Check-Up and Clean Procedure Note

Clinician Specialty: Dentist Chief Complaint: Routine dental check-up and clean; patient reports mild sensitivity in the lower right molar, present for approximately 3 months. History of Presenting Complaints: Patient presents for a routine check-up and clean. Reports intermittent mild sensitivity in tooth #46 (lower right first molar), especially with cold foods/drinks. No spontaneous pain, swelling, or difficulty chewing. Patient is concerned about maintaining good oral hygiene. Past Dental History: Regular dental check-ups every 6-9 months. Previous amalgam restorations on #16 and #37, placed 5 and 8 years ago respectively. Wisdom teeth extracted 10 years ago. No history of periodontal disease or major restorative work. Past Medical History: Generally healthy. No known medical conditions. Allergic to penicillin (rash). Currently taking multivitamin daily. No other medications. Personal History: Brushes twice daily with an electric toothbrush and fluoride toothpaste. Flosses inconsistently, approximately 3-4 times a week. Reports occasional clenching at night during stressful periods, but no history of grinding. Non-smoker. Consumes sugary drinks occasionally, 2-3 times per week. Family History: Mother has a history of mild periodontal disease. Father had multiple fillings and a crown in his 50s. No family history of oral cancer. Extra-Oral Examination: Facial symmetry appears normal. No palpable lymphadenopathy. Temporomandibular joints (TMJs) are asymptomatic with full range of motion; no clicking or crepitus noted on palpation. Lips and perioral tissues are healthy. Intra-Oral Examination: Soft Tissue: Buccal mucosa, tongue, palate, and floor of mouth appear healthy, pink, and moist. No suspicious lesions or abnormalities noted. Gingival: Generalized mild gingivitis observed, particularly in interproximal areas of posterior teeth. Gingiva are slightly erythematous and edematous, with isolated areas of bleeding on probing, especially around #36 and #46. Recession noted on buccal aspect of #33 (1mm). Hard Tissue: Caries: incipient enamel lesion on occlusal surface of #46. Restorations: intact amalgam restorations on #16 (MO) and #37 (DO). Missing teeth: #18, #28, #38, #48 (wisdom teeth previously extracted). Mobility: no tooth mobility detected. Wear: mild occlusal wear noted on anterior teeth, consistent with age. Oral Hygiene: Fair to good overall. Visible plaque accumulation noted along gingival margins and interproximal areas, especially in lower posterior quadrants. Moderate calculus present on lingual surfaces of lower anterior teeth. Occlusion: Class I molar relationship bilaterally. Moderate overjet and overbite. No significant crowding. Canine guidance observed. No signs of occlusal trauma. Radiographic Findings: Bitewing radiographs (taken today) reveal no periapical pathology. Incipient radiolucency consistent with enamel caries detected on the occlusal aspect of #46. No recurrent caries under existing restorations. Bone levels appear stable with mild horizontal bone loss consistent with age. Laboratory Investigations: None conducted. Treatment Done Today: Diagnoses: 1. Generalized mild gingivitis. 2. Incipient enamel caries on #46 (occlusal). 3. Mild dentin hypersensitivity #46. Scale and Clean: Full mouth supragingival scaling and polishing performed using ultrasonic scaler and hand instruments. Focus on removing plaque, calculus, and extrinsic stains. Patient tolerated procedure well. Fluoride Application: Topical fluoride varnish (5% Sodium Fluoride) applied to all dentition following scaling and polishing. Photographs: Clinical photographs were taken of the intra-oral condition before and after treatment, as well as specific areas of concern (e.g., #46 and gingival inflammation). Prognosis: Good prognosis for maintaining oral health with improved home care and regular professional cleaning. The incipient caries on #46 will be monitored. Advice given on improved flossing technique, use of a fluoride mouthwash, and avoiding frequent sugary snacks to manage sensitivity and prevent caries progression. Recommended sensitive toothpaste for #46. Review Date/Follow-Up: Recommended recall for routine check-up and clean in 6 months (1 November 2024).