| Time | Op 1 | Op 2 | Op 3 | Hygiene |
|---|
JM
Jane Martinez
DOB: 1987-04-12 · Crown Prep — Tooth #14 · Dr. Sarah Chen · Started: 9:02 AM
Allergy Alert: Penicillin — severe reaction
Last Visit Summary
Feb 8, 2026 — Periodic Exam & Prophy (D0120, D1110)
No new caries detected. Moderate calculus buildup lower anteriors. Patient reports sensitivity upper right. Recommended fluoride treatment. Follow-up scheduled for crown consultation (Tooth #14 existing MOD composite — fracture noted).
No new caries detected. Moderate calculus buildup lower anteriors. Patient reports sensitivity upper right. Recommended fluoride treatment. Follow-up scheduled for crown consultation (Tooth #14 existing MOD composite — fracture noted).
Vitals
118/76
BP (mmHg)
72
Pulse (bpm)
98.6°
Temp (F)
99%
SpO2
Chief Complaint
"Patient presents for crown preparation on Tooth #14. Reports mild sensitivity when biting. No acute pain at rest.
Existing MOD composite restoration with visible marginal fracture. Patient is anxious — nitrous requested."
Vitals
BP: 122/80 mmHg Pulse: 78 bpm Temp: 98.4°F SpO2: 98%
Chief Complaint
Patient presents as new patient for comprehensive exam. Reports no acute pain. States last dental visit was approximately 3 years ago.
Concerned about bleeding gums and visible staining. Dental anxiety noted — patient requested detailed explanation of each procedure.
Clinical Findings
AI flagged for review
Generalized moderate plaque and calculus. BPE scores: sextant 1=3, sextant 2=2, sextant 3=3, sextant 4=2, sextant 5=3, sextant 6=2. Bleeding on probing 40% of sites. Radiographic evidence of mild horizontal bone loss posterior regions. Tooth #30: occlusal caries suspected (verify on X-ray). No pathology of oral mucosa. Tonsils WNL.
Generalized moderate plaque and calculus. BPE scores: sextant 1=3, sextant 2=2, sextant 3=3, sextant 4=2, sextant 5=3, sextant 6=2. Bleeding on probing 40% of sites. Radiographic evidence of mild horizontal bone loss posterior regions. Tooth #30: occlusal caries suspected (verify on X-ray). No pathology of oral mucosa. Tonsils WNL.
Diagnosis
AI flagged for review
1. Generalized moderate chronic periodontitis (K05.31)
2. Suspected occlusal caries Tooth #30 (K02.51) — confirm with periapical radiograph
3. Extrinsic staining (K03.6)
1. Generalized moderate chronic periodontitis (K05.31)
2. Suspected occlusal caries Tooth #30 (K02.51) — confirm with periapical radiograph
3. Extrinsic staining (K03.6)
Treatment Plan
Phase 1 (Active): Full mouth debridement (D4355), periapical X-ray #30 (D0220), oral hygiene instruction.
Phase 2 (Restorative): If caries confirmed — composite restoration Tooth #30 (D2391).
Recall: 3-month perio maintenance intervals.
Phase 2 (Restorative): If caries confirmed — composite restoration Tooth #30 (D2391).
Recall: 3-month perio maintenance intervals.
MJ
Michael Johnson
New Patient · MRN: 00-4821 · PMS: Open Dental
Demographics
Full NameMichael R. Johnson
Date of Birth1978-11-03 (47 yrs)
Phone(303) 555-0184
Emailm.johnson@email.com
Address1428 Elm St, Denver CO 80203
InsuranceDelta Dental PPO
Member IDDD-88271-C
PMSOpen Dental
Medical History
Allergies: None reported
ConditionsHypertension (controlled)
MedicationsLisinopril 10mg daily
TobaccoFormer smoker (quit 2019)
Last UpdatedToday (patient-reported)
Visit History
| Date | Type | Provider | Score | Status | |
|---|---|---|---|---|---|
| Mar 6, 2026 | New Patient Exam | Dr. Chen | 72% | Review | View |
| Aug 12, 2022 | Periodic Exam | Dr. Torres | 94% | Approved | View |
| Jan 5, 2022 | Emergency Visit | Dr. Torres | 88% | Approved | View |
Open Treatment Plans
D4355
Pending
Full Mouth Debridement
Proposed · Phase 1
D2391
Future
Composite Restoration #30
Proposed · Phase 2 (confirm caries)
D0220
Ordered
Periapical X-Ray #30
Ordered · Today