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

Soft – Medium - Hard








  • 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):



Radiographic Evaluation



Plaque Retentive Factors:

Over-hangs / defective restorations:

Calculus

Caries:



Alveolar Bone Assessment:

Crestal Bone Density


Horizontal Bone Loss (%)


___________________________________________


Vertical Defects:



Furcation Radiolucencies:


PDL Width:

Root length/ form/proximity:
Other findings / pathology:


Supervisor’s Signature


Date

Diagnosis (Periodontal Diagnosis)


Prognosis



Overall:
Individual:
Treatment Plan

Supervisor’s Signature


Date

Revaluation


Definitive Treatment Plan



Supervisor’s Signature
Date

Recall



Supervisor’s Signature
Date



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