Student Name:

ODINvirtualpatient Group Practice #: Patient axiUm Chart #: Date:

MEDICAL HISTORY DENTAL HISTORY

Age:
21 Gender: M
I F Primary Chief Complaint:
Patient describes health as:
Very Poor Poor Good Very Good Excellent
I needacleaning
Last Dental Visit (Date) Last Dental Radiographs (Date)
Medical Condition Dental Implications 2yearsago
What was done? Last Cleaning (Date)
Panaetitss
cleaning
TB
gulstons
Any negative dental experience?
Describe:
Y
Q
N

Medication Name/Dosage Drug Class/Dental Considerations On a scale from 1 – 10 (with 10 being the highest), how would patient rate
nervousness with receiving dental treatment?
No 1 2 3 4 5 6 7 8 9 10
Existing Age of existing
Y N
Prostheses/Appliances prostheses/appliances
Is patient satisfied? Y N
Allergy Reaction Why or why not?

No Toothbrush
O Y N
Floss OYY N
O
Last Physical: Oral Hygiene
Rinse N
2Years
History:
Surgical Additional? Describe:
Areas of food trap/impaction? Y N
Psychosocial/Other:
No Where?
Recreational Drug Use Y N Details: Previous Periodontal Therapy Y N
Alcohol Consumption Y N Describe:
Tobacco Use Y N
scoeappdcooaua.sk
nota Sensitive teeth?
D Y N

C
Vital Signs COE 1 mighearmsiteed
COE 2 COE 3 Cold Hot Sweets Pressure
a st Where?
1 Reading
BPBates pion
f 2nd Reading
3rd Reading
How does the patient feel about his/her smile?

Medical Consult Needed:

TB DYY N What is patient’s oral health goal/desire?

O
Antibiotic Prophylaxis Indicated: N
ASA Status: I II III IV
no g
IsoLao
Student Name: Group Practice #: Patient axiUm Chart #: Date:

SOFT TISSUE EXAM

Extraoral Findings Intraoral Findings
Vermillion
Face/Skin
dneckup Lips
Border
Eyes, Ears, Nose Commissures
Honkarotul
Masticatory Muscle
Palpation
Labial Mucosa d
TMJ Palpation Buccal Mucosa
Restricted opening Y N R L
Gingiva
Restricted side-to-side
Y N R L
movements
Dorsum
Jaw deviation on opening Y N R L
TMJ Function
Jaw locking Y N R L
Tongue Lateral
Popping/Clicking Noise Y N R L
Crepitus Y N R L Ventrum
Pain Y N R L
Floor of Mouth
Comprehensive TMD Exam/Mounted Diagnostic Cast
Analysis Warranted? Hard Palate
‘Yes’ with symptoms
TMD Exam/Mounted Diagnostic Cast Analysis INDICATED Y N Soft Palate, Uvula,
‘Yes’ without symptoms
Check with Faculty and Oropharynx
‘No’ without symptoms
TMD Exam/Mounted Diagnostic Cast Analysis NOT INDICATED Salivary Glands

Head and Neck Amount

Lymph Nodes Saliva
Quality
Thyroid
Oral Pathology Consult Warranted Y N
Necessary radiographs and/or pictures uploaded in axiUm? Y N
Additional Soft Tissue
1.
Extra- and Intra-Oral
Findings Differential Diagnoses 2.
3.
Student Name: Group Practice #: Patient axiUm Chart #: Date:

HARD TISSUE EXAM

Occlusion Screening (Age 18+) - Ten Red Flags Tooth Relationships/Malocclusion/Space Management Evaluation
Class I Class II div 1 Class III
Lacks Anterior Disclusion Y N
R Class II div 2
Fremitus or Mobility Y N Angles Can’t Determine/Missing Teeth
Classification Class I Class II div 1 Class III
Wear Facets Y N L Class II div 2
Can’t Determine/Missing Teeth
Abfractions Y N
Occlusion R Canine Guidance Group Function Other
Gingival Clefts Y N Function Type
L Canine Guidance Group Function Other

2 or more Posterior Crowns due to Fractured Teeth Y N Facial Profile Convex Concave Straight
Overbite (%) Overjet (mm)
Clenches or Grinds Teeth Y N Orthodontic Referral Warranted? Y N
Comments:
Cracks or Fractured Cusps in Posterior Teeth Y N

CR and CO (MIP) are NOT coincident Y N

Freeway Space < 2-3mm (distance between PRP and CO) Y N

Mounted Diagnostic Cast Analysis Warranted?
‘Yes’ with symptoms
Mounted Diagnostic Cast Analysis INDICATED
‘Yes’ without symptoms Y N
Check with Faculty
‘No’ without symptoms
Mounted Diagnostic Cast Analysis NOT INDICATED

Any other significant intra-oral hard tissue findings NOT already Y N

recorded on the odontogram?
Describe:
Student Name: Group Practice #: Patient axiUm Chart #: Date:

RADIOGRAPHIC EXAM
Patient Information
TMJ
Patient Age
Osseous Structures
Patient Gender Male Female
Please note findings for specific teeth in
DENTAL EXAM
Dental Findings
X-Rays Series and Technique Evaluation
Date of Study
Acceptable
Panoramic Non-Diagnostic
(Diagnostic)
Acceptable Additional Findings
Bitewings Non-Diagnostic
(Diagnostic)
Acceptable
Periapicals Non-Diagnostic
(Diagnostic)
Acceptable
Non-Diagnostic Radiographic Impressions and Recommendations
(Diagnostic)
Acceptable All viewed structures were determined to have no significant findings and
Non-Diagnostic are reported as no abnormalities detected EXCEPT:
(Diagnostic)

Radiographic Findings
The listed structures are reviewed and evaluated for bilateral symmetry,
configuration, cortical outline, medullary space, and patent sinuses/airways.
Evaluation of the RADIOGRAPHS is intended as an overall review for Radiology Consult Warranted? Y N
pathology and abnormalities including dental and periodontal conditions. Necessary radiographs and/or pictures uploaded in axiUm? Y N
All viewed structures determined to have no significant findings are
reported as no abnormalities detected. 1.
Differential Diagnoses 2.
Paranasal Sinuses 3.
Additional Imaging Necessary? Y N Type:
Nasal Cavities
Reason(s):
Airway
Student Name: Group Practice #: Patient axiUm Chart #: Date:

ORAL DISEASE RISK ASSESSMENT Periodontal Risk Assessment

Periodontal Exam Posterior Right Anterior Posterior Left
Instructions: Circle all conditions that apply. Condition that is in highest risk Maxilla
category determines patient risk. If no condition is circled, assume low risk and set Mandible
Describe * Conditions:
recall interval at 6 months.
Plaque Level High Medium Low
Caries Risk Assessment
Calculus Level High Medium Low
Moderate Risk
Periodontal Status:
• No fluoride exposure
• Eating disorders (anorexia, bulimia, etc)
• Smokeless tobacco usage Comprehensive Periodontal Exam Warranted? Y N
• Exposed root surfaces &/or deep pits & fissures Moderate Risk
• Unusual tooth morphology compromising hygiene • Abnormal gingival architecture without inflammation
• Poor restorations (overhangs, open margins, open contacts, poor contours, • Past history of periodontal disease
etc.) • Low socioeconomic status
• Fixed or removable dental appliances (orthodontic appliances ie. retainers, • Past dental visit>6 months ago
space maintainers, RPD, etc.) • Cardiovascular disease
• Pregnancy
• Interproximal restoration(s) present
• Severe stress
• 1-2 carious lesions in last 3 years
• Medications with oral side effects
• No dental home • BMI>30
• Poor nutrition
High risk • Caries
• Frequent snacking between meals (>3x/day) • Non-vital teeth
• Poor oral hygiene • Xerostomia
• Alcohol or drug abuse Consider 3 month recall interval & treat risk factors if possible
• Low socioeconomic status
• White spots on smooth surfaces High Risk
• Carious lesion within past 6 months • Presence of Periodontal Disease / PD≥2
• 3+ carious lesions within last 3 years • Uncontrolled Diabetes
• Teeth missing due to caries in last 3 years • AIDS or other Immune deficiency
• Special Health Care Needs • Tobacco use
• Inadequate saliva flow/ xerostomia** • Recreational drug use
• Osteoporosis
• Saliva reducing factors (medications, radiation therapy, systemic)
• Rheumatoid Arthritis
** extreme risk • Genetic conditions causing early tooth loss
• High plaque/calculus level/scores (>1)
Caries Risk: Periodontal Risk: • Any local factors favoring plaque retention
• Furcation involvement
Recall Recommendation: • Occlusal trauma
3 month recall interval; perform periodontal therapy if disease present
 Student Name: Group Practice #: Patient axiUm Chart #: Date:

DENTAL EXAM - MAXILLA

ftp.periyhfkdmolaridecdfifaet.ae farkspothearroot
Existing Restoration s
Tooth # Clinical Findings Radiographic Findings Prognosis Treatment Suggestions

1
Surface Type Defective?
Y N
d y
missing
u 2
Y N PDamm
oAmal
sensitivesfor
3 Y N
OLAmalocariesmann
cold remnant
Ocarries
4 A forcold
sensitivity
u Y N
Ottmar Dcarlesannp minaya
Dcarries
5 B pawn
u Y N
okm.nlsensHiuHyfacold
6 C Y N PDawn
7 D Y N
Tcompifopenwmarg.cnB fcarries
8 E
Y N
9 F
DFComes
Y N
primary
10 G Y N a PD4 s.mn
NLFCariesprimary
11 H
Y N
NIFCariesPD4m
u
12 I
0AmalPann
Y N
13 J Y N
14 oltmatrew.ru D4nm
Y N
15
Ohkmalikaries
Y N
Ohana Poum
16 Y N
ICDAS radiographic codes: E1 (outer ½ of enamel); E2 (innerMissing
½ of enamel); D1 (outer 1/3 of dentin); D2 (middle 1/3 of dentin); D3 (inner 1/3 of dentin)
ICDAS Visual codes: 0-sound; 1-only visible after 5s air dry; 2- intact enamel, visible wet, widened; 3- localized enamel breakdown;
4- underlying dark shadow; 5 cavitation-visible dentin,< half the tooth; 6- extensive cavitation,>half the tooth
 Student Name: Group Practice #: Patient axiUm Chart #: Date:

DENTAL EXAM - MANDIBLE

Existing Restoration s
Tooth # Clinical Findings Radiographic Findings Prognosis Treatment Suggestions
Surface Type Defective?
17 Y N
NHssing
N 18
Y N PoDunn
Amalsensitivitycold
19 cold
sensitives poem
u Y N
OAnalyBbitCaries primary
20 K Y N
OAmal PD5mm
f 21 L
Y N
Odneal Beatles
PD45mm
primary
22 M
Ppa
Y N
23 N n
Y N
24 O
PD4nw
Y N
PDkum
25 P
Y N
26 Q
pD4nr
Y N
27 R
PD4nn
Y N
28 S
pD4uu
Y N
29 T Y N
PD4mn
30
Y N forced
sensitivity
Okhalcountesppulun
31
Y N
fowbpp.mn
sgYIYEE
ICDAS radiographic codes: E1 (outer ½ of enamel); E2 (inner ½ of enamel); D1 (outer 1/3 of dentin); D2 (middle 1/3 of dentin); D3 (inner 1/3 of dentin)
ICDAS Visual codes: 0-sound; 1-only visible after 5s air dry; 2- intact enamel, visible wet, widened; 3- localized enamel breakdown;
4- underlying dark shadow; 5 cavitation-visible dentin,< half the tooth; 6- extensive cavitation,>half the tooth
32 Y N
pressing PD4un

ICDAS radiographic codes: E1 (outer ½ of enamel); E2 (inner ½ of enamel); D1 (outer 1/3 of dentin); D2 (middle 1/3 of dentin); D3 (inner 1/3 of dentin)
ICDAS Visual codes: 0-sound; 1-only visible after 5s air dry; 2- intact enamel, visible wet, widened; 3- localized enamel breakdown;
4- underlying dark shadow; 5 cavitation-visible dentin,< half the tooth; 6- extensive cavitation,>half the tooth
Student Name: Group Practice #: Patient axiUm Chart #: Date:

TREATMENT PLANNING WORKSHEET

Risk Assessment: (Circle Treatment Options) OHI. Nutrition Counseling. Tobacco Counseling. Consult with physician (meds reducing saliva flow). Saliva
stimulating Rx. Referral to mental health professional. Antimicrobials (Bacterial testing, Chlorhexidine). Fluoride. Xylitol. MI paste. Sealants/PRR’s.
Modify/Replacing plaque-retaining restorations. Additional:
Diagnosis Treatment Plan
Oral Pathology
(Hard and Soft Tissue, Radiographic)
Overall Periodontal Assessment

Phase 0 Systemic Medical Consult Needed: Y N Antibiotic Prophylaxis Needed: Y N Reason:

Phase I Emergency

Phase II Periodontal

Restorative

Endodontic

Oral Surgery

Advanced
Phase III Periodontal
Therapy
Occlusion

Prosthodontics

Orthodontic

Esthetics

Phase IV Maintenance
 Student Name: Group Practice #: Patient axiUm Chart #: Date:

FULL MOUTH PROBE BLOOD PRESSURE PROTOCOL

Full mouth probing involves recording the greatest probing depth for each tooth.
Probing depth is determined and recorded by probing the whole tooth. Systolic Diastolic Dental Treatment
Pocket depths are recorded for the deepest areas observed for the
mesiofacial, midfacial, distofacial, and the corresponding lingual/palatal
areas. Six areas should be recorded for each tooth. No contraindications to elective dental
≤139 ≤89 treatment.
WesternU Cinical Protocol

Initial COE visits for patients with 6mm or greater pocket depths, any clinical
abnormalities including but not limited to furcation invasion, mobility, Elective dental treatment, monitor blood
140-159 90-99
mucogingival problems, or recession should have a comprehensive periodontal pressure during appointment.
exam. Otherwise only full mouth probing and BOP are required.
Patients presenting for prophylaxis (6 months recall) appointments. Should be full Emergency or non-invasive
mouth probed including recording of BOP once a year. dental elective treatment only.
Patients presenting for periodontal maintenance should be full mouth probed 160-179 100-109
including BOP and **full mouth charting at every periodontal maintenance visit. Medical consult prior to elective dental
** Full mouth charting is recording of clinical abnormalities including but not treatment needed.
limited to furcation invasion, mobility, mucogingival problems, or recession.
NO Treatment of any kind.
≥180 ≥110
Refer to Emergency Room.
Student Name: Group Practice #: Patient axiUm Chart #: Date:

PHASING AND SEQUENCING DENTAL TREATMENT 2. Reduce or eliminate parafunctional habits,

smoking
(as adapted and slightly modified from Stefanac, Stephen J., Treatment Planning in D. Caries Control
Dentistry, 2nd ed. C.V. Mosby, BOX 3-1.) 1. Caries risk assessment – [Medical Model Txt options
(education & medication)]
2. Provisional (temporary) restorations
Phasing is divided into 4 categories for Axium purposes (there is also a Pre- 3. Definitive restorations (i.e., amalgam, composite, glass
ionomers)
treatment category: Systemic)
E. Replace defective restorations
I. Acute Treatment F. Endodontic therapy for pathologic pulpal or periapical conditions
II. Disease Control G. Stabilization of teeth with provisional or foundation restorations
III. Definitive Treatment notetinitigency H. Post-treatment assessment
IV. Maintenance Therapy
longterm
congoingprevent
Phase 0: Systemic Treatment
Dentoy neutth Phase III: Definitive Treatment
A. Advanced periodontal therapy
A. Consultation with patient's physician

g
B. Stabilize occlusion (vertical dimension of occlusion, anterior
B. Premedication guidance, & plane of occlusion)
C. Stress/fear management C. Orthodontic, orthognathic surgical treatment
D. Any necessary treatment considerations for systemic disease D. Occlusal adjustment
E. Definitive restoration of individual teeth
a. For endodontically treated teeth
Phase I: Acute Treatment
b. For key teeth
A. Emergency treatment for pain or infection c. Other teeth
B. Treatment of the urgent chief complaint when possible l F. Esthetic

i
dentistry (i.e., esthetic restorations, bleaching)
G. Elective extraction of asymptomatic teeth
H. Prosthodontic replacement of missing teeth
Phase II: Disease Control a. Fixed partial dentures, implants
A. Caries removal to determine restorability of questionable teeth b. Removable partial dentures
B. Extraction of hopeless or problematic teeth c. Complete dentures
1. Possible provisional replacement of teeth I. Post-treatment Assessment
C. Periodontal disease control
1. Oral hygiene instruction
2. Initial therapy Phase IV: Maintenance Therapy
i. Scaling and root planning, prophylaxis A. Periodic visits
ii. Controlling other contributing factors
1. Replace defective restorations, remove
caries
Student Name: Group Practice #: Patient axiUm Chart #: Date:

PHASING AND SEQUENCING DENTAL TREATMENT (cont’d)

(as adapted and slightly modified from Stefanac, Stephen J., Treatment Planning in
Dentistry, 2nd ed. C.V. Mosby, BOX 3-1.)
Sequences will be done in 10’s (10= appt 1, 20= appt 2, 30= appt 3, 40= appt
4, etc.)
Sequencing is the order of the appointments - typically in order of most
severe to least, but may also have a “quadrant dentistry” component. This will allow for entering additional treatment into treatment plan
sequence as needed.
For example: #30-MO has deepest caries- a less deep #29-DO may
be sequenced at same appt because patient will be numb/rubber Phasing & Sequencing Examples:
dam isolated in that whole quadrant) Procedures Phases Sequences axiUm
Pulpal Debridement I (Acute Tx) 1 1:10
In Axium, Phasing & Sequencing is listed as Phase: Sequence Endodontic Therapy II (Disease 2 2:20
Control)
Core Build-up II (Disease 2 2:20
Phases are only 1, 2, 3, and 4
(including post) Control)
Crown III (Definitive Tx) 3 3:30

DENTAL EXAM - EXAMPLE

Existing Restorations
Tooth # Clinical Findings Radiographic Findings Prognosis Treatment Suggestions
Surface Type Defective?
14 Y N fractured OL amalgam
OL AM hairline fracture mesial Normal Good MOL resin OR inlay
marginal ridge
19 O AM Y N B decay Normal Good B resin
Mesial marginal ridge
30 Y N Mesial decay Good MO resin
decalcification
Student Name: Group Practice #:
“DMOXIS” NOTE
Use this note for Comprehensive Oral Exams, Periodic Oral Exams,
Emergency/Limited Oral Exams, Referrals and Consultations.
Dental History: Chief Complaint, description of dental pain, history of dental
care, past adverse dental experience.
Medical History: Review of medical history, surgical history, trauma history,
social history, medications with drug class, allergies, Vital Signs, ASA
classification, medical consideration and dental implication (including
antibiotic prophylaxis).
Oral Exam: Soft Tissue findings (Extraoral Exam including TMJ screening,
Intraoral/Oral Cancer Screening), Periodontal findings ( pocket depths,
plaque level, calculus level), Hard Tissue findings (Occlusion Screening,
Tooth Relationships, Prosthodontics Screening), Caries/Periodontal Risk
Assessment, clinical findings on dentition.
X-Ray: Document radiographs exposed and reviewed, state findings
Impressions (Diagnoses): List various diagnoses by numbers. 1)Pathology
Differential Diagnoses, 2) Periodontal Diagnosis, 3) Caries Diagnosis, 4)
Endodontic Diagnosis
Suggestions (Tx Plans): List subsequent treatment plans by numbers from
“Impressions”. 1) Tx plan for oral pathology, 2) Tx plan for periodontal
disease, 3) Tx plan for restoration, 4) Tx plan for endodontic procedures
Tx Rendered Today: Additional procedures performed. Indicate names of
supervising faculty if there are several.
NV: Next visit
Patient axiUm Chart #: Date:
DMOXIS Example for Limited Oral Exam
D: 35 y.o. female presents with CC: “My tooth hurt”. Pt pointed to #3 and
reported pain when drinking cold water for the last 2 weeks. The pain was
sharp but transient. Pt denies spontaneous or throbbing pain on #3. Pt has
not seen a dentist for the past 2 years, and pt was satisfied with her past
dental treatments.
M: Pt reports history of controlled hypertension. No past surgery or trauma
history. Pt denies drinking alcohol, smoking or using recreational drugs.
Medication: 5mg Lisinopril (ACE Inhibitor for hypertension). NKDA. Vital
Signs: BP 125/80 RAS, P 82. ASA II. No medical contraindications to dental
treatment.
O: Oral cancer screening: No apparent pathology. Exam focused on #3
revealed: pocket depths <3mm with no mobility, negative percussion,
negative palpation. Endo ice test: “+” with no lingering. #3 has an existing
occlusal amalgam restoration with defective margin.
X: 1 PA and 1 BWX taken on #3 and reviewed. X-ray revealed an occlusal
recurrent decay close to pulp with no periapical pathology.
I: Recurrent decay on #3. Pulpal diagnosis: reversible pulpitis. Apical
diagnosis: normal apical tissues.
S: #3, O, composite. Pt signed tx plan.
Tx rendered today: #3, O, Composite. 2% Lidocaine w/ 1:100k epi, 1 carp
(34mg Lidocaine, 0.017mg epi) via local infiltration. Rubber dam isolation.
Removed existing amalgam and recurrent decay. Vitrebond placed. Etch.
Optibond Solo Plus. Herculite A2 composite. Finish and polish. Occlusion
and contact checked. Pt tolerated procedure well and was satisfied with
occlusion and esthetics. Pt advised tooth may be thermal sensitive for up to
8 weeks and to call if any lingering pain. POI given.
NV: Screening
Student Name: Group Practice #: Patient axiUm Chart #: Date:

DMOXIS Example for Multiple-visit Comprehensive Oral Exam

COE Visit #1: Data Collection
D: 35 y.o. female presents with CC: “I need a checkup”. Pt reports no
discomfort and is satisfied with her smile. Pt had braces as a teenager. Pt
brushes and flosses twice daily. Pt has not seen a dentist for the past 2
years, and pt was satisfied with her past dental treatments. The pts goal is
to treat any cavities and get back into a regular check up and prophylaxis
regimen.
M: Pt reports history of controlled hypertension. No past surgery or trauma
history. Pt denies drinking alcohol, smoking or using recreational drugs.
Medication: 5mg Lisinopril (ACE inhibitor for hypertension). NKDA. Vital
signs: BP 125/80 RAS, P 82. ASA II. No medical contraindications to dental
treatment.
COE Visit #2: Tx Plan Presentation
D: Review dental history: no change.
M: Review medical history: no change.
O: IO/EO/Oral cancer screening: No apparent pathology. Periodontal
findings: greatest PD of 4mm. Mild plaque in upper posterior molars.
Mild calculus in the lower anterior lingual surfaces. Hard tissue findings:
Class I occlusion. Canine guidance. #3 has an existing occlusal amalgam
restoration with defective margin. Caries Risk: High
Periodontal risk: Low
X: 4 BWX taken and reviewed. X-ray revealed #3 has an occlusal recurrent
decay.

O: Oral cancer screening: No apparent pathology. I: 1) Localized mild gingivitis. 2) Secondary decay on #3.

X: 4 BWX taken and reviewed. S: Tx Plan: 1) Prophy, Fluoride, and OHI 2) #3, O, composite. Pt signed tx
plan.
I: Impressions to be determined.
Tx rendered today: Prophy, topical fluoride application and OHI. Procedures
supervised by Dr. Tobias Boehm.
S: Suggestions to be determined.
NV: #3, O, composite
Tx rendered today: Alginate impression for diagnostic cast.

NV: COE data collection continuation

Patient Name: Student Name:
Chart #. Design Date: _
Removable Partial Denture (RPD) Design Form

Max illa Mandible

32 17

1 16

Kennedy Class: Modification(s): Kennedy Class: Modification(s):

Major Connector: _ Major Connector:

Tooth # Guide Plane Rest Clasp Undercut Recip Final Restoration Tooth # Guide Plane Rest Clasp Undercut Recip Final Restoration

Required Items:
Approved By: _
Mounted Diagnostic Casts (1set) Appropriate Radiographs
Design Casts (1set) Complete Perio Chart Date Approved: _