ADVANCED DENTAL CLINIC
Oral Health Assessment Form
1. Patient Details
2. Extra Oral Examination
Jaw Joints (TMJ)
Tightness or clicking of jaw joints can be related to pattern chewing or jaw joint.
No abnormality detected
Clicking & popping
Deviation
Deflection
Reduced range of motion
Pain in joint
Others
Tenderness in Muscles
Tenderness in the jaw muscles occurs from bite issues, overuse, stress, and habits like clenching.
No abnormality detected
Temporalis
Masseter
Medial pterygoid
Lateral pterygoid
Others
History of Headache
A history of recurring headaches could sometimes be related to jaw stress or bite issues.
Lymph Nodes
Mild swelling in neck lymph nodes may be linked to an infection or inflammation.
No abnormality detected
Lymph node enlargement observed
Others
Swelling on Face
Swelling on the face indicates an underlying tooth or soft tissue concern that needs attention.
No abnormality detected
Swelling present
Others
3. Intraoral Soft Tissue Examination
We look for any irregularities of cheek, tongue, lip, and other soft tissues. Early detection here is key.
| Area | Finding |
|---|---|
| Cheek tissue |
|
| Tongue |
|
| Floor of mouth |
|
| Roof of mouth |
|
| Lip mucosa |
|
| Labial frenum |
|
| Buccal frenum |
|
| Lingual frenum |
|
Oral Cancer Lesion Check
No abnormality detected
Other
4. Tooth Health & Strength
S Codes:
S1 Sound / Healthy Tooth • S2 Caries / Decay • S3 Fracture / Cracked Tooth • S4 Existing Restoration Present •
S5 Root Canal Treated Tooth • S6 Missing Tooth • S7 Mobility / Loose Tooth • S8 Wear / Attrition / Abrasion •
S9 Old Crown Present • S10 Others
5. Functional Findings
TMJ Clicking / Sounds
Pain on Chewing
Limited Mouth Opening
Bruxism / Clenching Suspected
Attrition
Erosion
Abfraction
Compromised Vertical Occlusion Dimension
6. Periodontal Status
G Codes:
G1 Healthy Gingiva • G2 Gingivitis • G3 Periodontitis • G4 Bleeding on Brushing / Bleeding on Probing •
G5 Recession Present • G6 Mobility Present • G7 Pockets • G8 Occlusal Trauma
7. Smile / Aesthetic Check
8. Teeth Alignment
Deep bite
Cross bite
Scissor bite
Habits
Clenching
Grinding (Bruxism)
Nail biting
Pen/Pencil biting
Mouth breathing
Thumb sucking
Tongue thrust
Chewing on one side
Smoking / Tobacco
Betel nut / Supari
Others
9. Investigations
IOPA
OPG
CBCT
Photographs
Intraoral Scan
Study Models
Bite Record
Blood Investigations
Others
10. Treatment Required
T Codes:
T1 Restoration – Class I • T2 Restoration – Class II • T3 Restoration – Class V • T4 Build-up Only •
T5 Veneer • T6 Crown • T7 Extraction • T8 Implant • T9 Braces • T10 Aligners •
T11 Perio Treatment • T12 Pediatric Treatment • T13 Teeth Cleaning • T14 Whitening •
T15 Fluoride Therapy • T16 Gum Surgery • T17 Splint • T18 Denture • T19 FMR • T20 All-on-X
11. OPG
12. Scan