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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

Nationality XXXXXX

Marital Status: XXXXX

Date x.x.09

Chief Complaint:

Use patient own word exactly)

Dental History

Date & Type of any previous dental work (fillings, prosthesis, extractions, periodontal treatment…etc)

Medical History:

  • Heart diseases / need for AB coverage

  • Blood diseases

  • 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

  • Type of Tooth brush:

Soft – Medium - Hard

  • Brushing Technique

Horizontal- Vertical
Circular - Combination

  • Interdental Aids

Yes (type): No

  • Miswak

  • Other (tooth pick, mouthwash, proxabrush , superfloss..etc)
.1. Buccal Mucosa: Report if there is any linea alba, lesions, change in color …etc?

I.2. Gingiva:

I.2.a. Color:

I.2.b.Tone (consistency)


I.2.d.Attached Gingiva

I.3.Mucogingival Defects: (obvious recession, high frenum attachment…etc? )

Others: Report any lesions/ abnormalities in floor of the mouth, lips, checks, tongue..etc)

Radiographic Evaluation

Plaque Retentive Factors:

Calculus deposits

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)

Vertical Defects:

Correlate the clinical with radio-graphical findings to accurately evaluate the vertical defect

(M #11 )
Furcation Radiolucencies:

Record the tooth number of teeth with furcation involvement.

#36 and #47

PDL Width:

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

Supervisor’s Signature

Diagnosis (Overall Dental Diagnosis)

Multiple Caries lesion

Missing teeth #16, 26, 27,36,46,47

Priapical Pathosis 23, 24

Periodontal Diagnosis

Generalized moderate chronic periodontitis w/localized sever chronic periodontitis

Overall: Fair Individual: Poor for #11
Treatment Plan
Phase I:

  • Case presentation and pt motivation

  • OHI:

    • Soft (Aquafresh) tooth brush

    • Waxed Floss (Johnson and Johnson)

    • Proxabrush (Jordan)

    • Brushing technique: Modified Stillman technique

  • Gross U/L scaling and Selective root planning

  • Polishing and fluoride application

  • Restoration of carious teeth

  • Endodontic treatment

  • Re-evaluation of response to phase I

Phase II:
Replacement of missing teeth (RPD) and/or implant

Phase III:
Maintenance: periodic recheck |(4-6 months)

Plaque and calculus

Gingival condition

Occlusion and mobility

Other pathological changes

Supervisor’s Signature


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

2. Gingivectomy/Gingivoplasty

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

Pedicle Grafts

Bone Denudation procedures

Supervisor’s Signature

Supervisor’s Signature

Supervisor’s Signature

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

Supervisor’s Signature


Periodontal Charting

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:

Furcation involvement
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

Grade I

Detectable increased tooth mobility not exceeding 1 mm of bucco-lingual movement

Grade II

Detectable increased tooth mobility in excess of 1 mm but less than 2 mm of B-L movement

Grade III

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 direction

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