Dr's Note

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 that is exacerbated by chewing and cold foods. The pain is constant and rated as a 7/10 on the pain scale. There are no associated symptoms such as fever or swelling. Past Dental History: - Patient reports a filling in the upper right first molar placed 5 years ago. 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. - Patient denies any habits such as clenching, grinding, or smoking. Family History: - Father has a history of periodontal disease. Extra Oral Examination: - No significant findings. Lymph nodes are non-palpable. TMJ examination reveals normal range of motion. 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 lower left molar. No other caries or restorations are present. All other teeth are present. - Oral hygiene is 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. Laboratory Investigations: - No laboratory investigations were performed. Diagnoses: - Dental caries, lower left molar. Prognosis: - Good prognosis for the lower left molar with appropriate treatment. Treatment: - Recommend root canal treatment and crown for the lower left molar. - Recommend oral hygiene instructions, including proper brushing and flossing techniques. - Review in 1 week.