Basic Dental Consultation Notes

Consult notes

Dr. Marcus Vance consulted the patient today for an acute dental evaluation. The patient presented with a 4-day history of severe, throbbing pain in the lower right quadrant, exacerbated by biting pressure and thermal changes. The purpose of the consultation was to evaluate tooth #46 following an urgent referral from Sarah Jenkins, OTR/L, who noted the patient was experiencing severe oral pain and refusal to eat during an adaptive feeding assessment.

The patient underwent a deep MOD composite restoration on tooth #46 on 14/11/2023. The treatment was initially successful, though intermittent cold sensitivity persisted until the onset of acute symptoms this week. Previous extractions of third molars (#18, #28, #38, #48) were completed in 2018 without complications.

Medical History

• Conditions: HTN, T2DM.
• Medications: lisinopril (Prinivil®) 10 mg PO daily, metformin (Glucophage®) 500 mg PO BID.
• Allergies: Penicillin (urticaria).

Clinical examination

• E/O: NAD

• I/O: Soft tissues WNL, no buccal swelling or sinus tract noted. Tooth #46 presents with a large, intact MOD composite restoration with recurrent decay palpable at the distal margin. Oral hygiene is fair with generalized mild plaque and localized calculus in the lower anterior region. Occlusion is Class I with mild attrition on lower incisors.

Radiographic examination

1x PA radiograph of the LRQ taken today. Findings reveal a deep, radiolucent recurrent carious lesion beneath the distal box of the existing restoration on #46, extending into the pulp chamber. A distinct 3 mm periapical radiolucency is visible on the distal root of #46. Alveolar bone levels are generally WNL.

Clinical tests

• Percussion - #45 (-), #46 (++), #47 (-)
• Palpation - #45 (-), #46 (+ buccal apex), #47 (-)
• Mobility - #45 (Grade 0), #46 (Grade I), #47 (Grade 0)
• Perio probing - Generalized 2-3 mm; #46 presents with 3-4 mm pockets and localized BOP on the distolingual aspect
• Pulp vitality tests - Cold test (Endo-Ice): #45 (+ normal), #46 (- no response), #47 (+ normal)

My diagnoses were

Tooth #46 has a necrotic pulp with symptomatic apical periodontitis secondary to deep recurrent distal caries. The patient also presents with localized plaque-induced gingivitis.

Treatment Plan

A phased treatment plan was discussed and agreed upon with the patient to eliminate acute infection and restore function. Phase 1 involves emergency pulpal debridement or definitive RCT on tooth #46, followed by a core build-up and full-coverage zirconia crown (#46) in Phase 2 to prevent vertical root fracture. The rationale for full cuspal coverage following endodontic therapy on a molar was explained in detail. Prescriptions provided today for acute infection management: clindamycin (Cleocin®) 300 mg PO TID for 7 days and ibuprofen (Advil®) 600 mg PO Q6H PRN pain.

The patient has been referred to Dr. Elena Rostova (Endodontist) for definitive root canal treatment of tooth #46 due to calcified root canals noted on the radiograph. Following completion of RCT, the patient will return to this clinic for the definitive core and crown preparation by Dr. Vance.

Complications/risks discussed

• Post-operative pain, swelling, and bruising following endodontic therapy.
• Risk of instrument separation, perforation, or inability to negotiate calcified canals during RCT.
• Potential for crown or root fracture prior to placement of the definitive full-coverage restoration.
• Possibility of treatment failure requiring endodontic retreatment, apicoectomy, or extraction of tooth #46.

Quoted

$1,250 + $1,400 for specialty endodontic therapy (#46) and subsequent definitive core build-up and zirconia crown (#46)