Periodontal Assessment and Treatment Planning
- Identification
- Demographics
- Chief complaint
- History of present illness
- Location
- Quality
- Severity
- Duration
- Timing
- Context
- Modifying factors
- Associated signs and symptoms
- Past medical history
- Past illnesses
- Hospitalizations
- Injuries
- Accidents
- Surgeries
- Allergies
- Immunizations
- Substance abuse
- Diet
- Sleep
- Review of systems
- Constitutional symptoms
- Eyes
- Ears, nose, mouth, throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary
- Neurological
- Psychiatric
- Endochrine
- Hematologic/Lymphatic
- Allergic/Immunologic
- Family diseases
- Childhood diseases
- Social history
- Alcohol
- Tobacco
- Illicit drugs
- Occupation
- Sexual preferrence
- Incarceration
- Travel
- Allergies
- Current medications
- Dosage
- Frequency
- Purpose
- Last dental visit
- Last dental cleaning
- Last x-rays
- Frequency of dental exams
- Frequency of brushing
- Frequency of flossing
- Bleeding gums
- Sensitive teeth
- Sensitive gums
- Use of fluoridated toothpaste
- Use of fluoride supplements
- Use of mouthwashes
- Past treatment of gum disease
- Family history of gum disease
- Injuries to face or jaws
- Orthodontics
- Oral surgery
- TMJ treatments
- Removable appliances
- Problems with past dental treatment
- Anxieties or fears
- Mouth odors or unpleasant tastes
- Food traps
- Dry mouth
- Gagging
- Loose teeth
- Cold sores or canker sores
- Sore jaws, especially in the morning
- Appearance
- General physical status
- Communications; speech; voice; eye contact
- Stature; posture; gait
- Physical limitations
- Asymmetries
- Vital signs
- Blood pressure
- Pulse
- Temperature
- Respiration
- Face
- Symmetry
- Swelling
- Scars
- Muscle tone
- Jaw movement
- Expression
- Twitch
- Paralysis
- Signs of abuse
- Pigmentation
- Skin
- Color
- Moisture
- Tone
- Rash
- Lesions
- Growths
- Hair
- Loss
- Texture
- Breath
- Malodor
- Eyes
- Shape
- Size
- Color
- Lacrimation
- Dryness
- Dilated pupils
- Eye glasses
- Contact lenses
- Vision
- Bulging
- Movements
- Halos
- Sinuses
- Frontal
- Maxillary
- Parotid glands
- Location
- Enlargements
- Thyroid gland
- Location
- Asymmetry
- Enlargement
- Lymph nodes
- Enlargements
- Pain or tenderness
- Movable/fixed
- Indurated
- Length of time
- Temporomandibular joints
- Symptoms
- pain
- sounds
- headaches
- earaches
- locking
- pain in neck, shoulder, back
- pain during swallowing
- Changes in symptoms
- Pain on palpation, loading
- Sounds
- Crepitus
- Range of motion
- Maximum opening
- Deviation on opening or closing
- Lateral excursion
- Protrusion
- Retrusion
- Symptoms
- Muscles of mastication
- Masseter
- Temporalis
- Trapezius
- Sternocleidomastoid
- Lips
- Color
- Texture
- Size
- Lesions
- Ulcers
- Blisters
- Angular chielosis
- History of sun exposure
- Mucobuccal fold
- Color
- Contour
- Frenum
- Signs of tobacco use
- Buccal mucosa
- Color
- Traumatic lesions
- Linea alba
- Moistness
- Parotid papilla
- Fordyce granules
- Leukoedema
- Pigmentation
- Hard palate
- Height
- Contour
- Color
- Rugae
- Tori
- Incisive papilla
- Growths
- Ulcers
- Lesions
- Nicotinic stomatitis
- Denture stomatitis
- Soft palate
- Color
- Size
- Shape
- Lesions
- Ulcers
- Trauma
- Gag reflex
- Uvula
- Size
- Shape
- Midline location
- Oropharnyx
- Tonsils present
- Lesions
- Growths
- Tongue
- Shape
- Color
- Texture
- Consistency
- Papillae
- Coating
- Lesions
- Growths
- Functional deviation
- Scalloping
- Fissures
- Floor of mouth
- Wharton's duct openings
- Varicosities
- Lesions
- Frenum
- Muscles of mastication
- Medial pterygoid
- Lateral pterygoid
- Saliva
- Adequacy
- Patient complaints
- Color:
- pink
- erythematous
- cyanotic
- racial pigmentation
- metallic pigmentation
- uniformity
- Contour:
- recession
- clefts
- enlarged papillae
- cratered papillae
- blunted papillae
- highly rolled
- bulbous
- knife-edged
- scalloped
- stippled
- Consistency:
- firm
- edematous
- hyperplastic
- fibrotic
- Band of gingiva:
- amount
- quality
- location
- treatability
- Bleeding tendency:
- sulcus base, lining
- gingival margins
- Suppuration
- Sinus tract formation
- Pocket depths
- Pseudopockets
- Frena
- Vestibular depth
- Mucogingival line
- Lesions
- Pain
- Indications of tobacco use
- Other pathology
- Missing teeth
- Supernumerary teeth
- Retained primary teeth
- Defective restorations:
- overhangs
- open contacts
- poor contours
- Fractured cusps
- Caries
- Pulp exposures
- Food impactions
- Deposits:
- Type
- plaque
- calculus
- stain
- matera alba
- Location
- supragingival
- subgingival
- Severity
- mild
- moderate
- severe
- Type
- Wear facets
- Percussion sensitivity
- Tooth vitality
- Attrition, erosion, abrasion
- Occlusal plane level
- Occlusion findings
- Angle Class
- Overjet
- Overbite
- Midlines
- Alignment
- Malposed
- Super-eruption
- Ankylose
- Furcations
- Mobility
- Fremitus
- Removable prosthetics
- Film dates
- Crown:root ratio
- Amount of bone loss
- horizontal; vertical
- localized; generalized
- Root length and shape
- Overhangs
- Bulbous crowns
- Fenestrations
- Dehiscences
- Tooth resorption
- Retained root tips
- Impacted teeth
- Root proximities
- Tilted teeth
- Radiolucencies/opacities
- Endodontic lesions
- Perio-endo lesions
- Local:
- plaque/biofilm
- calculus
- overhangs
- orthodontic apparatus
- open margins
- open contacts
- improper pontic design
- stainless steel crown
- overcontoured restoration
- biologic width violation
- tooth position
- crowded teeth
- excessive overbite
- rotations
- tipping
- overeruptions
- exaggerated occlusal curves
- stepped occlusion
- fanning
- cross-bites
- plunger cusps
- uncleansable furca
- poor embrasures
- enamel pearl
- root fracture
- food impaction
- chemical irritation
- Functional:
- bruxism
- occlusal trauma
- tongue thrusting
- thumb sucking
- mouth breathing
- other habits
- Systemic:
- smoking
- pregnancy
- hormonal disturbances
- oral hormonal therapy
- diabetes
- blood dyscrasias
- collagen diseases
- cardiac disease (anoxic conditions)
- arthritis
- adolescence
- handicap/disability
- occupation
- nutritional deficiency
- immune disorders
- cancer treatment
- Other systemic disorders
- Periodontal diagnosis, as well as other diagnoses
- See the AAP Disease Classification reference.
- Patient cooperation
- Initial amount of disease present
- Initial rate of disease present
- Patient age
- Systemic problems
- Mobility
- Cause of mobility
- Pocket depth/proximity to apex
- Number of missing teeth
- Success of previous treatment
- Location of missing teeth
- Bone loss
- Crown to root ratio
- Furcation involvement
- Amount of gingiva
- Operator skill
- Patient finances
- Patient systemic background
- Severity of inflammation
- Malocclusion
- Tooth and root morphology
- Status of abutment teeth
- Infrabony pockets
- Nonvital teeth
- Tooth resorption
- Proposed therapy
- Patient education
- Management of periodontal-systemic factors
- Removal of local factors
- Chemotherapeutic agents
- Resective procedures
- Regenerative procedures
- Gingivoplasty procedures
- Occlusal procedures
- Preprosthetic procedures
- Extractions
- Orthodontics
- Implants
- Informed consent
- Risks and complications
- Alternate treatment plans
- Need for ongoing periodontal maintenance
- Need for patient compliance and oral hygiene
- Recommended referrals to physicians
- Recommended referrals to other dentists
- Reevaluations
- Periodontal maintenance
