02a perio disease
TRANSCRIPT
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Periodontal Charting and Documentation
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Periodontal Forms
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Electronic Perio Chart
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Pocket Depths! 6 sites per tooth
! 3 mm or less in blue
! 4 mm or greater in red
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Bleeding Documentati!Bleeding on probing
- circle number
!Describe - delayed bleeding on probing
- mild, moderate, heavy bleedin
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Bleeding Documentati
moderate generalized bleeding on probing
heavy bleeding posterior molars
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Attachment Los! 6 sites per tooth
!CEJ to base of pocket
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Attachment Loss
Documentation 6 sites per tooth
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RecessionDocumentation
1
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Furcation Documentation
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Furcation
Documentation
1 = slight depression
2 = roof and a catch
3 = through and through
4 = furca is supragingival
F3F3
F3F3
Premolar mand molar max molar
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Furcation Documentation
F3
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What Classification?
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Mobility
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Mobility Documentation
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Gingival Description
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Gingival Contours
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Gingival Descriptions Healthy 3 Cs
Color
- coral pink
Contour
- knife like
- embrasure filled
Consistency
- firm and stippled
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Gingival DescriptiColor
- red - erythema
Contour
- blunted, cratered - rolled
Consistency
- edema
- smooth and shiny - fibrotic
Location - generalized or localized
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SOAP DOCUMENTATION!S - SUBJECTIVE
!O - OBJECTIVE
!A - ASSESSMENT
!P - PLAN AND PROCEDURES
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SUBJECTIVEReason patient is present for treatment - Recall or Perio
Maintenance or Root Planing
Statements from the patient - Patient self-care
Changes in Medical History - Pre-Medication dosage taken
Chief complaint or concern
Patient Identification Verification PIV
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OBJECTIVE! Clinical observations and conditions
! Blood Pressure, pulse, ASA classification
! Summary and/or specifics from the periodontalassessment and the Head/Neck examination
! Areas of clinical concern
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Comments on clinical concerns and the patient
s self-care status
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ASSESSMENT! PERIODONTAL CLASSIFICATION
! CARIES STATUS - Active, At Risk, Controlled
! DEPOSIT CLASSIFICATION - calculus
! ETIOLOGY - - Plaque, Med systemic, Smoking,Self-Care, Patient Compliance
! PROGNOSIS - for a specific tooth or thedentition
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PROCEDURES AND PLAN! Specific procedures performed at the appointment - Root
Planing with anesthesia, Recall, Radiographs, Fluorideapplications, Consults with specialists, Documentation ofSelf-Care discussion with patient goals, Dispensing of Rx
samples with directions
! Plan for the next appointment - return to Clinic for RP,3MRC, Reevaluation, Operative