DENTAL CHARTING

Charting is used to record a patient’s dentition quickly and accurately

Charting can be broken down into the following styles:

― Palmer notation (tooth charting)

― International Dental Federation (FDI) notation (tooth charting)

― Basic Periodontal Exam (BPE) (Periodontal charting)

― Full Periodontal Charting

With tooth charting a two grid system is used (forensic notation) which separates the current dental status from any treatment required (see handout)

Palmer Notation

This is based on the division of the dentition into four quadrants when looking at the patient from the front:

Upper right and left and lower right and left. (UR, UL, LR, LL)

We use letters to represent the deciduous dentition and numbers to represent the permanent dentition

The Palmer notation is used by the majority of practitioners in the UK

International Dental Federation (FDI)This is a two digit system, it replaces the quadrant symbol with a number

SO for the permanent dentition transfers to

UR=Quadrant 1UL=Quadrant 2LL=Quadrant 3LR=Quadrant 4

And the deciduous dentition transfers to

UR=Quadrant 5UL=Quadrant 6LL=Quadrant 7LR=Quadrant 8

All teeth including the deciduous dentition are numbered

Basic Periodontal Examination (BPE)

Periodontal disease is the commonest dental disease found in adult patients, the system that is used to record the health of the periodontal tissue is the basic periodontal examination and is done in sextants.

Specially designed periodontal probes are used to record the presence and depth of any periodontal pockets discovered in each sextant

The following coding system is used

CODE 0- Healthy gingival tissues with no bleeding on probing

CODE 1- Pocket no more than 3.5mm, bleeding on probing, no calculus or plaque retention factor present

CODE 2- Pocket no more than 3.5mm but plaque retention factor detected

CODE 3- Pocket present up to 5.5mm deep

CODE 4- Pocket present deeper than 5.5mm

CODE *- Gingival recession or furcation involvement present

Periodontal Charting

If a code greater than 3 is recorded during the BPE it indicates a serious periodontal problem, therefore a full pocket depth record will be made of each tooth in that sextant, in addition sites of plaque and tooth mobility will also be recorded.

This will identify specific problem areas so that relevant treatment can be given.

Data Protection

The Data Protection Act 1998 requires anyone who handles personal information to comply with a number of important principles.

These principles ensure that personal information is………………….

Fairly and lawfully processed

Processed for limited purposes

Adequate, relevant and not excessive

Accurate and up to date

Not kept for longer than is necessary

Processed in line with rights

Secure

Not transferred to other countries without adequate protection

Guidelines and legislation relating to patient records and confidentiality

Under NHS regulations, dentists are expected to keep adequate records.

These records are legal documents and are important to ensure proper treatment planning.

Patient records are to be kept for at least 11 years after completion of treatment or to the age of 25 in the case of children’s records.

Methods of maintaining confidentiality

Patients must not be discussed in front of other patients

Privacy must be maintained when discussing any personal matters with patients

Attendance at the practice is private and cannot be revealed to other patients, employers or schools

All written communications with patients should be sent in sealed envelopes

Dental records must be kept for the correct length of time by the practice