Comprehensive Dental Exam

Specialty of Clinician: Dentist MC: Patient presents with discomfort in the lower left quadrant. - Routine dental check-up and evaluation of discomfort. HMC: Patient reports dull ache in the lower left molar region for the past two weeks. Pain is intermittent, worsened by cold food/drinks, and occasionally when biting. Over-the-counter pain relievers provide minimal relief. - Onset two weeks ago, described as a dull ache, sensitive to cold and pressure. - Last dental visit was 18 months ago for a routine cleaning; no significant treatment was performed. - Brushes twice daily with an electric toothbrush, flosses once a day, and uses fluoride mouthwash nightly. WHO: Patient is a 34-year-old female. - Graphic Designer. - Married with two young children. Expresses occasional stress related to work-life balance. - Enjoys hiking and photography. MED HX: Generally good health. - No significant medical conditions reported. - Takes a daily multivitamin and occasional ibuprofen for headaches. No other medications or supplements. - No known allergies, medical or non-medical. EOE: Extra-oral examination findings are within normal limits. - Muscles of mastication (temporalis, masseter): Symmetrical, non-tender to palpation. - TMJ: No clicking, popping, or tenderness on palpation or movement. - Lymph nodes (pre-auricular, parotid, submental, submandibular): Non-palpable, non-tender. - Swellings/asymmetries: None observed. IOE: Intra-oral examination reveals good general oral hygiene, but some concerns. - Lips: Intact, hydrated, no lesions. - Soft tissues (mucosa, gingiva): Pink, healthy appearance. Localised gingival inflammation noted around tooth #36, with slight bleeding on probing. No significant plaque or calculus accumulation generally, but minor deposits noted lingual to #36. No recession or other lesions. - Saliva: Normal flow and consistency. - Hard tissues: Carious lesion noted on the occlusal surface of tooth #36. No other active caries, arrested caries, unsound restorations, or significant tooth wear observed. - Missing teeth: No missing permanent teeth. - Monitor: Tooth #17 (partially erupted wisdom tooth, asymptomatic, no associated pathology), minor occlusal wear on #46 (asymptomatic). RADIO: Radiographic examination findings confirm a carious lesion. - Bitewing radiographs show a moderate-sized carious lesion extending into the dentin of tooth #36. Periapical radiographs show no periapical pathology or significant bone loss. No other significant findings. DONE: Treatment and discussions completed during this visit. - Consultation details and discussions held: Discussed findings with the patient, including the carious lesion on #36 and localised gingivitis. Explained treatment options for the caries and importance of targeted oral hygiene for gingivitis. Patient expressed understanding and consented to proposed treatment. - Diagnosis discussed (e.g. periodontal diagnosis): Dental caries (ICD-10: K02.1) affecting tooth #36, localised gingivitis (ICD-10: K05.1). - Procedures completed such as X-rays taken, scale and polish: Two bitewing radiographs and one periapical radiograph taken. Oral hygiene instruction provided. Scale and polish completed for all quadrants. TO-DO: Remaining treatment planned. - Remaining planned treatments such as root planing: Plan for composite restoration for tooth #36. No root planing indicated at this time. - Fillings planned: Composite filling for tooth #36. - Crowns, prostheses, or appliances planned: None planned. - Maintenance plans such as 3-month scale and polish: Recommend 6-month recall for routine check-up and scale and polish. Advised patient to focus on flossing around #36 to improve gingival health.