Routine Check-Up & Cleaning

Clinician: Dr. Marcus Vance, DDS

Date: 24/10/2023

Reason for Visit

6-month routine recall and prophylaxis. Pt reports occasional mild cold sensitivity in the LR quadrant.

Medical History Update

Diagnosed with HTN 3 months ago; commenced lisinopril 10 mg PO OD. NKDA. BP today: 128/82 mmHg.

Dental History Update

Nil dental tx since last recall 6 months ago.

Oral Hygiene Habits

Brushes BID with manual toothbrush and fluoridated toothpaste. Flosses 1-2x/week. Uses alcohol-free mouthwash sporadically. Advised switching to an electric toothbrush and daily interdental cleaning.

Extraoral Examination (E/O):

Facial symmetry WNL. TMJ asymptomatic, no clicking, crepitus, or trismus. Submandibular and cervical lymph nodes non-palpable and non-tender. Lips competent.

Intraoral Examination (I/O):

Mucosa moist and pink. Fair oral hygiene with localised gingival inflammation.

• Soft Tissues: Buccal mucosa, tongue, hard/soft palate, floor of mouth, and vestibule WNL. No ulcerations or suspicious lesions.
• Gingiva: Pink, firm anteriorly; localised marginal erythema and mild oedema in posterior sextants.
• Hard Tissue: Existing composite restorations on #14, #19, and #30 intact. Incipient buccal cervical lesion noted on #31. Mild incisal attrition on lower anterior teeth.
• Occlusion: Class I molar and canine relationship. Overjet 2 mm, overbite 20%. Mild lower anterior crowding.

Periodontal Assessment

• Plaque and Calculus Levels: Light generalised supragingival plaque. Moderate supragingival and subgingival calculus on lingual surfaces of mandibular anteriors and buccal surfaces of maxillary molars.
• Bleeding on Probing (BOP): Localised BOP in posterior interproximal sites (approx. 15% of sites).
• Pocket Depths: Generalised 1-3 mm; localised 4 mm pockets on mesial/distal of #3, #14, #19, and #30.
• Gingival Recession: 1 mm facial recession on #30 and #31 (accounting for cold sensitivity).
• Periodontal Status: Localised plaque-induced gingivitis.

Radiographic Examination

2x horizontal bitewings (left and right) taken. Alveolar bone levels WNL (< 15% horizontal bone loss). No interproximal caries or periapical pathology detected. Overhangs nil.

Scaling and Cleaning

• Plaque and Calculus Removal: Full-mouth debridement completed using ultrasonic scaler (Cavitron) and hand scalers (Universal and Gracey curettes) across all quadrants.
• Stain Removal/Polishing: Prophylaxis completed using rubber cup and fine grit fluoridated prophylaxis paste. Interproximal flossing performed.
• Fluoride Treatment: 5% sodium fluoride varnish (22,600 ppm) applied to all teeth with emphasis on cervical margins of #30 and #31.
• Oral Hygiene Instructions Given: Demonstrated modified Bass brushing technique and C-shape flossing. Recommended potassium nitrate 5% (Sensodyne®) toothpaste BID for LR sensitivity.

Findings & Diagnoses

• Localised plaque-induced gingivitis.
• Dentinal hypersensitivity #30, #31 secondary to mild gingival recession.
• Incipient arrested buccal caries #31 (watch).

Treatment Recommendations & Plan

• Monitor incipient lesion on #31; remineralisation protocol initiated with fluoride varnish and OHI.
• Use desensitising toothpaste daily; review sensitivity at next recall.

Referral

None required.

Patient Education & Preventative Advice

Instructed on post-fluoride varnish care (soft diet, avoid hot drinks and brushing for 4 hours). Discussed reduction of acidic beverages to prevent further cervical wear.

Next Recall Appointment

6 months for routine examination and prophylaxis.

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