Prosthodontist's note (custom)

Chief Complaint: - Patient presents with difficulty chewing and discomfort in the upper jaw for the past 3 months. History of Presenting Complaints: - The patient reports a gradual onset of discomfort in the upper jaw, which has progressively worsened over the last 3 months. The discomfort is aggravated by chewing hard foods and alleviated by resting the jaw. The patient also notes occasional swelling in the area. - The patient expresses concern about the appearance of their smile due to missing teeth. Past Dental History: - The patient had a root canal treatment on the lower right molar in 2020, which was successful. - Extraction of the upper left second molar in 2018 due to severe decay. Past Medical History: - The patient has a history of hypertension, managed with medication. - No known allergies. Personal History: - The patient brushes twice daily and uses dental floss regularly. - Reports occasional teeth grinding at night. Family History: - The patient's mother had a history of periodontal disease. Extra Oral Examination: - No significant findings in lymph node examination. - Facial symmetry is normal. Intra Oral Examination: - Soft tissue examination reveals healthy buccal mucosa and tongue. - Gingival examination shows mild gingivitis with slight bleeding on probing. - Hard tissue examination reveals missing upper left second molar and moderate dental caries on the upper right first molar. - Oral hygiene status is fair based on the OHI index. - Occlusion analysis indicates a Class I occlusion with mild crowding in the lower anterior teeth. Radiographic Findings: - Panoramic radiograph shows moderate bone loss around the upper right first molar and caries in the same tooth. Diagnoses: - Partial edentulism in the upper jaw. - Moderate dental caries on the upper right first molar. Prognosis: - Overall prognosis is good with appropriate treatment. - The upper right first molar has a fair prognosis due to caries and bone loss. Treatment: - Recommend a fixed partial denture to replace missing teeth in the upper jaw. - Restoration of the upper right first molar with a composite filling. - Preventative plan includes reinforcing oral hygiene practices and regular dental check-ups every 6 months. - Follow-up appointment scheduled for 15 November 2024.