Dental Note - Concise

RFA: Routine check-up and evaluation of recent tooth sensitivity. Covid questions: Negative C/o: - Tooth sensitivity in the upper right molar region - Onset: 2 weeks ago - Severity: Moderate - Aggravating factors: Cold beverages - Relieving factors: Warm water rinses HPC: The patient reports experiencing moderate sensitivity in the upper right molar region for the past two weeks. The sensitivity is exacerbated by cold beverages and somewhat relieved by warm water rinses. No previous self-management attempts have been made. PDH: - Brushes twice daily - Flosses occasionally - Last professional cleaning: 6 months ago - Previous dental procedures: Filling in lower left molar PMH: - Hypertension, managed with medication - No other relevant medical conditions SH: - Smokes 5 cigarettes per day - Moderate alcohol consumption E/O: Nil I/O ST: Nil OH: Fair Caries risk: Moderate O/E: Clinical examination reveals plaque accumulation and mild gingivitis. No visible caries in the upper right molar region, but sensitivity tests confirm heightened response in the area. Diagnosis: - Tooth sensitivity in upper right molar region - Mild gingivitis NHS and private Options: - NHS: Desensitizing toothpaste and fluoride varnish application - Private: In-office desensitizing treatment and custom fluoride trays Tx plan: - Use desensitizing toothpaste twice daily - Schedule fluoride varnish application - Follow-up in 4 weeks to reassess sensitivity n.v.: Follow-up appointment in 4 weeks for sensitivity reassessment and potential further treatment.