DENTAL RECORD CHART

Name: Gender: M/F

Age: Date:

STATUS

RIGHT LEFT

55 54 53 52 51 61 62 63 64 65

TEMPORARY
TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY
TEETH

85 84 83 82 81 71 72 73 74 75

STATUS

RIGHT LEFT
Legend: Condition Restorations & Prosthetics Surgery
 - Present Teeth Am - Amaigam Filling X - Extraction due to Caries

D - Decayed (Caries Indicated for Filling) Co - Composite Filling XO - Extraction due to Other Causes

M - Missing due to Caries JC - Jacket Crown

MO - Missing due to Other Causes Ab - Abutment X-ray Taken:

Im - Impacted Tooth Att - Attachment ___ Periapical (Tth No.: ____)

Sp - Supernumerary Tooth P - Pontic ___ Panoramic

Rf - Root Fragment In - Inlay ___ Cephalometric

Un - Unerupted Imp - Implant ___ Occlusal (Upper/Lower)

S - Sealants ___ Others: ___________________

RD - Removable Denture ___________________

Periodontal Screening Occlusion Appliances: TMD

_____________ Gingivitis _____________ Class (Molar) _____________ Orthodontic ___________ Clenching

_____________ Early Periodontitis _____________ Overjet _____________ Stayplate ___________ Clicking

_____________ Moderate Periodontitis _____________ Overbite _____________ Others ________ ___________ Trismus

_____________ Advanced Periodontitis _____________ Midline Deviation ___________________________ ___________ Muscle Spasm

_____________ Crossbite ___________________________

Name: Age: Gender: M/F _________

TREATMENT RECORD

Tooth Amount Amount Next

Date No./s Procedure Dentist/s charged Paid Balance Appt.