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D4910 - Perio Maintenance [Carious Legion Clinic Help]

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periodontics:4910_perio_maint

D4910 - Perio Maintenance

This is from the perio clinic manual - it needs improvement.

  • Patient Education
    • Review purpose of visit.
    • Set patient expectations for appointment.
  • Update medical history and vital signs.
  • Document in Axium.
  • Complete extraoral examination.
  • Intraoral Examination & Documentation
    • Examine soft tissue.
    • Check for caries/faulty restorations.
    • Check function and state of repair of prostheses.
    • Write gingival description.
    • Probe all areas.
      • Record only those deeper than 3 mm or that bleed on probing.
    • Make an accurate diagnosis based on the findings.
    • Make recommendations for further treatment or maintenance.
    • Record data on Periodontal Analysis Form.
  • Presentation to Faculty
    • Request presentation of patient findings to faculty member.
    • Present patient synopsis to faculty member.
    • Faculty member will examine patient.
  • Patient education
    • Give feedback on findings.
    • Disclose.
    • Calculate Plaque Index.
    • Reinforce individualized patient education and oral hygiene instruction.
    • Advise patient of recommended maintenance interval.
  • Instrumentation
    • Anesthetize if indicated.
    • Debride all tooth surfaces.
    • S/RP as needed; disrupt all subgingival plaque even when no calculus is detected.
    • Use dental floss interproximally.
  • After completion:
    • Request a final check at least 30 minutes before the end of the clinic session.
    • Polish all teeth unless polishing is contraindicated.
    • Apply topical fluoride if indicated.

Sample Progress Note

PERIO 4910 Med. hx update, B.P. 150/80, Plaque Index 60%. Gingiva healthy. OHI/ end-tuft TB, furcation #14. Prophylaxis complete. Polish, topical APF. Rx .05% NaF daily home fluoride rinse. NV: perio maintenance, Dec. 1998


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periodontics/4910_perio_maint.txt · Last modified: 2013/06/20 22:44 by brent