Comprehensive Dental Exam

Practitioner Details: Dr. Emily Carter, Dentist Type of Examination Conducted: Comprehensive dental examination conducted with patient consent obtained. Presenting Complaint: Patient reports sensitivity in the upper right molar region. Dental History: Patient has a history of dental caries, last dental review was six months ago. Regular brushing twice daily, occasional flossing. Medical History: No significant medical or surgical history. Social History: Non-smoker, occasional alcohol consumption, works as a software engineer. Medications: NAD Allergies: No known allergies. Clinical Findings and Observations: E/O Examination: NAD I/O Examination: Soft-tissue examination: NAD Oral cancer screen (FoM, palate, pharynx, soft tissues): NAD Gingiva: Mild gingivitis noted with slight bleeding on probing. Hard tissue examination: Caries detected on tooth #16, restored teeth #14 and #15, no missing teeth. Oral Hygiene Status: Fair, based on OHI index. Occlusion analysis: Class I occlusion with mild crowding in the lower anterior region. Other I/O findings: NAD Radiographic Findings: Bitewing radiographs taken today, consent obtained. Caries confirmed on tooth #16, no other pathologies noted. Diagnosis: Primary diagnosis: Dental caries on tooth #16. Treatment Options discussion: Discussed options: filling for tooth #16, risks include potential need for root canal if decay is extensive. Estimated cost: £150. Patient opted for filling. Proposed Treatment Plan: Filling for tooth #16, with follow-up in six months for review. Consent: Patient consented to proposed treatment. Procedures Conducted: NAD Instrument Tracking: Batch #12345 Medications/Therapeutics: NAD Advice Provided: Advised on improved oral hygiene practices, including daily flossing. Follow-up scheduled in six months. Follow-Up and Referrals: Follow-up in six months for routine check-up. Unusual Events: NAD Additional Digital and Laboratory Information: NAD Final Notes: Patient advised to monitor sensitivity and return if symptoms worsen. Future treatment may include orthodontic consultation for crowding. Other Details: NAD Document if patient consent was given: Yes, patient consent was given.