Good morning, Maria. How have you been since our last visit? Any issues with the crown we placed on tooth 14?
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Jatin Yadav
Jatin YadavI want to create SPA for the attached requirement pdf and color palletes are attached in the image
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Live Camera— Op Room 3 · Intraoral Cam
Intraoral camera feed — Ready
Clinical Chart
BP Sys118mmHg
BP Dia76mmHg
HR72bpm
SpO298%
Clinical Notes
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DADentist
MRPatient
Morning, Doctor. It's been okay, but I've been having some sensitivity on the lower left side when I drink cold water. It started about two weeks ago.
DADentist
I see. Let's take a look at that area. Can you point to exactly where you feel the sensitivity? Lower left — is it near the molars or more toward the front?
MRPatient
Towards the back. Like, the last two teeth. It's not constant, just when something cold touches there.
JMAsst.
I'm noting sensitivity in lower left quadrant, teeth 18-19 region. No spontaneous pain reported. I'll update the chart.
DADentist
Thank you, Jenny. Maria, I'm going to use the explorer to check for any exposed dentin or recurrent decay around the existing restorations. Let me know if anything hurts.
MRPatient
Okay, I will. Is this related to the filling I got last year?
DADentist
That's what I'm checking. The composite on tooth 19 looks intact but I'm seeing some gingival recession here that could be exposing the root surface. That would explain the cold sensitivity. I'd like to get a bitewing radiograph to rule out interproximal decay.
APDentist
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8 entries
AI Assistant4 recommendations pending
Treatment Suggestion
92% confidenceComposite Resin Restoration — Tooth #14 MOD
Based on radiographic findings, intraoral exam, and patient-reported thermal sensitivity, a Class II MOD composite restoration is recommended for tooth #14. The distal marginal ridge exhibits recurrent caries beneath the existing amalgam.
Radiograph shows radiolucency extending into dentin on distal aspect; thermal test confirms reversible pulpitis. Composite selected for esthetics and conservation of tooth structure.
Composite resin restoration (MOD) on tooth #14. Remove existing amalgam, caries excavation, apply universal bonding agent, incremental composite layering with 20s light-cure per increment. Verify occlusion and proximal contacts.
Imaging Insight
98% confidencePeriapical Radiolucency — Tooth #30 Mesial Root
CBCT analysis reveals a well-defined periapical radiolucency (4.2mm × 3.8mm) at the mesial root apex of tooth #30. Cortical plate intact. No sinus tract detected.
Lesion size exceeds 3mm threshold; proximity to mental foramen noted. Endodontic referral recommended with CBCT-guided access.
Periapical lesion tooth #30 mesial root — recommend endodontic consultation. CBCT-guided access advised due to proximity to mental foramen. Document pulp vitality testing results.
Treatment Suggestion
78% confidenceFull-Coverage Crown — Tooth #19 Post-Endo
Tooth #19 is endodontically treated with significant coronal tooth structure loss. Full-coverage zirconia crown recommended to prevent cuspal fracture.
Remaining walls <2mm; opposing dentition shows heavy occlusal wear. Zirconia selected for posterior strength and wear compatibility.
Full-coverage zirconia crown on tooth #19. Pre-op: verify endodontic seal, build-up core as needed. Prep: 1.5mm occlusal reduction, 1.0mm axial. Cement with resin-modified glass ionomer.
SOAP Note Draft
85% confidenceSOAP Note Draft — Visit 06/05/2026
AI-generated draft of today's encounter note based on transcription, imaging, and chairside findings. Includes chief complaint, findings, assessment, and plan.
Generated from real-time transcription and structured clinical data. Review and edit before signing.
S: Patient reports intermittent cold sensitivity on lower right quadrant × 3 weeks, now constant dull ache × 2 days.
O: Percussion test (+) tooth #30. PA radiograph shows 4.2mm periapical radiolucency at mesial root. Cold test — no response on #30.
A: Symptomatic irreversible pulpitis with apical periodontitis — tooth #30.
P: Endodontic referral for RCT #30. Prescribed amoxicillin 500mg TID × 7 days. Patient advised to call if swelling develops. Follow-up 2 weeks post-RCT completion.
SOAP Notes
AI-AssistedThis section was pre-populated by AI. Review and edit as needed before signing.
This section was pre-populated by AI. Review and edit as needed before signing.
K02.1 — Dental caries — dentinK05.1 — Chronic gingivitis — localizedK04.0 — Pulpitis — reversible
This section was pre-populated by AI. Review and edit as needed before signing.
| Code | Procedure | Tooth | Status |
|---|---|---|---|
| D2391 | Composite restoration — posterior, 1 surface | #19 | planned |
| D4341 | Periodontal scaling & root planing | Quad 3 | completed |
| D0274 | Bitewing radiograph — 4 films | — | completed |
Treatment Decision
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