Clinical Findings For Surgical Perio Benefits Determination Form printable pdf download

LINICAL

INDINGS

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:_____________________________________________________________________

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 _____________

DDITIONAL

UPPORTING

OCUMENTATION

NCLOSED

 Periodontal chart

 X-rays

 Chart notes

 Narrative

 Clinical/Intraoral photographs

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: ________________________________________________________

OOTH

ATHOLOGY

 Tooth #___ fractured below gingival attachment level.

 Tooth #___ has caries below gingival attachment level.

 Other tooth pathology: ________________________________________________________

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: __________________________________

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

Clinical Findings For Surgical Perio Benefits Determination Form

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