COMPREHENSIVE DIAGNOSIS AND TREATMENT PLANNING FORM: (COMPLETE ALL FIELDS)
Patient Name _______________________________Chart Number ________________________________Date started_____________________________
A.
CHIEF CONCERN_____________________________________________________
________________________________________________________________________
________________________________________________________________________
B. MEDICAL/DENTAL RELEVANT CONCERNS/HISTORY
Medical conditions__________________________________________________
________________________________________________________________________
Medications__________________________________________________________
________________________________________________________________________
Allergies_____________________________________________________________
C. SOCIAL HISTORY____________________________________________________
D. CARIES RISK ASSESSMENT High_____ Mod_____ Low_____
Caries in last 12 mos_____ Snack>3 between meals_____
Visible plaque anterior_____ Inadeq salivary flow_____
Inadeq Fl exposure_____ Decalcification>1_____
E. EXTRAORAL EXAMINATION
Head and Neck__________________________________________________________
Extremities/Skin_______________________________________________________
Lips______________________________________________________________________
T.M.J.
Maximum opening ____________mm Deviations_____________________
Clicking: Rt  Lt 
Crepitus: Rt  Lt 
Pain: Temporalis: Rt  Lt 
Med. Pterygoid: Rt  Lt 
Masseter:
Rt  Lt 
Lat. Pterygoid: Rt  Lt 
Ant Neck :
Rt  Lt 
Posterior Neck: Rt  Lt 
Habits_________________________________________________________________
History________________________________________________________________
G. SOFT TISSUE INTRAORAL
Lips___________________________________________________________________
Labial and Buccal Mucosa___________________________________________
Oropharynx__________________________________________________________
Floor of Mouth_______________________________________________________
Tongue________________________________________________________________
Palate_________________________________________________________________
Salivary Glands_______________________________________________________
F.
PSR Score
BOP
%
Plaque
______ %
Periodontal Diagnosis_____________________________________________________________________________
Perio instructor signature (PSR 3 & 4):_______________________________________Date:_____________
Revised: June 02 2014 – DR. TRENNA M. REEVE
H.
I.
J.
PERIODONTIUM: Complete Perio Form for PSR 3 and 4s
Gingiva________________________________________________________________
__________________________________PD range____________________________
Areas of localized disease/Suppuration __________________________
Calculus: Supra- Gingival: Generalized  Localized 
Sub- Gingival: Generalized  Localized 
Periodontitis Risk Profile: _________________OH_____________________
SIGNIFICANT RADIOGRAPHIC EXAMINATION FINDINGS
Bone Pathology:____________________________________________________
Bone Loss: H: ________________________V:____________________________
CR Ratio:____________________________________________________________
Root Shape/Length:________________________________________________
OCCLUSION: Complete Prostho Form for abutments
Class: Molar R _________L _________ Cuspid R __________L __________
CO vs MIP relationship __________________________
R. Lat.____________________
L. Lat.____________________
Pro. _____________________
Cross Bite_______________
Vert. O/Bite____________%
Horiz. O/Jet___________mm
I.O.D. at rest ________________mm
Abrasion ___________________
Erosion ___________________
SPECIALTY CONSULTS
DATE
Abfraction _________________
Attrition_____________________
Supra eruption ______________________________________________________
Malpositioned/Tipped______________________________________________
Parafunctional Habits_______________________________________________
K.
ENDODONTICS: Complete Endo Form for questionable teeth
Symptomatic_________________________________________________________
Radiographic lesions________________________________________________
Status of prior endo tx_______________________________________________
L.
ESTHETICS/PHONETICS
Esthetics _____________________________________________________________
Smile Line _______________________Diastemas_________________________
Colour ___________________________ Phonetics _________________________
M. DENTURE BEARING TISSUES: Complete Removable Form
Maxilla
Mandible
Mild Mod. Severe Mild Mod. Severe
Degree of Resorption 
 



Tori

 



Undercuts location
__________________
__________________
Gagging ________________________
Saliva ________________________
Consultants comments, date and signature
COMMENTS
INSTRUCTOR
SPECIALTY CONSULTS - REFERRALS
REFERRAL REQUEST INFORMATION
MEDICAL
ORAL
PATHOLOGY
TMJ/SLEEP
APNEA
ORAL SURGERY
GRAD PERIO
GRAD ORTHO
IMPLANT
Revised: June 02 2014 – DR. TRENNA M. REEVE
DATE
FOLLOW-UP
DISCIPLINE SPECIFIC PROBLEM LIST
PROBLEM/DIAGNOSIS
TOOTH RELATED PROBLEM LIST
TOOTH PROBLEM/DIAGNOSIS/CURRENT STATUS
#18
#17
#16
#15
#14
#13
#12
#11
#21
#22
#23
#24
#25
#26
#27
#28
#38
#37
#36
#35
#34
#33
#32
#31
#41
#42
#43
#44
#45
#46
#47
#48
Revised: June 02 2014 – DR. TRENNA M. REEVE
PROPOSED TREATMENT
TREATMENT OPTIONS/COST
PROGNOSIS
PROGNOSIS
COMPREHENSIVE TREATMENT PLAN, COSTS AND DATE COMPLETED
Phase I – Urgent Care/ Pain Management
Phase II –Preparatory/Disease Control and Re-evaluation
Phase III – Corrective
Phase IV – Maintenance/Follow-up
Phase
Tooth#/ Treatment
Surfaces
COST
TOTAL COST (PHASE I+II +III +IV) $___________
Pt
initial(s)
DATE
Completed
Patient Initial_______
I authorize the student clinicians at the U of M Dental Clinic to perform these treatments and have been
informed as to options for treatment, and understand my time and financial obligations.
Patient name ________________________________ Patient signature___________________________ Date_______________
Student name _______________________________ Student signature __________________________ Date_______________
Instructor name ____________________________ Instructor signature ________________________ Date_______________
Revised: June 02 2014 – DR. TRENNA M. REEVE
INFORMED CONSENT DOCUMENTATION:
I confirm that I understand the following:



My dental problems which have been diagnosed or identified, which are:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
The treatment that I have helped to select from a series of options that were explained to me and
which I understand will be provided is:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
I understand the risks involved in my treatment and the chances of success (prognosis) with
respect to the treatment are:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
I authorize the student clinicians at the U of M Dental Clinic to perform these treatments and
understand time and my financial obligations, and that annual fee increases can affect this
estimate:
Patient printed name_________________________________________________________________
Patient signature_____________________________________________ Date__________________
Instructor printed name______________________________________________________________
Instructor signature__________________________________________ Date__________________
Student printed name ________________________________________________________________
Student signature ____________________________________________ Date__________________
Revised: June 02 2014 – DR. TRENNA M. REEVE
CARIES RISK MANAGEMENT PROTOCOL
LOW RISK
Treatment
Recommendations
MODERATE RISK
HIGH RISK
Brush 2x/day with
fluoridated toothpaste
Brush 2x/day with
fluoridated toothpaste
Brush 2x/day with 5000ppm
fluoridated toothpaste
Sealants
Xylitol 6-10 mg/day – 3x/day Restore all areas of cavitation
x 5min
Application of 5% NaF
Application of 5% NaF
varnish every 3 months
varnish every 6 months
Diet analysis and counseling
Diet analysis and counseling
Sealants
Sealants
0.12% Chx mouthrinse
Close monitoring of incipient 1x/day for 1wk/month x 6
lesions
months
Xylitol 6-10 mg/day – 3x/day
x 5min
0.5% NaF rinse 2x/day
Calcium Phosphate several
times per day
Recall/Maintenance
Recall every 6-12
months
Radiographs every 1224 months
Revised: June 02 2014 – DR. TRENNA M. REEVE
Recall every 6 months
BWX every 6-12 months
Recall every 3 months
BWX every 6 months