"Clinical Findings Information Form for Surgical Perio Benefits Determination"

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C
F
F
LINICAL
INDINGS
OR
S
P
B
D
URGICAL
ERIO
ENEFITS
ETERMINATION
“I attest to the accuracy of the information based upon my clinical evaluation and chart review. All of these findings are
documented in the patient’s records.”
Dentist Signature:__________________________________________________________ Date:_________________________
Patient Name:______________________________________________
Tooth/Area:_______ Proposed Treatment:_____________________________________________________________________
Tooth/Area:_______ Proposed Treatment:_____________________________________________________________________
Tooth/Area:_______ Proposed Treatment:_____________________________________________________________________
Tooth/Area:_______ Proposed Treatment:_____________________________________________________________________
Patient’s periodontal disease diagnosis:_________________________________________________________
Additional diagnoses: _______________________________________________________________________
Date of initial evaluation/charting:
Date(s) of scaling/root planing:
Date of reevaluation/charting:
_______________
UR _____________
________________
UL _____________
LL _____________
LR _____________
A
S
D
E
:
DDITIONAL
UPPORTING
OCUMENTATION
NCLOSED
 Periodontal chart
 X-rays
 Chart notes
 Narrative
 Clinical/Intraoral photographs
B
P
ONE
ATHOLOGY
 Horizontal bone loss in these areas: ______________________________________________________________
 Vertical bone loss or defects in these areas: ________________________________________________________
 Loss of lamina dura integrity in these areas: ________________________________________________________
 Other bone pathology: ________________________________________________________
T
P
OOTH
ATHOLOGY
 Tooth #___ fractured below gingival attachment level.
 Tooth #___ has caries below gingival attachment level.
 Other tooth pathology: ________________________________________________________
S
T
P
OFT
ISSUE
ATHOLOGY
 Gingival hyperplasia/overgrowth in these areas: _____________________________________________
 Gingival margin recession in these areas: __________________________________________________
 Lack of attached gingiva in these areas: ___________________________________________________
 Cosmetic gingival recontouring desired in these areas: ________________________________________
 Frenum attachment in this area ________ is causing this problem: _______________________________
 Other soft tissue pathology: ________________________________________________________
EXTRACTIONS
 These teeth are treatment planned to be extracted: __________________________________
 These teeth are currently missing: __________________________________
B
G
ONE
RAFTING
 Being done for periodontal defects on these teeth: __________________________________
 Being done for periimplant defects on these implants: __________________________________
 Being done at the same time as placement of these implants: __________________________________
 Being done for ridge preservation during extraction of these teeth or implants: ___________________________
 Being done to augment sinus cavity via a sinus lift
C
F
F
LINICAL
INDINGS
OR
S
P
B
D
URGICAL
ERIO
ENEFITS
ETERMINATION
“I attest to the accuracy of the information based upon my clinical evaluation and chart review. All of these findings are
documented in the patient’s records.”
Dentist Signature:__________________________________________________________ Date:_________________________
Patient Name:______________________________________________
Tooth/Area:_______ Proposed Treatment:_____________________________________________________________________
Tooth/Area:_______ Proposed Treatment:_____________________________________________________________________
Tooth/Area:_______ Proposed Treatment:_____________________________________________________________________
Tooth/Area:_______ Proposed Treatment:_____________________________________________________________________
Patient’s periodontal disease diagnosis:_________________________________________________________
Additional diagnoses: _______________________________________________________________________
Date of initial evaluation/charting:
Date(s) of scaling/root planing:
Date of reevaluation/charting:
_______________
UR _____________
________________
UL _____________
LL _____________
LR _____________
A
S
D
E
:
DDITIONAL
UPPORTING
OCUMENTATION
NCLOSED
 Periodontal chart
 X-rays
 Chart notes
 Narrative
 Clinical/Intraoral photographs
B
P
ONE
ATHOLOGY
 Horizontal bone loss in these areas: ______________________________________________________________
 Vertical bone loss or defects in these areas: ________________________________________________________
 Loss of lamina dura integrity in these areas: ________________________________________________________
 Other bone pathology: ________________________________________________________
T
P
OOTH
ATHOLOGY
 Tooth #___ fractured below gingival attachment level.
 Tooth #___ has caries below gingival attachment level.
 Other tooth pathology: ________________________________________________________
S
T
P
OFT
ISSUE
ATHOLOGY
 Gingival hyperplasia/overgrowth in these areas: _____________________________________________
 Gingival margin recession in these areas: __________________________________________________
 Lack of attached gingiva in these areas: ___________________________________________________
 Cosmetic gingival recontouring desired in these areas: ________________________________________
 Frenum attachment in this area ________ is causing this problem: _______________________________
 Other soft tissue pathology: ________________________________________________________
EXTRACTIONS
 These teeth are treatment planned to be extracted: __________________________________
 These teeth are currently missing: __________________________________
B
G
ONE
RAFTING
 Being done for periodontal defects on these teeth: __________________________________
 Being done for periimplant defects on these implants: __________________________________
 Being done at the same time as placement of these implants: __________________________________
 Being done for ridge preservation during extraction of these teeth or implants: ___________________________
 Being done to augment sinus cavity via a sinus lift