Dental and Periodontal Charting

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Dental and Periodontal Charting

Definition

Dental and periodontal charting provide a graphic description of the conditions in a patient's mouth, including caries (i.e., decay), restorations, missing or malposed teeth, clinical attachment levels, furcation (root) involvement, mobility, pocket depths, bleeding sites, and other deviations from normal. Other conditions that may be charted include erosion, abrasion, developmental anomalies and use of prostheses.

Purpose

Thorough charting of both visual and radiographic findings allows dental practitioners to collate information needed to assess the patient's level of dental and periodontal health or disease. Charting should be updated with each visit to follow the patient's progress with home care, monitor disease progression, and to track completed dental procedures.

Description

Dental charting is part of both initial and periodic dental examinations, and is included in the cost of care. Exams are normally covered by dental insurance.

Charting begins with tooth naming and numbering. The maxillary, or upper arch, and the mandibular, or lower arch, each contain 16 teeth in a full adult dentition. Teeth are paired right and left by size, shape, and function. Beginning at the midline, each arch includes two central incisors side by side. Continuing outward to right and left are pairs of lateral incisors, canines (cuspids), first premolars (first bicuspids), second premolars (second cuspids), first molars, second molars, and third molars (wisdom teeth).

In a primary, or deciduous, dentition there are no premolars or third molars. From the midline, pairs are central incisors, lateral incisors, canines, first molars, and second molars. As the adult dentition erupts, first and second primary molars are replaced by adult premolars. Adult molars erupt behind the primary molars in space created by the lengthening maxilla and mandible.

The widely used universal system, adopted in 1974, assigns the permanent teeth numbers from 1 to 32. Primary teeth are assigned letters from a to t, regardless of their position in the mouth. In the permanent dentition, 1 is the third molar of the maxillary (upper jaw) right quadrant. Numbering continues sequentially around the upper arch to 16, the third molar of the maxillary left quadrant. Number 17 is the third molar of the mandibular (lower jaw) left quadrant, and numbering again continues sequentially around the lower arch to 32, the third molar of the mandibular right quadrant. Teeth may drift due to factors including other missing teeth, malocclusion, malpositioning, or congenital abnormalities.

Lettering of primary teeth is similar. An a is assigned to the second molar of the maxillary right quadrant, and lettering continues sequentially around the upper arch to j, the second molar of the maxillary left quadrant. The letter k is the second molar of the mandibular left quadrant, and lettering continues sequentially around the lower arch to t, the second molar of the mandibular right quadrant.

An older system, sometimes used by orthodontists, is Palmer's Notation. In that system, teeth are numbered 1 through 8 or lettered a through e by quadrant, beginning at the midline. Permanent maxillary canines, for instance, would be referred to as "upper right 3" and "upper left 3" instead of 6 and 11. Primary mandibular first molars would be referred to as "lower right d" and "lower left d" instead of s and l. When written down, the numbers or letters are enclosed in half boxes to denote upper or lower, left or right.

A dental chart can be anatomically correct, showing several views of each tooth, or it can be stylized, showing two rows of 16 circles each. Small boxes are usually placed above and below the rows to allow coded notations for each tooth. Each circle represents a tooth, and is divided to show a smaller round center and four outside surfaces. The round center represents the occlusal (i.e., biting surface) of posterior teeth, or the incisal (i.e., biting edge) of anterior teeth. The four surfaces surrounding the center, noted clockwise from the top, are buccal (i.e., outside surfaces of posterior teeth) or facial (i.e., outside surfaces of anterior teeth); mesial (i.e., proximal surface of a tooth closest to the midline); lingual (i.e., inside surface of a tooth); and distal (i.e., proximal surface of a tooth farthest from the midline).

For the purposes of communication, tooth surfaces are referred to by their first initial. For instance, a restoration on the mandibular left first molar that covers the mesial and occlusal surfaces would be called an MO on 19. A carious lesion that extends from mesial to facial to incisal surface of the maxillary right lateral incisor would be an MFI on 7.

Both restorations and lesions can also be classified according to location. The G.V. Black system of classification is as follows:

Class I: Pits and fissures of the occlusal surfaces of posterior teeth, and lingual surfaces of anterior teeth.
Class II: Proximal surfaces of posterior teeth.
Class III: Proximal surfaces of anterior teeth.
Class IV: Proximal surfaces of anterior teeth that involve an incisal edge.
Class V: Gingival third (i.e., closest to the gumline) of the facial, buccal, or lingual surfaces of anterior and posterior teeth.
Class VI: Cusp tips.

A carious lesion on the proximal surface of the maxillary left canine could therefore be referred to as a Class III lesion on 11.

Missing teeth are normally charted first, marked out with an X or a single vertical line. Unerupted teeth may be completely circled, with the circle altered if necessary to show partial eruption. Both carious lesions and restorations are marked by coloring the portion of the tooth affected, usually in different colors. For more precise charting, shadings, colors or coded letters may be used to differentiate between types of restorations. Amalgam (i.e., silver) restorations might be colored blue, for instance, while composite (i.e., white) restorations might be outlined in blue. Gold crowns might be marked with a "G" (or designated with a blue outline and oblique lines), and porcelain crowns with a "P." Additionally, full-coverage crowns are usually marked by circling just the crown of the tooth on the chart in blue. Areas of decay or defective restorations are marked in red.

Endodontic (i.e., root canal) restorations can be marked with a black line extending up the length of the tooth root. A periapical abscess (i.e., infection of the tooth nerve) is marked with a small circle at the apex of the root. Conditions such as erosion, abrasion, and congenital abnormalities can be identified with boxed notes. The directions of malpositioned, drifted, and super-erupted teeth can be indicated with arrows.

Implants can be drawn on the chart in their relative positions, with fixed bridgework noted by connected lines. Partial and complete dentures can be marked with brackets.

When a single clinician writes and draws findings on a dental chart, there are concerns about time, accuracy, and cross-contamination. Charting by hand is most efficient with two people, one performing the exam and the other recording the findings on the chart. If a computer is available in the treatment area, a clinician can use a headset microphone and voice-activated charting software for ease and convenience.

Once the teeth themselves have been charted, periodontal charting is indicated. The periodontium, or support structure for teeth, includes gingiva (i.e., gums), periodontal ligaments and membranes, and bone.

Baseline data, recorded as part of the initial examination, is a resource for treatment planning. During treatment, the chart offers direction for instrumentation, alerting the clinician to complex pocketing, mobility, and root furcation involvement. Later, periodically updated charts evaluate the success of home care and professional treatment. Further uses for periodontal charting are as legal evidence, to support a diagnosis and justify treatment, and as forensic evidence. The best defense in a malpractice suit is complete and accurate documentation.

For a periodontal chart, the clinician measures and records pocket depths surrounding the teeth. In a healthy mouth, each tooth is surrounded by a free collar of marginal gingiva. At a depth of 0-3 millimeters, the gingiva is attached to the cementum, the surface of the tooth root. The surrounding 0-3-mm space within the free collar is referred to as the sulcus. In an unhealthy condition, sulcus depths can be much greater because of loss of attachment and are referred to as periodontal pockets.

Measurement is accomplished with a calibrated periodontal probe, inserted into the sulcus parallel to the long axis of the tooth. Depending on design, the probe may be marked at each millimeter up to 10. A more common design has the markings at four and six deleted for easier reading. Color-coded probes may be marked in blocks, with a green block up to 3 mm (i.e., indicating a healthy condition), and a red block up to 6 mm (i.e., indicating and unhealthy condition and the presence of periodontal disease). Probes are designed with blunt or ball-tipped ends to avoid puncturing the junctional epithelium at the base of the sulcus during probing. Electronic probes are also available that record pocket depths automatically on a computerized chart.

For a full periodontal chart, six readings are taken on each tooth and recorded in six boxes above and below teeth on the chart. Beginning with tooth number 1, a measurement is taken at the mesio-buccal line angle, the midbuccal, the distobuccal line angle, the distolingual line angle, the mid-lingual, and the mesio-lingual line angle. The probe can be "walked" around the circumference of the tooth for complete exploration.

As the sulcus is probed, other conditions can be noted. Inflamed gingiva can bleed spontaneously from finger pressure or from probing, even though the probe does not puncture tissue. A bleeding index can be determined by dividing the number of sites bleeding by the number of sites examined. If 24 sites are probed, for example, resulting in 12 of those sites exhibiting bleeding, the patient has a bleeding index of 50%. Bleeding sites can be noted on the chart by a red dot or by the letter B.

A plaque index can be determined by the same method. A clinician counts the number of teeth where plaque, a biofilm, is present, and divides that by the number of teeth examined. A plaque index is a useful motivational tool for patients when measured at periodic intervals.

Other conditions that might be noted on a periodontal chart include the presence of exudate, tooth mobility, color and contour of the gingiva, recession, and the amount of plaque and calculus. All these conditions, when added together, provide the clinician a comprehensive picture of the patient's periodontal status. Planning and treatment can only begin when these conditions have been fully documented.

Some clinicians prefer to assign standardized classifications to the patient's degree of periodontal health. The five recognized classifications are:

Case Type I: Gingivitis is present when inflammation is apparent and the gingiva is characterized by changes in color, form, position and appearance. Bleeding and/or exudate may be present.
Case Type II: Slight periodontitis is present when inflammation has progressed from the gingiva to deeper periodontal structures and bone, with slight bone loss. Probing depths are 3-4 mm, and there is some loss of connective tissue attachment.
Case Type III: Moderate periodontitis is a more advanced stage of Slight Periodontitis, with increased destruction and tooth mobility. There may be furcation involvement in multirooted teeth.
Case Type IV: Advanced periodontitis involves major loss of bone support and increased tooth mobility and furcation involvement.
Case Type V: Refractory progressive periodontitis is diagnosed when there is rapid bone and attachment loss or slow, but continuous, loss. Normal therapy is resisted, and there is gingival inflammation and continued pocket formation.

A simplified method of charting periodontal conditions was adapted in 1992 from a system in use in Europe called the Community Periodontal Index of Treatment Needs (CPITN). The CPITN is endorsed by both the World Health Organization and the Federation Dentaire Internationale for periodontal screening. The 1992 adaptation, called Periodontal Screening and Recording (PSR), is endorsed by the American Dental Association (ADA) and the American Academy of Periodontology (AAP). It is best described as an early detection system for periodontal disease. PSR is not intended to replace full periodontal charting, but to serve as a simple and convenient screening tool. PSR can indicate to the clinician when a more comprehensive examination is needed. The ADA and AAP recommend using PSR at regular intervals as an integral part of oral examinations.

Pocket depths are scored in sections by codes, rather than individually by millimeters. For this system, the mouth is divided into sextants: maxillary right, anterior and left; and mandibular right, anterior and left. The PSR probe is ball-tipped and coded with a single colored marking from 3.5 mm to 5.5 mm. The clinician records a single sextant code according to the deepest probing depth found in that sextant. Where there are no teeth present in a sextant, an X is recorded.

Code 0 is used when the colored area of the probe remains visible in all the pockets of the sextant. The clinician detects no calculus and no defective margins on restorations. No bleeding is evident on probing.

Code 1 indicates nearly the same conditions as Code 0, but bleeding is detected on probing.

Code 2 is used when calculus, either above or below the gumline, is detected. It may also be used to indicate defective restorative margins. The colored area of the probe is still completely visible.

Code 3 is necessary when the colored area of the probe is only partly visible in at least one pocket of the sextant.

Code 4 is used when the colored area of the probe is not visible in at least one pocket of the sextant, indicating a program depth more than 5.5 mm.

An asterisk is added to a sextant score to indicate problems such as mobility, root furcation involvement, mucogingival abnormalities, or gingival recession greater than 3.5 mm. The sextant scores are recorded in a set of six attached boxes that can be drawn on the chart. Printed stickers are also available and can be added to the chart on the appropriate date.

Results

After dental and periodontal charting, a patient is found to be in good dental health if there is no decay, no restorations or replacements are needed, and the patient's periodontal pockets are between 0-3 mm with no bleeding or abnormal conditions. A prophylaxis (i.e., cleaning) is usually the only treatment prescribed. The patient is placed on recall at three to 12-month continued care intervals for routine, preventive, and oral health maintenance care.

Any decay found, however, calls for treatment by elimination of active disease, restoration, or extraction. Endodontics may be necessary to preserve a tooth. Crowns, bridgework, implants, or dentures may also be indicated. If periodontal pockets deeper than 3 mm are found, they indicate the presence of periodontal disease, which must then be evaluated and treated appropriately.

Health care team roles

Any member of the dental team is equipped to perform dental charting, including the dentist, hygienist, expanded function dental auxiliary, or assistant. If no computer is available, charting is easier with two people. One performs the examination and calls out the findings while the other enters them in the chart.

Dental hygienists normally handle periodontal charting as part of the initial or periodic exam. Again, if no computer is available, charting is easier with two people. Periodontal screenings provide an excellent opportunity for patient education. While working, the dental hygienist can explain the meaning of any findings to the patient, and discuss their implications. During periodic exams, the patient can be told if scores have improved since the last visit.

KEY TERMS

Calculus— Calcified mass of bacteria, fungi, dequamated epithelial cells and food debris that forms on the surface of a tooth.

Caries— Tooth decay.

Cusp— Pointed projection on the crown of the tooth.

Deciduous teeth— Primary, or "baby" teeth.

Distal— Proximal surface of tooth farthest from the midline.

Facial— Outside surface of anterior tooth, adjacent to the face. The term includes buccal (cheek) and labial (lips) areas.

Gingiva— Gum tissue.

Incisal— Biting edge of anterior tooth.

Lingual— Inside surface of tooth, adjacent to the tongue.

Mesial— Proximal surface of tooth closest to the midline.

Occlusal— Biting surface of posterior tooth.

Periodontics— Study of the support structures of teeth, including gingiva, ligaments and alveolar bone.

Plaque— Collection of bacteria growing in a soft mass on surface of tooth or gingiva. Also called biofilm.

Sulcus— Normal 0-3mm space between the tooth and the junctional epithelium and the gingival margin.

Resources

BOOKS

Darby, Michele Leonardi, R.D.H., M.S., and Eleanor J. Bushee, B.S., D.D.S., F.A.C.D. Comprehensive Review of Dental Hygiene, 4th ed. C.V. Mosby Co., 1998.

Woodall, Irene R. R.D.H., M.A., Ph.D. Comprehensive Dental Hygiene Care. C.V. Mosby Co., 1993.