PROTOCOLO DE PERIODONTAL

H.C: Nombre Paciente: Edad:

Dirección: Teléfono: Sexo: F___ M ____

Fecha: Estudiante: Código:

Teléfono estudiante: Nombre Periodoncista: Semestre

HALLAZGOS RADIOGRAFICOS

PERDIDA OSEA VERTICAL ____________________________________________________

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PERDIDA OSEA HORIZONTAL_________________________________________________
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FURCAS __________________________________________________________________
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LIGAMENTO PERIODONTAL __________________________________________________
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OTROS HALLAZGOS _________________________________________________________
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DIAGNOSTICO PERIODONTAL
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PLAN DE TRATAMIENTO PERIODONTAL

1. FASE URGENCIAS ________________________________________________________

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2. FASE SISTEMICA _________________________________________________________
3. FASE HIGIENICA __________________________________________________________
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4. FASE DE REEVALUACIÓN ___________________________________________________
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5. FASE CORRECTIVA ________________________________________________________
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6. FASE DE MANTENIMIENTO _________________________________________________
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PRONOSTICO PERIODONTAL

GENERAL _________________________________________________________________
INDIVIDUAL _______________________________________________________________
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OBSERVACIONES ___________________________________________________________
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FIRMA DEL DOCENTE: _____________________________

FECHA: _________________________________________