Templates

••• RESTORATIVE # Dx •••

MDHx: Reviewed verbally and using documentation. • Medical changes denied. • Medical history documented per patient report. • Premedication: BP: P: CC: Treatment: Patient presents for appointment and restorative addressed for # Topical benzocaine placed. Profound anesthesia achieved subsequent to local anesthetic administration. • 34mg lidocaine, 0.018mg epinephrine (IAN block/infiltration) • 68mg articaine, 0.018mg epinephrine (infiltration only) • 8.5mg bupivacaine, 0.009mg epinephrine (IAN block/infiltration) • 54mg mepivicaine (IAN block/infiltration) • No anesthesia administered; patient did well. Caries excavation completed and preparation defined; contoured considering a retentive design. Band/mylar/wedge/cord (removed by end of appointment). Isolation achieved. • 37% H3PO4 acid etch 15s, rinse 15s (not used for amalgams). Desensitizer applied 30s, airthinned. Prime/bond applied and airthinned, cured 10s. • Composite: packable/flowable: Light cured 20s/2mm increment. Shade: • RMGI: (EquiForte): Trituration and placed, light cured 40s upon 2mm placement and setting allowed. Shade: • Amalgam: Trituration and placed. Carving, contouring, and smoothing. Finishing and smoothing. Flash removed, margins checked. • Occlusion checked. • Interproximal contact region checked. • Patient satisfied with bite, feel, and result. NV:

 ••• EXTRACTION: NONSURGICAL# ••• 

MDHx: reviewed verbally and using documentation.

Covid screening.

Vitals:

Tx: Patient presents for extraction.

Both verbal and written consent obtained after all RBCAs explained to and understood by patient. Dentition # addressed.

Topical benzocaine placed. Profound anesthesia achieved with local anesthetic administration.

• 34mg lidocaine, 0.018mg epinephrine IAN block.

• 34mg lidocaine, 0.018mg epinephrine infiltration.

• 68mg articaine, 0.018mg epinephrine infiltration.

• 8.5mg bupivacaine, 0.009mg epinephrine

• 54mg mepivicaine

Gradual luxation with elevator instruments. Luxation with forceps gently.

• Conservative closed envelope, full thickness flap from # to #.

Tooth movement obtained and # removed with any and all apical root portions accounted for. Site debris thoroughly instrumented with currette carefully avoiding any anatomical areas of concern. Cleansing with sterile saline irrigant.

• Suture placed with 3-0 chromic gut suture.

Hemostasis achieved, fibrin clot noted. Gauze to bite. No complications encountered. POI given both verbally and written. Patient released in stable condition.

NV:

 ••• PERIODIC EXAM, Imaging: ••• 

 ••• COMPREHENSIVE EXAM, Imaging: ••• 

MDHx: reviewed verbally and using documentation.

Covid screening.

Vitals:

Extraoral Findings:

Intraoral Findings:

Radiographic Findings:

Periodontal:

Treatment Indications:

• Patient presents for periodic exam.

• Patient presents for comprehensive exam.

Subsequent to exam, findings evaluated and discussion facilitated. All patient questions and concerns entertained and treatment plan agreed upon.

• Rx:

NV:

 ••• LIMITED EXAM: PROBLEM FOCUSED •••

MDHx: reviewed verbally and using documentation.

Covid screening.

Vitals:

CC:

Radiographic Findings:

Extraoral findings:

Intraoral findings:

Radiographic Findings:

• Percussion:

• Palpation:

• Cold Test:

• EPT:

• Tooth Slooth:

• Probing:

Patient presents for limited exam. Subsequent to exam, findings evaluated and discussion facilitated. Treatment options presented. All patient questions and concerns entertained and treatment option or no treatment agreed upon.

• Rx:

NV:

 ••• DRY SOCKET TREATMENT (Dx: Dry socket) •••

Tx: Patient agreed to dry socket treatment.

Topical benzocaine placed. Profound anesthesia achieved with local anesthetic administration.

• 34mg lidocaine, 0.018mg epinephrine IAN block.

• 34mg lidocaine, 0.018mg epinephrine infiltration.

• 68mg articaine, 0.018mg epinephrine infiltration.

• 8.5mg bupivacaine, 0.009mg epinephrine

• 54mg mepivicaine

Thoroughly curetted socket removing debris and foul matter. Thorough cleansing with sterile saline irrigant. Dry socket paste placed.

• Gel foam utilized.

• Suture utilized to hold components (3-0 chromic gut suture)

• Rx:

NV:

 ••• FINAL IMPRESSIONS ••• 

MDHx: reviewed verbally and using documentation.

Covid screening.

Vitals:

Tx: Patient presents for final impressions.

• Blue Bite boarder molding. PVS medium body peripherals and light body center.

• Retention and anatomical capture of ridges was very good. PVS impressions stable and hard to remove upon checking.

• Rest seats placed. No anesthesia needed. Alginate impressions taken. Anatomical capture very good. Bite registration taken in MIP.

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NV:

 ••• JAW RELATION ••• 

MDHx: reviewed verbally and using documentation.

Covid screening.

Vitals:

Tx: Patient presents for jaw relation. The VDO and anterior/posterior relationships correctly adjusted for a good natural look and feel for the patient.

Midline and Alar extents marked.

Bite registration taken in CR.

Patient agreed on tooth shade and mold.

Shade:

Mold:

NV:

 ••• TRY-IN •••  MDHx: reviewed verbally and using documentation.

Covid screening.

Vitals:

Tx: Patient presents for removable try-in. Seated final wax up. Fixodent utilized as indicated. Patient observed look with mirror and got a feel for the bite and phonetics. Occlusion checked for appropriate approximation. Tooth mold and shade reviewed.

• Notes:

Patient approved of final tooth selection and results and have confirmed readiness for finalization of this prosthesis.

NV:

 ••• INSERTION ••• 

MDHx: reviewed verbally and using documentation.

Covid screening.

Vitals:

Tx: Patient presents for insertion. Seated removable prosthetic.

Stability, retention, and flanges observed and evaluated. Bite paper and PIP utilized where indicated. Adjustments performed accordingly for a comfortable fit and bite.

• Notes:

Patient satisfied with bite, feel, and esthetic result. Patient informed that PRN adjustments are common within a week as they are noticed and to return as needed for any final adjustments. POI given along with care package.

NV: