Chief Complaint:
- Severe toothache in the lower right molar region for the past 3 days.
History of Presenting Complaints:
- The patient reports a sharp, throbbing pain in the lower right molar that started suddenly 3 days ago. The pain worsens at night and is aggravated by hot and cold foods. The patient also notes swelling in the gum area and difficulty chewing on the affected side.
Past Dental History:
- The patient had a root canal treatment on the upper left molar in 2022, which was successful. No other significant dental treatments or surgeries.
Past Medical History:
- The patient has a history of hypertension, managed with medication. No known allergies. Currently taking Lisinopril 10 mg daily.
Personal History:
- The patient brushes twice daily but does not floss regularly. Reports occasional smoking, about 5 cigarettes per week.
Family History:
- No known familial dental diseases. Family history of hypertension.
Extra Oral Examination:
- Mild swelling observed on the right side of the face. TMJ examination shows normal range of motion.
Intra Oral Examination:
- Buccal mucosa appears normal. Gingival examination reveals redness and swelling around the lower right molar. Hard tissue examination shows a large cavity in the lower right first molar with tenderness on percussion. Oral hygiene status is fair.
Periodontic Findings:
- Lower right first molar (tooth #46) shows pocket depth of 5mm with bleeding on probing.
Radiographic Findings:
- Periapical radiograph of the lower right molar shows deep caries approaching the pulp with periapical radiolucency indicating possible abscess formation.
Laboratory Investigations:
- No laboratory investigations conducted.
Diagnoses:
- Acute pulpitis with periapical abscess in the lower right first molar.
Prognosis:
- The prognosis for the affected tooth is guarded, depending on the response to treatment.
Treatment:
- Recommend root canal treatment for the lower right first molar. Prescribe antibiotics and analgesics to manage infection and pain. Advise on improved oral hygiene practices, including regular flossing. Schedule a follow-up appointment in 1 week to assess progress.
