Good Record Keeping Is Essential in Patients with Periodontal Disease | QCS

Good Record Keeping Is Essential in Patients with Periodontal Disease

October 9, 2017


Undiagnosed or mismanaged periodontal disease is one of the most common reasons for patient complaints. It involves rising litigation costs, possible General Dental Council intervention as well as added stress to dental practitioners. It is therefore essential to have accurate and detailed records in relation to patient’s periodontal condition. Often patients only become aware of this condition when they unexpectedly loose teeth or are informed by a new dentist that they have advanced gum disease and that it is likely to have been present for many years.

Whilst it is important to be open and honest with patients when giving information about their oral health, dental colleagues should be careful in avoiding criticism of previous care unless they have firm evidence of neglect or misdiagnosis. It is clear that many risk factors such as stress, life-changing events, smoking and diabetes as well as genetic predisposition play a role in periodontal disease manifestation and progression.

Records of Screening for Periodontal Disease

Your patient’s dental records should have clear evidence of periodontal screening using a basic periodontal examination. Where appropriate, more detailed pocket assessment as well as bleeding scores, debris scores and mobility grades will be completed. Current oral hygiene habits such as brushing frequency, inter-dental cleaning and the use of any mouthwashes should be recorded. Notes should be made on patient motivation and compliance as well as the type of oral hygiene instructions given. This may include demonstration of flossing technique for example. In addition to screening and pocket scores, the use of radiographs may be justified to further aid the diagnosis of periodontal disease.

The records should include a justification for taking the radiograph and a detailed report of its findings. This may be details on bone loss and pattern of loss such as vertical or horizontal, furcation involvement and any calculus seen. Finally, the quality of the radiograph must be noted using a 1-3 grading system.

Patients should have been given a judgement on the prognosis of their condition with a detailed maintenance schedule. This may or may not include hygienist care and possible referral to a specialist periodontist. Again, the notes should reflect this and include failure to act upon any advice given and any missed hygienist appointments.

Recall periods should be discussed and noted. High-risk group patients such as smokers and diabetics should be seen more frequently for periodontal monitoring. Records should reflect advice on smoking cessation and control of diabetes with medication or diet.


Where referrals are made to dental hygienist the dentist would need a concise prescription to which the hygienist can work. This will include a diagnosis, prognosis, risk factors, oral hygiene and prevention advice, type of treatment required, recommendation for local anaesthesia, frequency of visits. It also includes a re-evaluation period by the referring dentist. These details should be clearly seen on the notes or pro-forma. Referrals to specialist should include risk factors, current pocket scores, any oral hygiene given and any treatment carried out.

The level of detail in record keeping described above will not only help in the management of patient care, but avoid any criticism should a patient complaint arise.


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Raj Majithia

Dental Specialist M.Clin.Dent, FFGDP, BDS, LDSRCS, MJDF (UK), DPDS


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