Adult Dental Recall

Adult recall examination Seen by: Dr. A. Smith Assisted by: Nurse Jones Payment method: Cash M/H: Nil S/H: - Smoking: Non-smoker - Alcohol: Socially D/H: - Last radiographs: 12/06/2024 - Toothbrush: Electric toothbrush - Toothpaste: Fluoride toothpaste - Interdental: Floss - Anxiety: Mild - Attendance: Regular C/O: None Examination (VCG given): E/O: Temporalis, TMJ, MoM, glands, nodes checked. No abnormalities detected. Findings: Within normal limits I/O Soft: Lips, buccal mucosa, gingiva, tongue, palate, FoM, tonsillar tissue checked. No abnormalities detected. Findings: Within normal limits I/O Hard: - Oral hygiene: Good - Occlusion: Class I - Stable ICP: Yes - Lateral excursions: Group function - Wear (where/type): Mild wear on occlusal surfaces - Removable appliance: Nil Perio: - Estimated BOP: 10% - Furcation: Nil - Recession: 1mm on lower incisors ORAL CANCER SCREEN: Within normal limits Investigations: Radiograph report Justification: assess caries, bone levels Type/grade: BWs L+R grade A Present: No caries detected Caries: Nil Restorations: Nil Endo: Nil Bone levels: Within normal limits Other: Nil RISK: CARIES – Low TSL – Low PERIO – Low SOFT TISSUE LESION – Low Diagnoses: Healthy dentition Discussion/Prevention advice/treatment options: Treatment options explained, including how the treatment will be carried out, the risks and benefits of each option. Agreed upon Tx plan below VCG: Treatment plan (VCG): - Leave and monitor with prevention - Band 1: Prevention advice - OHI, Diet advice Prevention advice given today. PREVENTION ADVICE PROMPTS (DBOH): OHI (guided by DBOH) - Brush 2x a day, once at bedtime and one other time - Use a pea sized amount (>3yrs) - Use a fluoride toothpaste with at least: 1350-1500 ppm (>6) - Spit, don’t rinse - Highlighted target areas for patient - Sugar free medications Diet - Minimise sugar intakes - Avoid NME sugars - Do not eat anything after brushing on an evening - Had brief discussion of typical diet in a day and where to minimise sugar - Advised to avoid acidic food and drink to minimise wear - Do not eat 1 hour before brushing at bedtime Tx completed today: Nil NV: Recall in 6 months