Clinical Notes

Crown Lengthening - Local Anesthesia

COVID-19 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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Patient seen at the request of the office general dentist for evaluation for need of crown lengthening.

 


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 popping 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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Crown Lengthening for # xxxxxxx  with Local Anesthesia

PROCEDURE :
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SURGEON 1:  Joseph Krajekian, D.M.D., M.D.
DENTAL ASSISTANT : Melinda / Shawna 
OPERATION/PROCEDURE :
Crown Lengthening for # xxxxxxx 

ANESTHESIA:  Local Anesthesia
PREOPERATIVE DIAGNOSIS:  Short Clinical Crown
POSTOPERATIVE DIAGNOSIS:  same
OPERATIVE INDICATIONS:  Short Clinical Crown

CONSENT
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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.

Local Anesthesia
3 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.


Intrasulcular incision mesial to distal of the intended tooth
Full thickness flap. Bone removed to maintain existing architecture and allow 3mm biologic with from the most inferior portion of the decay. Area aggressively curetted and tissue closed with intrasulcular suture 3.0 after confirm adequate bone removal and associated soft tissue

No complication

 

Left side performed in similar fashion


ESTIMATED BLOOD LOSS:  minimal

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 5 pill for 3 days
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) 2020 Dr. Joseph Krajekian

Telephone :  (440) 646-0597 Office 

                     (888) 774-7773 Answering Service

Fax #         :  (888) 774-7970