Dental Emergency Exam

Chief Complaint

• Severe, throbbing pain in the lower right back tooth for 3 days.

History of Presenting Complaints

• Acute onset of spontaneous, continuous throbbing pain localized to the mandibular right posterior quadrant, starting 3 days ago. Pain rated 8/10, radiating to the right ear and temple. Aggravated by mastication, thermal stimuli (lingering pain to heat), and supine positioning; partially relieved by ice water and ibuprofen 400 mg PO. Associated with localized right submandibular swelling and mild trismus over the past 24 hours.
• Patient expresses concern regarding dark discolouration of the affected molar and generalized extrinsic staining on anterior teeth.

Past Dental History

• Uneventful extractions of #1, #16, #17, and #32 on 14/05/2019. Composite restoration placed on #30 in 08/2021; patient missed scheduled 6-month recall appointments since 2022.

Past Medical History

• HTN, T2DM (diagnosed 2018).
• Medications: lisinopril 10 mg PO OD, metformin 500 mg PO BID, ibuprofen (Advil®) 400 mg PO PRN for dental pain.
• Allergies: Penicillin (hives).

Personal History

• Brushes once daily in the morning using a medium-bristle manual toothbrush and fluoridated toothpaste; does not floss or use interdental aids.
• Nocturnal bruxism reported by partner; smokes 10 cigarettes/day for 15 years; social alcohol intake (2–3 units/week).

Family History

• Father has T2DM and history of early tooth loss secondary to severe chronic periodontitis.

Extra Oral Examination

• Mild facial asymmetry due to diffuse, tender swelling over the right submandibular region. Right submandibular lymph nodes palpable, mobile, and tender. TMJ evaluation reveals bilateral clicking on opening without deviation; interincisal opening slightly restricted to 2 fingers (approx. 30 mm) due to pain. Lips competent and dry.
• Afebrile, tympanic temperature 37.2 °C, BP 138/86 mmHg, HR 82 bpm.

Intra Oral Examination

• Buccal mucosa, tongue, hard/soft palate, and floor of the mouth WNL. Vestibular tenderness and localized fluctuant swelling noted in the buccal vestibule adjacent to #30.
• Generalized erythematous, edematous, and rolled marginal gingiva with blunted interdental papillae. Loss of stippling and soft, spongy consistency around posterior sextants. Generalized BOP, with purulent exudate expressed upon palpation of the buccal gingiva of #30. Adequate width of attached gingiva throughout; gingival tension test negative.
• 28 teeth present (#1, #16, #17, #32 missing). Deep disto-occlusal (DO) recurrent caries with large undermined composite restoration on #30. Amalgam restoration intact on #19 (MO). Generalized mild-to-moderate attrition on anterior incisal edges; cervical abrasion noted on #5, #12, and #21. Grade I mobility on #30; all other teeth normal mobility. Moderate generalized subgingival and supragingival calculus with heavy extrinsic tobacco staining on lingual surfaces of mandibular anteriors.
• Fair oral hygiene status (OHI-S score: 2.8).
• Angle Class I molar and canine relationship bilaterally. Overjet 3 mm, overbite 3 mm. Prominent wear facets on mandibular and maxillary canines and incisors consistent with bruxism. Open distal contact on #30 due to carious breakdown. Fremitus test negative.
• Halitosis present.

Periondontic Findings

• #30: Probing depths 5 mm (MB), 4 mm (B), 6 mm (DB), 4 mm (ML), 3 mm (L), 6 mm (DL). Grade I furcation involvement (buccal). Severe tenderness to vertical and lateral percussion (+); digital palpation of buccal apex (+); Endo-Ice cold test negative (non-vital); EPT 80/80 (no response).
• #29, #31: Probing depths 3–4 mm, BOP (+), normal response to Endo-Ice without lingering pain, percussion (-), palpation (-).
• Remainder of dentition: Generalized probing depths 2–4 mm with localized 4 mm pockets in posterior interproximal sites; generalized BOP.

Radiographic Findings

• Periapical radiograph of #30 (taken 12/05/2026 at 09:15 America/Denver) reveals a large DO radiolucency extending into the pulp chamber beneath an existing radiopaque restoration. Widened PDL space and a well-defined periapical radiolucency (approx. 4 mm diameter) associated with both mesial and distal roots. Mild generalized horizontal bone loss (15–20%) noted compared to bitewings from 10/08/2021.

Laboratory Investigations

• Random capillary blood glucose (chairside): 142 mg/dL (7.9 mmol/L).

Diagnoses

• Pulp necrosis with acute apical abscess on #30.
• Generalized Stage I, Grade B periodontitis.
• Nocturnal bruxism.

Prognosis

• Overall prognosis is good, contingent on improved oral hygiene, smoking cessation, and glycemic control.
• Individual prognosis for #30 is fair-to-good following endodontic therapy, core buildup, and full-coverage crown restoration.

Treatment

• Emergency pulpectomy and incision and drainage (I&D) performed on #30 under local anaesthesia (2% lidocaine 36 mg with 1:100,000 epinephrine, 1.8 mL via right IANB and long buccal infiltration). Canals debrided, irrigated with 2.5% NaOCl, dried, and dressed with non-setting calcium hydroxide paste; access sealed with Cavit.
• Prescribed clindamycin (Cleocin®) 300 mg PO QID for 5 days, and paracetamol (acetaminophen, Tylenol®) 500 mg PO Q6H PRN for pain.
• Definitive plan: Completion of RCT on #30, followed by post/core and full-coverage crown; full-mouth scaling and root planing (SRP); fabrication of an occlusal nightguard.
• Advised warm saline rinses QID for 3 days. Instructed on Modified Bass brushing technique twice daily with a soft-bristle brush and daily flossing. Provided brief smoking cessation counselling.
• Review scheduled for 19/05/2026 at 10:00 America/Denver for symptom re-evaluation and RCT completion on #30.