Clinical Notes

Wisdom Teeth Erupted - Local Anesthesia

Progress Note

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Patient seen at the request of the office general dentist for evaluation and extraction of wisdom teeth. Patient reports occasional discomfort in right and left jaw for several months.

 

Review of Symptoms

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Facial pain                         Yes                                   Snoring                              No

Pain with chewing              No                                    Bleeding Gum                   No

Lumps in the neck             No                                    Difficulty Swallowing          No

Lumps in face                    No                                    Pain Swallowing                No

Shortness of breath          No                                     Limited Opening                No

TMJ pain                           No                                     Sinus Pain                         No

Dry Mouth                         No                                     Chills                                 No

Fever                                 No                                     Nausea / Vomiting             No

Hoarseness                       No

 

Past Medical History

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See med history from (in Document Center)

Past Surgical History

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See med history form (in Document Center)

Medication

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See med history form (in Document Center)

 

Allergies

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See med history form  (in Document Center)

Social History

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Smoking – See med history form  (in Document Center)

Alcohol - See med history form  (in Document Center)

Drugs - See med history form  (in Document Center)

 

CLINICAL EXAMINATION:

Extraoral, Head and Neck exam:

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Constitutional: general appearance of patient 

No extraoral swelling or erythema

Parotid and submandibular glands soft, nonpainful to palpation bilaterally

No lesion noted on facial skin

Facial palpitation exam reviews no swelling or no lymphadenopathy

CN V1, V2, V3, CN VII intact bilaterally

No neck masses noted

Thyroid midline with no evidence of any swelling

Musculoskeletal: TMJ joint seems to be normal. No poping upon opening

Maximum mouth opening within normal range

 

Intraoral Soft Tissues:

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Clear saliva extruded from bilateral Wharton's and Stenson's ducts

Tongue soft and non-tender with no apparent lesions

Buccal mucosa without lesions bilaterally

Hard palate, soft palate, and pharynx are within normal limits no pathology visualized

Floor of mouth without an evidence of pathology

Gingival tissues are pink, firm, and stippled and without erythema or swelling

Dentition:

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Normal complimentary maxillary and mandibular teeth

 

 

Radiographic examination:

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Panorex reviewed demonstrates

No bony pathology.  

ASSESSMENT / PLAN / RECOMMENDATION

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Extraction of teeth # 1.16,17, 32 under  Local  Anesthesia

 

PROCEDURE :

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SURGEON 1:  Joseph Krajekian, D.M.D., M.D.

DENTAL ASSISTANT : Melinda and Shawna

OPERATION/PROCEDURE :

Surgical  1,16,17 ,32

 

ANESTHESIA:  Local Anesthesia

PREOPERATIVE DIAGNOSIS:  Impacted wisdom teeth/ Tooth Eruption Disturbance

POSTOPERATIVE DIAGNOSIS:  same

 

OPERATIVE INDICATIONS:  Pt presents to Dental Office for evaluation of wisdom teeth.

 

CONSENT

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Wisdom teeth (1,16,17,32)

Discussed risk, benefits, complication of surgery including but not limited to bleeding swelling, infection, pain, retained root tip, sinus perforation, numbness of lower lip, chin, tongue. Patient understood risks informed, verbalized understanding and consented accordingly.

PROCEDURE:

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After patient was greeted and ID confirmed. The patient was placed in dental chair. Patient rinsed and spit for 30 second with peridex. Surgical Pause was performed to confirm consent, site and procedure with both assistants. Patient was then prepped and draped in standard oral and maxillofacial surgery fashion.

 

Wisdom Teeth Extraction

Local Anesthesia

  • 6 carpules of 2% lidocaine with 1:100,000 epinephrine

 

After proper time for local anesthesia to work.

Mouth prop utilized, throat pack used followed by sweetheart.

 

 

Surgical  #32

A hockey-stick full-thickness mucoperiosteal flap was reflected extending 5mm distolateral at the external oblique ridge from wisdom teeth all the way to mesial of tooth # 31 without any vertical release.  After that was completed, high speed W&H drill with fissure bur and copious irrigation to section the tooth. Minimal about of bone was removed. Straight elevator was used to fracture the tooth after it was sections. Bone file was used to remove any sharp edges..

 

Area was then smoothened with use of bone file.  Socket was then irrigated in addition to the subperiosteol flap. Area was then closed with 3.0 chromic gut suture interrupted x 1.

 

Surgical  #1

Attention was then given to tooth #1. Tooth was extracted in the standard oral maxillofacial surgery fashion. Incision was made intra-sulcular extending to mesial of #2. Rongeur was used to remove some of the bone. Tooth was then removed without any difficulty with appropriate straight elevator followed by appropriate concepts. Following removal of tooth any retained follicle was also removed. No sinus perforations was visualized or detected clinically.  A 3-0 gut suture was placed x 1 interrupted.

 

No complication

 

ESTIMATED BLOOD LOSS:  minimal

 

IV Fluids : None

DISPOSITION : Home with escort after meeting appropriate discharge criteria

 

FOLLOWUP :  1 week post-op with general dentist in office. 2 weeks with me if needed. Patient was provided post-op instruction/medication sheets in writing and they were also review with patient escort. Pt and escort were also provided with my 24 hour direct contact number and was also instructed to contact the office with any questions

 

PRISCRIPTION DISPENSED:

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Pen VK 500mg    1 tablet PO q6hrs x 7 days 

Norco 5/325        1 po q 6 hr prn x 20

Peridex                10cc Rinse and Spit bid x 7 days x 1 btl

Motrin 800mg      1 po every 8 hrs x 28 pills prn

Joseph Krajekian DMD, MD, FAAOMS, DABOMS

(C) 2019 Dr. Joseph Krajekian

Telephone :  (440) 646-0597 Office 

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Fax #         :  (888) 774-7970