Directions for Patient Data Forms

Periodontal Assessments:

Periodontal assessments are performed to identify patients’ periodontal health status.

Review previous periodontal assessments, compare with current data to identify changes.

Please view the link below to review how to perform an EIOE exam, pulp testing and the numerous elements of the clinical data forms, including the periodontal assessment form in the UMB Dental charts.

http://dentalweb.umaryland.edu/tpw/introduction.html

When the periodontal form is completed for a new patient:

• Document “everything”. A comprehensive periodontal charting must be done every three years for recall patients.

When the periodontal form is completed for a recall patient:

1. Document existing restorations and any new hard tissue findings (caries, broken restorations, new restoration etc.) at every recall visit on a new form
   • EPR: update the existing HTC. EPR provides you with the opportunity to view HTC saved at different periods of time.
2. Probe all the teeth, but record only probe readings (PD) that are ≥ 4mm at every recall visit on a new form
   • Limited exam in EPR
3. Record all readings (CEJ-GM, PD, AL) on teeth with probe depths (PD) ≥4mm for all recall patients.
4. Record all readings on teeth with areas of recession (+ CEJ-GM readings) that have CHANGED since the previous charting.
5. Record all bleeding sites.

Periodontal Classification:

To determine CAL, document the CEJ- GM reading, the probing depth (PD), and ADD or SUBTRACT to calculate the attachment level (CAL)*

Health –No inflammation or ≥4 mm probe depths

Periodontal Disease:

Gingivitis – Inflammation- erythema and/or edema, no 4 mm probing depths, bleeding on gentle probing, no attachment loss

Periodontitis- a combination of

• Inflammation

  ≥4 mm probe depths

• Attachment loss

Only those areas with probing depths of 4mm or more are classified as periodontal disease. Once periodontal disease been determined classify in terms of:

1. Extent*

   * Localized less than 30% of teeth present

   * Generalized ≥ 30% of teeth present

   *Classify EXTENT for Gingivitis also

2. Severity Clinical Attachment Loss/Level (CAL)

Types of Periodontitis:

• Chronic Periodontitis (most periodontitis patients are classified in this category)
• Aggressive Periodontitis
• Periodontitis as a Manifestation of Systemic Disease
• Necrotizing Periodontal Diseases
• Abscesses of the Periodontium
• Periodontitis as a result of Endodontic lesions
• Developmental or Acquired Deformities and Conditions
• Refractory Periodontitis

How to Chart

1. Chart all missing teeth
2. Record both the Probing Depth (PD) and the distance from the gingival margin (GM) to Cemento-enamel Junction (CEJ).

   For teeth with crowns, use the crown margin as the CEJ. For other situations, estimate where the CEJ is (e.g., cervical composites) or mark with an “X” if it is no longer discernable (e.g., fractured tooth).

   If the CEJ is apical to GM (inflammation), include a minus sign (-) next to the number. If the CEJ is coronal to the GM (recession), do NOT include a minus sign.

3. To record the clinical attachment level (CAL), add the CEJ-GM reading to the PD:
   • CEJ–GM reading of (-1mm) + PD of 4mm = CAL of 3 mm (-1 + 4 = 3mm)
   • CEJ-GM reading of 2mm + PD of 4mm = CAL of 6mm (2 + 4 = 6mm).
4. Record the keratinized gingival (KG) reading. Measure it in mm from the GM to the mucogingival junction (MGJ). Record one score for the facial surface on the maxillary and mandibular arches.
5. Complete a gingival description and calculate bleeding index. Bleeding Index = # of bleeding points divided by # of possible sites x 100%.

Gingival Description Guideline

Patient Difficulty Determination

Department of Dental Hygiene

Baltimore College of Dental Surgery

University of Maryland at Baltimore

Guidelines for Determining Case Difficulty Level

Instrumentation associated with Case Difficulty Levels*

*Difficulty level is determined by assessing both the quantity and quality

Hard Tissue Charting Codes

Click TX History tab --->

Chart add icon (on right) -->FINDINGS (on left)

Chart note entries in the EPR

While there are templates for chart notes in the EPR, chart notes should be written in the standard dental school form including all areas of the S.O.A.P. format as follows:

S=Subjective

What the patient tells you

Patient’s chief complaint, history of present illness (this complaint) Past medical history, past dental history

• update data from previous appointment 

  Health History, medications, allergies

• Patient Chief Complaint using their exact word in quotation marks
• Alterations in patient’s health behaviors Pt was recently hospitalized and unable to care for her mouth.

Example: Patient presents complaining of missing tooth #7. States that the tooth was extracted after an unsuccessful attempt at restoration (use quotations when appropriate). Past medical history is non-contributory, however patient admits to smoking 1/2 pack per day of cigarettes. Past dental history: Patient receives dental cleanings irregularly, does not use floss.

O=Objective

• what you see in your examination, including radiographic
  • information obtained in your EIOE, gingival/perio assessment, HTC, etc.
  • radiographic findings bone levels, caries, pathology

Example: Intra-oral exam reveals tongue, palate, FOM WNL. Gingiva is pink and stippled with localized swelling and redness in lower anterior and maxilla posterior regions. Pocketing and dentition as charted (see charting). Missing tooth #7. Adjacent teeth #6, 8 show slight drifting into space of #7. Slight plaque, moderate stain.

Slight stick to explorer in occlusal pits maxillary premolars, however bite-wing radiographs reveal no sign of decay. #31 with large IRM. Radiographic exam reveals IRM #31 is close to pulp. Bone loss seen in area of #23- 26.e

A=Assessment

• problem list, or diagnoses. It works well to number these and make corresponding remarks in the '"'Plan'"' section.

Example:

1. Missing #7
2. Localized periodontal disease #23-26
3. #31 restoration close to pulp, poss. pulpal pathology
4. Max. premolars non-carious

P=Plan

• what you plan to do, and what you did today. Try to address each problem.
  • Patient disposition pleasant, agitated, friendly, etc.
  • Interval of recall 3 mo recall
  • Planned treatment for next visits Ex, perio main, 4BW
  • Referrals to other departments OS for evaluation of lesion R lateral border of the tongue
  • Areas that require re-evaluation check 2 M incipiency on next BW
  • All services rendered

    Include instrumentation, methods and materials used. Such as 4 vertical BW exposed, scaled/Root planned maxillary molars with Gr11/12, 13/14, scaled all other teeth with Un 13/14,204S, rubber cup polish with extra fine paste, dried all teeth and placed 5% Fluoride Varnish. Gave post treatment instructions.

  • Local and/or topical anesthesia used

    Type, method of delivery, amount and with or without epinephrine (amount of epi). Obtain signature of student (if other than yourself) or faculty who administered the anesthetic.

  • Any recommendations made by student or faculty

    Homecare, dietary counseling, habit modifications, referrals, etc.

    Include anticipated outcome of your recommendations and the mechanism of measurement.

  • Note that radiographs were evaluated by dental faculty when applicable

Example:

Today: Examination, full mouth series radiographs taken and read. Alg. imps for study

1. Explained to patient that there are several different ways to restore missing #7. Will review study casts and discuss options and fees at next appointment.
2. Expl'd to patient need for more frequent prophy, and the use of floss. 
3. Will eval pulpal status of #31 with endodontic consult
4. Recommend no treatment for occlusal fissures of premolars RTC (Return to clinic) Discuss treatment plan options. Chart entries for initial visits, periodic evaluations, and emergency visits are well understood and legally complete if written in the form of a SOAP note. Subsequent treatment visits do not need such detail.

ALWAYS HAVE ALL FACULTY AND STUDENTS THAT WORKED WITH THE PATIENT SWIPE IN AXIUM.

ALWAYS DOCUMENT IF PATIENT ARRIVED LATE, CANCELLED OR DID NOT SHOW FOR AN APPOINTMENT AND ANY PHONE CALLS YOU MADE TO THEM REGARDING THE APPOINTMENT.