Patient Records
Contents
Medical History
When
- First appointment: Written form completed
- Every 1 year: Updated written form
- Every appointment: Verbal confirmation
How / Protocol
- Provide written form at first visit
- Update written form every 1 year (CareStack automates this)
- Confirm verbally at each appointment and document in notes
Why
- Ensures accurate, up‑to‑date medical profile
- Legal requirement
- Identifies risks (medications, allergies, systemic conditions)
Radiographs: OPG
When
- First evaluation appointment (age 18+)
- Every 5 years routinely
- Perio patients: every 2 years until stable
- Wisdom tooth symptoms
- Orthodontic records
How / Protocol
- Confirm patient is not pregnant
- Select full arch (P1) and correct patient size
- Take OPG
- Fee: $120
Why
- Baseline record
- Legal requirement
- Monitor pathology, bone levels, wisdom teeth
Radiographs: Bitewings
When
- First evaluation appointment
- Risk‑based intervals:
- Low: 18–24 months
- Medium: 12–18 months
- High: 6–12 months
- Children 6–12 years:
- First set when 6‑year molars erupt
- Mixed dentition: 18–24 months
- Primary dentition: 12–18 months if high risk
- After IP restoration or crown
How / Protocol
- Use size 2 film with paralleling device
- Children/sensitive: size 1 film
- If unable to tolerate: use OPG BW setting
- Fee: $45 per x‑ray
Why
- Detects caries, calculus, restoration integrity
- Essential for monitoring
Radiographs: Periapicals
When
- Limited exam with symptoms:
- Cold test negative
- Tender to percussion
- Irregular EPT
- Implant or RCT sites:
- Day of placement
- 3 months
- 6 months
- Every 12 months
- Trauma cases: follow trauma guidelines
How / Protocol
- Take PA using paralleling technique
- Ensure full apex capture
Why
- Baseline and diagnostic imaging
- Monitoring healing and pathology
Extra‑Oral Photographs
When
- First visit
- Orthodontic or cosmetic consultations
- Every 5 years
How / Protocol
- Use plain white wall
- Match patient head height
- Use portrait mode
- Required photos:
- Front relaxed + smile
- Left profile relaxed + smile
- Right profile relaxed + smile
- For smile design/lab work:
- Use retractors
- Full occlusion photos
- Natural smile
Why
- Baseline profile
- Treatment planning
Intra‑Oral Photographs
When
- First visit
- Orthodontic/cosmetic consultations
- Updated annually at OHTx
How / Protocol
- Use SLR camera, retractors, mirrors
- Standard set:
- Lips closed
- Lips partially open (“Emma”)
- Full smile
- Retracted occlusion
- Retracted slightly open
- Bite views:
- Right bite
- Left bite
- Arch views:
- Upper arch + sextants 1–3
- Lower arch + sextants 4–6
Why
- Baseline record
- Monitoring changes
- Diagnosis and planning
iTero Scan
When
- First visit
- Orthodontic consultations
- Lab cases
- Updated annually at OHTx
How / Protocol
- Create or locate patient file
- Complete full arch scan
- Capture natural bite + open bite
Why
- Baseline digital record
- Monitoring changes
- Required for ortho, splints, crowns, aligners
Summary Table
8. Quick Reference
| Record Type | When | Why |
|---|---|---|
| Medical History | First visit, 2‑year written update, every visit verbal | Legal requirement, safety |
| OPG | First eval (18+), 5‑yearly, perio 2‑yearly | Baseline, pathology, bone levels |
| BW | Risk‑based intervals, children, post‑restoration | Caries detection, monitoring |
| PA | Symptoms, implants, RCT, trauma | Diagnosis, healing monitoring |
| EO Photos | First visit, ortho/cosmetic, 5‑yearly | Baseline profile |
| IO Photos | First visit, ortho/cosmetic, annually | Monitoring, diagnosis |
| iTero Scan | First visit, ortho, lab cases, annually | Digital baseline, planning |