Dental Report Card

Patient __________________________________

Date __________________________

Periodontal Status
o
o
o

Healthy
Gingivitis: Reversible damage to gum tissue
Periodontitis: Irreversible destruction of the tissues of teeth resulting from a bacterial infection

Stable

Active

o Systemic Risk Factors

o
o
o
o
o

None
Diabetes Mellitus
Cardiovascular Disease
Arthritis
Immunocompromised
____________________________

o
o

Medications
___________________________
Other
___________________________
o

o
o Local Contributing Risk Factors
o
o
o
o
o

None
Plaque biofilm
Dental calculus
Faulty restoration/s
Cavities

o
o
o
o

Crowding/Spacing
Missing teeth
Cigarette/ smokeless tobacco use
Other
_____________________________

3 months (Probe depths > than 3mm

due to periodontitis)
Other:
________________________

o
o Recall Intervals
o
o

6 months (Probe reading 1-3mm,

SBI 20% or less)
4 months (General gingivitis
remains, SBI 20% or greater)

o
o Oral Hygiene Instructions
o

Brush:_________________________ Type:________________________

Floss:__________________________ Type:________________________

o Oral Hygiene Adjuncts

o
o
o
o
o
o
o
o
o
o
o
o
o

** All of the above products can be purchased at local WalMart, Walgreens, Target, or
CVS pharmacy. Items above are not limited to the stores listed.

Other:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________

If you have any questions or concerns please feel free to contact me.

Kendra B. Fox Valley Dental Hygiene Student

(920)216-6482