1

Mott Community College

Dental Hygiene Program
Comprehensive Skill Evaluation
DHYG 121

Student Name

Date:

SECTION I
Instrumentat
ion
Skill
Evaluation
CH 3 Explorer

Possibl Minimum
e
Possible
80%

16

13

32

26

16

13

16

13

14

11

40

32

24

19

40

32

40

32

Y
N
Y
N

Pg. 11

13/14 Universal
Curet

Y
N

Pg. 10

204SD Sickle

Y
N

Pg. 9

6/7 Sickle

Y
N

Pg. 8

11/12 Explorer

Y
N

Pg. 7

Hand Piece

Y
N

Pg. 6

Piezo

Y
N

Pg. 5

Ultrasonic

Remediat Remediati
ion
on
Required Complete
d (enter date
and faculty
initials)

Pg. 4

Probe

Points
Achieve
d

Y
N

Pg. 12

1/2 Gracey Curet

32

26

11/12 Gracey
Curet

Y
N

Pg. 13

32

26

Y
N

Pg. 14

13/14 Gracey
Curet

32

26

Y
N

Pg. 15

FH 3/7, 5/11
Files

16

13

Y
N

Pg. 16

SECTION I
Total Points
Possible
350

Total Points
Achieved:_________

Faculty/student sign upon

final review

SECTION II
PATIENT
EVALUATION
AND
PROCEDURES
Blood Pressure

Possibl Minimum Points

e
Possible Achieve
80%
d

and faculty
initials)

Y
N

Pg. 17

Pulse and
Respiration

Remediat Remediati
ion
on
Required Complete
d (enter date

Y
N

Pg. 18

Head and Neck

Examination

16

13

Y
N

Pg. 19

Oral Examination

11

Fluoride Tray

16

13

12

10

Y
N

Pg. 22

Fluoride Varnish

Y
N

Pg. 21

Fluoride Rinse

Y
N

Pg. 20

12

10

SECTION II
Total Points
Possible
79

Points SECTION I

Y
N

Pg. 23

Total Points
Achieved:_________

Faculty/student sign upon final

review

+ Points SECTION II

429

FINAL PERCENTAGE=

PASS

FAIL

MINIMUM 80% REQUIRED

ADA Accreditation Standard 2-19 states Graduates must be competent in providing the
dental hygiene process of care which includes; assessmentperiodontal and dental
examination.

CH 3 Explorer Skill Sheet

Activity

Max
3/4 O
1 pt

Mand
19/20 O/B
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt

0 pt

Wrist

1 pt

1 pt

-Keeps Straight with forearm

-Positions Palm toward
occlusal/incisal

0 pt

0 pt

Adaptation/Angulatio
n

1 pt

1 pt

-Addresses assigned tooth area

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

-Retraction/Reflection
-Grasp

0 pt

0 pt

Ergonomics/Lighting/
Location -Posture

1 pt

1 pt

-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

0 pt

0 pt

Professionalism

1 pt

1 pt

0 pt

0 pt

Grasp
-Modified Pen Grasp

Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas

Exploring Technique
-Uses a light exploring technique

Dental Mirror Uses

Proper

-OSHA
-Infection Control

Instructor
Comments

5
Total Points Possible
16
Minimum Points 13
_____yes_____no

Remediate

Total Points Earned_______

O=Occlusal B=Buccal

Additional Instructor Comments:

Probe Skill Sheet

Activity

B
3/4/5

F
8/9/10

L
19/20/21

L
23/24/25/
26

1 pt

1 pt

1 pt

1 pt

Fulcrum

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

-Keeps extended straight

-Stable
-Repositions to change areas

0 pt

0 pt

0 pt

0 pt

Wrist

1 pt

Grasp
-Modified Pen Grasp

-Keeps Straight with forearm

-Positions Palm toward
occlusl/incisal

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

Adaptation/Angulatio
n

1 pt

1 pt

1 pt

1 pt

-Inserts probe at line angle

-Probe 10angle from tooth 1-2
mm of the side of the probe
-Moves tip in an up and down
walking motion 1-2mm apart in
the sulcus

0 pt

0 pt

0 pt

0 pt

Exploring Stroke

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

-Angles probe under contact/col

area
-Covers entire circumference of
tooth using walking stroke
-Uses digital movement

Dental Mirror Uses

Instructo
r
Commen
ts

6
Proper
-Retraction/Reflection
-Grasp

0 pt

0 pt

0 pt

0 pt

Ergonomics/Lighting/
Location -Posture

1 pt

1 pt

1 pt

1 pt

-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

0 pt

0 pt

0 pt

0 pt

Professionalism

1pt
0pt

1pt
0pt

1pt
0pt

1pt
0pt

-OSHA
-Infection Control

Total Points Possible

32
Minimum Passing Score=26
_____yes_____no

Remediate

Total Points Earned_________

F=Facial

L=Lingual B=Buccal

Additional Instructor Comments:

Ultrasonic Skill Sheet

Activity
Set Up
-Attaches handle and holds
vertically to bleed for 60 sec.
-Seats insert tightly
-Sets power dial correctly
-Sets water volume correctly

Tuning
-Tunes for plaque removal(mist
and drip)
-Tunes for calculus removal(fine
mist)
-Verbalizes correct insert use
-Demonstrates foot pedal
controls
-Gives saliva ejector to patient
-Provides patient paper towels

Grasp
-Modified Pen Grasp

Fulcrum

7/8/9/10 F

23/24/25/26 L

(Completed
Correctly)
1 pt
0 pt
(Completed
Correctly)
1 pt
0 pt

1 pt
0 pt
1 pt

1 pt
0 pt
1 pt

Instructor
Comments

7
-Close to area being treated
-Intra or Extra Oral

0 pt

0 pt

Wrist

1 pt

1 pt

-Keeps straight with forearm

-Positions palm toward
occlusal/incisal

0 pt

0 pt

Adaptation/Angulatio
n

1 pt

1 pt

-Uses short overlapping

constant
motion
-Pivots tip to follow contour of
tooth and sub-gingival areas
-Uses lateral side of tip
-Light lateral pressure

0 pt

0 pt

Dental Mirror
Uses Proper

1 pt

1 pt

0 pt

0 pt

1 pt

1 pt

0 pt

0 pt

1 pt

1 pt

0 pt

0 pt

-Retraction/Reflection
-Grasp

Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

Professionalism
-OSHA
-Infection Control

Total Points Possible

16
Minimum Points 13
Remediate _____yes_____no
Total Points Earned______

F=Facial

L=Lingual

Additional Instructor Comments:

Piezo Skill Sheet

Activity
Set Up
-Irrigation bottle filled to
appropriate
Level
-Verbalizes criteria for proper tip
selection

7/8/9/10 F
(Completed
Correctly)
1 pt

23/24/25/26 L

Instructor
Comments

8
-Attaches tip to handpiece using
wrench
and rotates clockwise until a
click is
heard
-Selects appropriate operation
mode
-Selects appropriate water mode
-Selects appropriate power range
setting

Tuning
-Adjusts water flow
-Tunes for plaque removal(mist
and drip)
-Tunes for calculus removal(fine
mist)
-Gives saliva ejector to patient
-Provides patient paper towels

Grasp
-Modified Pen Grasp

Fulcrum
-Close to area being treated
-Intra or Extra Oral

Wrist

0 pt

(Completed
Correctly)
1 pt
0 pt
1
0
1
0

pt
pt
pt
pt

1
0
1
0

pt
pt
pt
pt

1 pt
0 pt

1 pt
0 pt

Adaptation/Angulatio
n

1 pt

1 pt

-Uses short overlapping

constant motion
-Pivots tip to follow contour of
tooth and sub-gingival areas
-Uses lateral side of tip only
-Light lateral pressure

0 pt

0 pt

1 pt

1 pt

0 pt

0 pt

1 pt

1 pt

0 pt

0 pt

1 pt

1 pt

0 pt

0 pt

-Keeps straight with forearm

-Positions palm toward
occlusal/incisal

Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp

Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

Professionalism
-OSHA
-Infection Control

Total Points Possible

16
Minimum Points 13
Remediate _____yes_____no
Total Points Earned______
Additional Instructor Comments:

F=Facial

L=Lingual

Hand Piece Skill Sheet

Activity

7/8/9/10
F
1 pt

28/29/30
L
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt

0 pt

Wrist

1 pt

1 pt

-Keeps straight with forearm

-Positions palm toward
occlusal/incisal

0 pt

0 pt

Adaptation/Polishing
Technique

1 pt

1 pt

-Uses sufficient polish

-Applies polish to 2-3 teeth at a
time
-Uses slow speed
-Flares cup with light pressure
-Uses patting motion proximal
to proximal

0 pt

0 pt

Dental Mirror Uses

Proper

1 pt

1 pt

0 pt

0 pt

1 pt

1 pt

0 pt

0 pt

1 pt

1 pt

Grasp

Instructor
Comments

-Modified Pen Grasp

Fulcrum
-Hard tissue fulcrum
-Close to area being treated
-Pivots on fulcrum finger

-Retraction/Reflection
-Grasp

Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

Professionalism
-OSHA
-Infection Control

0 pt

0 pt

Total Points Possible

14
Minimum Possible 11
_____yes_____no
Total Points Earned______

Remediate
F=Facial

L-Lingual

10
Additional Instructor Comments:

11/12 Explorer Skill Sheet

Activity

3/4/5
B

7/8/9
F-ST

19/20/2
1L

23/24/2
5 F-ST

23/24/2
5 L-ST

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

Wrist

1 pt

1 pt

1 pt

1 pt

1 pt

-Keeps straight with forearm

-Positions palm toward
occlusal/incisal

0 pt

0 pt

0 pt

0 pt

0 pt

Adaptation/Angulatio
n

1 pt

1 pt

1 pt

1 pt

1 pt

-Uses correct working end

-Keeps 1-2 mm of tip on tooth
-Keeps terminal shank parallel
to long axis of tooth
-Repositions at line angle
-Rotates to adapt proximally

0 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

Grasp
-Modified Pen Grasp
-Light Grasp

Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas

Exploring Stroke
-Uses digital action
-Uses a light lateral pressure
-Uses short overlapping strokes
-Rolls and pivots and keeps tip
on tooth
-Side of tip is in the sulcus and
finishes
under contact

Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp

Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.

Instruct
or
Comme
nts

11
-Uses loupes

Professionalism
-OSHA
-Infection Control

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

Total Points Possible

40
Minimum Points=32
_____yes_____no

Remediate

Total Points Earned_______

ST=Surfaces Toward

B-Buccal

F=Facial

L=Lingual

Additional Instructor Comments:

6/7 Sickle Skill Sheet

Activity

8/9/10
F-ST, F-SA
1 pt

25/26/27
F-SA, L-SA
1 pt

23/24/25
F-ST, L-ST
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

-Uses correct working end

-Moves from mid F/L to
proximal
-1-2 mm of blade engaged
-Repositions at line angle
-Rotates to adapt proximally

0 pt

0 pt

0 pt

Exploratory/Working
Strokes

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

Grasp
-Modified Pen Grasp

Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas

Wrist
-Keeps straight with forearm
-Positions palm toward incisal

Adaptation/Angulatio
n

-Begins with exploratory stroke

-Finishes with working stroke
-Uses short overlapping strokes

Dental Mirror Uses

Proper
-Retraction/Reflection
-Grasp

Instructor
Comments

12
Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

Professionalism
-OSHA
-Infection Control

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

Total Points 24
Minimum Points=19
_____yes_____no

Remediate

Total Points Earned______

SA=Surfaces Away

F=Facial

L=Lingual

ST=Surfaces Toward

Additional Instructor Comment:

204SD Universal Sickle Skill Sheet

Activity

3/4/5
B

12/13/
14
L

19/20/
21
L

30/29/
28
B

1 pt

1 pt

1 pt

1 pt

23/24/
25 FST LST
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

Wrist

1 pt

1 pt

1 pt

1 pt

1 pt

-Keeps straight with forearm

-Positions palm toward
occlusal/incisal

0 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

Grasp
-Modified Pen Grasp

Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas

Adaptation/Angulatio
n
-Uses correct working end
-Keeps terminal shank parallel
to long axis of tooth in posterior
-Terminal shank wraps to the

Instruct
or
Comme
nts

13
surface in
the anterior
-Repositions at line angles and
advances
toward proximal
-Rotates to adapt proximally

Exploratory/Working
Stroke
-Uses light exploratory stroke

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

initially
-Finishes with working stroke,
cutting
edge engaged 60-80
-Uses short overlapping strokes
-Rolls and pivots keeping
cutting edge
engaged on tooth

Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp

Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

Professionalism
-OSHA
-Infection Control

Total Points Possible

40
Minimum Points=32
_____yes_____no

Remediate

Total Points Earned______

Surfaces Toward

B=Buccal

L=Lingual

F=Facial

ST=

Additional Instructor Comments:

13/14 Universal Curet Skill Sheet

Activity

3/4/5
B

12/13/
14
L

19/20/
21
L

30/29/
28
B

23/24/
25 FST, LST

Instruct
or
Comme
nts

14
Grasp

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

Wrist

1 pt

1 pt

1 pt

1 pt

1 pt

-Keeps straight with forearm

-Positions palm toward
occlusal/incisal

0 pt

0 pt

0 pt

0 pt

0 pt

Adaptation/Angulatio
n

1 pt

1 pt

1 pt

1 pt

1 pt

-Uses correct working end

-Keeps terminal shank parallel
to long axis of tooth in posterior
-Terminal shank wraps to the
surface in
the anterior
-Repositions at line angles and
advances
toward proximal
-Rotates to adapt proximally

0 pt

0 pt

0 pt

0 pt

0 pt

Exploratory/Working
Stroke
-Uses light exploratory stroke

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

0 pt

1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

-Modified Pen Grasp

Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas

initially
-Finishes with working stroke,
cutting
edge engaged 60-80
-Uses short overlapping strokes
-Rolls and pivots keeping
cutting edge
engaged on tooth

Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp

Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

Professionalism
-OSHA
-Infection Control

Total Points Possible

40
Minimum Points=32
_____yes_____no
Total Points Earned______
Surfaces Toward

Remediate
B=Buccal

L=Lingual

F=Facial

ST=

15
Additional Instructor Comments:

Gracey 1 / 2 Curet Skill Sheet

Activity

7/8/9
F-ST

10/11
L-SA

25/26/2
7
F-ST

22/23/2
4
L-SA

1 pt

1 pt

1 pt

1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

-Uses correct working end

-Keeps terminal shank parallel
to long axis of tooth in anterior
-Repositions at line angles and
advances
toward proximal
-Rotates to adapt proximally

0 pt

0 pt

0 pt

0 pt

Exploratory/Working
Stroke
-Uses light exploratory stroke

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

Grasp
-Modified Pen Grasp

Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas

Wrist
-Keeps straight with forearm
-Positions palm toward incisal

Adaptation/Angulatio
n

initially
-Finishes with working stroke,
cutting
edge engaged 60-80
-Uses short overlapping strokes
-Rolls and pivots keeping
cutting edge
engaged on tooth

Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp

Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

Instruct
or
Comme
nts

16
Professionalism

1 pt
0 pt

-OSHA
-Infection Control

1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

Total Points Possible

32
Minimum Points=26
_____yes_____no

Remediate

Total Points Earned______

SA-Surfaces Away

F=Facial

L=Lingual

ST=Surfaces Toward

Additional Instructor Comments:

Gracey 11/12 Curet Skill Sheet

Activity

4/5
B

13/14
L

19/20
L

28/29
B

1 pt

1 pt

1 pt

1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt

0 pt

0 pt

0 pt

Wrist

1 pt

1 pt

1 pt

1 pt

-Keeps straight with forearm

-Positions palm toward
occlusal/incisal

0 pt

0 pt

0 pt

0 pt

Adaptation/Angulatio
n

1 pt

1 pt

1 pt

1 pt

-Uses correct working end

-Keeps terminal shank parallel
to long axis of tooth in posterior
mesial
surfaces
-Begins at buccal or lingual and
advances
to the mesial proximal
-Rotates to adapt proximally

0 pt

0 pt

0 pt

0 pt

Exploratory/Working
Stroke
-Uses light exploratory stroke

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

Grasp
-Modified Pen Grasp

Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas

Instruct
or
Comme
nts

17
initially
-Finishes with working stroke,
cutting
edge engaged 60-80
-Uses short overlapping strokes
-Rolls and pivots keeping
cutting edge
engaged on tooth

Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp

Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

Professionalism
-OSHA
-Infection Control

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

Total Points Possible

32
Minimum Points=26
_____yes_____no

Remediate

Total Points Earned______

B=Buccal

L=Lingual

Additional Instructor Comments:

Gracey 13/14 Curet Skill Sheet

Activity

Grasp

4/5
B

13/14
L

19/20
L

28/29
B

1 pt

1 pt

1 pt

1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

-Modified Pen Grasp

Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas

Wrist
-Keeps straight with forearm
-Positions palm toward

Instruct
or
Comme
nts

18
occlusal/incisal

Adaptation/Angulatio
n

1 pt

1 pt

1 pt

1 pt

-Uses correct working end

-Keeps terminal shank parallel
to long axis of tooth in posterior
-Begins distal line angle
advances to
distal proximal

0 pt

0 pt

0 pt

0 pt

Exploratory/Working
Stroke
-Uses light exploratory stroke

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

1 pt

1 pt

1 pt

1 pt

0 pt

0 pt

0 pt

0 pt

1pt
0 pt

1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

initially
-Finishes with working stroke,
cutting
edge engaged 60-80
-Uses short overlapping strokes
-Rolls and pivots keeping
cutting edge
engaged on tooth
-Rotates to adapt proximally

Dental Mirror
Uses Proper
-Retraction/Reflection
-Grasp

Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

Professionalism
-OSHA
-Infection Control

Total Points Possible

32
Minimum Points=26
_____yes_____no
Total Points Earned______

Remediate
B=Buccal

L=Lingual

Additional Instructor Comments:

FH 3/7 and FH 5/11 Periodontal File Skill Sheet

19
Activity

1 pt

FH 5/11
14DL,
30MB
1 pt

0 pt
1 pt

0 pt
1 pt

0 pt

0 pt

Wrist

1 pt

1 pt

-Keeps straight with forearm

-Positions palm toward
occlusal/incisal

0 pt

0 pt

1 pt

1 pt

-Uses correct working end

-Blades fully engaged
-Repositions when necessary

0 pt

0 pt

Exploratory/Working
Strokes

1 pt

1 pt

0 pt

0 pt

1 pt

1 pt

0 pt

0 pt

1 pt

1 pt

0 pt

0 pt

1 pt

1 pt

0 pt

0 pt

Grasp

FH 3/7
3B, 19L

Instructor Comments

-Modified Pen Grasp

Fulcrum
-Keeps extended straight
-Stable
-Repositions to change areas

Adaptation/Angulatio
n

-Begins with exploratory stroke

-Finishes with working stroke
-Uses short overlapping strokes

Dental Mirror Uses

Proper
-Retraction/Reflection
-Grasp

Ergonomics/Lighting/
Location
-Posture
-Patient/Operator Position
-Lighting
-Goes to tooth w/in 15 sec.
-Uses loupes

Professionalism
-OSHA
-Infection Control

Total Points 16
Minimum Points=13
_____yes_____no
Total Points Earned______

Remediate
B=Buccal
DL=Distolingual

Additional Instructor Comments:

L=Lingual
MB=Mesiobuccal

20

Blood Pressure Assessment

Activity
Patient Position
-Positions patient in upright position

Interview
-Determines patient has not had alcohol, tobacco,
caffeine or vigorous exercise within previous 30
minutes

Selection
-Selects an appropriate arm
-Selects appropriate size cuff

Instructor Comments
1
0
1
0

pt
pt
pt
pt

1 pt
0 pt

Cuff Placement

1 pt

-Asks patient to roll up sleeve, if necessary

-Has patient position arm with palm up
-Positions cuff with lower edge 1-2 in. above
antecubital fossa

0 pt

Manometer, Stethoscope,
Amplifying Device
-Places manometer so dial is clearly visible
-Places stethoscope earpieces into the ear canals
with earpieces angled forward
-Places amplifying device above antecubital fossa
-Supports patients arm so antecubital fossa is at
mid-sternum

Valve/Pressure
-Opens valve and rapidly inflates
-Opens valve so pressure drops no faster than 2
mm per second
-Notes point at which sounds appear
-Notes point at which sounds disappear
-Continues releasing pressure slowly for at least 10
mm Hg beyond last sound heard then rapidly
deflates

Professionalism
-OSHA
-Infection control

1 pt

0 pt

1 pt
0 pt

1 pt
0 pt

Total Points 7
Minimum Points=6
_____yes_____no
Total Points Earned______
Additional Instructor Comments:

Remediate

21

Pulse and Respiration Assessment

Activity
Patient Position
-Positions patient in upright position with arm
resting comfortably
-Faces patient

Preparation
-Grasps the patients wrist with the fingers of the
free hand (non-watch bearing)
-Using finger pads, locates radial pulse using
appropriate pressure

Technique to Measure Pulse

-Notes whether pulse is regular or irregular
-Counts the beats for a minimum of 30 seconds
-Calculates the pulse rate within two beats of the
evaluators rate
-Makes a mental note of the pulse rate and
proceeds to respiration

Respiration Technique
-without letting go of the wrist, student begins to
observe the patients breathing
-Does not inform the patient respirations are being
assessed
-Counts number of respirations for a minimum of 30
seconds
-Respiration rate within two breaths of the
evaluators rate

Professionalism
-OSHA
-Infection control

Instructor Comments
1 pt
0 pt
1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

1 pt
0 pt

Total Points 5
Minimum Points=4
_____yes_____no
Total Points Earned______
Additional Instructor Comments:

Remediate

22

Head and Neck Examination

Activity
Patient Position
-Positions patient in upright position or semireclined and removes patient eyewear

PPE/Lighting
-Using infection control protocol, student dons
eyewear, masks and patient care gloves
-Lighting used for visualization

Visually inspects:
-General appraisal
-Head, scalp and ears

Palpation:
-Occipital nodes
-Avoids walking fingers
-Posterior auricular nodes using circular
compression with fingertips
-Avoids walking fingers
-Pre-auricular nodes using circular compression
with fingertips
-Avoids walking fingers

-Submental nodes using digital compression with

the thumb and index finger
-Avoids walking fingers
-Submandibular nodes by rolling tissue over the
mandible
-Avoids walking fingers
-Anterior chain of cervical nodes from ear to
clavicle by compressing the SCM muscle using
thumb and index finger
-Avoids walking fingers
-Posterior chain of cervical nodes by applying
compression posterior to the SCM muscle using
fingertips
-Avoids walking fingers
-Supraclavicular nodes using circular
compression
-Avoids walking fingers
-Parotid gland using circular compression with
fingertips
-Avoids walking fingers

Instructor Comments
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt

23
-Maxillary and frontal sinuses using circular
compression with fingertips
-Avoids walking fingers
-TMJ using circular compression
-Has patient slowly open and close mouth
-Has patient make lateral excursions to the right
and left
-Thyroid gland, locates below thyroid cartilage
-Asks patient to swallow, provides water if
necessary
-Palpates the gland and inspects visually as patient
swallows

1 pt
0 pt

Professionalism

1 pt
0 pt

-OSHA
-Infection Control

1 pt
0 pt
1 pt
0 pt

Total Points 16
Minimum Points=13
_____yes_____no

Remediate

Total Points Earned______

Additional Instructor Comments:

Oral Examination
Activity
Patient Position
-Places patient in supine position
-Provides patient eyewear

Instructor Comments
1 pt
0 pt

PPE/Lighting

1 pt

-Using infection control protocol, student dons

eyewear, masks and patient care gloves
-Adjusts light so oral cavity is well illuminated

0 pt

Visually inspect:
-Lips and vermillion border

Inspection of the Mucosa

-Upper and lower lip: Visually inspects entire
labial mucosa including the vestibules
-Palpates entire lip by compressing tissue between
thumb and index finger
-Buccal mucosa: Visually inspects entire buccal
mucosa including the mucobuccal fold
-Using bi-manual compression, palpates entire
buccal mucosa
-Hard and soft palate: Visually inspects entire
mucosal surface
-Using the index finger palpates the hard palate
-Oropharynx and uvula: Visually inspects
oropharynx
-Using the mouth mirror, depresses the tongue and
requests patient say ah to visualize tonsillar
pillars
-Floor of mouth: Visually inspects floor of mouth
-Palpates entire floor of mouth using bi-manual

1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt
0 pt
1 pt

24
compression

Inspection of the Tongue

-Visually inspects dorsal, lateral and ventral
surfaces
-Using a damp 2x2 gauze, tip of tongue is grasped
and gently pulled to the left, right and up
-Tongue is palpated using compression between the
thumb and index finger

Salivary Gland Examination

-Using a cotton tip applicator, Stensons Duct is
milked to evaluate salivary flow

Professionalism

0 pt
1 pt

0 pt
1 pt
0 pt
1 pt
0 pt

-OSHA
-Infection Control

Total Points 11
Minimum Points=9
_____yes_____no

Remediate

Total Points Earned______

Additional Instructor Comments:

Fluoride Tray Assessment

Activity
1. Provides the patient the proper rationale for APF
fluoride treatment followed by informed consent
from patient
2. Selects correct tray size
3. Chooses correct fluoride (Neutral if needed)
4. Places adequate amount of solutions in tray
5. Seats patient in an upright position and offers
patient a drink of water
6. Places the saliva ejector in the patients mouth
and reminds not to swallow
7. Thoroughly dries mandibular teeth

Instructor
comments:
1 pt
0 pt
1
0
1
0
1
0
1
0
1
0
1

pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt

25
0 pt
1 pt

8. Using a sweeping motion, inserts mandibular

tray at the 8:00 (4:00) position seating posterior
portion of the tray first followed by the anterior
portion (Briefly removes saliva ejector if
necessary)
9. Thoroughly dries maxillary teeth

0 pt

10. Using a sweeping motion, inserts maxillary tray

standing at the 12:00 position seating posterior
portion of the tray first followed by the anterior
portion.
11. Instructs patient to tilt head forward and gently
tap teeth together several times
12. Continuously monitors patient
13. Follows proper timing of fluoride (60 seconds)
14. Removes maxillary tray first keeping saliva
ejector in place then removes mandibular tray
instructing patient not to swallow
15. Removes excess fluoride from tongue and
encourages patient to push excess fluoride to
front of mouth while using the saliva ejector
reminding them to avoid pursing lips around the
ejector tip
16. Gives appropriate post-operative instructions
including avoiding eating, rinsing, drinking, and
smoking for 30 minutes

1
0
1
0

pt
pt
pt
pt

1
0
1
0
1
0
1
0

pt
pt
pt
pt
pt
pt
pt
pt

1 pt
0 pt
1 pt
0 pt

Total points: 16
Minimum Points=13
_____yes_____no

Remediate

Total Points Earned______

Additional Instructor Comments:

Fluoride Rinse Assessment

Activity
1. Provides the patient the proper rationale for
the fluoride rinse treatment followed by
informed consent
2. Prepares two cups with measured amount per
cup
3. Seats the patient in an upright position

Instructor
comments:
1 pt
0 pt
1
0
1
0

pt
pt
pt
pt

26
4. Instructs the patient on the proper way to
swish the solution around the mouth but not to
swallow
5. Instructs the patient on the amount of time to
swish (30 seconds)
6. Continuously monitors patient and instructs
the patient not to swallow
7. Provides evacuation (saliva ejector) to patient
and instructs them to expectorate in the saliva
ejector and to avoid pursing lips around the
ejector tip
8. Repeats the swish with the second half
following the same instructions reminding the
patient on the proper way to swish the solution
around the mouth
9. Instructs the patient on the amount of time to
swish (30 seconds)
10. Continuously monitors patient and instructs
the patient not to swallow
11. Provides evacuation (saliva ejector) to patient
and instructs them to expectorate in the saliva
ejector and to avoid pursing lips around the
ejector tip
12. Gives appropriate post-operative instructions
including avoiding eating, rinsing, drinking,
and smoking for 30 minutes

1 pt
0 pt
1
0
1
0
1
0

pt
pt
pt
pt
pt
pt

1 pt
0 pt
1
0
1
0
1
0

pt
pt
pt
pt
pt
pt

1 pt
0 pt

Total points: 12
Minimum Points=10
_____yes_____no

Remediate

Total Points Earned______

Additional Instructor Comments:

Fluoride Varnish Assessment

Activity

Instructor
comments:

27
1. Provides the patient the proper rationale for
the use of fluoride varnish treatment followed
by informed consent
2. Seats patient in an upright position and offers
patient a drink of water
3. Grasps varnish cup between fingers and peels
off foil lid
4. Mixes varnish thoroughly with applicator brush
5. Using compressed air thoroughly dries
mandibular teeth
6. Paints a thin layer of fluoride varnish directly
on all surfaces of the mandibular teeth
7. Using compressed air thoroughly dries all
maxillary teeth
8. Paints a thin layer of fluoride varnish directly
on all surfaces of the maxillary teeth
9. Allows all surfaces to become wet either by
gentle rinsing or natural salivary flow
10. Instructs patient to expectorate using the
saliva ejector reminding the patient to avoid
pursing the lips around the ejector tip
11. Instructs patient to remain on a soft-food diet,
avoid mouth rinses containing fluoride or
alcohol, and avoid brushing or flossing treated
area for a minimum of four hours
12. Advises patient the varnish may begin to
gradually slough off from the tooth surface
after treatment and remaining varnish can be
removed by brushing and flossing after a
minimum of four hours

Total points possible: 12

Minimum Points=10
_____yes_____no
Total Points Earned______
Additional Instructor Comments:

1 pt
0 pt
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0

pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt
pt

1 pt
0 pt
1 pt
0 pt

Remediate