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Odontoscope® System
Institution *
Last name
Examiner *
Email
Patient *
Last name
First name
NISS number
Reason for the oral health assessment
Resident’s admission
Resident’s complaint
Deterioration of the resident’s oral health status following a fall or hospitalization
Follow-up in 3 - 6 - 12 months
Complaint description
Pain, dry mouth…
Intraoral photos
Maxillary arch
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Mandibular arch
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Tongue
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Oral mucosa
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Lips or cheeks as appropriate
Photos of dental prostheses
The patient wears an upper denture
Upper denture – cameo surface
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Upper denture – intaglio surface
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The patient wears a lower denture
Lower denture – cameo surface
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Lower denture – intaglio surface
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For their oral hygiene
The patient is independant
The patient is dependant
Tele-expertise
I request a dental analysis of this oral health examination by a dentist
I am conducting the analysis of this oral health examination myself
Oral health status analysis
Satisfactory
To be monitored
Requires care
Not assessable
Condition of the teeth
Condition of the gums
Condition of the tongue
Condition of the oral mucosa
Condition of the dentures
Oral hygiene assessment
Satisfactory
Needs improvement
Requires intervention
Not assessable
Teeth and gum hygiene
Tongue hygiene
Denture hygiene
Comments and Recommendations
Comment
Next follow-up examination in
3 months
6 months
12 months
Analyzed by
Last name
Function
I have read and I agree the
privacy policy
including my right to access my data, to have them rectified, to have them deleted and to put an end to the processing of my data. I also agree that the images submitted may be used anonymously to improve the quality of the service.
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