New Patient Periodontal Examination and Treatment Planning (01204)

  • 01204 is used for new patients
  • For new patients, the following must be completed and approved by an instructor before development the final treatment plan.
The following must be completed before asking an instructor to review the form.
Step 1: Complete page 1
Step 2: Complete page 2

Step 3: Complete the charting of the Maxilla and Mandible.

The following must be charted:

  • Missing and misplace teeth
  • Mobility of Teeth
  • Probing depths
  • Bleeding upon probing
  • Furcation Class I, II, III
  • Gingival Recession
  • Mucogingival attachment
  • Suppuration
  • Contact Points

Step 4: Complete page 15

  • The diagnosis, prognosis and sequence of periodontal therapy must be incorporated into the final treatment plan
  • The periodontal re-evaluation section is to be filled out at the time of phase I re-evaluation