Prosthodontist-Vorlage
Dental examination/consult
Eine professionelle Prosthodontist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
This dental examination/consult template is designed for prosthodontists and other dental professionals to efficiently document patient visits. It includes sections for chief complaints, medical history, social history, dental history, oral hygiene regime, and detailed oral examination findings. The template also covers risk assessments for caries, periodontitis, and oral cancer, as well as treatment discussions and patient education. This comprehensive template ensures thorough documentation, aiding in accurate diagnosis and effective patient communication. Ideal for prosthodontists, this template helps streamline the documentation process, making it easier to provide high-quality dental care.
Vorlagenvorschau
Nurse:
CO: Patient reports sensitivity in the upper right molar region for the past two weeks, exacerbated by cold drinks.
MH: Fit and healthy with no known drug allergies.
SH: Non-smoker. Drinking 5 units of alcohol per week. Occupation: Software Engineer.
DH: Last dental visit was 6 months ago.
Oral hygiene regime: Brushing 2 x daily with an electric toothbrush, flossing daily with interdental brushes.
OE:
E/O: TMJ, muscles of mastication, facial symmetry, lips, lymph nodes all ok.
I/O: Soft tissues: Hard/soft palate, buccal mucosa, tongue, floor of mouth, all ok.
Dentition: No caries detected. Slight wear on the upper right molar.
Gingivae: Healthy.
Calculus: Minimal.
BPE: 1 in all sextants.
Occlusion: Class I.
RHS - Canine guided.
LHS - Canine guided.
Caries risk: Low risk.
Periodontitis risk: Low risk.
Oral cancer risk: Low risk.
Rads - R+L BWs taken Q1. Assess caries and crestal bone levels: No caries or bone loss detected.
Dx: Mild dental wear on the upper right molar.
Discussed Dx with patient. Explained the wear is likely due to bruxism and recommended a night guard.
Treatment options along with pros/cons discussed with patient.
Pt opted for: Night guard.
Oral hygiene given to pt - adv to brush along gingival margins and interproximally with tepes/floss.
Diet adv given and adv to limit sugar to meal times only.
Recall: Next dental check-up advised in 6 months.
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