Periodontal Diagnosis Form

Transcription

1 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 to assessment@periodontal-net.com, 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 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.

2 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.

3 Ticket number: Periodontal Diagnosis Form Name of Patient: A Jones Anvon 2005 Date of Birth: day/month/year Gender/Sex: Male enter M or F Name of Dentist: A Singhi 20 Uxbridge Rd Postal Address: Southhall Postcode: Country: address: UK Singdent@btinternet.com 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 No Tooth loosening Which teeth? 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

4 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 Past illnesses Allergies Current medication None None N/A 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: Nail biting: Other abnormal activities: Yes No No

5 Dental history: Date last attended Regular/irregular attendee: Previous orthodontic treatment: Previous periodontal treatment (type): No No Oral hygiene activity: Toothbrushing: Interproximal cleaning: Other: Extra-oral examination: amount of times per day or week & method used 2x/d 1x/d M Wash 1x/w Swellings/Lumps Ulcers Draining sinuses/pus: Rashes: White patches: Red patches: Discoloration of soft tissues: Dry mouth/salivary flow: Intra-oral examination: Lips Buccal mucosa Tongue Floor of the mouth Hard palate Not usually closed: Dryness place 'x' box, and list abnormalities Salivary glands & orifices Pharynx white patch Tonsils Alveolar mucosa Saliva: dry mouth red and swollen red buccally upper anteriors mouth dry with poor

6 Soft palate Other: salivary flow

7 Calculus: Distribution: generalised/localised Interproximal/marginal Lower anteriors lingual 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:

8 Plaque: (annotate as necessary) Distribution: generalised/localised Interproximal/marginal Probing depths: Plaque score: 20% Distribution Localised Generalised Gingitivitis score: Generalised - range: Localised: Occlusion: Types I Class i delete as No Overjet/overbite appropriate None Other Class ii Class iii Distemata Where? Radiographs: Attached: No Being sent: Yes Observations: Bone loss arounr upper molars

9 Upper Teeth Plaque Buccal Lingual Lower Teeth Plaque Buccal Lingual

10 Upper Teeth Periodontal Pockets Buccal Lingual Lower Teeth Periodontal Pockets Buccal Lingual

11 Upper Teeth - Bleeding on Probing Buccal Lingual Lower Teeth Bleeding on Probing Buccal Lingual

12 Upper Teeth Mobility & Furcations Mobility Furcation Lower Teeth Mobility & Furcations Mobility Furcation

13 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