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Periodontal Assessment and Treatment Planning



Medical history
  • 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
Dental History
  • 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
Extraoral Description
  • 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
  • Muscles of mastication
    • Masseter
    • Temporalis
    • Trapezius
    • Sternocleidomastoid
Intraoral Description
  • 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
Gingival Description
  • 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
Dental Description
  • 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
  • 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
Radiographic Findings
  • 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
Etiologic Factors; Risk Factors
  • 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
Diagnosis
  • Periodontal diagnosis, as well as other diagnoses
  • See the AAP Disease Classification reference.
Prognosis
  • 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
Therapeutic Options
  • 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
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  • Home
  • Members Only
    • Member Directory
    • Meetings >
      • Current Schedule
      • Past Meetings
    • Live Surgeries
    • Topical Presentations
    • Case Discussions/Grand Rounds
    • Mentoring
    • Finances
    • CE Credits >
      • C.E. Instructions
      • Forms for Past Meetings
      • Blank CE Form
  • Reference
    • Lit Review Template
    • Supplies List
    • Suppliers
    • Clinical Photograph Sequence
    • Case Presentation Guide
    • Forms
    • Perio Exam and Treatment Planning
    • Perio Disease Classification System
    • Updates from Randall O
    • What Implant is That?
    • Pre-med Fax template
    • State Board Letter
  • Club Information
    • Club History
    • Club Bylaws
    • Sal Tribute
    • Extracurricular Activities
  • Patients
    • Informed Consent