COMPREHENSIVE CLINICAL

ASSESSMENT FORM
COMPREHENSIVE CLINICAL
ASSESSMENT FORM
TABLE OF
CONTENTS

PART 1: GENERAL ASSESSMENT 4

PRIMARY HISTORY 4

SOCIAL HISTORY 4

EXTRAORAL ASSESSMENT 5

INTRAORAL ASSESSMENT 5

FULL MOUTH HARD TISSUE/ TEETH ASSESSMENT 6

RADIOGRAPHIC ASSESSMENT 7

PART 2: OCCLUSAL ASSESSMENT 8

STATIC OCCLUSAL ASSESSMENT 8

DYNAMIC OCCLUSAL ASSESSMENT 8

OCCLUSAL ASSESSMENT OF INDIVIDUAL TEETH 9

PART 3: IMPLANT ASSESSMENT 10

GENERAL IMPLANT ASSESSMENT 10

RISK ASSESSMENT 11

AESTHETIC RISK 11

RISK OF DEGREE OF DIFFICULTY 12

OVERALL RISK PROFILE 13

PART 4: CONCLUSION 14
 Dr Devang Patel
BDS MFDS RCS (Eng) MCGDent MSc FHEA MBA

PART 1: GENERAL ASSESSMENT

PRIMARY HISTORY:
C/O (Patient’s presenting complaint, if any):

HPC (History of presenting complaint):

Patients concerns:

Patient’s treatment goals:

Medical History:

Age:

LDV (Last dental visit):

Regular or irregular attendee:

SOCIAL HISTORY:
Occupation:

History of Smoking: ( If yes then note since how long patient is a smoker, how many cigarettes per day, which
type of cigarettes)

History of Alcohol: ( if yes then note since how long patient has been drinking alcohol and how many units a
day)

Any other habit:

4
 Dr Devang Patel
BDS MFDS RCS (Eng) MCGDent MSc FHEA MBA

EXTRAORAL ASSESSMENT:
Extraoral swelling: Yes/No (if yes then describe the swelling)

TMJ:
♦ Lymphadenopathy
♦ Clicking
♦ Crepitus
♦ Pain associated with TMJ

Mouth opening: __________ mm

Full range of motion – Yes/No:

Muscle palpation for any pain/discomfort:

♦ Temporalis
♦ Masseter
♦ Medial Pterygoid
♦ Lateral Pterygoid
♦ Other

INTRAORAL ASSESSMENT:
Soft Tissue:

Cancer check:

Periodontal status ( 6 point pocket charting/BPE):

OH:
♦ Tooth brushing – ETB or manual
♦ Use of Floss
♦ Use of Interdental brushes

Diet:

5
 Dr Devang Patel
BDS MFDS RCS (Eng) MCGDent MSc FHEA MBA

FULL MOUTH HARD TISSUE/ TEETH ASSESSMENT:

TOOTH TYPE OF AVAILABILITY OF TTP MOBILITY VITALITY VITALITY OTHER
RESTORATION/ DENTIN (ENDO ICE) (EPT) COMMENTS
SURFACE (RADIOGRAPHS)
INVOLVED SUFFICIENT/
MODERATE/
INSUFFICIENT
(TRI)

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

6
 Dr Devang Patel
BDS MFDS RCS (Eng) MCGDent MSc FHEA MBA

RADIOGRAPHIC ASSESSMENT:
♦ Type of radiograph:

♦ Reason for radiograph:

♦ Grade:

♦ Findings:

Any other diagnostic tests:

Caries risk assessment: Mild/Moderate/Severe

Periodontal risk assessment: Mild/Moderate/Severe

7
 Dr Devang Patel
BDS MFDS RCS (Eng) MCGDent MSc FHEA MBA

PART 2: OCCLUSAL ASSESSMENT

STATIC OCCLUSAL ASSESSMENT:
Orthodontic classification : Class I or Class II DIV I or Class II DIV II or Class III

Any variations:

Crossbite:

Overbite:

Overjet:

Shimstock holds:

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

ICP: Stable or Unstable

CO (Centric occlusion/first point of contact in CR):

DYNAMIC OCCLUSAL ASSESSMENT:

CO to ICP Slide: Hv ( Large horizontal and small vertical) or Vh ( Large vertical and small horizontal)

Amount of CO to ICP slide in mm:

Load test: Painful / Not Painful

8
 Dr Devang Patel
BDS MFDS RCS (Eng) MCGDent MSc FHEA MBA

Right lateral excursion:

♦ Working side contact/s
♦ Non working side contact/s

Left lateral excursion:

♦ Working side contact/s
♦ Non working side contact/s

Protrusive excursion:
♦ Incisal guidance
♦ Posterior guidance Right
♦ Posterior guidance Left
♦ Posterior disclusion – Yes/ No

OCCLUSAL ASSESSMENT OF INDIVIDUAL TEETH:

Signs of occlusal instability causing imbalance ,broken or loose teeth:

occlusal disease - hypermobility, excessive wear, tooth migration or cusp fractures

Mobility:

Wear:

Supraeruption:

Lack of posterior support:

9
 Dr Devang Patel
BDS MFDS RCS (Eng) MCGDent MSc FHEA MBA

PART 3: IMPLANT ASSESSMENT

GENERAL IMPLANT ASSESSMENT:
Specific Medical History for Implant consideration:

Area for Implant consideration:

Health of the adjacent teeth and periodontal structure:

Vitality of adjacent teeth:

Lip line: High / Medium / Low

Gingival Biotype: Thick / Medium/ Thin

Interdental Papilla height/ bone:

Lack of attached mucosa : Yes/ No

Visible bone defect : Yes/ No

Site of the defect ( if present):

CBCT available : Yes/ No

♦ Bone level of the edentulous area:
♦ Bonegrafting/sinus lift required : Yes / No

Any other findings:

10
 Dr Devang Patel
BDS MFDS RCS (Eng) MCGDent MSc FHEA MBA

RISK ASSESSMENT:

AESTHETIC RISK:

LEVEL OF RISK
AESTHETIC RISK FACTOR

LOW MODERATE HIGH

Healthy, co-operative
patient
MEDICAL STATUS Reduced immune system
with an intact immune
system

Light smoker (<10 Heavy smoker (>10

SMOKING HABIT Non-smoker
cigs/day) cigs/day)

PATIENT›S AESTHETIC
Low Medium High
EXPECTATIONS

LIP LINE Low Medium High

Medium scalloped,
GINGIVAL BIOTYPE Low scalloped, thick High scalloped, thin
medium thick

SHAPE OF TOOTH
Rectangular Triangular
CROWNS

INFECTION AT IMPLANT
None Chronic Acute
SITE

BONE LEVEL AT ADJACENT 5.5 to 6.5 mm to contact

≤5 mm to contact point ≥7 mm to contact point
TEETH point

RESTORATIVE STATUS OF
Virgin Restored
NEIGHBOURING TEETH

WIDTH OF EDENTULOUS
1 tooth (≥7 mm) 1 tooth (≤7 mm) 2 teeth or more
SPAN

SOFT TISSUE ANATOMY Intact soft tissue Soft tissue defects

BONE ANATOMY OF Alveolar crest without Horizontal bone

Vertical bone deficiency
ALVEOLAR CREST bone deficiency deficiency

11
 Dr Devang Patel
BDS MFDS RCS (Eng) MCGDent MSc FHEA MBA

RISK OF DEGREE OF DIFFICULTY:

RISK OF DEGREE OF DIFFICULTY

SITE FACTORS
LOW MODERATE HIGH

BONE VOLUME

Deficient, but allowing

Deficient, requiring prior
Horizontal Adequate simultaneous
augmentation
augmentation
Small deficiency crestally,
requiring slightly deeper
corono-apical implant
position. Small deficiency Deficient, requiring prior
Vertical Adequate
apically due to proximity augmentation
to anatomical structures,
requiring shorter than
standard implant lengths

ANATOMIC RISK

Proximity to vital Minimal risk of Moderate risk of

High risk of involvement
anatomic structures involvement involvement

AESTHETIC RISK

Aesthetic zone No Yes

Biotype Thick Thin

Thickness of facial bone

Sufficient ≥1 mm Insufficient <1 mm
wall

COMPLEXITY

Implant placement
Number of prior or Implant placement with Implant placement with
without adjunctive
simultaneous procedures simultaneous procedures staged procedures
procedures

COMPLICATIONS

Risk of surgical
Minimal Moderate High
complications

Consequences of Severely compromised

No adverse effect Suboptimal outcome
complications outcome

12
 Dr Devang Patel
BDS MFDS RCS (Eng) MCGDent MSc FHEA MBA

RISK OF DEGREE OF DIFFICULTY:

DEGREE OF DIFFICULTY

ISSUE NOTES LOW MODERATE HIGH

PROVISIONAL RESTORATIONS

During implant
None required Removable Fixed
healing

Provisional
restorations will be
Restorative margin Restorative margin
Implant-supported needed to develop
Not required <3 mm apical to >3 mm apical to
provisionals needed aesthetics and soft
mucosal crest mucosal crest
tissue transition
zones
To date immediate
restoration and
loading procedures Conventional or
Loading protocol Immediate loading
are lacking early loading
scientific
documentation
Materials and
techniques used in Resin-based
Materials/ Porcelain fused to
the manufacture of materials + metal
Manufacture metal
definitive reinforcement
prostheses
Anticipated
maintenance needs
Maintenance Needs Low Moderate High
based on patient
presentation

OVERALL RISK PROFILE: High / Medium/ Low

Reason for above conclusion:

13
 Dr Devang Patel
BDS MFDS RCS (Eng) MCGDent MSc FHEA MBA

PART 4: CONCLUSION

Diagnosis:

Treatment Plan: (Discuss various options and advantages and disadvantages of each option including relevant
fees)

Recall interval:

14
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