COMPREHENSIVE DIAGNOSIS AND TREATMENT PLANNING FORM:(COMPLETE ALL FIELDS)

Patient Name ______Chart Number ______Date started______

Revised: June 02 2014 – DR. TRENNA M. REEVE

  1. CHIEF CONCERN______

______

______

  1. MEDICAL/DENTAL RELEVANT CONCERNS/HISTORY

Medical conditions______

______Medications______Allergies______

  1. SOCIAL HISTORY______
  2. CARIES RISK ASSESSMENT High_____ Mod_____ Low_____

Caries in last 12 mos_____ Snack>3 between meals_____

Visible plaque anterior_____ Inadeq salivary flow_____

InadeqFl exposure_____ Decalcification>1_____

  1. EXTRAORAL EXAMINATION

Head and Neck______

Extremities/Skin______

Lips______

  1. T.M.J.

Maximum opening ______mm Deviations______

Clicking: Rt LtCrepitus: Rt Lt 

Pain: Temporalis: Rt Lt Med.Pterygoid: Rt Lt 

Masseter: Rt Lt Lat. Pterygoid: Rt Lt 

Ant Neck: Rt Lt Posterior Neck: Rt Lt 

Habits______

History______

  1. SOFT TISSUEINTRAORAL

Lips______

Labial and Buccal Mucosa______

Oropharynx______

Floor of Mouth______

Tongue______

Palate______

Salivary Glands______

Revised: June 02 2014 – DR. TRENNA M. REEVE

Periodontal Diagnosis______

Perio instructor signature (PSR 3 & 4):______Date:______

Revised: June 02 2014 – DR. TRENNA M. REEVE

  1. PERIODONTIUM: Complete Perio Form for PSR 3 and 4s

Gingiva______PD range______

Areas of localized disease/Suppuration ______

Calculus:Supra- Gingival: Generalized  Localized 

Sub- Gingival: Generalized  Localized 

Periodontitis Risk Profile: ______OH______

  1. SIGNIFICANT RADIOGRAPHIC EXAMINATION FINDINGS

Bone Pathology:______

Bone Loss: H: ______V:______

CR Ratio:______

Root Shape/Length:______

  1. OCCLUSION: Complete Prostho Form for abutments

Class: Molar R ______L ______Cuspid R ______L ______

CO vs MIP relationship ______

R. Lat.______L. Lat.______

Pro. ______Cross Bite______

Vert. O/Bite______%Horiz. O/Jet______mm

I.O.D. at rest ______mm

Abrasion ______Erosion ______

Abfraction______Attrition______

Supra eruption ______

Malpositioned/Tipped______

Parafunctional Habits______

  1. ENDODONTICS: Complete Endo Form for questionable teeth

Symptomatic______

Radiographic lesions______

Status of prior endotx______

  1. ESTHETICS/PHONETICS

Esthetics______

Smile Line______Diastemas______

Colour______Phonetics ______

  1. DENTURE BEARING TISSUES: Complete Removable Form

MaxillaMandible

Mild Mod. SevereMild Mod. Severe

Degree of Resorption    

Tori   

Undercuts location ______

Gagging ______Saliva ______

Revised: June 02 2014 – DR. TRENNA M. REEVE

SPECIALTY CONSULTSConsultants comments, dateand signature

DATE / COMMENTS / INSTRUCTOR

SPECIALTY CONSULTS - REFERRALS

REFERRAL REQUEST INFORMATION / DATE / FOLLOW-UP
MEDICAL
ORAL PATHOLOGY
TMJ/SLEEP APNEA
ORAL SURGERY
GRAD PERIO
GRAD ORTHO
IMPLANT

DISCIPLINE SPECIFIC PROBLEM LIST

PROBLEM/DIAGNOSIS / PROPOSED TREATMENT / PROGNOSIS

TOOTH RELATED PROBLEM LIST

TOOTH / PROBLEM/DIAGNOSIS/CURRENT STATUS / TREATMENT OPTIONS/COST / PROGNOSIS
#18
#17
#16
#15
#14
#13
#12
#11
#21
#22
#23
#24
#25
#26
#27
#28
#38
#37
#36
#35
#34
#33
#32
#31
#41
#42
#43
#44
#45
#46
#47
#48

COMPREHENSIVE TREATMENT PLAN, COSTS AND DATE COMPLETED

Phase I – Urgent Care/ Pain Management

Phase II –Preparatory/Disease Control and Re-evaluation

Phase III – Corrective

Phase IV – Maintenance/Follow-up

Phase / Tooth#/
Surfaces / Treatment / COST / Pt initial(s) / DATE
Completed

TOTAL COST (PHASE I+II +III +IV) $______Patient Initial______

I authorize the student clinicians at the U of M Dental Clinic to perform these treatments and have been informed as to options for treatment, and understand mytime and financial obligations.

Patient name______Patient signature______Date______

Student name ______Student signature ______Date______

Instructor name______Instructor signature______Date______

INFORMED CONSENT DOCUMENTATION:

I confirm that I understand the following:

  • My dental problems which have been diagnosed or identified, which are:

______

  • The treatment that I have helped to select from a series of options that were explained to me and which I understand will be provided is: ______
  • I understand the risks involved in my treatment and the chances of success (prognosis) with respect to the treatment are: ______

I authorize the student clinicians at the U of M Dental Clinic to perform these treatments and understand time and my financial obligations, and that annual fee increases can affect this estimate:

Patient printed name______

Patient signature______Date______

Instructor printed name______

Instructor signature______Date______

Student printed name ______

Student signature ______Date______

LOW RISK / MODERATE RISK / HIGH RISK
Treatment Recommendations / Brush 2x/day with fluoridated toothpaste
Sealants / Brush 2x/day with fluoridated toothpaste
Xylitol 6-10 mg/day – 3x/day x 5min
Application of 5% NaF varnish every 6 months
Diet analysis and counseling
Sealants
Close monitoring of incipient lesions / Brush 2x/day with 5000ppm fluoridated toothpaste
Restore all areas of cavitation
Application of 5% NaF varnish every 3 months
Diet analysis and counseling
Sealants
0.12% Chxmouthrinse 1x/day for 1wk/month x 6 months
Xylitol 6-10 mg/day – 3x/day x 5min
0.5% NaF rinse 2x/day
Calcium Phosphate several times per day
Recall/Maintenance / Recall every 6-12 months
Radiographs every 12-24 months / Recall every 6 months
BWX every 6-12 months / Recall every 3 months
BWX every 6 months

CARIES RISK MANAGEMENT PROTOCOL

Revised: June 02 2014 – DR. TRENNA M. REEVE