Subjective:
Patient is a 85 y. o. white female with complaint of intermittent swelling in the left submandibular area associated with mastication of food. The patient also complained of odontalgia involving the right posterior maxilla.
Objective:
Sever dental caries of posterior maxillary tooth number 3. Supereruption of nonfunctional tooth number 2. Impaction of tooth number 1. Gingival erythema and edema. Paplation of the floor of the mouth revealed a hard ovoid mass on the left side.
Panorex x-ray reveals a radio-opaque ovoid lesion in the left submanbibular duct area and carious teeth with a radiolucent ovoid lesion in the right posterior maxilla.
Assessment:
- Left submandibular gland duct sialolithiasis (submandibular salivary gland stone / calculi)
- Dental Caries
- Periodontitis
- Right posterior maxillary odontogenic cyst (periapical cyst)
- Impacted tooth number 1
Plan:
- General anesthesia via nasotracheal intubation
- Transoral sialolithotomy
- Extraction of carious teeth 2,3 and 4
- Extraction of impacted tooth number 1
- Left posterior maxillary alveoloplasty
- Enucleation of maxillary periapical cyst
Patient treated by Dr. Steven R. Tucker
Steven R. Tucker DMD, PSC
Oral and Maxillofacial Surgery
909 Scherm Road
Owensboro, KY 42301
1-502-926-4107
fax: 1-502-926-4166
Last Modified: April 13, 1997
