………………………………
Pre-requisite - 1Formocresolpulpotomy ______ yes ______ no
Clinical competency exam for Formocresol Pulpotomy
Patient name …………………………………………. File # ……………………………… date ……………………. Instructor #1 name & signature …………………..…… Instructor #2 name & signature …………………..……
Pre-requisite - 1Formocresolpulpotomy ______ yes ______ no
Clinical competency exam for Stainless Steel Crown
Patient name …………………………………………. File # ……………………………… date ……………………. Instructor #1 name & signature …………………..…… Instructor #2 name & signature …………………..……
Pre-requisite - 1 Local Anesthesia ______ yes ______ no
Clinical competency exam for Local Anesthesia
Patient name …………………………………………. File # ……………………………… date ……………………. Instructor #1 name & signature …………………..…… Instructor #2 name & signature …………………..……
Form 3.6 Student's copy Competency
Exam
19
4. MPE Evaluation Forms
20
Pediatric Dentistry Division
Minimal Procedural Experiences (MPE) Evaluation Form Examination & Treatment Planning
5th yr
6th yr
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills
Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge Yes
No
Student knows the principles of the procedure and answers instructor’s questions correctly with justification
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. History and personal data * 2
2. Examination* 4
3. Radiographic Diagnosis * 2
4. Treatment Planning* 6
5. Behavior Guidance 1
6. Presenting the Case to Parents * 3
7. Time* 2
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Student Name Patient’s File No. Computer No. Pre-op approval
Form 4.1
21
Yes
No
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Oral Hygiene Instruction
5th yr
6th yr
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills
Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Use Model * 2
2. Technique description to child and parent *
4
3. Parents Instruction* 3
4. Behavior * 1
Note:
- Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO in any one of them
- Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval Serial No.
Form 4.2
22
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Prophylaxis and Topical Fluoride Application
5th yr
6th yr
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills
Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Prophy 1
2. Fluoride* 2
3. Behavior guidance 1
4. Time for Fluoride* 1
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval
Form 4.3
23
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Rubber Dam Isolation
5th yr
6th yr
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge
Yes
No Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Rubber Dam Preparation * 1
2. Procedure* 2
3. Behavior guidance 1
4. Time * 1
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval
Form 4.4
24
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Local Anesthesia
5th yr
6th yr
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Behavior * 1
2. Pre-operative procedure * 1
3. Procedure & Effectiveness* 3
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval Serial No. Quadrant/Tooth No.
Form 4.5
25
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Fissure Sealant
5th yr
6th yr
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge - Etching time and
steps - Bonding under
sealant
Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Effective Local Anesthesia
Yes
No
Patient experiences, no pain or discomfort during different procedures
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Rubber Dam/Cotton rolls 1
2. Prophylaxis 1
3. Sealant Application * 1
4. Behavior guidance 1
5. Time * 1
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval Serial No. Tooth No.
Form 4.6
26
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Preventive Resin Restorations
5th yr
6th yr
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge - Acid etching steps
and Technique
Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Effective Local Anesthesia
Yes
No
Patient experiences, no pain or discomfort during different procedures
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Rubber Dam 2
2. Prophylaxis and caries removal * 3
3. Restoration and sealant application * 3
4. Behavior guidance 1
5. Time * 1
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval Serial No. Tooth No.
Form 4.7
27
Pediatric Dentistry Division
Minimal Procedural Experiences (MPE) Evaluation Form Cavity Preparation and Restoration
5th yr
6th yr
Cavity Prep: Class I Class II Class III Class V
Type of restoration: Amalgam Composite G.I. Temporary
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Effective Local Anesthesia
Yes
No
Patient experiences, no pain or discomfort during different procedures
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Rubber Dam 1
2. Cavity Design and caries removal * 3
3. Gingiva or adjacent tooth are undamaged 1
4. Restoration* 2
5. Behavior guidance 1
6. Time* 2
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval Serial No. Tooth No.
Form 4.8
28
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Stainless Steel Crown/Strip Crown/Class IV Permanent
5th yr
6th yr
Type of restoration: SSC Strip Crown Class IV
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills
Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Effective Local Anesthesia
Yes
No Patient experiences no pain or discomfort during different procedures
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Rubber Dam 1
2. Tooth Preparation and caries removal* 3
3. SSC /CSC adaptation * 3
4. Cementation* /Composite restoration * 1
5. Behavior Guidance 1
6. Time* 1
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval Serial No. Tooth No.
Form 4.9
29
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Formocresol Pulpotomy
5th yr
6th yr
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills
Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Effective Local Anesthesia
Yes
No
Patient experiences, no pain or discomfort during different procedures
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Rubber Dam 1
2. Access and deroofing* 4
3. Formocresol Fixation and temporary restoration
2
4. Behavior Guidance 1
5. Time* 2
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval Serial No. Tooth No.
Form 4.10
30
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Extraction of Primary Teeth
5th yr
6th yr
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills
Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Effective Local Anesthesia
Yes
No
Patient experiences, no pain or discomfort during different procedures
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Pre-operative Precautions * 2
2. Procedure * 5
3. Post operative Instruction* 2
4. Behavior guidance 1
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval Serial No. Tooth No.
Form 4.11
31
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Diet Evaluation
5th yr
6th yr
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge Yes
No
Student knows the principles of the procedure and answers instructor’s questions correctly with justification
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Diet Evaluation * 3
2. Recommendation to patient and parents *
4
3. Behavior guidance 1
4. Time * 2
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval
Form 4.12
32
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Space Analysis
5th yr
6th yr
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Knowledge Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Time *
2. Case Selection
3. Teeth measurements *
4. Detect space deficiency *
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval
Form 4.13
33
Pediatric Dentistry Division Minimal Procedural Experiences (MPE) Evaluation Form
Space Maintainers I (Band/s Selection and Impression)
5th yr
6th yr
Appliance: Band and Loop Lingual Arch Nance TPA
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills
Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures
Weight Student self-evaluation Instructor evaluation Feedback
NA 0 1 2 NA 0 1 2
1. Band/s Selection 3
2. Impression and Band Placement 3
3. Behavior guidance 2
4. Time * 2
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval Serial No. Tooth No.
Form 4.14
34
Pediatric Dentistry Division
Minimal Procedural Experiences (MPE) Evaluation Form Space Maintainers II (Appliance Fitting and Cementation)
5th yr
6th yr
Appliance: Band and Loop Lingual Arch Nance TPA
Ethical conduct and professionalism
Yes
No
Student shows respect towards staff, patients, and colleagues, student follows faculty directions, student wears appropriate professional attire, presents only his/her work (no cheating)
Infection control Yes
No
Surfaces are clean, no visible littering, disinfected, properly wrapped
Communication skills
Yes
No
Student communicates efficiently with patient and instructor using clear words and logical sequence
Knowledge Yes
No
Student knows the principles of the procedure and material selection and answers instructor’s questions correctly with justification
Clinical Procedure Evaluation: 0 = incompetent, 1 = competent, 2 = proficient
Steps and procedures Weight
Student self-evaluation Instructor evaluation
Feedback NA 0 1 2 NA 0 1 2
1. Appliance fitting (General) * 3
2. Appliance fitting 3
3. Cementation * 2
4. Behavior guidance 1
5. Time* 1
Note: - Steps with (*) marks are CRITICAL STEPS. This clinical procedure will not be considered an MPE if you score ZERO
in any one of them - Detailed criteria of evaluation of each clinical step are found in the corresponding RUBRIC
Accepted as MPE Faculty Stamp and Signature Date
Yes
No
Student Name Patient’s File No. Computer No. Pre-op approval Serial No. Tooth No.
Form 4.15
35
5. Other Forms
36
ARABIC CONSENT FORM
االووقائي قسمم علوومم ططبب االأسنانن جامعة االملكك عبدد االعززیيزز فاللططبب االأطط شعبة ططبب االأسنانن كلیية
------------------------------------------االى وولي اامرر االططفلل االصحي االتارریيخ
.حدد علمي االأسئلة على جمیيع أأجبتت عنن لقدد ووفعالة. بططرریيقة آآمنة لتووفیيررعنایية أأسنانن لططفلي ضرروورريي االصحي االتارریيخ ااني أأعي بأنن
أيي تغیيیيرر ب أأخططرركمم ووسووفف. ططفلي عنن كلل ما تحتاجوونھه أأنن تسألوواا ططبیيببفاني آآذذنن لكمم مززیيدد منن االمعلووماتت٬، ااذذاا كانتت ھھھهناكك حاجة إإلىبالعلاجج. ددوویيتھه قبلل االبددءأأ وو ووضع ططفلي االصحي في
علاججاال خططة _________________٬، وواالتي تتضمنن: ططفلي ططبیيبب أأسنانن االتي ااقتررحھها خططة االعلاجج تماما أأفھهمم ااني
____________________________________________________________
____________________________________________________________
ووأأنا . االلتي قدد تتررتبب على االعلاججاالمضاعفاتت االمشاكلل االمحتملة وو٬، فضلا عنن عامة علاججاال ااعتباررااتتمناقشة خططة االعلاجج شررحتت لي لا تقتصرر على: تشملل٬، وولكنھهااالمشاكلل قدد وو االمضاعفاتت االمحتملة أأفھهمم أأنن
____________________________________________________________
____________________________________________________________
ااني . االعلاجج االشاملل لضمانن نجاحح إإضافي أأوو بددیيللفي االمستقبلل٬، قدد تنتج ظظررووفف تستددعي علاجج االعلاجج٬، وو أأثناء ووبعدد بأنھه ااني أأعيإإلى سارریية االمفعوولل ھھھهذذهه االموواافقة. لططفليمصلحة في أأنھه شعررتمم إإذذاااالموواادد االمستخددمة االعلاجج أأوو في أأيي تعددیيلاتت أأعططیيكمم االموواافقة على
.صووررةة كتابیية في ما أألغیيھها أأجلل غیيرر مسمى
منن جانبي. االمتفقق علیيھه االمووصى بھه وو االعلاجج لأددااء جمیيع منن االمووظظفیينن االمعیينن أأوو االشخصص ططفلي ططبیيبب أأسنانن أأفووضض
ووأأنا أأفھهمم. ھھھهذذاا االنمووذذجج محتوویياتت ووددررااسةقررااءةة كاملة لاالفررصة اال٬، _____________________________٬، قدد أأتیيحتت ليمع االعلمم اانن لأغررااضض تعلیيمیية. االصحیيةمعلووماتھه فاني موواافقق على علاجج ططفلي وو ااستخدداامم ھھھهذذاا االنمووذذجج منن خلالل تووقیيعي على أأنھه
منن االززیياررااتت لاكمالل علاجھه. ----------------االططبیيبب قدد ااخبررني اانن االعلاجج یيحتاجج االى عدددد
____________________ االتارریيخ ____________________٬، یيعاالتووق
Form 5.1
Department of Preventive Dental Sciences Pediatric Dentistry (PDS 615)
37