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Note Writing Made EasyAccurate and contemporaneous patient notes are essential in dentistry. However, with time constraints in general practice this can be a real struggle to get done well.So here our answer- some baseline templates that can easily be personalized to each situation to help ensure your notes are tip-top!DISLCOSURE: Please note that templates have not been approved by a dental professional body. They have been formulated only as a guide to aid record keeping. We take no responsibility for the accuracy of the information given.? Use at your own discretion.ExaminationAdult ExamPCO:?HPC:MH: See section & scanned sheetSH: Non-Smoker (never-smoker)/ Smokes x per day for x years / Ex smokerAlcohol: None/ x Units per weekDH: Brushes X daily with a high Fl toothpasteInterdental cleaning (floss/Tepes)Non- cariogenic/ Cariogenic- sweet foods/drinks & regular snackingE/O: TMJ nil/ LN nil/ Lips: Nil/ Facial Symmetry nilI/O:? Tongue nil, FOM nil, Palate nil, Mucosa nil, Gingivae nil?BPE: See sectionRadiographs: See sectionObservations:Diagnosis:Tx plan:?Today:?1) Reinforced OHI + TBI (interdental cleaning & demonstrated using tepe brushes/floss)2) Diet advice given3) Gum disease aetiology, treatment & prevention explained4) Smoking risks & cessation advice discussedCaries risk: Low/Med/HighPeriodontal risk: Low/Med/ HighOral Cancer risk: Low/Med/ HighNICE recall interval discussed with patient: 6/12?Child Exam?PCO:?HPC:MH: See section & scanned sheetSH: Attended with mum/dadDH: Brush X daily with a high Fl T.PNon- cariogenic/ Cariogenic- sweet foods/drinks & regular snackingComfortable with dental treatmentE/O: TMJ/ LN checkedI/O:? Soft tissues checked: NAD / BPE: See sectionCaries risk: Low/Med/HighOrthodontic assessment:Diagnosis:Tx plan:Today:?1) Reinforced OHI & TBI2) Diet assessed & advice given3) Fluoride varnish appliedNICE recall interval discussed with patient: 6/12?Treatment OptionsTx Options: XLA or RCTTx options discussed:1) XLAPatient fully informed & understands risks: Post op pain, swelling, bleeding, bruising, dry socket, OAC, root fracture followed by surgical XLA/referral, Damage to nerves2) RCT (followed by crown) with referral to specialist/ in general practicePatient fully informed & understands risks: Failure, file fracture, root perforation, resulting in need for XLAPatient’s choice:Tx Options: Missing tooth space1) Implant?Permanently fixed in pt's bone, requires minor oral surgery usually under local anaesthetic. Usually takes 3-6 months for implant to stabilise in bone before tooth can be placed and therefore may require temp bridge/denture in?meantime.?If looked after can last as long as a natural tooth. No damage or dependence on adjacent teeth. Implant immune to tooth decay but not gum?disease and therefore peri-implant mucositits/peri-implantitis can develop around implant like a natural tooth. Problematic tooth needs to removed ASAP as infection can undermine the health of?bone meaning bone graft may be required - increasing the cost.?Smoking and uncontrolled diabetes can lower success rates.2) BridgeConventional - good aesthetic option, but is quite destructive to adjacent teeth as considerable tooth preparation/reduction required resulting in long term loss of vitality (roughly 20% after 5 years), needing root canal treatment in future; also?can worsen any pre-existing periodontal problems. usual lifespan of 15-20yrs if well looked after.?Maryland (resin-bonded) bridge option explained advised can often need recementing, but little or no destruction of supporting tooth. Very good option for anterior space with healthy adjacent teeth.3) Denture (acrylic/ flexible/ chrome)Not fixed, needs to be removed to clean and left out over night - most conservative option - can take time to get used to. If immediate denture may need reline or new denture after healing - aprox 8-9mnts4) Leave spaceAdjacent teeth may drift, tilt or rotate. Opposing tooth may over-erupt into space.? No cost. No preparation/destruction of adjacent teeth.?Radiograph ReportingBitewing radiographic reportRadiographs: R&L BWJustification: IP caries detection and bone levelsBone levels: Normal/ Generalised horizontal bone loss/ Localised vertical bone lossCaries: NADPeriapical radiographic reportRadiographs: PAJustification:? Periapical pathology / Pre-treatment assessment / XLA assessmentBone levels: Normal/ Mesial/ Distal localised bone lossCaries:Periapical pathology: apical radiolucency??EmergencyPericoronitisCO: PAIN from wisdom toothHPC: Constant ache, disturbed sleep, bad taste, taking pain killers, face swollenMH: checked, see medical notesSH: Smoke: /dayAlcohol: units/weekE/O: TMJ nil, LN tender, Lips nil, Symmetry nilI/O: Tongue nil, FOM nil, Hard palate nil, Soft palate nil, Buccal mucosa nil, Gingivae inflamed around ll8Diagnosis(es): Pericoronitis ll8Treatment: irrigated with CXD, prescribed metronidazole 200mg tabs tds 7days and warned against alcohol.Rx options for tooth discussed: 1)monitor 2)xlaPt very appreciativeDN:SensitivityPatient experiencing generalized sensitivity/ localized sensitivity fromRecommended to directly apply desensitising T.P on region at nighttime. Advised to not rinse mouth after tooth brushing.? Recommended Sensodyne pro-enamel (containing potassium nitrate).?Tx: Duraphat varnish applied to sensitive areasIf does not improve in 1/12 can discuss further options (e.g. root coverage restorations or gingival grafts)Tooth acheCO: PAIN/Tooth acheHPC: Constant ache, disturbed sleep, lasts more than 5 mins, spontaneous, taking pain killersMH: checked, see medical notesSH: Smoke: /dayAlcohol: units/weekE/O: TMJ nil, LN nil, Lips nil, Symmetry nilI/O: Tongue nil, FOM nil, Hard palate nil, Soft palate nil, Buccal mucosa nil, Gingivae nil?Caries risk:Cancer risk:Diagnosis(es): irreversible pulpitits / acute apical periodontitis/ acute abscessTreatment:?LA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltration, pulp extirpated and dressed tooth with ledermix/CWP and kalzinolOrIncised & drained abscess, POIG, prescribed amox 250mg caps 7days.?Patient to return for long-term treatment when swelling reduced. If swelling gets worse and threatens airway/ eye closure then go to A&E ASAPRx options for tooth discussed: 1)xla 2)rctPt very appreciativeDry SocketCO: PAIN from socket after extractionHPC: Constant ache, disturbed sleep, spontaneous, taking pain killersMH: checked, see medical notesSH: Smoke: /dayAlcohol: units/weekE/O: TMJ nil, LN nil, Lips nil, Symmetry nilI/O: Tongue nil, FOM nil, Hard palate nil, Soft palate nil, Buccal mucosa nil, Gingivae very inflamed around XLA socket, socket packed with necrotic debrisDiagnosis(es): alveolar osteitisTreatment: irrigated socket with CXD, and packed socket with alvogyl, and gave reassurance that symptoms will subside within the next week and socket will eventually heal although it take longer than usualPt very appreciativePeriodontal AbscessPCO: Constant pain/ache from gum around?MH: checked, see medical notesE/O: TMJ nil, LN nil, Lips nil, Symmetry nilI/O:? Soft tissues checked: NADSwelling & pus draining from gingivae/Pocket, Tooth tender to lateral pressure, Tooth responds normally to vitality test (EC)Diagnosis: Periodontal abscessChronic periodontal disease & aetiology of abscess explained to pt.Tx) LA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltrationRSD using ultrasonic scaler & CHXD syringed in pocket. POIG (salt water M/W) & OHI?Advised to return for full assessment.Lost filling /# ToothCO: # tooth/lost filling?HPC: ULHS, not causing any pain, sharp to tongue, food getting trapped, afraid it will flare up if left openMH: checked, see medical notesE/O: TMJ nil, LN nil, Lips nil, Symmetry nilI/O: Tongue nil, FOM nil, Hard palate nil, Soft palate nil, Buccal mucosa nil, Gingivae inflamed around cavity?Caries risk: modDiagnosis(es):#tooth/lost filling UL8Treatment: no la, filled cavity with GIC as tempRx options for tooth discussed: 1)xla or 2) new filling -(amalgam or comp) 3)CrownPt very appreciative?TreatmentsRCT (Hand files) Visit 1Risks of treatment discussed: Pain, failure, instrument separation, perforation, discoloration need for crown postoperativelyHappy to proceed (verbal informed consent)LA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltrationRubber damAccess gained (caries removed) and canals located.Hypochlorite irrigant/ EDTA lubricant]Working length (confirmed with apex locator):D=mm, MB=mm, ML=mm? to file size / P=mm, DB=mm, MB=mm to file sizeWorking length radiograph: Good lengths achievedCleaned and shaped using K-flex files to MAF:?Step back (1mm interval) 3 file sizesDressed hypocal in canals/ cotton pledget in access cavity/ kavit temporary dressingRCT (Rotary files) Visit 1Risks of treatment discussed: Pain, failure, instrument separation, perforation, discoloration need for crown postoperativelyHappy to proceed (verbal informed consent)LA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltrationRubber dam placedAccess gained (caries removed) and x canals located.Hypochlorite irrigant/ EDTA lubricant]Working length (confirmed with apex locator):D= , MB= , ML=? to file size / P=, DB=, MB= to file sizeWorking length radiograph: Good lengths achievedCleaned and shaped (crown down) using rotary Protaper to MAF:?Dressed hypocal in canals/ cotton pledget in access cavity/ kavit temporary dressingRCT Obturate StandardNo LA / LA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltrationRubber damRemoved temporary dressing?Hypochlorite irrigant/ EDTA lubricant]Re-cleaned and shaped canals to WLDry run radiograph confirms WL?Obturated with cold lateral condensation using tubiseal sealerPost operative radiograph- satisfactory (showed pt)Restored with GIC/ AmalgamOcclusion checked/ POIGWarned will need cuspal coverage restoration to protect from fracture and proved adequate seal.Obturate System BLA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltrationRubber damRemoved temporary dressing?Hypochlorite irrigant/ EDTA lubricant]Re-cleaned and shaped canals to MALDry run radiograph confirms WLObturated with warm vertical condensation (System B & Backfill)Post operative radiograph- satisfactory (showed pt)Restored with GIC/ AmalgamOcclusion checked/ POIGWarned will need cuspal coverage restoration to protect from fracture.Crown preparationDifferent types of crowns available discussed with patient. Choice:?Risks: Devitalisation, destruction of tooth tissue, difficulties in exact shade matchHappy to proceed (verbal informed consent)Shade chosen with patient: Vita / GoldLA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltrationPre-op imp taken for temp crownTooth preparation completed for FGC/PBC/all-ceramicRetraction cord with astringent used.?Impressions taken with PVS in 1 stage techniqueTemp crown made – protempCemented with - temp bondSent to:???? Return date:?N/V: Crown fitCrown FitLA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltrationTemp crown removed using excavatorUltrasonic scaling to remove temp cementCrown tried in- good occlusion/ marginal fitFitting surface sandblasted and cemented using fuji plus.Excess cement cleared and flossed through contact points.?Occlusion checked. Patient happy.POIG inc OHI (extra care needed around restored teeth)XLARisks of treatment discussed: Pain, bleeding, swelling, infection, surgical procedure (gum flap/ bone removal), retained roots, damage to adjacent teethTemporary/ permanent numbness/tingling to lip/chin/tongueRoots close to sinus (OAC/ root tips displaced into sinus and need for hospital referral)?Informed verbal consent gainedLA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltrationXLA using elevation and forcep delivery (apicies intact)Haemostasis achievedUneventful Extraction/Difficult extractionPOIGChronic PeriodontitisDiscussed diagnosis of chronic periodontitis.?Aetiology: Poor OH/ Smoking/ DiabetesResult: Irreversible damage (bone and attachment loss) and drifting of teeth/ mobility?Patient understands and is motivated.Tx:?OHI (demonstrated using interdental cleaning aids)Smoking cessation adviceGross scale providedIf OH improves in 3/12 can consider RSD.RSDDiscussed diagnosis of chronic periodontitis.?Aetiology: Poor OH/ Smoking/ DiabetesResult: Irreversible damage and drifting of teeth/ mobilityDiscussed tx options: referral to specialist/ general practice- prefers to be treated in general practice initiallyRisks of RSD: Pain, bleeding, recession, sensitivityPatient understands and is motivated.Tx:OHI (demonstrated using disclosing dye, tepe brushes, floss, toothbrush)Smoking cess adviceLA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltrationRSD using ultrasonic scaler & CHXD? irrigation of pockets. POIGPeriodontal pocket charting updatedRev pocket depths 3/12Anterior compositeRisks: Difficulties achieving exact colour match, discolouration & marginal staining, chipping & fracture, sensitivityPatient happy to proceedLA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltrationCaries removed & tooth isolatedEtched with phosphoric acid, prime & bond appliedClear matrix strip usedComposite shade A3 usedFinished with sof-lex discs and polishedOcclusion checked + POIGPatient happy with fit and appearancePosterior compositeRisks: Discolouration & marginal staining of composite, chipping & fracture, post-op sensitivityPatient happy to proceedLA - LA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltrationRubber dam placedCaries removedMatrix band & wedge placedTooth etched with phosphoric acid, Prime&bond appliedSDR base with composite overlay (gradia shade x) used.Occlusion checked + POIGPatient happyAmalgamRisks: Caries very deep and may result in exposure of pulp resulting in need for RCT/ XLAPatient happy to proceedLA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltration/ 4% Articaine 1/200K Adrenaline infiltrationCaries removed & tooth isolatedDycal liner to protect pulpRestored with amalgam using matrix band/wedgeOcclusion checked + POIGPatient satisfiedDenture Primary ImpressionsTx: Used a well fitting stock tray (sprayed with tray adhesive) to take alginate impressions.Disinfected. Stored in damp tissue and sent to lab.??Lab: ??? Return date:N/V: Jaw reg & Secondary ImpsJaw registration & Secondary ImpressionsTx: Special trays (sprayed with tray adhesive) used to take alginate impressions.Jaw registration completed with wax rim and bite recorded.Centre, canine, smile lines marked on wax rim.Disinfected. Imps stored in damp tissue and sent to lab.??Shade chosen with patient:?Lab: ??? Return date:N/V: Try inTry inRetentive try in denture.Occlusion checked & adjusted as necessaryPatient happy with shade and mould of teethClasps to be placed on:?Disinfected & returned to lab.Lab: ??? Return date:N/V: FitDenture FitDenture tried in- good retention/ stable.?Occlusion checked & adjusted as necessaryShowed patient how to insert/remove. Patient happy with fit & appearance.Denture hygiene advice given.?Advised to return for denture ease if sore.Warned that denture may require reline in future if it becomes loose.Whitening1Tx options: Chair side/ Home whitening- pt chosen home whitening.?Risks: Sensitivity, relapse, restorations will not whiten & may need replacement in the future.Verbal & written consent obtained. Consent form signedPatient happy to proceed.Tx: Upper and lower alginate impressions taken for bleaching trays.Disinfected & sent to lab.Lab: ??? Return date:Whitening2Advice: Reduce tea/coffee/ smoking/ foods that cause staining during use. If teeth become sensitive use every other night/ use sensitive t.p in tray alternative nights.?Trays fit well & pt shown how to insert/remove?Instructions for home whitening given:Place drop of bleach on labial surface of each tooth compartment and wear for a minimum of 2 hours each day. Explained to dry teeth before insertion and wipe away any excess.Pt supplied with 10 syringes of 10% carbamide peroxideCurrent shade agreed with pt:Pre-op photos takenN/V: 2/52 rev whiteningVeneer PreparationRisks: Destruction of tooth tissue, difficulties in achieving exact shade match, marginal staining, 5-10yr lifespan, enter restoration cycle, wear of opposing dentition.Patient happy to proceedLA - 2.2ml 2% Lidocaine with 1/80K Adrenaline IDB/infiltrationTooth prepared minimally for veneer. Margins placed slightly subgingival.?Shade chosen with patient:?Temp placed.N/V: Veneer fit?PrescriptionsDuraphat toothpastePatient is high caries risk.Sodium Fluoride Toothpaste, 0.619% (2800 ppm)Send: 75 mlLabel: Brush teeth for 1 minute after meals using 1 cm, before spitting out, twice dailyorSodium Fluoride Toothpaste, 1.1% (5000 ppm)Send: 51 gLabel: Brush teeth for 3 minutes after meals using 2 cm, before spitting out, three times dailyMetronidazoleMetronidazole tabs 200mg t.d.s 5/7Warnings given inc No alcohol, pill efficacy, pregnancyIf swelling gets worse and threatens airway then go to A&E ASAPAugmentin (Co-amoxiclav)Swelling not resolving and patient is not allergicPx: Co-amoxiclav Tablets 250/125 t.d.s 5/7?(amoxicillin?250 mg as trihydrate, clavulanic acid?125 mg as potassium salt)Warnings: Pill efficacy +?If swelling gets worse and threatens airway then go to A&E ASAPAmoxcillinPatient is not allergicWarnings: Pill efficacy?Px: Amoxcillin capsules 250mg/500mg t.d.s 5/7ErythromycinWarnings: Pill efficacyPx: Erythromycin tabs 250mg q.d.s 5/7ChildPatient is not allergicPx: 6m-1yr: Amoxicillin oral suspension (sugar free) 62.5mg/5ml. Take 5ml t.d.s for 5/7. 100ml1-5yr: Amoxicillin oral suspension (sugar free) 125mg/5ml. Take 5ml t.d.s for 5/7. 100ml5+yr: Amoxicillin oral suspension (sugar free) 250mg/5ml. Take 5ml t.d.s for 5/7. 100mlOR6m-2yr: Erythromycin oral suspension (sugar free) 125mg/5ml. 5ml q.ds for 5/72+yr: Erythromycin oral suspension (sugar free) 250mg/5ml. 5ml q.ds for 5/7Pain KillersParacetamol tabs 500mg. Take 2 tabs q.d.s. Send 40 tabsIbuprofen tabs 400mg Take 1 tab q.d.s after food. Send: 20 tabsDiclofenac tabs 50mg Take 1 tab t.d.s. Send: 15 tabsDiflam mouthwashBenzydamine Mouthwash, 0.15%Send: 300 mlLabel: Rinse or gargle using 15 ml every1.5 hours as requiredSteroids for ulcerationHydrocortisone Oromucosal Tablets 2.5 mgSend: 20 tabletsLabel: 1 tablet dissolved next to lesion four times dailyORBetamethasone soluble tabs 500 micrograms.?Send: 100 tabletsLabel: 1 tablet dissolved in 10 ml water as a mouthwash four times dailySaliva substituteSaliva orthana oral spray t.d.s. 50mlBiotene oralbalance saliva replacement gel. Apply as required. 50g.?BioXtra Gel. Apply as required. 40g.DiazepamDiazepam tabs 5mg. Take 1 tabs night before and 1 tab 2hr preoperatively. 2 tabs.POIG (inc escort for rest of the day/ no signing important documents/ no public transport etc)EphedrineEphedrine nasal drops 0.5%. 1 drop up nostril t.d.s. 10mlMiconazoleMiconazole oromucosal gel 24mg/ml. Apply 10ml to affected area q.d.s after food. 80g (Use for 2 days after lesions has healed)ORMiconazole cream 2%. Apply b.d to angles of mouth. Use for 10 days after lesions have healed. 20g.NystatinNystatin oral suspension 100000units/ml. Rinse 1ml q.d.s after food for 7days. 30mlFluconazole50mg once daily 7/7Chlorhexidine MouthwashChlorhexidine Mouthwash, 0.2%Send: 300 mlLabel: Rinse mouth for 1 minute with 10 ml twice daily ................
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