Oral Surgery

Oral Surgery Consultation: Patient Name: Sarah Jenkins Date of Birth: 15/05/1988 Date of Consultation: 1 November 2024 Referring Dentist: Name: Dr. Emily Roberts Practice: City Dental Care Contact: 020 7123 4567 Reason for Referral: Patient referred for evaluation and potential extraction of a partially impacted lower right third molar (tooth #48). Patient reports persistent pain, recurrent pericoronitis, and difficulty with oral hygiene in the area over the last three months, despite conservative management by her general dentist. Swelling and discomfort are exacerbated during chewing. Medical History: Generally healthy, no significant past medical history. No hospitalisations or major surgeries. Family history significant for hypertension (father) and type 2 diabetes (mother), but patient denies these conditions personally. No known history of bleeding disorders or immune deficiencies. Medications: - Ibuprofen 400mg PRN for pain (patient takes 2-3 times per week) - Combined oral contraceptive pill (Microgynon 30) daily - No known drug allergies or reactions. Dental History: Regular dental check-ups, no previous extractions. History of orthodontic treatment in adolescence (braces 2000-2002). No history of periodontal disease, trauma, or active caries. Patient reports occasional sensitivity to cold in upper left quadrant. Social History: Smoking Status: Never smoked. Alcohol Consumption: Occasional social drinker, 1-2 units per week. Other Recreational Drug Use: Denies any recreational drug use. Occupation: Primary School Teacher Living Situation: Lives with partner in an apartment. Clinical Examination Findings: Extra-Oral Examination: Facial symmetry appears normal. No palpable lymphadenopathy. TMJ assessment reveals full range of motion, no clicking or tenderness on palpation or movement. No external abnormalities noted. Intra-Oral Examination: Soft tissues of the oral cavity are healthy, with no signs of inflammation or lesions, apart from the specific area of concern. Dentition is generally good, no gross caries noted. Periodontal status is healthy. Occlusion appears stable, Angle Class I. Mucosa is pink and moist. Specific Area of Concern: Tooth #48 is partially erupted, mesially impacted, with a significant operculum present. The operculum is erythematous and swollen, tender to palpation. Signs of chronic inflammation around the tooth, with food debris entrapment. Distal caries noted on tooth #47, likely due to impingement from #48. Radiographic Findings: Panoramic radiograph (taken 28/10/2024) shows a mesio-angularly impacted tooth #48, with roots in close proximity to the inferior alveolar nerve canal. Moderate bone impaction. Distal caries extending into the dentin of tooth #47. No other significant pathology noted. Diagnosis: Partially impacted lower right third molar (tooth #48) with recurrent pericoronitis and distal caries on adjacent tooth #47. Discussion with Patient: Discussed the diagnosis and the chronic nature of the problem. Explained treatment options including observation, antibiotic therapy (for acute episodes), and surgical extraction. Detailed the risks of extraction, including pain, swelling, bleeding, infection, potential nerve injury (paraesthesia/anaesthesia of lip/chin), trismus, and damage to adjacent teeth. Benefits of extraction (resolution of pain, prevention of further pericoronitis and caries on #47) were highlighted. Patient's questions regarding recovery time and post-operative care were addressed. Patient expressed understanding and readiness for extraction. Treatment Plan: - Surgical extraction of tooth #48 under local anaesthesia with conscious sedation (if desired by patient). - Post-operative instructions provided verbally and in writing (pain management, diet, oral hygiene). - Referral for restorative treatment of distal caries on tooth #47 post-extraction healing. - Informed consent obtained for surgical extraction of #48. Patient verbally confirmed agreement to proceed. Prognosis: Good prognosis for complete resolution of symptoms and prevention of further complications following surgical extraction and subsequent restoration of #47. Next Steps: Schedule surgical extraction for tooth #48 within the next two weeks. Patient to be contacted by reception for booking. Prescription for post-operative analgesics and antibiotics (if deemed necessary) to be provided at time of surgery. Follow-up appointment for suture removal and wound check one week post-op.