DENTAL CHARTING

Dental Records provide descriptions & assessmentsof the patient’s 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 examinationand every subsequent visit.

Uses of these dental records include:•DIAGNOSIS•CONSULTATION•BILLING•FORSENSIC DENTISTRY IDENTIFICATION

The Oral Examination used to record the dental historyConsists 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

MirrorExplorerAir Water syringePeriodontal probeBlack ink penRed and Blue pencilCharting form or computer program2 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 managementsoftware 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 ABBREVIATIONAmalgam 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

Facial F

Fluoride fl2

Full Crown FC

TERM ABBREVIATION

Full veneer Crown FVC

Three quarter Crown ¾ 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

COMMON DENTAL ABBREVIATIONS

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 CHARTING KEY

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