Dental Data Exchange
0.1.0 - STU1 Ballot

This page is part of the Dental Data Exchange (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Scenario 3 Dental to Dental (Endodontist) Referral

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Patient A contacts Dr. Drew Dentist complaining about pain in lower right quadrant of his mouth. He mentioned the pain started two weeks ago and has worsened. He noticed sharp, stabbing pain provoked by drinking cold beverages in the past week and lingering pain with biting in the last 2 days. Patient A is able to eat regular food, but is only chewing on the left side. He is taking 400mg ibuprofen every 8 hours for pain.

Patient A has a history of hypertension and takes Lisinopril 10mg tablet once daily. He is also taking erythromycin 500mg every 6 hours for the infection, and additional ibuprofen for pain as needed. He is allergic to penicillin.

Dr. Dentist takes Patient A’s clinical impressions and sends referral to Endodontist for an evaluation of tooth #30 and endodontic therapy #30. Referral included medications prescribed, diagnosis, prognosis, treatment notes, images, and follow up recommendations.

#30 pulpal necrosis and periapical pathosis with draining fistula. Clinical impression is that possible vital pulp remnants remain. #30 possible cracked DB cusp; rule out cracked tooth. Clinical impression is that tooth is restorable. #29 D caries lesion. On exam of the right lower quadrant, tooth #30 was sensitive to percussion (lingering for 45 seconds) and to cold (sharp, stops when cold removed). No sensitivity to palpation, pain upon biting with relief upon opening. No evidence of new caries on distal; missing #28, replaced with endosteal (root form) implant with full crown tooth-colored restoration;#32 impacted with possible full boney impaction. One cm swelling present on buccal free-gingiva around #29 and #30 with sinus tract present #30B. Periodontal pocket depth WNL.

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