General Dental Assessment Template

Medical History

Medical history reviewed and updated.

Presenting

Lachlan Mitchell arrived for a comprehensive examination

Attended alone; referred by his physiotherapist for concurrent TMJ and bruxism co-management.

WKY

Works full-time as a high school physical education teacher. Enjoys surfing and running. Married with two young children. Born in Perth, Australia.

Relevant Medical History

Asthma (managed with salbutamol 100 mcg INH PRN), seasonal allergic rhinitis. NKDA.

Main Concern

Routine check-up and clean; also notes bilateral morning jaw tightness and mild cold sensitivity on the lower right side.

Dental and Social History

Brushing

2x daily with fluoridated toothpaste (Sensodyne®) using a medium manual toothbrush.

Interdental Cleaning

Flossettes 2–3x weekly.

Diet

Occasional afternoon snacking on muesli bars and fruit. 2x flat whites daily, 1x sports drink post-exercise 3x/week.

Water

Good

Sleep Quality

Fair, 6.5 hours per night; reports bilateral masseter tenderness on waking.

Last Dental Visit

15/02/2024 for a routine scale and clean.

Trauma History

Nil history of dental or maxillofacial trauma.

Smoking Status

Non-smoker, never smoked.

Extra-Oral Examination

Mild bilateral masseter hypertrophy and tenderness to palpation. TMJ mild clicking on R side during opening, no locking or deviation, normal ROM. Lymph nodes NAD.

Intra-Oral Examination

Soft Tissue

Bilateral buccal linea alba present; otherwise NAD.

Oral Cancer Screening

NAD

Dentition and Caries Charting

Missing: 18, 28, 38, 48. 16: OL composite restoration intact. 26: MO composite restoration intact. 36: O amalgam restoration with ditching. 46: DO recurrent caries with defective composite margin; TTP -, cold + (transient). 47: MO incipient caries. Mobility: Nil pathological mobility.

PSR

212, 222

Plaque

Calculus

++ (predominantly lingual of lower anteriors)

Nctl

Mild attrition on 13, 12, 11, 21, 22, 23, 33, 32, 31, 41, 42, 43 incisal edges. Mild cervical abrasion on 14, 24.

Occlusion

Class I

Overbite

30%

Overjet

2 mm

Crowding

Mild lower anterior crowding.

Other

Small mandibular tori bilaterally.

Imaging

Full series intraoral photographs obtained.

iTero scan obtained for occlusal wear analysis and records.

Diagnocam imaging obtained for posterior quadrants.

Radiographic Findings

Bitewings (L and R) and PA of 46 obtained.

Bitewings: 46 DO radiolucency extending into middle third of dentine beneath existing restoration. 47 M radiolucency confined to outer half of enamel. Crest bone levels within normal limits (< 15% bone loss). PA 46: Periapical tissues NAD, PDL space normal, deep DO caries noted clear of pulp horn.

Problem List / Diagnoses

1. Chronic generalised gingivitis with localised calculus deposits.
2. 46 DO secondary caries (reversible pulpitis).
3. 47 M incipient enamel caries.
4. Nocturnal bruxism with mild attrition, cervical abrasion, and myofascial pain.

Discussion and Treatment Options

1. Discussed oral hygiene findings; patient opted for full mouth scale, prophy, and fluoride application today, plus switching to a soft-bristled electric toothbrush and daily interdental cleaning.
2. Discussed 46 DO caries and risks of deep decay (potential future endodontic need if symptomatic); patient opted for replacement DO composite restoration at next visit.
3. Discussed 47 M early lesion; patient opted for conservative remineralisation protocol using topical fluoride and daily interdental flossing, to be monitored at recall.
4. Discussed nocturnal bruxism and physiotherapy co-management; patient opted to proceed with an occlusal splint (nightguard) following completion of 46 restoration.

The patient opted to proceed with the plan below.

Treatment Plan

1. Today: Comprehensive examination, radiographs, intraoral scan, full mouth scale, prophy, and topical fluoride varnish.
2. 2 weeks: 46 DO adhesive composite restoration and upper/lower digital scan for occlusal splint construction.
3. 4 weeks: Occlusal splint issue and adjustment.
4. 6/12 with OHT

Post-Operative Instructions

NV

45-minute appointment with Dentist in 2 weeks for 46 DO restoration and occlusal splint scan.

RTR

Returning in 2 weeks to replace the leaky filling and fix the decay on your lower right molar (tooth 46), and to take a scan for your nightguard to protect your teeth from grinding.

Lachlan well on discharge

• Sari

Additional Information

• Provided written quote for item numbers 532 (46 DO) and 965 (Occlusal splint).
• Advised patient to avoid eating or drinking for 30 minutes post-fluoride application.