Endodontist's note

Chief Complaint: - Patient presents with a throbbing pain in the upper left molar, which has been present for 3 days. History of Presenting Complaints: - The patient reports a throbbing pain in the upper left molar, specifically tooth #14. The pain started gradually 3 days ago and has progressively worsened. It is exacerbated by chewing and cold stimuli. The patient denies any alleviating factors. The pain is constant and rated as an 8/10 on the pain scale. There are no associated symptoms. Past Dental History: - Patient had a root canal treatment on tooth #19 five years ago. No other significant dental history. 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 habits such as clenching or grinding. Family History: - No relevant family history. 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 around tooth #14 is slightly inflamed and tender to palpation. - Tooth #14 has a large amalgam restoration. There is tenderness to percussion and palpation. No mobility noted. Shade analysis is within normal limits. - Oral hygiene is fair based on OHI index. - Occlusion appears normal. - Cold test on tooth #14 elicits a lingering pain. Percussion test is positive. Radiographic Findings: - Periapical radiograph of tooth #14 reveals a large radiolucency at the apex, indicating periapical pathology. The existing restoration is adequate. Laboratory Investigations: - No laboratory investigations performed. Diagnoses: - Pulpal Diagnosis: Irreversible pulpitis. - Periapical Diagnosis: Symptomatic apical periodontitis. Prognosis: - Overall prognosis for tooth #14 is good with root canal treatment. Treatment: - Discussed the need for root canal treatment with the patient. Informed consent obtained. - Root canal treatment of tooth #14 will be performed. - Patient was advised to take ibuprofen 400mg every 6 hours as needed for pain. - Patient was advised to return in 1 week for the next appointment. - Patient was advised to maintain good oral hygiene. - Review date: 8 November 2024.