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Case Presentation 5
Case Presentation 5
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
TMJ Tender
Masseter Tender
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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
INTRA-ORAL EXAMINATION
Dorsal tongue NAD
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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
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