Patient Information:

  • Name: Pratik Agarwal
  • Age: 38 years
  • Gender: Male
  • Date: 09-05-2025

Chief Complaint: I have been having pain in my lower right back tooth for the past few days. It hurts especially when I eat something cold or sweet.

History of Present Illness:

  • Pain started - 5 days ago
  • Initially mild, now constant and sharp
  • Worse at night and with cold/sweets
  • No trauma or swelling noted

Medical History:

  • Non-contributory
  • No known allergies or systemic diseases

Clinical Examination:

  • Tooth #46 shows a deep mesial carious lesion
  • Tender on percussion
  • No mobility or swelling
  • Cold test exaggerated and lingering pain
  • Normal periodontal probing

Radiographic Examination:

Findings:

  • Large mesial radiolucency involving dentin and close to pulp
  • PDL space intact
  • No periapical radiolucency

Diagnosis:

Tooth #46 – Symptomatic Irreversible Pulpitis

Treatment Plan:

  • Root Canal Treatment (RCT)
  • Access cavity preparation
  • Working length determination
  • Cleaning and shaping
  • Irrigation with NaOCl, EDTA
  • Obturation with Gutta-percha

Prognosis:

Good, with proper RCT and crown

Patient Instructions:

  • Maintain oral hygiene
  • Avoid chewing hard foods until the crown placed
  • Return if pain/swelling occurs

Follow-up in 1 week, and again after crown cementation

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