Comprehensive Dental Examination Note

Clinician Specialty: Dentist **Exam:** Identification check confirmed verbally Introduced patient to Dr. Thomas Kelly (dentist) and Sarah Jones (dental nurse). Both present. Verbal consent for dental examination gained Last dental visit: Approximately 18 months ago, for a routine check-up and clean. **Complaints:** * Patient concerned about recent sensitivity to cold drinks, particularly on the upper right side. * Expressed a desire for whiter teeth. **Goals:** **Now:** To alleviate sensitivity and improve the aesthetic appearance of her smile. **Why?:** Sensitivity is impacting her enjoyment of food and drink, and she feels her teeth look discoloured, affecting her confidence. **10/20 years time:** To maintain a healthy, functional, and aesthetically pleasing dentition throughout her life, avoiding major dental work. **Why?:** She values her oral health as part of her overall well-being and wants to avoid pain and discomfort as she ages. **Patient personal information:** Patient recently returned from a holiday in Spain and mentioned enjoying tapas. She works as a primary school teacher. **Medical history:** Medical history reviewed and recorded in relevant tab **Dental history:** **Toothbrush** Manual toothbrush (medium bristles) **Brushes:** Brushes twice daily for approximately 2 minutes each time, using a circular motion. **Interdental cleaning:** Uses dental floss approximately 3-4 times per week, specifically before bedtime. **Diet:** Patient reports a moderate sugar intake, often having a sweet snack in the afternoon. Drinks one fizzy drink daily. **Examination:** Extraoral: TMJ, lymph nodes, muscles of mastication: NAD Intraoral: soft palate, hard palate, mucosae, tongue, floor of mouth, lips, arches: NAD **Oral hygiene:** Fair oral hygiene with some plaque accumulation on posterior teeth and mild gingival inflammation. **BPE recording:** BPE: recorded in relevant tab (322/222) **Toothwear:** Mild attrition noted on incisal edges of upper anterior teeth (11, 21), consistent with parafunctional habits. **Radiographs:** Verbal consent for radiographs gained **Justification:** To assess interproximal caries, bone levels, and periapical status following patient's complaint of sensitivity and for comprehensive baseline. **Grade:** Grade 2 - Diagnostically acceptable **Bone levels:** Horizontal bone loss observed in posterior quadrants, consistent with early to moderate periodontitis. No significant vertical defects. **Findings:** Bitewing radiographs reveal early interproximal caries on 15 DO and 26 MO. Periapical radiograph of 16 shows no periapical pathology; slight widening of PDL around 16 mesial root due to occlusal trauma. **Risk assessment:** **Caries:** Moderate caries risk due to reported sugar intake and presence of new carious lesions. **Perio:** Moderate periodontal risk due to mild gingival inflammation, some plaque accumulation, and horizontal bone loss. **Toothwear:** Low to moderate toothwear risk due to mild attrition, suggesting ongoing but not rapidly progressing parafunctional activity. **Oral cancer:** Low oral cancer risk; no specific risk factors identified. **Diagnoses:** * Early interproximal caries on 15 DO and 26 MO. * Localised mild gingivitis. * Early to moderate chronic periodontitis. * Mild generalised attrition. **Perio diagnosis** Stage II, Grade B Periodontitis, with risk factors including fair plaque control and occlusal trauma on 16. **Appointment 1 (Completed today):** Tailored oral hygiene instruction provided, focusing on improved interdental cleaning techniques using interdental brushes and modified brushing technique for plaque removal. Dietary discussion included advice on reducing frequency of sugar intake, particularly afternoon snacks and fizzy drinks. Full comprehensive dental examination completed. **Treatment plan:** **Emergency:** No immediate dental emergency identified. **Preventive:** * Scale and polish. * Fluoride varnish application. * Ongoing dietary counselling and oral hygiene instruction. **Elective:** * Composite restoration for 15 DO and 26 MO. * At-home tooth whitening kit as per patient's request. * Referral to hygienist for further periodontal management and maintenance. **Discussions with patient:** Diagnoses of early caries, gingivitis, and periodontitis, along with mild attrition, were explained to the patient. The proposed treatment plan, including preventive and elective options, was discussed thoroughly. Recall period agreement: 6-month recall for routine examination and hygiene appointments. Discussion of treatment options included pros and cons of composite vs. amalgam (patient preferred composite), expected outcomes of whitening, and importance of periodontal management. Price estimates for each treatment option were provided, and patient understood the benefits and potential risks. Patient satisfaction statement: Patient expressed satisfaction with the thoroughness of the examination and clarity of the explanations. **Price estimate:** Total estimated cost for proposed treatment (including restorations, whitening, and hygiene appointments) provided verbally and in a written estimate: £650.