Case Presentation 5

Dent 352
Preclinical Training in Oral Diagnosis

and Radiology
Final Case presentation
• Student name : Aseel alqaisi, Dania syouri

• Student ID: 144141 , 144249
• Section Number: 9
PATIENT DEMOGRAPHICS
 Initials: Muneera
 Gender: female
 D.O.B: 7/6/1970
 Age: 53
 Occupation: housewife
 Marital status: married
Chief Complaint
• Severe tender pain in the upper right quadrant,
Patient pointed at the 2nd premolar
History of Chief Complaints
• Well localized Severe pain at first the tooth was

uncomfortable and then became tender to touch or
mastication , pain started week ago ( following an
RCT done for the same tooth ‘‘15’’ ). Intermittent
Pain that lasts for 3 min . Relieved by releasing the
pressure and taking analgesics. No treatment done
for the C.C
Medical History
Details of Positive Medical History
Patient with well controlled DM type 2 from 20 years. She is very
cooperative and does regular check ups every 2 months. Last visit
was done a month ago and FBG and HBA1C measures were taken
( FBG= 128, HBA1C= 7.5). She takes her medication regularly and
have taken them today before eating her meal. Few complications
are seen such as vision issues.
GERD started 3 years ago , patient doesn’t do regular check up,

avoids certain type of food that makes her stomach worst.
Medications taken are Iansoprazole and Carafate.
No hospitalization,blood transfusion and allergies have been

documented.
PAST DENTAL HISTORY
•Dental History : last visit 5 years ago. Routine dental care, multiple extractions with
no complications, brushes her teeth once daily.
•Parafunctional habits :bruxism
•Tobacco use:
•1. Smoking: Yes No Quantity: Duration:
•2. Nargeleh: Yes No Frequency
•

EXTRA-ORAL EXAMINATION
General, eyes, Obesity
nails, hair
Skin of Face and Multiple nevi
neck
Facial symmetry, Class 1 profile, symmetrical,
profile, lip competent lips
competence
TMJ Tender
Jaw movements NAD

Continued
Temporalis Tender
Masseter Tender
Lymph nodes NAD
Neck, thyroid NAD

gland
Salivary glands NAD
Lip vermilion Fordyce granules on the upper

borders vermilion border
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INTRA-ORAL EXAMINATION
Upper labial NAD
mucosa
Lower labial NAD
mucosa
Right buccal Diffused keratosis
mucosa
Left buccal mucosa NAD
Hard palate Dark pigmented macule
Soft NAD
palate/oropharynx
Saliva NAD
Continued
Dorsal tongue NAD
Lateral tongue NAD
Ventral tongue NAD
Floor of mouth NAD
Gingivae Inflammation and recession
Alveolar mucosa NAD
Maxilla and NAD

Mandible
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I. Dental Charting:
Surface by surface examination, tenderness to percussion
II. General Examination of Teeth
Occlusion, tooth structure loss, color change, dental malformation, etc
Occlusion: normal
Angles classification, overbite, overjet,
Anterior crossbites, Posterior crossbite,
Edge-to-edge, bite, Open bite.
Plaque and calculus, calculus
gingivitis/periodontitis Periodontitis
Abnormal discoloration of teeth none

Tooth structure loss: excessive attrition, attrition, palatal erosion

erosion, abrasion

Dental malformations like peg laterals normal

General notes on 1. extensive carious extensive restoration at 15 and 37
lesions or restorations
2. multiple missing teeth
Other Findings: none

INVESTIGATIONS
1. Tenderness to percussion: 15 (extremely tender to
mild percussion)
2. Pulp Vitality testing : 15( Negative response)
3. Radiographs ordered and Radiographic Findings:
2 Bitewings, PA for 15
Generalized bone loss
Multiple carious lesions as seen in next slide .
3. Radiographic findings
G = Gross, M = Mesial, O = Occlusal/Incisal, D = Distal, F = Facial, L= Lingual/Palatal, I = Incipient, (R) =

Recurrent, R – Rareying osteitis (abscess, cyst, granuloma), S = Sclerosing osteitis, H = Hypercementosis, E
.= Enostosis, X = External resorption
DIAGNOSES/ PROBLEM LIST
• Controlled diabetes
• uncontrolled JERD
• Acute periapical periodontitis at 15
• Tenderness in TMJ, temporalis, and masseter due to bruxism
• Diffused keratosis in right buccal mucosa
• Inflammation and recession in gingiva
• Dark pigmented macule at hard palate
• Carious lesion in ( 14 ,16 , 25 , 26 , 34 , 35(R) , 44 , 45(R) )
• Failed RCT at 15
• Extracted ( 36 , 47 )
• Palatal erosion due to GERD , attrition due to bruxism
• calculus , generalized horizontal bone loss with recession
Treatment Plan Phases:
1. Systemic Phase: Medical Consultation: yes needed
2. Acute/Urgent phase: retreatment RCT for 15 due to acute periodontitis
3. Disease Control phase
 Periodontics: ( advanced care )
 Oral surgery: Extraction: none
 Conservative:
6 4 5 6 5
5 4 4 5
Oral Medicine ( attrition , dark pigmented macule at hard palate, diffused

keratosis at right buccal mucosa )
4. Definitive phase
Prosthodontics: partial denture for 36 , 47
Orthodontics : none

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Dent 352

Preclinical Training in Oral Diagnosis

• Student name : Aseel alqaisi, Dania syouri

• Well localized Severe pain at first the tooth was

GERD started 3 years ago , patient doesn’t do regular check up,

No hospitalization,blood transfusion and allergies have been

Jaw movements NAD

Lymph nodes NAD

Neck, thyroid NAD

Lip vermilion Fordyce granules on the upper

Lateral tongue NAD

Ventral tongue NAD

Floor of mouth NAD

Gingivae Inflammation and recession

Alveolar mucosa NAD

Maxilla and NAD

Tooth structure loss: excessive attrition, attrition, palatal erosion

Dental malformations like peg laterals normal

Other Findings: none

G = Gross, M = Mesial, O = Occlusal/Incisal, D = Distal, F = Facial, L= Lingual/Palatal, I = Incipient, (R) =

Oral Medicine ( attrition , dark pigmented macule at hard palate, diffused

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