Patient Assessment and Data Collection
Patient Assessment and Data Collection
This domain tests whether you can gather, verify, and interpret the data that drive every later decision: medical history, vital signs, extraoral and intraoral inspection, periodontal charting, radiographs, caries risk, and patient-reported outcomes. The exam favors clinical interpretation over simple recall.
Core charting rules
- Record probing depth (PD) as the distance from the gingival margin to the junctional epithelium; record recession separately; calculate clinical attachment level (CAL) = PD + recession when the margin is apical to the CEJ.
- Bleeding on probing (BOP), suppuration, mobility, furcation involvement, and plaque indices document activity and risk.
- Take vital signs when history suggests risk; assign an ASA class to flag medical consultation needs.
- Use radiographs as adjuncts: bitewings for interproximal caries and bone, periapicals for periapical pathology, panoramic for broad survey.
Worked example
A facial site has PD 6 mm and the gingival margin is 2 mm apical to the CEJ. CAL = 6 + 2 = 8 mm. If the margin were 2 mm coronal to the CEJ (pseudopocket), CAL = 6 - 2 = 4 mm. The reasoning: PD alone measures sulcus depth, not attachment loss; CAL locates the junctional epithelium relative to the CEJ.
Traps
- Calling a 6-mm pocket “periodontitis” without CAL or bone loss.
- Charting recession with the wrong sign, which reverses CAL.
- Using excessive probing force, which increases false PD and BOP.
- Treating a panoramic image as a substitute for periapicals.
- Missing a medical condition (e.g., anticoagulant use) that changes treatment.