Chief Complaint:
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Patient came for follow-up visit to continue the treatment of her upper left tooth.
Pre-preparation: Correct patient, correct procedure, correct side, correct site/safety
procedure followed: YES
Informed consent form obtained: YES
Patient was educated and informed about the cost of service: YES
Clinical Finding:
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Tooth #13, Non-vital tooth, pulpectomy treated with temporary filling, no pain, no
tenderness, no swelling and no signs and symptoms of any other abnormalities, tooth
is ready for RCT (obturation)
Primary Diagnosis:
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Fractured dental restorative material (composite) without loss of material tooth #13
Secondary Diagnosis:
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Necrotic pulp tooth #13
Treatment Planned:
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RCT and 2 periapical x-rays for tooth #13
Tooth #13 we will do root canal treatment to repair and save the tooth.
Treatment Done:
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No anesthesia was given, non-vital tooth #13 + removal of the temporary filling
and cotton pellet + cleaning of the canals
RCT 2 canals (Palatal, buccal) was done for tooth #13 which includes preparation of the
canals with 2 shape file system using J-morita machine + RC irrigation of 3% NaOCL
1 periapical x-ray was taken showing tooth #13 with master apical cones inside the canals
to check the working lengths and accuracy of the canals
RC irrigation with normal saline solution + Drying of the canals using paper points + RC
obturation with gutta-percha points and Endodent root canal sealant
Placement of temporary filling zinc oxide, eugenol free
1 periapical x-ray was taken to check the accuracy of the obturation of tooth #13
Tooth #13
(palatal) WL: 23mm MAC: 25 taper 4%
(buccal) WL: 22mm MAC:25 taper 4%
Medication: None
Xrays: Tooth #13
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Indication for Xray:
o To check the working lengths and the accuracy of the root canal treatment for
tooth #13
Technique or approach:
o Periapical Xray
No. of views:
o 2 views
Findings:
o Showing the above lengths of the canals and obturation was fit and accurate.
Impression:
o Root canal treatment is absolutely fit and accurate.
Sick Leave Given: none.
Instruction and Education: Oral Hygiene Intructions, Post root Canal Treatment Instructions.
Person Instructed: Patient.
Method of Instruction: Verbal Instructions.