Periodontal Assessment and Recordkeeping at the Mitchell's Plain Dental Clinic

Periodontal assessment is becoming more important since the adult population is retaining their teeth longer. A link between periodontal disease and systemic conditions and vice versa has also been reported. It is therefore important to assess patients' periodontal status at regular intervals. According to Tomson, 2002 “a clinician would be ill advised to treat a patient without appropriate comprehensive baseline assessment”. These skills of monitoring and recording information should thus form an integral part of the undergraduate training. Objective: To assess the current periodontal monitoring by students at the Oral Health Centre, Mitchell Plain. Method: A descriptive study to assess current methods of monitoring periodontal patients at the Faculty of Dentistry, UWC in 2006. Patient folders were randomly selected using student record books, which gave access to file numbers for patients that have been diagnosed with periodontal disease. Data was collected using the clinical audit framework from Dental Protection, which uses 16 key landmarks. Each landmark was scored with 0 indicating no entry, 1 an incomplete entry and 2 a complete entry. A maximum score of 32 was calculated for each record. Two examiners recorded the data; one reviewed the records and repeated the exercise to standardize the scoring system. Data was entered and analyzed in SPSS. Results: The preliminary results indicate that complete entries were for medical history, diagnosis and identification of risk factors. Incomplete or missing entries included the following: appropriate screening; measurement of the severity of disease; and patient advice, which included diagnosis, disease process and prognosis, role of risk factors and lack of compliance. Conclusion: There is a strong focus on diagnosis, identification of risk factors and taking of medical history with limited baseline information to support the diagnosis. Recordings indicated limited information of patient involvement in the understanding and management of their periodontal status.