Clinical Notes

Extraction with Bone Grafting 

Patient seen at the request of the office general dentist for evaluation of dental caries, and need for extractions, bone grafting and dental implants. Reviewed referral sheet with patient and identified the teeth to be extracted by marking 3 on printed xray sheet. Discussed in length various available option including but not limited to  Fixed bridge vs dental implants. After patient demonstrated complete understanding of the proposed options decided to proceed with procedure. Risks /Benefits / Complications discussed including all steps with patient from placement to final restoration. Risks, benefits, complications in particular to their case were also discussed.

Past Medical History
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Refer to patient history form

Past Surgical History
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Refer to patient history form

Medications
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Refer to patient history form

Allergies
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Refer to patient history form

Social History
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Smoking – Refer to patient history form
Alcohol - Refer to patient history form
Drugs - Refer to patient history form

CLINICAL EXAMINATION: 
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Extraoral, Head and Neck exam: 

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: 

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

Dentition: 

Refer to dental chart for detail dental caries evaluation

Radiographic examination: 
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Panorex reviewed demonstrates
No bony pathology. 
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ASSESSMENT / PLAN / RECOMMENDATION
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Surgical #3. Socket preservation, membrane

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

Local Anesthesia
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___ 2% lido w/ 1:100,000 epi Carpules (1.7 cc)
___ 4% sepocaine Carpules (1.7 cc)
___ 3% Carbocaine w/o epi Carpules (1.7 cc)

Procedure Performed
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SURGEON 1:  Joseph Krajekian, D.M.D., M.D.
DENTAL ASSISTANT : Shawna / Melinda


OPERATION/PROCEDURE : 
    Surgical Implant Placement   tooth # : xxxxxx

After proper time for local anesthesia to work.
Mouth prop utilized, throat pack used followed by sweetheart.

After case was discuss with referring dentist.

Patient rinsed with peridex for 30 sec prior to starting procedure

 

Attention was giving to xxxxxxmaxillary. Tooth was surgical extractions and in standard oral and maxillofacial surgery fashion with use 15 blade intra-sulcular incision, periosteol elevator to reflect full thickness mucoperiosteol flap, straight elevator,  drill used with copious irrigation to section the tooth and create a purchase point.

 

All attempts were made to preserve the buccal wall.  Tooth was then removed by elevators/crane picks and rongeur. Following extraction socket was aggressively curretted and socket graft was placed followed with membrane/collplug  and 3.0 vicryl suture

 

Follow-up in _ 3-4__ weeks

ESTIMATED BLOOD LOSS:  minimal

DISPOSITION : Home 

PRISCRIPTION DISPENSED:
Pen VK 500mg    PO q6 hrs Disp 7 days                     refill 0
Norco 5/325        1 tabs PO q6 hrs prn Disp 5 days    refill 0
Peridex                Provided from the office                  refill 0
Mortin 800mg      1 tablet every 8 hrs prn x 28 pills    refill 0

 

FOLLOWUP : 
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4 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

DICTATED BY :                    
Dr. Joseph Krajekian DMD, MD            

(C) 2020 Dr. Joseph Krajekian

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