Clinical Findings For Restoration Benefits Determination Form printable pdf download

LINICAL

INDINGS

ESTORATION BENEFITS DETERMINATION

“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:______________________________________________

Tooth #:_______ New/Proposed Restoration:_________________________________________________

Prior Restoration(s):______________________________________________ Date of Prior Placement: _______________

The new restoration will be/were placed for the following reason(s):

ECAY

 Caries extensive enough to undermine cusps, requiring cuspal coverage: MB DB ML DL

 Recurrent caries adjacent to existing restoration(s) at M O D B L surface(s)

 Recurrent marginal caries involving crowns, not repairable, at M O D B L surface(s)

 Caries undermining the incisal angle of an anterior tooth: MI DI

RACTURE

 Tooth fractured; cannot be reasonably restored with a direct restorative material.

___Previous fracture, previously restored cusp(s): MB DB ML DL

___New fracture, with the loss of cusp(s): MB DB ML DL

___Incisal angle(s) on anteriors: MI DI

___From trauma; cause: ________________________________________________

 Prior restoration fractured; cannot be reasonably restored with direct restorative material.

 True cracks and/or fissures with loss or displacement of enamel (not "craze lines"), in these areas:

a. Horizontal, in dentin at base of these cusps: MB DB ML DL

b. Mesial to distal, in dentin of pulpal floor

c. Mesial to distal, across occlusal surface enamel

d. Across the ( __mesial / __distal ) marginal ridge(s)

___ Seen clinically, not visible on x-ray

___ Stops transilluminated light

 Fractured porcelain on existing crown: Mesial Distal MB DB ML DL MI DI

– Clinically confirmed diagnosis of Cracked Tooth Syndrome

AIN

 Pain on biting and/or release of pressure, on these cusps: MB DB ML DL

 Pain upon thermal stimuli: __hot / __cold / __both

 Clinically reproduced pain goes away in: ___seconds / ____minutes

NDODONTICALLY

REATED

OOTH

 Tooth has had a root canal treatment done on this date: _____________

 Tooth will have root canal treatment prior to this restoration

 Coronal area is lacking in dentin and enamel, and is unsupported

/ E

BRASION

ROSION

 Severe abrasion, into dentin, with no enamel protection

 Close to pulp.

- Inadequate remaining sound tooth structure to support a direct restoration.

NSUFFICIENT

OOTH

TRUCTURE

Approximate amount of missing clinical crown structure:

__25% __40% __50% __60% __70% __80% __90%

UILD

UP PLACED

 Build-up material is not being used only as a filler, or to eliminate prep undercuts, box form, or concave irregularity.

 Insufficient anatomical crown structure for retention of a new crown (see above).

 Tooth has been endodontically treated

DDITIONAL

UPPORTING

OCUMENTATION

NCLOSED

 Clinical/Intraoral photographs

 Copy of chart notes

 X-rays

 Narrative describing prognosis if there is uncertainty about decay proximity to bone or furcation, periapical

radiolucencies, prior endodontic treatment fill, root fracture, or periodontal bone loss.

Clinical Findings For Restoration Benefits Determination Form

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