The Periodontal Surgery Notes Template (Step 3)

Periodontal surgery records need both the pre-op parameters AND the intra-op findings — the surgical decision is justified by what you find when you raise the flap. Below is a template for UK periodontists and surgically trained GPs to paste into their PMS.

Why this periodontal surgery template wins

• Pre-op AND intra-op findings recorded — the surgical decision is justified by what was found on flap raising.
• Bone defect morphology classified — drives the choice between access / resective / regenerative.
• Materials with brand AND lot number — MDR + traceability + audit defence.
• Aesthetic recession discussed in consent — Montgomery defence for any anterior surgery.
• Written consent specifically called out — best practice for surgical procedures.

The template (paste into your PMS notes field)

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

INDICATION: [Persistent pocket ≥6mm with BoP after Step 2 / furcation grade 2-3 / regenerative case / aesthetic recession]

PROCEDURE TYPE: [Access flap (open flap debridement) / resective (apically positioned flap, ostectomy) / regenerative (GTR with membrane + graft) / mucogingival (root coverage)]

TOOTH/TEETH: [FDI]

PRE-OPERATIVE CLINICAL PARAMETERS:
- Pocket depths per site: [Pre-op measurements]
- BoP: [Sites bleeding]
- Furcation grade: [Hamp 1/2/3]
- Mobility grade: [Miller]
- Pre-op radiograph: [PA — bone level, defect morphology if visible]

CONSENT (Montgomery, written): Risks — post-op pain/swelling, gingival recession (expected — anterior aesthetic implications discussed), root sensitivity, recurrence requiring re-treatment, need for ongoing maintenance, possibility of tooth loss if surgery fails. Benefit: pocket reduction, ability to maintain at SPC, retain tooth. Alternative: extraction + implant/bridge, continued Step 2 monitoring (with progression risk). WRITTEN CONSENT signed and dated.

LA: [Agent + volume + sites]. Profound anaesthesia.

FLAP DESIGN:
- Incision: [Sulcular / paramarginal / Widman / modified Widman / coronally advanced / lateral pedicle]
- Releasing incisions: [None / mesial / distal / both]
- Flap reflection: [Full-thickness / split-thickness]
- Both buccal + lingual/palatal: [Y/N]

INTRA-OP FINDINGS:
- Bone defect morphology: [Suprabony / 1-wall / 2-wall / 3-wall / intrabony / circumferential]
- Furcation confirmed: [Hamp grade]
- Granulation tissue: [Removed]
- Root surface assessment: [Smooth / residual deposits removed during surgery]

PROCEDURE-SPECIFIC:
- Access flap: Debridement with curettes + ultrasonic under direct vision. Root surface conditioning [EDTA / none].
- Resective: Ostectomy of __ mm to eliminate suprabony pockets. Osteoplasty for soft tissue contour.
- Regenerative: GTR membrane [type + brand + lot number]. Bone graft [autograft / allograft / xenograft / alloplast — brand + lot number]. Coronal advancement / flap fixation.
- Mucogingival: Root coverage with [coronally advanced flap / connective tissue graft from palate / acellular dermal matrix].

SUTURES: [Material — Vicryl 5-0 / 6-0 / nylon / silk / chromic — number — pattern: interrupted / horizontal mattress / sling — sites]

POST-OP RADIOGRAPH: [Y/N — confirms graft/membrane position if regenerative]

POST-OP DRESSING: [Periodontal pack — Coe-Pak / none]

POST-OP INSTRUCTIONS (verbal + written): Avoid mechanical trauma to surgical site. CHX 0.2% mouthwash twice daily from day 2 (rinse only, no brushing of surgical site for 7-10 days). Soft diet 1 week. Analgesia. Antibiotic per protocol if regenerative. Avoid smoking (impacts outcome). Contact if bleeding, severe swelling, suture loss.

PRESCRIPTIONS: [Analgesia / CHX / antibiotic if regenerative — clinical justification documented]

REVIEW: Suture removal 7-10 days. Subsequent reviews at 2 weeks, 6 weeks, 3 months, 6 months. Pocket re-measurement and SPC at 6 months.

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

What good looks like — a worked example

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

INDICATION: Persistent 8mm pocket distal LL6 with BoP and Grade 2 furcation after Step 2 NSPT + smoking cessation. Non-responsive. Patient prefers retention over extraction.

PROCEDURE TYPE: Regenerative — GTR with membrane + xenograft for intrabony defect

TOOTH: LL6

PRE-OPERATIVE CLINICAL PARAMETERS:
- Pocket depths: Distal LL6 — MB 5mm, B 7mm, DB 8mm. ML 4mm, L 6mm, DL 8mm.
- BoP: At all distal sites
- Furcation grade: Hamp 2 (buccal furcation)
- Mobility grade: Miller 1
- Pre-op radiograph: PA today (quality A) — intrabony defect distal LL6 visible, ~4mm depth, 2-wall morphology suggested

CONSENT (Montgomery, written): Risks discussed in detail — post-op pain/swelling (manageable), recession expected especially anterior of LL6 (already established loss), root sensitivity, recurrence requiring re-treatment, need for ongoing 3-monthly SPC, possibility of LL6 loss if surgery fails (long-term success ~70-80% for regenerative). Benefit: pocket reduction, bone regeneration, retain LL6. Alternative: extraction + implant (more expensive, longer Tx), continued non-surgical (progression risk to tooth loss). WRITTEN CONSENT signed and dated.

LA: Articaine 4% w/ adrenaline 1:100,000, 3.4ml — IDB + long buccal + lingual infiltration LL. Profound anaesthesia.

FLAP DESIGN:
- Incision: Sulcular LL5-LL7 with conservative papilla preservation
- Releasing incisions: Vertical mesial LL5
- Flap reflection: Full-thickness mucoperiosteal
- Both buccal + lingual: Yes — to expose distal LL6 furcation and intrabony defect

INTRA-OP FINDINGS:
- Bone defect morphology: 2-wall intrabony defect distal LL6, ~4mm depth, ~6mm wide. Apical extent within attached gingiva.
- Furcation confirmed: Hamp 2 (buccal, ~3mm horizontal probing into furcation)
- Granulation tissue: Completely removed from defect and root surface
- Root surface assessment: Smooth after surgical debridement. EDTA conditioning 1 min, rinsed.

REGENERATIVE PROCEDURE:
- GTR membrane: Bio-Gide resorbable collagen membrane (Geistlich). Lot number: [BG-2026-04-456]
- Bone graft: Bio-Oss xenograft (Geistlich), 0.5g particle 0.25-1mm. Lot number: [BO-2026-03-789]
- Defect filled with Bio-Oss to bone crest level
- Membrane placed over graft, extending 3mm onto adjacent bone
- Coronal advancement of flap to cover membrane

SUTURES: Vicryl 6-0, 8 sutures — interrupted papilla sutures + horizontal mattress for coronal advancement + 2 closing relieving incision

POST-OP RADIOGRAPH: PA taken — graft material visible in defect, membrane radiolucent. Position acceptable.

POST-OP DRESSING: None — flap secure with sutures.

POST-OP INSTRUCTIONS (verbal + written): Avoid mechanical trauma. CHX 0.2% mouthwash twice daily from day 2 (rinse only, NO brushing of surgical site for 14 days). Soft diet 2 weeks. Analgesia — ibuprofen 400mg + paracetamol 1g PRN. Amoxicillin 500mg TDS for 7 days (regenerative protocol — antibiotic indicated to support healing). Avoid smoking. Contact if bleeding, severe swelling, suture loss.

PRESCRIPTIONS: Ibuprofen + paracetamol PRN. CHX 0.2%. Amoxicillin 500mg TDS for 7 days (clinical justification: regenerative procedure with foreign material requiring antibiotic prophylaxis).

REVIEW: Suture removal 14 days (longer for regenerative). Reviews at 2, 6, 12 weeks. 3-month pocket re-measurement. 6-month definitive outcome assessment. SPC 3-monthly thereafter.

Compliance: the medico-legal angle

• BSP UK CPG (EFP S3, 2021) Step 3 — surgical management framework.
• MDR 2017 — biomaterials (membrane, bone graft) are regulated medical devices requiring lot traceability.
• Montgomery — surgical risks (recession, sensitivity, recurrence, tooth loss) must be specifically discussed.
• CGDent — surgical records must be sufficient for continuation by another clinician.
• SDCEP antimicrobial guidance — antibiotic for regenerative cases is acceptable with documented rationale; not for routine access flap.

Common documentation mistakes

• Proceeding to surgery without adequate Step 2 trial — BSP requires Step 2 NSPT first.
• Bone defect morphology not classified intra-op — regenerative case selection undocumented.
• No lot numbers for biomaterials — MDR breach + traceability gap if material recall.
• Routine antibiotic prescription for non-regenerative surgery — not indicated; antimicrobial stewardship issue.
• No detailed long-term review schedule — surgical outcomes assessed at 6 months minimum, often 1-2 years for regeneration.

Sources

• 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)
• 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

Patient leaflets for this treatment

• After Your Gum Treatment
• Caring for Stitches After Dental Surgery
• Your Guide to Gum Surgery

Related dental note templates

Browse the full set of free dental notes templates.