pc- checkup
o e- MH CHECKED YES
CPITN | |
| |
Cavities
—————–|—————–
Extra Oral Assessment – no visible swelling or asymmetry identified, TMJ NAD, no lymphadenopathy
Soft Tissue Checked tongue, fauces, hard and soft palate, retromolar areas, FOM, lips, gingiva and oral mucosa systematically and NAD
OH fair Plaque Calculus
FP17 DC yes
TMJ : NAD
Patient Caries Risk Assessment:-
Low risk – good standard of OH and low cariogenic diet
Medium risk – OH rather poor requires improvement and reduction in moderately cariogenic diet
High risk – OH is poor and requires significant improvement and reduction of high cariogenic diet
Patient Perio Risk Assessment:-
Low risk – good standard of OH and BPE between 0-2 low risk factors
Medium risk – OH rather poor and signs of attachment loss
High risk – OH poor with significant attachment loss and poor general periodontal health
Recall interval assessment and justification:-
24 months – excellent dental health with minimal risk factors for caries and PD
12 months – good dental health low risk factors for caries and PD
6 months – stable current dental health status with potential identifiable risk factors requiring observation and reviewing
3 months – potential for identifiable risk factors to detriment dental health therefore necessitating regular review and maintenance of dental status
Occlusion : class
Dx –
Plan agreed:s&p,
r x- Exam, ohi – tbi,flossing , interdentals
dietary advice,
s&p
jk
Check up
COVID-19 protocol followed
Nurse: Katie
Names of anyone who attended with pt: None
Informed consent obtain
COVID-19 status of the above: see scanned section- patient asymptomatic
MH: checked and updated
RFA:
DH: Last dental visit: 1YRS
Dental treatment done so far: FILLING, XLA
Brushes 2 daily x manual TB; duration TB: 2MINS
Interdental cleaning (floss/Tepes) as and when needed
MW: no
Diet- cariogenic LOW
Acid: LOW
Grinding habit: NAD
Sensitivity: NAD
SH: see medical history section
Smoking: na
Alcohol: NA
EXTRA-ORAL: TMJ: NAD
Palpable Lymph Node: NAD
Lips: NAD
Facial asymmetry: NAD
INTRA-ORAL:
SOFT TISSUES-
Lips:NAD
Buccal Mucosa: NAD
Labial Mucosa: NAD
Floor of Mouth: NAD
Dorsal Tongue: NAD
Left and Right Lateral Tongue: NAD
Ventral Surface Tongue: NAD
Hard and Soft Palate: NAD
Palatoglossal and Palatopharyngeal Arches: NAD
Soft tissues and oral cancer screen- Clear
Cancer risk: low
Basic Periodontal Examination: recorded check BPE chart
Oral hygiene: needs improvement
Gingivae- tender, inflamed around LOWER ANT LING ____
BOP: generalized
extrinsic staining: +
Plaque: generalized : moderate
Calculus – gen : moderate deposited : lower ant ling surface post teeth
Gingival recession: na
Gingivitis – gen /mODERATE
6 PPC- NA
Mobility: na ; furcation: na
bone loss- NA
periodontal risk: moderate OHI NEEDS IMPROVEMENT
HARD TISSUE:
Teeth: see dental chart
Tooth wear: NAD
CLINICAL FINDINGS SUMMARY: moderate marginal gingivitis , retained roots of ll7 and ll5
Radiographs:
Bitewing radiographic report
Radiographs: R&L BW
Justification: IP caries detection and assess bone levels
Bone levels: Normal/ Generalised horizontal bone loss/ Localised vertical bone loss
Caries: NAD / as seen per chart / tx plan
Grade: 1/2/3
Other findings: NAD
Advised/ discussed radiographic findings with the patients
DIAGNOSIS: Moderate marginal gingivitis, retained roots of ll7 and ll5
Dental Caries Risk: LOW
Periodontal Risk: med oral hygiene needs improvement
TSL Risk: low
OC Risk: low
TREATMENT PLAN:
Explained to pt that treatment options available are limited due to the circumstances of COVID-19 and in accordance with the OCDO guideline
1) Preventative advice regarding OHI, Fluoride use, dietary advice, smoking cessation
2) Gum disease aetiology, prevention and treatment explained
3) Indications for scaling and polishing
4) retained roots of ll7 and ll5- no tx xla or post retained crown on ll5
Discussed all the clinical and radiographic findings including possible options for no treatment and referral. Risks, benefits and cost of the treatments discussed, patient made aware that all treatment plan are dynamic and subjective to change
Pt given opportunity to ask questions.
PATIENT OPTED FOR wait and watch for ll5 ll7
Patient happy about the treatment plan and cost.
Pt verbally consents to carry out treatment plan
TREATMENT TODAY:
COVID-19 SOP/OCOD guidelines followed
PPE USED:
AGP- Filtering face piece respirator, Visor, Long sleeve fluid repellent gown, Gloves , air purifier fallow time, 10min
AGP used:,3 in 1 , Slow handpiece, polishing brush, ultrasonic scaler tip
1) supra and subgingival debribgment done using US tip. OHI reinforced. Reinforced brushing x2/day; demo modified bass tech given, importance of ID cleaning discussed, demo on flossing tech/ ID brushed given. use of ID brushes regularly, be gentle on TB, warm saline rinses after every main meal, if using MW use it different time then brushing time. Advised to concentrate more on the lower ant ling surface and in the posterior teeth. Dietary advice given. Explained about perio diseases and importance of ID brushing and flossing
Pt advised to maintain OH
Explained pt might experience slight discomfort and if any problems tca any sooner
Pt happy with treatment and did not experience any pain or discomfort during the entire procedure
NICE Recall length discussed, happy to maintain at 6/12
Advised pt if any dental concents to book early appointments according to their needs. Layman’s terms used. Patient happy and understands and did not ask any further questions.
TREATMENT close
NV: