DENTAL CHARTING Dental Records provide descriptions & assessments

DENTAL CHARTING Dental Records provide descriptions & assessments

DENTAL CHARTING Dental Records provide descriptions & assessments of the patients medical and dental status Medical History Forms provide the medical information Dental charts provide the oral conditions, assessment and prognosis for dental treatment Dental Records are conducted to record the Dental conditions present in the oral cavity and treatment needed. It is part of the legal record Dental records are preformed at the initial examination and every subsequent visit.

Uses of these dental records include: DIAGNOSIS CONSULTATION BILLING FORSENSIC DENTISTRY IDENTIFICATION The Oral Examination used to record the dental history Consists of the following: VISUAL EXAMINATION PALPATION CLINICAL EXTRAORAL EXAMINATION Face, neck Lymph Nodes TMJ

Lips CLINICAL INTRAORAL EXAMINATION Soft Tissue Exam Oral mucosa and frenums Tongue Palate Uvula Floor of mouth Hard Tissue Exam of teeth Periodontal Charting (next semester) Perio pocket readings Gum levels RADIOGRAPHS INTRAORAL IMAGING

PHOTOS Armamentarium (set up) for oral examination for charting Mirror Explorer Air Water syringe Periodontal probe Black ink pen Red and Blue pencil Charting form or computer program 2 x 2 gauze There are several formats or styles of dental charts: ANATOMICAL - teeth are outlined on their crown, root, occlusal

mesial, distal, facial and lingual GEOMETRIC geometrical shapes like circles, triangular are representative of the tooth and surfaces NUMERICAL uses letters, symbols and codes to describe conditions AUTOMATIC/COMPUTERIZE Usually part of the dental office management software using a wand, voice activation or computer keyboard to chart conditions Anatomical Chart completed Example of a geometric chart system COMPUTERIZED CHARTING

THE DENTAL CHART USES THE FOLLOWING FOR NOTATIONS: Symbols Figure 28-11 in MDA Color Red needed; blue done Numbers Abbreviations Next 4 slides Mobility 0, 1, 2, 3 or I, II, III Furcation I, II, III the lost of attachment between bifurcated or trifurcated roots COMMON DENTAL ABBREVIATIONS TERM

ABBREVIATION Amalgam Am, Amal Bonding Bd Bridge Br, Bdg

Fixed Bridge F Bdg Removable Bridge R Bdg Buccal B Calcium Hydroxide

CaOH Composite Comp Denture DTR DMF Decay, missing, filled index

Full upper denture FUDTR Full lower denture FLDTR Diagnosis Diag Distal

D Emergency Treatment Emer RX Examination Exam Extraction Ext


TERM ABBREVIATION Full veneer Crown FVC Three quarter Crown Cr Gold

G Gold Inlay GI Home Care HC Immediate Denture Immed Dtr

Incisal I Labial LA Lingual L Mandibular

Mand Maxillary Max Meisal M TERM ABBREVIATION

Nitrous Oxide N2O Occlusal O Oral Diagnosis Treatment Plan ODTP Oral Hygiene

OH Pontic Pont Porcelain fused to metal PFM Porcelain Jacket PJ

Post operative POT Prophylaxis Prophy Proximal Prox Root Canal Treatment

RCT Study Model SM Sealant SLT Stainless steel crown SSC

TERM ABBREVIATION Temporary Temp Treatment Tr X-ray

x/r Full mouth series FMX Bitewing x-rays BW Within normal limits WNL

Another anatomical chart completed with additional information Review of classifications of cavities Caries chart symbols Oral Conditions Charting Symbols Additional Charting Symbols of oral conditions More charting Symbols of oral conditions PRACTICE CHARTING


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