New Patient Assessment

**Adult Exam** Nurse: Sarah Jones c/o: Patient reports sensitivity to cold in upper right molars. Relevant history: Patient reports the sensitivity started approximately 2 weeks ago. No other symptoms. Appropriate PPE worn by patient and dentist: Yes, gloves, mask, and eye protection were worn by both. Patient consents to examination: Yes, patient provided verbal consent. --- **Medical History** Updated and reviewed. Allergies: No known allergies. Special needs: None. --- **Social History** Smoking status: Non-smoker. Alcohol intake <14 units/week?: Yes. Dietary information or oral hygiene measures: Patient brushes twice daily and flosses once daily. --- **Dental History** Attendance pattern or date of last visit: Last dental visit was 6 months ago for a check-up. --- **Extra Oral Exam** Facial asymmetries: None observed. Neck and lymph nodes: No palpable lymph nodes. Muscles of mastication: No tenderness to palpation. Lips: Normal appearance. TMJ findings: No clicking or popping. Range of movement/opening: Normal range of motion. Rotation and translation: Normal. --- **Intra Oral Exam** Soft tissues check including: Tongue: Normal appearance. Palate: Normal appearance. Buccal mucosa: Normal appearance. Lingual mucosa: Normal appearance. Floor of mouth: Normal appearance. --- **Occlusion** ICP stability: Stable. Posterior support: Adequate. Protrusive guidance: Canine guidance. Right excursion: Canine guidance. Left excursion: Canine guidance. Interferences: None. --- **Periodontal Exam** Oral hygiene: Good. Gingival biotype: Thick. Gingival condition: Healthy, no signs of inflammation. Recession: None. Mobility: None. BPE recorded: 0,0,0,0/0,0,0,0 --- **Tooth Surface Loss** Attrition severity: Mild. Pathological/physiological: Physiological. Evidence of parafunction: None. Erosion severity: None. BEWE Index: 0. Abfraction/abrasion severity: None. Affected surfaces: see iTero scan. --- **Hard Tissues** Charting status: Complete. Caries, defective restorations, cracks, heavily restored teeth: Caries noted on upper right molar. --- **Aesthetics** Any concerns reported by the patient: No aesthetic concerns reported. --- **Radiographs and Special Tests** Radiographs: Bitewing radiographs taken. Special tests: Cold sensitivity test positive on upper right molar. iTero scan status: Completed. Photos taken: Yes. --- **Diagnosis/es** List all diagnoses here: Caries on upper right molar. Periodontal classification including overview, stage, grade, risk factors: Periodontal health. --- **Discussions with Patient** Summary of discussions held about dental health, periodontal condition, tooth wear, diet advice, restorations, or treatment options: Discussed the caries and treatment options, including a filling. --- **Risk Assessment** Caries risk: Moderate. Periodontal risk: Low. Wear risk: Low. Oral cancer risk: Low. --- **Recall Interval** Recall interval and justification: 6 months, for routine check-up and caries monitoring. --- **Treatment Plan** Summarise the overall outcomes and list the agreed actions: Agreed to proceed with a composite filling on the upper right molar. Written treatment plan provided if mentioned: No. Patient agreement recorded: Yes.