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NATIONAL AUTONOMOUS UNIVERSITY OF HONDURAS IN THE SULA VALLEY

UNIVERSITY SCHOOL OF HEALTH SCIENCES
DEPARTMENT OF DENTISTRY

PERIODONTIC CLINICAL RECORD

No. File: _______________

Patient's name: _______________ _______________ _______________ _______________

1st number second name First surname 2nd surname

No. Identity:
Date of birth: _____ / ______ / ______ Age:
Day Month Year

Sexo: Female Male Profession or trade:

Current address: Telephone:
Responsible person: Phone:
In case of emergency, contact: Telephone:
Exam date: _____ / ______ / ______
Day Me Year
Student Operator Name: ____________ ____________ _____________ ____________
1st name second name First surname second surname
Assistant Student Name: ____________ ____________ _____________ ____________
first number second name First surname second surname

1. REVIEW BY ORGANS AND SYSTEMS: Mark with an X in the box if the answer of the
the patient is affirmative.

Cardiovascular Urinary Genital Diseases

infectious
Myocardial infarction Renal insufficiency
Rheumatic fever Urinary infections Hepatitis A, B, C
Valvulopathies Calculations HIV
High blood pressure Cystitis Tuberculosis
Hypotension Nephrotic syndrome ETS
Chest pain Prostatitis Toxoplasmosis
Others__________ Urethritis Others__________
Others__________

Neurological

Frequent headaches - Migraine Gastrointestinal Skeletal Muscle

Cerebrovascular accident
Meningitis Ulcers Muscle pain
Epilepsy Gastritis Arthralgia
Schizophrenia gastroesophageal reflux Muscle spasms
Stress Colitis Rigidity
Others__________ Others__________ Others__________

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Endocrine Allergies Female reproductive system

Diabetes Medications Pregnancy

Hyperthyroidism Anesthesia Fecha de parto________
Hypothyroidism Foods Date of last
Goiter and thyroid nodule Latex menstruation
Hypoglycemia Allergic rhinitis Contraceptives
Rheumatoid arthritis Detergents or Oral
Collagen diseases Chlorine Injected
Others Patches
Specify______________ She is breastfeeding
Others________________ Abortions
Respiratory No. Partos________
C-sections
Asma
Pulmonary Emphysema
Sinusitis Lung disease
Frequent colds chronic obstructive
Pneumonia Your chronic
Adenoid problems Chronic bronchitis
Others

Others

Cancer
Specify___________

2. MEDICAL HISTORY
___________________________________________________________________________

___________________________________________________________________________

Medications being taken: ______________________________________________________

3. ORAL HYGIENE HABITS

Tipo de Cepillo Dental que usa: ____________________________ Técnica: ______________

Use other dental hygiene instruments If No Which ones?
Onychophagy Bite lip Suck on citrus fruits

Lingual interposition Grind teeth Alcoholism

Interposition of objects Bruxism Tobacco use
Digital Suction Mouth Respirator Others_______________

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4. CURRENT BACKGROUND OF PERIODONTAL DISEASE

Pain in teeth Yes No Pain in the gum Yes No

Others: ______________________________________________________________________
Gum bleeding Spontaneous Provoked Explain: ___________________
Dental Mobility Yes No
Halitosis Yes No
Family background Father Mother Brothers Others: ____________
Explain: ____________________________________________________________________

5. PERIODONTAL EXAMINATION

a. Description of the characteristics of the gum

Color:

Form:

Position:

Size:

Consistency and surface:

b. Local etiological factors

FACTOR TOOTH(S) PROVOKED EFFECT

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Mucogingival alterations Yes No

Describe:

6. OCCLUSAL EXAMINATION

Mouth Opening: Augmented Normal (4.2-4.4 cm) Diminished

Deviation: No Yes Left Right
Incisal Guide: No Yes Dientes en Contacto: _____________________________
Protrusion Interferences: No If Pieces in contact:_______________________

Right lateral movements: Increased Normal Diminished

Dog Guide No Yes Parts by Group Function: ___________________________
Interference in Balance: No Yes Contact parts:_______________________

Left lateral movements: Increased Normal Reduced

Dog Guide No Yes Parts by Group Function: ___________________________
Interference in balance: No If Parts in contact:_______________________

Pain in the A.T.M. No Yes

Law Left Provoked Spontaneous

Joint Noises: No Yes Click Crepitation

Opening Closure Unilateral Bilateral

Difficulty in: Opening Closure

Maximum aperture _______ mm Minimum opening _______ m.m
Pain while chewing: Yes No

Dental wear Attrition Abfraction Erosion Abrasion

Open bite Anterior crossbite Crossbite posterior

Bite edge to edge Overjet ________ mm Overbite ________ m.m

Angle Classification
Right canine relationship __________ Left canine relationship __________
Right molar relationship __________ Left molar ratio __________

Arch shape: Square Oval Triangular

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7. PERIODONTOGRAM AGE _____ DATE: _____/_____/_____

1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
Suppuration
Bleeding
Mobility
Fork: V
Level. Insertion
Survey

["4.8","4.7","4.6","4.5","4.4","4.3","4.2","4.1","3.1","3.2","3.3","3.4","3.5","3.6","3.7","3.8"]

Survey
Niv. Insertion
Fork: V
Mobility
Bleeding
Suppuration

1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
Suppuration
Bleeding
Furca: MP
Fork: DP
Niv. Insertion
Poll

4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
Poll
Level. Insertion
Fork: L
Bleeding
Suppuration

Prepared by the Department of Dentistry UNAH-VS. 2016

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8. Gingival Index (G.I.): LÖE & SILNESS 1963

Note on each side of each tooth in the mouth the graduations 0, 1, 2, and 3 as appropriate.
0: normal gum, no inflammation, no change in color or bleeding.
Mild inflammation and alteration of the gingival surface. There is no bleeding.
2: moderate inflammation, erythema and edema, bleeding upon probing or under pressure.
3: severe inflammation, significant erythema, and edema. Tendency to spontaneous bleeding.

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
VESTIBULAR
MESIAL
PALATINO
DISTAL
Index Group I: Index Group II: Index Group III:

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
VESTIBULAR
MESIAL
LINGUAL
DISTAL
Index Group IV: Index Group V: Index Group VI:

9. O ’LEARY INDEX (plate control)

FECHA: ______________ Percentage of plaque ________

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

4.8 4.7 4,6 4,5 4,4 4,3 4,2 4,1 3,1 3,2 3,3 3,4 3,5 3,6 3,7 3,8

FECHA: ______________ Percentage of plaque ________

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

4.8 4.7 4,6 4,5 4,4 4,3 4,2 4,1 3,1 3,2 3,3 3,4 3,5 3,6 3,7 3,8

DATE: ______________ Percentage of plaque ________

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

4.8 4.7 4,6 4,5 4,4 4,3 4,2 4,1 3,1 3,2 3,3 3,4 3,5 3,6 3,7 3,8

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DATE: ______________ Percentage of plaque ________

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

4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

DATE: ______________ Percentage of plaque ________

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

4,8 4,7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

[Link]

Relevant elements for the diagnosis:

Occlusal trauma: Yes No

Involved parts:

Periodontal Diagnosis:

Fundamentals of diagnosis:

11. FORECAST

Psychological disposition Nervous Indifferent Cooperator

Another observation:

General:

Fundamentals of Forecasting:

Prepared by the Department of Dentistry UNAH-VS. 2016

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[Link] PLAN (valid with the teacher's signature)

STAGE OF
TREATMENT DESCRIPTION No. QUOTES COST
TREATMENT

___________________________ ___________________________
Patient name Patient I.D. signature

___________________________ ___________________________
Name of the student(s) Student(s) I.D. Signature

___________________________ ___________________________
Teacher's name Firma docente I.D.

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13. EVOLUTION OF TREATMENT

Signature of Signature of Signature of
Date Clinical activities performed patient student teacher

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[Link] THERAPY
Date: ______ / ______ / ______

Periodontal Maintenance Program:

___________________________ ___________________________
Patient name Patient I.D. signature

___________________________ ___________________________
Nombre del estudiante(s) Student(s) signature I.D.

___________________________ ___________________________
Name of teacher Teaching staff I.D.

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PAYMENT CONTROL

No.
Date Patient's name Fertilizer Balance Patient's signature Student signature
receipt

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NATIONAL AUTONOMOUS UNIVERSITY OF HONDURAS IN THE VALLEY OF SULA

UNIVERSITY SCHOOL OF HEALTH SCIENCES
DEPARTMENT OF DENTISTRY

INFORMED CONSENT FOR PERIODONTAL TREATMENT

I ____________________________________________________, identified with national document of

identity _________________________________, residing at
_________________________________________________________.
I declare that the student _____________________________________________________ has informed me
about the need and convenience of undergoing periodontal treatment, regarding this I understand that:
1. Periodontal Treatment is indicated in the following cases: swollen gums, plaque accumulation.
bacterial and tartar, mobility of the teeth due to loss of the tissues that support them, periodontal abscesses,
gum enlargement, mucocutaneous lesions.
2. Periodontal therapy is structured as follows:
a. Conservative treatment: it consists of instruction on proper oral hygiene techniques, taking
relevant data for diagnosis such as the depth of periodontal pockets and other data
important clinics. Manual and sonic devices will be used, which are placed between the tooth and
the gum. These instruments will be used for the removal of bacteria, tartar, and infected cement that
It accumulates on the root of the tooth and in the periodontal pockets. This phase of the treatment can be carried out
in various cases, the administration of local anesthetics, antibiotics, or antiseptics may
to be part of the treatment.
b. Surgical treatment: consists of the administration of local anesthetic before cutting and opening the gum.
to allow better access to the root and the eroded bone, and the root surface will be cleaned to
background. The administration of antibiotics and antiseptics may be part of this treatment.
c. Unforeseen conditions may require a modification or changes that were not anticipated in the
surgical plan. These may include: the extraction of hopeless dental pieces to improve the
cure of the adjacent pieces, the removal of a hopeless root of a tooth with
multiple roots in order to preserve the tooth, or the completion of the procedure prior to the implementation of
all those of the surgery initially outlined.
d. The consumption of alcohol, smoking, or uncontrolled systemic diseases can affect
negatively to the healing of the gums and can limit the success of any surgery. It is important
that patients adhere to the specific prescriptions and instructions given by the students.
The treatment requires the application of anesthesia to carry out dental treatment without
pain, applying it through an injection of substances that reversibly block the impulses
nervous in such a way that the sensitivity of the area to be treated is temporarily interrupted, which
it will produce a feeling of numbness; this effect will usually go away on its own
in two or three hours.
f. The NON-compliance with the given instructions may cause the infection to return or worsen.
causing the continuous loss of periodontal tissues, resulting in partial or total loss of the
teeth.

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RISKS AND POSSIBLE COMPLICATIONS

1. Due to the application of local anesthetic: ulcers in the mucosa, pain, hematoma, and in some cases limitations
in the movement of opening the mouth, hypotension, dizziness, alterations in sensitivity, manifestations
allergic and in extreme cases anaphylactic shock.
2. By medications: allergic reactions causing inflammation and redness of the tissues, pain,
itching, vomiting and/or anaphylactic shock.
It is common to notice an increase in dental sensitivity and mobility of the after treatment.
teeth.
4. Pain, edema, inflammation and/or bleeding.

Having understood everything stated above about the treatment, risks, potential complications;
having had the opportunity to clarify doubts and ask everything necessary, I am satisfied with the information
received and that I understand the scope and risks of the treatment, and under such conditions:
I give my consent for the anesthesia previously indicated to be administered.
I give my consent for students in training to participate in the implementation of the treatment.
accompanied by the responsible teacher.
3. I give my authorization for the necessary diagnostic procedures to be carried out (sampling.
de modelos de estudio, radiografías periapicales y panorámica, fotografías) para la obtención de un correcto
diagnosis.
4. I am aware that if I discontinue the treatment, the student will not be held responsible for the damages.
that it can produce.
5. I declare that I have been informed of the risks and complications, and that they were explained to me and I understand them.
perfectly, I understand that the student cannot guarantee the outcome of the treatment.
6. The payment for the treatment will be made by giving _____% of the total amount before starting the treatment and
_____ % during its execution.
7. Therefore, and with full knowledge of what has been stated above, I give my full consent to undergo the
respective periodontal procedures.

AUTHORIZATION

I certify that I have read or have been read to me, and I have understood this document in its entirety before signing it and
authorizes doctor _________________________________ and the assigned students who will be under
your responsibility and direct supervision, so that they carry out the proposed procedure.

______________________________ ______________________________
Patient name Patient's signature I.D.

______________________________ ______________________________
Nombre del testigo Witness signature I.D.

______________________________ ______________________________
Teacher's name Teacher's signature I.D.

______________________________ ______________________________
Student's name(s) Student's signature(s) I.D.

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If the patient is legally incapable of signing this document, please complete the following information:
The patient is legally incapacitated to give informed consent and to sign this document due to the fact that:
He/She is a minor:____________
Is your mental state compromised:_________________
Relationship of the person authorized for the procedure and the written informed consent with the patient
_______________________________________

San Pedro Sula, __________ of ______________________________ of _____________

This document must be kept as a mandatory annex to the medical history.

Revocation of Informed Consent

I, ____________________________________________ identified with document __________________,

I have decided to revoke the informed consent, therefore I do not wish to continue with the treatment.

Given in the city ________________________, the day ______ month ______ year ______

______________________________ __________________________________________
Patient's name Patient's signature I.D.

______________________________ __________________________________________
Name of the witness Witness signature I.D.

______________________________ __________________________________________
Name of the teacher Teacher's signature I.D.

______________________________ __________________________________________
Student name(s) Student's signature(s) I.D.

The dentist will respect the patient's wishes to forgo their services, as long as the patient has...
capacity to freely express one's will.

Prepared by the Dentistry Department UNAH-VS. 2016