Practitioner ID numeric
GENDER: MALE, FEMALE
Hispanic 1-y 0-else
WHITE 1-y 0-else
Black 1-y 0-else
Asian 1-y 0-else
American Indian 1-y 0-else
Hawaii/Pac Island 1-y 0-else
Insurance: 1=NONE 0=else
Insurance: 1=PRIVATE 0=else
Insurance: 1=PUBLIC/GOVERNMENT 0=else
Insurance: 1=OTHER 0=else
Insurance: 1=UNKNOWN 0=else
SIDE AVOID CHEW FOOD 1=Right 2=LEFT
Freq Clench/Grind teeth sleep
Freq wear night guard
Freq Clench/Grind teeth when awake
Freq press, touch, hold teeth together
Freq hold objects, chew hard candy/ice
Freq Chew Gum
Freq chew one side
STRESS LEVEL 1-5
Spontaneous pain
Vitality test used: Cold refrig spray
Vitality test used: Electric pulp tester
Vitality test used: Cold ice
Vitality test used: Other
Response to cold test
Response to bite test
Tooth: occlusion with opposing tooth/teeth
Tooth: has wear facet through enamel
Tooth: roots exposed to oral cavity
Tooth: Caries present
Tooth: removable partial denture abutment
Tooth: fixed partial denture (bridge) abutment
Tooth: non-carious cervical lesion (nccl) or abfraction
Tooth: has none of characteristics listed
Opp Tooth[1]: Natural or restored tooth
Opp Tooth[2]: Implant restored crown
Opp Tooth[3]: Fixed partial denture (bridge) pontic
Opp Tooth[4]: Removable full denture or partial denture
Opp Tooth[5]: No opposing tooth
Rad 1: Evidence of crack(s) on radiograph
Rad 2: Evidence of periradicular lucency
Rad 3: No crack-related findings on radiograph
Rad 4: No radiograph taken past 12 months
Treatment rec at base: Monitor only
Treatment rec at base: Extraction
Treatment rec at base: Endodontics
Treatment rec at base: Restoration
Treatment rec at base: Other
Recommend restoration at base: Type placement 1:Direct 2:Indirect
Recommend restoration at base: Type 1:Intracoronal 2:Crown 3:Partial
Recommend restoration at base: 1:Bonded 2:Not bonded
Recommend restoration at base: IF crown, buildup prior 1:Yes 2:No 3:NA
Reason treat: Caries Associated With Crack
Reason treat: Caries Not Associated With Crack
Reason treat: Broken/Defective Restoration
Reason treat: Compromised Tooth Structure
Reason treat: Periodontal Involvement
Reason treat: Pulpal Involvement
Reason treat: Tooth Sensitive To Hot/Cold
Reason treat: Tooth Painful Or Infected
Reason treat: Broken Tooth
Reason treat: Other
PILOT Rec at base restore bonded intracoronal
PILOT Rec at base restore non-bonded intracoronal
PILOT Rec at base restore bonded indirect
PILOT Rec at base restore bonded extracoronal - partial cusp
PILOT Rec at base restore bonded extracoronal - full cusp
PILOT Rec at base restore non-bonded extracoronal - full cusp
PILOT Rec at base restore temporary extracoronal - full cusp
PILOT Rec restore at base - other
Recommend temporary restoration at base [pilot only]
Assessment of internal cracks can be made
Number of internal cracks assessed
Tx Complete at Base: Extraction
Tx Complete at Base: Endodontics
Tx Complete at Base: Restoration
Tx Complete at Base: Other
Tx at BASE if Restore, placement 1:Direct 2:Indirect
Tx at BASE if Restore, type 1:Intracoronal 2:Crown 3:Partial
Tx at BASE if Restore, Bonded 1:Yes 2:No
Surface restored at BASE: Mesial
Surface restored at BASE: Occlusal
Surface restored at BASE: Distal
Surface restored at BASE: Frontal
Surface restored at BASE: Lingual
Material used in restoration at BASE: Amalgam
Material used in restoration at BASE: Composite
Material used in restoration at BASE: Glass Ionomer
Material used in restoration at BASE: Ceramic
Material used in restoration at BASE: Metal
Material used in restoration at BASE: Other
IF Crown at Base, BuildUp 1:Yes 2:No 3:NA
IF Crown at Base, Temporary 1:Yes 2:No 3:NA
Tx rec at base after initial Tx completed: Monitor
Tx rec at base after initial Tx completed: Extraction
Tx rec at base after initial Tx completed: Endodontics
Tx rec at base after initial Tx completed: Restoration
Tx rec at base after initial Tx completed: Other
If rec restoration at base AFTER initial Tx completed, placement: 1:Direct 2:Indirect
If rec restoration at base AFTER initial Tx completed, TYPE: 1:Intracoronal 2:Crown 3:Partial
If rec restoration at base AFTER initial Tx completed, BONDED: 1:Yes 2:No
If rec CROWN restoration at base AFTER initial Tx completed, BuildUp prior 1:Yes 2:No 3:NA
Total number of restorations
Total number of external cracks
Tooth position
Molar =1, Premolar =0
Lower, Mandibular
Sensitive to cold test
Sensitive to bite test
Symptomatic, Cold, Bite, or Spontaneous
DOB Month - clean
Visit date Year numeric
Visit date Month numeric
Education 4-groups
Has an Internal Crack