Referring Dentist: {{ getReferringDentist }}
Regarding Patient: {{ getPatient }}
Reason: {{ (apptReason === 'Other') ? 'Reason' : 'Sites' }}:
Date:
Medical History:
Chief complaint:
Hygiene Appointments:
Brushing frequency:
Flossing frequency:
Parafunctional Habits:
Nightguard:
Tooth display at rest (mm):
Excessive gingival display (mm):
Short clinical crowns:
Vertical maxillary excess
Short upper lip
Hypermobile upper lip
Over eruption
Complete edentulism: Max Mand
Attrition:
Abrasion Lesions:
Oral Hygiene:
Bleeding on probing:
Periodontal Pockets
See odontogram
Peri-implant Pockets
See odontogram
Recession defects
See odontogram
Minimally attached gingiva
Peri-implant recession
See odontogram
Lack of keratinized mucosa / tissue volume
Mobility:
Class II
Class III
Furcation:
Class II
Class III
Occlusion:
Frenectomy
Root Fracture
Eligible for implant
Vertical
Oblique
Non Restorable Tooth Eligible for implant
Pathological lesion
Seibert deficiency
CBCT Scan
Sinus pneumatization
at sites
Eligible for implant
Apical Radiolucency
Root Resorption
Teeth:
Impacted Canine
Site:
Pathological lesion
Root Fracture
Vertical
Oblique
Other
Other
Excessive gingival display: Altered passive eruption
Vertical maxillary excess
Short upper lip
Hypermobile upper lip
Over eruption compensatory to wear
Periodontal disease stage grade
Peri-implantitis
Peri-implant mucositis
Peri-implant soft tissue deficiency
Gingival recession
Lack of keratinized tissue
Aberrant frenum attachment
Occlusal trauma {{clinical.occlusionTraumaText}}
Root fracture {{ `${(this.clinical.rootFractureHorizontal) ? 'Horizontal ' + this.clinical.rootFractureHorizontalText : ''} ${(this.clinical.rootFractureVertical) ? 'Vertical ' + this.clinical.rootFractureVerticalText : ''} ${(this.clinical.rootFractureOblique) ? 'Oblique ' + this.clinical.rootFractureObliqueText : ''}` }}
Seibert deficiency {{ `${(this.clinical.seibert1) ? 'Class I ' + this.clinical.seibert1text : ''} ${(this.clinical.seibert2) ? 'Class II ' + this.clinical.seibert2text : ''} ${(this.clinical.seibert3) ? 'Class III ' + this.clinical.seibert3text : ''}` }}
Sinus pneumatization
Oral Pathological Lesion
Apical periodontitis
{{ (clinical.cbctRootResorptionTeethWhere === 'internal') ? 'Internal' : 'External' }} root resorption
Impacted Canine at {{clinical.cbctImpactedCanineTeeth}}
Non Restorable tooth {{clinical.nonrestorableTooth}}
Combined endo/perio lesion
Other
Good
Fair
Poor
Questionable
Hopeless
Review Oral hygiene instruction
Reinforce oral hygiene
Reinforce the need for continuous maintenance care
Consider botox therapy to limit lip hypermobility
Consider orthodontic consultation to address vertical maxillary excess
Consider orthodontic consultation to address over eruption
Consider prosthodontic/orthodontic consultation to address wear
Consider oral pathology consultation
Monitor gingival recession defects
Re-evaluate 4 - 6 weeks following initial treatment
Re-evaluate 3 - 4 weeks following initial treatment
occlusal adjustment to eliminate premature contacts
Consider surgical exposure of site {{clinical.cbctImpactedCanineTeeth}}
Consider esthetic crown lengthening for the maxillary arch
Consider repositioning of the maxillary lip
Consider biopsy of the pathological lesion, to establish a definitive diagnosis
Consider elimination of Maxillary Labial frenum
Consider elimination of Mandibular Labial frenum
Consider elimination of Lingual frenum
Allow 3 months for osseointegration
Consider pocket reduction surgery, as needed
Allow 3 months for osseointegration
Allow 3 months for osseointegration
{{ textClinicalNote}}
First Name:
Last Name:
Clinic:
Salutation:
First Name:
Last Name:
Date of Birth:
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