Periodontal Evaluation

Periodontal Evaluation
Patient Name*

First NameLast Name
Treating Dentist or Periodontist:

As part of our evaluation of your patient for possible orthodontic treatment, we are in need of your opinion as to the patient’s periodontal status. Please include a full mouth series with your evaluation if you think it is necessary. Thank you for your assistance in this matter. If you have additional comments or questions, please include them in the space provided below.
Treating Dentist or Periodontist Name*

First NameLast Name
PROBING DEPTHS GREATER THAN 4.0 mm:
RADIOGRAPHIC EVIDENCE OF BONE LOSS:
AREAS OF ACTIVE PERIODONTAL DISEASE:
ORAL HYGIENE

ExcellentGoodFairUnacceptable
PATIENT NEEDS ACTIVE PERIODONTAL TREATMENT PRIOR TO ORTHODONTICS?*

YesNo
RECOMMENDED FREQUENCY OF RECALL VISITS? number of months monthly intervals.
ADDITIONAL COMMENTS?
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