Dentist Template

Routine Check-Up & Cleaning

A professional Dentist template for healthcare professionals.

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Specialty

Dentist

Used

190 times

Type

Note

Last edited

3/11/2025

Created by

Andres Hald

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About this template

This Routine Check-Up & Cleaning template is designed for dentists to document comprehensive dental examinations. It covers all aspects of a routine dental visit, including medical and dental history updates, oral hygiene habits, and detailed intraoral and extraoral examinations. The template also includes sections for periodontal assessment, radiographic findings, and scaling and cleaning procedures. Dentists can use this template to efficiently record findings, diagnoses, and treatment recommendations, ensuring thorough patient care. Ideal for routine dental check-ups, this template helps maintain accurate and detailed patient records.

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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.