Adult Exam:
Nurse: Sarah Jenkins
c/o: Routine dental check-up and mild sensitivity in lower left quadrant.
Relevant history: Patient reports occasional mild sensitivity to cold drinks in the lower left quadrant for the past 2 months. No sharp pain or swelling. Last dental visit 18 months ago. Previously had a filling on tooth #36 (lower left first molar) approximately 5 years ago.
Appropriate PPE worn pt and dentist.
Patient consents to examination.
Medical History:
Updated and reviewed.
Allergies: Penicillin (rash), Latex (skin irritation)
Special needs: None documented.
Social History:
Smoking: Non-smoker
Alcohol intake <14upw?: 4 units per week, occasional red wine.
Diet: Balanced diet, occasional sugary snacks. Patient reports having a fizzy drink once a day with lunch.
Dental History:
Attendance pattern: Irregular, last visit 18 months ago. Previously attended every 1-2 years.
Extra Oral Exam:
Facial asymmetries: Symmetrical.
Neck and Lymph nodes: No palpable lymphadenopathy or abnormalities.
Muscles of Mastication: Non-tender on palpation, no hypertrophy.
Lips: Healthy, no lesions.
TMJ: No clicking, crepitus, or tenderness on palpation.
Range of movement/opening normal?: Normal opening, approximately 45mm.
Rotate and translate smoothly?: Smooth rotation and translation.
Intra Oral Exam:
Soft tissues check including:
Tongue: Normal appearance, no lesions.
Palate: Normal, pink, no lesions.
Buccal mucosa: Healthy, no white patches or lesions.
Lingual mucosa: Healthy, no lesions.
FOM: Healthy, no lesions or swelling.
Occlusion:
Currently stable ICP?: Stable ICP.
Posterior support: Adequate posterior support bilaterally.
Guidance:
Protrusive: Anterior guidance present.
R excursion: Canine guidance.
L excursion: Canine guidance.
Interferences: No significant interferences noted.
Periodontal exam:
Oral Hygiene: Fair, some plaque accumulation interdentally, particularly in posterior segments. Mild gingivitis present.
Gingival biotype: Medium.
Gingival condition: Mildly inflamed, no bleeding on probing generally, isolated bleeding on probing at 36ML.
Recession: Generalized mild recession (1-2mm) buccally on canines and premolars.
Mobility: All teeth firm (Grade 0 mobility).
BPE recorded: Sextants 1,2,3: 2; Sextants 4,5,6: 2.
Tooth Surface Loss:
Attrition: Mild attrition on incisal edges of anterior teeth.
Severity: Mild.
Pathological/physiological?: Physiological.
Evidence of Parafunction: None observed.
Erosion:
Severity: Mild, generalized on buccal surfaces of posterior teeth.
BEWE Index: 1.
Abfraction/abrasion: Mild abrasion on cervical margins of 13, 23, 33, 43.
Severity: Mild.
Affected surfaces: Buccal cervical 13, 23, 33, 43.
Hard Tissues:
Charting: Charting updated. Existing amalgam restoration on 36DO intact, no recurrent caries noted. Small occlusal carious lesion on 47.
Caries / Leaking or defective restorations: New carious lesion detected on occlusal surface of 47. No leaking or defective restorations.
Cracks: No visible cracks.
Heavily restored teeth: Tooth 36 with large amalgam restoration.
Aesthetics:
Any concerns: Patient expresses mild concern about generalized yellowing of teeth.
Radiographs and Special Tests:
Radiographs: Bitewings taken. Show carious lesion on 47, no other significant pathology. Periapical radiograph of 36 shows adequate root canal treatment and no periapical pathology.
Special tests: Vitality testing of 36 and 47 (positive to cold, within normal limits).
iTero scan: Not performed.
Photos: Clinical photographs taken of intraoral tissues and dentition.
Diagnosis/es:
Dental caries (47 Occlusal).
Mild generalized gingivitis.
Physiological attrition.
Mild generalized erosion.
Mild abrasion (cervical surfaces).
Periodontal classification: Stage I, Grade A, stable periodontitis.
Discussions with patient:
Overall dental health: Patient's overall dental health is fair, with areas needing attention including oral hygiene and the newly identified caries.
Periodontal condition: Discussed mild gingivitis and mild generalized recession. Emphasized the importance of improved oral hygiene techniques and regular dental cleanings.
Tooth wear: Explained the findings of mild attrition, erosion, and abrasion. Advised on dietary habits to reduce acidic intake and recommended a soft-bristled toothbrush with gentle brushing technique.
Diet advice: Advised to reduce frequency of sugary and acidic drinks/foods. Recommended rinsing with water after consuming acidic foods.
Restorations advised: Advised restorative treatment for the carious lesion on 47.
Treatment options: Discussed composite filling for 47. Recommended professional cleanings with the hygienist.
Other: Discussed options for addressing aesthetic concerns regarding tooth shade, including professional whitening.
Risk assessment:
Caries: Moderate risk due to occasional sugary snacks and fizzy drinks.
Periodontal: Low to moderate risk, manageable with improved oral hygiene.
Wear: Moderate risk due to combination of dietary acids and brushing habits.
Oral Cancer: Low risk.
Recall Intervals:
Maintain the currently set recall program.
Treatment Plan:
1. Provide oral hygiene instructions, including flossing and interdental cleaning techniques.
2. Schedule appointment for composite restoration of tooth 47.
3. Recommend hygiene appointment for scale and polish and further oral hygiene education.
4. Discussed options for tooth whitening at a future appointment if desired by the patient.
5. Recall in 6 months for routine check-up and review of oral hygiene.
Adult Exam:
Nurse: [Name of nurse assisting with the examination] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
c/o: [Primary presenting complaint and reason for attendance] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Relevant history: [Relevant history directly related to the presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Appropriate PPE worn pt and dentist.
Patient consents to examination.
Medical History:
Updated and reviewed.
Allergies: [Documented allergies and reactions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Special needs: [Any documented special needs or additional support requirements] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Social History:
Smoking: [Smoking status and relevant details] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Alcohol intake <14upw?: [Alcohol intake details and assessment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Diet: [Dietary habits or discussions relevant to oral health] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Dental History:
Attendance pattern: [Attendance pattern or timing of last dental visit] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Extra Oral Exam:
Facial asymmetries: [Findings related to facial symmetry] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Neck and Lymph nodes: [Neck and lymph node examination findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Muscles of Mastication: [Findings relating to muscles of mastication] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Lips: [Lip examination findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
TMJ: [Temporomandibular joint findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Range of movement/opening normal?: [Jaw range of movement findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Rotate and translate smoothly?: [TMJ movement characteristics] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Intra Oral Exam:
Soft tissues check including:
Tongue: [Tongue examination findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Palate: [Palatal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Buccal mucosa: [Buccal mucosa findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Lingual mucosa: [Lingual mucosa findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
FOM: [Floor of mouth findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Occlusion:
Currently stable ICP?: [Status of intercuspal position stability] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Posterior support: [Posterior occlusal support status] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Guidance:
Protrusive: [Protrusive guidance findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
R excursion: [Right excursion guidance findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
L excursion: [Left excursion guidance findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Interferences: [Occlusal interference findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Periodontal exam:
Oral Hygiene: [Assessment of oral hygiene] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Gingival biotype: [Gingival biotype description] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Gingival condition: [Gingival health findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Recession: [Presence and extent of gingival recession] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Mobility: [Tooth mobility findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
BPE recorded: [Basic Periodontal Examination score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Tooth Surface Loss:
Attrition: [Presence and distribution of attrition] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Severity: [Severity of attrition] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Pathological/physiological?: [Classification of tooth wear] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Evidence of Parafunction: [Evidence of parafunctional activity] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Erosion:
Severity: [Severity of erosion] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
BEWE Index: [BEWE score] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Abfraction/abrasion: [Presence of abfraction or abrasion] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Severity: [Severity of abfraction or abrasion] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Affected surfaces: [Tooth surfaces affected] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Hard Tissues:
Charting: [Status or completion of dental charting] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Caries / Leaking or defective restorations: [Hard tissue pathology or restoration issues] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Cracks: [Cracked tooth findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Heavily restored teeth: [Teeth with extensive restorations] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Aesthetics:
Any concerns: [Aesthetic concerns raised or identified] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Radiographs and Special Tests:
Radiographs: [Radiographs taken or reviewed and key findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Special tests: [Special tests performed and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
iTero scan: [iTero scan status or findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Photos: [Clinical photographs taken or reviewed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Diagnosis/es:
[Confirmed diagnoses as stated explicitly by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely. Do not invent or infer a diagnosis.)
Periodontal classification: [Periodontal diagnosis including stage, grade, and risk factors as stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely. Do not invent or infer a diagnosis.)
Discussions with patient:
Overall dental health: [Discussion of overall dental health] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Periodontal condition: [Discussion of periodontal findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Tooth wear: [Discussion of tooth wear] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Diet advice: [Dietary advice discussed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Restorations advised: [Restorative treatments advised] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Treatment options: [Treatment options discussed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Other: [Any other discussion points] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Risk assessment:
Caries: [Caries risk assessment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Periodontal: [Periodontal risk assessment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Wear: [Tooth wear risk assessment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Oral Cancer: [Oral cancer risk assessment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
Recall Intervals:
Maintain the currently set recall program.
Treatment Plan:
[Treatment plan details and agreed actions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit completely.)
(Summarise in a professional clinical record style written in the dentist’s voice. Do not include transcript excerpts, verbatim quotes, or bracketed quotations. Base all entries only on the transcript, contextual notes, or clinical note, and do not invent or assume information. Do not include risks, benefits, or alternative options unless explicitly mentioned. Use bullet points only where they already exist in the template.)
