Paediatric Dental Assessment
Personal Information
Office*
Please Select
Central
Repulse Bay
Patient Name*
Patient Email Address
Diagnostic and preventive procedures performed during this visit*:
Clinical Examination
Includes exam for potential decay/cavities, gum disease, and oral cancer
Prophylaxis (polishing to remove plaque and stains)
Scaling & Prophylaxis
Includes dental scaling to remove calculus (tartar), and polishing to remove plaque and stains
Oral hygiene instructions
X-ray (PA)
X-ray (BW)
X-ray (OPG)
Fluoride Varnish
Sealants
Other
Dental Examination
During your dental examination today we noted the following:
Oral Hygiene
Good
Fair
Unsatisfactory
Plaque
Slight
Moderate
Heavy
Calculus (tartar)
Slight
Moderate
Heavy
Stain
Slight
Moderate
Heavy
Teeth
Teeth
Healthy, No Problems
White spots (potential cavities)
Deep grooves
Sealant for grooves
Cavities
Decay around old fillings
Evidence of grinding or clenching
Incorrect bite (malocclusion)
Under Orthodontic care
Trauma
Gums
Gums
Normal and healthy
Inflammation
Bleeding gums (gingivitis)
Advanced gum disease
Other
Home Treatment Program
Home Treatment Program
Toothbrushing, 2 mins, 2x daily
Flossing daily
Electric Toothbrush
Special Toothpaste
Fluoride Rinse
GC mousse / Plus
Other
Remarks
Teeth Chart
Black
Blue
Red
Undo
Eraser
Clear
Recommendation
1. Next Visit: 2. Recall + scaling: 3.
