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May 2006

Patient Age: 53

Tooth # (1 - 32): 19 Procedure Category: Emergency Non-surgical root canal treatment (NSRCT)

Chief Complaint: “My tooth is killing me and I am worried about the swelling”

Medical History: Cardiac, pulmonary, gastrointestinal, renal, and neural systems review; non-significant; Pt denies taking any other medications either recently or currently. NKA, NKDA. BP 139/87 PR 65/min, RR14/min.

Dental History: Hx regular dental treatment throughout life; visits GDP annual examination & cleaning; gold crowns placed on #19 and 18 ~ 5 years. Hx of pain; body L Md; started ~ 1 wk prior; pain on function; avoids L function ~ 2 days; avoids occluding ~12 hrs; denies a Hx of sensitivity/pain to thermal stimulation; interrupted sleep ~ 3 days; buccal swelling started ~ 24 hrs; progressive larger ~ 12 hrs; little sleep last 24 hrs; OH difficult ~ 24-36 hrs

Clinical Evaluation: Extra-orally: (Figure 1) Relative to the R side of face; L angle of Md visibly enlarged; extending into the neck proper; L masseter, temporalis, digastric muscles tender to palpation; L submandibular gland lymphadenopathy. Mandibular ROM limited to 3 cm; normal range ~ 4.5cm

Intra-orally: well maintained dentition consistent with dental Hx; #18 & 19 lingual and buccal swelling present, lingiual swelling extend into floor of mouth; #19 & 18 have gold crown present; #18 is elevated;OH lacking as reported; denies difficulty in breathing or swallowing; Temp 37.6°C

Diagnosis:

• Pulpal: #18 Necrosis
• Periradicular: #18 Acute alveolar abscess

Treatment Plan:

• Recommended: Emergency: pulpectomy, apical trephination and I&D; Definitive: NS RCT

Alternative: Extraction

Restorative: Bonded core to restore access cavity; replace crown

PROGNOSIS: Good