Clinical Notes

PROVIDER NAME:

- Dr Denver Maloney

DATE OF TREATMENT

PATIENT NAME:

First

Last

PATIENT EMAIL:

TREATMENT CONSENT:

- Used images and webpage content to help describe treatment options.
- Treatment quote signed
- Discussed options and alternative treatment options
- Confirmed patient/guardian understood risks and benefits of all treatment options. of
- Attained informed consent for todays procedure

PREMEDICATION NEEDED:

- Yes
- No

PREMEDICATION TAKEN:

- Yes, witnessed patient taking medication
- Yes, patient/guardian reported taking of the medication one hour before this appointment
- No

NAME OF PREMEDICATION TAKEN:

- Anxiolytic
- Antibiotic

ANXIOLYTIC MEDICATION TAKEN:

- Valium
- Chloral Hydrate
- Other

PROPHYLACTIC ANTIOBIOTIC TAKEN:

- Amoxycillin
- Other

PATIENT WORK & DRIVING ADVICE:

Confirmed patient has been driven to the practice
Confirmed patient will be driven from the practice to home.
Confiirmed patient will not operate any machinery or tools that can cause personal injury for the rest of the day.
Confirmed patient will avoid alcohol for the remainder of the day

TREATMENT PROVIDED:

- Restoration
- Oral Surgery (not ready)
- Periodontal (not ready)

LOCAL ANAESTHETIC GIVEN:

No
Yes

Local Anaesthetic Details

LOCAL ANAESTHETIC TECHNIQUE:

MANDIBULAR BLOCK WARNING:

- There is a possibility the patient may experience restricted jaw opening for a short period of time

INJECTION SITE WARNING:

- Pain
- Bruising
- Infection

INFILTRATION LOCATION:

- Lingual or Palatal
- Buccal/Labial

LOCAL ANAESTHETIC USED:

- 2% Xylocaine (lignocaine 38.1mg/2.2m2% and adrenaline 27.5ug/2.2mL carpule).
- 3% Citanest with Octapressin (Prilocaine 43.6mg and Felypressin 0.054IU per 1.8 mL carpule)
- Septanest (Articaine Hydrochloride 88mg and Adrenaline as acid tartrate 22 ug per 2.2 mL carpule).
- Post LA instructions given not to eat or chew until the anaestheic affect has totall worn off.

LA VOLUME GIVEN

- 1 to 2 mL
- 2 to 4 mL
- 4 to 6 mL
- 6 to 8 mL

Restorative Procedure

RESTORATIVE PROCEDURE:

TEETH RESTORED:

PRE-OP TOOTH STATUS:

EXISTING FILLING STATUS:

POST-PREPARATION CARIES STATUS:

- Made Caries free
- Some affected dentine left in place
- Some demineralised enamel left at the margin due to extent of the demineralised area. Treat with remineralising agent at home.

POST-PREPARATION CAVITY STATUS:

SOME AFFECTED DENTINE LEFT IN TEETH:

SOME DEMINERALISED ENAMEL LEFT IN TEETH:

CARIES FREE TEETH:

DEEP CAVITIES:

WIDE CAVITIES WITH WEAKENED CUSPS:

DEEP CAVITIES CLOSE TO PULP:

CAVITIES WITH PULP EXPOSURE NON-BLEEDING:

CAVITIES WITH PULP EXPOSURE BLEEDING:

Restorative Materials Used:

RESTORATIVE MATERIALS USED:

- Composite resin
- GIC
- Cast or Milled

COMPOSITE USED:

- Filtek Supreme XTE

GIC USED:

- Fuji IX Extra
- Fuji 2 LC

CAST/MILLED RESTORATION:

- Porcelain
- Metallic
- Porcelain Fused to Metal

RESTORATION COLOR:

- A
- B
- C
- D

A SHADE:

Select all that apply

A SHADE FOR TEETH:

Record the tooth number and shade placed in each tooth.

B SHADE:

- B1
- B2
- B3
- B4

Select all that apply

B SHADE FOR TEETH:

Record the tooth number and shade placed in each tooth.

C SHADE:

- C1
- C2
- C3
- C4

Select all that apply

C SHADE FOR TEETH:

Record the tooth number and shade placed in each tooth.

D SHADE:

- D1
- D2
- D3
- D4

Select all that apply

D SHADE FOR TEETH:

Record the tooth number and shade placed in each tooth.

Admin To-Do

The details below provide instructions on additional activities the support staff need to do.

AFFECTED DENTINE MONITORING:

Personal assistant to add Quicktask
Set Quicktask to start in 12-months from today
Personal assistant to add the notes below into the General Alerts in the personal details of the patient file.

QUICK TASK DETAILS

March 2024, x-ray of tooth #16 check for recurrent caries on the margin M or D

DEMINERALISED ENAMEL MONITORING

Personal Assistant to ADD and set Quicktask to start in 6-months from today
Personal Assistant to add the PRAKTIKA GENERAL ALERT NOTE below into the General Alerts field of the patient file.

PRAKTIKA GENERAL ALERT NOTE:

Check demineralised enamel margin of restoration of tooth #16 in December 2024

QUICKTASK TITLE:

QUICKTASK DETAILS:

Check denineralised enamel marging of restoration of tooth #16 in December 2024

ADVICE_STRONGER FILLING MATERIAL NEEDED

Inlay/Onlay recommended and quoted
Crown recommended and quoted

STRONGER FILLING TYPE RECOMMENDED:

All creamic
Full metal
Porcelain Fused to Metal (PFM)
Consented to crown

NEXT VISIT APPOINTMENT LENGTH:

TIME NEEDED FOR NEXT VISIT:

Appointment length for the next visit in minutes or hours.

SCHEDULE NEXT VISIT ON OR AFTER:

NEXT VISIT DETAILS:

Record the reason for the next visit.

TEETH WITH CAVITIES DEEP & CLOSE TO PULP_NO EXPOSURE

TEETH WITH CAVITIES_SMALL NON-BLEEDING NEAR EXPOSURE

TEETH WITH CAVITIES_SMALL PULP EXPOSURE

TEETH WITH CAVITIES_LARGE BLEEDING PULP EXPOSURE

TEETH WITH CAVITIES_PULP DRY_NO ODOUR

TEETH WITH CAVITIES_PULP WET_HAS ODOUR

PERSONAL ASSISTANT TO DO_PULP EXPOSURE

Add General Alert to patient file
Add Quick task to commence in 5-years time.

QUICKTASK DETAILS_PULP EXPOSURE

Quicktask heading: Patient Name
Quicktask details: Take x-ray of tooth treated on todays date.
Assign Quicktask to Dr Denver

PERSONAL ASSISTANT_ADD GENERAL ALERT TO PATIENT FILE

Quicktask heading: Patient Name
Quicktask details: Take x-ray of tooth treated on todays date.
Assign Quicktask to Dr Denver

ADD BELOW GENERAL ALERT TO PATIENT FILE

Note the tooth number and year the x-ray needs to be taken.

FILLING MATERIAL USED:

Composite Resin
Fuji IX Extra A3
Fuji 2LC A3

TEETH FILLED WITH COMPOSITE RESIN:

Tooth number and surface filled.

TEETH FILLED WITH FUJI IX EXTRA:

Tooth number and surface filled.

TEETH FILLED WITH FUJI 2LC:

Tooth number and surface filled.

COMPOSITE RESIN USED:

CAVITY PREPARATION & LINING FOR COMPOSITE:

Cavity lined with Vitrebond
Isolation with cotton rolls
Fuji IX Extra used as base
Total etch for 10 seconds, washed, dried and confirmed adequate etch
Fuji 2LC used as base
Placed Clearfil Universal bond and cured

RESTORATION FINISHING:

Could not establish good contact with composite. Recommended cast or milled restoration.
Occlusion checked with articulating paper and adjusted
Adequacy of contacts checked with dental floss and confirmed no overhangs.nd Choice

RESTORATION WITH POOR CONTACT:

Tooth number and surface filled.

Other Advice Given to Patient:

DEMINERALISED ENAMEL POIG:

Advised to buy Tooth Mouse from Chemist.
Advised daily use of Tooth Mouse. Instructions given.
Six monthly application of Duraphat
Given tube of Tooth Mouse.
Reduce frequency carb and sugar ingestion.

WHAT TO EXPECT OVER THE NEXT TWO WEEKS OR MORE:

Sensitivity to cold that should progressively go away
Some tenderness on chewing that should progressively go away

RETURN FOR REVIEW::

- If sensitivity to cold that gets progressively worse over the next two weeks
- If tenderness on chewing gets progressively worse over the next few weeks
- If the filling feels to high when biting, return immediately to get the filling adjusted, at no additional fee/cost.
- If the filling feels too high when biting, return immediately to get the filling adjusted, at no additional fee/cost.

RESTORATION WITH POOR CONTACT:

Could not establish a good contact with the adjacent tooth
If food gets caught between the teeth just filled ed and the adjacent tooth, keep it clean with daily flossing
If the food geting caught causes pain or bad breath return to the practice so I can try to establish a better contact, this will be at no additional charge.
In the event a better contact cannot be established using direct filling technique, we may need to get a filling made in the laboratory and glue that in place. There will be additional fee for this procedure.

ADVICE_WEAKENED TOOTH_WIDE CAVITY:

Restoration is likely to fracture during function
Remaining cusps are thin and are likely to fracture during function
If this happens, need to consider stronger indirect restoraton

PULP ADVICE ABOUT DEEP CAVITY

Expect tooth sensitivity for a minimum of a few weeks
If tooth sensitivity is diminishing it is likely that the pulp will recover.
If tooth sensitivity is not improving it is likely that the pulp will die. Root canal treatment will be needed to keep the tooth, or extraction will ne required.

PULP ADVICE ABOUT EXPOSURE

Statistically it is likely the pulp will die.
The procedure done today may cause worsening sensitivity or toothache to develop.
Return to the prctice to remove the tooth or start root canal treatment to save the tooth if symptoms worsen.
Sometmes the tooth will die without any symptoms of pain or infection.
We recommend 5 yearly radiographic review of this tooth to pick up asymptomatic pulp death.

ADVICE_WEAKENED TOOTH_DEEP CAVITY:

Remaining tooth structure is weak and there is a risk of crack development and or tooth splitting
If the tooth develops a crack, it may become increasingnl sensitive to cold and occasional pain on chewing
Pain on chewing and cold sentitivity will need to be assessed
Teeth that develop these symptoms may need root canal treatment or removal to alleviate symptoms

ADVICE_TOOTH NERVE STATUS_DOUBTFUL:

Sensitivity and or pain to cold may develop
Sensitivity and or pain to heat may develop
Pain on chewing may develop
Spontaneous pain may be experienced
Toothache may develop
Return to the practice if any of these symptoms develop.

PATIENT DISMISSED

Care call needed.
Satisfied with outcome
Understoon post operative advice

Personal Assistant to Set Care Call Quicktask

See details for the quick task below.

CARECALL QUICKTASK DETAILS

For next business day
Ask patient if they are having any problems with the filling done at their last visit.
Record patient response in clinical notes
Reassign the Care Call to Dr Maloney and Katrine if the patient is not happy with the filling in any way.

Single Line Text

Local Anaesthetic Details

Restorative Procedure

Restorative Materials Used:

Admin To-Do

Other Advice Given to Patient:

Personal Assistant to Set Care Call Quicktask

About Riverina Dental