Adam, 30 years old, works as a occupation therapist, come today for check-up and clean. He just moved back from Tas for work and settle now in Melbourne. Brushing twice a day with soft toothbrush, flossing but not using interdental toothbrush as advise, his last visit dentist was 16 months ago. Good health condition, family history of diabetes type 1. Healthy diet with veges, drinks tap water.
Appointment Note
C/C: Check-up and clean
MHx: Nil changes, family history of diabetes type 1
DHx: Last visit 16m, family history of periodontal disease
OH: Brush 2x. Floss 1x Daily, not using interdental brush as recommended from last visit; soft manual TP, Colgate
SHx: occupational therapy, come back from Tas
Diet: vege, rice; tap water
Verbal consent from patient for check up and clean
E/O:
TMJ: RHS Click- since was kid. No pain.
I/O:
Soft tissue: slight Bilateral Linea Alba
Occlusal assessment: Class I molar on canine, overjet 6mm, overbite 30%, midline centre, 21,23, 33, 43 mesial rotate
Gingival: Pink, puffy gingiva anterior, bleeding when prop.
PSR: 444/434
Hard tissue: as charted, general stain on back molar, amelogenesis
Treatment done today: Exam, Periodontal chart, OHI
Discussion:
Pt is aware that he has quite severe periodontitis.
Deep pocket noted on 14,24,37,47 6mm, general 4 to 6mm on around.
Pt has amelogenesis general, abfraction on all buccal surfaces teeth
Advice to have buccal restoration with uni student dentist
OHI: Gently brush with soft toothbrush due to amelogenesis – weak enamel
Treatment plan:
- Debridement RHS
- Debridement LHS
- Resto NCTL maxillary
- Resto NCTL mandibular
NV: Debridement RHS
Next Appointment
Debridement RHS