Comprehensive Dental Exam

Practitioner Details: Dr. Emily Carter, Dentist Type of Examination Conducted: Comprehensive dental examination conducted, consent obtained verbally from the patient. Presenting Complaint: Patient reports, "My back tooth on the bottom right has been aching on and off for the past two weeks, especially when I drink cold water." Dental History: Previous treatments include several fillings in childhood. Last dental review was approximately 18 months ago. Patient brushes twice daily with a manual toothbrush and flosses inconsistently, about 2-3 times per week. Medical History: Patient has no significant medical or surgical history. Denies any chronic illnesses or recent hospitalisations. Social History: Patient is a non-smoker. Reports occasional social alcohol consumption (1-2 units per week). Denies illicit drug use. Works as a primary school teacher. Medications: Currently taking no prescribed medications. Takes paracetamol occasionally for headaches. Allergies: No known drug allergies. Reports an allergy to latex (mild rash). Clinical Findings and Observations: E/O Examination: TMJ: No tenderness or clicking noted. Lymph nodes: Non-palpable. Lips: Healthy appearance, no lesions. Facial symmetry: Symmetrical. I/O Examination: Soft-tissue examination: Buccal mucosa, tongue, palate, floor of mouth, vestibule: All soft tissues appear healthy, pink, and moist. No lesions or abnormalities observed. Oral cancer screen (FoM, palate, pharynx, soft tissues): NAD. Gingiva: Generalized mild gingivitis noted with some redness and slight swelling, particularly around posterior teeth. Bleeding on probing in several areas, but no exudation. Hard tissue examination: Caries: Distal caries noted on tooth #46. Missing teeth: #18, #28, #38, #48 (wisdom teeth extracted previously). Restored teeth: #16 DO, #26 MO. Mobility: No mobility detected. Impactions: None. Wasting disease: Mild attrition on incisal edges of anterior teeth. Oral Hygiene Status: Fair. Plaque accumulation noted along the gingival margins, particularly on the lingual surfaces of mandibular incisors and buccal surfaces of maxillary molars. Occlusion analysis: Class I molar relationship bilaterally. Moderate overbite, slight overjet. Mild crowding in the mandibular anterior region. No open contacts. Other I/O findings: NAD. Radiographic Findings: Bitewing radiographs taken today reveal a distal radiolucency on tooth #46, extending into the dentin, consistent with a carious lesion. No periapical pathology noted. Bone levels appear stable. Other Investigations: N/A Biopsy Findings: N/A Diagnosis: Primary Diagnosis: Dental caries, tooth #46 distal surface. Secondary: Mild generalized gingivitis. Treatment Options Discussion: Discussed with patient: (1) Amalgam restoration for tooth #46. (2) Composite restoration for tooth #46. Explained risks (post-operative sensitivity, possibility of root canal if decay is deeper), benefits (restores function, prevents further decay), and costs for both options. Alternatives discussed included extraction if restorative options are not viable (patient expressed strong desire to save the tooth). Patient expressed concern about the appearance of amalgam and inquired about the longevity of composite. Proposed Treatment Plan: 1. Apply fluoride varnish to address generalized sensitivity. 2. Composite restoration of tooth #46 distal surface. 3. Oral hygiene instruction focusing on effective flossing techniques. 4. Recommend regular 6-month recall appointments. Consent: Verbal informed consent obtained for the proposed composite restoration of tooth #46 and fluoride varnish application. Patient understood and agreed to the treatment plan. Procedures Conducted: N/A (Procedure scheduled for next visit) Instrument Tracking: N/A Coding of Dental Service/s Provided: D0120 (Periodic Oral Evaluation) (Today) D0274 (Bitewings - 4 films) (Today) Medications/Therapeutics: Prescribed: None. Administered: N/A. Dispensed: N/A. Advice Provided: Detailed oral hygiene instruction provided, demonstrating proper brushing and flossing techniques. Advised on reducing frequency of sugary snacks and drinks. Post-treatment care for potential sensitivity to be expected after restoration was briefly discussed. Follow-Up and Referrals: Next appointment scheduled for 1 November 2024 for composite restoration of tooth #46. Patient provided with cost quote for the procedure. Unusual Events: No unusual events or adverse reactions during today's examination. Additional Digital and Laboratory Information: N/A Final Notes: Patient is motivated to improve oral hygiene and proceed with restorative treatment. Discussed the importance of regular dental check-ups. Other Details: N/A