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PERIODONTAL CLINICAL EXAMINATION

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Subi:ineival Calculus Detection
In the large boxes to the left. enter the number of the 6 to 8 teeth and indicate in the smaller adjacent box. the

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surface on that tooth where the calculus is located that you have selected for removal. {M = Mesia!. F = Facial.
D = Distal. L = Lingual) Twelve surfaces must be indicated. lfmore than one surface is selected on the same

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tooth. enter the tooth number each time a new surface is listed example:
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Am least three of the selected teeth must be molars and/or premolars including one molar. All posterior teeth

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must have at least one .approximating tooth within 2 mm distance. Record the tooth numbers in ascending order
using the 1 10 32 system. Each tooth selected must have at least one surface of calculus indicated for removal.

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No more than 4 surfaces may be selected on incisors. At least 3 surfaces must be on interproxi.mal surfaces
[b of molars and/or premolars.

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Enter the numbers of the first 6 separate teeth (from the list of teeth above selected for (/') � .0

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Subgingival Calculus Detection). These teeth will be evaluated for the removal of plaque, .g 1: E

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stain. and supragingival calculus on the crowns of the teeth.
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