To send us a diagnosis, you may either use our online form (see a completed example) or you may send us your own diagnosis form. We would prefer if you took advantage of the online form available.

In the downloadable format , our online form can be printed out or filled in with a word-processor. Other documents may be sent as supporting evidence: these are listed.

Anvon © 2001

Click here to pay for a diagnosis. You will be given a choice to select an online diagnosis, or send in your own.

Professional Periodontal Consultations

Example
Diagnosis
Form

Notes on the use of the online form:

1. The form that follows is a comprehensive analysis of your patient, taking into account many factors that might contribute to oral conditions.

2. Many of the questions asked may not in fact apply to your patient, and if this is the case, please leave the questions that you cannot answer, or that do not apply blank, or preferably annotate them as n/a (ie not applicable).

3. It is important to give as much information as possible so that we can give you the best possible advice on how best to manage your patient's problem.

4. It would be extremely useful if you could send us photographs and/or x-ray images of your patient. These can be forwarded as an attachment to an email to assessment@periodontal-net.com, preferably in jpg, gif or bmp format. Alternatively, these could be sent to us by surface mail, but you need to contact us to make the necessary arrangements in advance.

5. If you are having any difficulty in filling out the form, or you are unsure as to how you should fill in any aspect of it, please do contact us by email for support.

6. Always include your ticket number in any communication (the number is issued when the diagnosis form is ordered on-line).

7. While we prefer you to use the form provided online, if you want to send a form of your own, particularly for clinical details such as pocket charting, please feel free to do so.

NB These notes are attached to the download form.
The colours used in the document below are inverted; the downloadable document is in standard format.

Periodontal Diagnosis Form

Anvon © 2001
Name of Patient: Tom Smith
Date of Birth:
12
06
1982
   day/month/year
Gender/Sex: Male enter M or F
Name of Dentist: Dr James
Postal Address: 26 Raven Road
Chicago
Illinois
Postcode: 611456
Country: USA
Email address: tjames@homail.com

Local Symptoms:

Y Pain Where? When?
Y Difficulties in chewing Why?  
  Swelling/infection/pus/discharge Y Bad taste/breath  
Y Bleeding gums  
  Food impaction Which teeth?  
Y Tooth loosening Which teeth?  
Y Tooth migration Upper anterior teeth and UL6
  Aesthetic problems:
History of main complaint/other relevant details of Presenting complaint:
 Been to several dentists; never found the problem: Generalised pain in mouth

Family History of Periodontal problems:

Y Early tooth loss
Y Bleeding of gums
  Recurrent abcesses
Y Bleeding gums
  Which members of the family?
Y Father Y Mother Y Siblings Y Other

Medical history:

Current illnesses Back trouble three years ago
Past illnesses Hepatitis A

Allergies

 Penicillin
Current medication

thyroxin, tetracycline

Social history:

Smoker
Y
   Pipe/cigarettes/other Per day:
20
Alcohol
Y
   Number of units Per week
16

Other drugs: (chewed/sucked/inhaled)

 

Chews betal nut, and sucks peppermints all day

 
Tooth grinding/clenching: N    
Nail biting: N    
Other abnormal activities: Y    


Dental history:

Date last attended
Regular/irregular attendee:
Y
  
12
05
01
Previous orthodontic treatment:
N
  
Previous periodontal treatment (type):
N
  


Oral hygiene activity:

amount of times per day or week & method used
Toothbrushing: Once a day
Interproximal cleaning: None
Other: Occasional use of mouthwash


Extra-oral examination:

Swellings/Lumps  
Ulcers No
Draining sinuses/pus: No
Rashes:  
White patches: On left hand side of mouth opposite the upper molars
Red patches:  
Discoloration of soft tissues:  
Dry mouth/salivary flow: Yes


Intra-oral examination:

place 'x' box, and list abnormalities
Lips
  
Salivary glands & orifices  
X
 Buccal mucosa white patch
X
 Pharynx white patch white patch
Tongue  
Tonsils  
Floor of the mouth  
Alveolar mucosa  
Hard palate  
X
 Saliva: dry mouth dry mouth
Soft palate  
Other:  

Calculus:

Distribution: generalised/localised
 Localised on lower interdental
Interproximal/marginal None

Gingivae:

Appearance Consistency
X
 Red
X
 Thin
X
 Bleeding
X
 Thick
Swollen
X
 Wide zone of attachment
Overgrown
Thin zone of attachment

Additional Notes:

 

Recession:

 Generalised - range (mm):
X
 Localised: (annotate teeth and amount below)
43 345
543 356

Abrasion:

 Generalised - range (mm):
X
 Localised: (annotate teeth and amount below)
543 36
6543 23467

BPE score:

4
3
4
3
2
3

Plaque: (annotate as necessary)

Distribution: generalised/localised Plaque score: see chart
Interproximal/marginal  
  Distribution Localised
  Generalised
  Gingitivitis score:

Probing depths:

Generalised - range:  
Localised:  
Instructions for charting:

Please
mark the surfaces of each tooth contaminated by dental plaque or that bleeds on probing
annotate the probing depths of the periodontal pockets
annotate the other clinical variables appropriate in the following chart

1. For this chart scores, use the following notation:

Buccal
Mesial
Distal
Palatal/lingual

Example: from the buccal surface type the number of the measurement of each surface:

2
2
2
2

Note: gingival bleeding on gentle probing use the same method as above but replace the numerical with an 'x'. Please note these lines are pre-coloured.

2. Key:

Code
Notation symbol
V
 Vitality
X
M
 Mobility
1
Pk
 Pocketing
Numerical only
G
 Gingival bleeding on gentle probing
X
S
 Sensitivity
X
F
 Furcations
X
Pl
 Plaque present
X
D
 Decay
X

NB: To save space, only the charting of one quadrant is given in this illustration.
D
Xx
X
X
X
X
X
D
V
X
X
X
X
X
X
X
V
S
Xxx
X
X
X
 
X
X
X
S
M
I
Ii
Iii
Iii
M
F
X
X
X
F
Pk
1
1
8
1
8
8
7
8
8
2
3
5
7
7
3
3
3
3
2
2
3
4
4
8
8
8
8
8
8
9
9
6
Pk
1
1
8
1
7
7
8
9
12
2
4
5
7
7
3
3
2
2
2
2
4
2
5
7
7
8
8
8
8
8
5
4
Pl
X
X
X
Pl
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
G
X
X
X
X
X
X
X
X
X
G
X
X
X
X
X
X
X
X
X
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
G
X
X
X
X
X
X
G
X
X
X
X
X
X
X
X
X
X
Pl
X
X
X
Pl
X
X