HISTORY OF PRESENT ILLNESS: This (XX)-year-old female, who is 29 weeks pregnant, presents to the emergency department with dental pain. The patient states she thinks that she had a filling fall on her back tooth in the right upper jaw. She states she has been having pain for two days. She does not remember any inciting event, as in chewing on something hard or displacement by clinching her jaw. She states she has been having difficulty chewing since then. She has had sensitivity to cold. She states there is tenderness with any palpation. She feels slightly lightheaded with this and the pain radiates into her jaw. She has had no swelling, no fevers, no chills or any signs of infection in this area. The patient states that she tried to contact her dentist to have this evaluated; however, they told her at 29 weeks pregnant she will have to see her OB before being evaluated. The patient is a G3, P1-0-1-1. Previous delivery was vaginal for full term.

PAST MEDICAL HISTORY: Negative.

PAST SURGICAL HISTORY: Tonsillectomy and adenoidectomy.

MEDICATIONS: Prenatal vitamins.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient smokes half pack a day. Denies alcohol or drug use.

FAMILY HISTORY: Negative.

REVIEW OF SYSTEMS: A 13-point review of systems was done, negative except for that noted above.

PHYSICAL EXAMINATION:
VITAL SIGNS: On admission, temperature 35.9, pulse 94, respirations 18, blood pressure 142/82, and O2 saturation 97% on room air.
GENERAL: The patient is alert and oriented x3.
HEENT: Head: Normocephalic, atraumatic. Eyes: PERRLA, EOM intact. Ears: TMs are pearly gray. Nose: No mucosal congestion. Mouth/Oropharynx: The patient has multiple dental caries on her upper teeth, both right and left. The tooth in question does not have any erythema, no swelling, no pockets of pus around the gumline. It is tender to palpation. Does not seem loose or displaced, does look cracked and has a large dental caries.
NECK: Supple. No palpable masses, no lymphadenopathy, carotid bruits or JVD.
CHEST: Breath sounds are clear and equal bilaterally.
HEART: Regular rate and rhythm. No murmurs, gallops or rubs.
ABDOMEN: Soft, nontender, nondistended with normal bowel sounds. There is a palpable uterine fundus consistent with a 29-week pregnancy.
SKIN: No rashes, lesions or pigment changes.
CNS: The patient is alert and oriented. Muscle strength +5/5 bilaterally, upper and lower extremities. Cranial nerves are intact. Sensation is intact. DTRs are intact.
MUSCULOSKELETAL: No deformity, cyanosis or edema. Peripheral pulses, dorsalis pedis, posterior tibial and radial are +2/4.

EMERGENCY DEPARTMENT COURSE: The patient presents to the emergency department with dental pain. The patient states she called her dentist’s office, who stated that they would be unable to do anything due to her pregnancy. At this time, we contacted Dr. John Doe’s office, we talked to them, and they said that they had in fact set her up for an appointment tomorrow and she can come in tomorrow as scheduled for care and treatment. At this time, this was explained to the patient. We offered the patient a Marcaine shot to block the tooth decreasing her pain. She is agreeable to this at this time. We injected the area in the gum above the affected tooth, the first molar on the right upper jaw, with approximately 3 mL of 0.5% Marcaine. Adequate anesthesia was obtained. The patient was comfortable going home at this time with followup with Dr. John Doe as scheduled.

IMPRESSION: Dental caries.

DISPOSITION: We will discharge the patient home. Penicillin V potassium 500 mg t.i.d. x10 days. If fever, swelling, increased pain, please return to the emergency department as soon as possible. Follow up with Dr. John Doe as scheduled tomorrow.

PREOPERATIVE DIAGNOSIS: Mandibular fracture, bilateral subcondylar fracture.

POSTOPERATIVE DIAGNOSIS: Mandibular fracture, bilateral subcondylar fracture.

OPERATIONS PERFORMED:
1.  ORIF of mandibular fracture.
2.  Application of maxillomandibular fixation.

SURGEON:  John Doe, MD

ANESTHESIA:  General and 10 mL of a 1:1 mix of 1% lidocaine with epinephrine and 0.5% Marcaine plain.

ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF OPERATION:  After explaining potential risks and benefits of the procedure to the patient, written consent was obtained. The patient was taken to the operating room by gurney and transferred to the operating room table in the supine position. An endotracheal tube was placed and secured into position with an 0 silk suture through his septum. The patient’s mouth was prepped with Peridex and the above local anesthetic was infused superiorly and inferiorly into the gingival buccal sulcus. A timeout was performed indicating the patient, the procedure, and site to be operated on. One gram of Ancef was given preoperatively.

First, we placed arch bars on both the upper and lower dentition. The patient had very damaged and poor dentition, and therefore, it was somewhat difficult to get adequate fixation. However, this was performed on the superior and inferior rows of teeth. Once fixation had been applied, we then made a gingival buccal sulcus incision and dissected down to the level of the mandible, stripped the mandible of mentalis and overlying muscle. The mental foramina were visualized bilaterally. The nerves were intact.

Once we visualized the fracture, we then debrided the fracture off any granulation tissue. The fracture was then reduced with a reduction clamp and two 2.0 Mini Plates were applied, one along the inferior border with bicortical screws and one along the superior border with unicortical screws. The reduction clamp was replaced and the mandible stayed in good reduction. The mandible subcondylar fractures were addressed by application of MMF. The arch bars had already been placed. The patient was pulled up into proper occlusion and his mouth wired shut. Prior to wiring mouth shut, a previously placed throat pack was removed and an NG tube was placed and put on suction to clean his stomach and oropharynx out.

The incision was then irrigated and closed with 3-0 chromic suture with 3-0 Vicryl suture suspending the mentalis. The patient tolerated the procedure well without any immediate complications. He was awoken from anesthesia and taken to the recovery room. The patient left the operating room in good condition.

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DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Dental infection with a behavior problem.

POSTOPERATIVE DIAGNOSIS:  Dental infection with a behavior problem.

DESCRIPTION OF PROCEDURE:  This (XX)-year-old girl was brought into the operating room and placed in the supine position. After a satisfactory level of general anesthesia had been administered by nasotracheal intubation, a 4 x 4 gauze throat pack was placed and the following dental procedures were then carried out based upon a thorough oral examination and radiographs, which are available to review.

The upper right second primary molar and both lower second primary molars were excavated of caries and prepared to receive stainless steel crowns. Prior to crown placement, a pulpotomy was performed on these three teeth. Crowns were closely fitted to these teeth and cemented with FujiCEM cement. The upper left primary canine and first and second primary molars were excavated of caries and restored with light-bonded Z100. The lower right first primary molar was then extracted by means of elevator and forceps. Tissue around the extraction site was closely approximately and sutured with 3-0 chromic suture.

A thorough prophylaxis with topical fluoride was then performed. The mouth was suctioned, throat pack removed, and the patient was taken to the recovery room in satisfactory condition having tolerated the procedure well.