Periodontal Treatment Notes Template: Complete Guide With Template (2024)

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PERIODONTAL TREATMENT

Complaints: .....
Consent to start examination and treatment: Written/Verbal
Medical History: Checked, no changes, see attached sheet
Extra-Oral: TMJ, LN, FS, Lips : no abnormalities detectedIntra-Oral: Gingivae appearance:
Buccal mucosa, palate, floor of mouth, tongue: No abnormalities detected
BPE:
6PPC :
Approximate plaque score …%
Approximate bleeding score …%

DISCUSSION:

Gingivitis explained – inflamed gums and is reversible with improved oral hygiene. May progress to periodontitis if not managed.
Explained to patient disease process of periodontitis. If there is some bone loss, teeth will start to feel wobbly. With significant bone loss, teeth will start to fall out. Patient knows we can only slow down or stop the disease process. Patient informed of importance of own responsibility and the relationship between oral hygiene and disease. Discussed risks and benefits of root surface debridement as treatment.
Risk: Appearance of ‘black triangles’. Teeth may appear longer when gums are less inflamed. Recession. Sensitivity
Benefits: Stop disease process. Healthier gums

….. colour tepe use demonstrated to patient. Reinforced good brushing technique with patient.

Procedure: Root Surface Debridement of ….
Local Anaesthetic:
......
Root surface debridement carried out using combination of ultrasonic scaler and hand scaler.
POIG. Explained poss sensitivity. Painkillers if sensitive + not contraindicated
Patient given an opportunity to ask questions.
Patient happy.

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Periodontal disease management is a significant part of dental care. Effective documentation of periodontal treatment through detailed notes is essential for patient care, legal compliance, and practice management. This guide presents a comprehensive approach to writing periodontal treatment notes complemented by a template that reflects 2024 standards.

The Relevance of Detailed Periodontal Treatment Notes

Detailed periodontal treatment notes serve numerous important functions:

They provide a record of the examination findings and treatments administered.
They help in planning future care and evaluating the treatment’s efficacy.
They ensure clear communication across the dental care team.

These notes should include observations, patient education, and specific treatments performed.