clinical notes Flashcards
exo
Operative Notes
Time-Out Procedure: Verified patient, correct site, and procedure.
Local Anesthetic Administered:
[Insert type, e.g., Lignospan 2% with adrenaline 1:80,000].
Amount: [Insert total amount used].
Technique: [e.g., Inferior Alveolar Nerve (IAN) block and Long Buccal infiltration].
Extraction Technique:
Used appropriate pediatric forceps for lower primary molar.
Buccolingual movement applied to expand the alveolar socket.
Tooth delivered intact with no complications.
Socket Management:
Examined socket for remaining root fragments or debris.
Socket gently compressed to approximate bone.
Post-Operative Notes
Haemostasis Achieved: Rolled gauze placed over socket, patient instructed to bite down firmly for 5 minutes.
Tooth Examination: Tooth #85 removed intact.
Patient Cooperation: Patient tolerated procedure well.
Post-Operative Instructions:
Avoid eating or drinking hot liquids until numbness subsides.
Avoid spitting, using straws, or vigorous rinsing for the next 24 hours.
If bleeding recurs, use sterile gauze and apply firm pressure. Contact clinic if bleeding persists.
Mild discomfort can be managed with appropriate dose of Panadol or Nurofen (as instructed).
Discharge Notes: Patient left in stable condition with guardian, provided with sterile gauze and written instructions.
Next Visit
Review healing at [insert follow-up date, typically 1-2 weeks].
Clinical Notes: Tooth #16 Indirect Pulp Cap and Bulk-fill Composite Restoration
Purpose of Each Step:
Rubber Dam Placed: Isolates the tooth to maintain a dry field and prevent contamination.
Caries Removal:
High-speed handpiece with #330 bur: To access carious lesion and remove bulk of decay.
Slow-speed handpiece with a round bur: For precise removal of caries near the pulp, reducing the risk of pulpal exposure.
Calcium Hydroxide Placement (Dycal): Protects the pulp and promotes secondary dentin formation over the thin affected dentin layer.
3M VITREBOND PLUS Liner: Provides additional protection, seals dentin tubules, and prevents microleakage.
Curing: Light-cured for 20 seconds to harden the liner for a stable base.
Selective Etch (37% Phosphoric Acid): Applied to enamel only, preserving dentin integrity. Rinsed and dried to prepare the surface for bonding.
3M Primer & Bond: Enhances adhesion of the composite to the tooth structure.
A2 Bulk-fill Composite Placement: Restores the tooth structure with durable, aesthetic material.
Contouring and Polishing: Achieves anatomical form and smooth surface for aesthetics and function.
Occlusion Checked: Ensures no high points and maintains proper bite alignment.
Outcome: Procedure completed successfully with no complications. Patient tolerated the procedure well.
Clinician Name and Signature:
[Insert your name and credentials]
Let me know if you need any revisions!
Clinical Notes: Tooth #26 Direct Pulp Cap and Composite Restoration
Purpose of Each Step:
Caries Removal:
High-speed handpiece used to access and remove caries.
Confirmed pulp exposure during caries removal, necessitating direct pulp capping.
Hemostasis: Achieved using sterile saline and cotton pellets to control bleeding and create a clean environment for pulp capping.
Direct Pulp Cap Placement: Mineral Trioxide Aggregate (MTA) applied directly onto the exposed pulp to protect it, promote healing, and encourage dentin bridge formation.
Protective Base Placement (RMGI): Provides a seal over the pulp cap and supports the composite restoration.
Composite Placement: Restored with Filtek Bulk Fill composite, layered and light-cured in 40-second intervals to achieve durable and aesthetic restoration.
Finishing and Polishing: Final shaping with finishing burs and polishing to restore the natural occlusal anatomy and achieve a smooth surface.
Outcome: Procedure completed successfully with no complications. Patient tolerated the procedure well.
Clinician Name and Signature:
[Insert your name and credentials]
Let me know if further adjustments are needed!
Explanation of Plaque Dye Colors for Patients
The plaque disclosing dye helps identify areas of plaque on your teeth, and each color indicates how long the plaque has been there:
Pink: This shows new plaque that has formed in the last 24 hours. It’s easier to remove with regular brushing and flossing.
Purple: This indicates mature plaque that has been on your teeth for about 48 hours or longer. It’s more stubborn and needs thorough cleaning to remove.
Blue: This reveals older plaque that has been present for 72 hours or more. It’s hardened and may start forming tartar, which requires professional cleaning to remove.
- What is your diagnosis?
- What is your proposed treatment?
- What nerve/s do you need to anaesthetise?
4
- What type of local anaesthetic and injection would you use?
- How much local anaesthetic would you give?
- Where are the site/s of injection?
Scenario 2
Diagnosis: Advanced caries with periapical infection or resorption associated with tooth 85.
Proposed Treatment: Extraction of tooth 85.
Nerve/s to Anaesthetise: Inferior alveolar nerve, lingual nerve, and long buccal nerve.
Type of Local Anaesthetic and Injection: Lidocaine 2% with 1:100,000 adrenaline; inferior alveolar nerve block and long buccal infiltration.
Amount of Local Anaesthetic: Approximately 1.8 ml for the block and 0.2 ml for the buccal infiltration.
Site/s of Injection: Inferior alveolar nerve injection in the pterygomandibular space and buccal infiltration near 85.
- What is your diagnosis?
- What is your proposed treatment?
- What nerve/s do you need to anaesthetise?
4
- What type of local anaesthetic and injection would you use?
- How much local anaesthetic would you give?
- Where are the site/s of injection?
Scenario 3
Diagnosis: Caries with pulpal involvement in tooth 54 and potential early resorption of tooth 55.
Proposed Treatment: Extraction of tooth 54 and monitoring of tooth 55.
Nerve/s to Anaesthetise: Posterior superior alveolar nerve.
Type of Local Anaesthetic and Injection: Lidocaine 2% with 1:100,000 adrenaline; buccal infiltration for tooth 54.
Amount of Local Anaesthetic: Approximately 1.5 ml.
Site/s of Injection: Buccal sulcus adjacent to 54.
What is your diagnosis?
- What is your proposed treatment?
- What nerve/s do you need to anaesthetise?
4
- What type of local anaesthetic and injection would you use?
- How much local anaesthetic would you give?
- Where are the site/s of injection?
Scenario 4
Diagnosis: Extensive caries with likely pulpal pathology in teeth 74 and 75.
Proposed Treatment: Extraction of teeth 74 and 75.
Nerve/s to Anaesthetise: Inferior alveolar nerve, lingual nerve, and long buccal nerve.
Type of Local Anaesthetic and Injection: Lidocaine 2% with 1:100,000 adrenaline; inferior alveolar nerve block and long buccal infiltration.
Amount of Local Anaesthetic: Approximately 1.8 ml for the block and 0.2 ml for the buccal infiltration.
Site/s of Injection: Inferior alveolar nerve injection and buccal infiltration near 74 and 75.
What is your diagnosis?
- What is your proposed treatment?
- What nerve/s do you need to anaesthetise?
4
- What type of local anaesthetic and injection would you use?
- How much local anaesthetic would you give?
- Where are the site/s of injection?
Scenario 5
Diagnosis: Over-retained deciduous teeth (51 and 61) causing delayed eruption of permanent incisors.
Proposed Treatment: Extraction of teeth 51 and 61.
Nerve/s to Anaesthetise: Nasopalatine nerve and anterior superior alveolar nerve.
Type of Local Anaesthetic and Injection: Lidocaine 2% with 1:100,000 adrenaline; infiltrations for buccal and palatal sides.
Amount of Local Anaesthetic: Approximately 1.5 ml total.
Site/s of Injection: Buccal sulcus adjacent to 51 and 61, and palatal tissue near the midline.
- What is your diagnosis?
- What is your proposed treatment?
- What nerve/s do you need to anaesthetise?
- What type of local anaesthetic and injection would you use?
- How much local anaesthetic would you give?
12
6. Where are the site/s of injection?
Scenario 6
Diagnosis: Over-retained and mobile primary teeth (71 and 81).
Proposed Treatment: Extraction of teeth 71 and 81.
Nerve/s to Anaesthetise: Inferior alveolar nerve and lingual nerve (if needed for soft tissue anesthesia).
Type of Local Anaesthetic and Injection: Lidocaine 2% with 1:100,000 adrenaline; infiltration around the lower anterior region.
Amount of Local Anaesthetic: Approximately 1.0–1.5 ml.
Site/s of Injection: Labial sulcus near 71 and 81.
BOH2 SAMPLE EXAMINATION QUESTIONS
Meet Jim, a 45-year-old new patient seeking dental care at your practice. He specifically requests a clean only and mentions in passing that he is experiencing pain on the lower right-hand side, pointing to tooth 46. His primary concern, however, is the staining on his teeth. Jim’s medical history includes smoking, diabetes, and asthma. In the past, he had an implant placed to replace tooth 11, and three years ago, he had a clean to remove the ‘black spots’. Additionally, Jim feels Gatorade best alleviates his dry mouth and reports that he enjoys red wine with his meals.
Discussion questions:
Q1. Identify the necessary additional information required from Jim during today’s visit to complete his history, enabling the safe and effective development of a treatment plan.
“SMARTS DENTAL”:
S - Smoking History:
Confirm the frequency and duration of smoking habits to assess oral health risks.
M - Medications:
Ask about medications for diabetes, asthma, or any other conditions to identify potential side effects on oral health, such as dry mouth or bleeding risk.
A - Allergies:
Check for any drug allergies or reactions, especially if local anesthetics or antibiotics may be needed.
R - Recent changes:
Inquire about recent changes in health, including control of diabetes and asthma, and any recent hospitalizations.
T - Trauma or sensitivity:
Explore the history and characteristics of pain in tooth 46 (e.g., duration, triggers, type of pain).
S - Staining concerns:
Discuss the patient’s main aesthetic concern to align expectations for cleaning or whitening.
D - Diet:
Evaluate frequency of Gatorade and red wine consumption to assess the risk of caries and erosion.
E - Exercise and lifestyle:
Ask about lifestyle habits, including stress and physical activity, to gauge overall health impact on oral care.
N - Neurological symptoms:
Clarify if any tingling, numbness, or jaw pain is present, especially around the implant or affected areas.
T - Thirst and hydration:
Investigate dry mouth complaints and potential xerostomia causes beyond Gatorade consumption.
A - Appointments:
Confirm the frequency of past dental visits and any prior treatment outcomes or dissatisfaction.
L - Lung health:
Ask about asthma triggers and management to prevent exacerbation during the dental visit.
Q2. Explore strategies for managing a situation where the patient insists on a ‘clean only,’ but you suspect other dental issues may be present.
1.
Q3. Determine any tests or additional clinical records needed to aid in establishing a diagnosis and treatment plan.
Q4. Analyse the risk factors associated with Jim’s case.
Smoking: Raises Jim’s risk for gum disease and oral cancer. Smoking also contributes to dry mouth and staining.
Medical History: Diabetes complicates wound healing and increases susceptibility to infections, including periodontal disease.
Oral Hygiene: Brushing only once daily is insufficient, likely leading to plaque buildup and exacerbating staining and caries.
Dietary Habits: Gatorade (acidic and sugary) and red wine contribute to enamel erosion, caries, and further staining.
Implant: Requires monitoring for peri-implantitis, especially given Jim’s systemic risks and oral hygiene practices.
Focus on Staining: While aesthetic concerns are valid, they might overshadow critical issues like pain and periodontal health.
Devise appropriate oral health advice for Jim and outline a staged approach for delivering this information.
A fourteen year old patient requires an MO restoration on the 46.
What structures need to be anaesthetized?
The branch of which nerve/s needs to be anesthetized?
What technique do you need to perform to achieve this? Describe the technique.
During the injection the clients face starts to droop ipsilateral to the side of injection. What has happened? How could it have been prevented? How would you manage this?
A fourteen year old patient requires an MO restoration on the 46.
What structures need to be anaesthetized?
The branch of which nerve/s needs to be anesthetized?
What technique do you need to perform to achieve this? Describe the technique.
During the injection the clients face starts to droop ipsilateral to the side of injection. What has happened? How could it have been prevented? How would you manage this?
Scenario 1:
A six year old patient requires extraction of the 82.
What structures need to be anaesthetized?
The branch of which nerve/s needs to be anesthetized?
What technique do you need to perform to achieve this? Describe the technique.
Scenario 1:
A six year old patient requires extraction of the 82.
What structures need to be anaesthetized?
Pulp and soft tissue
The branch of which nerve/s needs to be anesthetized?
Incisive nerve
What technique do you need to perform to achieve this? Describe the technique.
Infiltrations (See separate technique handout)
The morning after the appointment the patient phones reporting pain when they open their mouth and is having difficult chewing. What are the likely causes of this pain? How would you manage this?
During the injection, the patient complains of a very sharp transient electric shock like pain. They don’t have this pain during the appointment, or after treatment. 3 days later they present to you, and their primary complaint is that they still can’t feel their tongue. What may have resulted in this? How would you manage this client?
