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1、PERIDONTALRECORD KEEPING,1,PERIODONTALRECORD 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 tr
2、eatment, and monitoring the patient.,2,PERIODONTAL RECORD KEEPING,KEY COMPONENTS OF PERIODONTAL RECORD KEEPING 1. Comprehensive Health History 2. Comprehensive Charting and documentation 3. Radiographs,3,PERIODONTAL RECORD KEEPING,HEALTH HISTORY ARE YOU: ALIVE DEAD,4,PERIODONTAL RECORD KEEPING,5,PER
3、IODONTAL RECORD KEEPING,6,PERIODONTAL RECORD KEEPING,7,PERIODONTAL RECORD KEEPING,8,PERIODONTAL RECORD KEEPING,Comprehensive exam should include an evaluation of soft tissue, bleeding, and exudate on probing, probing depths, gingival recession, mobility, furcation involvement, occlusal analysis, and
4、 TMD assessment. JADA article April 2000,9,PERIODONTAL RECORD KEEPING,10,PERIODONTAL RECORD KEEPING,11,PERIODONTAL RECORD KEEPING,12,PERIODONTAL RECORD KEEPING,Evaluation of a complete series of diagnostic quality periapical and bite wing radiographs is necessary for diagnosis and treatment planning
5、. JADA article April 2000,13,PERIODONTAL RECORD KEEPING,14,PERIODONTAL RECORD KEEPING,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 are
6、as and alveolar bone crest. FDA Guidelines,15,PERIODONTAL RECORD KEEPING,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 d
7、iagnostic radiographs for dental patients.,16,PERIODONTAL RECORD KEEPING,Fall 1996 Journal of the MA Dental Society OHI should be provided at each appointment during initial therapy. The patients progress should be evaluated, and the plaque control program should be modified to fit the needs of indi
8、vidual patients. A reevaluation interval is necessary to allow time for the tissues to heal and respond to initial therapy. Usually 4 to 6 weeks.,17,PERIODONTAL RECORD KEEPING,Fall 1996 Journal of the MA Dental Society (Continued) Clinical examination at reevaluation appointments should be similar t
9、o that of the initial examination.,18,PERIODONTALRECORD KEEPING,American Academy of Periodontics Classifications: CPT 1Gingivitis 2Slight Periodontitis 3Medium Periodontitis 4Advanced Periodontitis OR Slight - Moderate - Severe (Advanced),19,PERIODONTAL RECORD KEEPING,PSR Periodontal Screening and R
10、ecording 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.,20,PERIODONTAL RECORD KEEPING,PSR Code * - Denotes clinical abnormalities including but not limited to: a. fur
11、cation invasion b. mobility c. mucogingival problems d. recession extending to the colored area of the probe 3.5 mm or greater.),21,PERIODONTAL RECORD KEEPING,PSR Code 0 - Appropriate preventative care Code 1 - Oral hygiene instruction and appropriate therapy, including subgingival plaque removal.,2
12、2,PERIODONTAL RECORD KEEPING,PSR Code 2 - OHI and appropriate therapy, including subgingival plaque removal, plus removal of calculus and correction of plaque-retentive margins of restorations.,23,PERIODONTAL RECORD KEEPING,PSR Code 3 - A comprehensive periodontal examination and charting of the aff
13、ected 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.,24,PERIODO
14、NTAL RECORD KEEPING,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.,25,P
15、ERIODONTAL RECORD KEEPING,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, muco
16、gingival problems, and furcation invasions as well as appropriate radiographs.,26,PERIODONTAL RECORD KEEPING,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.,27,PERIODONTALRECORD KEEPING,Chart/define Re
