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    2 0gradesheetstolastbox

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    » DECLINED FAS D-T MN pockets Bored Qu WY CALC 7 lat ellen: : ’ [GS pts bstsementec in UE hance, stat Dr vet incested in Boas, ‘Student Name rom] Medical History Information Periodontal Case Type Tate | BP] | agieviowsd | Oven a Gin 051 eM West tye Tpprenic — C Aogressive (Awd a aa eaeae tise wipes — jeans a m0 ‘Patient Phone Number a (312) C Adol Y]5|' P47 gp f Patient Credit” BK-SALY HT] 5 Govate ¢ ies at : Zz ‘Medical ‘Oral Charting ‘OHI Treatment | Asepsis Profes- Points Points % X25 Partl oa a OE eee ec omen creel oe ents 7 7 el Ms 5 fai 2 eee x {Oo = 3 ee © He et 23 oie — at | aie mma] Sa] Namberot [Subseom | Fam | A ETO ee ed ee | Se Le me — * as eee EAI al aD Hsu ae TG L122 q2 Bes oO = IS aes aa “Ma =~; aA A Re QS 1S 1, FSG erasing instructor signature: _T Put student sijnatueQ/ | Total Score: 270 Ww HS LO é : ‘Errors Radiographs Made: Horizontal BWs- 0 Vertical BWs. 0 Periapical(s) Polishing ‘Supra Calc SD ‘Sub Calo) D5. aS instructor Comments/Progress c! points earned Sairiagt dental hygiene careit A ADHDIADD ALGO ALLER ALZEINVDEM, ANGINA ANXIDEP. ARTHRTS ARTJOINT ASTHMA CHF COAG see MES guaere DIGAB(PHY er NT) GERD MOARMISCAL HANRAD HRTOZ IMPLANT LUPUS MI MS PREG SEIZURE THROID Aenean OTHER: “ Pb $e Smee oxo qp! c Ceasing,. oA 10, Operatory organization ‘Student Nae! “Professionalism points earned Periodontal Case Type, Hth Gin Si Mod w a i) Clinic 3. Professional conduct 4. Complete Record keeping a 5. Operatory organization Asepsie S sq] TAH Update PF 28 | 28 points must be earned to a> receive a passing grade on patents, of a | Treatment plan complete Y No = Pox be received as a grade Treatment evaluation complete Y_N nyyds Chay hin ual and may rele eatent modifications due to isk factors. Identify allmed codes/sk factors for in as needed. IS): ANXIDEP ARTHRTS ARTJOINT ASTHMA CHF COAG CONGHR? COPD DIABETE [DISABIPHY or INT) GERD HEARIVISUAL H&NRAD HRTDZ IMPLANT LUPUS MI MS PREG SEIZURE THROID TOBACCO , OTHER Number of | Polish | Number of | Supra | Numberof | Sub Score | Tissue | Percent | +124 | x10 re ‘Sub Trauma_| Totals S ae [SS [ FST ~ Student Signature Tx Gusemerear> ? 5 a os Radiographs made: Als lishing ‘The following quadrant has been selected for periodontal evaluation: UR UL UR. UL “1 point per error “Supra Cale # = ¥ = ¥ z 2|\r [oF [pF [) oF DF OF OF SubGale SS 395 F Ft F F F fF iE _) iF OME MF aE MF DL DL S [out DL DL. DL, Lit ad tT cI c t mic ca iL mL mL ML ing when deseribing findin ize, shape, color, surface texture, consistency, location, symptoms, asymmetry and ing descriptor) Head/Neck/Face: WNL TM: WNC (Oral Mucosa/ Lips: WNL ‘Alveolar Ridge: WNLG. ‘Tongue: WNLO Lymph Node: WNEG Floor of Mouth: WNL DENTAL HYGIENE DIAGNOSIS AND TREATMENT PLAN fw been completed, use the data obtained to analyze the patient's needs. 1, PATIENT HEALTH/LIMITATIONS/SPECIAL NEEDS: Referencing your grade sheet, are there any physical, mental or medical conditions that require treatment modifications?/No Yes ‘Yes - Describe condition(s} and modifications necessary to meet patient's individual needs: 2. EXTRA AND INTRA-ORAL EXAM: Are there any condit S ttrasonie (where and why?) fas) 5. PLAQUE & STAIN REMOVAL: Gased on the extent ofthe plague, stain and restorations, determine the best method(s) of removal. ~Prophy angle(cup/brush) —_Tooth brush Floss Torher SUkeasonie & FLUORIDE: Considering the typeof restorations, senltity, caries history and periodontal health, determine the best fluoride therapy andl why? APF (trays) é Neutral trays) (varnish) OS Cah, QB. hs T-AUXILARY PROCEDURES: there condition that indicates a need fr auxiliary procédures? Neves: SLanesthesla __Local Oragix®_Arestin Desenstiing product and location, sealants #s Nutritional counseling No - ‘Subgingivalrrgation 3. RADIOGRAPHS: Is there a condition or change Inthe condition of the patient's te2th or supporting structures that require radiographs? _Yes “x/No Date of last bitewingsy/0 1% “BW Perlapicals Che hine (0°200___CMS ‘9, PLAQUE CONTROL INDEX: To be completed at each visit. Place disclosing solution on all teeth. Identify all areas that are stalned by coloring in the area on the diagram below. Use this information to determine your patient's personalized Oral Hygiene instruction. If your patient needs multiple visits, use different colors at each visit to show changes. Plaque Score Calculation: # of teeth x 4 surfaces ide pink surfaces/total surfaces x 100 36/11: 112. Following disclosing, count surfaces with pink 36 (Oral Hygiene Instruction: (check all that apply) Brushing, _Flossing, auntiary ai “Developing routine or habit Product recommendation SS ‘a Teton a) Chinie Grade Sheer Medical Histor /Information P sriodontal Case Type Meds reviewed | CHth 0 GinJg'si‘Bdio! O Adv: CO Chronie GAggres: ive 7 ‘Localized'\z General zed TS Caleulus Class oo XA 0B oc cD ‘Age! G Child @42) 0 Adolescent (147) [72 P tient Credit Dt adult (18-59) 0 Ge atric (60+ years) re 02 Ciaring | OHI | ‘Treatment | Asepiis | Profes ] Pots] Pointe” | X25 Sart 10 s | Planfeval | 5. | sionalism | total é orpttx | fo |x 50 “x > 5 tee > Par : Number af | Polish] Numberof | Supra] Numberof | Sub'Score| Tissue] Percent | +284 Radiographs Wade: 0 Horizontal BWs 5 Vertical BWs 0 Periapic al(s) Proficiencies completed: 1. Time management ‘lental hygiene careftre atment plan as neede:|. fieemsau meatal pe Pt convenience | WOMOIADD ALCO /LLER ALZEIWDEM ANGINA ‘ SEANNDEP ARTHRTS. ARTJOINT- ASTHN.. CHE coac _ | ‘Professional langua ye SONGHRT COPD DIABETE “ 5. Operatory organization/Asepsis Plaque Score Fi “HH Update 7 F [CALE 25 | 28 ‘earned to Occlusion: LZ RD xxbiteCVE, Pro-med roquirea © | supra |x |<] |= rade on patients, ora | Treatment comple {_ [ee Te Te [Te] “0” will be received as a grade ‘Treatment evaluation compiet/Y)N Special Needs Patient: Each patient we treat is an individual and may, PRES egonocications dus te dak actors. Went al med codenak ator for teach patient and modify dental hygiene caretreatment plan as needed ADHDIADD ALCO ALLER AIZEIMIDEM ANGINA ANXIDEP ARTHRTSARTUOINT ASTHMA CHF COAG CONGHRT COPD DIABETE DISAB(PHY orINT) GERD HEARIVISUAL H&NRAD HRTOZ IMPLANT LUPUS MI MS PREG SEIZURE THROID TOBACCO OTHER Number of Polish Number of | Supra’ Number of | Sub Score Tissue Percent 242,34 ‘x100 ~ 1 point per | “Prof pts Tosh | Seow | “supe | semea| Sub | ed tna | “Toume peri give a 2G z BES GL SAC Tres) coer ee T pa ry eBid) Gi, Z Grading Instructor Signature_ ‘Student Signature’ LORAe) Total Score__/ “5 nee ek _ Radiographs made: ire been seas meee ean, ORY UR th Tomi peranor COmpeetea eps : oa Oud Sine to gma Z # #V #7 = # F DF | i I OF | Lor OF, F_ mt F li o oe DL Oe “iF ite i [ I Significant Findings: Consider the fol when describing findings: Size, shape, color, surface texture, consistency, location, symptoms, asymmetry and duration. (Must mention 5 descriptors. 1 point deduction for each missing descriptor) HeadiNeck/Face: WANES TW: WNL ak Oral Mucosal LeU @ 0, ‘Aivedlar Ridge: WNLS ar ae “Tongue: WNL cavecesat Lymph Node: WALE_ 1 Floor of Mouth: WNLS Palate/Oral Pharynx: WNDS ra Bian Ken Pah s . eg rook Tk far 0 ot Cri Se Oe ae doe Se oyuclify BEN Ceksa0in ea 22- ) le DENTAL HYGIENE DIAGNOSIS AND reearvoutobaw? R B (@ ws) {After the initial examination {health history, dental history, exra-oral exam, intraoral exam, periodontal assessment, charting) has been completed, use the data obtained to analyze the patient's needs. 1. PATIENT HEALTH/LIMITATIONS/SPECIAL NEEDS: Referencing your grade sheet, are there any physical, mental or medical conditions that require treatment moans NoYes Yes Describe condition(s) and modifications necessary to meet patient's individual needs: 2, EXTRA AND INTRA-ORAL EXAM: Are there any conditions noted on the extra/oral exam that require treatment modi No __Yes_Describe conditions and modifications: ‘3, ORAL HYGIENE: Describe the current OHI condition of the patient. Check all that apply None light Moderate Hew, Yes No Bleeding: eee eee Periodontal pockets a Calculus eS eee de Furcation involvement eee Mobility y “4, SCALING TYPE: Based on the extent and the composition of the supra and subgingival calculus, determine the scaling regimen. Scaling type: >< Hand instruments (rational for specific instruments) <__ultrasonie (where and why?) of pot. \ in 5. PLAQUE & STAIN REMOVAL: Based on the extent of the plaque, st restorations, determine the best method{s) of removal rProphy-anetetcup/brush) “Frooth brush ash lowe Floss ‘Other e Ws V5 alles SZ Ultrasonic ae or Pro wee wae 6. FLUORIDE: Considering the type of restorations, sensitivity, caries history and periodontal health, determine the best fluoride therapy and why? APF (trays) ; Neutral (trays) 44 (varnish) AUKILLARY PROCEDURESHs-theré a con Syed ion that indgates a need Tor aur procedures? Anesthesia Local ~<_Oraqix® ___Arestin —Desensting product and location, Sealants Ws “Kutrtional counseling 2 subatngivatiiation RADIOGRAPHS; Is there z-eonlton or change in the condition of the patients teeth or upporng aructures that require radiographs?| V.Yes Date of last bitewings . BW __Periapicals NS was See AE Y \oeso0 cvs 9, PLAQUE CONTROL INDEX: Tobe completed at each vist. Pace disclosing solution ona teeth. Iden all areas that are stained by

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