Oral Health Screening Survey
Instructions
Nashville Area Dental Support Center
711 Stewarts Ferry Pike
Nashville, TN 37214
615-872-7900
For more information contact:
M. Catherine Hollister, RDH, MSPH, PhD
Dental Support Center Director
Instructions and criteria in this manual have been adapted from:
Basic Screening Survey
Association of State and Territorial Dental Directors 1999, Revised September 2003
www.astdd.org
Indian Health Service
Oral Health Survey Examination Protocol 1999
TABLE OF CONTENTS
Introduction ........................................................................................ 3
Selecting Survey Method ................................................................... 4
Age Cohorts....................................................................................... 7
Sampling............................................................................................ 7
Sample Size ...................................................................................... 7
General Survey Guidelines ................................................................ 7
Chart Reviews......................................................................... 9
Screenings .............................................................................. 9
Exams ..................................................................................... 10
Selecting Indicators .......................................................................... 11
Data Collection Format ...................................................................... 12
Optional Preventive Services ............................................................. 12
Data Analysis ..................................................................................... 13
Oral Health Screening Form .............................................................. 14
Appendices ........................................................................................ 15
Appendix A: Planning Worksheet ........................................... 15
Appendix B: Sample Size Calculations ................................... 18
Appendix C: Instructions for Each Data Field ........................ 19
Appendix D: Oral Health Survey Calibration Form .................. 29
Appendix E: RPMS Computer Search Instructions ................. 30
PADA ................................................................. 30
SCOM ................................................................ 32
QMAN ................................................................ 34
Appendix F: Sample Consent and Parent Report Forms ........ 37
Appendix G: Sample Screening Forms ................................... 41
2
INTRODUCTION
Local dental programs may want to determine oral health status of Tribal or community
members. Information on health status may have several applications: comparison to State,
regional or national surveys, evaluate the results of a local intervention, identify workload
needs, or determine the need for future staff or dental facilities. National, regional or state data
is useful to local programs, but local data is needed to make local decisions.
The most useful local data will be comparable to larger surveys. Therefore, all local surveys
should attempt to gather data using methods and definitions similar to larger oral health
surveys. Local survey forms can be customized for certain target groups or designed to
measure oral health conditions of interest to the program.
This guidebook offers instructions for conducting local surveys that will yield data that is
comparable to the Association of State and Territorial Dental Directors’ (ASTDD)Basic
Screening Surveys used by most state programs, and the Indian Health Service Oral Health
Surveys. Because of sample size limitations and variations in survey type, some differences
will occur. But by following the definitions and methods contained in this guide the differences
will be minimized.
Advantages of local surveys are:
 For Tribal programs, the Tribe retains and controls the data
 Standardized forms and collection methods will produce reliable information
that can be easily repeated
 Health status data is timely and easily updated
 Current data is available for program evaluation or grant writing
 Interventions can be easily evaluated
 Surveys can be customized to meet local values and area of interest
 Comparisons in health status can be made to the entire Area or the general
population of a state (if the state conducts an oral health survey using ASTDD
protocols)
Limitations of local surveys include:
 Convenience samples and small sample sizes will limit the ability to make
strong conclusions or generalize to the entire population
 Differences in survey methods may limit the ability to make comparisons to
larger surveys
 There may be limited ability to calibrate examiners or reviewers across
programs. (Examiners within a program should be calibrated.) There is a
similar limitation in comparing data across states because intra-state
examiners are calibrated but inter-state examiners are not.
Reviewing some background information may be beneficial to planners before making specific
decisions such as type of survey and what data will be collected. Some pertinent questions to
consider might be:
 What oral health data is currently available?
o RPMS
o IHS Oral Health Survey
3
o State surveys
 What are the limitations of the existing data?
 How will the local data collected be used?
o Evaluate current programs
o Project future staffing or facility needs
o Comparability to other groups or published disease rates
o Determine health disparities
o Target intervention to specific groups
Considering these issues will help direct the planning process and ensure that the end product
meets the expectations of the clinical and administrative staffs. See Appendix 7 for a
worksheet that may help guide the planning process.
SELECTING SURVEY METHOD
This manual describes three possible forms of data collection: chart reviews, screening and
examination. Each method has pros and cons. Dental staff and Tribal administrators should
consider needs and resources carefully, and then select the method that meets local needs.
Things to consider when selecting a survey method:
 How much staff is available for the survey?
 How often will the survey be repeated?
 What data is available? (information contained in charts)
 Do large numbers of Tribal members gather for community events (Health
Fairs) where screenings or exams could be done?
 What level of detail is desired? (Chart reviews and full exams will give more
detail than screening but screening may include the largest number of
participants)
 How will the data be used?
 What are the relevant comparison surveys (state, IHS, NHANES, other)?
Regardless of survey method used, following the definitions and methods described in this
manual will provide accurate and reliable data for local dental programs.
Screening
Screening surveys are quick and easy to perform if large numbers of the target group are
present in a single location. Therefore for children in schools or preschools, nursing homes or
health fairs, this may be the preferred method.
Data generated from a screening survey will have the highest level of comparability with most
State surveys.
Exams without Radiographs
This method will provide more complete information than a screening. The caries index of
decayed, missing and filled teeth(DMFT/dmft) is usually calculated in this type of survey.
Periodontal information can also be gathered. Informed consent and a medical history are
needed for this type of survey. These limitations may result in a lower total number of
participants. Also, dental equipment is needed for an exam survey.
4
Data generated from an exam survey will have the highest level of comparability with the IHS
Oral Health Surveys and National Health And Nutrition Examination Survey (NHANES).
Chart Review
A chart review has many advantages over a face-to-face survey. No additional informed
consent is needed and detailed information can be gathered. Charts can be pulled at the
convenience of the reviewers. One limitation of this type of survey is that only those patients
with a complete exam are included. Also because diagnoses have been made with the benefit
of radiographs, decay rates may be higher than surveys with a visual only evaluation.
Chart reviews may overestimate caries and treatment needs in young children. Parents of very
young children with healthy teeth may or may not come in for a routine exam. However,
parents of children in pain or with obvious dental needs are very likely to visit the dental clinic.
The ability to generalize to the larger IHS population is good because the IHS Oral Health
Survey included only patients with complete exams.
5
General Considerations for Selecting Survey Methods
Method
Screening
Exams w/o
Radiographs
Chart Reviews
Target Group
Benefits
 Any
 Quick and timely
 This method
 Easy to include large
will give results
numbers
that are
 May be repeated
comparable to
frequently
most State
 Passive consent may
surveys.
be used
 Easy to compare
results to State data
 Can be done by
dentists or
hygienists
 Clinic Patients
 Detailed information
 Some school
 Similar to IHS survey
groups (if dental
units & chairs
are available)
 This method will
give results that
are most
comparable to
IHS Oral Health
Surveys
 Clinic Patients
 Can be done at
with complete
dental staff’s
exams
convenience
 Detailed information
 Easy to repeat
Frequently
 Most accurate for
trending purposes
Limitations
 Data not detailed
(may not include
DMFT/dmft)
 Requires large
numbers of
people at a single
location (Head
Start, Health
Fairs, nursing
homes)
 Time Consuming
 Difficult to repeat
 Requires informed
consent
 Patients must be
recruited for survey
 Limited to patients
with complete
exams
 Limited to data on
exam forms
 Will give higher
decay rates than
“visual only”
surveys because
radiographs are
used
6
AGE COHORTS
A cohort is defined as a group of people sharing a particular demographic characteristic, such
as age. Surveys frequently use “Age Cohorts” as a means of categorizing data. State surveys
frequently include only the cohort of 3rd Grade Students. The 1999 IHS Oral Health Survey
gathered data on selected age groups of: 3-5 years; 6-14 years; 15-19 years; 35-44 years; and
55+ years. These age groups were selected to because they most closely matched groups
addressed in Healthy People and GPRA objectives.
Local programs may choose to collect data in other age groups, but comparability to IHS data
will be limited to those groups listed above. For screenings and exams planners do not have to
decide on Age Cohorts before data collection. Local programs may collect data on all ages,
then group age cohorts in the data analysis phase. Age cohorts should be identified prior to a
chart review so only those charts in the age groups are identified for inclusion.
SAMPLING
See “Assessing Oral Health Needs: ASTDD Seven-Step Model,” by Barbara Carnahan, RDH,
MS (www.adtdd.org) for an in depth discussion of sampling methods and benefits and
limitations of each method. For most Tribal programs one of the following sampling methods
will be used:
1. (Screening or Exams) Convenience Sample: group of individuals in a location such as
school, nursing home or community center who choose to participate in the assessment
2. (Chart Review) Review of all patients completing a comprehensive exam within the
previous 12 months. If this is a very large number, a random sample may be used.
SAMPLE SIZE
The number of charts or participants needed is determined by population size. If data is to be
collected by age cohort, a sufficient number of individuals in each age group will be needed.
For groups with very small numbers, everyone may need to be included. This is very likely if
chart reviews are used as the survey method because only those who have completed a
comprehensive exam can be included.
To determine the number of individuals that must be included in the sample the prevalence of
the condition must be known. IHS has data from the 1999 OH Survey, but the current
prevalence is unknown. Because of this limitation, sample size estimates used by the IHS
Diabetes Program may be used as an approximate guide to determine sample sizes needed
for the oral health assessment. See Appendix B for estimated sample sizes by population.
7
GENERAL SURVEY GUIDELINES
After the decisions regarding type of survey is made, the planners must decide what
information will be gathered. Planners are strongly encouraged to include all of the “Required
Fields” in the survey. These fields represent the minimum data that is needed to determine
basic oral health status. Planners may then decide to add to the “Required Fields”. The
following instructions describe important considerations in developing the oral health survey.
1. If the survey is done by a Tribal program, all forms and data will be retained by the
Tribe. Data may be shared with IHS or external agencies at the Tribe’s discretion.
2. Health Information Protection and Accountability Act (HIPAA): Individual patient
information is retained by Tribe or assessing organization and subject to the Tribe’s
HIPAA policies for protected patient information. Because epidemiological data does not
contain individual patient information, it is not protected under HIPAA therefore
releasing epidemiological data does not violate HIPAA. Programs should consult with
Tribal policies regarding release of epidemiological data.
3. All surveys, regardless of type, should include the “Required Fields”.
4. Individual programs may select any or all of the optional fields.
5. Programs may design a data collection form that includes all of the Required and
Optional Fields (if any have been selected).
6. Programs are encouraged to use the same data fields at each assessment.
7. Programs MUST use the same data collection definitions and criteria to ensure reliable
results.
8. It is critical that each criterion is scored according to the instructions. Failure to follow
scoring instructions will lead to unreliable data. Instructions included in this guidebook
follow similar surveys conducted by dental public professional organizations and
agencies such as Association of State and Territorial Dental Directors and the Indian
Health Service. Following the instructions provided in this manual will increase the
comparability of data gathered in larger oral health surveys. (See Appendix C for
Instructions for Each Data Field)
9. Always use Code Numbers where indicated for data collection and data entry. Failure to
use code number will increase the likelihood of data entry errors and may limit the ability
to perform statistical analysis on the data and to compare results to larger surveys.
Example:
Notice on the sample forms that each entry option has a related code number. (e.g.
Male=1, Female=2)
10. Consent: Chart reviews of clinic patients may not require consent. Visual only
screenings may be done with passive consent (inform parents/guardians that children
will be screened unless the parent/guardian does not want the child to be screened).
Consult with the agency’s policies to verify the need for consent forms for minors.
Informed consent MUST be obtained for children and adults that receive full exams with
charting. Obtain written active consent if optional preventive procedures such as fluoride
varnish are done at screenings. Customize the consent form to include all services,
risks and benefits, and coding information if needed.
11. Calibration: If more than 1 screener or examiner participates, training and calibration
should be done. Each examiner should complete the Training Form described in the
Basic Screening Survey manual published by the Association of State and Territorial
Dental Directors (www.astdd.org) on a minimum of 10 individuals, or as many as
necessary to attain agreement on the majority of the criteria. Individuals should
complete the assessments independently and not discuss results. A recorder will enter
8
screening results on the training form. (See Appendix D for a Sample Calibration form).
After the screening forms are complete, examine the results and discuss any
discrepancies.
Chart Reviews
1. Generate a list from the computer system used to record dental services. Identify the
date range for the review and age cohorts. If the sample is very large a random sample
may be used. Request patients with code D0150 during the specified data range. If a
dental program routinely documents diagnoses at Recall exams, D0120 may be
included in the sample.
2. RPMS Users: Generate a random sample of patients in QMAN or a list of dental
patients using the SCOM function in the Dental Data System (DDS) package. See
Appendix E for computer search instructions.
3. Reviewers should primarily use information included on the Comprehensive
Examination or Medical History form. Progress notes or other documentation included in
the dental record may be reviewed if needed for clarification.
Screenings
1. Infection Control: For screenings and exams, follow CDC recommendations for infection
control according to the level of anticipated exposure. For screening, eye protection and
face masks are not required because no spatter is anticipated. Handwashing or
cleansing is strongly recommended between patients if hands are within a close
proximity to the mouth. Exams may require face protection if compressed air is used,
thereby increasing the risk of spatter. Gloves are required if any contact with mucus
membrane is anticipated. Whenever possible disposable mirrors should be used to
eliminate the need for instrument sterilization.
2. Participation in screening and/or examination is voluntary. Persons who feel ill, want to
discontinue or do not want to participate should not be included in data collection.
Persons who begin screening but choose to discontinue should not be included in the
data analysis.
3. Consent: Passive consent may be used for screenings only. If other services are
included (eg. Fluoride varnish) active consents are needed. See Appendix F for sample
consent forms and notes to parent/guardian.
4. Lighting
a. A light source such as flashlights, head lamps or non-dental lights should be
used. Disposable lighted mirrors will provide both illumination and retraction.
5. Retraction/Visualization
a. Choices for retraction include tongue blades, dental mirrors or disposable
mirrors.
6. Removing Debris
a. If tooth surfaces cannot be evaluated because of debris, a toothbrush or
toothpick may be used to remove loose deposits of food or plaque.
7. Instrumentation
a. Probes and explorers are not necessary for the BSS protocols, but according to
the BSS manual, they may be incorporated. If used, explorers should be limited
to dentists, and be used primarily for detection of sealants. Explorers should not
be used to determine a “stick” for caries detection. Caries should be visually
evaluated according to the BSS instructions.
9
8. Supplies:
a. Disposable mirrors
b. Flashlight or other light source
c. Toothpicks (removing debris or sealant detection)
d. Trash bags
e. Screening Report Forms
f. Recording materials (paper forms, scan forms or computers for direct entry)
g. Optional: toothbrushes for oral hygiene instructions, hand mirror
9. Complete a Screening Report Letter to inform participants of critical findings. (See
Appendix F)
Exams
1. Data Collection: Comprehensive Examination Form will be completed during the exam.
Data is than transferred to the data collection form (paper form, scan, direct data entry
into a computer). If direct data entry is done, a recorder may choose to enter data into a
program as the examiner calls out findings during the exam. The only drawback of this
method is that no written record exists of the exam so data cannot be verified and if a
record is lost it cannot be replicated. If the examiner does not have a person to record
the exam results, an alternative is a small voice recorder that the examiner can play
back after the exam is finished and complete the form.
2. Medical History: Patients should complete the standard medical history form used for all
routine dental treatment. Precautions for physical status should be the same as those
taken for comprehensive dental examinations.
3. Consent: informed consent must be obtained for each participant and must be retained
by the dental program.
4. Supplies: (Off–site exams)
a. Mirrors, #23 explorers, WHO Periodontal Probes, air syringe tips
b. Sharps container (for broken or damaged instruments)
c. 4x4 gauze
d. Portable dental chair and light
e. Barrier chair covers
f. Personal Protective Equipment (Face masks, eye protection, lab coats or gowns)
g. Operator stool (optional recorder stool)
h. Exam gloves (assorted sizes)
i. Air compressor w/ air syringe or portable dental unit
j. Instrument tray
k. Holding container (Capable of being sealed) for dirty instruments
l. Holding solution (pre mixed)
m. High level surface disinfectant
n. Denture adhesive (if adults are included in survey)
o. Utility gloves
p. Sink w/ running water
q. Hand soap (alcohol based hand cleaner is optional)
r. Recording supplies (forms, pens or computers for direct entry)
s. Waste basket or trash bags and tape
(When exams are done off site with portable equipment, instruments can be rinsed,
disinfected, then sealed in a puncture resistant container for transport back to the
dental clinic for packaging and sterilization)
10
12. Exam Procedures: Conduct comprehensive exams in a similar manner each time. Hard
and soft tissues should be completed in the same sequence when possible. Use an air
syringe to dry teeth prior to making the diagnosis. Use single surface mouth mirrors. A
mounted dental light (not a headlamp or sunlight) must be used. Transillumination by
external light source may be used. No explorer should be used for caries detection.
Probes may be used to remove debris or for sealant detection. (This is consistent with
IHS Oral Health Survey examination procedures) Radiographs ARE NOT used for
caries detection.
SELECTING INDICATORS
The purpose of this assessment is surveillance. Surveillance data can be used to trend status
or compare status to a State, regional or national survey. Surveillance IS NOT intended to
provide a detailed account of each individual patient. Data that is collected must be available
for most of the target group and must be recorded consistently. Before selecting which
indicators will be used, consider what information is available and how the data will be used. If
collection is done at a community screening event (e.g. Health Fair) you may elect to only
collect the required fields. Other options in this setting may be Dentate Status or Dental Visit in
the last 12 Months.
A basic tenet of surveillance is that minimum data is collected as needed to provide basic
information. Addition of more data fields will decrease the number of patients that can be
included in the assessment and may not give important additional information.
Example
The dental program wants to determine if a community intervention has reduced the number of
children with decay (treated or untreated). Determining DMFT (dmft) is ideal but requires more
equipment and time than is readily available. Finding DMFT (dmft) may only be reasonably
accomplished every 5-10 years. Informed consent is also needed, limiting the number of
children that can be included. Children can be screened at a school, day care, or Head Start
center for treated and untreated decay. This screening can be done with passive consent, is
easily repeated annually and gives the information that is needed to determine the effect of the
intervention on the population.
After you have selected the recommended and optional indicators, develop a data collection
form. The form should contain all of the REQUIRED fields and any desired optional fields.
YOU MUST USE the same data collection form and follow consistent definitions throughout
your survey. The forms will be used during data collection and for data entry. Retain the forms
for any necessary data verification. See Appendix G for sample Screening Forms.
11
DATA COLLECTION FORMAT
Data may be collected in one of three ways: paper forms, scan forms or direct data entry. Each
method has related pros and cons. See the summary below for points to consider when
selecting a data collection method.
Method
Pros
Cons
Paper Forms
 Easy for exam staff
 Requires collection of
forms
 Does not require a
computer for each
 Time consuming data
examiner
entry
 Can be used if electricity is
a problem
Scan Forms
 Easy for exam staff
 Requires scan form
software
 Does not require a
computer for each
examiner
 Can be used in electricity
is a problem
 Quick data entry
 Reduces data recording
errors
Direct Data Entry
 Limits data entry to
 Requires a computer for
allowable values
each examiner
 Can automatically enter
 Staff must be comfortable
certain variables such as
with a computer
date and site
 No ability to verify values
after data collection
Adapted from: Basic Screening Surveys: An approach to monitoring community oral health.
Association of State and Territorial Dental Directors, 1999, revised 2003. p.10.
Most small dental programs will use paper data collection forms. The data will then be
transferred to an Excel spreadsheet or statistical program for analysis. (Data entered on a
spreadsheet can be imported to a statistical program at a later date if a higher level of
statistical analysis is desired)
Forms may be completed by the reviewer or a recorder if available. If paper or scan forms are
used, at some point the data must then be entered into a computer file.
OPTIONAL PREVENTIVE SERVICES
If a small number of individuals are expected to participate in a screening or exam session,
planners may choose to offer some prevention services. Optional services may include: oral
hygiene instructions, nutritional or tobacco counseling, or fluoride varnish treatments. If these
services are planned, include the codes for the services on the data recording forms. At the
end of the session, record all clinical services in the clinic’s computer system (e.g. RPMS),
then record epidemiological data in the data recording system (spreadsheet or statistical
program). See Appendix G for sample screening forms.
12
DATA ANALYSIS
Several software programs are suitable for analyzing survey data. The easiest to use and most
readily available is a spreadsheet. If using a spreadsheet, build the spreadsheet such that the
columns are the data fields and the rows are the individual records. ONE ROW ONLY should
be used for titles. Most statistical programs will assume the first row is titles and will not include
data in the first row in the statistical analysis. If statistical analysis is desired that is not
available in the spreadsheet, the files can be imported to other databases such as EpiInfo,
SAS or other commercially available statistical programs. In developing a data analysis plan,
local programs should decide what software is available, understood by local staff and will
allow easy retrieval and analysis.
Sample Spreadsheet
Date
Site
6/25/2009 Tribe X
6/25/2009 Tribe X
6/25/2009 Tribe X
8/8/2009 Tribe X
8/8/2009 Tribe X
6/25/2009 Tribe X
Scr
CH
CH
CH
BLT
BLT
CH
Type
Age
3
3
3
2
2
3
Gender
9
9
9
9
9
10
1
1
2
1
2
2
UntreatedTreated Sealants Tr UrgencyRampant
1
1
1
1
0
0
0
1
0
0
1
1
0
2
1
0
0
1
0
1
0
0
0
0
0
1
0
0
1
0
13
ORAL HEALTH SCREENING FORM
The screening form that is used in the survey can and should be customized according to
specific areas of interest. Certain fields are listed as REQUIRED. These criteria are standard in
most oral health surveys and therefore should always be included in local assessments.
Failure to collect the REQUIRED data fields will severely limit the ability to compare local oral
health status to larger surveys.
The next group of criteria is STRONGLY RECOMMENDED. Criteria in this group may be
selected based on the type of survey conducted or the survey that is most likely to be used as
a comparison. For example: the periodontal data may be readily available in a chart review
and is consistently used in the IHS Oral Health Survey. So if a chart review is planned and the
Tribe wants comparability with the IHS Oral Health Survey, perio data should be included.
The final group of criteria is OPTIONAL. Some of these will be easier than others depending
on the type of survey done; based on the indicators selected, some may be redundant. For
example: if DMFT is counted, dentate status can be calculated. If DMFT is not included in the
assessment, using the dentate status indicator may be considered.
REQUIRED ELEMENTS
1. Date
2. Tribe or Site (may be preprinted if all assessments are at a single site)
3. Screener/Examiner
4. Type of Assessment
5. Name or ID Number (Needed to ensure no one is included more than once)
6. Age
7. Gender
8. Untreated Decay
9. Treated Decay
10. Treatment Urgency
11. Rampant Decay
HIGHLY RECOMMENDED
1. Grade (may be eliminated for adult only surveys, e.g. nursing homes; Should
ALWAYS be included for screenings or exams if the survey includes children)
2. Sealants (may be eliminated for adult only surveys, e.g. nursing homes; Should
ALWAYS be included if the survey includes children)
3. Prophylaxis in the last 12 months
4. Visit in the past 12 months (screenings or exams only)
5. Dentate status (adults included in survey)
OPTIONAL
1.
Removable Prosthetics
2.
DMFT/dmft
3.
Non-Cavitated Lesions
4.
Root caries
5.
Fluorosis
6.
Highest CPITN
7.
Soft tissue lesion
8.
Orthodontic status
9.
Tobacco use (Personal use and/or Smoker in the Home)
14
Appendix A: Planning Worksheet
Current Status
Oral Health data currently available:

IHS Oral Health Survey Date _________

RPMS Data

Local chart review

State surveys

Other _________________
Limitations of Current data:






Not precise to local community
Not timely
Does not include specific areas of interest
Not specific to target groups
Status information is not available
Other ________________________________________________________
Goals of Survey
Data will be used to:

Trend health status of Tribe/community

Compare to larger surveys

Grant writing

Other ___________________
Survey Frequency:





Annual
Biannual
Every 5 Years
Every 10 years
Other _____________________
Oral Health Assessment Needs
Type of Survey

Screening

Exam

Chart Review:
Computer Search Option
 QMAN
 SCOM
 PADA
15
Staff

Dental Staff

Other program staff

External staff
Data Collection Form

Paper forms

Scan Forms

Direct entry
Data to Be Collected (Check all to be included in assessment)
REQUIRED ELEMENTS
 Date
 Tribe or Site (may be preprinted if all assessments are at a single site)
 Screener/Examiner
 Type of Assessment
 Name/ID Number
 Age
 Gender
 Untreated Decay
 Treated Decay
 Treatment Urgency
HIGHLY RECOMMENDED
 Grade (may be eliminated for chart reviews or adult only surveys, e.g. nursing homes;
Should ALWAYS be included for screenings or exams if the survey includes children)
 Sealants (may be eliminated for adult only surveys, e.g. nursing homes; Should ALWAYS
be included if the survey includes children)
 Prophylaxis in the last 12 months
 Visit in the past 12 months
 Dentate status (adults included in survey)
OPTIONAL
 Removable Prosthetics
 DMFT/dmft
 Non-Cavitated Lesions
 Root caries
 Fluorosis
 Highest CPITN
 Soft tissue lesion
 Orthodontic status
 Tobacco use (Personal)
 Smoker in Home
 Oral Hygiene
16
Data Analysis

Spreadsheet

Statistical Software Program _________________________

Other ________________________
Additional Comments:
17
Appendix B: Sample Size Calculations
Sample size needed to be 90% or 95% certain that the rate you find is within 10% or within 5% of the true
rate, for populations up to 3000.
Population
(# of DM Patients)
<30
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
190
200
220
240
260
280
300
320
340
360
380
400
420
440
460
480
500
525
550
575
600
650
700
800
900
1000
2000
3000
╒═══════ 90% Certainty ══════╕
Within 10%
Within 5%
all
all
21
27
25
35
29
42
32
49
34
56
37
62
39
68
40
73
42
78
43
83
44
88
46
92
47
96
48
101
48
104
49
108
50
112
51
115
52
121
53
127
54
133
54
138
55
142
56
147
56
151
57
154
57
158
58
161
58
165
59
168
59
170
59
173
60
176
60
179
60
181
61
184
61
186
61
191
62
195
62
202
62
208
63
213
65
238
66
248
▲
╒═══════ 95% Certainty ══════╕
Within 10%
Within 5%
all
all
23
28
28
36
33
44
37
52
40
59
44
66
46
73
49
79
51
86
53
91
55
97
57
103
59
108
60
113
61
118
63
123
64
127
65
132
67
140
69
148
70
155
72
162
73
168
74
175
75
180
76
186
77
191
77
196
78
201
79
205
79
209
80
213
81
217
81
222
82
226
82
230
83
234
84
241
84
248
86
260
87
269
88
278
92
322
93
341
Minimum
Number of Charts
Recommended
Adapted from: IHS Diabetes Care and Outcomes Chart Audit for Quality Assurance and
Quality Improvement 08 Instructions. Appendix 1: Sample Forms
18
Appendix C: Instructions for each Data Field
The following instructions have been adapted from the Basic Screening Survey Manual and/or
the Indian Health Service Oral Health Survey Examiner Instruction Manual. Chart review
criteria have been modified from those instructions and assumes examination data has been
recorded according to IHS guidelines.
1. Date
a. Date actual screening or data collection was conducted
2. Date Range (Chart Reviews Only)
a. Identify range of dates that will be included in the assessment. Include ONLY
documentation that was actually done within the specified date range. This date
may be preprinted on forms. (Printing the date on each form will help avoid
inclusion of services done outside the specified date range)
b. The only exception is that “Treated Decay” on permanent teeth only may be
assessed using documentation outside the date range. Treated decay on
permanent teeth will not change throughout the life span, so historical data may
be used for this indicator. “Treated Decay” of primary teeth should not be
included.
3. Site Code or Tribe
a. For single site programs, enter Tribe Name (this may be preprinted on forms)
b. For multiple site programs, assign a unique code number for each location such
as clinics, schools or other locations. (Codes may be preprinted with check boxes
for convenience. This will also reduce data entry errors.)
c. Option: programs may choose to track location type such as nursing home, day
care center in addition to specific location.
4. Screener’s Initials
a. Person conducting assessment
b. If more than 1 person is involved in a single assessment (examiner + recorder),
enter examiner only
5. Type (May be preprinted on form)
a. Check one box only
b. (1)Exam: Complete exam done with dental chair, light, mirror and explorer. Xrays should not be used for assessment. Examination form is completed
including documentation of all hard and soft tissues. (May be hard copy or
electronic)
c. (2)Screen:
i. Visual screen only. External light sources such as head lamp, flashlight
are ;highly recommended but are not required if natural or room light is
sufficient. Mouth mirrors are highly recommended but are not required.
OR
ii. Groups of Head start children, school release programs or other exams
done in the clinic that are a part of a required program
d. (3) Chart Review: No face to face encounter for the purpose of assessment.
Review of dental record only. Radiographs may be included.
6. Name or ID Number
a. Patient’s Name or Chart number or other unique identifier (may be determined by
individual programs)
7. Age (Whole numbers only)
19
a. Exams and screening: Age in years at the last birthday time of exam.
b. Chart Review: Age in years at the time of the last birthday when the dental exam
being assessed was done.
8. Gender
a. 1
Male
b. 2
Female
c. Determine by observation
9. Untreated Decay (Cavitated lesions only)
a. 0
No Untreated
i. No caries experience OR
ii. All cavities have been treated with permanent or temporary restorations
iii. Broken or lost fillings without caries
b. 1
Untreated
i. Any untreated decay. Untreated decay is defined as:
1. a loss of at least 1/2mm of tooth structure at the enamel surface
(the ball at the tip of a CPITN or PSR periodontal probe is 1/2mm in
diameter) AND
2. Brown to dark-brown coloration of the walls of the cavity
ii. Teeth that meet both of these criteria are considered decayed, even if a
filling or a crown is also present.
iii. Broken or chipped teeth with caries
iv. Do not include non-cavitated lesions (white spots) even if these spots are
being treated with remineralization
c. 2
Cannot be determined
i. Insufficient data in chart OR
ii. Behavior or other factors prevent making a determination
10. Treated Decay (Cavitated lesions only)
a. 0
No Treated
i. No caries experience
ii. Caries experience without any cavities treated
iii. Do not include sealed teeth if in the judgment of the examiner no enamel
was removed prior to sealant placement
iv. Do not include teeth extracted for reasons other than caries
v. Do not include treatment of non-cavitated lesions (remineralization of
white spots)
b. 1
Treated
i. Caries experience, any cavities treated with fillings or extractions
ii. Include sealants if in the opinion of the examiner tooth structure was
removed for sealant placement
iii. Count temporary fillings as “Treated”
iv. Include crowned teeth
v. Do not include teeth extracted for reasons other than caries (ortho, perio,
trauma or impacted teeth, or non-carious 3rd molars)
vi. Historical evidence can be used to determine “Treated” for permanent
teeth or primary teeth without succedaneous teeth only
c. 2
Cannot be determined
i. Insufficient data in chart OR
ii. Behavior or other factors prevent making a determination
20
11. Treatment Urgency
a. Screening or Exams:
i. 0
None of the below are present
ii. 1
Caries (Cavitated lesions) without accompanying signs of pain or
infection. Includes patients with spontaneous gingival bleeding,
suspicious soft tissue lesion or ill fitting denture
iii. 2
Signs or symptoms that include pain or infection or soft tissue
ulceration of more than 2 weeks duration (determined by
questioning)
iv. 3
Patient cannot accurately report symptoms
b. Chart Reviews
i. 0
No treatment needed. May include patients with frequent recall
needs.
ii. 1
Diagnosis of routine caries, extractions for perio or periodontal
treatment, denture care
iii. 2
Diagnosed pulp disease (fistula tract, extraction for caries,
pulpotomies or endodontic therapy is planned) or documentation of
moderate to severe pain for any reason
iv. 3
Insufficient data in the dental record to make a determination
12. Rampant Decay
a. 0
6 or less teeth with treated or untreated decay
b. 1
7 or more teeth with treated or untreated decay
c. 2
Unable to determine due to inadequate documentation (chart
reviews), or behavior or other factors (screening or exams)
13. Grade (screenings or exams only)
a. N
Not yet in school (age 0-3) or no longer in school
b. P
Preschool
c. K or Number
School Children: K or Current Grade in school or most
recent grade completed
14. Sealants on Permanent Molars
a. 0
No: No sealant on any permanent molar
b. 1
Yes: Intact or partially intact sealants on permanent molars
c. 2
Cannot be determined: Visibility is poor due to plaque or if
charting is insufficient to determine status
d. Teeth with both sealants and decay are scored as “Yes” in both categories
15. Prophylaxis in the Last 12 months:
a. 0
No: no self-reported visit or indication of professional dental
cleaning (ADA Code 1110, 1120, 4341, 4342, 4355 or 4910)
within 12 months of screening date.
b. 1
Yes: Reported professional dental cleaning, indication in a
chart or computerized record of a professional dental
cleaning (ADA Code 1110, 1120, 4341, 4342, 4355 or 4910)
within 12 months of screening date. Screening and Exams:
may be self reported or determined by documentation. Chart
Reviews: service was provided at any time within the review
date range.
c. 2
Cannot be determined: Inadequate documentation or patient
cannot accurately report history of dental visit
21
16. Reported professional dental visit
a. 0
No: no self-reported visit or indication of professional dental
visit within 12 months of screening date (do not include
previous screening or preventive service by a non-dental
professional)
b. 1
Yes: indication in a chart or computerized record of a
professional dental visit within 12 months of screening date
c. 2
Cannot be determined: Inadequate documentation or patient
cannot accurately report history of dental cleaning
17. Dentate Status (Count teeth regardless of caries or periodontal status)
a. 0
Edentulous (No remaining natural teeth)
b. 1
Partially Dentate: less than 20 teeth (count only natural
permanent teeth)
c. 2
Partially Dentate: 20 or more teeth (count only natural
permanent teeth)
d. 3
Fully Dentate (All permanent teeth, excluding 3rd molars and
teeth extracted for orthodontic treatment)
e. 4
Cannot be determined or mixed dentition
18. Removable Prosthetics: Determine by direct observation, questioning or chart
documentation. Score as “Yes” if a patient reports having a removable prosthesis
regardless of functionality. Score full dentures designed to fit over implants as
“Removable”. Do not include single crowns or partial dentures attached to implants
(patient cannot remove). Do not include “Maryland” bridges if permanently cemented.
Include these devices if the patient can remove the appliance. For each category, count
if the patient has an appliance, regardless of functionality.
19. For upper and lower appliances, if the patient HAS both upper and lower, but only
wears the upper, report as F/F.
a. 0
None: no removable appliance
b. 1
F/ (Full upper denture) Appliance intended to replace all upper teeth.
c. 2
/F (Full lower denture) Appliance intended to replace all lower teeth.
d. 3
F/F (Full upper AND lower denture)
e. 4
RDP/ (Upper removable partial denture) Removable appliance intended to
replace at least 1 tooth but not all teeth in the arch.
f. 5
/RPD (Lower removable partial denture) Removable appliance intended to
replace at least 1 tooth but not all teeth in the arch.
g. 6
RPD/RPD (Upper and lower removable partial denture) Removable
appliance intended to replace at least 1 tooth in each arch but not all teeth
in either arch.
h. 7
F/RPD (Full upper denture and removable partial denture)
i. 8
RPD/F (Upper removable partial denture and full lower denture)
j. 9
Cannot be determined (Patient cannot accurately report if an existing
appliance has been worn in the past 30 days OR adequate documentation
is not present in the dental record)
20. DMFT/dmft (The following have been adapted from the BSS and the IHS Protocol
instructions.)
a. DMFT (permanent teeth) and dmft (primary teeth) are scored as a count only.
This is not a rate so the number of teeth present is not a consideration.
b. For mixed dentition, report both DMFT and dmft
c. Scores:
22
i. D
Active decay on any surface
ii. M
Missing due to caries
iii. F
Any filling is present
iv. X
Cannot determine if missing tooth or filled tooth had a caries history
d. Screening and Exams:
The dental caries examination should be conducted on all patients having one or
more teeth in the mouth. Removable prosthesis should be removed prior to the
examination for caries. A tooth is considered erupted when any part of its crown
projects through the gum. All visible surfaces of banded or bracketed teeth are
to be examined and coded in the usual manner.
e. A cavity is detected when the screener can readily observe two things:
i. A loss of at least ½ mm of tooth structure at the enamel surface (the ball
of a CPITN or PSR probe is ½ mm in diameter)
ii. Brown to dark brown coloration of the walls of the cavity
f. Teeth that meet both of these criteria are considered decayed, even if a filling or
a crown is also present.
g. The M component of the DMF index represents those permanent teeth that have
been extracted as a result of caries. It is essential to distinguish between teeth
extracted due to caries and those extracted or missing for other reasons, such as
trauma, orthodontics, or periodontal disease. Prior to the eruption of the first
permanent molars into occlusion (usually by age seven), the M code can be used
to score primary teeth missing due to caries. If the examiner is uncertain as to
the reason a primary tooth is not present in the mixed dentition, its permanent
successor should be considered (unerupted) and the primary tooth data not
included in the dmft count.
h. If a tooth has both a filling and a cavity, include that in the “Decayed” count and
not in the “Filled” count.
i. When determining “Filled” teeth, count only teeth filled for caries. Do not include
teeth that have been restored for enamel defects, trauma or esthetics.
j. Consider Stainless Steel Crowns (SSC) on primary teeth as “Decayed” unless
the examiner can determine the SSC was placed for reasons other than decay.
k. Teeth with broken or lost fillings should only be counted as “Decayed” if caries
are present. Broken fillings with no recurrent decay should be counted as “Filled”.
l. Chipped or broken teeth with no caries should not be included in the “Filled” or
“Decayed” count
m. Sealed teeth should not be included in the “Filled” count unless the examiner can
determine that caries were removed prior to sealant placement (e.g. preventive
resin restoration due to enamel caries).
n. “Missing” teeth should include ONLY teeth that are missing due to caries.
Unerupted, congenitally missing, teeth missing due to trauma or orthodontic
treatment should not be included in the “Missing” count.
o. Retained primary teeth roots should only be included in the “Missing” count if the
examiner can determine that the entire crown was destroyed by caries.
p. Do not score supernumeraries. It is up to the examiner to decide which tooth is
the “legitimate” occupant of the space.
q. Non-vital teeth are to be coded in the usual manner. If in the examiner’s opinion
a restoration of a non-vital tooth was placed solely in order to seal a root canal
filling and not for caries, that surface will be considered sound.
23
21. Non-Cativated Lesions
a. 0
No: No color change in enamel
b. 1
Yes: White spot lesion, no cavitation
c. 2
Cannot be determined: unable to visualize due to poor oral hygiene,
questionable diagnosis (fluorosis) or inadequate documentation in the
chart.
22. Root Caries (Only assessed on permanent teeth)
a. 0
No: no decay that originates below the Cemento-enamel junction
b. 1
Yes: Any decay that originates below the Cemento-enamel junction.
(Chart reviews: If this is not clearly indicated on the examination form,
score as “Cannot be determined”. Caries that are diagnosed on the Exam
form may still be included in the Treated, Untreated or DMFT categories,
even if “Root Caries” cannot be determined)
c. 2
Cannot be determined: unable to visualize due to poor oral hygiene,
questionable diagnosis or inadequate documentation in the chart.
d.
Always count the diagnosed caries in the “Treated” and “Untreated Caries”
or DMFT sections
23. Fluorosis (Only assessed on permanent teeth)
The most commonly used system for clinically classifying and scoring dental fluorosis
is the system described by Dean in 1942. In Dean's system, each tooth is examined
and assigned to one of six categories according to its degree of fluorosis. (Chart
reviews: use this data field ONLY if fluorosis is routinely evaluated and diagnosed as
an “Enamel Defect”.)
Classification of a person is based on the two teeth most affected by fluorosis. If the
two teeth are not equally affected, the classification given is that of the less involved
tooth. The criteria for Dean's classification system and the corresponding scores are
as follows:
Score
(0) None
Criteria
The enamel represents the usual translucent
semivitriform type of structure. The surface is
smooth, glossy, and usually of a pale creamy white
color.
(1) Questionable
The enamel discloses slight aberrations from the
translucency of normal enamel, ranging from a few
white flecks to occasional white spots. This
classification is utilized in those instances where a
definite diagnosis of the very mildest form of fluorosis
is not warranted and a classification of "normal" is not
justified.
(2) Very Mild
Small, opaque, paper white areas scattered irregularly
over the enamel but not involving as much as
approximately 25 percent of the tooth surface.
Frequently included in this classification are teeth
24
showing no more than about 1-2 mm of white opacity
at the tip of the summit of the cusps of the bicuspids
or second molars.
(3)Mild
The white opaque areas in the enamel of the teeth
are more extensive, but do not involve as much as 50
percent of the tooth.
(4)Moderate
All enamel surfaces of the teeth are affected, and
surfaces subject to attrition show marked wear.
Brown stain is frequently a disfiguring feature.
(5)Severe
All enamel surfaces are affected and hypoplasia is so
marked that that the general form of the tooth may be
altered. The major diagnostic sign required for this
classification is discrete or confluent pitting. Brown
stains are widespread and teeth often present a
corroded appearance.
(6)Cannot be determined
The surface area could not be assessed or adequate
documentation is not available in the dental record
(chart review).
24. Highest CPITN (Exams and Chart Reviews)
The Community Periodontal Index of Treatment Needs (CPITN) is a general screening
procedure to determine status and treatment needs based upon the presence of
bleeding, calculus and pocket depth in each sextant of the mouth.
Note: Patients who require prophylactic premedication SHOULD NOT be medicated for
the SOLE PURPOSE of the oral health assessment. Such patients should be given a
score of “6 Cannot be determined”.
Oral Health Assessment Scoring
0
1
2
3
4
5
6
Highest CPITN Score is 0
Highest CPITN Score is 1
Highest CPITN Score is 2
Highest CPITN Score is 3
Highest CPITN Score is 4
Edentulous
Patient not included in this assessment or inadequate documentation in the chart
The following describes the procedure to determine the CPITN Scores:
The definition of sextant is second molar to 1st bicuspid and cuspid to cuspid in each
dental arch. The teeth included in each sextant are listed by tooth number in the
following figure.
25
UR
UA
UL
2-5
6-11
12-15
LR
LA
LL
31-28
27-22
21-18
All teeth should be examined on persons 15 years of age and older. Third molars are
not included in the CPITN assessments unless they function in the place of the missing
second molars. A sextant must have at least one tooth to be scored. The criterion for a
functioning tooth is that it is not indicated for extraction.
USE OF THE CPITN PROBE
The recommended instrument for assessing CPITN data is the CPITN probe. The
small spherical tip aids in the detection of calculus from any angle and it reduces the
risk of over-measurement in pocket depth, particularly when the base of the pocket is
inflamed. The color-coded segment allows direct reading of pocket depth to correspond
with CPITN scoring. There are graduations at the 3.5 and 5.5 mm marks.
CPITN probing should be conducted in the following manner:

Hold the probe gently so that another person could remove it easily from the
examiner’s hand.
 Use a hand or finger rest which is distant from the tooth/teeth being examined.
 Use a 45-60 degree angulation of the probe from the long axis of the tooth during
insertion into the pocket. Then move the probe parallel to the long axis of the tooth
to measure pocket depth.
 Maintain the tip of the probe in contact with the tooth surface during probing.
 Use tactile sense only and avoid "scraping" of the tooth surfaces.
 Detect "solid" resistance from subgingival calculus and "soft" resistance at the base
of the pocket.
 Probe around supra or subgingival calculus to reach the base of the pocket.
 When gently retracting the probe, the apical ledge of subgingival calculus can be
detected with the ball tip of the probe.
Note: Probing should not cause extreme discomfort to the patient. No more than 25
grams of pressure should be placed on the tip of the probe.
CPITN SCORING BY SEXTANTS OF THE MOUTH
The CPITN classifies the need for therapy in each sextant into codes using the “worst”
findings (or highest score) observed in the sextant. Thus, only one score is recorded
for every sextant examined. The CPTIN codes, diagnostic features, and the
recommended therapies are given in the following table:
CPITN
SCORE
DIAGNOSTIC
FEATURES
RECOMMENDED
THERAPY
26
0
Healthy tissues
None
1
Bleeding upon
gentle probing
Education to promote
effective “self-care”
2
Presence of calculus
or overhangs and no
pockets deeper than 3.5 mm
Education + prophylaxis
3
At least one pocket
which is 3.5 – 5.5 mm
Education + prophylaxis +
root scaling/planing
4
At least one pocket
of 5.5 mm or deeper
Education + prophylaxis +
deep scaling + surgery (prn)
X
No teeth present
Excluded from separate
needs assessment
A general rule for scoring is if doubt exists, assign the lesser score. When heavy
extrinsic staining is present in the absence of calculus or pockets, the sextant may be
scored as ‘2” if a prophy is needed to remove the stain.
25. Soft Tissue Lesions
a. (1) Yes
Abnormal tissue is indicated on examination form or
observed
b. (2) No
Tissue appears normal on examination or indicated
as “Normal” or “Within Normal Limits” on examination
form
c. (3) Cannot be determined Questionable area that does not warrant a “Yes”
classification or inadequate documentation in the
dental record
26. Orthodontic Status
(Record for chart reviews or exams only.)
a. (0)
Not assessed
No record of orthodontic exam
b. (1)
No need
No orthodontic needs
c. (2)
Need-not started
Treatment is needed but not started
d. (3)
In treatment
Currently in treatment (any type)
e. (4)  Treatment Completed
27. Tobacco Use
a. (0) None
b. (1) Current
Active treatment is complete (patient may still
be followed by orthodontist or in retainers
No tobacco history noted on Health History or
Prevention section of exam form OR patients
reports no tobacco use history
Tobacco use is indicated on Health History
Form or Prevention section of exam form or
patient reports use in the past 30 days
27
i. (If yes), type
c. (2) Former
d. (3) Cannot be determined
28. Smoker in Home
a. (0) No
Indicate type: smoked or smokeless
History of tobacco use with NO use in the past
30 days
Inadequate documentation or patient cannot
recall last use
Self reported or documented in health record
b. (1) yes
Self reported or documented in health record
c. (2) Cannot be determined
Unable to answer question or no
documentation in health record
29. Oral Hygiene
(Chart reviews) Determine by exam form or
progress note (prophy) related to the exam
being reviewed. (Screening or Exam)
Determine by direct observation of plaque
present.
a. (0)
Not assessed (Chart reviews only)
b. (1)
Good
c. (2)
Fair
d. (3)
Poor
28
Appendix D: Oral Health Survey Calibration Form
Name _____________________________
Measure
Codes
1
Age
Grade
Untreated decay
Caries Experience
Sealants on
permanent molars
Treatment
Urgency
Visit in last 12
months
Prophy in last 12
months
Add other selected
fields
2
Screener Number
3
4
5
6
(N)Not in school
(P) Preschool
Grade ______
(0) No untreated
(1) Untreated
(2) Cannot be
determined
(0) No
(1) Yes
(2) Cannot be
determined
(0) No Sealants
(1) Sealants
(2) Cannot be
determined
(0) Early Care Need
(2) Urgent Care
(3) Cannot be
determined
(0) No
(1) Yes
(2) Cannot be
determined
(0) No
(1) Yes
(2) Cannot be
determined
Add selected field
codes
Adapted from: Basic Screening Surveys: An approach to monitoring community oral health.
Association of State and Territorial Dental Directors, 1999, Revised September 2003. p. 32
29
Appendix E: RPMS Computer Search Instructions
The following examples come from the Nashville Area training database and do not represent
actual patients or services rendered.
PADA Search:
Search Parameters:
Date and Code
This is the most basic search. It requires the least number of entries. It is the least specific
of the searches so you will not be able to specify location, age or provider. For small
programs with a single location and few number of providers, this is the preferred search.
RPMS PROMPT
USER REPLY
INQ Inquiry to Patient Records ...
PM Patient Management ...
DVIS Dental Visit Data Entry ...
QAT
QAT Quality Assurance Tracking ...
REPT Clinical Services Reports ...
SUP Supervisory Functions
COPC Community-Oriented Primary Care
Activities ...
TECH Technical QA Functions (for chart audits) TECH
MGT Program Management QA Functions ...
PADA Patient Listing By a Range of Procedure
Codes
SCOM Patients receiving a combination of
Services
ENDO Endodontic Tooth Access Report
START WITH VISIT DATE:
GO TO VISIT DATE:
Previous selection: ADA CODE equals 0150
START WITH ADA CODE: 0150//
GO TO ADA CODE: 0150//
DEVICE:
Right Margin: 80//
PADA
Enter date
Enter date
Enter Code 0120 if using recall exams, enter
0150 if only using comprehensive exams
0150
RETURN
30
Output:
PATIENT LISTING BY SELECTED DENTAL PROCEDURES
NOV 6,2008 08:59
PAGE 1
CHART#
DATE
PATIENT
DENTIST
-------------------------------------------------------------------------------PROCEDURE CODE: 0150
SMITH,ALLISON
200001
OCT 24,2007 08:00
GRAU
COOLIDGE,ELIZABETH
100072
FEB 2,2008 08:00
DAVIS
MAR 24,2008 08:00
DAVIS
WHEELWRIGHT,VELMA
102029
JACKSON,TRUDY
101901
DEC 15,2007 08:00
RICKS
VON BRAUN,CHRIS
101693
NOV 5,2007 08:00
GRAU
DEMO,JANICE DUNNO
666666
OCT 15,2007 08:00
GRAU
DEC 2,2007 08:00
RICKS
MAR 31,2008 08:00
RICKS
MARTINK,JOHN TYLER
MARTINA,JOHN TYLER
555738
555517
31
SCOM Search
Search Parameters:
Date
Age
Provider
Location
Codes
Codes followed by other codes
Opsite
This search has more parameters so use this if you need to identify location or providers. This
is the preferred search for programs with multiple clinics because you will need to identify the
location of the chart that will be reviewed.
RPMS PROMPT
USER REPLY
INQ Inquiry to Patient Records ...
PM Patient Management ...
DVIS Dental Visit Data Entry ...
QAT Quality Assurance Tracking ...
REPT Clinical Services Reports ...
SUP Supervisory Functions
QAT
COPC Community-Oriented Primary
Care
Activities ...
TECH Technical QA Functions (for chart
audits)
MGT Program Management QA Functions ...
PADA Patient Listing By a Range of
Procedure Codes
SCOM Patients receiving a combination of
Services
ENDO Endodontic Tooth Access Report
TECH
SCOM
Start with (and include) date:
Enter date, then RETURN
Go to (and include) DATE:
Enter date, then RETURN
Do you want to limit the search according to the
AGE at the time of visit? NO//
RETURN
Limit search to specific ATTENDING DENTIST(s))
NO//
RETURN
Limit search to specific
HYGIENISTS/THERAPISTS? No//
RETURN
Do you want to limit search to visits at a particular
facility? NO//
RETURN
Limit the search to a particular ADA code or set of
codes? YES//
RETURN
Select ADA Code:
0120 (If using recall exams)
Select ADA Code:
0150
Select ADA Code:
RETURN
Do you want these ADA codes to apply to a
particular opsite or opsites? YES//
NO
Limit the search to ADA codes which are
FOLLOWED BY a particular code? YES//
NO
Do you want to review your search parameters?
Y
32
***STEP TWO: Specify OUTPUT
FORMAT***
You have the following options for
displaying this report.
Select one of the following:
1
2
3
4
5
Count Patients
Print Dental Record
Review for Each
Patient
Count ADA codes
Count visits
Print Visit List
Template will be attached to the DENTAL
PROCEDURE FILE.
Do you want to store the results of this search
in a TEMPLATE? NO//
5
RETURN
Output
DENTAL PROCEDURE LIST
NOV 6,2008 09:12
CHART# PATIENT
DATE
DENTIST
-------------------------------------------------------------------------------101693 VON BRAUN,CHRIS
11-05-2007 GRAU
PAGE 1
HYG/THER
CODE SITE
0000
0150
0220
0230
0274
8
24
33
QMAN Search
Search Parameters:
Any field entered into any RPMS package
The instruction below will provide a list of all patients with the specific attributes and conditions.
Other options include RANDOM SAMPLE that will give a list of a sample patients that meet the
search criteria. See next example for RANDOM SAMPLE search instructions.
QMAN PROMPT
USER REPLY
Subject of your Search?
LIVING PATIENTS
Attribute of Living Patients?
Dent
1 DENTAL EXAM
2 DENTAL PROCEDURE
CHOOSE 1-2:
2
Enter ADA CODE:
0120 (if including recall exams, if not omit this)
Enter ADA CODE
0150
Enter ADA CODE
RETURN
First condition of "ADA CODE":
BETWEEN DATES
Exact starting date:
010107
Exact ending date:
123107
Next Condition of "ADA CODE"
RETURN
Attribute of Living Patients?
Age
First condition of "Age”:
Between
Start with (and include) AGE:
End with (and include) AGE:
2
5
Next condition of "Age":
Return
Select one of the following:
1 DISPLAY results on the screen
2 PRINT results on paper
3 COUNT 'hits'
4 STORE results of a search in a FM
search template
5 SAVE search logic for future use
6 R-MAN special report generator
9 HELP
0 EXIT
2 (at next prompt enter the printer number)
You have 3 options for listing ADA CODES
=>
1) List every ADA CODES meeting
search criteria.
2) List every ADA CODES and SERVICE
DESCRIPTIONS meeting search criteria.
3) List all PATIENTS with ADA CODES
you specified, but DO NOT list
individual ADA CODES or SERVICE
DESCRIPTIONS (FASTEST OPTION!!)
(Displays UNDUPLICATED list of
PATIENTS)
3
34
...EXCUSE ME, LET ME THINK ABOUT THAT A MOMENT...
Please note: Patients whose names are marked with an "*" may have aliases.
PATIENTS
SELLS
SERVICE
AGE
NUMBER
-----------------------------------------------------------------------------MARTINA,JOHN TYL
555517 +
BELLG,ANGELA MAR
555683 +
MARTINK,JOHN TYL
555738 +
COOLIDGE,ELIZAB*
100072 +
Total: 4
Enter RETURN to continue or '^' to exit:
ADA CODE
9
9
9
45
35
To Generate a Random Sample of Patients (for very large programs)
To determine percentage needed you will need to determine the number of exams that were
done in the time frame. To get this number, run search above and Select Output Option #3,
Count Hits
QMAN PROMPT
USER REPLY
Subject of your Search?
Random Sample of Patients
Attribute of Living Patients?
Dent
1 RANDOM SAMPLE OF PATIENTS
2 RANDOM SAMPLE OF VISITS
What percent of the patients do you want in
the sample: 50%
1
Select Percentage
Attribute of RAMDOM SAMPLE OF
PATIENTS:
DENT
1 DENTAL EXAM
2 DENTAL PROCEDURE
CHOOSE 1-2:
2
Enter ADA CODE:
0120
Enter ADA CODE
0150
Enter ADA CODE
RETURN
First condition of "ADA CODE":
BETWEEN DATES
Exact starting date:
010107
Exact ending date:
123107
Next Condition of "ADA CODE"
RETURN
Attribute of Living Patients?
Age
First condition of "Age”:
Between
Start with (and include) AGE:
End with (and include) AGE:
2
5
Next condition of "Age":
Return
Select one of the following:
1 DISPLAY results on the screen
2 PRINT results on paper
3 COUNT 'hits'
4 STORE results of a search in a FM
search template
5 SAVE search logic for future use
6 R-MAN special report generator
9 HELP
0 EXIT
2 (at next prompt enter the printer number)
You have 3 options for listing ADA CODES
=>
1) List every ADA CODES meeting search
criteria.
2) List every ADA CODES and SERVICE
DESCRIPTIONS meeting search criteria.
3) List all PATIENTS with ADA CODES you
specified, but DO NOT list individual ADA
CODES or SERVICE DESCRIPTIONS
(FASTEST OPTION!!) (Displays
UNDUPLICATED list of PATIENTS)
3
36
Appendix F: Sample Consent Forms
Sample Passive Consent Cover Letter for Parents
Dear Parent/Guardian:
Your child’s school has been chosen to take part in the [tribe] Early Childhood Caries (ECC) Initiative
Survey. The purpose of the ECC Survey is to gather information on the dental health needs of children
in your community and throughout the Indian Health Service . This will allow us to create a plan to
improve dental care for all of [Tribe]’s children.
If you choose to let your child participate, a dentist or dental hygienist will perform a one-minute “smile
check” using only a mouth mirror. Dental gloves will be worn, and we will use a new, disposable,
sterilized mirror for each child. Results of your child’s assessment will be kept confidential, and your
child will not be named in any ECC Survey report.
As a token of appreciation, your child will receive a toothbrush. We will also send home a letter to let
you know if we find any dental problems. This screening, however, does not take the place of regular
dental check-ups by your family dentist. Even if you have a family dentist, we encourage you to
participate in the ECC Survey. By surveying all children in selected schools, we will have a better
understanding of the dental health needs of children throughout {state}.
If you do not wish for your child to have this quick “smile check”, please check the NO box
below and return the form to your child’s teacher tomorrow. If you want your child to have a
“smile check” you do not need to return this form.
As you know, a healthy mouth is part of total health and wellness and makes a child more ready to
learn. By letting your child take part in this dental screening, you will help contribute new information
that may benefit all of [Tribe]’s children. If you have any questions about the ECC Survey, please
contact
------------------------------------------------------------------------------------------------------------------------------------
If you do not want your child to have a dental screening, please check the NO box, sign, and
return to your child’s teacher tomorrow.
Child’s Name: _____________________________________________________________________
Child’s Teacher: ___________________________________________________________________
_____ NO, I do not want my child to receive a dental screening
_______________________________________ _________________________________
Parent/Guardian Signature
Date
Source: ASTDD Basic Screening Survey manual
37
Sample Positive Consent Cover Letter for Parents
Dear Parent/Guardian:
Your child’s school has been chosen to take part in the [Tribe] Early Childhood Caries (ECC) Initiative
survey to learn about the health of children’s teeth in your county and across the state.
The ECC Initiative will help us plan future dental health programs. As you know, a healthy
mouth is part of total health and wellness and makes a child more ready to learn.
With your consent, a dentist or dental hygienist will screen your child’s teeth to check for tooth decay
and other dental problems. Your child will receive a toothbrush and a letter to take home that tells
you about the health of your child’s teeth. This screening does not take the place of regular dental
check-ups.
Please be assured that the dental screening will be carried out in a healthy manner. Dental gloves
will be worn, and we will use a new, disposable, sterilized mirror and probe for each child, which will
be thrown away after one use. The dentist or dental hygienist will follow all guidelines to prevent the
spread of disease set by the Centers for Disease Control and Prevention (CDC) for this type of
dental survey. Results of your child’s screening will be added to those of other children, and your
child will not be named in any ECC Survey report.
Please complete and sign the attached consent form. This will allow your child to be in ECC Survey.
Return the form to your child’s teacher tomorrow.
Thank you for working with us to learn how to improve the dental health of the children of our state.
If you have any questions about the ECC Survey please contact [local contact person]
Please complete this form and return it to your child’s teacher tomorrow. Thank you.
Child’s Name: ____________________________________________ Child’s Age: ______________________
____ Yes, I give permission for my child to have his/her teeth checked.
____ No, I do not give permission for my child to have his/her teeth checked.
________________________________________________________ _____________________________
Parent/Guardian Signature
Date
Adapted from: ASTDD Basic Screening Survey manual
38
Sample Consent Form with Fluoride Varnish and Optional Questions
Child’s Name: _____________________________ Date of Birth: _______________________
Your child’s school has been chosen to take part in the [Tribe] Early Childhood Caries (ECC) Initiative
survey to learn about the health of children’s teeth in your county and across the state.
The ECC Initiative will help us plan future dental health programs. As you know, a healthy
mouth is part of total health and wellness and makes a child more ready to learn.
With your consent, a dentist or dental hygienist will screen your child’s teeth to check for tooth decay
and other dental problems. Your child will receive a toothbrush and a letter to take home that tells
you about the health of your child’s teeth. This screening does not take the place of regular dental
check-ups.
Please be assured that the dental screening will be carried out in a healthy manner. Dental gloves
will be worn, and we will use a new, disposable, sterilized mirror and probe for each child, which will
be thrown away after one use. The dentist or dental hygienist will follow all guidelines to prevent the
spread of disease set by the Centers for Disease Control and Prevention (CDC) for this type of
dental survey. Results of your child’s screening will be added to those of other children, and your
child will not be named in any ECC Survey report.
After your child is screened a fluoride varnish can be painted on teeth to prevent tooth decay delivering
a safe and effective dose of fluoride. The varnish sets up on contact with saliva so children usually
cannot swallow the varnish. Used at the right levels, it is safe and effective. Swallowing too much
fluoride can cause stomach upset or make white or brown spots on permanent teeth.
Please complete and sign the attached consent form. This will allow your child to be in ECC Survey.
Return the form to your child’s teacher tomorrow.
Thank you for working with us to learn how to improve the dental health of the children of our state.
If you have any questions about the ECC Survey please contact [local contact person]
1. During the past 6 months, did your child have a toothache more than once, when biting or
chewing?
1. No
2. Yes
3. Don’t know/don’t remember
2. How long has it been since your child last visited a dentist?
1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year ago, but not more than 3 years ago
4. More than 3 years ago
5. Never have been
6. Don’t know/don’t remember
____ Yes, I give permission for my child to have his/her teeth checked and fluoride varnish.
____ No, I do not give permission for my child to have his/her teeth checked and fluoride varnish.
____ Yes, I give permission for my child to have his/her teeth checked with no fluoride varnish.
____ No, I do not give permission for my child to have his/her teeth checked with no fluoride varnish.
____________________________ _________________
Signature (Parent/Guardian)
Date
39
Screening Report Letter
Dental Screening Program
Dear Tribal Member or Parent/Guardian:
Thank you for participating (allowing your child to participate) in the Dental Screening Program.
The following was found during the screening:

The need for dental sealants.

No obvious problems- yearly dental exams are recommended.

Better brushing and flossing is needed.

Questionable area(s) on the teeth that should be examined by a dentist in the near
future, or at the next routine exam.

Urgent dental needs. Contact your dentist as soon as possible.
You are encouraged to make an appointment with a dentist for a regular dental exam. Please
contact your local dental provider for information about receiving care.
(Insert Dental Provider information here: Clinic name, hours, phone number)
Please understand that dentists are very busy. They will make every effort to see provide care
as soon as possible. If appointments are not kept, this may affect your ability to make further
appointments.
40
Appendix G: Sample Screening Forms
Required Data Fields: Preschool Children
Screen Date:
Site Code or Tribe:
Screener’s
Initials
Name or ID Number:
Birth Date:
Gender:
(1)  Male
(2)  Female
Untreated Decay:
(0)  No Untreated
(1)  Untreated
(2)  Cannot be determined
Treatment Urgency:
(0)  No obvious problem
(1)  Early Care Need
(2)  Urgent Care
(3)  Cannot be determined
Age
(In Years at last
birthday):
Treated Decay:
(0)
(1)
(2)
Rampant Decay
(0)
(1)
(2)
Type:
(1)  Exam
(2)  Screen
(3)  Ch.Rev.
 No Treated
 Treated
 Cannot be determined
 No
 Yes
 Cannot be determined
Other fields may be added as needed
Note: For very short forms, consider putting 2 records per page
41
Required Data Fields: School Age Children
Screen Date:
Site Code or Tribe:
Name or ID Number:
Age
(In Years at
last birthday):
Screener’s
Initials
Type:
(1)  Exam
(2)  Screen
(3)  Ch.Rev.
Grade:
Gender:
(N) Not in school
(1)  Male
(P) Preschool
(2)  Female
Grade ______
Untreated Decay:
Treated Decay:
Treatment Urgency:
(0)  No Untreated
(0)  No Treated
(0)  No obvious problem
(1)  Untreated
(1)  Treated
(1)  Early Care Need
(2)  Cannot be
(2)  Cannot be determined
(2)  Urgent Care
determined
(3)  Cannot be
determined
Rampant Decay:
Sealants on Permanent Molars:
(0)  No
(0)  No
(1)  Yes
(1)  Yes
(2)  Cannot be determined
(2)  Cannot be determined
Other fields may be added as needed
42