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Recording the Periodontal Examination: A Program for Dental Assistants

On 2011年12月28日 by Dr. Paulo Camargo Resource:ucla Hits:

Introducd:Recording the Periodontal Examination: A Program for Dental Assistants

 

All patients need and deserve to have a complete periodontal examination and to have a complete record of their status recorded in their dental chart.

This is the only way to ensure that advanced periodontal disease is detected; it provides a way to identify beginning changes in periodontal status that will benefit patients by initiating early and simple treatment.

Accuracy is essential. You as the dental professional, are responsible for setting up the appropriate instruments and chart for recording all the data.

You play a central role in periodontal health maintenance for your patients. Accurate periodontal information recorded in the chart, will give your office the security that you have provided all your patients the best available dental care.

It will also add to the productivity of your office by increasing the scope of periodontal treatment offered to your patients.







To begin the periodontal examination, it is important that the patient complete a health questionnaire so that the doctor can check to see if any special precautions are to be considered before beginning the periodontal examination.

During periodontal probing, bacteria from the gingival surfaces enter the blood stream and can cause serious problems to damaged or artificial heart valves.

Patients with a history of heart valve defects or with artificial heart valves will need to have their physician contacted to see if the patient requires antibiotic coverage prior to the periodontal examination.

Other conditions such as, artificial joints and bleeding disorders may also need special precautions prior to periodontal probing.

It is a good idea to place an alert label on the outside of the patient's chart to warn of these problems, keeping in mind to maintain patient confidentiality.
Prior to the periodontal evaluation a general examination of the oral cavity and its mucosal tissues is done.
When the periodontal examination is completed, a general dental exam involving plaque score, caries, restorations and occlusion is done to thoroughly assess the patient's dental needs.


The periodontal examination involves 6 cycles of data collecting going systematically around the dentition.
The 6 cycles include:
  1. Missing Teeth & Tooth Mobility
  2. Pocket Depths
  3. Furcations
  4. Mucogingival Problems
  5. Assessing Contact Points
  6. Radiographic Evaluation
You will be able to complete this procedure in 9 minutes for most patients.
There are many ways to carry out this process. We will describe a method using a hand held periodontal probe and the data will be recorded on the UCLA periodontal examination form.
An examination set of instruments will be required. The UCLA examination kit consists of:
  • a periodontal probe with markings color coded at 3 millimeters, 6 millimeters, 9 millimeters and 12 millimeters.
  • a dental explorer for evaluation of furcation involvement
  • a dental explorer for evaluation of furcation involvement
  • a mouth mirror
  • a pair of cotton pliers
  • gauze to dry the gingival tissues
  • dental floss is also included to assess for open contacts


A clipboard will be helpful to stabilize the chart during the charting procedure. All data should be recorded with a pen.
The UCLA examination form has all the teeth outlined and allows for five different recordings of pocket depth at five different dates.
Mobility is scored for each tooth in the appropriate box.
The patient's name, number and date is placed on the lower portion
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