Dental New Patient Exam

OVERALL_INSTRUCTIONS

[Use professional and medically accurate language. Use abbreviations when possible. Be concise but make sure to include all details. Use singular third person pronouns only. Leave blank lines between major sections for readability. Italicize any special notes or disclaimers as needed. Teeth numbering follows FDI numbering. In conversation, tooth 18 is read as one-eight or eighteen. Another example = tooth 23 as two-three or twenty-three. Write teeth number without dash. eg 18, not 1-8. Acceptable acronyms to use: ETB - electric toothbrush NSF - No significant findings ir - in region of max - maxilla or maxillary mand - mandible or mandibulary ant - anterior Ag - amalgam filling Comp - composite filling NA - next appointment TMJ - temporomandibular joint TMD - temporomandibular disorder FCP - frictional chewing pattern CCP - constricted chewing pattern OD - occlusal dysfunction NG - nightguard BW or BW's - bitewing(s) PA or PA's - periapical(s) Pan - panoramic Dx - Diagnosis KD - Kois deprogrammer TE - Trial equilibration OE - Occlusal equilibration PARL - periapical radiolucency NCCL - non-carious cervical lesion PFM - porcelain fused to metal Zirc - Zirconia ]

Chief Complaint

[Insert chief complaint or reason for consultation]

Template

CC: [chief complaint, describe in detail the primary concern or symptom reported by the patient in their own words. There may be more than one chief concerns - record and number if unrelated.] [How did the patient find us? Google? Referred by an existing patient (record exact name of referrer)? Record personal details, notes about last dental visit, history.] Reviewed med/dent hx. Comp ex. Photos. [Concise medical history summary if discussed] [Concise past dental events/history summary if discussed] [Include investigations/clinical findings related to CC. Otherwise record other assessments in appropriate categories P/BM/F/DF below] Low/mod/high P – [Current oral hygiene routine including flossing, waterflossing, brushing - manual vs electric toothbrush, mouthwash, etc. Insert generalized/localized, mild/moderate/severe, horizontal/vertical defects. Describe bone level changes over the years, e.g., bone levels similar between 1998 and 2025. Note previous teeth loss from P, smoker/diabetes status, wisdom teeth, implants, staging/grading. Include CTA such as will request for older x-rays from last DMD, update anterior PAs as needed @ NA, etc. Example note would look as follows: Generalized mild horizontal bone loss w/ localized mod horizontal bone loss ir mand ant, similar between 1998 and 2025. Stage I gr B. Previous smoker for 10 years, 1 pack/d, quit in 2010. Current vaper. Implants 25 bone level stable. 27D mod vertical defect secondary to previous 28 impaction. ] Low/mod/high BM – [ -always start this section with either most recent caries for example "Last caries 14DO restored May 2023" or "No recent cavities for at least 3 years (or another number of years if specifically mentioned). -always insert details for each tooth in this order of FDI teeth numbering starting with 18, 17, 16, 15, 14, 13, 12, 11, 21, 22, 23, 24, 25, 26, 27, 28, 38, 37, 36, 35, 34, 33, 32, 31, 41, 42, 43,44, 45, 46, 47, and 48. One line for each tooth (unless teeth are splinted). Include line break after notes for each tooth. Include decal, caries, chip, abfraction, abrasion, attrition, fracture into enamel or dentin, discolouration, overhang, marginal discrepancy, cracks (class I/II/III/IV), width (eg >1/2 isthmus), structural compromise, direct-indirect resto recommendations, prognosis, etc. Only start each line with tooth numbering, do not include descriptors such as upper / lower / left / right / incisor / premolar / molar. For example, 18DB decal, previous OB comp 17MO caries w/ pulpal proximity, asymptomatic 16MO comp >1/2 isthmus - structurally compromised. M shreds floss. Crown/onlay when ready. 15-14 RCT/splinted PFM crowns w/ bulbous crown margins. 15PARL. No obvious caries noted. 13RCT/Ag core, P PARL but shows healing compared to Oct 2024 x-rays at time of RCT. 12ML discolouration, possible radiolucency on PA - watch 11ML/DL caries into dentin 21ML comp w/ marginal discrepancy, smooth as needed 22ML/DL caries into dentin 23D decal 24 previous RCT/screw post/comp build up. Pt reports done Oct 2024, fractured soon after, caries present today. Advised guarded restorative prognosis and would need to assess restorability after comp/post/caries removal. 25 RCT/screw post/PFM crown w/ fractured porcelain/iatrogenic damage, PARL 26M class I/II crack - negative to tooth slooth, structurally compromised, crown/onlay when ready. 28O stain 37-36 RCT/post/splinted PFM crowns, bulky margins, 36PARL 34D decal 46 RCT/screw post/PFM crown, bulky margins, PARL 47O stain 48O caries, erupted towards L Include any discussions about chemistry, dry mouth / hyposalivation / xerostomia, and recommendations such as pH balancing mouthwash, DIY baking soda rinse, toothpastes, xylimelts, xylitol gum/lozenges, etc] Low/mod/high F – [Insert no awareness of TMJ/muscles or if yes, describe. Must include "Dx:" of Acceptable function, FCP, CCP, OD, and/or parafunction. Include findings: TMD, Wear, Clenching/Grinding, “N” position or neutral resting position of tip of tongue on anterior palate, NGs, Airway.] DF -[Assess and document any aesthetic concerns. Omit DF if none mentioned.] NA: [List next action steps such as restorative, x-ray update or requests from other offices, etc. Omit general recommendations.]