The Root Surface Debridement (Step 2) Notes Template

BSP UK CPG (2021) now uses the term "subgingival PMPR" instead of "root planing" — and requires documentation of patient engagement before Step 2 starts. Below is a template for UK clinicians to paste into their PMS for each Step 2 visit.

Why this root surface debridement (Step 2 NSPT) template wins

• BSP-aligned terminology: "subgingival PMPR" not "root planing" — current UK standard.
• Patient engagement re-assessment BEFORE Step 2 — BSP CPG requires evidence of OH compliance before progressing.
• Specific instruments documented (ultrasonic + Gracey) — defends against "you didn't treat properly" if pockets fail to resolve.
• Adjunct decision rationale — local antimicrobials and PDT are evidence-based for specific scenarios; document the indication.
• Furcation-specific access noted — Grade 2 furcations are the hardest to manage; specific technique documented.

The template (paste into your PMS notes field)

Paste the root surface debridement (Step 2 NSPT) template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

STEP: 2 (Non-surgical periodontal therapy — subgingival PMPR)
QUADRANT(S) THIS VISIT: [UR / UL / LR / LL — typically one per visit, sometimes two for full-mouth scaling protocols]
VISIT NUMBER: [__ of __ planned]

PRE-TREATMENT RE-ASSESSMENT:
- Time since Step 1: [Weeks]
- OH compliance: [Plaque score / qualitative / patient engagement]
- BoP at quadrant being treated today: [%]
- Pocket depths to be addressed today: [Range / specific sites]

MHx UPDATE: [Reviewed — unchanged / changes]

ANAESTHESIA: [None / topical / LA — agent + volume + technique per quadrant]

SITES TREATED (this visit):
- Teeth: [List FDI]
- Pocket depths addressed: [Per site or per quadrant]
- Instruments used: [Ultrasonic (piezo/cavitron — tip used) + Gracey curettes / mini-blade Gracey for deep pockets / both]
- Subgingival access: [Closed (non-surgical) approach]

ADJUNCTS:
- Local antimicrobial: [None / chlorhexidine chip (PerioChip) / minocycline (Arestin) — clinical justification]
- Photodynamic therapy (PDT): [None / used — clinical justification]
- Systemic antibiotic: [None — not first-line per BSP / amoxicillin + metronidazole only for aggressive forms — justification documented]

POST-DEBRIDEMENT CHECK:
- BoP immediately post: [Reduced / similar — note]
- Pocket depth reduction expected at re-evaluation
- Subgingival deposits removed: [Confirmed by tactile sweep]

OH REINFORCEMENT: [Targeted advice for sites bleeding — interdental aid, technique, dietary]

PATIENT TOLERANCE: [Well / discomfort — paused / re-anaesthetised]

REVIEW: 8-12 weeks post-completion of all Step 2 visits — full reassessment including pocket depths, BoP, staging review.

Try the root surface debridement (Step 2 NSPT) note in the live demo → No account needed.

What good looks like — a worked example

The same root surface debridement (Step 2 NSPT) template, completed for a realistic case.

STEP: 2 — Subgingival PMPR
QUADRANT(S) THIS VISIT: LL
VISIT NUMBER: 1 of 4 planned (1 quadrant per visit)

PRE-TREATMENT RE-ASSESSMENT:
- Time since Step 1: 6 weeks
- OH compliance: Plaque score improved from 65% to 40% since Step 1. Patient now flossing daily, using TePe interdentals as advised. Smoking cessation: cut down from 15/day to 8/day (engaged with NHS Stop Smoking).
- BoP at LL today: 45% sites
- Pocket depths to be addressed today: LL6 distal 7mm (Grade 2 furcation), LL6 mesial 5mm, LL7 mesial 5mm, LL7 distal 4mm, LL5 distal 5mm

MHx UPDATE: Reviewed — unchanged. HbA1c stable at 6.5%.

ANAESTHESIA: IDB + long buccal articaine 4% 1:100,000, 2ml. Profound anaesthesia LL quadrant.

SITES TREATED:
- Teeth: LL5, LL6, LL7
- Pocket depths addressed: All ≥4mm sites instrumented
- Instruments used: Ultrasonic (EMS Piezon, PI tip for pockets) — initial debridement. Followed by Gracey curettes (1/2 anterior, 11/12 + 13/14 for LL molars, mini-blade 11/12 for deep LL6 distal pocket). Furcation accessed with curved ultrasonic tip.
- Subgingival access: Closed (non-surgical) approach throughout. No flap.

ADJUNCTS:
- Local antimicrobial: PerioChip placed at LL6 distal (7mm pocket with Grade 2 furcation — high-risk site for non-response).
- PDT: Not used
- Systemic antibiotic: None — not first-line per BSP for periodontitis Stage III Grade B.

POST-DEBRIDEMENT CHECK:
- BoP immediately post: Reduced at most sites
- Subgingival deposits removed: Confirmed by tactile sweep — no detectable residual calculus
- Subjective: smooth root surface achieved

OH REINFORCEMENT: Targeted advice for LL6 — interdental brush (TePe 0.4mm pink) plus rubber-tipped stimulator for furcation. Specific technique demonstrated for furcation access.

PATIENT TOLERANCE: Well. No discomfort. Mild post-LA numbness expected for 2-3 hours.

REVIEW: Next Step 2 visit (LR quadrant) in 2 weeks. All 4 quadrants to be completed within 6 weeks. Full reassessment booked for 8 weeks after last Step 2 visit.

Compliance: the medico-legal angle

• BSP UK Clinical Practice Guidelines (EFP S3, 2021) — Step 2 NSPT framework including patient engagement requirement.
• Terminology change — "subgingival PMPR" replaces "root planing" per BSP 2021.
• GDC Principle 4 — operative records sufficient for continuation by another clinician.
• BSP guidance on antimicrobial stewardship — systemic antibiotics only for aggressive (now Grade C / Stage III/IV with rapid progression) forms.

Common documentation mistakes

• Starting Step 2 without patient engagement evidence (improved OH score) — BSP requires Step 1 success first.
• Routine systemic antibiotic prescription for Step 2 — antimicrobial stewardship issue, NOT BSP first-line.
• No 8-12 week re-evaluation booked — without this, Step 3 decision (surgery or refer) can't be made.
• Using "root planing" terminology — outdated; BSP has moved to PMPR.
• No furcation-specific access documented for grade 2/3 furcation sites — leaves the area under-treated.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (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

• Direct Access Records for Hygienists and Therapists (UK): What to Document
• Periodontal Staging and Grading: A UK Reference (2017 World Workshop / BSP)

Patient leaflets for this treatment

• After Your Gum Treatment
• Your Guide to Periodontal Treatment
• Understanding Gum Disease

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Browse the full set of free dental notes templates.