|Periodontal Examination & Charting Form
Student Name: X student
Computer No. : xxxxxxxx
Patient’s Name: X Patient
File No. xxxxxxx
Age: _X yrs. Gender: x Occupation: xxxxxx
Marital Status: XXXXX
“Use patient own word exactly)
Date & Type of any previous dental work (fillings, prosthesis, extractions, periodontal treatment…etc)
Heart diseases / need for AB coverage
Diabetes mellitus (Duration, Type, Hbc1?)
Medications (Aspirin / blood thinner…etc) dose / for what ?
Smoking: (now or before ?)
If smoker before when stopped? And for how long used to smoke
No – Yes (type?, frequency?, how long?)
I. Extra-Oral Examination:
L.N: Movable? Palpable? Tender?
TMJ: Pain? Clicking? Any deviation during closure?
Thyroid gland: Any swelling
Any other observable extra-oral abnormalities
II. Intra-Oral Examination:
Oral Hygiene Habits
Soft – Medium - Hard
Horizontal- Vertical –
Circular - Combination
Yes (type): No
.1. Buccal Mucosa: Report if there is any linea alba, lesions, change in color …etc?
Other (tooth pick, mouthwash, proxabrush , superfloss..etc)
I.3.Mucogingival Defects: (obvious recession, high frenum attachment…etc? )
Others: Report any lesions/ abnormalities in floor of the mouth, lips, checks, tongue..etc)
Plaque Retentive Factors:
Caries at or near the gingival margin
Defective restorations (overhanging margins, poor contour and open margins)
Alveolar Bone Assessment:
0% Bone Loss bone level 1.5 mm apical to the CEJ with no signs of loss of crestal density loss it suggest normal bone level.
20% Bone Loss bone level will be between 2-4 mm apical to the CEJ, it suggests slight bone loss.
20%-50% Bone Loss bone level more than 4 mm but <6 mm apical to the CEJ, it suggests Moderate bone loss.
50% Bone Loss bone level >6 mm apical to the CEJ it suggest severe bone loss.
Horizontal Bone Loss (%)
20% 30% 25%
30 % 50% 25%
Crestal Bone Density:
Examine the continuity of the crestal lamina dura (Less dense (Fuzzy) / Normal)
Correlate the clinical with radio-graphical findings to accurately evaluate the vertical defect
(M #11 )
Record the tooth number of teeth with furcation involvement.
#36 and #47
Record any areas with obvious widening of the PDL space.
Wide around #11 and #24
Root length/ form/proximity:
Record any root abnormalities seen radiographically, e.g. Dilaceration, periapical lesions,
short roots (poor crown to root ratio).
Root proximity between 14 and 15
Other findings / pathology: (periapical pathology , cysts, impacted teeth..etc)
RL around #11 and Pericapical to #24
Diagnosis (Overall Dental Diagnosis)
Multiple Caries lesion
Missing teeth #16, 26, 27,36,46,47
Priapical Pathosis 23, 24
Generalized moderate chronic periodontitis w/localized sever chronic periodontitis
Overall: Fair Individual: Poor for #11
Case presentation and pt motivation
Soft (Aquafresh) tooth brush
Waxed Floss (Johnson and Johnson)
Brushing technique: Modified Stillman technique
Gross U/L scaling and Selective root planning
Polishing and fluoride application
Restoration of carious teeth
Re-evaluation of response to phase I
Replacement of missing teeth (RPD) and/or implant
Maintenance: periodic recheck |(4-6 months)
Plaque and calculus
Occlusion and mobility
Other pathological changes
In this step you need to know if the patient is following a good oral hygiene regimen and if you did a good job with your scaling and root planning in addition to the hygiene instruction, so you should Re-evaluate results of initial therapy (4-6 weeks after initial therapy) and Re-evaluate oral hygiene status of the patient using the Bleeding and plaque score.
Compare with initial findings:
Therefore, a patient to be ready for re-evaluation must have no obvious calculus present clinically and have all local etiologic factors eliminated, "hopeless" teeth extracted, carious teeth filled, over hanged restorations or over contoured crowns corrected and the patients achieved a satisfactory level of oral hygiene (assess plaque control (<20%), bleeding score (<18%), assess tissues response to initial treatment, plan further treatment that should take the form of a definitive treatment plan and may include maintenance care or periodontal surgery.
Definitive Treatment Plan
A. Pocket Elimination Surgery
1. Gingival Curettage
3. Various types of Flap Operations [Mucogingival Flap (unrepositioned) Mucogingival Flap (apically repositioned)]
4. Osseous Surgery (Bone Grafts Ostectomy/Osteoplasty)
B. Non-Pocket Elimination Surgery
1. Mucogingival Surgery
Free Gingival Graft
Bone Denudation procedures
Recall and Maintenance
Recall/Maintenance (Supportive Therapy)
Recall visits should be depending on the Periodontal Status and clinicians judgment.
1. Patients with high motivation and no systemic conditions (every 6 months).
2. Patients with moderate or severe periodontal disease (3-4 months or even earlier in high risk patients).
On each recall visit. The following should be emphasized:
1. Evaluation of the current oral health status.
2. Necessary maintenance treatment.
3. See if recurrence of disease or any other dental treatment needed.
4. Provide necessary periodontal scaling and root planning.
5. Patient motivation
Unless otherwise mentioned by the instructor, perform the following:
1. Use Williams periodontal probe
2. Determine the location of CEJ in relation to GM, if not visible consider GM-CEJ= -3mm (normal)
3.Record PD for all teeth, six locations for each tooth
4.Probe should be inserted parallel to the long axis of the tooth
5. Inter-proximally, probe should be inserted at 10-15º below the contact area to be able to detect the interdental crater if it is present
6. Use 25gm force (Gentle force)
7. Calculate the CAL by adding the GM-CEJ to PD
Examples for different situations that may be found:
Use the following chart as a guide:
Use periodontal or Nabers probe
Use end of handles of two instrument to check the mobility (Handle of mouth mirror and handle of the probe
Detectable increased tooth mobility not exceeding 1 mm of bucco-lingual movement
Detectable increased tooth mobility in excess of 1 mm but less than 2 mm of B-L movement
Detectable increased tooth mobility in excess of 2 mm B-L movement or clinically evident apical movement upon application of force with an instrument handle on the tooth crown directed in an apical direction6>