PROGRAM STUDI KEDOKTERAN GIGI

FAKULTAS KEDOKTERAN
UNIVERSITAS SRIWIJAYA

STATUS KONSERVASI GIGI

Nama Operator : ..........................................

NPM : ............................................
Nama Pasien :............................................... Tanggal :.....................................................
Jenis Kelamin :............................................... No. RM :......................................................
Umur :............................................... Alamat :......................................................
Pekerjaan :............................................... No. Telp :......................................................

ANAMNESIS
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RIWAYAT PENYAKIT SISTEMIK

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ODONTOGRAM
PEMERIKSAAN EKSTRA ORAL
Wajah :..................................................................................................
Bibir :..................................................................................................
KGB :..................................................................................................

STATUS LOKALIS PEMERIKSAAN RADIOGRAFI

Elemen gigi Mahkota
Sondasi Kamar pulpa
Perkusi Saluran akar
Tekan Akar
Palpasi Furkasi
Jaringan sekitar Membran periodontal
Tes termal Lamina dura
Tes kavitas Tulang alveolar
Mobiliti
DIAGNOSIS RENCANA PERAWATAN PARAF DOSEN