Below I share the templates I personally use to document my appointments. Feel free to copy (Ctrl + C) and paste (Ctrl + Shift + V) and EDIT to fit your particular needs.
Prophylaxis Recall/Periodontal Maintenance
Reason for today’s visit: Adult prophy, Periodontal Charting, Periodontal Maintenance, Periodic Exam, X-rays 4BWs 2PAs
Medical History: Reviewed medical history and patient states there are no changes.
Blood Pressure: Pulse: Respiration:
Patient’s Concerns: Patient reports no concerns.
Procedures performed today: X-rays taken: 4BWs, PA #8, PA #25, Patient tolerated x-rays well.
Removed plaque with prophy cup and paste. Used ultrasonic to remove hard deposits and stain. Flossed to detect remaining calculus and hand-scaled to remove.
Findings:
Gingiva: generalized pink, firm, stippled; localized red, inflamed, rolled margins, ulcerated sulcus
Recession: localized to posterior buccal molars and mandibular buccal premolars 1-2 mm
Plaque: generalized light interproximal, localized moderate distal to second molars
Calculus: light supragingival localized to the lower lingual anterior teeth and maxillary buccal molar interproximal.
Stain: light extrinsic stain localized to the lingual surfaces of anterior incisors
Bleeding: light generalized interproximal to posterior molars
Tongue Coating: light moderate heavy white yellow coating
Periodontal Charting: full mouth probing with generalized 2-3 mm probing depths and localized 4mm probing depths. Generalized slight bleeding on probing.
Periodontal Status:
Periodontal health and gingival health
Gingivitis: biofilm-induced
Periodontitis:
Extent and distribution: Localized (less than 30% of teeth), generalized (greater than 30% of teeth)
Stage: Stage I: Initial periodontitis
Stage II: Moderate periodontitis
Stage III: Severe periodontitis with the potential for additional tooth loss
Stage IV: Severe periodontitis with the potential for loss of dentition
Grade: Grade A: Slow rate of progression
Grade B: Moderate rate of progression
Grade C: Rapid rate of progression
Intraoral/Extraoral Cancer Exam: normal findings; Non-smoker
TMJ: Normal. Patient reports no pain.
Patient’s Home Oral Hygiene: Good Fair Poor; patient uses manual toothbrush and flosses irregularly with string floss floss picks
Oral hygiene instruction recommendations: recommended
Dental Exam: Performed by Dr. . No findings. Diagnosed: Treatment Planned:
Next Hygiene Visit: 6 month recall
Attending Hygienist: Natalie Fritz, RDH License #:
Non-surgical Scaling and Root Planing Procedure
Reason for today’s visit: Scaling and Root Planing (SRP) Procedure for UL/LL UR/LR quadrants
Medical History: Reviewed medical history and patient states there are no changes. There are no contraindications for treatment.
Blood Pressure: Pulse: Respiration:
Chief Complaint/ Patient’s Concerns: Patient reports no concerns concerns of halitosis, pain, aesthetic concerns, tooth sensitivity (in patient’s own words)
Explained SRP procedure to patient and what to expect during and after the procedure. Explained the need for local anesthesia and how it will aid in pain control and allow a more comfortable removal of the subgingival debris for better gingival reattachment.
Procedures performed today: UL/LL UR/LR SRPs, Local Anesthesia administration, gingival irrigation with Chlorhexidine gluconate 0.12%
Local Anesthesia Administration:
Administered Right / Left side PSA, MSA, ASA, IA, Lingual, and Buccal nerve blocks.
Administered 2 cartridges (72mg) of lidocaine 2% 1:100,000 epinephrine
Administered 1 cartridge of Articaine (septocaine) (72mg) 4% 1:100,000 epinephrine
Patient tolerated procedure well.
Used ultrasonic scaler and hand instruments to remove supra and subgingival debris.
Irrigated gingival tissue with Chlorhexidine gluconate 0.12%
Findings:
Gingiva: Generalized red, inflamed, rolled margins, ulcerated sulcus; localized areas of pink, firm, stippled tissue.
Recession: localized to posterior buccal molars and mandibular buccal premolars 1-2 mm
Plaque: generalized moderate interproximal and marginal
Calculus: light supragingival localized to the lower lingual anterior teeth and maxillary buccal molar interproximal. Moderate dark black subgingival calculus localized to the posterior molars.
Stain: moderate dark extrinsic stain localized to the lingual surfaces of anterior incisors
Bleeding: light generalized interproximal to posterior molars
Tongue Coating: light moderate heavy white yellow coat
Periodontal Status: Periodontitis:
Extent and distribution: Localized (less than 30% of teeth), generalized (greater than 30% of teeth)
Stage: Stage I: Initial periodontitis
Stage II: Moderate periodontitis
Stage III: Severe periodontitis with the potential for additional tooth loss
Stage IV: Severe periodontitis with the potential for loss of dentition
Grade: Grade A: Slow rate of progression
Grade B: Moderate rate of progression
Grade C: Rapid rate of progression
Post-op Instructions: Instructed patient of the expected duration of the local anesthesia and the need to avoid chewing on the anesthetized part of the mouth to prevent trauma to the tissues. Advised to consume soft foods for the duration of the anesthesia. Instructed patient to rinse with warm salt water rinses to aid in the healing of the gum tissues. If needed, patient can take over the counter medications for pain control.
Next Visit: UR/LR UL/LL SRPs 6-week re-evaluation
Attending Hygienist: Natalie Fritz, RDH License #:
