Emergency Dental Consultation

Clinician: Dr. Marcus Vance, DDS

Date: 24/10/2023

Chief Complaint

Pt presents with severe, throbbing pain in the LLQ and noticeable left facial swelling, onset 3 days ago. Pain rated 8/10, keeping pt awake at night.

History of Presenting Complaint

• Onset and Duration: Began 3 days ago as a dull ache in LL6, escalating to severe constant pain over the past 24 hours.
• Pain Characteristics: Constant, severe, throbbing pain radiating to the left ear and temple.
• Aggravating and Relieving Factors: Exacerbated by biting, supine position, and hot stimuli. Minimal relief from OTC analgesics.
• Previous Treatments: Self-medicated with ibuprofen (Advil®) 400 mg PO QID for 2 days with diminishing efficacy.
• Associated Symptoms: Mild malaise, subjective low-grade fever, and localized gingival swelling. Denies dysphagia, dyspnea, or paresthesia.

Medical History

HTN, T2DM. Meds: lisinopril (Prinivil®) 10 mg PO OD, metformin (Glucophage®) 500 mg PO BID. Allergies: Penicillin (urticaria). Vitals: BP 138/84 mmHg, HR 82 bpm, Temp 37.6 °C.

Extraoral Examination (E/O)

• Facial Swelling: Mild, diffuse, firm swelling of the left buccal and submandibular regions. Warm to palpation.
• TMJ Assessment: NAD. Normal ROM, max opening 42 mm, no trismus or clicking.
• Lymph Nodes: Palpable, tender, mobile left submandibular lymphadenopathy.
• Other Findings: Mild left lower facial asymmetry secondary to buccal swelling. No cutaneous erythema or extraoral sinus tract.

Intraoral Examination (I/O)

• Soft Tissues: Fluctuant, erythematous vestibular swelling adjacent to LL6 (tooth #19), obliterated mucobuccal fold. No discharging sinus tract.
• Periodontal Findings: Localized moderate gingival erythema buccal to LL6; probing depths 3–4 mm generally, 6 mm mid-buccal LL6. Grade I mobility LL6.
• Caries and Restorations: Large, deep disto-occlusal (DO) amalgam restoration on LL6 with secondary caries and marginal breakdown.
• Pulpal Status: LL6 negative to cold testing (Endo-Ice), exquisitely tender to percussion (TTP +++) and buccal palpation. Adjacent teeth LL5 and LL7 normal to cold and percussion.
• Tooth Fracture: Lingual wall craze line noted on LL6, no displaceable cusp fracture.
• Occlusion: LL6 in slight supraocclusion due to periapical inflammation, causing premature contact on closure.

Radiographic Examination

• Radiographs Taken: 1x Periapical (PA) radiograph of LL6.
• Findings: Deep DO restoration in close proximity to the pulp chamber with recurrent radiolucency beneath the distal margin. Well-defined periapical radiolucency (approx. 5 mm x 5 mm) associated with both mesial and distal roots of LL6. PDL space widened.

Diagnosis

Pulp necrosis with acute apical abscess, LL6 (tooth #19).

Emergency Treatment Provided

• Pain Management: Lidocaine 2% with epinephrine 1:100,000 (Xylocaine®), 3.4 mL (2 cartridges) via left inferior alveolar nerve block and long buccal infiltration. Ibuprofen (Advil®) 600 mg PO Q6H PRN pain and paracetamol (acetaminophen, Tylenol®) 1,000 mg PO Q6H PRN pain.
• Infection Control: Incision and drainage (I&D) performed at the most fluctuant point of the LL6 buccal vestibule; copious purulent exudate expressed and irrigated with sterile saline. Clindamycin (Cleocin®) 300 mg PO QID for 5 days.
• Temporary Treatment: Emergency pulpectomy performed on LL6 under rubber dam isolation; 3 canals located, extirpated, and irrigated with 5.25% NaOCl. Non-setting calcium hydroxide medicament placed in canals, access cavity sealed with sterile cotton pellet and Cavit™ temporary restoration. Occlusion reduced.

Patient Instructions and Advice

• Post-Treatment Care: Avoid chewing on the left side until definitive restoration is placed. Perform warm salt water rinses (1/2 tsp salt in warm water) QID starting tomorrow. Maintain soft diet for 24–48 hours.
• Medications: Take clindamycin 300 mg PO QID until finished. Alternate ibuprofen 600 mg and paracetamol 1,000 mg PO every 3–4 hours as needed for pain control.
• Signs to Watch For: Seek immediate emergency medical attention if experiencing spreading facial or neck swelling, difficulty swallowing or breathing, trismus (inability to open mouth), or persistent high fever.

Follow-Up Plan

• Review in 7 days.
• Further Treatment Needed: Completion of root canal treatment (RCT) on LL6 followed by core build-up and full-coverage crown, or extraction if patient declines endodontic therapy.
• Referral: Referral to endodontist (Dr. Sarah Jenkins) provided for completion of molar RCT on LL6.

Quoted

• $420.00
• $1,250.00 for completion of molar root canal therapy (excluding final crown restoration)