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PERIDONTAL RECORD KEEPING

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

Mercy
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PERIDONTAL RECORD KEEPING

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  1. PERIDONTALRECORD KEEPING 1

  2. 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. PERIODONTALRECORD KEEPING 2

  3. KEY COMPONENTS OF PERIODONTAL RECORD KEEPING 1. Comprehensive Health History 2. Comprehensive Charting and documentation 3. Radiographs PERIODONTAL RECORD KEEPING 3

  4. HEALTH HISTORY ARE YOU:  ALIVE  DEAD PERIODONTAL RECORD KEEPING 4

  5. PERIODONTAL RECORD KEEPING 5

  6. PERIODONTAL RECORD KEEPING 6

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  8. PERIODONTAL RECORD KEEPING 8

  9. 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 PERIODONTAL RECORD KEEPING 9

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  13. Evaluation of a complete series of diagnostic quality periapical and bite wing radiographs is necessary for diagnosis and treatment planning. JADA article April 2000 PERIODONTAL RECORD KEEPING 13

  14. PERIODONTAL RECORD KEEPING 14

  15. 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 PERIODONTAL RECORD KEEPING 15

  16. 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. PERIODONTAL RECORD KEEPING 16

  17. 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. PERIODONTAL RECORD KEEPING 17

  18. Fall 1996 Journal of the MA Dental Society (Continued) Clinical examination at reevaluation appointments should be similar to that of the initial examination. PERIODONTAL RECORD KEEPING 18

  19. American Academy of Periodontics Classifications: CPT 1 Gingivitis 2 Slight Periodontitis 3 Medium Periodontitis 4 Advanced Periodontitis OR Slight - Moderate - Severe (Advanced) PERIODONTALRECORD KEEPING 19

  20. 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. PERIODONTAL RECORD KEEPING 20

  21. 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.) PERIODONTAL RECORD KEEPING 21

  22. PSR Code 0 -- Appropriate preventative care Code 1 -- Oral hygiene instruction and appropriate therapy, including subgingival plaque removal. PERIODONTAL RECORD KEEPING 22

  23. PSR Code 2 -- OHI and appropriate therapy, including subgingival plaque removal, plus removal of calculus and correction of plaque-retentive margins of restorations. PERIODONTAL RECORD KEEPING 23

  24. 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. PERIODONTAL RECORD KEEPING 24

  25. 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. PERIODONTAL RECORD KEEPING 25

  26. 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. PERIODONTAL RECORD KEEPING 26

  27. 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. PERIODONTAL RECORD KEEPING 27

  28. 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 PERIODONTALRECORD KEEPING 28

  29. 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 PERIODONTAL RECORD KEEPING 29

  30. CONCLUSION If it is not in the chart, it didn’t happen!! PERIODONTAL RECORD KEEPING 30

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