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Planning and providing optimal care require a thorough and systematic overall observation and clinical assessment. Components of the clinical assessment include an examination of the head and neck and oral cavity including an oral cancer screening, documentation of normal or abnormal findings, and assessment of the temporomandibular function.

A current, complete, and diagnostic set of radiographs provides needed data for a comprehensive dental and periodontal assessment.

A comprehensive periodontal examination is part of clinical assessment. It includes:
A. Full-mouth periodontal charting including the following data points reported by location, severity, quality, written description, or numerically:
    1. Probing depths
    2. Bleeding points
    3. Suppuration
    4. Mucogingival relationships/defects
    5. Recession
    6. Attachment level/attachment loss

B. Presence, degree, and distribution of plaque and calculus
C. Gingival health/disease
D. Bone height/bone loss
E. Mobility and fremitus
F. Presence, location, and extent of furcation involvement

A comprehensive hard-tissue evaluation that includes the charting of existing conditions and oral habits, with intraoral photographs and radiographs that supplement the data.
A. Demineralization
B. Caries
C. Defects
D. Sealants
E. Existing restorations and potential needs
F. Implants
G. Anomalies
H. Occlusion
I. Fixed and removable prostheses retained by natural teeth or implant abutments
J. Missing teeth

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