Dental Recall 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. 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. Keep to 1-2 sentences without losing details. There may be more than one chief concerns.] SOFT TISSUE - [Insert findings. "NSF" if no findings. Examples of findings to include: lip/cheek biting, bilateral linea alba, tongue scalloping, denture stomatitis, etc, followed by ", otherwise NSF".] RADIOGRAPHS - [No need to write whether new x-rays taken today or x-rays interpretation here. X-ray interpretation will be included in the P/BM sections below. Insert any instructions given on when to update BW/PA/pan next only if discussed eg update horizontal BWs in 6 months (write month and year given today's date).] Low/mod/high P – [ Never write just "NSF", leave blank after low/mod/high P if no relevant details discussed. 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. 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. Include findings only if discussed.] 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. Include line break after notes for each tooth. Include decal, caries, chip, 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 Abfractions/NCCL - 16/15/24/25/26/36/35/45/46, restoring if sensitive or plaque trap, asymptomatic. 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 yes/no awareness of TMJ/muscles. Include "Dx:" 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: [leave blank.]