I

PPP/C1 4/09/e&d101 /201 8/semakan02

Tarikh kuatkuasa: S

a?rr" Patient's Name

,&-€**urn J
EPEPAICUN- -Z
Registration No.
iffi-*lfif^.*.r# Date of Birth
W@Y*
CLINICIAN: YEARY SESSION
START DATE

H/SIORY
CHIEF COMPLAINT:

HISTORY OF CHIEF COMPLAINT:

MEDICAL HISTORY

Cardiovascular System : Respiratory System :

Hypertension Asthma
Angina Bronchitis
Myocardial lnfarction TB
lnfective Endocarditis
Rheumatic Fever Gastrointestinal / Hepatic System
Blood Dyscrasias Bleeding problems
Oedema Jaundice
Hepatitis
Endocrine System
Diabetes Mellitus Neurological System:
Thyroid Epilepsy
Loss of consciousness (LOC)

Pregnancy:

Details of the medical problem(s):

Medications
Allergy
Hospitalization: NO / YES (Reason)

Others

DENTAL HISTORY

SOCIAL HISTORY

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EXAMINATIOIi
Extra-oral examination

lntra-oral examination

Area/Tooth of complaint

soFT ITSSUE ASSESS'i.iE# r

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CamanLre

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L{utoa

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RIGI{T I{tlr Illlff' LEF-I
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Tongu* Tongu
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He{l#*thrF

ORAL HYGIENE AND PERIODONTAI- STATUS

Oral Hygiene POOR/FAIR/GOOD

Plaque Score o/
Generalized / Localized
Gingival score to Generalized i Localized
Calculus tiainirnat / Moderate/ Abundant Generalized / Localized
-o/
Supragingival / Subgingival

BPE Pocket>4mm :YES/NO

Gingival Status
Others .

Prophylaxis : REQUIRED I NOT REQUIRED

Gross Scaling : REQUIRED / NOT REQUIRED

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PPP/C1 4109/e&d/01/201 8/semakan02

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G Caries RCT Root Canal Treatrnent X Missing teeth

C Restoration NV Non vital tooth

/ For et'traction

V Crown/ AbutmenU Pontic # Fracture M1, M2, M3 Mobility

lnitial examination : Date

PROGNOSIS
ICDAS
SCORE

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ICDAS
SCORE
PROGNOSIS

PROGNOSIS : G = GOOD, Q = QUESTIOIiABLE, P = POOR

IGDAS SCORE (CODES A GRffERIA)

RESTORATION AND SEALANT
CARIES CODES DESCRIPTION
GODES
0 = Unrestored tooth 0 = Sound tooth surface 2 digit codes, a restoration/ sealant code
= First visual change in enamel: opacity or followed by a caries code.
1 = Sealant, partial I
discolouration (white or brown) after air dryinq E.g.:
2 = Sealant, full 2 = Distinct visual chanoe in enamel when wet . Unrestored and sound surface = 00
3 = Localized enamel breakdown without . Unrestored cavity in dentine = 05
= Tooth colored restoration J
dentine involvement Amalgam with underlying dark
4 "
= Amalgam restoration = Underllng shadow = 44
5 = Stainless steel crown cavity with visible dentine . Composite with sound tooth structure
6 = Crown orveneer 6 = Extensive (> half the surface) cavitv =30
7 = Lost restoration . PFM crown with distinct cavity with
8 = Temporary restoration visible dentine caries = 65

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Status of Crown / abutments (if present):

DENTURE xAMII{ATIAN

Upper Lower

Type

Kennedy Classification

Retention

Support

Extension

Stability

Hygiene

Others

Occlusion:

Occlusal Vertical Dimension:

OCGI-USAL ANALYSIS

INITIAL OCCLUSAL FINDINGS

Centric Relation Occlusion
(CR)

Maximum intercuspation (Ml)

CR=Ml _ mm shift from CR to MI

Right Lateral Excursion

Left Lateral Excursion

Protrusion

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Differential Diagnosis:

D'AGNOSI'C TESTS

RADIOGRAPH:

Bitewings

Periapicals

(oPG)

Others:

PULP SENSIBILITY TESTS:

TOOTH EPT COLD CONCLUSION

Control:

Test:

Control:

Test:

Control:

Test:

Control:

Test:

Guide (For Cold Test) :

+++ flypsr responsive
+ Normal
0 No Response

Other Tests:

Smoking status: YES/NO (lf yes, CO level:

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OTHERS:

Test Findinqs

CAR'ES R'SK ASSESSAfENI

iicl in the appropriate boxes,

i: Risk Factor Assessment

Caries Risk Matrix
flviribt" ptaque

Number of No active caries lnitial stage active Moderate or

ENo fluoride exposure
risk iactors lesion (ICDAS 0) caries lesion extensive active
.x
Dcrowding/oeep pit and fissures (rcDAS 1 & 2) caries Iesion
ro (rcDAS 3 * 6)
Eory mouth
.6
Low Moderate Moderate
flAny dental appliances e.g. (Fixed E. OEI
O rth odo nti c/p rosth eses) ol
'=
rI,
U
nsugar/snacks intake between
mea ls o.1
rE zE Low Moderate High
q
o)
tr tuedical ly compromised rn
E tr,4other/sibling experience 3 or more Moderate High High
history

DtAGIT,OSTS

Diagnosis of Chief Complaint:

Other diagnosis / Problern list:

tf any tooth is indicated for root canal treatment, fill in Endodontic Case Difficulty Assessment Form.
Dental charting and treatment plan are to be updated every 12 months.

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TREATMENT PLAT,I

E &D TP.EATMENT PLANNING: CASE COMPLETE:

S''l:erviscr : Supervisor :
Sicnature : Signaiure :

U 1L=

TREATMENT TREATMENT PROCEDURE COMPLETED

CHARGES GOMPLETED BY:
(Supervisors
(RM) (HAMH MATRTCS Signature,
No) Date)

TOTAL
 PPP/C1409ie&d/01 i20i Sisemakan02
S
TREATMENT TREATMEI{T PROCEDURE COMPLETED
GHARGES COMPLETED BY:
(Supervisor,s
(RM) (NflnE/ MATRtcs Signature,
N D

TOTAL

Irave exnlaineo ro the patient: hisher l'eatment

ooiions, the nsks and beneflts cf
sava telah meneranokan keaada pesakit land ahernatives to) each.
-"rs;;;i ;;ii;;, rawaLan iir,-'iiii,. iJ'^lrrrrt rawatan bekenaan.

S Perawat Nama
Datel
I understand the recommended treatrnent and
my financial respcnsibiiity as expiained
to me. r arso acknowradge that during
Hi:tillJ,ffl,iil:"tr"##":lt:f;tiim:i:f=*[#:;," :iH;oif"l'?"?o *hire wo*ing ;ff;"d;; ,nu, u,",r
saya memahami rawatanvalo dr,slofuan dan ranggungjaw* seperti yang dilerlnukll kepada
mengambil maklum bahawa rawatah atuu p,o"rauiit
yang tidak dapat dikenalpas, aiiitrt * !.yunq3, saya. saya juga
atau iitambai ieiAiyu t"rruput keperuansema.sa
se,asa pemeiksaan- saya tersetuiu/ tidak bersetuju rawaian
dengan rawatan yang dicadanokan

Patient Signature / Tandatangan ( Parent or Guardian/ lbu bapa

atau Penjaga)

Nama
Date/ Tarikh

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