Periodontal Evaluation & Charting Note

Date/Time: [Date and time of encounter]

Location: [Clinic/location]

Clinician(s): [Examining dentist/periodontist and hygienist if applicable]

Patient: [Name, DOB, MRN]

Referral Source: [Referring provider and reason / Self-referred]

Records Reviewed: [Prior periodontal charts, radiographs, outside records, medical consults reviewed today]

Chief Concern / Reason for Evaluation

[Patient's stated reason for visit and clinician-identified triggers for evaluation] (1–3 sentences. Begin with a direct quote if it meaningfully captures the complaint. Include patient-reported symptoms and pertinent negatives. Note clinician-identified triggers such as radiographic findings, increased probing depths, or need for periodontal clearance. If asymptomatic, state: "Here for periodontal evaluation due to [findings/history]; patient denies symptoms.")

Relevant History & Risk Factors

• [Medical conditions affecting periodontal status or therapy] (e.g., diabetes with control status, cardiovascular disease, immunosuppression, bleeding disorders/anticoagulants)
• [Medications affecting gingiva, bleeding, or healing] (e.g., calcium channel blockers, antiepileptics, immunosuppressants)
• [Relevant allergies] (e.g., antibiotics, chlorhexidine, local anesthetics)
• [Tobacco/nicotine use with type, quantity, and duration]
• [Home care practices and prior maintenance frequency/adherence]
• [Bruxism/parafunction] (Only include if relevant to mobility or occlusal trauma)
• [Periodontal treatment history] (Prior SRP with approximate date, periodontal surgery, implants, recurrent abscesses, last maintenance visit)
• [Local plaque-retentive factors] (Defective restorations, open margins, malpositioning)

(For unknown key risk factors, document "Unknown" with reason such as "patient unsure" or "outside records pending.")

Clinical Periodontal Examination

[Overview of clinical examination findings] (1–2 sentences. Reference that full periodontal chart is attached and summarize clinically meaningful patterns.)

Charting Status: [Comprehensive / Partial] periodontal charting completed today. [Dentition status, missing teeth, implant sites] (If partial, include reason.)

Probing Depths: [Range, distribution, and pattern of PDs; worst sites with tooth numbers and surfaces] (If only screening was performed, label as such and avoid definitive staging.)

Bleeding on Probing / Inflammation: [Presence and distribution; percent of sites if available; suppuration locations; gingival description] (State "Not assessed today" if not evaluated.)

Recession & Clinical Attachment Level: [Sites with recession by tooth and surface; CAL patterns or worst measurements; method of CAL determination; keratinized tissue adequacy; mucogingival concerns]

Mobility & Occlusal Findings: [Mobility grades by tooth; pathologic migration; fremitus; wear facets; occlusal trauma findings] (If assessed and normal, state succinctly. If not assessed, state "Not assessed today.")

Furcation Involvement: [Furcation class/grade and locations for affected multirooted teeth] (If not assessed, state "Furcations not assessed today.")

Plaque & Local Factors: [Plaque biofilm level; calculus distribution; plaque-retentive factors such as overhangs, open contacts, defective restorations]

Radiographic Findings

Imaging Reviewed: [Type, date obtained, source, diagnostic quality] (If no current radiographs available, document reason, recommended imaging, and label uncertainty in diagnostic conclusions.)

Bone Level Assessment: [Presence/absence and distribution of bone loss; pattern with locations; severity; key teeth with worst loss; radiographic furcation involvement; other relevant findings]

Assessment

Periodontal Diagnosis

[Primary diagnosis using current classification: gingival health / gingivitis / periodontitis] (For periodontitis, include stage, grade, extent, and stability status. Include acute entities with affected tooth when present.)

Diagnostic Rationale

• [CAL or radiographic bone loss findings used for staging]
• [Maximum probing depths and complexity factors]
• [Tooth loss attributable to periodontitis] (If applicable)
• [Progression estimate basis]
• [Grade modifiers: smoking, diabetes, other risk factors]

(If prior records are missing, label diagnosis as "provisional" and specify pending data.)

Prognosis

[Overall prognosis: good / fair / poor / guarded] — [Rationale tied to severity, risk factors, and expected compliance] (List key teeth/sites with guarded prognosis and reasons. Include modifying factors. Omit this subsection for straightforward gingivitis-only cases.)

Treatment Plan

Urgent/Stabilization Care

[Management of acute concerns: abscess/pain/infection management; palliative measures; antibiotics; medical clearance needs] (Only include this section if applicable.)

Phase I: Nonsurgical Periodontal Therapy

• Oral Hygiene Instruction: [Specific tools/techniques recommended]
• Scaling and Root Planing: [Quadrants/teeth to treat; anesthesia plan; adjuncts with indication]
• Local Factor Correction: [Overhang removal; caries control; other factors to address]
• Risk Factor Counseling: [Tobacco cessation; diabetes coordination; other modifiable risks]

Re-evaluation Plan

[Target interval post-SRP completion] — [Parameters to reassess: PD, BOP, inflammation, plaque control, mobility, furcations] — [Criteria for escalation to surgical therapy] (Required when active therapy is initiated.)

Phase II: Surgical Therapy

[Procedures under consideration with clinical indication linked to specific sites; referral plan if applicable; prerequisites for surgery] (Include if surgical therapy is indicated or anticipated. Omit if not applicable.)

Phase III: Supportive Periodontal Therapy

[Recommended maintenance interval: 3 months / 4 months / other] — [Rationale based on risk and stability] — [Criteria to shorten interval or re-enter active therapy]

Patient Discussion & Consent

[Summary of discussion including diagnosis, proposed therapies, alternatives, and risks of no treatment] — [Patient questions and preferences] — [Consent: written / verbal per policy] (If care refused/declined, document what and that risks were explained. If plan is conditional on pending data, document what recommendation will be once obtained.)

Follow-up & Attachments

• [Next visit type and timing]
• [Radiographs ordered if deferred, with rationale]
• [Attachments: periodontal chart, imaging, consent documents]

Signature

Clinician Signature: [Name, credentials]

Date/Time Signed: [Date and time]