Please Complete This Form by DELETING Any Treatment That You Do Not Want Us to Carry Out(For
STUDENT DENTAL HYGIENE & THERAPY
TREATMENT PLAN
Reception: 01642 738256
Please complete this form by DELETING any treatment that you do not want us to carry out(for restorative treatment please use chart at bottom of page 1)and post OR email to;Teesside University, Dental Reception, School of Health & Social Care, Centuria South, Middlesbrough, Tees Valley, TS1 3BA.
Name of patient: / Title:Address of patient:
Postcode: / Date of Birth:
Home tel: / Mobile:
Diagnosis: / BPE:
Medical History(Please indicate any relevant and current medical history) / Please Enclose:
- Copies of relevant radiographs
- Copies of relevant hospital/specialist correspondence relevant to prescribed treatment
History of challenging behaviour? YES/NO (please delete as appropriate)
If Yes, please give brief details.
Interpreter needed: YES/ NO
If Yes, specify language ………………………………………………
Restorative Treatment Plan (Please use notation and also write the treatment required)
* Please add additional information;
E.g.: Known preferences, diverse needs or further clinical information.
Prilocaine 3% with felypressin / Articaine 4% with adrenaline
1:100,000 (Infiltration only) / Lidocaine 2% and adrenaline / Scandonest 3% Plain / Oraquix 25% lidocaine 25% prilocaine (intra-pocket anaesthesia)
Maximum dose per treatment session:(please delete as appropriate)
1 2 3 4 5 / Route: (please delete as appropriate)
Infiltration IDB
Radiographs (please delete)
Right BW / Left BW / Periapical (specify tooth/teeth ………………………)
Please delete treatments as appropriate
OHI
A comprehensive& intensive instruction, tailored to the individual needs of the patient.
Dietary Analysis/Advice
A comprehensive& intensive instruction, tailored to the individual needs of the patient.
Brief Intervention Smoking Cessation
Using evidence based intensive instruction & appropriate signposting.
Fluoride Varnish Application 2.2% 0.25ml / 0.5ml / 0.75ml (delete as appropriate)
Routine Scale & Polish
Involves recording indices, removal of plaque, extrinsic staining and supragingival calculus deposits & full mouth prophylaxis, completed with OHI for home maintenance. Recommended for patients with BPE 1 - 2
Non-Surgical Periodontal Treatment
Incorporates routine periodontal treatment, with the removal of marginal calculus deposits. Involves recording indices, removal of plaque, extrinsic staining and supragingival calculus deposits & full mouth prophylaxis, completed with OHI for home maintenance Recommended for patients with BPE 2 – 3
Root Surface Debridement
A non-surgical approach to deep periodontal pocket biofilm disruption. Involves recording indices, removal of plaque, extrinsic staining and supragingival calculus deposits & full mouth prophylaxis, completed with OHI for home maintenance Recommended for patients with BPE 3 – 4
Localised delivery of antimicrobials as an adjunct to Periodontal Treatment
Specify type ……………………………………………………….. Site…………………………………………......
Dose…………………………………………… ……………………….. Frequency…………………………………………………..
Fissure sealant
Please record teeth to fissure seal on clinical notation, Restorative Treatment Plan, overleaf – denote them as ‘FS’
Restorative treatment (Not in inner third of dentine or with any likely pulpal involvement)
Please record on Restorative Treatment Plan overleaf. Procedures Dental Therapy students can perform; routine restorations in permanent teeth, from class I-V. Use of all dental materials except pins or pre-cast.
Paediatric treatment Please record on Restorative Treatment Plan overleaf. Procedures Dental Therapy students can perform; routine restorations in deciduous teeth, from class I-V.
(Including Stainless Steel Crowns, Pulpotomies and Deciduous Extractions.)
Ledermix Microabrasion (specify teeth………………………………………)
Please enclose radiographs to support your referral to assist in our diagnosis and treatment – thank you.
Recall Period to the Student Dental Facility for Maintenance Visits. This request will last for 2 years
Hygiene Treatment Monthly / 3 Monthly / as needed(Please delete as appropriate)
Fluoride Varnish Application (as specified above) 3 Monthly / 6 Monthly
Signature of referring Dentist:
______
Printed Name:
______
Date:
Practice E-mail: / Practice stamp: (Essential)
Practice Telephone No:
Please note; the patient remains under the care of the referring dentist and referring practice, this includes emergency appointments. This is not a Specialist referral service.. By signing this form you are agreeing to emergency drugs being administered by our GDC registered clinical supervisors.