II . Directive for case documentation : Case reports must contain - - PDF document

Guidelines for Comprehensive Case Presentation

I . Case Type: Generalized moderate to advanced periodontitis with deep pockets and moderate to severe bone loss must be present in both arches. Cases must be of sufficient periodontal complexity to test the diagnostic and therapeutic competence of an expert in periodontitics. At least twenty (20) natural teeth including at least (2) molars must be present in each case after treatment. All periodontal and other dental treatment must be

• completed. Restorative dentistry may be of a provisional nature if is

aesthetically and functionally acceptable and if it does not adversely affect periodontal health. II . Directive for case documentation: Case reports must contain the following data: Medical History: A full history, including medical history, ASA classification, an assessment of the patient's expectations and desires for treatment, evaluation of the patient's motivation. Clinical examination: This should be both extra-oral and intra-oral. The intra-oral examination will include information concerning the functional state of the gingiva, probing pocket depth, probing attachment loss and furcation involvment in addition to the state of the

• ral mucous membranes. Where applicable, a restorative status and

pulp vitalities should be recorded. The examination must include plaque and bleeding indices. Radiographic Examination: Complete dental radiographs, including posterior “bite wings” using periapical-sized films, are required before treatment and at least one year after completion of periodontal

• treatment. Vertical bitewings may enhance the diagnostic qualities of

the radiographic survey. Digital Radiographs may also be used. All radiographs must be of diagnostic quality, reproducing with proper contrast and density of the teeth and alveolar bone in anatomically correct relationships. All teeth and implants, including third molars, must be shown in their entirely in at leas one radiograph, both before and after treatment. All occluding posterior must be shown on bite wing radiographs before and after treatment. All radiographs must be placed in suitable mounts. Radiographs taken during treatment may be included.

Photographs: Color photographs illustrating at least one surgical

• peration must be included in each case. The following views are

required as a minimum:

• A. Initial pre-treatment , post-initial therapy and at least one year post

–treatment: A minimum series of 9-12 slides is required at both pre-and post-treatment.

• 1. Facial – anterior, right posterior, and left posterior facial views of

each arch (6 slides). Optionally, the same three facial views of the teeth in or near occlusion that show sufficient gingival tissue of both arches in each view may be substituted (3 slides). Any combination of the above may be used.

• 2. Lingual – anterior, right posterior, and left posterior lingual views of

each arch (6 slides)

• B. At least one surgical operation involving periodontally diseased

teeth shall be documented in each case with the following series of slides;

• 1. Pre-surgical condition
• 2. Flap elevation, surgical debridement and bony architecture
• 3. Surgical site after regenerative or resective procedure, if performed
• 4. Flap closure
• 5. Healing between 7 and 14 days after surgery

Special tests: When indicated bacteriological and/or hematological tests. Models: In cases where occlusal discrepancies are present,

• rthodontic type models should be available. Study models should be

made of all cases. Diagnosis: This must relate to the overall case as well as each individual tooth. Etiology: The major causes and the predisposing factors should be presented. Prognosis: This must relate to the overall situation as well as each individual tooth. Treatment plan: The treatment plan must be described in detail together with possible alternatives. Progress of treatment: The treatment carried out must be described in detail together with an ongoing assessment, including all aspects of

• documentation. The time spent on various aspects of treatment should

also be recorded. General Documentation: The finished recalled cases should be submitted in a CD. The quality of the scanned radiographs and clinical photographs must be excellent and sufficient to convey the information recorded.

Instructions for Completion of Fully Documented Periodontics Case Report Records General

• A. The original and two (2) duplicates of the Case Report Record must be in
• colour. Red, green, black and blue markers or pens will be needed.
• B. Completeness and accuracy of the Case Report Record is graded as part of

the Oral Examination.

• C. Abbreviations used:

GM - gingival margin CEJ - cemento-enamel junction BOP - bleeding on probing PI - plaque and/or calculus PD - probing depth CAL - clinical attachment level DI - dental implant

Specific

• 1. Missing Tooth Structures:

Missing teeth; missing/removed roots; or missing (decayed or fractured) portions of the crowns should be coloured in solidly in black. Impacted and/or unerupted teeth should be outlined in black. Dental implants that replace missing teeth should be indicated by a heavy black outline surrounding diagonal black lines reflecting the relative implant size and

• shape. Also, write in the space above or below the appropriate tooth

number boxes.

• 2. Recording of measurements:

Boxes actual measurements in millimeters of GM, PD, and CAL should be entered in the boxes associated with each tooth. Three measurements on the facial and three measurements on the lingual are required for each

• tooth. When dental implants are present, the restoration margin shall be

considered the CEJ and similar recordings must be entered in the boxes nearest the implant site. GM distance from the CEJ to the GM. When the GM is apical to the CEJ, enter a positive number (e.g. 1). When the GM is coronal to the CEJ, enter a negative number (e.g. 2). PD probing depth from GM to base of pocket/sulcus PI if plaque and/or calculus is present, place a blue dot near the probing depth number for that site.

CAL clinical attachment level from CEJ to base of pocket/sulcus. This may be measured directly or calculated from GM-CEJ and PD. BOP presence of bleeding on probing should be noted with a red dot near the CAL number for that site.

• 3. Colouring of chart (consider the lines between the teeth to be 2mm apart):

a) Draw GM in blue related to the CEJ b) Colour only those PD's > 4 mm vertically in red along the appropriate tooth surface. c) Note any areas where the zone of keratinized gingiva is < 2 mm with a green star or asterisk between the box for GM measurement and the drawing of the tooth or DI. d) Specify the furcation involvement grading system used in the space provided. Furcation involvement should be marked in red adjacent to the appropriate tooth surface according to the following scheme: Grade I Grade II Grade III

• 4. Mobility scores greater than zero (0) should be recorded in blue in the
• cclusal surface drawing of the appropriate teeth. Specify the mobility

classification or measurement system used in the space provided.

• 5. Root canal fillings should be indicated with a heavy blue line in the root(s)
• f the appropriate teeth. Periapical radiolucency should be noted by an
• pen blue circle at the tooth apex.
• 6. Caries or overhanging restorative margins should be indicated with a

jagged red line on the appropriate tooth surfaces.

• 7. Open, poor, or improper tooth contacts should be indicated with a jagged

blue line through the appropriate contact areas(s).