2 - Tx Planning Clinic Preparedness

Question 1

Steps on how to treat a pt in clinic

Answer 1

1. Be prepared - know chart
2. Start check
3. Signed in
4. Prepare tooth
5. Restore tooth
6. Write clinic note
7. Evaluation
8. Signed out
9. Assist pt to pt accounts
10. Next appt

Question 2

How to write a new patient note?

Answer 2

Patient presents for NPX. Reviewed med hx with patient. (should be in your note every time. If
there are changes document, if not document that). Patient’s chief complaint- missing tooth.
FMX. Completed diagnosis. Patient has good OH, minimal plaque and calculus. Caries
charted. Missing #3. Discussed potential (do not promise them anything- will need to mount
case and develop treatment plan. If Implant is an option then have to go thru implant
committee- be upfront with patient process and time) options for replacing #3. Implant, bridge,
or leave space. Took alginate impressions. Will mount models and develop treatment plan.
NA- Present tx plan options, prophy

Question 3

How to write an operative note?

Answer 3

Option 1:
Patient presents for #19 MOC. Reviewed med hx- no changes. Injected 36 mg 2% Lido w/
.0018 mg epi. Mod deep prep. Etch, bond, composite A2. Adjusted occlusion. Reviewed with
patient tooth may be cold sensitive for a period of time. If other symptoms develop patient
instructed to call. Patient aware will be numb for 1-2 hours. NA – op #4

Option 2:
Patient presents for #14 MODLC. Reviewed medical history-no changes. Reviewed with patient
prior to appt that #14 has deep caries and may need RCT and crown. Injected 72 mg 2% Lido
w/.0036 mg epi. #14- Indirect pulp cap. Dycal, Etch, bond, composite A2. Adjusted occlusion.
Reviewed with pt indirect pulp cap. Will likely be cold sensitive but if symptons are lingering or
have throbbing to call asap. Reviewed that RCT may be necessary now or in the future. If RCT
is needed then would need a crown as well. Patient will be numb for 1-2 hours. NA- #18- MOA.

Question 4

How to write misc note?

Answer 4

Reviewed treatment plan with patient. Discussed with patient the need to extract all remaining
teeth, alveloplasty, wait 6-8 weeks for healing and then fabricate max/mand CD.
Patient does not want to extract teeth. Wants to try and keep remaining teeth.

Advised patient
that this is not possible do to bone loss, caries, and infection. Referred pt to another clinic.

Question 5

How to write a restorative consult for:
Patient has a broken #12 that extends to the gumline and is causing the patient pain

Answer 5

Patient fractured #12. Fracture extends subgingival. Patient is having mod/severe pain. Please evaluate for
restorability

Question 6

How to write a perio consult for:
Patient has a broken #12 that extends to the gumline and is causing the patient pain

Answer 6

Patient broke #12 and is having pain. Tooth has been redeemed restorable with RCT, CBU, and crown. The fracture
extends below the gumline. Please evaluate for crown lengthening

Question 7

How to write an endo consult for:
Patient has a broken #12 that extends to the gumline and is causing the patient pain

Answer 7

Please evaluate #12 for RCT. #12 is deemed restorable but may need crown lengthening. #12 is causing mod/severe
pain for the last 2 days