Consultation Implant

Referred from [referring dr.'s name] for [reason for visit] Chief Complaint: - [mention chief complaint along with duration (if available)] History of Presenting Complaints: - [provide a detailed description of all complaints one-by-one including onset, progressed, aggravate or alleviating factors, associated symptoms, duration, intensity, nature, frequency of symptoms, etc (if available)] - [include description of any cosmetic concerns (mention only if applicable)] - [mention patient's oral hygiene routine (only if applicable and available)] - [mention any habits such as clenching, grinding, biting, smoking, etc (if applicable)] - [mention any relevant history of periodontal disease in the family] - [mention any previous dental treatments, surgeries, significant dental diseases or injuries, etc (if available). Include dates and outcomes of treatments (if available)] Past Medical History: - [List any known medical conditions, previous surgeries, hospitalizations, ongoing treatments] (otherwise say no medical conditions) - [List any known medications being taken] (or state no medications if not on anything) - [List any known allergies] (or state NKDA if there are no allergies) - [List smoking status and if relevant when they quit and whether they vape] (or state non-smoker if there is no relevant smoking history) EXAMINATION: (be very detailed and specific with this section, try for dictation in this section as possible) - Extraoral: [mention all extra-oral examination findings such as lymph node examination, TMJ findings, mouth opening, smile line] - Soft tissues: [mention/describe any soft tissue examination findings including findings on buccal mucosa, tongue, palate, floor of the mouth, vestibule, etc (if nothing then write NAD)] - Dentition: [mention/describe all hard tissue examination findings like continuity of dentition, crowding or spacing, amount of overbite, amount of overjet, fremitus, missing teeth, dental caries, restored teeth, periapical problems, pathologic migration, impacted teeth, supernumerary teeth, attrition / abrasion / erosion / abfraction, mobility, etc] - Oral Hygiene: [mention findings on plaque control, for e.g. excellent/good/fair/poor and locations of plaque if present] - Periodontal findings: [mention/describe all gingival examination findings including heath, inflammation, colour, contour, size, consistency, recession, bleeding, suppuration, etc (mention/describe only if applicable and available)]. - [mention/describe any periodontal examination findings including pocketing depth range, extent of pocketing e.g. localised or generalised, presence of calculus, mobility, furcation involvement, overhang, CEPs, etc] (put every detail possible in this section) - Implant site: - [mention/describe all findings about future implant site including site involved, whether tooth present or not] - Bone Assessment: [assess the ridge width, height, and quality of bone at the proposed implant site] (mention any resorption or defects, etc if applicable) - Keratinized Tissue: [assess the width in mm , and quality of keratinized tissue at the implant site] (mention any deficiencies, etc if applicable) - Soft Tissue Biotype: [note whether the patient has a thin or thick biotype and any implications for implant placement] - Space: [amount of mesial to distal space in mm, occlusal space in mm, - Guidance: [mention whether involved in guidance], - Other: [mention whether infection present or absent, inflammation present or absent, state of adjacent teeth etc] Radiographic Findings: - Cone Beam Computed Tomography (CBCT): [detail 3D assessment of the proposed implant site, including bone volume, density, and proximity to vital structures] (include any critical measurements if available) - [describe findings from dental radiographs, noting any pathologies like caries/cysts/tumours, tooth positions, bone levels, etc (if available) and mention comparisons with previous radiographs (if applicable and available)] Intra-oral scan done with Trios Diagnoses: - [list/mention diagnoses relevant to implant treatment, including any periodontal, dental, or systemic conditions] (mention one-by-one if applicable) Impression: - Prognosis: [describe the overall prognosis for implant success, considering patient-specific factors] (mention any factors that may affect long-term outcomes) - [describe whether candidate is good/fair/poor candidate for implant or not (mention/describe only if applicable and available)] - [describe whether implant can be placed immediate, delayed with natural healing, or delayed following bone graft (mention/describe only if applicable and available)] - [describe whether any additional procedures are needed along with implant like bone grafting or gingival grafting (mention/describe only if applicable and available)] Discussion with patient: - [summarise discussion with patient about their disease and treatment options, and include any questions that the patient asks] - [mention consent forms that have been given for patient to take home and review] - (briefly mention costs for treatment) Treatment Plan: - Treatment Options: - [outline all potential treatment options, including benefits and risks of each] (mention the recommended option and rationale) - Surgical Plan: - [describe the surgical approach, including implant type, size, placement technique, and any adjunctive procedures like bone grafting or sinus lift] (provide detailed surgical steps) - Osseointegration Test: [detail whether second stage surgery is required]. [state whether osseointegration test will be done in 3 or 4 months] - Prosthetic Plan: - [outline the prosthetic plan, including type of restoration, timeline, and any provisional prosthesis, who is responsible for restoration] (mention materials and design considerations if discussed) - Supportive implant therapy: - [detail oral hygiene practices, annual follow-up visits, hygienist recall interval] (provide a comprehensive care plan) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that it has not been mentioned and instead leave the relevant placeholder blank.)