Dental Specialist Consultation Report

Response Letter to Referring Clinician

Dr. Marcus Vance Mile High Endodontics 1450 Wazee St, Suite 310, Denver, CO 80202 (303) 555-0192 m.vance@milehighendo.com Date: 14/05/2024

To

Dr. Sarah Jenkins Apex Family Dentistry 820 Clermont St, Suite 100, Denver, CO 80220 (303) 555-0148 s.jenkins@apexdentalco.com

Re: Thomas Miller Date of Birth: 22/08/1978

Dear Dr. Sarah Jenkins,

Thank you for sending Thomas Miller to our practice for endodontic evaluation and management of tooth #19. The patient attended on 14/05/2024, when I carried out the initial specialist assessment and established the management plan below:

Summary of Consultation

Pt presents with a 4-day Hx of severe, spontaneous throbbing pain in the LLQ, exacerbated by thermal stimuli (linger > 30 s to cold) and mastication. Sleep disturbed for the past 2 nights.

PMHx: HTN, well-controlled. Meds: lisinopril (Prinivil®) 10 mg PO daily, ibuprofen (Advil®) 400 mg PO Q6H PRN for dental pain. Allergies: NKDA. Dental Hx: Deep MOD amalgam placed on #19 approx. 5 yrs ago.

Clinical Examination:

• Extraoral Findings: NAD. No facial asymmetry, swelling, or cervical lymphadenopathy. TMJ WNL.
• Intraoral Findings: Soft tissues WNL, no sinus tract or vestibular swelling noted. Tooth #19 exhibits a large MOD amalgam restoration with recurrent distal caries. TTP (+), palpation (-), Cold test (Endo-Ice) elicited severe lingering pain. Probing depths WNL (2–3 mm generalised, no isolated deep pockets).
• Radiographic & Diagnostic Findings: Pre-op PA and BW radiographs of #19 reveal a deep MOD restoration approaching the pulp horns, recurrent radiolucency at the distal margin, and widening of the apical PDL space on both mesial and distal roots. No vertical root fracture detected on CBCT.
• Diagnosis: Symptomatic irreversible pulpitis with symptomatic apical periodontitis, tooth #19.

Management Plan

Single-visit non-surgical root canal treatment (NSRCT) on tooth #19, followed by placement of a core build-up and referral back for a definitive full-coverage restoration.

Treatment Completed: Informed consent obtained. Administered local anaesthesia: lidocaine 2% with 1:100,000 epinephrine (Xylocaine®) 3.4 mL via left IANB and long buccal infiltration. Rubber dam isolation achieved. Caries and existing MOD amalgam removed; access cavity prepared. Four canals identified under dental operating microscope (MB, ML, DB, DL). Working lengths determined via electronic apex locator and confirmed radiographically. Canals instrumented using rotary NiTi files to size 35/.04 (mesials) and 40/.04 (distals). Copious irrigation with 5.25% NaOCl and 17% EDTA activated ultrasonically. Canals dried with paper points and obturated via warm vertical condensation using gutta-percha and bioceramic sealer (EndoSequence® BC Sealer™). Orifices sealed and access cavity temporised with Fuji IX GP® glass ionomer over a cotton pellet. Post-op PA radiograph confirms dense, three-dimensional obturation to working length without extrusion. Post-op analgesia instructions provided: paracetamol (acetaminophen, Tylenol®) 500 mg PO Q6H PRN and ibuprofen (Advil®) 400 mg PO Q6H PRN.

Ongoing Treatment Required: Tooth #19 requires a definitive coronal build-up and full-coverage cuspal protection (crown) as soon as possible to prevent coronal microleakage and structural fracture.

Patient Education & Preventative Advice: Advised pt to avoid chewing hard or sticky foods on the left side until the permanent crown is placed by your office. Reviewed standard post-op expectations (mild percussion sensitivity for 3–5 days).

Follow-Up & Referral Back

Patient to Continue Care with Referring Clinician: Pt has been instructed to contact your office immediately to schedule the definitive core build-up and crown preparation for tooth #19 within the next 2–4 weeks.

Specialist Follow-Up Required: Recall scheduled at our practice in 12 months for clinical and radiographic assessment of periapical healing.

Referral to Another Specialist: None required at this stage.

Attachments

1. Pre-operative periapical radiograph (Tooth #19) - 14/05/2024
2. Post-operative periapical radiograph (Tooth #19) - 14/05/2024

Thank you for referring Thomas Miller and for working collaboratively in the patient’s care. Please contact me if you need further information or would like to discuss this case.

Kind regards,

Dr. Marcus Vance DDS, MS, Cert. Endo Mile High Endodontics (303) 555-0192 | m.vance@milehighendo.com