Letter Back to Referring Clinician

1 November 2024 Dr. Sarah Jenkins Maple Dental Clinic 123 Oak Avenue, Anytown, AB T1A 2B3 Re: John Smith - Assessment of chronic tooth sensitivity Dear Dr. Sarah Jenkins, Thank you for referring the above patient to me. Please find feedback from our session below. Summary of Healthcare Encounter: Mr. John Smith, a 45-year-old male, presented with a chief complaint of chronic sensitivity in the upper right quadrant, particularly to cold stimuli, which has been ongoing for approximately three months. Clinical examination revealed significant enamel erosion on teeth #14 and #15, with minor gingival recession noted around #14. There was no evidence of active caries or significant periodontal pocketing. Percussion and palpation tests were negative. A thermal test confirmed heightened sensitivity to cold on teeth #14 and #15, which lingered briefly after stimulus removal. Radiographs showed no periapical pathology or significant pulpal involvement. Plan: Patient was advised on strategies to reduce tooth sensitivity, including using a desensitising toothpaste twice daily and avoiding highly acidic foods and drinks. A custom-fitted occlusal guard was recommended for night-time wear to address potential parafunctional habits contributing to the enamel erosion. A fluoride varnish application was performed during the visit to help remineralise affected enamel. The patient was scheduled for a follow-up appointment in six weeks to reassess sensitivity levels and evaluate the effectiveness of the occlusal guard. Should symptoms persist or worsen, further investigations such as vitality testing or referral for endodontic assessment will be considered. Should you have any further questions regarding the above patient, please do not hesitate to contact me. Sincerely, Dr. Emily White BDS, MSc (Restorative Dentistry) HPCSA Reg. No. DT1234567 info@whitesmiledental.com