Periodontist Note
Patient reports:
- Patient reports that their gums have been bleeding less since the last visit and they are more confident in their ability to maintain good oral hygiene. They are still experiencing some sensitivity to cold drinks.
Medical History Updates:
- no change.
Clinical Findings:
- Oral Hygiene: Good, with some plaque present on the lingual surfaces of the lower incisors.
- Gingiva: Generalized mild gingivitis with slight redness and swelling in some areas. No recession noted.
- Pocketing: Pocket depths range from 2-4mm, with bleeding on probing in a few sites.
- Other: No mobility. No furcation involvement. No caries or broken teeth noted.
- Radiographic Imaging: Bitewing radiographs taken today show stable bone levels since the last visit.
Impression:
- Good response to treatment. Stable periodontitis.
- Patient can continue periodontal maintenance.
Treatment Performed:
- Full mouth debridement with piezon and airprophy.
- Graceys at PPD>5mm
- LA: none
Discussion:
- Discussed the importance of continued meticulous oral hygiene and the use of interdental cleaning aids. Reviewed proper brushing technique and flossing. Explained the signs of gingivitis and periodontitis and the importance of early intervention. Addressed patient's concerns about sensitivity, recommending a desensitizing toothpaste.
Plan:
- Next appointment in 3 months for periodontal maintenance. Patient will return if recommended by dentist or Hygienist if there is concern over progressive disease.
Patient reports:
- [patient to describe how things have been since last visit] (only include reason for consultation/review if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medical History Updates:
- [medical history updates] (only include medical history updates if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise add the phrase: no change.)
Clinical Findings:
- Oral Hygiene: [Mention any findings on oral hygiene status, e.g., excellent/good/fair/poor and where plaque is present, etc.]
- Gingiva: [Mention/describe any gingival examination findings, including color, contour, size, consistency, position, , recession, keratinised tissue, etc.]
- Pocketing: [Mention/describe any pocketing examination findings, including depth, location, whether there is bleeding, whether there is suppuration, bleeding position]
- Other: [Mention/describe any findings of other examination findings including mobility, furcation involvement, fremitus, caries, broken teeth, infections etc]
- Radiographic Imaging: [radiographic and photographic imaging] (only include radiographic and photographic imaging if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Impression:
- [comment on treatment outcomes using words like good response to treatment, periodontal remission, partial response to treatment, poor response to treatment, unstable periodontitis]
- [recommendations as to whether surgery is indicated, further root planing indicated, or whether patient can continue periodontal maintenance] (only include recommendations if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Treatment Performed:
- Full mouth debridement with piezon and airprophy.
- Graceys at PPD>5mm
- LA: none / 4x 2.2ml art 4% with 1:100k adr
Discussion:
- [fill this section with any discussion had with patient about how treatment has gone and what the next steps are, include different options available and their risks and benefits. Include any questions asked by patient] (only include discussion if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Plan:
- [next appointments] (only include next appointments if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Include any explicit mention on discharge and recommended recall interval for SPT, add that the patient will return if recommended by dentist or Hygienist if there is concern over progressive disease.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)