P serial #: Group: eriodontal Examination & Charting Form



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Serial #:_____
Group: ______
eriodontal Examination & Charting Form



Student Name:

Computer No.:

Patient’s Name:

File No.

Age:_____ yrs. Gender:

Nationality

Marital Status: Occupation:

Date / /



Chief Complaint:


Dental History


M
Smoking:

No - Yes (type?, frequency?, how long?)


edical History




I. Extra-Oral Examination:


II. Intra-Oral Examination:

A


Oral Hygiene Habits


  • Type of Tooth brush:

Soft – Medium - Hard




  • Brushing Technique





  • Interdental Aids

Yes (type):

No

  • Miswak

Yes – No


  • Others:
- Gingiva:
i) Color:

ii) Tone (consistency):


iii) Contour:


iv) Surface texture:


v) Mucogingival Defects:


B- Other Oral Soft Tissues (Alveolar mucosa, Buccal mucosa, Tongue):





P
PATIENT NAME: ______________________ FILE NO.: ______________ DATE: __________


PERIODONTAL CHART

re-treatment Re-evaluation Recall maintenance






Diagnosis

















































CAL, BOP

















































































































































PD, PI, Calc

















































































































































CEJ-GM

















































































































































FACIAL









Mobility




LINGUAL



CEJ-GM

















































































































































PD, PI, Calc

















































































































































CAL, BOP









































































































































































































































































































































CAL, BOP

















































































































































PD, PI, Calc

















































































































































CEJ-GM

















































































































































LINGUAL






Mobility







FACIAL

CEJ-GM

















































































































































PD, PI, Calc

















































































































































CAL, BOP

















































































































































Diagnosis

















































GM- Gingival Margin. CAL- Clinical Attachment Loss. CEJ- Cementoenamel Junction. PD- Probing Depth

Pl- Plaque, if presents put *. Calc- Calculus, if presents put *. BOP- Bleeding on probing, if presents put red dot



Plaque Index




Bleeding Index








Periodontal Diagnosis:

Supervisor’s Signature

Radiographic Evaluation




Plaque Retentive Factors:

Over-hangs / defective restorations:


Calculus

Caries:

Alveolar Bone Assessment:

Horizontal Bone Loss (%)




___________________________________________


Crestal Bone Density

Vertical Defects:




Furcation Radiolucencies:


PDL Width:

Root length/ form/proximity:

Other findings / pathology:



Supervisor’s Signature


Date

Diagnosis (Oral Diagnosis)


Prognosis



Overall:
Individual:
Initial Treatment Plan

Supervisor’s Signature


Date

Revaluation


Definitive Treatment Plan



Supervisor’s Signature
Date

Recall



Supervisor’s Signature
Date



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