Preventative Care – Scale & Clean, Fluoride, Sealants

Clinician: [Clinician’s Name] Date: [Date of Consultation] **Reason for Visit:** [Describe the patient’s reason for attending. Specify if the visit is for routine preventative care, recall appointment, or if the patient has presented with concerns related to oral hygiene, staining, sensitivity, or gingival health.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note. If not discussed, leave blank or omit.) **Medical History Update:** [List any relevant medical updates, medications, or allergies. Include any medical conditions that may impact treatment.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note. If not discussed, leave blank or omit.) **Dental History Update:** [Describe any dental treatments since the last visit. Mention previous scaling, periodontal therapy, or history of high caries risk.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note. If not discussed, leave blank or omit.) **Oral Hygiene Habits:** - Brushing: [Frequency, technique, type of toothbrush used] - Flossing: [Frequency and technique] - Mouthwash: [Usage and type] - Additional Cleaning Aids: [Interdental brushes, water flossers, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note. If not discussed, leave blank or omit.) **Clinical Examination:** - Extraoral Examination (E/O): [Facial symmetry, lymph nodes, TMJ assessment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Intraoral Examination (I/O): - Soft Tissues: [Assess mucosa, tongue, palate, floor of mouth] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Gingival Health: [Document any gingival inflammation, bleeding on probing, recession, or periodontal pockets] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Plaque & Calculus Levels: [Mild, moderate, or heavy deposits present] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Staining: [Presence, location, and possible cause] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) **Periodontal Assessment:** - Bleeding on Probing (BOP): [Mention areas with bleeding and severity] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Pocket Depths: [Document probing depths if periodontal charting was conducted] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Gingival Recession: [Record any areas of concern] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Overall Periodontal Status: [Stable/mild gingivitis/moderate periodontitis/severe periodontitis] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) **Scaling & Cleaning Treatment Provided:** - Method Used: [Hand scaling, ultrasonic scaling, or a combination] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Extent of Cleaning: [Full mouth, localized scaling, deep cleaning if indicated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Polishing: [Describe if polishing was performed and paste used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Debridement: [Indicate if heavy deposits required extensive scaling or multiple visits] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) **Fluoride Treatment:** (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Type of Fluoride Applied: [Fluoride varnish, gel, or rinse] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Concentration & Brand (if specified):** [Mention if applicable] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Indications for Use: [High caries risk, sensitivity, enamel protection] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) **Fissure Sealants:** (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Teeth Sealed: [List teeth numbers where sealants were applied] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Material Used: [Glass ionomer, resin-based] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Indications: [Caries prevention in high-risk areas] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) **Preventative Advice Given:** (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Oral Hygiene Instructions: [Advice on brushing, flossing, mouthwash use] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Dietary Advice: [Reducing sugar intake, acid erosion prevention] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Risk Factor Discussion: [Smoking, alcohol, dry mouth, bruxism] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Recommended Products: [Fluoride toothpaste, interdental cleaning aids] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) **Patient Response & Compliance:** (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - [Describe patient’s engagement, understanding, and willingness to follow recommendations.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) **Follow-Up Plan:** (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Next Routine Visit: [Recommended recall interval based on periodontal status] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) - Additional Treatment Required: [If further periodontal therapy, restorations, or further sealants are needed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.) --- (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care—use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output—just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points as needed to capture all the relevant information from the transcript.)