Routine Check-Up & Cleaning

Routine Check-Up & Cleaning Clinician: Dr. Emily Carter Date: 1 November 2024 **Reason for Visit:** The patient attended for a routine check-up and cleaning, with no specific concerns reported. **Medical History Update:** No changes in medical history, medications, or allergies since the last visit. **Dental History Update:** Since the last visit, the patient has had a filling on the upper right molar. **Oral Hygiene Habits:** The patient brushes twice daily and flosses occasionally. Advised to increase flossing frequency and use a fluoride mouthwash. **Extraoral Examination (E/O):** Facial symmetry normal, TMJ function normal, no lymphadenopathy or soft tissue abnormalities noted. **Intraoral Examination (I/O):** - Soft Tissues: Buccal mucosa, tongue, palate, floor of the mouth, and vestibule appear normal. - Gingiva: Mild gingival inflammation noted, no recession or attachment loss. - Hard Tissue: All teeth present, restorations intact, no new caries detected. - Occlusion: Class I occlusion, mild crowding in lower anterior teeth. **Periodontal Assessment:** - Plaque and Calculus Levels: Moderate plaque and calculus deposits noted. - Bleeding on Probing (BOP): Mild bleeding on probing in the posterior sextants. - Pocket Depths: Probing depths within normal limits. - Gingival Recession: No recession present. - Periodontal Status: Overall periodontal health is stable. **Radiographic Examination:** Bitewing radiographs taken, showing no new caries or periapical pathology. Bone levels appear normal. **Scaling and Cleaning:** - Plaque and Calculus Removal: Ultrasonic scaler used for plaque and calculus removal in all quadrants. - Stain Removal/Polishing: Polishing performed with a medium grit paste. - Fluoride Treatment: 2% sodium fluoride gel applied using trays. - Oral Hygiene Instructions Given: Demonstrated proper brushing and flossing techniques, recommended a fluoride toothpaste. **Findings & Diagnoses:** Mild gingivitis diagnosed, no other significant findings. **Treatment Recommendations & Plan:** Recommend regular 6-monthly cleanings and improved oral hygiene practices. **Referral:** No referral necessary. **Patient Education & Preventative Advice:** Advised on the importance of regular flossing and using fluoride mouthwash to prevent gingivitis. **Next Recall Appointment:** Recommended follow-up in 6 months.