A dental chart is used to measure the depth of gum pockets around the teeth. It is a way of noting abnormal clinical and radiographic findings as a permanent part of the patient's dental record.
Recording the condition of all teeth as well as soft and hard tissues is necessary for a number of reasons including the need to provide quality care. The charting of existing conditions provides basic information for an accurate comprehensive treatment plan. Communicating the patient's history is also an important reason for using a dental chart as well as the chart being a legal document.
The dental chart is a permanent record a patient's dental care and usually includes dental history oral hygiene tooth abnormalities radiographic findings periodontal examination proposed treatment actual treatment future treatment plans and home care instructions
A thorough clinical examination must be conducted in order to complete the chart. Each examination must be systematic in that it follows the same sequence each time and requires clean dry teeth good lighting visibility and dental radiographs.
Two person charting is the fastest and most efficient type of dental charting examination. One person examines the mouth and the other records information on the chart. Charting begins with general evaluation of the gingiva for presence of calculus on the teeth. Grading is from 1 to 3 where 3 is heavy calculus. Next the mouth is examined for missing teeth. A circle is placed on the chart around missing teeth Enamel/ dentin+enamel/ pulpal fractures are then observed and noted. A periodontal probe with millimeter gradations is inserted at the interface between the free gingiva and tooth surface. The probe is gently pressed down to the bottom of the sulcus ﾔwalkedﾔ around the tooth and measurements are noted at the four corners of each tooth. The attachment loss probe depths are noted on the chart. Finally other lesions are observed and noted.
Charting shorthand-letters are placed over a tooth during charting to indicate type of pathology noted. The main abbreviations are:
Tooth surfaces are abbreviated as:
O= occlusal (posterior teeth)
I=incisal (anterior teeth)
F=facial (anterior teeth)
B=buccal (posterior teeth)
Other abbreviations include:
A - absence of a tooth or multiple teeth AB ﾖ abrasion ACB - anterior cross bite AK ﾖ ankylosis ARF - apical repositioned flap AT ﾖ attrition AV ﾖ avulsion
BNC - base narrow canine CA - carious lesion CR ﾖ crowding C/SL - calculus slight C/MOD - calculus moderate C/H - calculus heavy D ﾖ dehiscence
E - enamel defect EH - enamel hypoplasia EP ﾖ epulis ER - external resorption F - furcation exposure F1 - Class I (incipient) furcation exposure
F2 - Class II (definite) furcation exposure FEN ﾖ fenestration FGG - free gingival graft FU ﾖ fusion FWS - freeway space FX - fractured tooth GE ﾖ gemination
GV ﾖ gingivectomy GR - gingival recession H - gingival hyperplasia
I - impacted tooth LB - level bite M - mobile tooth N - neck lesion NE - near exposure O - missing tooth OB - open bite OD ﾖ odontoplasty OM - oral mass
ONF - oronasal fistula PCB - posterior cross bite PE - pulpal exposure
PP - periodontal pocket PU ﾖ pulpitis R - rotated tooth RD - retained deciduous teeth RR - retained root RCT - root canal therapy R/A - restoration amalgam R/C - restoration composite R/M - restoration metallic crown R/I - restoration glass ionomer RPC - root planing closedRPO - root planing open
S - supernumerary tooth SD - repairative or sclerotic dentin SE ﾖ supereruption
V - vital pulpotomy W - worn tooth WF - wear facet - a flattened highly polished area on the tooth's surface from chronic wear WB - wry bite or wry mouth X - extracted tooth.