Templates







 ••• LIMITED EXAM: PROBLEM FOCUSED: ••• Medical History reviewed verbally and using documentation. • Medical changes denied by patient. • Medical history documented per patient report. • Premedication: BP, P: CC: Radiographic Findings: Extraoral findings: Intraoral findings: • Percussion: • Palpation: • Cold Test: • EPT: • Tooth Sleuth: • Probing: Dx: Patient presents for limited exam. Findings were evaluated and discussion facilitated. Treatment options presented and 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 ••• 
 * 1) de10bb

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:

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