What should be recorded

What should be recorded

Historically, full periodontal charting before, during and after treatment included comprehensive recording of multiple periodontal parameters. Although this process is time consuming, it gives extensive information that may be useful in some cases, for example where recession or increased tooth mobility is recognised as a problem.

The British Society of Periodontology and Implant Dentistry (BSP) recognise less comprehensive charting for routine use in patients who have BPE scores of 3 and 4. This involves assessing probing pocket depth and bleeding on probing at 6 sites around each tooth.  Recording is required for all sites where probing pocket depths are ≥4 mm and for all sites which bleed on probing. 

While it is now accepted that extensive periodontal charting may not be required for all patients at every visit, the recording of all periodontal parameters at baseline is advised for those with BPE scores of 3 and 4 so that a full understanding of the clinical situation is obtained. The recording of the additional features such as tooth mobility, recession, furcation involvement and suppuration will allow the dentist to determine tooth prognosis and case management, particularly in complex periodontal disease; see Baseline charting for diagnosis for advice on the parameters which should be recorded as part of baseline charting.

Interim charting during treatment or maintenance is a matter of clinical judgement, but as a minimum should include assessment of pocket depths and bleeding on probing, with probing pocket depths at sites of ≥4 mm and sites which bleed on probing recorded in the patient’s clinical notes; see Review charting for advice on the parameters which should be recorded as part of review charting. This is in addition to assessing plaque biofilm and bleeding levels and the patient’s oral hygiene status.

In addition, a radiographic record of bone levels supplements periodontal charting (see Use of radiographs) to give a complete understanding of the patient’s periodontal status and prognosis