Dental Hygiene Assessment and Treatment Note

Reason for Attendance: Hygiene visit Chief Complaint: - Patient concerned about gum bleeding - Wants whiter teeth Medical History: - Medications: None reported - Allergies: Penicillin (rash) Past Dental History: Regular dental attendance, last check-up 6 months ago. Social History: - Smoking status: Non-smoker - Alcohol consumption: Occasional, 2-3 units per week Oral Hygiene Regime: - Brushing: Manual toothbrush twice daily, 2 minutes each time - Interdental cleaning: Dental floss occasionally, no interdental brushes Extraoral Examination: NAD Intraoral Examination: - Soft tissues: Healthy mucosa, no pathology noted - Hard tissues: No active caries detected, several old amalgam restorations, one composite restoration on UR6 - Gingival appearance: Mild inflammation, localised redness on lower anterior sextant - Soft deposits: Moderate plaque accumulation throughout, particularly on lingual surfaces of lower anterior teeth - Hard deposits: Moderate calculus on lingual surfaces of lower anterior teeth, slight supra-gingival calculus elsewhere - Oral hygiene: Fair - Bleeding on probing: Present in lower anterior sextant, localised in upper posterior sextant - Recession: UR3 (1mm), LL1 (1mm) - Mobility: No mobility detected - Furcation: No furcation involvement detected Periodontal Assessment: BPE Scores: Upper Right: 2 Upper Left: 2 Lower Right: 3 Lower Left: 3 Pocket chart: Lower Right Sextant: LL4: 4mm, LL5: 4mm, LL6: 3mm Lower Left Sextant: LR4: 4mm, LR5: 4mm, LR6: 3mm Diagnosis: - Localised gingivitis - Chronic periodontitis (Stage I, Grade A) in lower anterior region Discussion: - Explained findings of gingivitis and localised periodontitis. - Discussed importance of effective plaque control. - Advised on appropriate brushing technique and interdental cleaning. - Explained planned treatment of scaling and polishing. - Patient expressed understanding and consented to treatment. Treatment Provided: PMPR - Full mouth supra- and sub-gingival scaling using ultrasonic scaler and hand instruments, followed by polishing with prophylactic paste. Oral Health Education: - Demonstrated modified Bass technique for toothbrushing. - Recommended daily use of interdental brushes for lower anterior teeth. - Advised on use of fluoride toothpaste. Recall: 3-month recall for review and further periodontal assessment due to localised periodontitis and gingivitis. Clinician: Ms. Eleanor Vance Registered Dental Hygienist