Clinician Specialty: Oral/Dental Hygienist
Chief Complaint:
Patient desires a brighter smile due to discolouration affecting their confidence.
Medical History:
No significant medical conditions. Patient reports no known allergies. Currently taking oral contraceptives. No contraindications to whitening identified.
Dental History:
Routine dental check-ups and cleanings every six months. No history of extensive restorative work. Has not undergone professional whitening procedures previously, but has tried over-the-counter whitening strips with limited success.
Current Oral Health Status:
Teeth appear generally healthy with no active decay or gum disease. Two small, well-sealed composite restorations on maxillary anterior teeth (tooth #11 and #21). Mild generalised sensitivity to cold reported previously, but managed well with sensitive toothpaste. No signs of bruxism or erosion. Shade assessment prior to treatment: A3.
Treatment Goals:
Patient aims for a noticeable improvement in brightness, ideally to a shade of A1 or lighter, to achieve a more aesthetically pleasing smile.
Pros and Cons of Treatment:
Pros discussed: Significant improvement in tooth shade, enhanced confidence, non-invasive procedure. Cons discussed: Potential for temporary tooth sensitivity, temporary gum irritation, possibility of uneven results if existing restorations are present (patient advised these will not whiten), cost of treatment, and the need for maintenance.
Whitening Method Selected:
Combination approach: In-office whitening followed by custom take-home trays for touch-ups.
Pre-Treatment Instructions:
Patient advised to brush and floss thoroughly before appointment. Recommended to avoid highly pigmented foods and drinks for 24-48 hours prior to treatment. Signed consent form obtained.
Treatment Performed:
In-office whitening completed using 35% hydrogen peroxide gel (Opalescence Boost). Gums isolated with a liquid dam. Three 15-minute applications performed. Shade achieved post-treatment: B1. No adverse reactions during procedure.
Post-Treatment Instructions:
Advised to avoid highly pigmented foods and drinks (coffee, red wine, berries, dark sauces) for 48 hours. Recommended to use Sensodyne toothpaste for temporary sensitivity. Provided instructions on how to use take-home trays with 10% carbamide peroxide gel, to be used for 30 minutes daily for 7 days, or as needed for touch-ups. Given leaflet on post-whitening care.
Follow-up Plan:
Scheduled a follow-up appointment in two weeks to assess results and address any concerns. Recommended touch-up applications with take-home trays every 3-6 months as desired.
Patient Response:
Patient expressed satisfaction with the immediate results, noting a significant improvement in brightness. Reported mild, transient sensitivity during the procedure, which subsided shortly after. No other concerns expressed.
Clinician
Dr. Eleanor Vance
Dental Therapist
