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- RDH Notes:
- DDS Notes:
- Consent: Verbal consent obtained for COVID screening, vitals, med/dental hx, and Tx. Parent consented to assessments, radiographs, debridement, fluoride, and polishing. Adolescent's capacity confirmed.
- COVID: Pt neg for COVID signs/sx and exposure.
- Mouthrinse: 20ml Listerine Zero (30s); 7ml Listerine Kids Smart Mint.
- Med Hx: No changes, verbally confirmed. Form updated, no contraindications.
- Medications/Allergies: Verified.
- Vitals: BP 123/77, Pulse 79 BPM, Resp 16 RPM.
- Changes: [Specify changes]
- Premed: 4x500mg/2g Amox pre-Tx.
- Infection Control: PPE as per CDHO, hand hygiene.
- Sterilization: CI5 passed for Hygiene Kit, Cavitron, Polisher, XCP, .
- Dental Hx: No contraindications.
- Oral Care: Fair. Brushing 1x/day MTB, Flossing infrequent.
- Assessment:
- Verbal consent for EO/IO, H/T, Perio, X-rays.
- PSR: 222, 323
- PI: 121, 121
- CI: 222, 232
- Bleeding: Min
- Staining: Mild
- Cancer Screening: WNL
- Soft Tissue: Pink, rolled contour, blunt papillae, soft.
- Salivary Flow: Adequate.
- X-Rays: Last June 2023, 4 BW's prescribed, consented, images uploaded.
- Perio:
- Probing: 1-5mm, Recession: 1-2mm
- Periodontitis: Stage I Grade B
- Gingivitis: Moderate
- Tx:
- PPE for procedure. Verbal consent for FMD, fluoride, polishing, OHE.
- FMD: Cavitron/Hand scaling (43 mins), Moderate deposits, Minimal bleeding.
- Anesthesia: Oraqix for sensitivity, no issues.
- Post-op: Flossed, re - assessed tissues W.N.L
- Polish: Enamel Pro ACP fluoride, 6 mins.
- Fluoride: 5%, 4 mins, post-care: provided verbally and written.
- OHE:
- Brush 2x/day, floss 1x/day.
- Gingivitis/Perio education.
- Recommend Waterpik, Proenamel Sensodyne, Listerine Zero, salt rinse.
- OHI:
- Brushing, flossing demo w/ mirror.
- Proxabrush, super floss technique.
- Goals:
- Short-term: Brush 2x/day oscillating, floss 1x/day string,
- Long-term: Reduce bleeding 25%, plaque/calculus 25%.
- Loot Bag: Oral-B brush, Crest Sensitivity/Gum Detoxify, Oral-B floss.
- Referrals: None.
- Prescriptions: Chlorohexidine 475ml, 20ml 2x/day, 30s, no swallow, no food/drink 2-3hrs.
- Recare: 4 Months
- Personality: Friendly
- Mohamed Eldossoky RDH
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