Clinical Notes

​Single Implant

COVID SCREENING

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Patient was pre-screened per OS protocol prior to appointment.

Patient was additionally screening via phone when they arrived outside the practice and temperature was checked. 

COVID-19 Consent was completed in addition all OS paperwork . Patient signature was verified.

Room was disinfected using Super Sani-Cloth Germicidal Disposable Wipe (EPA Reg # 9480-4 ) techniques per manufactures protocols, followed by Clorox® Clean-Up® Cleaner + Bleach (EPA Reg. No. 5813-21) Spray and room dry. Room was verified by the other assistant for completion via COVID-19 Room disinfection checklist.

Patient also rinsed with 1.5% hydrogen peroxide for 30 second 

Progress NOTE

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Patients seen at the request of the office general dentist for evaluation of dental implant(s). Discussed in length various available option including but not limited to no treatment, removal partial denture (flipper), fixed partial dental (bridge) and or dental implant. After patient demonstrated complete understanding of the proposed options decided to proceed with placement of  #xxxxx  implant in xxxx jaw. Reviewed all steps with patient from placement to final restoration. Risks, benefits, complications 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. 
Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx


ASSESSMENT / PLAN / RECOMMENDATION
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Implant Placement tooth #xxxxxxx


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

 

Mid ridge incision was made. Full thickness mucoperiosteol flap was exposed. Bone was evaluated and it was determined that patient has adequate bone width and height. 

Width : 6mm     Height 14

 

With use of sequential drilling sequence per Straumann guidelines 800/600 RPM with chilled saline. Started with 2 pointed bur, followed by pilot at depth of 8mm. Intra-operative xray taken to review position. Appropriate corrections make and drill hole was extended to appropriate depth with accommodated the planted implant below. Multiple intra-operative xrays taken during every step in additional to a final placement xray.

Straumann SLA Tapered implant 4.1 x10mm was placed.

Quality of bone was :      __ D1    _X_D2   __D3   __ D4

Expected stage II : 4 months

 

Follow-up in _ 3-4__ weeks

ESTIMATED BLOOD LOSS:  minimal

DISPOSITION : Home 

PRISCRIPTION DISPENSED:

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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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next day with general dentist. 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

DICTATED BY :                    
Dr. Joseph Krajekian DMD, MD            

(C) 2020 Dr. Joseph Krajekian

Telephone :  (440) 646-0597 Office 

                     (888) 774-7773 Answering Service

Fax #         :  (888) 774-7970