Periodontal Assessment Notes Template for UK Dentists

Recording BPE only when full 6-point charting is indicated is a recurring deficiency in UK periodontal claims — failure to diagnose, monitor, or communicate periodontal disease is a frequent allegation in GP dental claims. Below is a full assessment template for UK clinicians to paste into their PMS.

Why this periodontal assessment template wins

• Risk factors structured — smoking, diabetes, family history, medications all explicitly captured. Drives grading.
• BPE + full 6-point chart triggering rule — code 3 or 4 triggers full chart. Defends against "you only did BPE" claims.
• BSP/EFP 2017 staging + grading — current UK standard, replaces old AAP classification.
• Stepped treatment plan — BSP Step 1-4 framework so the patient (and you) know what comes next.
• Diagnosis communicated to patient documented — failure to communicate the diagnosis is a common basis for periodontal complaints.

The template (paste into your PMS notes field)

Paste the periodontal assessment template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

REASON FOR ASSESSMENT: [New patient / recall / specific concern / referral baseline]

RISK FACTORS:
- Smoking: [Never / Ex (years ago) / Current — cigs/day]
- Diabetes: [None / Type 1 / Type 2 — HbA1c if known]
- Family Hx of perio: [Y/N]
- Medications affecting gums: [CCBs / phenytoin / ciclosporin / none]
- Stress / occlusal trauma: [Noted]
- Diet / vitamin C / nutrition flags: [None / specify]

BPE — all 6 sextants:
  UR _   UA _   UL _
  LR _   LA _   LL _
(* if furcation visible)

PLAQUE SCORE: [% sites with plaque on disclosure / visible plaque qualitative]
BLEEDING ON PROBING (BoP): [% sites with bleeding on light probing]

[IF BPE 3 (any sextant) or BPE 4 (whole mouth) — proceed to FULL 6-POINT CHART:]

FULL PERIODONTAL CHART:
- 6-point pocket depths per tooth (MB / B / DB / ML / L / DL)
- Bleeding sites marked
- Recession measured per site
- Furcation grade per molar (Hamp 1/2/3)
- Mobility grade per tooth (Miller 1/2/3)

RADIOGRAPHIC ASSESSMENT: [Bitewings / PA / OPG — bone levels generalised vs localised; horizontal vs angular pattern]

STAGING (BSP/EFP 2017):
- Stage: I (mild) / II (moderate) / III (severe) / IV (severe with complexity) — from interdental CAL / bone loss by root third, tooth loss and complexity
- Extent: localised (<30% teeth) / generalised
- Distribution: molar-incisor pattern / other

GRADING:
- Grade (BSP UK): % bone loss ÷ age <0.5 = A (slow) / 0.5-1.0 = B (moderate) / >1.0 = C (rapid)
- Modifying risk factors (Grade modifier): smoking, diabetes

DIAGNOSIS COMMUNICATED TO PATIENT: [Documented — diagnosis explained, prognosis discussed, treatment options outlined]

INITIAL TREATMENT PLAN (BSP Steps):
- Step 1: OHI, risk factor control, supragingival PMPR, professional motivation
- Step 2 (if pocket >4mm with BoP): subgingival PMPR
- Step 3 (if persistent ≥6mm pockets after Step 2): surgical management or referral
- Step 4 (SPC): maintenance interval planned

CONSENT: [Diagnosis, treatment options, alternatives (including non-treatment with progression risk), prognosis discussed and documented]

REVIEW: [8-12 weeks for Step 2 reassessment if NSPT initiated]

Try the periodontal assessment note in the live demo → No account needed.

What good looks like — a worked example

The same periodontal assessment template, completed for a realistic case.

REASON FOR ASSESSMENT: New patient — recently moved to area. BPE today showed 4s in both lower sextants, full chart indicated.

RISK FACTORS:
- Smoking: Current — 15 cigs/day for 20 years. Discussed cessation. Provided NHS Stop Smoking Service leaflet.
- Diabetes: Type 2, well-controlled. Last HbA1c 6.5% (5 months ago).
- Family Hx of perio: Patient reports mother lost teeth in 40s — possible familial component.
- Medications: Metformin 500mg BD. No CCBs.
- Stress: Reports work stress. No obvious bruxism.
- Diet: Adequate fruit/veg.

BPE — all 6 sextants:
  UR 2   UA 1   UL 2
  LR 4   LA 1   LL 4*
(* = furcation visible LL6)

PLAQUE SCORE: 65% sites visible plaque (heavy). Disclosing not done today — qualitative.
BLEEDING ON PROBING (BoP): ~50% sites bled on light probing.

FULL PERIODONTAL CHART completed (saved to attached chart on PMS):
- Generalised pockets 4-5mm
- Localised 7-8mm pockets LL6-7 area (mesial-buccal aspect, distal-buccal aspect, mesial-lingual)
- Significant 7mm pocket distal LL6 with Grade 2 furcation
- Recession 2-3mm UR3, UL3
- Mobility Grade 1 LL6, LL7
- BoP at 80% of pocketed sites

RADIOGRAPHIC ASSESSMENT: BWs + PAs LL sextant. Generalised horizontal bone loss ~40% of root length. Localised angular bone loss LL6 distal extending to mid-root level. Apical 1/3 of LL6 distal root unaffected.

STAGING:
- Stage III (severe — based on >50% bone loss at LL6)
- Extent: generalised (>30% teeth affected by some bone loss; severe localised LL sextant)
- Distribution: Molar-related (LL6 worst affected; otherwise generalised mild-moderate)

GRADING:
- Grade B (moderate progression) — interproximal bone loss / age ratio (BSP UK) ~1.0 (40% loss at age 40), in the 0.5-1.0 band
- Modifying factors: smoking (significant — would push to Grade C if not controlled), diabetes (well-controlled, not modifying)

DIAGNOSIS COMMUNICATED TO PATIENT: Diagnosis explained as "moderate-to-severe gum disease, worst around lower back-left tooth where loss is significant." Prognosis without treatment: progressive bone loss, tooth mobility, eventual tooth loss especially LL6. Prognosis with full treatment + smoking cessation: significant improvement possible.

INITIAL TREATMENT PLAN (BSP Steps):
- Step 1 (this visit): OHI — modified Bass, TePe interdental sizing demonstrated. Smoking cessation strongly recommended. Diabetes liaison with GP. Supragingival PMPR today (initial debridement).
- Step 2 booked: subgingival PMPR all pocketed sites (4 visits planned, 1 quadrant each).
- Step 3 will be considered at 8-12 week re-evaluation if LL6 pockets persist ≥6mm.
- Step 4 SPC: 3-monthly intervals planned post-treatment.

CONSENT: Full diagnosis, treatment plan over 4-6 months, smoking cessation impact, prognosis, alternatives (extraction of LL6 if doesn't respond) all discussed. Patient understands and consents to staged treatment.

REVIEW: 8-12 weeks after Step 2 completion for full reassessment.

Compliance: the medico-legal angle

• BSP BPE Guidelines (2019) — BPE screen at every assessment; full chart when code 3 or 4.
• BSP UK Clinical Practice Guidelines (EFP S3 implementation, 2021) — staging + grading framework, stepped treatment.
• CGDent record-keeping — periodontal records must enable monitoring over time.
• GDC Principle 4.1 — contemporaneous, complete record.
• Montgomery — non-treatment is an option that carries progression risk; this must be discussed and documented.

Common documentation mistakes

• BPE only, no full chart when Code 3 or 4 present — BSP non-compliance.
• No staging or grading recorded — fails the BSP/EFP 2017 standard.
• Risk factors (especially smoking, diabetes) not captured — grading is incomplete without them.
• No diagnosis communicated to patient — a common basis for periodontal complaints.
• Inappropriate referral or no referral when treatment is beyond competence — GDC Principle 6 breach.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• GDC Standards for the Dental Team, Principle 6: Work with colleagues in a way that is in patients’ best interests (accessed 18 October 2026)
• CGDent: Clinical Examination and Record-Keeping, Good Practice Guidelines (3rd edition) (accessed 18 October 2026)
• Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)
• BSP: The Basic Periodontal Examination (BPE), 2019 (accessed 18 October 2026)
• West N, et al. BSP implementation of European S3-level evidence-based treatment guidelines for stage I–III periodontitis in UK clinical practice. J Dent 2021 (accessed 18 October 2026)
• Sanz M, et al. Treatment of stage I–III periodontitis: the EFP S3 level clinical practice guideline. J Clin Periodontol 2020 (accessed 18 October 2026)

Frequently asked questions

Guides that cover this

• Hygienist & Therapist Notes Templates: 4 Worked Examples (UK)
• Dental Therapist vs Hygienist: Scope, Pay & Differences (UK)
• Periodontal Staging and Grading: A UK Reference (2017 World Workshop / BSP)
• UK Dental Charting & Clinical Notes: A Guide for Overseas-Trained Dentists
• GDC Registration for Overseas Dentists: Complete Route Guide (UK)
• Dental Hygienist New Graduate UK Guide

Patient leaflets for this treatment

• Understanding Gum Disease
• Your Guide to Periodontal Treatment

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