Dental Clearance Form

Specialty: Dentist **Dental Clearance Form** **Patient Information:** * **Patient Name:** [Sarah Jenkins] * **Date of Birth:** [15/03/1988] * **Medical Record Number:** [SJ880315-A] **Referring Physician/Specialist:** * **Name:** "Dr. Eleanor Vance" * **Specialty:** [Cardiologist] * **Contact Number:** [020 7946 0123] * **Reason for Referral/Specific Concerns:** [Pre-cardiac surgery clearance; specifically requesting assessment for any active infections or significant dental pathology that could pose a risk for infective endocarditis.] **Dental Examination Findings:** * **Date of Examination:** 1 November 2024 * **Chief Complaint (if any):** [No acute dental complaints reported by the patient. Referred for routine pre-surgical dental clearance.] * **Relevant Medical History (from patient/referral):** [History of rheumatic heart disease, scheduled for aortic valve replacement. Currently on prophylactic antibiotics for a previous dental procedure six months ago. No known allergies. Controlled hypertension.] * **Clinical Findings (oral cavity, teeth, periodontium, soft tissues):** [Generalised good oral hygiene. Mild gingivitis present in posterior regions. No signs of active caries. One fractured cusp on tooth 37 (lower right second molar) with no sensitivity. No active abscesses or signs of periapical infection. Soft tissues appear healthy. TMJ non-tender, full range of motion.] * **Radiographic Findings (if taken):** [Panoramic radiograph taken (dated 1 November 2024) shows no gross pathology. No periapical radiolucencies. Moderate horizontal bone loss noted generalised. Impacted wisdom tooth 48 (lower right third molar) with no associated pathology.] **Dental Diagnosis:** * [Mild gingivitis (localised). Fractured cusp tooth 37 (asymptomatic). Impacted tooth 48 (asymptomatic).] (include a list of diagnoses) **Treatment Plan and Recommendations:** * [Phase I: Oral hygiene instructions, scaling and root planing (full mouth). Assessment of tooth 37 for restoration (composite or crown) post-surgery. Monitoring of tooth 48 unless symptomatic.] (include a list of treatment recommendations) **Clearance Status:** * **Dental Clearance:** [Cleared with recommendations/conditions] * **Explanation/Conditions:** [Patient can proceed with cardiac surgery. Dental treatment (scaling and root planing, restoration of tooth 37) can be completed post-operatively. No immediate dental concerns that would contraindicate surgery at this time. Standard antibiotic prophylaxis for infective endocarditis as per AHA guidelines is recommended for future dental procedures in this patient.] (explain any conditions or follow-up needed) **Dentist Information:** * **Dentist's Name:** "Dr. Thomas Kelly" * **Signature:** [Electronically Signed] * **Date:** 1 November 2024