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PERIDONTAL RECORD KEEPING. 1. Consensus Reports from the 1996 World Workshop in Periodontics, published in a special supplement to JADA, Sept 1998

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periodontal record keeping
Consensus Reports from the 1996 World Workshop in Periodontics, published in a special supplement to JADA, Sept 1998

Providing the most appropriate periodontal treatments requires making an accurate diagnosis, assessing risk, performing optimum treatment, and monitoring the patient.

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KEY COMPONENTS OF

PERIODONTAL RECORD KEEPING

1. Comprehensive Health History

2. Comprehensive Charting and documentation

3. Radiographs

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Comprehensive exam should include an evaluation of soft tissue, bleeding, and exudate on probing, probing depths, gingival recession, mobility, furcation involvement, occlusal analysis, and TMD assessment.

JADA article April 2000

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Evaluation of a complete series of diagnostic quality periapical and bite wing radiographs is necessary for diagnosis and treatment planning.

JADA article April 2000

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Full Mouth Intraoral Radiographic Examination

(FMX)

A set of intraoral radiographs consisting of 14 to 22 periapial and posterior bite wing films intended to display the crown and roots of all teeth, periapical areas and alveolar bone crest.

FDA Guidelines

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Feb 2001 JADA: ADA Council on

Scientific Affairs

The FDA guidelines…. are not meant to be considered as practice standards.

The guidelines, published in 1989, direct dentists to exercise professional judgement when prescribing diagnostic radiographs for dental patients.

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Fall 1996 Journal of the MA Dental Society

OHI should be provided at each appointment during initial therapy. The patient’s progress should be evaluated, and the plaque control program should be modified to fit the needs of individual patients.

A reevaluation interval is necessary to allow time for the tissues to heal and respond to initial therapy…. Usually 4 to 6 weeks.

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Fall 1996 Journal of the MA Dental Society

(Continued)

Clinical examination at reevaluation appointments should be similar to that of the initial examination.

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American Academy of Periodontics

Classifications:

CPT 1 Gingivitis

2 Slight Periodontitis

3 Medium Periodontitis

4 Advanced Periodontitis

OR

Slight - Moderate - Severe (Advanced)

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PSR

Periodontal Screening and Recording

1. Good System if used appropriately and

according to the guidelines.

2. Dentists can not redefine the parameters.

3. Recommended by the ADA and American

Academy of Periodontology.

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PSR

Code * -- Denotes clinical abnormalities including but not limited to:

a. furcation invasion

b. mobility

c. mucogingival problems

d. recession extending to the colored area of

the probe 3.5 mm or greater.)

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PSR

Code 0 -- Appropriate preventative care

Code 1 -- Oral hygiene instruction and

appropriate therapy, including

subgingival plaque removal.

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PSR

Code 2 -- OHI and appropriate therapy, including subgingival plaque removal, plus removal of calculus and correction of plaque-retentive margins of restorations.

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PSR

Code 3 -- A comprehensive periodontal examination and charting of the affected sextant is necessary to determine an appropriate treatment plan. This examination and documentation should include but not be limited to identification of probing depths, mobility, gingival recession, mucogingival problems, and furcation invasions as well as appropriate radiographs.

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PSR

Code 3 (continued)

If two or more sextants score code 3, a comprehensive full mouth examination and charting is indicated. Should therapy be indicated and performed, a comprehensive examination is necessary to assess the results of therapy and need for further treatment.

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PSR

Code 4 -- A comprehensive full mouth periodontal examination and charting is necessary to determine an appropriate treatment plan. This examination and documentation should include but not be limited to identification of probing depths, mobility, gingival recession, mucogingival problems, and furcation invasions as well as appropriate radiographs.

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PSR

Code * -- If an abnormality exists in the presence of codes 0, 1, and 2, specific notation and/or treatment for that condition is warranted. If an abnormality exists in the presence of code 3 or 4, a comprehensive periodontal examination and charting is necessary to determine an appropriate treatment plan.

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Chart/define Recommendations to Patients

What Did You Discuss with the Patient

On Follow-up Visit, Did They Comply?

Frequency of Recall Visits (4 months - 6 Months)

Reevaluate Phase I Treatment

Patient Should be Recharted

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WHEN TO REFER

General Dentists should refer patients who are on 2, 3, or 4 month periodontal recalls who continue to show signs of periodontitis with deep pocketing, bleeding or probing, purulence, or any signs of disease progression for specialty periodontal therapy.

JADA article April 2000

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CONCLUSION

If it is not in the chart,

it didn’t happen!!

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