Dental Examination and Hygiene Note

Clinician Specialty: Oral/Dental Hygienist Examination and Hygiene: Made patient aware they are seeing a Dental Therapist today - scope explained - out of scope referrals will be made appropriately. Medical History: Checked and updated. Presenting Complaint: Pt c/o: General sensitivity, occasional bleeding gums when brushing Cosmetic concerns: Mild staining on front teeth. Past Dental History: Attendance pattern: Regular 6-monthly check-ups, annual hygiene appointments. LDV: 1 April 2024 LHV: 1 November 2023 Social History: Smoking status: Non-smoker. Advised on maintaining non-smoking status due to reduced risks for periodontal disease and oral cancer. Alcohol consumption: Moderate. Advised on risks of high consumption and encouraged moderation. Sugar intake: Moderate. Advised to reduce intake of sugary snacks between meals and limit consumption to mealtimes. Given advice on healthier alternatives. Acidic diet: Occasional citrus fruits. Assessment shows no significant erosive wear currently. Advised to rinse with water after consuming acidic foods/drinks. Stress levels: Moderate due to work, reports clenching jaw at night. Oral Hygiene Regime: Brushing: Twice per day IDC: Daily with interdental brushes (size red and blue) Fluoride: Sensodyne Repair & Protect toothpaste MW: No Protective glasses given to patient Extraoral Examination: Face/head: NAD TMJ: Mild tenderness on palpation of left masseter, patient reports clenching. Neck: NAD Lymphadenopathy: NAD MOM: 50mm, symmetrical opening Bruxism awareness: Patient aware of clenching, advised on potential for bruxism. Intraoral Examination: Soft Tissues: NAD (tongue, palate, floor of mouth, buccal mucosa, buccal sulcus, lips) Oral cancer screen: -ve Hard Tissues: Dentition as charted Caries: No active caries detected. Defective fills: NAD Abnormalities: NAD Teeth to watch: 36 (UR6) occlusal fissure stain. Other findings: NAD Extra coronal restorations: n/a Removable prosthetics: n/a Occlusion: Incisal classification: Class I Lateral excursion: Balanced contacts Parafunction: Patient reports clenching. Other: NAD Tooth Surface Loss: BEWE: 1 Type: Attrition evident on posterior teeth. Periodontal Assessment: BPE: 2,2,2,2,2,2 Perio Chart: Full periodontal chart completed, available in digital records. Gingival appearance: Generalised mild gingivitis, erythematous and oedematous. Deposits: Generalised light supra-gingival calculus, moderate plaque. OH status: Suboptimal plaque control, PII 2.1. Recession: Localised mild recession 1mm on 13 (UR3) buccal. Mobility: NAD Furcation: NAD Radiographs: Radiographs Taken: Two bitewings. Justification: Routine screening for interproximal caries and alveolar bone levels. Grade: 2 (diagnostic quality) Alveolar bone levels: Horizontal bone loss consistent with age. Caries: No interproximal caries detected. Pathology: NAD Sensibility / Vitality Testing: Teeth tested: 15 (UR5), 25 (UL5) Method: Cold test with endo-ice Result: Positive response, quick return to normal. Photos taken Itero scan recorded Clinical Diagnosis: 1. Generalised mild gingivitis. 2. Localised attrition. 3. Bruxism (suspected). Risk Classification: Oral cancer risk: Low Perio risk: Moderate (due to gingivitis and suboptimal OH) Caries risk: Low TSL risk: Moderate (due to suspected bruxism) Discussion of Options: Gingivitis - gingival inflammation present, advised this is reversible, personalised OHI given, advised continued inflammation can lead to permanent damage to the periodontium and progression into periodontitis which is irreversible. Further hygiene treatment required: Yes. Treatment Completed Today: [1] Exam and any required investigations [2] f/m PMPR using airpolishing w/ erytritol powder and USS [3] OHI - demonstration of modified Bass technique, interdental brush use, and discussion of fluoride toothpaste benefits. Treatment Required: 1. Follow-up hygiene appointment for further oral hygiene instruction and targeted scaling. 2. Discussion with dentist regarding bruxism management options (e.g., occlusal guard). Referrals: N/A Recall: SDCEP & NICE guidelines reviewed and agreed Examination recall of: 6 / 12 SDCEP & BSP guidelines reviewed and agreed Hygiene recall of: 3 / 12 Therapist: Sarah Jones Nurse: Emily White TC / TCA Tx