Dentist's note adjusted to perio and fillings

Dentist Chief Complaint: - Patient presents with persistent pain in the lower right quadrant for approximately two weeks, exacerbated by cold food and pressure. History of Presenting Complaint: - Onset: Approximately two weeks ago after consuming cold drinks. - Progression: Pain initially intermittent, now more constant and sharp. - Aggravating factors: Cold food/drinks, biting pressure. - Alleviating factors: Warm compresses provide minimal temporary relief. - Associated symptoms: Occasional throbbing sensation. - Duration: Constant pain for the last 3 days. - Intensity: 7/10 on a pain scale. - Nature: Sharp, shooting pain. - Frequency: Daily, multiple times per day. - Patient also expressed concern about the discolouration of their front teeth, stating it affects their confidence when smiling. Past Dental History: - Routine check-ups and cleanings every six months. - One previous amalgam filling in tooth #30 (lower right first molar) approximately 8 years ago. - Orthodontic treatment (braces) from ages 12-14. - No significant dental diseases or injuries. Past Medical History: - Known medical conditions: Mild hypertension, well-controlled with medication. - Previous surgeries: Appendectomy at age 10. - Hospitalisations: None recent. - Ongoing treatments: Taking Lisinopril 10mg daily for hypertension. - Allergies: Penicillin (causes rash). - Current medications: Lisinopril 10mg daily. Personal History: - Patient brushes twice daily with a fluoride toothpaste and flosses once daily. Uses an electric toothbrush. Reports generally good oral hygiene but admits to sometimes forgetting to floss. - Relevant habits: Reports occasional teeth clenching during stressful periods. Denies tobacco chewing, smoking, or excessive alcohol intake. Family History: - Mother has a history of severe periodontitis and multiple dental caries. Father had several fillings in his youth. No known genetic conditions related to dental health. Extra Oral Examination: - Lymph node examination: No palpable cervical lymphadenopathy. - Facial symmetry: Symmetrical at rest and during movement. - TMJ examination: No clicks, pops, or tenderness on palpation; full range of motion. - Lip assessment: Competent lip closure, no lesions. - No additional extra oral examination findings. Intra Oral Examination: - Soft tissue examination findings: Buccal mucosa, tongue, palate, floor of mouth, and vestibule all appear healthy with no lesions or abnormalities. - Gingival examination findings: Pink, firm, and stippled gingiva. No bleeding on probing except for localised bleeding on probing distal surface of tooth #46. No exudation. Adequate amount of attached gingiva. Gingival tension test negative. - Hard tissue examination findings: 28 teeth present. Missing teeth #18, #28, #38, #48 (wisdom teeth previously extracted). Dental caries noted on occlusal surface of tooth #46 (distal aspect) and mesial surface of tooth #36. Restored teeth include #30 (amalgam). No periapical problems evident clinically. No pathologic migration, overhanging restorations, impacted teeth, or supernumerary teeth. Wasting disease: Mild attrition on incisal edges of anterior teeth. Mobility grading: All teeth Grade 0 mobility. Shade analysis: A3 for anterior teeth. Stains or deposits: Light plaque and calculus supra-gingivally, particularly on lower anterior teeth. - Oral hygiene status: Fair (OHI index rating). - Occlusion analysis findings: Class I molar relationship (Angles classification). Normal overbite (2mm) and overjet (3mm). No crossbite or open contacts. Mild crowding in lower anterior region. Small facets noted on canine cusps. No supra contacts. Fremitus test negative. - No additional intra oral examination findings. Periodontal: - Periodontal findings: PSR score 2 in all quadrants with localised 3 in lower right posterior. Generalised slight marginal recession (1-2mm) in anterior region. Bone levels appear stable radiographically, with localised slight bone loss around #46. Radiographic Findings: - Findings from dental radiographs: Bitewing radiographs reveal deep carious lesion involving dentin on the occlusal surface of tooth #46, extending towards the pulp. Interproximal caries on the mesial aspect of tooth #36, reaching the dentin-enamel junction. Periapical radiograph of #46 shows no periapical pathology. Bone levels are generally good with localised slight bone loss on the distal aspect of #46 compared to previous radiographs from 2 years prior. Laboratory Investigations: - Laboratory investigations and results: Not performed. - Biopsy findings: Not performed. Diagnoses: 1. Dental Caries, primary, occlusal surface, tooth #46. 2. Dental Caries, primary, mesial surface, tooth #36. 3. Gingivitis, generalised, mild. 4. Localised Periodontitis, Stage I, Grade A, around tooth #46. 5. Aesthetic concern: Tooth discolouration. Prognosis: - Overall prognosis for the patient is good with appropriate intervention and continued good oral hygiene practices. - Individual prognosis for teeth at risk: Tooth #46 has a fair prognosis due to the deep carious lesion, but is restorable. Tooth #36 has a good prognosis after restoration. Treatment: - Treatment completed today: - Lignocaine 2.2 ml with adrenaline 1:80,000 administered. Caries removed. SE primer and SE bond applied. Flowable lining placed. Shade A2 Esterlight Composite placed using matrix and wedges in increments of 3mm with light cure. - Treatment plan and recommendations: 1. Composite filling for tooth #36 (mesial surface). 2. Professional dental cleaning and scaling. 3. Oral hygiene instruction focusing on interdental cleaning around #46. 4. Discussion and evaluation of options for aesthetic improvement of anterior tooth discolouration. 5. Periodontal charting and further assessment of localised periodontitis around #46 at next visit. - Preventative plans and oral hygiene recommendations: 1. Reinforce daily flossing technique. 2. Recommend use of an interdental brush for the lower right posterior region. 3. Suggest fluoride mouthwash for caries prevention. - Review date and follow-up plans: Patient scheduled for review in 2 weeks for filling of tooth #36 and then in 3 months for a periodontal re-evaluation and hygiene appointment. Advised to return sooner if experiencing any issues. Next routine recall in 6 months from 1 November 2024.