21 September 2017

Salam dear Dr Haikal

This is a brief summary for my case.

Name : Miss Faznorharyati Fauzi

Age : 30 /Malay /Female

Chief complaint : Request for crown on anterior tooth

I/O : 11- Tooth fracture ½ of the crown, gutta percha (pink colored) noted at orifice above
CEJ level, tenderness upon palpation of buccal mucosa, tenderness on percussion, no
sinus tract, no pus , no bleeding.

Radiograph : PA taken last week

:
Diagnosis : 11-Symptomatic previously root canal treated tooth

Treatment plan:

Temporary- Composite build up on 11

Definite-

1)Oral hygiene education and instruction

2)Scaling and polishing

3)Refer to periodontal department for further periodontal assessment (BPE 3 on sextant 1,3,4)

4)Conservative tx- Amalgam: 27(DO), 28(O), 36 (DO)

Composite: 15 (D), 12 (M), 22 (M), 24 (DO), 37 (B.P.)

PRR: 18 (O), 47 (O &B.P.)

5)Refer to specialist for root canal re-treatment on 11

6)Fixed prosthodontic treatment –post and core on 11

7)Review

8)Recall