Preventative Care – Scale & Clean, Fluoride, Sealants

Clinician: Dr. Emily Carter Date: 1 November 2024 **Reason for Visit:** Routine preventative care and concerns about mild tooth sensitivity. **Medical History Update:** No changes in medical history. Patient is not on any medications and has no known allergies. **Dental History Update:** Patient had scaling and polishing six months ago. No history of periodontal therapy or high caries risk. **Oral Hygiene Habits:** - Brushing: Twice daily with a soft-bristled toothbrush using the Bass technique - Flossing: Once daily using traditional floss - Mouthwash: Uses alcohol-free mouthwash twice a week - Additional Cleaning Aids: None **Clinical Examination:** - Extraoral Examination (E/O): Normal facial symmetry, no lymphadenopathy, TMJ functioning well - Intraoral Examination (I/O): - Soft Tissues: Healthy mucosa, tongue, palate, and floor of mouth - Gingival Health: Mild gingival inflammation, no bleeding on probing, no recession - Plaque & Calculus Levels: Mild deposits present - Staining: Mild staining on the lingual surfaces of lower incisors, likely due to tea consumption **Periodontal Assessment:** - Bleeding on Probing (BOP): None - Pocket Depths: 2-3 mm throughout - Gingival Recession: None - Overall Periodontal Status: Stable **Scaling & Cleaning Treatment Provided:** - Method Used: Combination of hand scaling and ultrasonic scaling - Extent of Cleaning: Full mouth - Polishing: Polishing performed using a fluoride-containing paste - Debridement: Not required **Fluoride Treatment:** - Type of Fluoride Applied: Fluoride varnish - Indications for Use: Sensitivity and enamel protection **Fissure Sealants:** - Teeth Sealed: None **Preventative Advice Given:** - Oral Hygiene Instructions: Advised to continue current brushing and flossing routine - Dietary Advice: Reduce tea consumption to minimize staining - Risk Factor Discussion: Discussed the impact of acidic drinks on enamel - Recommended Products: Suggested using a fluoride toothpaste **Patient Response & Compliance:** - Patient is engaged and understands the importance of maintaining oral hygiene. Willing to follow dietary advice. **Follow-Up Plan:** - Next Routine Visit: Recommended recall interval of six months - Additional Treatment Required: None at this time