Periodontal Assessment Guideline
Case Type I Case Type II Case Type III Case IV
Mild to Moderate Periodontitis Moderate Perio Advanced Perio
Data Base: Data Base: Data Base: Data Base:
Comprehensive Comprehensive Comprehensive Exam, Comprehensive Exam,
Exam, FMX or BW Exam, FMX** FMX** FMX**
Full Mouth Probe: Full Mouth Probe Full Mouth Probe
Full Mouth Probe or 4 – 5 mm pockets. 4 – 6 mm pockets. 5 – 8+ mm pockets.
First Appt: Data First Appt: Data First Appt: Data Base,
Treatment Base, Plus Initial Base, Plus Initial plus Initial Therapy
Option 1: Prophy Therapy (D1110, or Therapy (D1110 or (D1110 or D4355).
(D1110), OHI, D4355). D4355) Specialty Specialty referral.
ReCare Interval 6 referral at initial
months to 1 year. Second Appt: assessment or after Second Appt: RP/S
The time for this RP/S (D4341 or initial therapy (D4341)*
appt. should be D4342)* This appt. can be 60 –
45-60 minutes for This appt. can be 60 Second Appt: RP/S 90 minutes.
adults. – 90 minutes. (D4341)*
This appt. can be 60 – Third Appt:
Treatment Third Appt: RP/S 90 minutes. RP/S (D4341)* OHI.
Option 2: (D4341 or D4342)* This appt. can be 60 –
OHI. This appt. can Third Appt: RP/S 90 minutes.
1 Appt: be 60 – 90 minutes. (D4341)* OHI. This
Debridement appt. can be 60 – 90 Refer to periodontist
(D4355). The time Fourth Appt: Perio minutes. after initial assessment.
for this appt. should Re-evaluation
be 45 – 60 minutes (D0170) by the Fourth Appt: Perio
for adults. periodontist 4 weeks Re-evaluation (D0170)
after S R/P by the periodontist 4 Periodontal
2 Appt: weeks after S R/P. maintenance (D4910)
Prophy, OHI, Schedule 3 – 4 schedule will be
Recare Interval 6 month periodontal Periodontal determined by
months. The time maintenance maintenance (D4910) Periodontist when
for this appt. should (D4910) This appt. schedule will be appropriate. (D4910)
be 45 – 60 minutes should be 45 – 60 determined by This appt. should be 45
for adults. minutes. Periodontist when – 60 minutes.
appropriate. This appt.
should be 45 -60
These recommendations are guidelines. Clinical decisions are at doctor’s
discretion.**An FMX is preferred for patients diagnosed with periodontal disease.