Headings
Medical history update · Probing depths · Bleeding on probing · Mobility and recession · Debridement · Home care review · Recall interval
When to use it
Use this for patients who have had periodontal therapy and now come in every three or four months. It tracks probing depths, bleeding and mobility against last time, so you can tell stable sites from active ones. A routine prophylaxis on healthy gums belongs in the hygiene visit note.
Example
Fictional example
Medical history update
Type 2 diabetes. Patient reports last A1c of 7.4%.
Probing depths
4 to 5 mm on posteriors. 6 mm distolingual #18, up from 5 mm.
Bleeding on probing
18% of sites, down from 26%.
Mobility and recession
Class I mobility #24 and #25. 2 mm facial recession #11.
Debridement
Full mouth ultrasonic debridement. Root planing at #18 after infiltration, 1 carpule 4% articaine with 1:100,000 epinephrine, 68 mg.
Home care review
Plaque on lingual of lower molars. Fitted interdental brushes.
Recall interval
3 months. If #18 does not improve, refer to periodontist.