AOX Consult Casey Dental

**Smile Consult** **Provider: Dr. Emily Carter** **Assistant: Sarah Jones** --- **1. History of Presenting Complaint** Patient presents today for a consultation regarding options for replacing missing teeth. The patient is concerned about the appearance of their smile and difficulty chewing. They report that they have been missing teeth for several years and are now seeking a long-term solution. --- **2. Past Medical History (MHx)** - Chronic illnesses: Hypertension, controlled with medication. - Medications: Lisinopril 20mg daily. - Allergies: No known drug allergies. - Relevant surgeries: Appendectomy at age 10. - ASA classification: ASA I. --- **3. Dental History (DHx)** - Previous dental treatments (implants, dentures, root canals, etc.): Patient has had multiple fillings and one root canal in the past. No implants or dentures. - History of extractions or infections: Several extractions due to decay and periodontal disease. - Periodontal status: Moderate generalized bone loss. - Previous prosthesis failures: None. --- **4. Social History (SHx)** - Smoking, vaping, alcohol: Non-smoker, occasional alcohol consumption. - Occupation: Accountant. - Financial/social support: Patient has a supportive family and adequate financial resources. - Anxiety or relevant social factors: Patient expresses some anxiety about dental procedures. --- **5. Clinical Examination** - Extraoral: TMJ appears normal, no facial asymmetry, no palpable lymph nodes. - Intraoral: Multiple missing teeth in the upper and lower arches. Generalized gingival inflammation. No active caries. Retained root in lower left quadrant. - Prosthetic space: Adequate interarch clearance. Occlusion is compromised due to missing teeth. Ridge form is adequate for implant placement. --- **6. Radiographic and Diagnostic Investigations** - OPG/CBCT findings: CBCT scan reveals adequate bone volume for implant placement in several areas. Sinus proximity is noted in the upper posterior regions. Nerve pathways are identified. - Extraoral/intraoral photographs taken: Full series of intraoral and extraoral photographs taken. - Study models or TRIOS scans, noting leaf gauge or increased OVD if relevant: Study models taken. --- **7. Diagnosis** - Terminal dentition if relevant: Partially edentulous. - Generalised bone loss: Moderate generalized bone loss. - Other clinical/radiographic diagnoses stated: Missing teeth, compromised occlusion, retained root. --- **8. Treatment Options Discussed** - Option A: [Save Teeth] Not applicable. - Option B: [Remove Teeth] Not applicable. - No Treatment option: Patient declines any treatment. - Conventional Dentures: Discussed the option of conventional dentures, Pros: Cost-effective, Cons: Removable, may affect taste and speech, Costs: £1,500, Patient Reactions: Patient is hesitant about removable dentures. - Implant-Retained Overdentures: Discussed the option of implant-retained overdentures, Pros: Improved stability and retention, Cons: More invasive, higher cost, Costs: £8,000, Patient Reactions: Patient is interested but concerned about the cost. - All-on-X Fixed Prosthesis: Discussed the option of All-on-X fixed prosthesis, Pros: Fixed, natural-looking, Cons: Most invasive, highest cost, Costs: £25,000, Patient Reactions: Patient is very interested but wants to consider all options. - Combination Approaches: Not applicable. --- **9. Risks and Complications Discussed** - Post-op pain, swelling, sinus issues, paraesthesia, fractures, implant failure, bruxism management, smoking-related complications: Risks of implant failure, post-operative pain and swelling, and the importance of good oral hygiene were discussed. --- **10. Maintenance Plan** - Follow-up hygiene, reviews, imaging, prosthesis maintenance if discussed: Patient advised to maintain excellent oral hygiene, regular check-ups, and professional cleanings. --- **11. Treatment Sequence** - GA, extractions, implant placement, temporary prosthesis, reviews, dietary advice: The treatment sequence was discussed, including extractions, implant placement, and the use of a temporary prosthesis. --- **12. Payment Options** - Payment methods only if explicitly mentioned: Payment options were discussed, including payment plans. --- **13. Patient Autonomy and Decision** - Patient encouraged to take time: Patient was encouraged to take time to consider all options. - No pressure to proceed: No pressure was placed on the patient to proceed with any treatment. - Options outlined clearly: All treatment options were outlined clearly. - Clinician recommendation noted: Dr. Carter recommended the All-on-X fixed prosthesis as the best long-term solution. - Final patient decision documented: Patient is considering all options and will make a decision after further thought. --- **14. Wrap-Up and Next Steps** - Asked if patient had further questions: Patient was asked if they had any further questions. - Referred to Treatment Coordinator: Patient was referred to the Treatment Coordinator for further information. - Plan to be formulated in Smile Connect: A treatment plan will be formulated in Smile Connect. - Advised to contact if further clarification needed: Patient was advised to contact the clinic if further clarification was needed. --- **15. Additional Notes or Comments** Patient expressed some anxiety about the procedures but is motivated to improve their smile and chewing function. The patient was provided with written information about all treatment options. The patient was advised to contact the clinic if they had any further questions. The patient was advised to contact the clinic if they had any further questions.