Rubric for Examination, Diagnosis & Treatment Planning

Faculty:_______________________ Student:_________________________ Final

Grade:_____________

Instructor Evaluation
Compete
Dependent
Profic
nt

Steps and procedures

1. History and Personal Data
Patient's Personal Data recorded*
Medical History recorded *
Chief Complaint correctly noted *
Instructor's questions correctly
answered

One or more
of the critical
steps missed
(*)

Completed
only
Critical
steps*

Compl
all cri
steps
additi
step

One or more
of the critical
steps missed
(*) e.g
misdiagnose
d cavitated
caries

Completed
only
Critical
steps*
excluding
misdiagno
sed
noncavitat
ed carious
lesions.

Compl
all cri
steps
additi
step

Missed 2
proximal
caries in
dentin in
bitewing
radiograph

Missed 2
proximal
caries in
dentin in
bitewing

4. Caries Risk Assessment

Correctly recorded DMF*
Correctly Identified Risk Level

Incorrectly
recorded
DMF

Correctly
recorded
DMF

5. Treatment Planning
Preventive protocol planned *
Accurate comprehensive treatment
plan

One or more
of the critical
steps missed
(*) or

Completed
all critical
steps (*)
but

2. Examination:
a. Extra oral/Intra Oral

Head and neck

Soft Tissue Evaluation: Gingiva, mucosa,

etc.

Oral hygiene
b. Occlusion and Orthodontic

Evaluation

Canine/Molar relationship*
General orthodontic evaluation

c. Dental Charting:

Decayed teeth *
Teeth present or absent*

Existing restorations

Developmental anomalies
Dental trauma

3. Radiographic Diagnosis:
Indicated radiographs were taken*
Correct radiographic diagnosis
Identify proximal caries in bite wing *

Did n
missed
proxi
carie
denti
bite w
Incorre
recor
DMF
Corre
identi
ris
Compl
all cri
steps
wit

Space maintenance needs identified*

Space maintenance needs correctly
incorrectly

planned for
noted

Recall period of 3 to 6 months recorded 4 teeth

*

incorrectly
planned
for 4
teeth

additi
step

Rubric for Formocresol Pulpotomy & Stainless Steel Crown

(SSC)
Faculty:_______________________ Student:_________________________ Final
Grade:_____________

Instructor Evaluation
Compete
Dependent
Profic
nt

Steps and procedures

Student
unable to
identify or
provide
anesthetic
needs

1. Local anesthesia*

2.

Student
able to
provide
anesthetic
needs

Stude
knowled
le in

Seepage of
fluids, clamp
unstable,
Rubber dam
blocking
access

A quadrant
is exposed,
following
critical
criteria

Compl
all crit
steps
cente
rubber

One or more
of the critical
steps missed
(*)

Completed
all critical
steps (*)
with proper
access and
extension

Rubber Dam
Working field is dry*
Clear and Direct access*
Floss tied to clamp*
Allow patient breathing
Rubber dam frame centered

3. Access cavity preparation

Complete removal of caries*

Proper access opening. All pulp horns are
uncovered and are readily accessible.
Complete removal of the coronal pulp
tissue *
No perforation*
Hemorrhage control
Formocresol application
Placement of temporary restoration

Compl
all crit
steps
with
additi
step

4. Tooth Preparation
Occlusal Reduction

- Adequate inter-occlusal
clearance*
- Follows original anatomy
Proximal Reduction:

- Break contacts*
- No Ledges *
- Are convergent occlusally
Buccal Lingual
Surfaces and Bevel:
- Round line angles
- Bevel occlusal 1/3 of buccally &
lingually
Avoid Damage to
Adjacent Teeth *
5. SSC Adaptation/ cementation

One or more
of the critical
steps missed
(*)

Completed
all critical
steps (*)

One or more
of the critical
steps missed
(*) e.g. under
extended
margins, the
bite is opened

Completed
all critical
steps (*)
but with
slight or
restricted
blanching

Compl
all crit
steps
wit
additi
step

Original occlusion restored *

Original contacts restored
Margins 1mm sub-gingival*
Sound retention of SSC*
Properly remove excess cement
Correct position maintained after
cementation

Compl
all crit
steps
witho
blanch