Read the case notes and complete the writing task which follows.

Notes:

Assume that today’s date is 15 May 2021. You are a dentist at Newtown Dentistry Clinic. Mr Ivanov is a regularclient with a history of cancelling appointments.

PATIENT DETAILS:

Name: Mr Viktor Ivanov

DOB: 26 May 1979 (41 y.o.)

Address: 99 Shore Road, Newtown

Social background: Non-smoker, drinks 3 units of alcohol per week (approx.)

Oral care: Poor, irregular clinic attendance

Allergies: None

Medical history: No relevant medical history

Medications: Nil

Intraoral examination:

• Missing: 14, 18, 25, 27, 28, 38, 46, 48
• Restorations: 45, 26

Treatment Record

12 Jan 2020
     Reason for presenting (RFP):

• Pain in upper left (UL) quadrant

Exam: Pain associated with 26 (UL first molar); tooth tender to palpation (TTP). Non-vital (CO2 –ve)
4mm pocket on distal

Treatment:

• Advised Pt will need root canal therapy (RCT) over two visits or extraction
• Pt agreed to have RCT
• Next visit 1 week

22 Jan 2020
RFP: RCT 26 (1st visit)
Treatment:

• Local anaesthetic
• Rubber dam (RD) placed
• Access cavity. 3 canals located
• Irrigated & dressed
• 2 periapical (PA) radiographs for WLs (working lengths)

29 Jan 2020

RFP: RCT 26 (2nd visit)

Treatment:

• Local anaesthetic
• RD placed
• Irrigation & canal dried with paper points
• Obturation: gutta-percha and AH26, vertical and lateral condensation
• Final PA radiograph taken
• Restored access cavity
• Advised Pt – need for full coverage porcelain fused to metal crown in 1 mth but to return
  next week for core prep
  

05 Feb 2020

• Pt cancelled appt for core prep

02 Mar 2020

• Pt cancelled appt for core and crown prep, not willing to rebook

15 May 2021
RFP: Pain UL quadrant
Examination:

• 26 TTP and draining buccal sinus present
  

Diagnosis:

• PA radiograph – periapical abscess associated with 26
• Noted no crown placed on this tooth after RCT and provisional access cavity restoration
  broken down
• ?Reinfection of canal system

Treatment:

Advised Pt:

• need for endodontic retreatment of 26
• placement of crown on tooth necessary after treatment

Plan: Refer to endodontist

Writing Task:

Using the information given in the case notes, write a letter of referral to Dr Moon, an endodontist at Newtown
Dentistry Hospital. In your letter, outline Mr Ivanov’s relevant history and request further treatment. Address the letter
to Dr Deborah Moon, Newtown Dentistry Hospital, 60 Bay Street, Newtown.
In your answer:

• Expand the relevant notes into complete sentences
• Do not use note form
• Use letter format

The body of the letter should be approximately 180–200 words.