Clinical Findings for Surgical Perio Benefits Determination

CLINICAL FINDINGS FOR SURGICAL PERIO BENEFITS DETERMINATION

“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 ______

ADDITIONAL SUPPORTING DOCUMENTATION ENCLOSED:  Periodontal chart  X-rays  Chart notes  Narrative  Clinical/Intraoral photographs

BONE PATHOLOGY  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: ______

TOOTH PATHOLOGY  Tooth #___ fractured below gingival attachment level.  Tooth #___ has caries below gingival attachment level.  Other tooth pathology: ______

SOFT TISSUE PATHOLOGY  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: ______

BONE GRAFTING  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