SOAP Notes

What Procedure(s) was/were Done?
Note: Procedure code(s) and description (i.e. D0150 Initial Exam)
Note: all faculty you worked with, including any specialists and consultants
Note: that the sterilization strips were checked

Exams / Perio

Periodic Oral Exam
Screening
Periodontal Maintenance
Failed Appointment

*If a procedure isn’t listed above, please check axiUm templates

S: Subjective

ID: patient age, sex, race
CC: chief concern (quote patient)
HCC: history of chief concern
MH: medical history (significant findings and precautions, most current lab values, as needed, and patient meds, etc.
Allergies: to medications, latex, etc. (if none, note NKDA: no known drug allergies)
DH: dental history (last dental visit, last ODTP, last cleaning, history of extractions, ortho, endo)
Last FMX: most recent full mouth radiographs / panoramic / CBCT, and update BWs / other images since the FMX was taken. If a new FMX was taken today, note it here and above under “Procedures Done”
SH: social history (marital status, children, employment situation, hobbies, etc.) tobacco/alcohol use, recreational drug use

O: Objective

PE/VS:  physical exam/vital signs (general notes on physical appearance [well-nourished, frail, etc.])
BP: blood pressure (systolic/diastolic in mm Hg; specify which arm used, i.e. RAS = Right Arm Seated)
Pulse: beats/minute (bpm), strength, and regularity
EOE:  extraoral  exam  (position,  size,  characteristics  of  abnormal  findings;  if  no  significant findings, note NSF)
IOE: intraoral exam (position, size, characteristics of abnormal findings; if no significant findings, note NSF)
TMJ:  temporomandibular  joint  findings  (deviation,  sounds,  range  of  motion,  history  of problems; if no significant findings, note NSF)
Ging:  periodontal  exam  findings  and  observations  (general  appearance  of  gingiva,  plaque control, gum recession, specific problems)
RE: radiographic exam findings (general findings, interproximal caries lesions, PA radiolucencies, bony defects, root resorption, horizontal bone level etc.) * If new radiographs are taken, note that they  have  been  interpreted,  and  note  all  significant  findings  or  note  “no  pathology  / abnormalities found”
HTE:  hard  tissue  exam  findings  (general  findings,  extensive  caries  lesions,  fractured teeth/restorations, occlusal issues, etc)
ATP: saliva assessment (saliva consistency, ATP and pH measurements)

*If no significant findings, note as NSF

A:  Assessment/Analysis

Perio Dx: periodontal diagnosis, with etiologies and prognosis
Caries Disease Dx: active, progressing, no caries
Caries  risk  assessment:  (low,  moderate,  high,  extreme)  and  prognosis  for  disease  control  / restorability of specific teeth/the dentition in general
Endo Dx: Pupal and Apical Dx for all teeth that require it

P: Plan and/or Procedure Done

DWP: discussed with patient

  • details of RBAs (risks and benefits of all alternatives) presented to the  patient,  and  decisions  made
  • recommendations,  prescriptions,  and  referrals
  • oral hygiene instruction (OHI)
  • patient comments and concerns
  • everything discussed with the patient, including the consequences of no treatment.

Tx  Plan:  summarized  final  plan  for  all  treatment,  in  sequence  in  which  it  will  be  delivered, including  CAMBRA,  Perio,  Restorative,  etc.  and/or  Procedure(s)  done:  any  treatments  / procedures completed, with details of anesthetic agents, materials, rubber dam, etc. used
NV: next visit (note date, if known, and for what; or “patient to call me” / ”I will call patient to schedule“)

D0120 – Periodic oral exam

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).:
Pt was early / on time / ___ min late to apt

S)
age/sex:
CC: wants check up and cleaning
HCC:
MH:
Meds:
Allergies:
DH:   lightly/moderately/highly restored,  UoP pt. for _____ years
Last FMX:
SH:  non-smoker, lives in city with _______

O)
BP, pulse: / mmHg, bpm RAS
EOE:
IOE:
TMJ:  nsf / slight/moderate/extreme popping/clicking on right/left side; painful/non-painful; pt aware/unaware
Ging: nsf / healthy pink /erythematous inflamed
RE: nsf / radiolucencies on teeth & surface(s):
Overhanging margins:
Inadequate contour:
Open Margin:
PA Radiolucencies:
HTE:

Recurrent caries on teeth/surface(s):
Caries on teeth:
Defective restorations:

A)
The following teeth need restorations:
Perio Dx: generalized mild/moderate/severe chronic periodontitis, with localized
mild/moderate/severe on teeth _______ (stabilized/active)
Perio Dx: Stage I/II/III/IV Grade A/B/C/D Periodontitis
Caries Disease Dx:

P)
DWP:  Pt’s goals and expectations, which were:
Q&A of pt desires, which revealed:
DWP: Pt oral health status, including perio disease diagnosis (including what perio disease means to them), Caries risk status, HT diagnosis. Pt understood.
OHI, RBAs of utilizing CAMBRA products and caries progression and risk due to bacterial overload, hygiene habits etc. Pt Understood.
RBAs of proposed treatment plans.  Discussed: Cost, tx time, number of appointments, benefits, limitations of all possible treatments (including no treatment).   Pt understood.
DWP what will happen if no treatment is pursued including the possible worst consequence, which for this patient would be ____________________________.  Pt understood.

Tx Plan:

NV:

D0190 Screening

Sterile strips checked, all instruments sterile. Operatory disinfected  (double wipe 10 minutes prior to operation).
Worked with Dr(s).

S)     
CC:
Med Hx: 
Meds: 
Allergies: 

O/A)      
Vitals:       mmHg RAS,       bpm ; 
DH: 
Last time at Dentist, why so long?:
Last FMX:
​Radiographs needed: FMX / Pano + BWX

P)    
DWP:
Our clinic takes up to 4X longer and 4X more appointments to get treatment.
Pt. understands that he/she will be treated by students chosen at random.
Pt. agrees to get FMX. 2 appointment failure policy. Fee for service.

Pt Needs:
Endo ; 
Operative ; 
Fixed (advanced / minimal) ; 
Perio (advanced / minimal) ; 
Oral Surgery ; 
Removable ; 
Additional Needs/Comments:

NV:

​D4910 – Periodontal Maintenance (SPT)

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).

​S)  
CC:  
Med Hx changes:

O&A)  
Stain:     generalized / localized   none / light / moderate / heavy 
Plaque:     generalized / localized   none / light / moderate / heavy 
Supragingival Calculus:     generalized / localized   none / light / moderate / heavy 
Subgingival Calculus:   generalized / localized    none / light / moderate / heavy 

P) 
Anesthesia:   
Topical 20% benzocaine for 1 minute at penetration site(s).  
2% Lido with 1:100k epi No. Carpules 1, 2, 3, 4, 5, 6 
PSA  Right / Left     
IA  Right / Left   
LB  Right / Left   
GG  Right / Left   
GP  Right / Left   
Infiltration  Tooth #____  
Pt was determined to be numb. 

​SPT (PMT) completed / in progress 
Bleeding: light / moderate / heavy
Apprehensive patient?   Y / N
Difficult access?  Y / N

NV:

D0180P – Initial Treatment Evaluation (ITE)/ Re-Evaluation

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).

​S)  
CC:  
Med Hx changes:

O)  
BP, Pulse:   mmHg,   bpm RAS
Ging: describe gingival color, contour and consistency
Re-Evaluation Date Due:
Re-Evaluation Date Performed:

A)
Bleeding: Yes / No; <10% sites / 10-30% sites / >30% sites
PD Changes: Increased / Decreased / No Changes; Sites:
Attachment Level Changes: Increased / Decreased / No Changes; Sites:
Plaque Index Score:
Risk Assessment:

P) 
ITE/Re-evaluation: Completed / In Progress
Patient Ready to enter Recall/SPT: Yes / No (if no, what is the treatment plan)
Diagnosis:
Prognosis:
Recommended Recall Frequency: 2 / 3 / 4 / 6 months

DWP:

NV: 

Additional Notes:

Amalgam Restoration D2140 / D2150 / D2160 / D2161

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).:

S)           
CC:    
Med Hx. changes:      

O/A)          
Caries: Tooth # ___ & Surface ___
Recurrent Caries:  Tooth # ___ & Surface ___ 

P)           
​Anesthesia:   
Topical 20% benzocaine for 1 minute at penetration site(s).
2% Lido with 1:100k epi No. Carpules 1, 2, 3, 4   
PSA  Right / Left   
IA  Right / Left 
LB  Right / Left  
GG  Right / Left  
GP  Right / Left     
Infiltration  Tooth#   
Pt was determined to be numb.

Isolation:
Rubber dam:  Placed clamp on #      ; extended from tooth # to #       
Isolite used: Y / N, size:
Dry angles / Cotton rolls / Gauze  
Optragate used: Y / N

Caries removed completely:   Yes / No  
Caries Remaining: on pulpal floor ;   M D  axial floor  ;   M D B L  gingival floor 
Carious exposure:   Yes / No 
Direct pulp cap: Yes / No; MTA & Activa; Location:
Indirect pulp cap: Yes / No;  Activa; Location:
Matrix band: Tofflemire / Sectional matrix   

Rubber dam removal complete.  Occlusion checked in all excursions. Contacts: Proper;  Redo required: No  
Finished using carvers, discoid cleoid, ½ Hollenback.
Home Care instructions given:  Verbal / Written     
Pt left in:  Excellent spirits / Good Spirits;  Alone /  Accompanied by: Parent / Spouse / Friend / Relative

NV:

Composite Restoration: D2330 / D2331 / D2332 / D2445 / D2391 / D2392 / D2393 / D2394

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).

S)           
CC:
Med Hx. changes: 

O/A)          
Caries: Tooth #____ & Surface: ____ 
Recurrent Caries: Tooth #____ & Surface:  ____  

P)  
​Anesthesia:   
Topical 20% benzocaine for 1 minute at penetration site(s).
2% Lido with 1:100k epi No. Carpules 1, 2, 3, 4   
PSA  Right / Left   
IA  Right / Left 
LB  Right / Left  
GG  Right / Left  
GP  Right / Left     
Infiltration  Tooth#  
​Pt was determined to be numb.

​Isolation:
Rubber dam:  Placed clamp on #      ; extended from tooth #      to #       
Isolite used: Y / N, size:
Dry angles / Cotton rolls / Gauze  
Optragate used: Y / N

Caries removed completely: Yes / No 
Caries Remaining:  pulpal floor ; M D  axial floor ;  M D B L  gingival floor 
Carious exposure: Yes / No
Direct pulp cap: Yes / No; MTA & Activa; Location:
Indirect pulp cap: Yes / No;  Activa; Location:
Matrix band: Tofflemire / Sectional matrix 

Etch: Self / Selective with 35% phosphoric acid
Adhesive: Prelude system primer and adhesive / ScotchBond Universal

Composite:
Tetric EvoFlow; shade __  
Harmonize; shade __ 
Pt approved of shade.

Rubber dam removal complete.
Finished: Carbides, polishing discs
Occlusion checked in all excursions. Contacts proper.  
Polished: Gazelle points, diamond brush and paste
Redo required:  Yes / No
Home Care instructions given:  Verbal / Written   
Pt left in:  Excellent spirits / Good Spirits;  Alone / Accompanied by: Parent / Spouse / Friend / Relative

NV:

Build-up / Prep & Temp for tooth #______

Fixed Resin / LAVA / PFM / 3/4FVC / FVC / Zirconia / e.max
Crown/Bridge restoration – D2710 / D2740 / D2752 / D2782 / D2792 / D6740 / D6752 / D6782 / D6783 / D6792

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).

S)   
CC:      
Med Hx. changes:      

O)     
Caries: Tooth # ___ & Surface ___
Recurrent Caries: Tooth # ___ & Surface ___ 
Tooth shade: 
Photo taken with shade guide in photo?: Yes / No 
Stump shade of prepped tooth: 
​Photo taken with shade guide in photo of stump?: Yes / No 

A)          
Needs build-up, prep, temp, and final restoration

P)           
Anesthesia:
Topical 20% benzocaine for 1 minute at penetration site(s). 
2% Lido with 1:100k epi No. Carps 1, 2, 3, 4 
PSA  Right / Left 
IA  Right / Left  
LB  Right / Left 
GG  Right / Left 
GP  Right / Left 
Infiltration  Tooth #  
Pt was determined to be numb.

Isolation:
Rubber dam: Placed clamp on #___; extended from tooth # to #
Isolite used:  Y / N
Dry angles / Cotton rolls / Gauze
Optragate used: Y / N

Caries removed completely:  Yes / No 
Caries Remaining:  ______ Floor   MODBL
Carious exposure: Yes / No
Base placed:  Yes / No;  MTA & Activa; Location:  
Build-up placed: Yes/No
Matrix band: Tofflemire / Sectional Matrix

Etch: Self / Selective with 35% phosphoric acid
Adhesive: Prelude system Primer, Adhesive, Link / ScotchBond Universal
Build-up material: RockCore / PhotoCore

Build up left in place as temporary.
OR
Tooth preparation completed. Tooth preparation was reduced to have adequate occlusal and axial clearance for bulk of material thickness for restoration.   

Rubber dam removal complete.
Temporary created with (Integrity / TuffTemp), shade:     .

Finished: Carbides / diamonds / polishing discs
Cemented with (TempBond NE / UltraTemp). Throat pack used.
Occlusion checked in all excursions. Contacts proper.  Margins, adjacent teeth, and sulci cleaned of cement.
Polished: Gazelle points, diamond brush and paste
Redo required:  Yes / No

Home care instructions given:  Verbal / Written. Reviewed flossing technique, no sticky or chewy foods. If any pain occurs on tooth, please notify student doctor.
Pt left in:  Excellent spirits / Good Spirits;  Alone / Accompanied by: Parent / Spouse / Friend / Relative

NV: Final impression

CIMOE Crown Delivery for tooth #_______

Fixed Resin / LAVA / PFM / 3/4FVC / FVC / Zirconia / e.max
Crown/Bridge restoration – D2710 / D2740 / D2752 / D2782 / D2792 / D6740 / D6752 / D6782 / D6783 / D6792 

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).
S: 
Med Hx changes:
Patient likes temporary.  No sensitivity.

O:
BP/Pulse:      mmHg      bpm RAS
HTE:  Temporary still in place / lost.
Model with Restoration Exam: Restoration margins closed circumferentially around prepped model with removable die, and model with non-removable die. Contacts proper / heavy / light.

A: 
Needs final restoration.

P: 
Anesthesia:
Topical 20% benzocaine for 1 minute at penetration site(s).
2% Lido with 1:100k epi    No. Carpules: 1, 2, 3, 4
PSA  Right / Left
IA  Right / Left
LB  Right / Left
GG  Right / Left
GP  Right / Left 
Infiltration  Tooth #    
Pt was determined to be numb. 

Throat pack placed.  Temporary removed.  Preparation cleaned off with spoon and pumice on slow speed.  No caries at margins.

CIMOE completed.   
Pt approved of crown color, match, contour, occlusion, etc.  
Dental Esthetics Pt Approval Form signed (LABDEP Form):  Yes / No
Micro etched contacts (for all gold restorations), red flossed inter-proximal contacts.
Contacts checked and proper. Internal fit checker  0, 1, 2 … times. Margins checked with explorer. Articulation paper and shim stock used to check occlusion. 

Cemented with:
FujiCem 2 Automix (GI)
RelyX UniCem 2 Automix (SARC); shade: ____
NX3 Nexus Light Cure
NX3 Nexus Dual Cure

Margins and sulci cleaned of cement, occlusion adjusted, polished all surfaces.

DWP:  Home care instructions given for final restoration.  Any biting pressure or other sensitivities to call me.  Pt understood. 
Pt left in excellent / good spirits, alone / with spouse / relative.

NV:
​​

D9460 – Office Visit No Charge – Immediate Denture Adjustment

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).:
S)           
CC: Pain around immediate denture  
Med Hx changes: 

O)          
Sore spots around upper buccal / lower buccal / anterior lingual / posterior flange / alveolar ridge.

A)          
Immediate denture needs adjustment. 

P)           
Used PIP spray. ​Adjusted denture intaglio and flanges. Denture finished and polished.
Home Care instructions given:  Verbal 
Aids dispensed: Yes / No;  Type:  
Pt left in:  Excellent spirits / Good spirits;  Alone / Accompanied by:    Parent / Spouse / Friend / Relative

NV:

​EMERGENCY VISIT #_
D9430 Visit for Observation (Charge) / D9460 Office Visit No Charge / D9110 Palliative tx of dental pain / D2920 Recement crown / D3221 Pulpal debridement / D9950 Occlusal adjustment

EMERGENCY VISIT #___

FACULTY: 

S:
CC:
HPI:
Pain Scale (0 – 10):
Med Hx:
Meds:
Allergies:

O:
Vitals:  BP:  Pulse:
Hard tissue findings:
Soft tissue findings:
Perio findings:
Endo findings:

Radiographs taken:

A:
Diagnoses: 

P:
Procedure/Plan:  
DWP:  ​

Endo Access, Shape, and Clean

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).:

S)     
CC:
    Med Hx. changes:  none
O)     
Suspect tooth #:
           Cold: WNL /  + (slight)  /  ++  /  +++ (severe)  /  0  (No response)        Seconds:
           Hot:  WNL /  + (slight)  /  ++  /  +++ (severe)  /  0  (No response)        Seconds:
           EPT #:
           Palpation: WNL /  + (slight)  /  ++  /  +++ (severe)  /  0  (No response)
           Percussion: WNL /  + (slight)  /  ++  /  +++ (severe)  /  0  (No response)

Control tooth/teeth #s:   (Copy and paste for like 2 control teeth)

A)    
Pulpal Dx:  Normal pulp  /  Reversible pulpitis  /  Symptomatic irreversible pulpitis  /  Asymptomatic irreversible pulpitis /  Pulp necrosis  /  Previously treated  /  Previously initiated therapy

Periapical Dx:  Normal apical tissues  /  Symptomatic apical periodontitis  /  Asymptomatic apical periodontitis  /  Acute apical abcess  /  Chronic apical abscess (sinus tract)  /  Condensing osteitis

Summary of endo findings:  Pulpless  /  Vital pulp, asymptomatic   /  Vital pulp, symptomatic   /  Inflamed pulp, without radiolucency  /  Inflamed or partially necrotic pulp, radiolucency  /  Necrotic pulp without radiolucency  /  Necrotic pulp with radiolucency

Needs root canal therapy on #(s):

P)       
Topical 20% benzocaine for 1 minute at penetration site(s).
2% Lido with 1:100k epi No. Carpules 1, 2, 3,  4 
PSA  Right / Left
IA  Right / Left 
LB  Right / Left
GG  Right / Left
GP  Right / Left 
Infiltration tooth#  
Pt was determined to be numb.

Rubber dam placed clamp on tooth #  ;
Information from Endo/Emergency Record (ERENDO Form)

____ canal reference point “_________ edge / cusp tip / marginal ridge”
Electronic Working Length(WL) _____ mm
Radiographic WL ______ mm
Working length  ______ mm

____ canal reference point “_________ edge / cusp tip / marginal ridge”
Electronic Working Length(WL) _____ mm
Radiographic WL ______ mm
Working length  ______ mm

____ canal reference point “_________ edge / cusp tip / marginal ridge”
Electronic Working Length(WL) _____ mm
Radiographic WL ______ mm
Working length  ______ mm

Initial apical file size for the _____ canal  was 25 red / 40 black rotary
Initial apical file size for the _____ canal  was 25 red / 40 black rotary
Initial apical file size for the _____ canal  was 25 red / 40 black rotary

Final apical file size for the _____ canal  was 25 red / 40 black rotary
Final apical file size for the _____ canal  was 25 red / 40 black rotary
Final apical file size for the _____ canal  was 25 red / 40 black rotary

WaveOne was used after canals were cleaned and shaped .5 from the apex with a 20 size file.

Pulpdent was placed in the canals, cotton above the orifices and Cavit, Tempbond NE, and the temporary/final crown was cemented.
Pt left in: Excellent spirits;   Alone

NV: Obturation #___

Endo Access & Testing/Diagnosis

​Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).:

S)     
CC:
Med Hx. Changes: 

O)     
Suspect tooth #:
           Cold: WNL /  + (slight)  /  ++  /  +++ (severe)  /  0  (No response)        Seconds:
           Hot:  WNL /  + (slight)  /  ++  /  +++ (severe)  /  0  (No response)        Seconds:
           EPT #:
           Palpation: WNL /  + (slight)  /  ++  /  +++ (severe)  /  0  (No response)
           Percussion: WNL /  + (slight)  /  ++  /  +++ (severe)  /  0  (No response)

Control tooth/teeth #s:   (Copy and paste for like 2 control teeth)

A)    
Pulpal Dx:  Normal pulp  /  Reversible pulpitis  /  Symptomatic irreversible pulpitis  /  Asymptomatic irreversible pulpitis /  Pulp necrosis  /  Previously treated  /  Previously initiated therapy

Periapical Dx:  Normal apical tissues  /  Symptomatic apical periodontitis  /  Asymptomatic apical periodontitis  /  Acute apical abcess  /  Chronic apical abscess (sinus tract)  /  Condensing osteitis

Summary of endo findings:  Pulpless  /  Vital pulp, asymptomatic   /  Vital pulp, symptomatic   /  Inflamed pulp, without radiolucency  /  Inflamed or partially necrotic pulp, radiolucency  /  Necrotic pulp without radiolucency  /  Necrotic pulp with radiolucency

Needs root canal therapy on #(s):

Endosteal Implant Placement D6010 Site(s):_____, ______, _____

Preoperative Diagnosis:   Edentulous site # ___

Postoperative Diagnosis:  Same

Procedure:  Implant placement site#

Faculty & Student: 

Anesthesia:  Local Anesthesia with 2% lidocaine with 1:100000 epinephrine

Pt presents for implant placement site #__ and bone graft. all r/b/a were reviewed including sinus infection, perforation, damage to adjacent teeth, nerve damage, bleeding, infection, implant failure, need for further procedures. pt understood. consent was signed. all questions answered. pt started preop abx on __.

pt was prepped and drapped in usual fashion for OMFS procedure. nasal hood was placed and nitrous oxide was started in a 1:1 ratio with oxygen. vitals were monitored. 2% lidocaine with 1:100,000 epi, 2 carpules, were injected for local infiltration and greater palatine block. bite block and throat pack was used throughout the entire procedure.

The site was confirmed.  Crestal incision was made with a 15 blade and full thickness flap was reflected.  The bone was identified.  A pilot hole was made with pricision drill and enlarged with twist drill down to length of __mml and PA xray was taken to confirm angulation and orientation. Successive osteotomies were made using the standard drill sequence with copious irrigation with verification of position and angulation.

The implant was placed with primary stability under irrigation; implant torqued at __Ncm and burried 1mm subcrestal.  Chlorhexidine was placed in the implant and cover screw placed.  The wound was irrigated and closed with 3-0 chromic gut suture, 3 total, in interrupted fashion.

Nitrous was turned off, and 100% oxygen delivered for at least 5 minutes.

Postop pano:/post op PA  good positioning of implant, bone surrounding the apex at the floor of the sinus, no lesions.

complications: none

EBL less than 2cc

POI were given verbally and written form. all questions answered.

f/u in 1 week

STAGE II IMPLANT

Preoperative Diagnosis:   Loss of tooth

Postoperative Diagnosis:  Same

Procedure:  Stage II – #

Faculty & Student: 

Anesthesia:  Local Anesthesia with 2% lidocaine with 1:100000 epinephrine

Indications:  This is a _ y.o . female with.  The risks, benefits, and alternatives to the surgery were explained and the patient consented to the procedure.

Procedure:

The patient was prepped and draped in a routine fashion for an oral surgery procedure.   1.8 ml of local anesthetic was administered via local infiltration.

A 15 blade was used to make an incision and flap was reflected to identify the implant.  Cover screw was removed.  The wound was irrigated and implant was found to have integrated.  Chlorhexidine was placed within the implant and healing abutment was placed.  The wound was irrigated and the soft tissue was adapted and closed with 4-0 chromic gut suture.  A radiograph confirmed appropriate placement of the healing abutment and stability of the implant.

A throat drape was used at all times.  A bite block was used to stabilize the mandible.  The wounds were hemostatic.  The patient tolerated the procedure well.  POI given.

Complications:  None

Condition:  Stable

Disposition:  Home

Follow-Up:  1 Week

Failed appointment.   (1st, 2nd, 3rd Failed appointment with student #D12345;    1st, 2nd, 3rd failed appointment overall)

Pt was called on  mm/dd/yyyy  at (415)-555-1234 at  ______ am/pm to confirm ahead of time of our appointment. 
Pt did not answer and message was left. 
Or
Pt answered.  Pt confirmed time and did not mention any issues/difficulties making appointment. 

Pt was called 10 minutes after appointment was supposed to begin. 
Pt did not answer and message was left.
Or
Pt answered.  Pt’s reason for cancellation was _____________________.

Pt was reminded of our 24 hour cancellation policy, and our three day failed appointment policy.  Pt understood that this would be one of their 3 allotted failed appointments.  Pt was also reminded of their current number of cancellations, and that after 3 failed appointments our GPLs no longer allow us to schedule appointments with a patient.  Pt was notified that prior to their next appointment, they would be notified a few times to confirm. 

Pt understood.

NV:  Remind them prior to appointment more often.

Final Impression for Maxillary/Mandibular Removable Partial Denture – D5213 / D5214

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).: 
S)           
CC:  wants to fill spaces with teeth
Med Hx. changes: 
Pt reports: No pain or sensitivity associated with rest preparations.

O)          
Missing teeth.  

A)          
Needs final impression and partial denture.

P)           
Final rest preparations were checked by Dr(s).:    
Impression was completed in  (1, 2, 3, 4)    attempt(s). Impression technique with light body pink, and medium body green PVS impression material.
Isolated with 2x2s and suction and air syringe.
Final impression was approved by Dr(s).            and          .
Margins, other teeth, embrasures, and sulci were cleaned. 
Pt was given mouth rinse after impression.

DWP: 
Aids dispensed: Yes / No
Pt left in:  Excellent spirits, Alone / Accompanied by:    Parent / Spouse / Friend / Relative

NV: Framework try-in and tooth shade selection

Final Impression for tooth #______  Fixed Resin/LAVA/PFM/3/4FVC/FVC  Crown/Bridge Restoration  – D2710/D2740/D2752/D2782/D2792   /   D6740/D6752/D6782/D6783/D6792

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).:

S)           
CC:         
Med Hx. changes: 
Pt reports: No pain or sensitivity associated with temporary restoration.

O)          
BP/Pulse:            mmHg &              bpm RAS; 
Tooth shade of surrounding and/or contralateral teeth:
Photo taken with Shade Guide in photo?: Yes / No
Stump shade of prepped tooth:
Photo taken with Shade Guide in photo of stump?: Yes / No

A)          
Needs final impression and final restoration.

P)           
Anesthesia:
Topical 20% benzocaine for 1 minute at penetration site(s).
2% Lido with 1:100k epi No. Carpules 1, 2, 3, 4
PSA  Right / Left
IA  Right / Left
LB  Right / Left
GG  Right / Left
GP  Right / Left 
​Infiltration  Tooth#  
Pt was determined to be numb.

Isolation: Dry angles / Cotton rolls / Suction and air syringe

Throat pack placed. Temporary was removed with spoon.  Tooth cleaned with pumice and spoon. 
Final preparation check was completed by Dr(s).        and        .

Impression was completed in ___ attempt(s).  Used double cord impression technique with light body and heavy body PVS impression material.  
Final impression was scoped and approved by Dr(s).        and        .

Temporary was re-cemented using temporary cement (TempBond NE / UltraTemp) and throat pack.
Margins checked, occlusion checked and adjusted in all excursions. Contacts proper. Margins, other teeth, and sulci were cleaned. ​
Polished with:
Redo required: Yes / No

DWP:

NV:

Reline Mandibular Partial – Laboratory – D5761

Sterile strips checked, all instruments sterile. Operatory disinfected (2x wipe 10 min prior to operation).
Worked with Dr(s).:     

Med hx changes:
Pt presented with no painful areas, nor areas of redness/inflammation.
Polysulfide impression taken.

NV: Delivery

Final Impression for MODBL Implant Crown #____

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).:

S:           
CC:  No pain associated with implant site. Pt wants space filled with implant(s).
Med hx changes:

O:          
Edentulous site ______.
Implant sounded good when sounded by OS faculty (Nattestad/Bedrossian/Boghossian/Park).
Implant healing abutment too short (buried in gingiva) / adequate height / too tall.
RE: Osseointegration complete around implant / osseointegration incomplete around implant.

A:          
Needs final impression and crown.

P:           
Anesthesia:
Topical 20% benzocaine for 1 minute at penetration site(s).
2% Lido with 1:100k epi No. Carpules 1, 2, 3, 4 
PSA  Right / Left
IA  Right / Left
LB  Right / Left
GG  Right / Left
GP  Right / Left 
Infiltration site____ 
Patient was determined to be numb. 

Implant sounding was performed. 

Placed throat pack.  Removed healing abutment.
Internal hex was flat edge / pointed corner towards the buccal.
Placed impression coping.   Open / Closed tray impression coping was utilized.
Radiograph taken to make sure implant was completely seated.
​Impression taken in _____ attempt(s). Used PVS (light / medium / heavy) body impression material.
Impression approved by Dr.(s)_________ and  ________.
Healing abutment was replaced and torqued to 15Ncm. Other teeth and sulci were cleaned. 

DWP: Pt left alone and in excellent spirits.

NV:  CIMOE

Rest Preparations for Mandibular/Maxillary Partial D5213 / D5214

Sterile strips checked, all instruments sterile. Operatory disinfected (double wipe 10 minutes prior to operation).
Worked with Dr(s).: 

S)   
CC:  wants to fill spaces with teeth
Med Hx. changes: 

O) 
Missing teeth.   

A)   
Needs rest preps, and final impression for partial fabrication.   Casts were surveyed and determined that with rest preps, dimples and guide planes that a partial could be fabricated.

P)  
Anesthesia:
2% Lido with 1:100k epi No. Carpules 1, 2, 3, 4
PSA  Right / Left
IA  Right / Left
LB  Right / Left
GG  Right / Left
GP  Right / Left 
​Infiltration  Tooth #
Pt was determined to be numb.  

Prepped guide planes on teeth & surfaces:
Prepped rest preps on teeth & surfaces:
Prepped dimples for undercuts on teeth & surfaces:

Final rest preparations were checked by Dr.         .

DWP:  Instructed pt that if anything bothered them, to let student dentist know
Aids dispensed: Yes / No
Pt left in:  Excellent spirits;  Alone

NV:  Final impression for partial

Oral Surgery Notes

Common Abbreviations

  • HPI: History of Present Illness
  • PMH: Pertinent Medical History
  • Meds: Medications
  • All: Allergies
  • Hosp: Hospitalizations within the last 5 years
  • PSH: Past Surgical History
  • Habits: smoking, alcohol, recreational drug use, etc.

OS Consult Note: ext #

S:
PP:   yo M / F
CC:
HPI:
PMH:
Meds:
All:
Hosp:
PSH:
Habits:

O:
VS: BP    , HR
Labs:
EOE:
IOE:
Imaging (pano/CBCT/PA):

A:
ASA Classification:
Dental Dx:

P:
Procedure: Ext #
Treating Provider: Student / Resident / Faculty
Anesthesia Type: LA / N2O / IVSA

OS Follow-up Note

S:
PP:   yo M / F
CC:
HPI:
PMH:
Meds:
All:
Hosp:
PSH:
Habits:

O:
VS: BP    , HR
Labs:
EOE:
IOE:
Imaging (pano/CBCT/PA):

A:
ASA Classification:
Assessment:

P:

OMFS Procedure Note: Ext #

S:
PP:   yo M / F
CC:
HPI:
PMH:
Meds:
All:
Hosp:
PSH:
Habits:

O:
VS: BP    , HR
Labs:
EOE:
IOE:
Imaging (pano/CBCT/PA):

A:
ASA Classification:
Dental Dx:

Tx:
Consent in Axium. Reviewed risks again, including probability of nerve damage resulting in temporary/permanent changes in feeling/numbness, damage to adjacent teeth/bone including fractures, involvement of sinus, and other surgical risks. Patient wishes to proceed with procedure.
LA:    mL 2% Lidocaine with 1:100k epi.
Throat pack and bite block in place.

Routine/Surgical ext #:

POI: Verbal and written
Rx: rec OTC
RTC: prn

OS Consult & Procedure Note: ext #

S:
PP:   yo M / F
CC:
HPI:
PMH:
Meds:
All:
Hosp:
PSH:
Habits:

O:
VS: BP    , HR
Labs:
EOE:
IOE:
Imaging (pano/CBCT/PA):

A:
ASA Classification:
Dental Dx:

P:
Procedure: ext #
Treating Provider: Student / Resident / Faculty
Anesthesia Type: LA / N2O / IVSA

Tx:
Consent in Axium. Reviewed risks again, including probability of nerve damage resulting in temporary/permanent changes in feeling/numbness, damage to adjacent teeth/bone including fractures, involvement of sinus, and other surgical risks. Patient wishes to proceed with procedure.
LA:    mL 2% Lidocaine with 1:100k epi.
Throat pack and bite block in place.

Routine/Surgical ext #:

POI: Verbal and written
Rx: rec OTC
RTC: prn

IVSA Consult Note

CHIEF COMPLAINT: Impacted teeth #__

Pericoronitis tooth #__

Patient presents for evaluation of third molars and pericoronitis associated with tooth #__. Pt denies pain, swelling, drainage, airway issues, dysphagia, numbness, or other symptoms. Pt requests removal of all third molars.

 Pt denies h/o of head and neck radiation or treatment for osteoporosis with bisphosphonates.

PMHx:

PSHx:

Meds:

Allergies:

Habits:  denies tobacco use, alcohol use, or other drug use.

Social Hx:

PE:

GENERAL:  Well-developed, well-nourished.

MAXILLOFACIAL: Patient is WDWN and sitting in dental chair in NAD. Forehead, Eye, ears and lower face are symmetric. No cervical or submandibular LAD. No tenderness of palpation of facial bony prominences. No clicking, popping or crepitus of TMJ. Intraoral exam reveals clear oropharynx, soft and non-tender FOM. No vestibular swelling or purulent drainage. Mucosa and soft tissues are pink, moist and healthy appearing.

Gross decay present on #__. Tooth #__ is soft tissue impacted and #__ is errupted, periodontal pockets of __mm present with bleeding at distal of #2,15,18,31. 

ASA Classification:

VITALS:  BP:       P:      RR:     Temp:       pain score:

CV: reg rate and rythm

PULM: CTA Bilaterally  no w/r/r

AIRWAY: MP  1     2     3     4

Panoramic Radiograph (Date): #17 and #32 are in close proximity to IA nerve and has widening of PDL at its apex.

Teeth #__ is erupted, Teeth #__ soft tissue impacted, teeth #__ partial bony impacted, teeth #__ full bony impacted. No bony pathology present.

CBCT (Date): teeth #17 and #32 visualized and lingual and superior to the IA nerve. IA nerve course is __.

A/P:

Patient otherwise healthy presents for evaluation for extraction of teeth #1,16,17, and 32. Teeth #17 and #32 are indicated for extractions due to periodontal disease, operculum with associated history of pain, risk of infection. Teeth #1 and #16 are also indicated for extraction due to periodontal concerns and difficulty with cleaning distal to second molar. We discussed the risks, benefits, and alternatives to treatment including no treatment and coronectomy. This included the risk of bleeding, infection, sinus exposure, nerve involvement of the inferior alveolar and lingual nerve which may result in partial or total numbness of the teeth, tongue, gums, and lip and loss of taste and which may be either temporary or permanent, damage to adjacent teeth or structures, retained roots, fracture, displacement of teeth, and need for futher surgery. The patient understands.

 IV sedation was offered for management of anxiety and apprehension during the procedure and r/b/a also reviewed.

Patient was given the information on third molar extractions and sedation . All questions answered. pt will schedule appointment. pt informed to return sooner if he/she develops worsening swelling or present to ER with airway issues; pt appreciative. 

NPO Status & Escort protocol discussed.

Pt informed to not smoke Cig/ MJ at least 1 wk prior

Covid test needed within 1 wk of the procedure.

-chlorhexidine, salt water rinses, hygiene

-Extraction teeth #1,16,17,32 under__

IVSA Procedure Note (Impacted Teeth)

Preoperative Diagnosis: Impacted #1,16,17,32
Postoperative Diagnosis: Same
Procedure: Extraction of #1,16,17,32
Faculty:
Assistant:
Anesthesia: Local Anesthesia with 2% lidocaine with 1:100000 epinephrine
Deep Sedation: with mg midazolam, mcg fentanyl, mg propofol, 4 mg dexamethasone
Indications: This is a _ y.o. female with inadequate arch space and impacted wisdom teeth.
The risks, benefits, and alternatives to the surgery were explained prior to surgery day and the
patient and/or guardian was consented to the procedure. Npo and escort confirmed. All ASA
Standard monitors applied.
VS:
BP:
HR:
EKG:
CTAB/L:

Procedure:
An intravenous line was established with normal saline and catheter. Heme specimen obtained
for L prf Plug harvesting. The patient was then placed on 100% oxygen and intravenous
medications were titrated to effect. The patient was prepped and draped in a routine fashion
for an oral surgery procedure. __ml of local anesthetic was administered via local infiltration
and bilateral inferior alveolar, long buccal, and lingual nerve blocks. Bilateral posterior superior alveolar and greater palatine nerve blocks. All blocks confirmed for negative aspiration.

#17 : FTMP Flap reflected with DB Hockey stick incision w/ # 15 blade., buccal trough made, crown sectioned and roots sectioned, removed crown and roots separately. No IAN canal visualized. Bone file used to smoothen bone, curettage socket removed dental follicle. Irrigation with NS. L PRF plug placed in socket. 3-0 chromic placed to obtain primary closure.

#16 – FTMP Flap reflected with DB Extension w/ # 15 blade. Removed bone from MB # 16 with ostetomes and periotomes. Elevated and removed # 16. No sinus perforation noted. Bone file used to smoothen bone, curettage socket removed dental follicle. Irrigation with NS.
3-0 chromic placed to obtain primary closure.

Bone file used to smoothen bone, curettage socket removed dental follicle. Irrigation with NS.
3-0 chromic placed to obtain primary closure.

#32 was completed in a similar fashion as #17.

#1 was completed in a similar fashion as #16.

A throat drape/C-sponge was used at all times. A bite block was used to stabilize the mandible. The wounds were hemostatic. The patient tolerated the procedure well. Discharge criteria met.
POI given to patient and escort.
Complications: None
Condition: Stable
Disposition: Home
Follow-Up: 1 Week.

Extraction,/Ridge Preservation & Implant consult

CHIEF COMPLAINT: Gross carious lesion teeth #__, dental implant evaluation

This patient presents for evaluation of gross carious lesion teeth #__ and potential implant placement. She/He reports intermittent pain with teeth #__, no drainage, swelling, erythema, numbness, or other symptoms at current. She denies h/o of head and neck radiation or treatment for osteoporosis with bisphosphonates.

PMHx:

PSHx:

Meds:

Allergies:

Habits:  Bruxism:         clenching:      

Social Hx:

PHYSICAL EXAMINATION

GENERAL:  Well-developed, well-nourished.

VITALS:

 Extraoral:

Forehead, eye, ears and lower face are symmetric.

No tenderness of palpation of facial bony prominences.

PERRLA/EOMI nares patent, EAM patent

OP clear

neck supple no adenopathy or thyromegaly

Intraoral:

Intraoral exam reveals clear oropharynx, soft and non-tender and softFOM.

No vestibular swelling or purulent drainage.

Mucosa and soft tissues are pink, moist and healthy appearing.

Oropharynx is clear

gingiva type:

lesions:

TMJ: No clicking, popping or crepitus of TMJ

DENTAL:

missing teeth: __.

Bilateral crossbite present; right m and c class __, left m and c class __, mandibular midline to the left by __mm, max midline on with the MSP.

Tooth #__ crown fractured to gumline with no signs of erythema, swelling, TTP,

 interocclusal distance __mm, mesial distal __mm,

Pocket depth __mm around #__.

adequate bony width.

 hygiene good.

 On smiling, __mm gingival show present and __% incisor show,

OJ __mm, OB __mm,

generalized recession.

Bruxism signs present/absent.

Pt has (canine guidance, group function) on lateral movement.

Fremitis present at teeth #__ on repitetive biting.

VITALS:  BP:       P:      RR:     Temp:       pain score:

CV: reg rate and rythm

PULM:CTA Bilaterally  no w/r/r

SINUS: findings:none

AIRWAY: MP  1     2     3     4

Panoramic (Date): adequate bone in site #__,

no osseous abnormalities,

Tooth #__ with periapical radiolucency,

TMJ wnl

missing teeth as above.

low maxillary sinus floor with minimal bone height bilaterally.

 no bony lesions,

TMJs wnl

CBCT (Date): low maxillary sinus floor bilaterally with less than __mm of bone height.

 thin mandibular ridge bilaterally and limited height due to proximity of IA nerve.

no bony pathology seen.

Panoramic Radiograph: Condyles are well corticated and properly seated in the glenoid fossa. Maxillary sinuses are clear. #__  missing; #__ with some bone loss. #__ with gross carious lesion. No bony pathology present.

A/P:

Patient presents with gross decay #__ and missing teeth #__. We discussed the risks, benefits, and alternatives to treatment including no treatment.

Pt was given the options for ext #__ with socket preservation

We discussed the risk of bleeding, infection, sinus exposure, nerve involvement of the inferior alveolar and lingual nerve which may result in partial or total numbness of the teeth, gums, and lip and which may be either temporary or permanent, damage to adjacent teeth or structures, retained roots, displacement of teeth. The patient understands.

 The patient elected to proceed with __.

Informed pt that we would do ext and bone graft at first visit. second visit around 3 months for consult and CBCT. third visit around 3-4 months from now for implant with possible healing abutment. fourth visit for stage 2 and implant check followed by additional visits with Restorative faculty for crown fabrication. pt understood.

Patient was given the information on extractions, bone grafting, and implant placement. All questions answered. pt will schedule appointment. pt informed to return sooner if she develops worsening swelling or present to ER with airway issues. pt satisfied with treatment plan and appreciative; all questions answered.

-impressions, photos, and measurements taken today

-Care coordinated with pt’s dentist.

Phase 1: –

Phase 2:

Consults/Clearances:

Implant Consult Note

C.C:

HPI: Patient with PMH of __ s/p ext #__ with ridge preservation presents for evaluation of implant placement. Ext and bone graft was completed roughly 3 months ago. Pt denies pain, swelling, or any other issues.

PMH: Pt denies any updates or changes to medical history and medications.

Extraoral:

No tenderness of palpation of facial bony prominences.

neck supple no adenopathy or thyromegaly

TMJ: No clicking, popping or crepitus of TMJ

Intraoral:

Intraoral exam reveals clear oropharynx, soft and non-tender FOM.

No vestibular swelling or purulent drainage.

Mucosa and soft tissues are pink, moist and healthy appearing.

gingiva type:

lesions:

missing teeth: __.

Bilateral crossbite present; right m and c class __,

left m and c class __,

mandibular midline to the left by __mm,

. Tooth #__ crown fractured to gumline with no signs of erythema, swelling, TTP, interocclusal distance __mm, mesial distal __mm,

Pocket depth __mm around #__.

Adequate bony width. hygiene good.

On smiling, __mm gingival show present and __% incisor show, OJ __mm, OB __mm, generalized recession. Bruxism signs present.

 Pt has (canine guidance, group function) on lateral movement.

 Fremitis present at teeth #__ on repitetive biting.

VITALS:  BP:       P:      RR:     Temp:       pain score:

AIRWAY: MP  1     2     3     4

Panoramic (Date):

Adequate bone in site #__,

no osseous abnormalities,

Tooth #__ with periapical radiolucency,

no bony lesions,

CBCT (Date): Site #__ with good bony consolidation and no signs of radiolucency, roughly __ mm of buccal and lingual width, and around __mm from crest to the mental nerve. no pathology

A/P:

Patient   s/p ext #__ with ridge preservation now ready for implant placement.

Options include do nothing, bridge, implant, or partial denture.

pt will proceed with implant site #__.

Will plan for ___ ( implant system) __mm length implant at site #__/__/__

-Diagnostic photos, casts obtained

-plan for abx pre-op and after implant placement.

-reviewed all r/b/a including but not limited to infection, bleeding, damage to adjacent teeth, implant failure, crown and screw and implant  fracture, screw loosening, IA and lingual nerve injury. pt understood. all questions answered.

-pt would like to proceed with implant

-Anesthesia plan: local anesthsia with (Nitrous, IV Sedation). Patient was given information regarding IV Sedation and all r/b/a reviewed.