periodontal diagnosis form
TRANSCRIPT
Periodontal Diagnosis Form
Notes on the use of the form
1. The form that follows is a comprehensive analysis of your patient, taking into account many factors that might contribute to oral conditions.
2. Many of the questions asked may not in fact apply to your
patient, and if this is the case, please leave blank the questions that you cannot answer, or that do not apply, or preferably annotate them as n/a (ie not applicable).
3. It is important to give as much information as possible so that
we can give you the best possible advice on how best to manage your patient's problem.
4. It would be extremely useful if you could send us
photographs and/or x-ray images of your patient. These can be forwarded as an attachment to an email to [email protected], preferably in jpg, gif or bmp format. Alternatively, these could be sent to us by surface mail but you need to contact us to make the necessary arrangements in advance.
5. If you are having any difficulty in filling out the form, or you
are unsure as to how you should fill in any aspect of it, please do contact us by e-mail for support.
6. Always include your ticket number in any communication
(the number is issued when the diagnosis form is ordered on-line).
Instructions for filling in the Clinical Charts
In order to make the filling in of the form is simple and quick as possible, the preliminary information is listed was a box next to each item. Simply clicking on each box will activate a positive response, and the word "yes" will appear in the box. If you have made a mistake, simply click on the spot again, and it will disappear.
In providing clinical information, and more information that you give to us, the more accurate diagnosis we can make, and a better treatment plan we can draw up for your patient. Please give us as much information from the following clinical charts as you possibly can. You can use the CPITN (also known as the WHO, BPE, BPI, in different countries) assessment of treatment needs grid below. This is a simple assessment grid, designed to give an overview of the presence of periodontal diseases and the need treatment. However, this is only a very simple assessment, and it is preferable to do the full charting is that appears on the following pages. While it is possible to make a diagnosis based on the basic periodontal assessment only, (supplemented with some basic information about the amount of plaque present, and bleeding on probing) it is preferable and more accurate is a detailed clinical assessment charts that follow in preference are to the basic assessment only. You may use in the combination of the basic and detailed assessment grids for each clinical variable.
After the basic periodontal assessment, is a series of four pages containing a graphical representation of the teeth, and grids for you to fill in with the clinical variables. For each of the clinical variables of plaque, gingivitis, and periodontal pocketing you will be presented with the picture illustrating the upper and lower teeth. Below each picture is a grid into which you can place up to 3 readings per tooth. In the case of plaque and gingivitis, enter 1 on those surfaces which are positive for these variables, and a zero (or simply leave these spaces blank) where there is an absence. In the case of periodontal pocketing, mark the depth reading in millimetres in each of space. If you wish you may leave a blank space at those sites which have insignificant readings.(ie less than 3mm) to save clinical time. In the final page, mobility and furcation involvements are to be annotated, and these should be annotated as 1, 2, 3 to represent Class I, II, III respectively for these clinical variables. If you are unfamiliar with doing periodontal chartings, please do not hesitate to contact us for help and advice on how to fill them in.
Ticket number:
Periodontal Diagnosis Form
Anvon © 2005
Name of Patient: A Jones
Date of Birth: 25 03 52 day/month/year
Gender/Sex: Male enter M or F
Name of Dentist: A Singhi
Postal Address:
20 Uxbridge Rd
Southhall
Postcode:
Country: UK
Email address: [email protected]
Local Symptoms:
No Pain Where? When?
Yes Difficulties in chewing Why?
Yes Swelling/infection/pus/discharge No Bad taste/breath
Yes Bleeding gums
No Food impaction Which teeth?
No Tooth loosening Which teeth?
No Tooth migration
No Aesthetic problems:
History of main complaint/other relevant details of Presenting complaint:
2 years of swellings leading to toothloss, and now further teeth are affected and may be lost
Family History of Periodontal problems:
No Early tooth loss
Yes Bleeding of gums
No Recurrent abcesses
No Bleeding gums
Which members of the family?
No Father Yes Mother No Siblings No Other
Medical history:
Current illnesses None
Past illnesses None
Allergies N/A
Current medication N/A
Social history:
Smoker No Pipe/cigarettes/other Per day:
Alcohol No Number of units Per week
Other drugs: (chewed/sucked/inhaled)
Tooth grinding/clenching: Yes
Nail biting: No
Other abnormal activities: No
Dental history:
Date last attended
Regular/irregular attendee: No
Previous orthodontic treatment: No
Previous periodontal treatment (type):
Oral hygiene activity:
amount of times per day or week & method used
Toothbrushing: 2x/d
Interproximal cleaning: 1x/d
Other: M Wash 1x/w
Extra-oral examination:
Swellings/Lumps
Ulcers
Draining sinuses/pus:
Rashes:
White patches:
Red patches:
Discoloration of soft tissues:
Dry mouth/salivary flow:
Intra-oral examination:
place 'x' box, and list abnormalities
Lips Not usually closed: Dryness
Salivary glands & orifices
Buccal mucosa
Pharynx white patch
Tongue Tonsils red and swollen
Floor of the mouth
Alveolar mucosa red buccally upper anteriors
Hard palate Saliva: dry mouth mouth dry with poor
salivary flow
Soft palate Other:
Calculus:
Distribution: generalised/localised
Lower anteriors lingual
Interproximal/marginal
Gingivae:
Appearance Consistency
Yes Red Yes Thin
Yes Bleeding No Thick
No Swollen No Wide zone of attachment
No Overgrown Yes Thin zone of attachment
Additional Notes: susceptible to recession
Recession:
3-5 Generalised - range (mm):
Localised: (annotate teeth and amount below)
Abrasion:
Generalised - range (mm):
2-3 Localised: (annotate teeth and amount below)
4,3 3,4
3
BPE score:
4 2 4
3 1 2
Plaque: (annotate as necessary)
Distribution: generalised/localised
Plaque score: 20%
Interproximal/marginal
Distribution Localised
Generalised
Gingitivitis score:
Probing depths:
Generalised - range:
Localised:
Occlusion:
Types I Class i
Class ii
Class iii
No Overjet/overbite delete as appropriate
Distemata Where ?
None Other
Radiographs:
Attached: No
Being sent: Yes
Observations: Bone loss arounr upper molars
Upper Teeth – Plaque
Buccal 101 110 011 111 100 001 001 101 000 110 101 100 110 001 101 111
Lingual 111 111 111 111 111 111 111 111 111 111 101 101 110 101 111 111
Lower Teeth – Plaque
Buccal 000 000 000 000 101 100 000 001 100 001 101 000 000 001 101 101
Lingual 010 110 110 010 111 111 110 000 000 011 111 111 010 010 010 111
Upper Teeth – Periodontal Pockets
Buccal 457 653 445 354 335 312 212 212 212 211 213 513 313 625 636 744
Lingual 443 334 333 322 234 422 433 222 212 212 212 421 435 735 634 644
Lower Teeth – Periodontal Pockets
Buccal 333 323 543 322 222 212 212 212 212 214 424 422 355 543 323 334
Lingual 433 323 522 423 333 212 211 212 111 214 423 534 445 423 443 345
Upper Teeth - Bleeding on Probing
Buccal 223 323 333 322 222 101 100 000 000 000 000 202 222 313 313 211
Lingual 333 333 333 332 333 201 101 111 111 111 102 222 230 002 103 322
Lower Teeth – Bleeding on Probing
Buccal 333 323 323 212 222 210 101 000 000 110 111 121 122 103 021 111
Lingual 333 333 333 323 322 222 211 111 101 000 112 211 111 103 333 322
Upper Teeth – Mobility & Furcations
Mobility 1 1 2 3
Furcation 2 1 3 2
Lower Teeth – Mobility & Furcations
Mobility 2 2 2 3
Furcation 2 2 2 3 2 2
Additional information
Please add any additional information you consider may assist in the diagnosis. The patient wants teeth straigtened after perio treatment. Initials of referring practitioner: 1005 Note this form is copyright Anvon 2006