Dental Consultation Summary and Care Plan

Patient Summary

Patient Name: Robert Miller Date of Birth: 14/05/1958 Clinician: Dr. Elena Rostova, DDS (with Sarah Jenkins, OTR/L)

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Dear Robert Miller,

We are giving you a summary of your recent dental appointment so that you can understand your oral health and the care you received more easily. It covers the examination, findings, treatments carried out, and recommendations for ongoing care.

Your Dental Examination

At your appointment on 24/10/2023, we completed a comprehensive dental examination, including:

• A visual check of all your teeth, gums, tongue, and the inside of your cheeks.
• Measurements of the spaces around your gums to check for gum disease.
• A check of your bite and how your jaw moves when you open and close your mouth.
• Two bitewing X-rays to look for cavities between your back teeth.
• A review of how easily you can hold and use your toothbrush and floss, given the arthritis in your hands.

What We Found

• Mild gum inflammation (gingivitis) and plaque buildup around your lower back teeth, where it is harder for you to reach when brushing.
• A small new cavity on the chewing surface of your upper right back tooth (first molar).
• Mild wear on the flat surfaces of your front teeth from grinding your teeth at night.
• Your jaw opens smoothly without pain or clicking, and your soft tissues are healthy.

Treatments Provided

• A full professional dental cleaning to remove plaque and hardened tartar from your teeth and gumline.
• Polishing of all teeth to remove surface stains.
• A fluoride varnish treatment painted onto your teeth to strengthen the enamel and help prevent new cavities.

Our Recommendations for You

• Switch to an electric toothbrush with a wide, easy-grip handle, or slide a foam grip tube over your current toothbrush handle to make holding it easier with your arthritis.
• Use a water flosser or long-handled floss picks once a day instead of string floss to clean between your teeth more easily.
• Brush twice a day for two minutes using a high-fluoride toothpaste (sodium fluoride 5000 ppm) to protect your teeth.
• Limit sugary snacks and acidic drinks between meals to stop new cavities from forming.
• Wear a custom nightguard while sleeping to protect your front teeth from further wear.

Next Steps & Follow-Up Appointments

• Your next recommended visit: 07/11/2023 at 10:00 for your filling, and in 6 months for your next regular check-up and cleaning.
• Treatment still needed: A tooth-coloured filling on your upper right back tooth, and impressions to make a custom nightguard.
• Referrals: Occupational Therapy follow-up with Sarah Jenkins, OTR/L to check how you are managing with your new adapted brushing and flossing tools at home.

Your Questions Answered

• How can I clean my back teeth better when my hands are stiff in the morning? We showed you how to attach a foam grip to your brush and suggested doing your main flossing and thorough brushing in the afternoon or evening when your hand joints feel less stiff.
• Will getting the filling hurt? The cavity is small. We will numb the area completely with local anaesthetic so you will not feel any pain during the procedure.

Contact Us

"If you have questions or concerns about your treatment, please contact us. We are here to help you understand your dental care and feel comfortable with it.

Thank you for allowing us to care for your smile. We look forward to seeing you at your next appointment."

Sincerely, Dr. Elena Rostova, DDS (with Sarah Jenkins, OTR/L)

"This summary is intended for your personal records and does not replace professional medical or dental advice. If you develop unusual pain, swelling, or discomfort after treatment, contact the clinic immediately."