Adult Dental Examination

Seen by: TK Assisted by: AB Payment method: Cash M/H: signed and updated today S/H: - Attends with: Toothache in upper right molar - Smoking: Smoker, 10 cigarettes per day - Alcohol: Drinks alcohol socially, 2-3 units per week - Recreational drugs: Denies recreational drug use - Cessation advice: Advised to reduce smoking and provided information on cessation services. D/H: - Toothbrush: Electric toothbrush - Toothpaste: Fluoride toothpaste - Interdental: Floss daily - Anxiety: Mild anxiety related to dental visits - Attendance: Attends regularly for check-ups C/O: Toothache in upper right molar Examination (VCG given): E/O: Temporalis, TMJ, MoM, glands, nodes checked. Findings: No abnormalities detected. I/O Soft: Lips, buccal mucosa, gingiva, tongue, palate, FoM, tonsillar tissue checked. Findings: No significant findings. I/O Hard: - Oral hygiene: Good - Occlusion: Class I - Stable ICP: Stable - Lateral excursions: Group function - Wear (where/type): Mild wear on occlusal surfaces - Removable appliance: None Perio: - Estimated BOP: 10% - Furcation: No furcation involvement - Recession: 1mm recession on lower incisors ORAL CANCER SCREEN: No suspicious lesions detected. Investigations: Last radiographs: 15/09/2024 Radiograph report Justification: assess caries, bone levels Type/grade: BWs L+R grade A Present: No caries detected Caries: None Restorations: Amalgam restoration on UR6 Endo: No endodontic involvement Bone levels: Within normal limits Other: None RISK: CARIES – Low TSL – Low PERIO – Moderate SOFT TISSUE LESION – Low Diagnoses: Reversible pulpitis UR6, Mild gingivitis Discussion/Prevention advice/treatment options: Treatment options explained, including how the treatment will be carried out, the risks and benefits of each option. Agreed upon Tx plan below VCG: Treatment plan (VCG): - Leave and monitor with prevention - Band 1 [Cost]: Prevention advice - OHI, Diet advice - Band 2 [Cost]: Composite restoration UR6 - Band 3 [Cost]: None - Referral: None Prevention advice given today. ** ** PREVENTION ADVICE PROMPTS (DBOH): OHI (guided by DBOH) - Brush 2x a day, once at bedtime and one other time - Use a smear (<3yrs) / pea sized amount (>3yrs) - Use a fluoride toothpaste with at least: 1000 ppm (less than 6), 1350-1500 ppm (>6) - Spit, don’t rinse - Highlighted target areas for patient - Sugar free medications Diet - Minimise sugar intakes - Avoid NME sugars - Do not eat anything after brushing on an evening - Had brief discussion of typical diet in a day and where to minimise sugar - Advised to avoid acidic food and drink to minimise wear - Do not eat 1 hour before brushing at bedtime Tx completed today: OHI, composite restoration UR6 NV: Review in 6 months