dental smiles - perio chart

dental smiles

Periodontal Examination Record

Patient Name:

Date:

Clinician:

F

L

L

F

Perio Assessment

Gingival Color:

Gen Loc Pink Red Marg Cyanotic Diff Red Pigment Other:

Inflammation:

Light Moderate Severe

Calculus:

Light Moderate Heavy

Case Type:

I II III IV

Treatment Plan

Proc	UR	UL	LL	LR
SRP
Gingivectomy
Osseous/MG

Notes: