Case Sheet of Preventive Dentistry

Student’s name: Medical history:

Patient’s name:
Age:
Date: Allergy:

M D B L O Sum
UPPER 8
RIGHT 7
6
E 5
D 4
C 3
B 2
A 1
A 1
B 2
C 3
D 4
E 5
UPPER 6
LEFT 7
8
LOWER 8
LEFT 7
6
E 5
D 4
C 3
B 2
A 1
DMFT=
A 1 DMFS=
B 2
C 3 dmft=
D 4
E 5 dmfs=
LOWER 6
RIGHT 7
8
Case Sheet of Preventive Dentistry

6 2 4 6 2 4
E B D E B D
Plaque D
Index B
M
L
Gingival D
Index B
M
L
Calculus D
Index B
M
L
Mean plaque index= Supervisor’s signature:
Mean gingival index=
Mean calculus index =

Visit Treatment Signature