Dental Extraction Note

**Dental Extraction Note** **Subjective** Chief Complaint: Patient presents with severe throbbing pain in the lower left quadrant, specifically tooth #30 (mandibular left first molar), which started approximately 3 days ago and has progressively worsened. Reports discomfort upon biting and sensitivity to cold. Relevant Dental and Medical History: Patient reports a history of multiple dental fillings. No known medical allergies. Medically fit and well. Last dental check-up was 6 months ago. No significant past dental treatments relevant to the extraction of #30. **Assessment** Extra-oral findings: Mild facial swelling noted in the left mandibular region. No palpable lymphadenopathy. Intra-oral findings: Tooth #30 exhibits a large carious lesion extending subgingivally on the mesial aspect. Significant tenderness to percussion. Periodontal probing depths within normal limits on adjacent teeth. Tooth #30 non-vital to vitality testing. Radiographic findings: Periapical radiograph of #30 reveals a large periapical radiolucency approximately 5mm in diameter associated with the mesial root. Bone support appears adequate around adjacent teeth. Root morphology appears normal with no significant dilacerations or anomalies. Diagnosis: Irreversible pulpitis with symptomatic apical periodontitis of tooth #30. **Consent** "Risks of extraction discussed including pain, bleeding, swelling, infection, damage to adjacent teeth/restorations, delayed healing, dry socket, paresthesia (if applicable). Patient provided opportunity to ask questions. Verbal and written consent obtained." **Treatment** Local anaesthetic: 2 cartridges of 2% Lidocaine with 1:100,000 Epinephrine administered via inferior alveolar nerve block and buccal infiltration. Extraction details: Tooth #30 was extracted using universal mandibular forceps (Ash 74N) following luxation with straight elevators (Coupland's Elevators #1, #2, #3). Tooth delivered in one piece without complication. Socket management: Socket inspected for any remaining root fragments or pathology. Irrigated thoroughly with saline. Haemostasis achieved with firm pressure applied with gauze. No bleeding observed post-pressure. Complications: No complications encountered. **Post-Operative Instructions** Post-operative instructions: Verbal and written post-operative instructions provided to the patient, including advice on pain management, diet, oral hygiene, and signs of complications. Analgesia advice: Advised to take Ibuprofen 400mg every 6 hours as needed for pain, and Paracetamol 500mg every 4-6 hours if pain persists. Follow-up: Advised to return for review in 7 days, or sooner if any concerns arise. **Other Notes** Other notes: Patient tolerated the procedure well. Discussed importance of maintaining good oral hygiene and considering future prosthetic replacement for the extracted tooth.