TEMPLATE 1 (Copy and Paste into Titanium):
Highgate Clinic / Off Waitlist Consult / DMD Recall
Presented with:
P/C:
HxP/C:
Med hx:
Dent hx:
Social hx:
OH:
Diet:
Trauma:
Habits:
EXAM: tipback/upright in chair/semi-reclined/supine. beh()
E/O:
I/O:
SOFT TISSUES –
Perio:
HARD TISSUES –
Teeth present:
Caries:
DDEs:
Anomalies:
Mobile teeth:
ORTHO: Molar relations - . OJ - . OB - . Crowding - . Crossbites - . Primate spaces - . Canines palpable / not palpable buccally. Space loss - . Midlines - .
RADIOGRAPHS:
Findings –
Caries in enamel –
Caries in outer half dentine –
Caries in inner half dentine –
Caries involving pulp –
Furcation radiolucencies / pathological root resorption -
Diagnosis:
D/W Parent:
Treatment Plan:
NV:
TEMPLATE2 (Detailed guide):
Highgate Clinic / Off Waitlist Consult / DMD Recall
Presented with: (alone, mother, father, siblings, foster mum etc)
P/C: Referred from …. (date of referral). Short line about presenting complaint, may be from referral.
HxP/C: Detailed info about presenting complaint. Include details about nature and location of complaint. If pain, where, when (nocturnal/when eating), what type (sensitivity, ache), if analgesia needed.
Med hx: Form 52 completed by parents (if Highgate). Medication conditions including natal history such as prematurity (or NAD if no issues). Medications. Allergies including reaction type (NKA – no known allergies - if none). Vaccinations (often IUTD – immunisations up to date- ). E.g. NAD NKA IUTD.
Dent hx: Details of previous checkups (including where e.g. SDS, general dentist, specialist, PCH), any tx completed and how pt coped.
Social hx: Who they live with, year at school, likes and dislikes, family structure e.g. parents separated, GMo legal guardian, under care of Department of Communities.
OH: Frequency, type of brush (ETB or manual), type of TP (looking for F- strength), supervision/assistance from parents. Any issues faced e.g. pt doesn’t like mint.
Diet: likes, dislikes, snacks, drinks.
Trauma: Dental trauma in past.
Habits: Thumb sucking, dummy etc. when ceased or if still ongoing.
EXAM: tipback/upright in chair/semi-reclined/supine. beh() (Frankl rating —, -, +, ++)
E/O: Skin, neck, facial symmetry, TMJ, lymph nodes. Lips – competent, incompetent, lower lip trap.
I/O:
SOFT TISSUES – draining sinuses, swelling, redness, ulcers. Look at buccal mucosa, palate, throat, uvula, tongue, floor of mouth gingiva.
Maxillary frenum – Kotlow Class I (mucosa), II (inserts to attached gingiva), III (inserts between teeth), IV (inserts to anterior papilla/palate).
Tongue insertion – extent of protrusion beyond lower lip – normal 16mm+, Class I (mild restriction, 12-16mm), II (moderate, 8-12mm), III (severe, 4-8mm), IV (complete 0-4mm).
Perio: mild/moderate/severe generalised/localised Plaque induced gingivitis. Pockets, recession.
HARD TISSUES – change charting to mixed dentition on odontogram.
Teeth present: Mark on odontogram as exfoliated / unerupted / partially erupted.
Caries: Use ICDAS 1-6 scoring and list surface E.g. 55O ICDAS 5, 54O ICDAS 4, 54B ICDAS 2.
DDEs: Hypomin/hypoplasia. Brown/yellow/white, well demarcated/ diffuse, surface affected, post-eruptive breakdown, sensitivity.
Anomalies: Talon cusp, hypodontia, infraocclusion, etc
Mobile teeth: grade I, II, III.
ORTHO: Molar relations – FTP/Mesial step/Distal step or Class I, II (div 1 and 2) or III. OJ - mm. OB - %. Crowding – upper/lower mild/severe etc. Crossbites – teeth affected e.g. 64/74 crossbite . Primate spaces – present or missing (mesial to canines in upper, distal to canines in lower). Canines palpable / not palpable buccally in mixed dentition stage. Space loss – describe region. Midlines – coincident / upper/lower deviated right or left ?mm.
RADIOGRAPHS: brief rationale for imaging taken. Describe radiographs e.g. 2xBWs, 1xMax Occ, 1xOPG.
Findings – Findings of radiographs. Teeth close to exfoliation.
Caries in enamel –
Caries in outer half dentine –
Caries in inner half dentine –
Caries involving pulp –
Furcation radiolucencies / pathological root resorption -
Diagnosis: Caries, hypodontia, enamel hypomineralisation tooth 36.
D/W Parent:
-
Discussion of findings.
-
Discussion of proposed treatment. If SSC, show demo crown and document this is shown to parent and pt. Confirm no nickel allergies.
-
OHI / diet advice provided.
Treatment Plan:
List planned steps. Emergency phase, prevention (OHI, prophy, fluoride, F/S), restorative (generally small before large to gauge pt compliance), extractions.
NV: e.g. Next available appt in Highgate Clinic for 54 SSC. Or 6/12 recall in Highgate clinic.
Note: Please make sure that you put a pop-up note (pink colour) at the end of the appt for the reception to book the next visit accordingly. For DMD Recall / W/L Consult patients specify in pop-up that patient to be booked in first Highgate appt slot / with DCD as necessary, and please ask your tutor to update the patient waitlist status with their next recall time e.g. 2024_05 Recall.