Dental Medical Report

Dental Medical Report

Patient Information

Patient Name:

[Your Name]

Patient ID:

123456789

Date of Birth:

January 1, 2050

Gender:

Female

Contact Information:

123-456-7890

  • Date of Examination: 10/01/2055

  • Referring Dentist/Physician: Dr. Jane Doe, Springfield Dental Clinic, (555) 987-6543

  • Reason for Visit: The patient reports sensitivity to cold and mild pain in the lower right molar (tooth #30).

Medical History

  1. Allergies:

    • Medications: Amoxicillin (rash)

    • Food Allergies: None

    • Environmental Allergies: Seasonal pollen

  2. Medical Conditions:

    • Hypertension (controlled)

    • No history of bleeding disorders or other systemic conditions.

  3. Medications:

    • Lisinopril 10 mg, once daily

    • Aspirin 81 mg, once daily

  4. Previous Dental History:

    • Orthodontic treatment at age 14.

    • The last dental visit was 06/15/2055, where a filling was placed in tooth #14.

Examination Findings

  1. General Health Status:
    Patient appears in good health, with no signs of distress or anxiety. Blood pressure reading was 120/80 mmHg.

  2. Oral Examination:

    • Soft Tissues:

      • Gingiva is pink and firm with no signs of inflammation or recession noted. No lesions present on the tongue or buccal mucosa.

    • Hard Tissues:

      • Teeth are generally caries-free except for a small cavity in tooth #30, which exhibits demineralization.

    • Periodontal Health:

      • Probing depths range from 1-3 mm with no bleeding on probing; no signs of periodontitis.

    • Occlusion:

      • Class I occlusion with a slight overjet; no crossbites or open bites present.

Diagnostic Imaging

  1. X-Rays Taken:

    • Bitewing X-rays and a panoramic X-ray were taken.

  2. Findings:

    • No caries detected on bitewing radiographs. Bone levels are within normal limits.

    • Panoramic X-ray shows an impacted tooth (#18) with surrounding periapical radiolucency indicative of possible infection.

Treatment Plan

  1. Proposed Treatments:

    • Composite filling for tooth #30 (cavity treatment).

    • Extraction of tooth #18 due to impaction and potential infection.

    • Referral to an oral surgeon for the extraction.

  2. Patient Education:

    • Instructed on proper brushing techniques (2 minutes, twice daily) and the importance of daily flossing.

    • Discussed dietary recommendations, advising to reduce sugar intake to prevent further caries.

  3. Follow-Up Appointments:

    • Follow-up in 2 weeks for extraction of tooth #18 and evaluation of the filling on tooth #30.

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