7.2 Dental Examination Charting, FDI Notation & Periodontal Documentation

7.2 Dental Examination Charting, FDI Notation & Periodontal Documentation

Dental charting is the standardized graphic and alphanumeric documentation of a patient's complete oral condition. As an indispensable component of the patient's permanent legal record, the dental chart serves as a diagnostic roadmap, a clinical treatment planning guide, a forensic identification record, and a legal instrument in civil litigation and professional regulatory proceedings. Dental assistants in Canada must master the Fédération Dentaire Internationale (FDI) Two-Digit System, clinical color-coding conventions, specialized restorative charting symbols, and comprehensive periodontal recording metrics.

Clinical Charting Modalities: Anatomical vs. Geometric

In both traditional paper charts and modern Electronic Dental Record (EDR) software, dental conditions are charted using one of two primary visual modalities:

1. Anatomical Charting Systems

• Design: Displays realistic graphical illustrations of the exact anatomical morphology of tooth crowns and roots from facial/buccal, lingual/palatal, and occlusal/incisal perspectives.
• Clinical Utility: Superior for charting complex periodontal bone loss, root canal therapy, apicoectomies, root fractures, furcation involvements, impacted roots, and surgical implants. Anatomical representations illustrate the spatial relationship between roots and surrounding structures (e.g., maxillary sinus floor, mandibular canal).

2. Geometric Charting Systems

• Design: Represents each tooth as a simplified geometric diagram—typically a circle or square divided into five distinct compartments representing the five primary anatomical tooth surfaces: central compartment represents the occlusal or incisal surface, bordered by four outer compartments representing the mesial, distal, facial/buccal, and lingual surfaces.
• Clinical Utility: Highly streamlined and efficient for recording surface-specific operative and restorative procedures (e.g., Class I occlusal amalgams, Class II mesio-occlusal composites).

The FDI Two-Digit Tooth Notation System (Canadian Standard)

Adopted by the Canadian Dental Association (CDA), the National Dental Assisting Examining Board (NDAEB), and the International Organization for Standardization (ISO 3950), the FDI (Fédération Dentaire Internationale) Two-Digit System is the universal standard across Canada.

Quadrant Numbering Architecture

The oral cavity is divided into four quadrants by a vertical median sagittal line (dividing left and right arches) and a horizontal occlusal plane (dividing maxillary and mandibular arches). Quadrants are numbered clockwise from the operator's perspective facing the patient:

                    PATIENT'S MAXILLARY RIGHT     |     PATIENT'S MAXILLARY LEFT
                                                  |
                                  Quadrant 1      |      Quadrant 2
                           (Permanent Max Right)  |  (Permanent Max Left)
                                  Quadrant 5      |      Quadrant 6
                             (Primary Max Right)  |    (Primary Max Left)
                         -------------------------+-------------------------
                                  Quadrant 4      |      Quadrant 3
                            (Permanent Mand Right)|  (Permanent Mand Left)
                                  Quadrant 8      |      Quadrant 7
                             (Primary Mand Right) |    (Primary Mand Left)
                                                  |
                    PATIENT'S MANDIBULAR RIGHT    |    PATIENT'S MANDIBULAR LEFT

Permanent Dentition (Quadrants 1 to 4)

• First Digit (Quadrant):
  • 1: Maxillary Right Quadrant
  • 2: Maxillary Left Quadrant
  • 3: Mandibular Left Quadrant
  • 4: Mandibular Right Quadrant
• Second Digit (Tooth Position from Midline):
  • 1: Central Incisor
  • 2: Lateral Incisor
  • 3: Canine (Cuspid)
  • 4: First Premolar (Bicuspid)
  • 5: Second Premolar (Bicuspid)
  • 6: First Molar (6-year molar)
  • 7: Second Molar (12-year molar)
  • 8: Third Molar (Wisdom tooth)
• Clinical Pronunciation Rule: The two digits are always pronounced as individual numbers, never as a combined cardinal number. For example, tooth 16 is pronounced "one-six" (never "sixteen"); tooth 47 is pronounced "four-seven" (never "forty-seven").

Primary / Deciduous Dentition (Quadrants 5 to 8)

• First Digit (Quadrant):
  • 5: Maxillary Right Primary Quadrant
  • 6: Maxillary Left Primary Quadrant
  • 7: Mandibular Left Primary Quadrant
  • 8: Mandibular Right Primary Quadrant
• Second Digit (Tooth Position from Midline):
  • 1: Primary Central Incisor
  • 2: Primary Lateral Incisor
  • 3: Primary Canine
  • 4: Primary First Molar
  • 5: Primary Second Molar
• Clinical Pronunciation Rule: Tooth 55 is pronounced "five-five" (never "fifty-five"); tooth 74 is pronounced "seven-four".

Standard Clinical Color-Coding Conventions

Universal color-coding provides an instantaneous visual distinction between conditions that have already been treated and conditions that require clinical intervention:

1. Blue or Black Ink

• Clinical Significance: Identifies existing, completed, clinically sound restorations, completed dental treatments, and healthy physiological baselines.
• Examples: Sound amalgam restorations, intact composite fillings, cemented crowns, completed endodontic obturations, healed extracted sockets, and congenitally missing teeth.

2. Red Ink

• Clinical Significance: Identifies active pathology, active carious lesions, defective restorations, failed endodontic treatments, and all proposed / planned future treatments requiring scheduling.
• Examples: Primary caries, recurrent/secondary caries, cracked teeth, periapical abscesses, fractured restorations, planned extractions, and proposed crowns.

Standardized Restorative & Pathological Charting Symbols

Standard clinical symbols provide a universal visual shorthand across Canadian dental practices:

1. Restorative Materials & Prosthodontic Symbols

• Amalgam Restoration: Outlined and filled in solid blue or black on the exact anatomical surfaces involved (e.g., solid blue occlusal-lingual on tooth 16).
• Composite Resin Restoration: Outlined in blue or black following the contours of the affected surfaces without filling the interior (reflecting the tooth-colored nature of resin).
• Gold Inlay / Onlay / Full Cast Gold Crown: Outlined with diagonal parallel hatching lines in blue/black across the involved surface or entire anatomical crown.
• Porcelain / Ceramic Crown: Outlined crown with internal cross-hatching or stippling/dots in blue/black.
• Porcelain-Fused-to-Metal (PFM) Crown: Outlined crown with diagonal hatching on the lingual/margin (representing the metal substructure) and an open/dotted facial surface (representing the porcelain veneer).
• Stainless Steel Crown (SSC): Outlined crown with the letters "SS" written in the center or a criss-cross hatched pattern in blue/black (frequently placed on primary molars).
• Veneer: Outlined facial surface with dotted/cross-hatched pattern in blue/black.
• Fixed Partial Denture (Bridge): Abutment teeth charted with their respective crown symbols; pontic teeth charted with full crown outline; all units linked by connecting lines across the interproximal spaces in blue/black.

2. Pathological Conditions & Treatment Requirements

• Primary Carious Lesion (Incipient or Cavitated): Outlined and filled in solid RED on the affected anatomical surfaces.
• Recurrent / Secondary Caries: Existing restoration charted in blue/black, with a bold RED outline drawn around the margin of the existing restoration indicating new caries developing beneath or adjacent to the restoration.
• Defective Restoration: Existing restoration charted in blue/black, with a red notation or red "X" placed across the restoration indicating structural breakdown, open margins, or overhang.
• Periapical Abscess / Radiolucency: A solid or open RED circle drawn at the apex of the involved root.
• Root Canal Therapy (RCT):
  • Completed RCT: A solid blue/black vertical line drawn down the center of each root canal from chamber to apex.
  • Planned / Indicated RCT: A solid RED vertical line drawn down the center of each root canal.
• Missing Tooth (Previously Extracted or Congenitally Absent): A single clean diagonal black/blue line or a neat "X" drawn through the entire tooth (crown and root).
• Tooth Indicated for Extraction: A bold RED diagonal line or bold RED "X" drawn through the entire tooth.
• Impacted / Unerupted Tooth: A complete circle drawn in red (if requiring surgical exposure/extraction) or blue (if asymptomatic/monitoring) enclosing the entire tooth (crown and root).
• Fractured Tooth / Cusp: A jagged red zig-zag line drawn across the anatomical surface corresponding to the fracture line.

3. Positional Variants & Arch Relationships

• Diastema: Two parallel vertical lines (||) drawn between the contacting proximal surfaces of the adjacent separated teeth.
• Tipped / Drifted Tooth: A straight horizontal arrow drawn over the crown pointing in the direction of drifting (arrow pointing toward midline = mesial drift; pointing away from midline = distal drift).
• Rotated Tooth: A curved arrow drawn above or on the occlusal surface indicating the direction of rotation (clockwise or counter-clockwise).
• Supernumerary Tooth: An extra tooth drawn in its approximate anatomical position, designated with an "S" symbol.

Comprehensive Periodontal Charting Parameters

Periodontal charting records quantitative and qualitative metrics to diagnose periodontal health, gingivitis, or periodontitis under the AAP/EFP (American Academy of Periodontology / European Federation of Periodontology) classification system.

           BUCCAL ASPECT                                LINGUAL ASPECT
  +-------------+-------------+             +-------------+-------------+
  | Distobuccal | Mid-Buccal  | Mesiobuccal | | Distolingual| Mid-Lingual | Mesiolingual|
  |    (DB)     |     (B)     |    (MB)     | |    (DL)     |     (L)     |    (ML)     |
  +-------------+-------------+-------------+ +-------------+-------------+-------------+
  |   Site 1    |   Site 2    |   Site 3    | |   Site 4    |   Site 5    |   Site 6    |
  +-------------+-------------+-------------+ +-------------+-------------+-------------+

1. Six-Point Probing Depth (PD) Measurement

Probing depth is measured from the free gingival margin (FGM) to the base of the gingival sulcus or periodontal pocket using a calibrated, millimeter-marked periodontal probe (such as the Williams probe, Marquis probe, or UNC-15 probe).

• Six Standard Measurement Sites per Tooth:
  1. Distobuccal (DB): From the distal contact point to the distobuccal line angle.
  2. Mid-Buccal (B): Across the central facial surface.
  3. Mesiobuccal (MB): From the mesial line angle to the mesial contact point.
  4. Distolingual (DL): From the distal contact point to the distolingual line angle.
  5. Mid-Lingual (L): Across the central lingual/palatal surface.
  6. Mesiolingual (ML): From the mesial line angle to the mesial contact point.
• Probing Technique: The probe is inserted into the sulcus parallel to the long axis of the tooth and gently "walked" (bobbing motion in 1 mm increments) around the circumference of the tooth. At interproximal contact areas, the probe is angled slightly (approximately 10°–15°) into the col area beneath the contact point to reach the deepest pocket depth.
• Diagnostic Interpretation:
  • Normal / Healthy Sulcus: 1 to 3 mm, firm tissue, zero bleeding.
  • Periodontal Pocket: ≥ 4 mm. Pocket depths ≥ 4 mm represent pathological deepening of the sulcus resulting from apical migration of the junctional epithelium (true pocket) or gingival tissue enlargement (pseudopocket). Depths ≥ 4 mm are routinely charted or highlighted in red ink.

2. Bleeding on Probing (BOP)

• Bleeding on probing occurs when the probe tip contacts ulcerated, chronically inflamed microvasculature within the sulcular pocket epithelium under gentle probing force (approximately 20 to 25 grams, equivalent to the force required to slightly blanch the thumbnail).
• Recording: Charted as a red dot or red highlight at the specific probing site.
• Clinical Significance: BOP is the single most reliable, objective clinical indicator of active marginal and subgingival inflammation. The absence of BOP is an exceptional prognostic indicator of periodontal stability.

3. Clinical Attachment Level (CAL) / Clinical Attachment Loss

While probing depth measures the distance from the movable gingival margin to the pocket base, the gingival margin fluctuates due to inflammation, swelling, or recession. Therefore, Clinical Attachment Loss (CAL) is the true measure of cumulative periodontal tissue and alveolar bone destruction, measured from a fixed anatomical landmark: the Cementoenamel Junction (CEJ).

The Three Clinical Calculations for CAL

1. Gingival Recession Present (Gingival margin is APICAL to the CEJ):
   • The CEJ is clinically visible.
   • Formula: $\text{CAL} = \text{Probing Depth (PD)} + \text{Gingival Recession (GR)}$
   • Example: Probing depth is 4 mm; gingival recession is 3 mm.
   • $\text{CAL} = 4\,\text{mm} + 3\,\text{mm} = 7\,\text{mm}\text{ of attachment loss}.$
2. Normal Gingival Position (Gingival margin is exactly AT the CEJ):
   • Formula: $\text{CAL} = \text{Probing Depth (PD)}$
   • Example: Probing depth is 5 mm; recession is 0 mm.
   • $\text{CAL} = 5\,\text{mm}\text{ of attachment loss}.$
3. Gingival Overgrowth / Hyperplasia / Pseudopocket (Gingival margin is CORONAL to the CEJ):
   • Gingival tissue covers the CEJ due to drug-induced hyperplasia (e.g., phenytoin, cyclosporine, nifedipine) or severe edematous swelling.
   • Formula: $\text{CAL} = \text{Probing Depth (PD)} - \text{Gingival Height Coronal to CEJ}$
   • Example: Probing depth is 6 mm; gingival margin extends 2 mm coronal to the CEJ.
   • $\text{CAL} = 6\,\text{mm} - 2\,\text{mm} = 4\,\text{mm}\text{ of true attachment loss}.$

4. Furcation Involvement (Glickman Classification)

Furcation involvement occurs when periodontal bone resorption extends into the bi- or trifurcation of multi-rooted teeth (maxillary molars, mandibular molars, and maxillary first premolars). It is assessed using a curved, blunt-ended Nabers furcation probe.

5. Tooth Mobility (Miller Classification)

Tooth mobility evaluates the functional integrity of the periodontal ligament (PDL) and alveolar housing. Mobility must ALWAYS be evaluated using two rigid instrument handles (e.g., the blunt ends of two mouth mirrors). Fingers must never be used because resilient finger pads compress, giving a false impression of movement.

• Class I Mobility: The first distinguishable sign of movement greater than normal (physiologic) mobility.
• Class II Mobility: Movement of the crown of about 1 mm in any direction.
• Class III Mobility: Movement of more than 1 mm in any direction, and/or vertical depression or rotation of the tooth in its socket.

Recording Extraoral and Intraoral Examination Findings

Competency 4.2.3 asks the assistant to record intra-oral and extra-oral examination findings and diagnoses accurately. The dentist examines the patient and makes the diagnosis. The assistant records what the dentist reports, in the dentist's words, with the date.

• Extraoral findings: facial symmetry, skin lesions, the lips and vermilion border, TMJ sounds, deviation or tenderness, and the cervical lymph nodes (size, consistency, tenderness, mobility; section 3.4).
• Intraoral soft tissues: buccal and labial mucosa, tongue, floor of the mouth, palate, oropharynx and gingiva. For any lesion, record:
  • its location (using landmarks and FDI tooth numbers)
  • size in millimetres
  • colour, shape, surface texture and consistency
  • whether it is raised, flat or ulcerated
  • the duration reported by the patient.
• Hard tissues: existing restorations, caries, missing teeth, fractures and wear, charted with the office's symbols and colour code.
• Occlusion: molar and canine classification, overjet, overbite and crossbites when the dentist reports them (section 15.1).
• Diagnoses and referrals: record the dentist's diagnosis (for example, "irreversible pulpitis 36" or "localized gingivitis") and any biopsy or referral. Use only accepted abbreviations, and never add your own interpretation.