Periodontal Risk and Disease Analysis Input Form

Prepared by         ,              Exam Date:     Last Assessment Date:     Prepared for     Name:     Date of Birth:     Internal Patient ID:     Previser Patient ID:

Patient History and Clinical Data   Dental Care Frequency   Smoking History   Diabetic     Periodontal Surgery for Pockets Has Been Done   Bleeding on Probing   Furcation Involvements   Defective Subgingival Restorations   Vertical Bone Lesions   Calculus on Radiographs or Below the Gingival Margin     a) Unknown b) Never/First Visit c) 1 - 2 per year d) > 2 per year e) Irregular f) Emergency   a) Unknown b) Never smoked c) Former smoker d) Smokes < 10 per day e) Smokes >= 10 per day   a) Unknown b) Not diabetic c) Good diabetic control d) Fair diabetic control e) Poor diabetic control       Oral Hygiene     a) Excellent: improvement not possible b) Acceptable: slight improvement possible c) Unacceptable: substantial improvement needed

Pocket Depths Upper Right   Upper Anterior   Upper Left a) < 5 mm b) 5 - 7 mm c) > 7 mm d) No Teeth   a) < 5 mm b) 5 - 7 mm c) > 7 mm d) No Teeth   a) < 5 mm b) 5 - 7 mm c) > 7 mm d) No Teeth   Lower Right   Lower Anterior   Lower Left a) < 5 mm b) 5 - 7 mm c) > 7 mm d) No Teeth   a) < 5 mm b) 5 - 7 mm c) > 7 mm d) No Teeth   a) < 5 mm b) 5 - 7 mm c) > 7 mm d) No Teeth Radiographic Bone Height from CEJ Upper Right   Upper Anterior   Upper Left a) < 2 mm b) 2 - 4 mm c) > 4 mm d) No Teeth   a) < 2 mm b) 2 - 4 mm c) > 4 mm d) No Teeth e) No X-Ray   a) < 2 mm b) 2 - 4 mm c) > 4 mm d) No Teeth   Lower Right   Lower Anterior   Lower Left a) < 2 mm b) 2 - 4 mm c) > 4 mm d) No Teeth   a) < 2 mm b) 2 - 4 mm c) > 4 mm d) No Teeth e) No X-Ray   a) < 2 mm b) 2 - 4 mm c) > 4 mm d) No Teeth Choose the greatest measurement per sextant (not the average).

Treatments Performed since last Risk Assessment

Preventive Treatment Prophylaxis/Maintenance # procedures   Nutritional counseling/referral # times Sealants # teeth   Tobacco counseling/referral # times Topical fluoride # procedures   Medical condition referral # times Oral hygiene instruction # times   Oral habit instruction # times Therapeutic Oral Rinse # weeks   Bite guard # procedures       Related to Teeth   Related to Tooth Replacement Restorations # teeth   Extractions # teeth Endodontics # teeth   Single tooth replacement - implants # implants Related to Periodontium   Fixed prosthesis # prostheses Systemic chemotherapy # weeks   Teeth abutments # teeth Local delivery - chemotherapy # sites   Implant abutments # implants Scaling and root planing # quadrants   Pontics # pontics Surgery-pockets, vertical bone, furcas # quadrants   Removable prosthesis # prostheses Surgery-other # procedures   Implant abutments # implants   Provisional splinting # teeth+pontics