PST Surgery CHECKLIST:

8

o 3 PST instrument cassettes o Hygiene set-up

o Hand scalers o Perio-probe plastic/metal o 2 mouth mirrors o 2 cotton pliers o Explorer (metal/plastic)

o Intra-oral mirrors o Black intra-oral background o Cheek retractors small/medium o Nikon/canon camera for before/after photos o Ligaject o 2 syringes

1 bottle sterile water o 2 bottle of Sodium Chloride (1 form membrane only) o Monoject syringes (5) o Fast hand piece (2) o Narrow diamond (interproximal) o Medium flame diamond bur (prep) o Boley gauge o 2 dappen dishes (1 for cotton pallets with EDTA) (1 for sterile cut 2x2 with

Peridex) o 4 Scissors (angled) o 2 Hemostat o 2 surgical suctions o Sterile gauze o Sterile cotton rolls o Sterile towels o Barrier sleeves o Microscope cover o Collagen (Bioguide by: Geistlich) (large and medium sizes) o Surgical gloves o Fill water bottle o Hand mirror

________________________________________________________________ o Perio charting (quad of area must be filled out buccal and lingual for insurance) o Consent form for PST o PST form: with teeth #(s) and time o "No brushing..." instructions sheet o PST Post op instructions o PST claim form with: recession classification (per tooth) o Trim trays (bite/night guard, perio protect) o Peridex-for patient o Icepacks-for patient