Student Name: Computer No



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Periodontal Examination & Charting Form


Student Name:

Computer No. :

Patient’s Name:

File No.

Age: _____ yrs. Gender: Occupation:

Nationality

Marital Status:

Date



Chief Complaint:


Dental History


M
Smoking:

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


edical History


I. Extra-Oral Examination:


II. Intra-Oral Examination:

I.1. Buccal Mucosa:


I
Oral Hygiene Habits

Soft – Medium - Hard




Horizontal- Vertical –


Circular - Combination


  • Interdental Aids

Yes (type):

No

  • Miswak

Yes – No


  • Other
.2. Gingiva:

I.2.a. Color:

I.2.b. Tone (consistency)

I.2.c. Contour

I.2.d. Attached Gingiva

I.3. Mucogingival Defects



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 (Overall Dental Diagnosis)


Periodontal Diagnosis

Prognosis
Overall: Individual:

Treatment Plan



Phase I:



Supervisor’s Signature
Date


Revaluation


Definitive Treatment Plan

Supervisor’s Signature
Date



Recall and Maintenance


Supervisor’s Signature


Date





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