Note provision of consent given for use of AI scribe to assist with speed, convenience and completeness of dental notes.
Chief Complaint:
- "I'm unhappy with the appearance of my front teeth. They're a bit crooked and stained, and I'd like to explore options to improve my smile."
Past Dental History:
- Patient reports having had fillings in the past, but no major dental surgeries or significant dental diseases.
Extra Oral Examination:
- Facial symmetry appears normal.
- TMJ examination: 3-finger mouth opening test is within normal limits.
Intra Oral Examination:
- Soft tissue examination: Buccal mucosa, tongue, palate, and floor of the mouth appear healthy.
- Gingival examination: Gingiva appears pink, firm, and without signs of inflammation or bleeding.
- Hard tissue examination: Several teeth exhibit mild staining. There is slight crowding of the lower incisors. No caries or cracks are noted. Existing fillings are in good condition.
- Oral hygiene status: Fair, based on OHI index.
- Occlusion analysis: Class I occlusion. Mild overbite and overjet present. No crowding or facets noted.
Radiographic Findings:
- Bitewing radiographs show no interproximal caries. Periapical radiographs show no periapical pathology.
Diagnoses:
- Mild dental staining.
- Mild crowding of lower incisors.
Note provision of consent given for use of AI scribe to assist with speed, convenience and completeness of dental notes.
Chief Complaint:
- [mention chief complaint and wishes (use patient's own words wherever possible) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Past Dental History:
- [mention any previous dental treatments, surgeries, significant dental diseases or injuries, etc. Include outcomes of treatments (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Extra Oral Examination:
- [mention any extra-oral examination findings such as facial symmetry, TMJ examination such as 3-finger mouth opening test, lip (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [mention/describe any other extra oral examination findings (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Intra Oral Examination:
- [mention/describe any soft tissue examination findings including findings on buccal mucosa, tongue, palate, floor of the mouth, vestibule, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [mention/describe any gingival examination findings including colour, contour, size, consistency, surface texture, position, asymmetry, tooth coverage, visibility in smile, bleeding (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [mention/describe any hard tissue examination findings like number of teeth present, missing teeth, dental caries, cracks in teeth or in dental restorations, restored teeth, aesthetic blemishes, periapical problems, pathologic migration, overhanging restorations, impacted teeth, supernumerary teeth, wasting disease such as attrition/abrasion/erosion/abfraction, mobility grading, shade analysis, stains/deposits, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [mention any findings on oral hygiene status, e.g., good/fair/poor based on OHI index, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [mention/describe any occlusion analysis findings such as type of occlusion (Angles classification, etc.), overbite, overjet, crossbite, open contacts, crowding, facets, supra contacts, trauma from occlusion, Fremitus test, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [mention/describe any other intra oral examination findings (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [mention/describe any findings about lost or detached crown, veneer, inlay, onlay, or other dental prosthesis or appliance (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Radiographic Findings:
- [describe findings from dental radiographs, noting any pathologies like caries/cysts/tumours, tooth positions, bone levels, etc. and mention comparisons with previous radiographs (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Diagnoses:
- [List/mention diagnoses one-by-one (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Mention any specialist referred to (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
