________________________________

Name

________________________
ID Card No

M/F
Sex

________________________
Date of Birth (YYYY-MM-DD)

_____________
Age

_______________________________________________________________________________________

Date
______________________________________________________________________________________

Chief Complain

_______________________________________________________________________________________

Past Medical History

Nil Relevant
Diabetes
Hypertension
Heart Disease
Allergy
Smoking
Stroke

Remarks

_______________________________________________________________________________________

Past Dental History

Last Dental Visit

Remarks

___________________ for ___________________

Date

Treatment

Long time ago

Unknown
Family and Social History
Bruxism

Yes
No

Remarks

Smoke
Drink
Brushing habit: frequency
Toothpaste
Floss
IDB

Extra Oral Examination

Facial symmetry
Facial swellings
Lymph nodes

Normal Others: _____________________________________

NAD
Exist
Tender Location/Details: ________________
NAD
Palpable
Tender Location/Details: ________________

Temporo-mandibular
Joints

Normal

Remarks

Others
_______________________________________________________________________________________

Intra Oral Examination

Periodontium
BPE

Oral Hygiene

Remarks

Plaque
Calculus

Overall

Mild
Moderate
Severe
Mild
Moderate
Severe
Good
Fair
Poor

Preliminary Periodontal Diagnosis

Healthy
Gingivitis
Periodontitis
Periodontal Risk

High

Low

Endodontic
Root filled teeth (as shown on available radiographs)
Pulp testing
Nil
Coronal
Abrasion NAD________________________
Attrition NAD _________________________
Erosion NAD _______________________

Remarks

Occlusion
Incisor
Molar
Lateral excursion: L: Canine guidance Group function
Protrusion
Incisor guidance
Occlusal interference
Over-eruption
Drifted teeth
Function
Missing teeth
Mastication capability

No

Normal

Aesthetics
Missing teeth
Midline
Others

Soft Tissue
Lips
Cheeks
Palate
Tongue
Floor of mouth
Oral mucosa
Others
Hard tissue
Exostoses
Torus palatine
Torus mandibularis

Assess periodontal risk

BPE
+/- Radiographs
Risk factors: smoking, diabetes, medical history (e.g. Ca2+ channel blockers), family history, previous
periodontitis

No / Low Risk

Yes / High Risk

BPE
Smoking
Diabetes
Other medical history
Family history
Previous periodontitis
Poor oral hygiene

1/2

>=3
Yes
Yes
Yes
Yes
Yes
Yes

Treatment Guidelines
Yes / High Risk

No / Low Risk
Annual reasssesment

Risk
man
age
men
t

BPE 1/2
Recall 3-6/12

Recall 6-12/12
1. BPE
2. Risk re-assessment
3. Reset recall interval

BPE >=3
1. Full periodontal charting
2. Review every 3-4 weeks for 3
months
3. Maintenance every 3 months i.e.
supportive periodontal therapy,
e.g. RSD
1. Risk re-assessment
2. Annual full periodontal charting
3. Long-term risk management
4. Long-term maintenance care i.e.
supportive periodontal therapy
5. Referral?

Dx:
Healthy
Gingivitis
Chronic Periodontitis
Slight
Moderate
Severe
Localized =<30% sites
Generalized >30% sites
Aggressive periodontitis
Localized Generalized Mild Moderate Severe e.g. chronic periodontitis, aggressive periodontitis
Periodontal referral for high risk, non-responsive to previous treatment, aggressive periodontitis based on
severity of disease for age and rapid rate of periodontal breakdown
Caries Risk Assessment (Form)
CAMBRA/ADA
CAMBRA Preventive and Therapeutic Product Primer
CAMBRA Practice Protocols
Periodontal Risk Assessment in Supportive Periodontal Therapy (after Active Periodontal Therapy)
Recall/Maintenance System

Appendix

Basic Periodontal Examination (BPE)

0 No periodontal treatment
1 Oral hygiene instruction (OHI)
2 OHI, removal of plaque retentive factors, including all supra- and subgingival calculus
3 OHI, root surface debridement (RSD)
4 OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated.

* OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated.
Full periodontal charting for code 3 or above
PA Radiographs for 3 and 4 sextants
Annual full periodontal charting