Dental and Oral Syndrome

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

Narrative: Regional Office action is required for all dental treatment based on combat wounds, service trauma, prisoner of war or extracted teeth under 38 CFR 17.123.

A. Review of Medical Records:


B. Medical History (Subjective Complaints):
C. Physical Examination (Objective Findings):

Address each of the following and fully describe:

1. Describe extent of functional impairment due to loss of motion and masticatory function loss.
2. Describe the extent and number of missing teeth and whether the masticatory surface can be replaced by a prosthesis.
3. If limitation of inter-incisal range of motion, provide actual range in mm (i.e., 0-Xmm) and also provide lateral excursion (i.e., 0-Xmm).
4. Describe the extent of any bone loss of mandible, maxilla, or hard palate. For hard palate and maxilla bone loss, state whether replaceable by prosthesis.

D. Diagnostic and Clinical Tests:

Provide:

1. X-ray to determine extent of bone tissue loss.
2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. Give etiology where there is loss of teeth due to loss of substance of body of maxilla or mandible.

Signature:

Date: