Dental template

Chief Complaint: - Patient presents with a chief complaint of toothache in the lower left molar, which started approximately 3 days ago. History of Presenting Complaints: - The patient reports a throbbing pain in the lower left molar, rated as a 7/10 on the pain scale. The pain is exacerbated by chewing and cold foods. There is no relief with over-the-counter pain medication. The pain is constant and has been progressively worsening over the past three days. Past Dental History: - Patient reports a history of fillings in multiple teeth. No previous root canals or extractions. Past Medical History: - Patient has no known medical conditions. No known allergies. Taking no medications. Personal History: - Patient reports brushing twice daily and flossing once daily. No history of smoking or alcohol consumption. Family History: - Father has a history of periodontal disease. Extra Oral Examination: - No facial asymmetry noted. TMJ examination reveals normal range of motion with no clicking or popping. Intra Oral Examination: - Soft tissues appear healthy. No lesions or abnormalities noted. - Gingiva appears slightly inflamed around the lower left molar. - Hard tissue examination reveals a large carious lesion on the distal surface of the lower left molar. No other caries or restorations noted. - Oral hygiene appears fair. - Occlusion appears normal. Radiographic Findings: - Bitewing radiograph reveals a large carious lesion on the distal surface of the lower left molar, extending into the dentin. No periapical pathology noted. Laboratory Investigations: - No laboratory investigations performed. Diagnoses: - Dental caries, lower left molar. Prognosis: - Good prognosis with appropriate treatment. Treatment: - Recommend root canal treatment and crown for the affected tooth. - Provide oral hygiene instructions, including proper brushing and flossing techniques. - Schedule a follow-up appointment in one week to discuss treatment options. - Review date: 8 November 2024