Dental Medical Report

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Patient Information

Patient Name:	[Your Name]
Patient ID:	123456789
Date of Birth:	January 1, 2050
Gender:	Female
Contact Information:	123-456-7890

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• 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).

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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.

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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.

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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.

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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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