Dental Examination - Regular

Adult Exam: Nurse: Sarah Jenkins c/o: Routine dental check-up and mild sensitivity in lower left quadrant. Relevant history: Patient reports occasional mild sensitivity to cold drinks in the lower left quadrant for the past 2 months. No sharp pain or swelling. Last dental visit 18 months ago. Previously had a filling on tooth #36 (lower left first molar) approximately 5 years ago. Appropriate PPE worn pt and dentist. Patient consents to examination. Medical History: Updated and reviewed. Allergies: Penicillin (rash), Latex (skin irritation) Special needs: None documented. Social History: Smoking: Non-smoker Alcohol intake <14upw?: 4 units per week, occasional red wine. Diet: Balanced diet, occasional sugary snacks. Patient reports having a fizzy drink once a day with lunch. Dental History: Attendance pattern: Irregular, last visit 18 months ago. Previously attended every 1-2 years. Extra Oral Exam: Facial asymmetries: Symmetrical. Neck and Lymph nodes: No palpable lymphadenopathy or abnormalities. Muscles of Mastication: Non-tender on palpation, no hypertrophy. Lips: Healthy, no lesions. TMJ: No clicking, crepitus, or tenderness on palpation. Range of movement/opening normal?: Normal opening, approximately 45mm. Rotate and translate smoothly?: Smooth rotation and translation. Intra Oral Exam: Soft tissues check including: Tongue: Normal appearance, no lesions. Palate: Normal, pink, no lesions. Buccal mucosa: Healthy, no white patches or lesions. Lingual mucosa: Healthy, no lesions. FOM: Healthy, no lesions or swelling. Occlusion: Currently stable ICP?: Stable ICP. Posterior support: Adequate posterior support bilaterally. Guidance: Protrusive: Anterior guidance present. R excursion: Canine guidance. L excursion: Canine guidance. Interferences: No significant interferences noted. Periodontal exam: Oral Hygiene: Fair, some plaque accumulation interdentally, particularly in posterior segments. Mild gingivitis present. Gingival biotype: Medium. Gingival condition: Mildly inflamed, no bleeding on probing generally, isolated bleeding on probing at 36ML. Recession: Generalized mild recession (1-2mm) buccally on canines and premolars. Mobility: All teeth firm (Grade 0 mobility). BPE recorded: Sextants 1,2,3: 2; Sextants 4,5,6: 2. Tooth Surface Loss: Attrition: Mild attrition on incisal edges of anterior teeth. Severity: Mild. Pathological/physiological?: Physiological. Evidence of Parafunction: None observed. Erosion: Severity: Mild, generalized on buccal surfaces of posterior teeth. BEWE Index: 1. Abfraction/abrasion: Mild abrasion on cervical margins of 13, 23, 33, 43. Severity: Mild. Affected surfaces: Buccal cervical 13, 23, 33, 43. Hard Tissues: Charting: Charting updated. Existing amalgam restoration on 36DO intact, no recurrent caries noted. Small occlusal carious lesion on 47. Caries / Leaking or defective restorations: New carious lesion detected on occlusal surface of 47. No leaking or defective restorations. Cracks: No visible cracks. Heavily restored teeth: Tooth 36 with large amalgam restoration. Aesthetics: Any concerns: Patient expresses mild concern about generalized yellowing of teeth. Radiographs and Special Tests: Radiographs: Bitewings taken. Show carious lesion on 47, no other significant pathology. Periapical radiograph of 36 shows adequate root canal treatment and no periapical pathology. Special tests: Vitality testing of 36 and 47 (positive to cold, within normal limits). iTero scan: Not performed. Photos: Clinical photographs taken of intraoral tissues and dentition. Diagnosis/es: Dental caries (47 Occlusal). Mild generalized gingivitis. Physiological attrition. Mild generalized erosion. Mild abrasion (cervical surfaces). Periodontal classification: Stage I, Grade A, stable periodontitis. Discussions with patient: Overall dental health: Patient's overall dental health is fair, with areas needing attention including oral hygiene and the newly identified caries. Periodontal condition: Discussed mild gingivitis and mild generalized recession. Emphasized the importance of improved oral hygiene techniques and regular dental cleanings. Tooth wear: Explained the findings of mild attrition, erosion, and abrasion. Advised on dietary habits to reduce acidic intake and recommended a soft-bristled toothbrush with gentle brushing technique. Diet advice: Advised to reduce frequency of sugary and acidic drinks/foods. Recommended rinsing with water after consuming acidic foods. Restorations advised: Advised restorative treatment for the carious lesion on 47. Treatment options: Discussed composite filling for 47. Recommended professional cleanings with the hygienist. Other: Discussed options for addressing aesthetic concerns regarding tooth shade, including professional whitening. Risk assessment: Caries: Moderate risk due to occasional sugary snacks and fizzy drinks. Periodontal: Low to moderate risk, manageable with improved oral hygiene. Wear: Moderate risk due to combination of dietary acids and brushing habits. Oral Cancer: Low risk. Recall Intervals: Maintain the currently set recall program. Treatment Plan: 1. Provide oral hygiene instructions, including flossing and interdental cleaning techniques. 2. Schedule appointment for composite restoration of tooth 47. 3. Recommend hygiene appointment for scale and polish and further oral hygiene education. 4. Discussed options for tooth whitening at a future appointment if desired by the patient. 5. Recall in 6 months for routine check-up and review of oral hygiene.