DEPARTMENT OF

ORAL MEDICINE AND RADIOLOGY

540020507555
BACHELOR OF DENTAL SURGERY
AUGUST 2024-2025

DEPARTMENT OF ORAL MEDICINE

AND RADIOLOGY

BONAFIDE CERTIFICATE
This certify that this clinical case record was done by
S.SANTHIYA Final year BDS in Department of Oral
Medicine and Radiology, during the period between
AUGUST 2024-2025.

SIGNATURE OF MENTOR SIGNATURE OF HOD

INDEX
S.NO LONG CASES

1. Anemic Glossitis

2. Dental fluorosis

3. Homogenous Leukoplakia

4. Traumatic fibroma
5. Herpes labialis

6. Pseudomembranous candidiasis

7. Inflammatory gingival enlargement

8. Tobacco pouch keratosis

9. Smoker’s melanosis

10. Dental caries leading to Dentoalveolar abscess

 LONG CASE - 01

NAME ;- Ms. Akshitha

OP. NO. ;- 25954 / 24

AGE / SEX ;- 20 / F

ADDRESS ;- Pallavaram

OCCUPATION ;- Student

RELIGION ;- Hindu

CONTACT NO ;- 6383009269

CHIEF COMPLAINT:
Patient gives a complaint of pain in her upper right back tooth region for the past 3
months.

HISTORY OF PRESENTING ILLNESS:

Patient gives history of sharp pain while eating sweet and hot food in her upper back
tooth region. Patient gives no history of medication for pain relief. No history of bleeding
gums, bleeding while brushing and bad breath.

PAST MEDICAL HISTORY:

Patient is a known anaemic.

PAST DENTAL HISTORY:

This is the patient's first dental visit.

FAMILY HISTORY:
Patient's father is a known hypertensive and is under medications for the past 10 years.

MARITAL STATUS ;- Unmarried

NO. OF CHILDREN ;- NIL

DIET ;- Vegetarian

BRUSHING HABITS ;- Once daily with toothbrush and toothpaste

OTHER HABITS ;- NIL

GENERAL EXAMINATION

APPEARANCE ;- Patient is calm, conscious and co-operative

BUILT ;- Moderately built

NOURISHMENT ;- Moderately measured

ANEMIA ;- Present

ICTERUS ;- Absent

CYANOSIS ;- Absent

CLUBBING ;- Absent

PEDAL EDEMA ;- Absent

STRUCTURAL ALTERNATION ;- Unaltered

VITAL SIGNS
PULSE RATE ;- 78 beats / min

RESPIRATORY RATE ;- 14 breaths / min

BLOOD PRESSURE ;- 116 / 75 mm Hg

TEMPERATURE ;- 98˚ F

SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM:
 No loss of memory
 No vomiting
 No headache
CARDIOVASCULAR SYSTEM:
 No pain
 No palpitation
 No syncope

GASTROINTESTINAL SYSTEM:
 No burning sensation, No dysphagia while having food
 No loss of taste
 No stomach ache

RESPIRATORY SYSTEM:
 No cough
 No breathlessness
 No tuberculosis

URINOGENITAL SYSTEM:
 Regular micturition
 No polyuria or discolouration
 No burning sensation or abdominal discharge

SKELETAL SYSTEM:
 No spasm
 No stiffness of joints
 No abnormal growth

LOCAL EXAMINATION
EXTRAORAL EXAMINATION
FACIAL SYMMETRY:
No gross facial asymmetry.
TMJ EXAMINATION
INSPECTION:
No pain/ jaw deviation/ deflection detected in the right or left TMI upon mouth opening and
closing.

PALPATION:
No deflection, No significant clicking sound heard in the right or left TMI upon mouth
opening and closing.

LYMPHNODE EXAMINATION:
No clinically palpable lymphnode in the cervicofacial region.

MOUTH OPENING: 37mm (Interincisal distance)

INTRAORAL EXAMINATION
SOFT TISSUE

LABIAL MUCOSA ;- No abnormalities detected

ALVEOLAR MUCOSA ;- No abnormalities detected

FLOOR OF THE MOUTH ;- No abnormalities detected

HARD PALATE ;- No abnormalities detected

UVULA ;- No abnormalities detected

SOFT PALATE ;- No abnormalities detected

TONSILLAR AREA ;- No abnormalities detected

FRENUM ;- No abnormalities detected

TONGUE ;- Pale tongue with atrophy

VESTIBULE ;- No abnormalities detected

LIP ;- No abnormalities detected

 BUCCAL MUCOSA

INSPECTION:
Diffuse erythematous appearance seen in anterior 2/3rd of tongue extending from the tip
of tongue to sulcus terminals on dorsal surface of tongue. The erythematous lesion
superimposed by white patches of each measuring 1x 2 cm, roughly irregular in shape with
well-defined margins.

PALPATION:
On palpation, all inspectory findings are confirmed smooth surface texture. Soft in
consistency. No tender on percussion. The white patches are scrapable.

GINGIVA:
COLOUR ;- Pale pink with melanin pigmentation

CONTOUR ;- Scalloped marginal gingiva with knife edged interdental papilla

CONSISTENCY ;- Firm and Resilient

POSITION ;- At the level of cemento-enamel junction

SIZE ;- Unaltered

SHAPE ;- Unaltered

SURFACE TEXTURE ;- Stippling absent

BLEEDING ON PROBING ;- NIL

EXUDATE ;- Absent

POCKET DEPTH ;- Absent

GINGIVAL RECESSION ;- NIL

HARD TISSUE EXAMINATION

TYPE OF DENTITION ;- Permanent

NO. OF TEETH ;- 28
 DENTAL CARIES ;- 16, 17, 27

PIT AND TISSUE CARIES ;- 26, 36, 37, 46, 47

TENDER ON PERCUSSION ;- 27

MISSING ;- 18, 28, 38, 48

CALCULUS ;- Mild calculus present

STAINS ;- NIL

ROOT STUMPS ;- NIL

FILLED TOOTH ;- NIL

FRACTURED TOOTH ;- 13, 23

WASTING DISEASE ;- NIL

MOBILITY ;- NIL

FRACTURED RESTORATION ;- NIL

PARTIAL ERUPTION ;- NIL

PROSTHETIC CROWN ;- NIL

CERVICAL ABRASION ;- NIL

GROSSLY DECAYED ;- NIL

SUMMARY:

Patient named Ms. Akshitha, 20 years old, female, reported to the department of oral
medicine with chief complaint of pain in her upper right back tooth region for the past 3
months. Patient gives history of sharp pain while eating sweet and hot food in her upper back
tooth region. Patient gives no history of medications, bleeding while brushing and bad breadth.
Patient’s past medical history reveals that patient is anemic.

Patient’s past medical history reveals that patient has not undergone any dental
treatment. Patient’s family history reveals that the patient’s father is a known hypertensive and
is under regular medication for the past 10 years. Patient consumes only vegetarian diet,
brushes once daily with toothpaste and toothbrush.
 On general examination, no abnormalities are detected. Patient’s vital signs are normal
and no abnormalities are detected in systemic examination. Extraoral examination reveals no
gross face asymmetry, No pain, No jaw deviation, No restricted mouth opening on inspection
and palpation of TMI, No evidence of clicking sound heard on opening and closing of mouth
on the right and left TMI with maximum mouth opening of 37mm interincisal distance.

On intraoral examination of buccal mucosa, on inspection diffuse erythematous

appearance seen on the anterior 2/3rd of tongue extending from top of tongue sulcus terminals.
On dorsal surface of tongue, the erythematous lesions are superimposed by white patches of
each measuring 1x 2cm roughly irregular in shape with well-defined margins. On palpation,
all inspectory findings are confirmed. Smooth surface texture, soft in consistency, non-tender
and the white patches are scrapable.

On examination of hard tissue, reveals dental caries irt 16, 17 and 27. Pit and tissue
caries irt 26, 36, 37, 46, 47 and mild calculus are present. 18, 28, 38, 48 are missing and fracture
irt 13, 23.

On co-relating with chief complaint, history of presenting illness, intraoral examination,

a provisional diagnosis of dental caries with reversible pulpitis in 17 was arrived.

PROVISIONAL DIAGNOSIS:
Dental caries with reversible pulpitis irt 17.

INVESTIGATION:
On investigation, the IOPA reveals radiation involving enamel, dentin and pulp irt 17.

OTHER DIAGNOSIS:
1) Anemic glossitis
2) Dental Caries – 16, 26, 24, 36, 37, 46, 47
3) Chronic generalized gingivitis

FINAL DIAGNOSIS:
Dental caries with reversible pulpitis irt 17.
TREATMENT PLAN:
1) Patient is advised for restoration for deep caries management irt 17.
2) Patient is advised to take candid mouth paint topical use only twice daily for 5 days.
3) Patient is asked to be in follow regarding anaemic glossitis.
4) Patient is advised to take Haemoglobin test and CBC test and is asked to report
back after one week.

STAFF’S SIGNATURE
 LONG CASE - 02

NAME ;- Mr. Arjun

OP. NO. ;- 26034 / 24

AGE / SEX ;- 28 / Male

ADDRESS ;- Unaimanchery

OCCUPATION ;- Police officer

RELIGION ;- Hindu

CONTACT NO ;- 7448447623

CHIEF COMPLAINT:
Patient gives a complaint of missing tooth in his lower front tooth region for past 3
months.
HISTORY OF PRESENTING ILLNESS:
Patient gives a history of fallen tooth three months before. Patient gives no history of
pain, sensitivity, food lodgment, bleeding while brushing, and bad breath.
PAST MEDICAL HISTORY:
Patient gives history of knee pain four years back and was under siddha medication.
PAST DENTAL HISTORY:
Patient had underwent restoration 4 years back.
FAMILY HISTORY:
Patient’s family members are apparently healthy.

MARITAL STATUS ;- Unmarried

NO. OF CHILDREN ;- NIL

DIET ;- Mixed diet

BRUSHING HABITS ;- Once daily with toothbrush and toothpaste

OTHER HABITS ;- NIL

ANY OTHER HABITS ;- NIL

 GENERAL EXAMINATION

APPEARANCE ;- Normal

BUILT ;- Moderately built

NOURISHMENT ;- Moderately nourished

ANEMIA ;- Absent

ICTERUS ;- Absent

CYANOSIS ;- Absent

CLUBBING ;- Absent

PEDAL EDEMA ;- Absent

STRUCTURAL ALTERNATION ;- Absent

VITAL SIGNS
PULSE RATE ;- 72 beats/minute

RESPIRATORY RATE ;- 12 breaths/minute

BLOOD PRESSURE ;- 126/90 mm hg

TEMPERATURE ;- 98 F

SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM:
 No loss of memory
 No vomiting
 No headache

CARDIOVASCULAR SYSTEM:
 No pain
 No palpitation
 No syncope
GASTROINTESTINAL SYSTEM:
 No dysphagia
 No burning sensation while having food
 No loss of taste
 No stomach ache, constipation and diarrhoea

RESPIRATORY SYSTEM:
 No cough
 No breathlessness
 No tuberculosis

URINOGENITAL SYSTEM:
 No polyuria
 No burning sensation
 No discharge
 Regular micturition

SKELETAL SYSTEM:
 No spasm
 No stiffness of joints
 No abnormal growth

LOCAL EXAMINATION
EXTRAORAL EXAMINATION
FACIAL SYMMETRY:
No gross facial asymmetry

TMJ EXAMINATION
INSPECTION:
No pain or jaw deviation or deflection detected in right and left TMJ upon opening
and closing of mouth.
PALPATION:
No crepitus, No clicking sound detected in right and left TMJ upon opening and
closing of mouth.

LYMPHNODE EXAMINATION:
No clinically palpable lymph node detected in cervicofacial region.
MOUTH OPENING: 45mm (Interincisal distance)

INTRAORAL EXAMINATION
SOFT TISSUE

LABIAL MUCOSA ;- No abnormalities detected

ALVEOLAR MUCOSA ;- No abnormalities detected

FLOOR OF THE MOUTH ;- No abnormalities detected

HARD PALATE ;- No abnormalities detected

SOFT PALATE ;- No abnormalities detected

UVULA ;- No abnormalities detected

TONSILLAR AREA ;- No abnormalities detected

FRENUM ;- No abnormalities detected

TONGUE ;- No abnormalities detected

VESTIBULE ;- No abnormalities detected

LIP ;- No abnormalities detected

BUCCAL MUCOSA
INSPECTION:
Diffuse opaque white areas over incisal edge and cusp of maxillary, mandibular, anterior
and posterior teeth showing no more than 1-2cm of white opacity of all tooth.
PALPATION:
All inspectory findings are confirmed. Surface was smooth. No irregularities. Pitting of
enamel is seen.
 GINGIVA:
COLOUR ;- Pale pink with melanin pigmentation

CONTOUR ;- Scalloping margin with blunt interdental papilla

CONSISTENCY ;- Soft and edematous irt 32, 33, 34, 42, 43 and 44

POSITION ;- At the level of cemento enamel junction

SIZE ;- Altered irt 32, 33, 34, 42, 43 and 44

SHAPE ;- Altered irt 32, 33, 34, 42, 43 and 44

SURFACE TEXTURE ;- Stippling absent

BLEEDING ON PROBING ;- Absent

EXUDATE ;- Absent

POCKET DEPTH ;- Absent

GINGIVAL RECESSION ;- Absent

HARD TISSUE EXAMINATION

TYPE OF DENTITION ;- Permanent dentition

NO. OF TEETH ;- 26+1(Retained deciduous teeth)

DENTAL CARIES ;- NIL

PIT AND TISSUE CARIES ;- 17,27,37,46

TENDER ON PERCUSSION ;- NIL

MISSING ;- 31, 41, 18, 28, 38 and 48

CALCULUS ;- Moderate

STAINS ;- Mild

ROOT STUMPS ;- NIL

FILLED TOOTH ;- 47

FRACTURED TOOTH ;- NIL

WASTING DISEASE ;- NIL

 MOBILITY ;- NIL

FRACTURED RESTORATION ;- NIL

PARTIAL ERUPTION ;- NIL

PROSTHETIC CROWN ;- NIL

CERVICAL ABRASION ;- NIL

GROSSLY DECAYED ;- NIL

SUMMARY:

Patient named Mr. Arjun, 28 years old, male, reported to the department of Oral
Medicine and Radiology, Tagore Dental College and Hospital, with the chief complaint of
missing tooth in his lower front back tooth region for past three months. Patient gives no
history of pain, sensitivity, food lodgment, bleeding while brushing and bad breath. Patient’s
medical history reveals that patient had met with a road traffic accident 1 year back and had a
fracture in his left leg and is under calcium tablets. Patient’s dental history reveals that patient
underwent restoration 4 years back and it was uneventful.
Patient’s family history reveals that his family members are apparently healthy. Patient
consumes mixed diet and brushes once daily with toothpaste and tooth brush.
On General Examination, No abnormalities are detected. Patient’s vital signs are normal and
no abnormalities detected in systemic examination. Extra oral examination reveals no gross
facial asymmetry. No restricted mouth opening.
On inspection of TMJ No pain or jaw deviation or deflection detected in right and left
TMJ upon closing and opening of mouth and on palpation of TMJ. No evidence of clicking
sound, No crepticus heard upon opening and closing of mouth with maximum Interincisal
distance of 45mm.
On Intraoral examination, no abnormalities were detected. On Hard tissue examination,
On Inspection, Diffuse opaque white areas over incisal edge and cusps of maxillary
mandibular, anterior and posterior teeth showing no more than 1-2cm of white opacity at all
teeth. On palpation, all inspectory findings are confirmed. Surface was smooth. No
irregularities, pitting of enamel is seen. Pit and fissure caries irt 46, 17, 37, 27. Mild calculus
and mild stains present. Partially edentulous Mandibular arch irt 41, 31 is seen.
 On co relating with the chief complaint, history of presenting illness, intraoral
examination, a provisional diagnosis of partially edentulous Mandibular arch irt 31, 41 was
arrived.

PROVISIONAL DIAGNOSIS:
Partially edentulous Mandibular arch irt 41, 31.

OTHER DIAGNOSIS:
1. Dental fluorosis
2. Pit and fissure caries irt 17, 27, 37, 46
3. Attrition irt 32, 33, 34, 42, 43, 44

FINAL DIAGNOSIS:
Partially edentulous Mandibular arch irt 41, 31.

INVESTIGATION: NIL

TREATMENT PLAN:
1. Patient is advised for veneers for management of Dental fluorosis in maxillary anterior
region.
2. Later, patient is advised for removable denture prosthesis for management of partially
edentulous Mandibular arch irt 31, 41.
3. Later, patient is advised for ultrasonic scaling.
4. Later, patient is advised for restoration of pit and fissure caries irt 17,27,37,46.
5. Later, patient is advised for management of Attrition irt 32, 33, 34, 42, 43, 44.

STAFF’S SIGNATURE
 LONG CASE - 03

NAME ;- Mr. Krishnamoorthy

OP. NO. ;- 27091 / 24

AGE / SEX ;- 54 / Male

ADDRESS ;- Vandalur

OCCUPATION ;- Mason

RELIGION ;- Hindu

CONTACT NO ;-

CHIEF COMPLAINT:
Patient gives a complaint of shaking tooth in his upper right back tooth region for past
6 months.
HISTORY OF PRESENTING ILLNESS:
Patient gives a history of shaking tooth in upper right back tooth region for past 6
months. Patient gives a history of pain in upper right back tooth region for past 2 months. The
pain is sharp, both intermittent and continuous, radiating and nocturnal in region. The pain
aggravates on mastication and relieves on medication. Patient also gives history of sensitivity
on consuming hot and cold food in that region for past 3 days. Patient gives no history of food
lodgment, bleeding while brushing and bad breath.
PAST MEDICAL HISTORY:
Patient gives history of knee pain four years back and was under siddha medication.
PAST DENTAL HISTORY:
Patient underwent oral prophylaxis, 3 months back.
FAMILY HISTORY:
Patient’s family members are apparently healthy.

MARITAL STATUS ;- Married

NO. OF CHILDREN ;- Three

DIET ;- Mixed diet

BRUSHING HABITS ;- Once daily with toothpaste and toothbrush.

Patient gives history of smoking and usage of smokeless tobacco
OTHER HABITS ;-
for past 30 years since childhood and quitted it 10 years back.
ANY OTHER HABITS ;- Nail biting since childhood.

GENERAL EXAMINATION

APPEARANCE ;- Patient is calm, conscious, co-operative

BUILT ;- Moderately built

NOURISHMENT ;- Moderately nourished

ANEMIA ;- Absent

ICTERUS ;- Absent

CYANOSIS ;- Absent

CLUBBING ;- Absent

PEDAL EDEMA ;- Absent

STRUCTURAL ALTERNATION ;- Absent

VITAL SIGNS
PULSE RATE ;- 76 beats/minute

RESPIRATORY RATE ;- 15 breaths/minute

BLOOD PRESSURE ;- 128/66 mm hg

TEMPERATURE ;- 98 F

SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM:
 No loss of memory
 No vomiting
 No headache
CARDIOVASCULAR SYSTEM:
 No pain
 No palpitation
 No syncope

GASTROURINARY SYSTEM:
 No dysphagia
 No burning sensation while having food
 No loss of taste
 No stomach ache, constipation and diarrhoea

RESPIRATORY SYSTEM:
 No cough
 No breathlessness
 No tuberculosis

URINOGENITAL SYSTEM:
 No polyuria
 No burning sensation
 No discharge
 Regular micturition

LOCAL EXAMINATION
EXTRAORAL EXAMINATION
FACIAL SYMMETRY:
No gross facial asymmetry

TMJ EXAMINATION
INSPECTION:
No pain or jaw deviation or deflection detected in right and left TMJ upon opening and
closing of the mouth.
PALPATION:
No crepitus, No clicking sound detected in right and left TMJ upon opening and closing
of mouth.

LYMPHNODE EXAMINATION:
No clinically palpable lymph node detected in cervicofacial region.
MOUTH OPENING: 37mm (Interincisal distance)

INTRAORAL EXAMINATION
SOFT TISSUE

LABIAL MUCOSA ;- No abnormalities detected

ALVEOLAR MUCOSA ;- No abnormalities detected

FLOOR OF THE MOUTH ;- No abnormalities detected

HARD PALATE ;- No abnormalities detected

UVULA ;- No abnormalities detected

SOFT PALATE ;- No abnormalities detected

TONSILLAR AREA ;- No abnormalities detected

FRENUM ;- No abnormalities detected

TONGUE ;- No abnormalities detected

VESTIBULE ;- No abnormalities detected

LIP ;- No abnormalities detected

BUCCAL MUCOSA
INSPECTION:
A well-defined grayish white patch like lesion, is present on buccal mucosa extending
antero-posteriorly from commissure of lip to retro molar region. Roughly irregular in shape
with well-defined margins. The surface texture is cracked mud appearance.
PALPATION:
On palpation, all inspectory findings are confirmed. The lesion is soft in consistency,
non-scrapable, and non-tender on percussion.

GINGIVA:
COLOUR ;- Pale pink with melanin pigmentation

CONTOUR ;- Scalloping marginal gingiva with knife edged interdental papilla.

CONSISTENCY ;- Firm and resilient.

POSITION ;- At the level of cemento enamel junction

SIZE ;- Unaltered

SHAPE ;- Unaltered

SURFACE TEXTURE ;- Stippling present

BLEEDING ON PROBING ;- Absent

EXUDATE ;- Absent

POCKET DEPTH ;- Absent

GINGIVAL RECESSION ;- Absent

HARD TISSUE EXAMINATION

TYPE OF DENTITION ;- Permanent dentition

NO. OF TEETH ;- 31

DENTAL CARIES ;- NIL

PIT AND TISSUE CARIES ;- Buccal pit irt 16

TENDER ON PERCUSSION ;- NIL

MISSING ;- 27

CALCULUS ;- Mild

STAINS ;- Moderate

ROOT STUMPS ;- NIL

FILLED TOOTH ;- NIL

FRACTURED TOOTH ;- NIL

WASTING DISEASE ;- Generalized attrition

 Grade I mobility irt 16,18,31,32,37,41,42,43,46

MOBILITY ;-  Grade II mobility irt 28,37
 Grade III mobility irt 17

MALOCCLUSION ;- NIL

PARTIAL ERUPTION ;- NIL

PROSTHETIC CROWN ;- NIL

CERVICAL ABRASION ;- NIL

GROSSLY DECAYED ;- NIL

SUMMARY:

Patient named Mr. Krishnamoorthy, 54 years old, male, reported to the department of
Oral Medicine and Radiology, Tagore Dental College and Hospital, with the chief complaint
of shaking tooth in his upper right back tooth region for past six months. Patient gives history
of pain in that region for past 2 months. The pain is sharp, both intermittent and continuous,
radiating and nocturnal in nature. The pain aggravates on mastication and relieves after
medication. Patient also gives history of sensitivity in that region on consuming hot and cold
foods for past 3 days.

Patient gives no history of food lodgment, bleeding while brushing and bad breath.
Patient’s medical history reveals that patient had knee pain for 4 years and was under siddha
medication. Patient’s dental history reveals that patient underwent oral prophylaxis 3 months
back and it was uneventful. Patient’s family history reveals that his family members are
apparently healthy. Patient consumes mixed diet and brushes once daily with toothpaste and
tooth brush.

On General Examination, No abnormalities are detected. Patient’s vital signs are normal
and no abnormalities detected in systemic examination. Extra oral examination reveals no
gross facial asymmetry. No restricted mouth opening. On inspection of TMJ No pain or jaw
deviation or deflection detected in right and left TMJ upon closing and opening of mouth and
on palpation of TMJ. No evidence of clicking sound, No crepticus heard upon opening and
closing of mouth with maximum Interincisal distance of 45mm.

On Intraoral examination, on buccal mucosa ,on inspection, A well-defined grayish

white patch like lesion extending antero posteriorly from commissure of lip to retro molar
region is seen. It is roughly irregular in shape and has well-defined margins. The surface
texture is cracked mud appearance.

On palpation, all inspectory findings are confirmed. The lesion if soft in consistency,
non-scrapable, non-tender on percussion.

On Hard tissue examination, buccal pit irt 16, mild calculus and moderate stains present.
Chronic generalized periodontitis irt 16, 18, 31, 32, 37, 41, 42, 43, 46, 28, 37 and 17 is present.

On co-relating with the chief complaint, history of presenting illness and intraoral
examination, a provisional diagnosis of chronic periodontitis is arrived.

PROVISIONAL DIAGNOSIS:
Chronic periodontitis.

OTHER DIAGNOSIS:
1) Homogenous leukoplakia in right and left buccal mucosa
2) Buccal pit irt 46
3) Partially edentulous maxillary arch irt 27
4) Generalized attrition.

FINAL DIAGNOSIS:
Chronic periodontitis.

INVESTIGATION: NIL
TREATMENT PLAN:
1) Patient is advised for extraction of 17 under L.A
2) Patient is advised to quit the habit of smoking and usage of smokeless tobacco.
3) Later, patient is advised for removable denture prosthesis for management of partially
edentulous Maxillary arch irt 27.
4) Later, patient is advised for ultrasonic scaling and periodontic opinion.
5) Later, patient is advised for restoration of buccal pit irt 46.
6) Later, patient is advised for management of generalized attrition.
7) Patient is advised medication and asked to report back after 15 days to the department
for review.

Tab. Antoxid*30 days – 1-0-0(After food)

STAFF’S SIGNATURE
 LONG CASE - 04

NAME ;- Mr. Elumalai

OP NO ;- 27290 / 24
AGE / SEX ;- 24 / Male
ADDRESS ;- Vallathy, Chennai
OCCUPATION ;- Student
RELIGION ;- Hindu
CONTACT NO ;- 8124898340

CHIEF COMPLAINT:
Patient gives complaint of sensitivity in his lower front tooth region for past 2 weeks.

HISTORY OF PRESENTING ILLNESS:

Patient gives history of sensitivity in his lower front tooth region for past 2 weeks.
Patient gives history of usage of sensitivity toothpaste on a dentist advice after which
sensitivity reduced to a certain extent.
Patient gives no history of pain, bleeding while brushing and malodor.

PAST MEDICAL HISTORY:

Patient gives history of road traffic accident 12 years back in his lower border of
mandible and it was treated by stitches. Patient also gives history of hernia operation he
underwent before 6 years.

PAST DENTAL HISTORY:

Patient underwent consultation before 5 days.

FAMILY HISTORY:
Patient’s father and sister is known hyperthyroid patient for past 10 years and 5 years
respectively and under regular medication.

MARITAL STATUS ;- Married

NO. OF CHILDREN ;- One

ORAL HYGIENE HABIT ;- Brushes once daily with toothpaste and toothbrush.

DELETERIOUS HABIT ;- NIL

Patient was smoker and alcoholic for past 6 years and quitted
OTHER HABITS ;-
it before 6 months

GENERAL EXAMINATION
APPEARANCE ;- Normal

BUILT ;- Moderate

NOURISHMENT ;- Moderately nourished

ANEMIA ;- Absent

ICTERUS ;- Absent

CYANOSIS ;- Absent

CLUBBING ;- Absent

PEDAL EDEMA ;- Absent

STRUCTURAL AITERATION ;- No abnormalities detected

VITAL SIGNS
PULSE RATE ;- 76 beats/minute

BLOOD PRESSURE ;- 118/78 mmHg

RESPIRATORY RATE ;- 16 breaths/minute

TEMPERATURE ;- Afebrile at the time of examination

SYSTEMIC EXAMINATION
Central nervous system:
 No loss of memory
 No vomiting
 No headache
Cardiovascular system:
 No pain
 No palpitation
 No syncope
Respiratory system:
 No cough
 No breathlessness
 No tuberculosis

Gastrointestinal system:
 No dysphagia
 No burning sensation while having food
 No loss of taste
 No stomachache

Urogenital system:
 Regular micturition
 No polyuria or discolouration of urine
 No burning sensation
 No abdominal discharge

Skeletal system:
 No spasm
 No stiffness or joints
 No abnormal growth

LOCAL EXAMINATION

EXTRA ORAL EXAMINATION

FACIAL SYMMETRY:
No gross facial asymmetry.

TMJ EXAMINATION:
INSPECTION:
No pain or jaw deviation.

PALPATION:
No deflection, no clicking sound heard upon mouth opening and closing.

LYMPH NODE:
No clinically palpable, abnormal lymph node present in cervicofacial region.

MOUTH OPENING: 42mm (Interincisal distance).

 INTRAORAL EXAMINATION

SOFT TISSUE EXAMINATION

LABIAL MUCOSA ;- No abnormalities detected

ALVEOLAR MUCOSA ;- No abnormalities detected

FLOOR OF MOUTH ;- No abnormalities detected

UVULA ;- No abnormalities detected

SOFT PALATE ;- No abnormalities detected

HARD PALATE ;- No abnormalities detected

TONSILAR AREA ;- No abnormalities detected

FRENUM ;- No abnormalities detected

PHARYNX ;- No abnormalities detected

VESTIBULE ;- No abnormalities detected

LIP ;- No abnormalities detected

BUCCAL MUCOSA

INSPECTION:
A Solitary growth like lesion, pale pink in colour present on right buccal mucosa in
relation to 47 region, measuring of size approximately 33 mm roughly oval in shape with well-
defined margins and surface texture is smooth in appearance

PALPATION:
On palpation all inspectory findings are confirmed. The growth is firm in consistency,
non-scrapable, non-tender on palpation.

GINGIVA
Color ;- Pale pink with melanin pigmentation

Contour ;- Scalloped marginal gingiva with knife edge interdental papilla

Consistency ;- Firm and resilient

Position ;- At the level of cementoenamel junction

Size ;- Unaltered
Shape ;- Unaltered

Surface texture ;- Stippling present

Bleeding on
;- Absent
probing
Exudate ;- Absent

Pocket depth ;- Absent

Gingival recession ;- Absent

HARD TISSUE EXAMINATION

Type of dentition ;- Permanent

No of teeth present ;- 32

Dental caries ;- NIL

Tender on percussion ;- NIL

Missing ;- NIL

Calculus ;- NIL

Stains ;- Moderate

Root stump ;- NIL

Filled ;- NIL

Fractured tooth ;- 11, 21, 12, 22

Wasting disease ;- Attrition[11, 21, 31, 32, 33, 41, 42, 43]

Mobility ;- NIL

Grossly decayed ;- NIL

Prosthetic ;- NIL

DENTAL FLUOROSIS:
INSPECTION:
Diffuse opaque white areas over the cervical two third of mandibular, maxillary anterior,
posterior teeth showing no more than 1- 2 cm of white opacity at all the teeth.
PALPATION:
On palpation, all inspectory findings are confirmed. Surface was smooth. No
irregularities, Pitting of enamel is seen.

SUMMARY
Patient named Mr. Elumalai, 24 year old, male reported to the department of oral
medicine and radiology with chief complaint of sensitivity in his lower anterior tooth region
for past 2 weeks. Patient gives history of sensitivity in his lower front tooth region for past 2
weeks. Patient gives history of usage of sensitivity toothpaste on a dentist advice after which
sensitivity reduced to a certain extent. Patient gives no history of pain, bleeding while brushing
and malodor.
Patient gives history of road traffic accident 12 years back in his lower border of
mandible and it was treated by stitches. Patient also gives history of hernia operation he
underwent before 6 years. Family history reveals that patient’s father and sister is known
hyperthyroid for past 10 years and 5 years respectively and under regular medication. Patient
gives personal history of married, on mixed diet, brushes once daily and was smoker and
alcoholic for past 6 years and quitted it 6 months back.
No abnormalities detected on general examination, patient’s vital signs and systemic
examination. Patient has a no abnormal finding in facial symmetry, TMJ examination, lymph
node and mouth opening.
On intraoral examination of buccal mucosa, on inspection a solitary growth like lesion
pale pink in colour present on right buccal mucosa in relation to 47 region, measuring of size
approximately 33 mm roughly oval in shape with well-defined margins and surface texture is
smooth in appearance. On palpation, all inspectory findings are confirmed. The growth is firm
in consistency, non-scrapable, non-tender on palpation.
On examination of gingiva reveals pale pink with melanin pigmentation, rolled out
margin with knife edge interdental papilla, firm in consistency, positioned at the level of
cementoenamel junction, size & shape unaltered, stippling is present, absence of bleeding on
probing, exudate & pocket depth.
On hard tissue examination, patient has total of 32 permanent teeth, fractured tooth irt
11, 12, 21, 22, mild calculus, mild stains present, attrition irt 11, 21, 31, 32, 33, 41, 42, 43. On
inspection diffuse opaque white areas over the cervical two third of mandibular, maxillary,
anterior and posterior tooth showing no more than 1-2 cm of white opacity at all the teeth. On
palpation, all inspectory findings are confirmed, surface texture was smooth. No irregularities,
pitting of enamel is seen.
On correlating the chief complaint, history of presenting illness and intra oral
examination, a provisional diagnosis is dentinal hypersensitivity irt lower anterior teeth region.

PROVISIONAL DIAGNOSIS:
Dentinal hypersensitivity irt 31, 32, 33, 41, 42, 43.

OTHER DIAGNOSIS:
1) Traumatic fibroma in right buccal mucosa irt 47 region
2) Generalized dental fluorosis
3) Chronic generalized gingivitis
4) Buccoverted 18

FINAL DIGNOSIS:
Dentinal hypersensitivity irt 31, 32, 33, 41, 42, 43.

INVESTIGATION: NIL

TREATMENT PLAN:
1) Patient advised for extraction of 18 under LA.
2) Patient is advised to take excisional biopsy of traumatic fibroma in relation to right
buccal mucosa
3) Patient advised for bleaching or veneer for management of dental fluorosis
4) Patient is advised for ultrasonic scaling for the management of chronic generalized
gingivitis

STAFF’S SIGNATURE
 LONG CASE – 05

NAME ;- Mrs. Partive Shah

OP NO ;- 45224 / 24

AGE / SEX ;- 29 / Female

ADDRESS ;- Kolapakkam, Chennai

OCCUPATION ;- Homemaker

RELIGION ;- Hindu

CONTACT NO ;- 8124898340

CHIEF COMPLAINT:
Patient gives complaint of dislodged restoration from root canal treated tooth in upper
right back tooth region for past 4 days and complains of pain in her lower right back tooth
region for past 4 days.

HISTORY OF PRESENTING ILLNESS:

Patient gives history of dislodged restoration from root canal treated tooth in upper right
back tooth region for past 4 days and complains of pain in her lower right back tooth region
for past 4 days. Patient gives history of dull, continuous pain which radiates towards neck
region for past 4 days. The pain aggravates during mastication and relieves on medication for
past 3 days. Gives history of bleeding while brushing, food lodgement in her lower right back
tooth region for past 3 days. Gives no history of sensitivity, bad breath.

PAST MEDICAL HISTORY:

Patient underwent heart surgery before 15 months and was under medication for 3
months and currently not under medication.

PAST DENTAL HISTORY:

Patient underwent Root canal treatment before 2 years.
FAMILY HISTORY:
All family members are apparently healthy.

MARITAL STATUS ;- Married

NO. OF CHILDREN ;- One

DIET ;- Mixed diet

ORAL HYGIENE HABIT ;- Brushes once daily with toothpaste and toothbrush

DELETERIOUS HABIT ;- NIL

OTHER HABITS ;- NIL

GENERAL EXAMINATION

APPEARANCE ;- Normal

BUILT ;- Moderate

NOURISHMENT ;- Moderately nourished

ANEMIA ;- Absent

ICTERUS ;- Absent

CYANOSIS ;- Absent

CLUBBING ;- Absent

PEDAL EDEMA ;- Absent

STRUCTURAL ALTERATION ;- No abnormalities detected

VITAL SIGNS

PULSE RATE ;- 72 beats/minute

BLOOD PRESSURE ;- 120/75 mmHg

RESPIRATORY RATE ;- 16 breaths/minute

TEMPERATURE ;- Afebrile at the time of examination

 SYSTEMIC EXAMINATION
Central nervous system:
 No loss of memory
 No vomiting
 No headache
Cardiovascular system:
 No pain
 No palpitation
 No syncope
Respiratory system:
 No cough
 No breathlessness
 No tuberculosis
Gastrointestinal system:
 No dysphagia
 No burning sensation while having food
 No loss of taste
 No stomachache
Urogenital system:
 Regular micturition
 No polyuria or discolouration of urine
 No burning sensation
 No abdominal discharge
Skeletal system:
 No spasm
 No stiffness or joints
 No abnormal growth

LOCAL EXAMINATION
EXTRA ORAL EXAMINATION
FACIAL SYMMETRY:
No gross facial asymmetry.
TMJ EXAMINATION:
INSPECTION:
No pain or jaw deviation.
PALPATION:
No deflection, no clicking sound heard upon mouth opening and closing.

LYMPH NODE:
No clinically palpable, abnormal lymph node present in cervicofacial region.

MOUTH OPENING: 42mm (Interincisal distance).

INTRA ORAL EXAMINATION

SOFT TISSUE EXAMINATION

LABIAL MUCOSA ;- No abnormalities detected

ALVEOLAR MUCOSA ;- No abnormalities detected

FLOOR OF MOUTH ;- No abnormalities detected

UVULA ;- No abnormalities detected

SOFT PALATE ;- No abnormalities detected

HARD PALATE ;- No abnormalities detected

TONSILAR AREA ;- No abnormalities detected

FRENUM ;- No abnormalities detected

PHARYNX ;- No abnormalities detected

VESTIBULE ;- No abnormalities detected

BUCCAL MUCOSA ;- No abnormalities detected

LIP ;- No abnormalities detected

BUCCAL MUCOSA
INSPECTION:
A Solitary ulcer like lesion erythematous in colour is present on the left side of the
upper lip measuring of size 3×2 cm roughly oval in shape with well-defined margins.
PALPATION
On palpation all inspectory findings are confirmed. The lesion is soft in consistency
and non-scrapable and non-tender on palpation.

GINGIVA
Color ;- Pale pink with melanin pigmentation
Rolled out marginal gingiva with blunt interdental papilla irt
Contour ;-
41, 42, 43, 44, 31
Consistency ;- Soft and edematous irt 41, 42, 43, 44, 31

Position ;- Apical to the level of cementoenamel junction

Size ;- Altered irt 41, 42, 43, 44, 31

Shape ;- Altered irt 41, 42, 43, 44, 31

Surface texture ;- Stippling absent irt 41, 42, 43, 44, 31

Bleeding on probing ;- Absent

Exudate ;- Absent

Pocket depth ;- Absent

Gingival recession ;- Present irt 31

HARD TISSUE EXAMINATION

Type of dentition ;- Permanent

No of teeth present ;- 28

Dental caries ;- 16, 26, 27

Tender on percussion ;- NIL

Missing ;- 18, 28, 38, 48

Calculus ;- Mild

Stains ;- NIL

Root stump ;- NIL

Filled ;- NIL
Fractured tooth ;- NIL

Fractured restoration ;- 17

Wasting disease ;- NIL

Mobility ;- NIL

Grossly decayed ;- NIL

Prosthetic ;- NIL

SUMMARY
Patient named Mrs. Partive Shah, 29 year old, female reported to the department of oral
medicine and radiology with chief complaint of dislodged restoration from root canal treated
tooth in upper right back tooth region for past 4 days and complains of pain in her lower right
back tooth region for past 4 days.

Patient gives history of dull, continuous pain which radiates towards neck region for
past 4 days. The pain aggravates during mastication and relieves on medication for past 3 days.
Gives history of bleeding while brushing, food lodgement in her lower right back tooth region
for past 3 days. Gives no history of sensitivity and bad breath.

Patient gives history of heart surgery 15 months back and was under medication for 3
months. Patient dental history reveals that he underwent root canal treatment before 2 years.
Patient’s Family members are apparently healthy. Patient gives personal history of married,
on mixed diet, brushes once daily.

No abnormalities detected on general examination, patient’s vital signs and systemic

examination. Patient has a no abnormal finding in facial symmetry, TMJ examination, lymph
node and mouth opening.

On intraoral examination of lip, on inspection, A Solitary ulcer like lesion erythematous

in colour is present on the left side of the upper lip measuring of size 3×2 cm roughly oval in
shape with well-defined margins. On palpation all inspectory findings are confirmed. The
lesion is soft in consistency and non-scrapable and non-tender on palpation.
On examination of gingiva reveals pink colour with melanin pigmentation, rolled out
margin with knife edge interdental papilla, soft and edematous irt 41, 42, 43, 44, positioned at
the level of cementoenamel junction, size & shape altered irt 41, 42, 43, 44, stippling is absent,
absence of bleeding on probing, exudate & pocket depth.
On hard tissue examination, patient has total of 28 permanent teeth, dental caries in 16,
26, 27, pit and fissure caries in 36, 37, 17, mild calculus, fractured restoration in 17.
On correlating the chief complaint, history of presenting illness and intra oral
examination, a provisional diagnosis is fractured restoration irt 17.

PROVISIONAL DIAGNOSIS:
Fractured restoration in 17.
OTHER DIAGNOSIS:
1) Herpes Labialis
2) Dental Caries in 16, 26, 37
3) Pit and fissure caries in 17, 36, 37
4) Chronic generalized gingivitis
INVESTIGATION: Nil
FINAL DIGNOSIS:
Fractured Restoration in 17
TREATMENT PLAN:
1) Patient advised for Root Canal treatment in 17 for the management of Fractured
restoration Patient is advised for ultrasonic scaling for the management of chronic
generalized gingivitis Patient advised for restoration for Dental Caries irt 26,
16,27,17,36,37
2) Patient advised for medication
 Rx - Topical Acyclovir (5% cream ) ( twice daily for 5 days )
3) Patient asked to report back for follow up after 1 week.

STAFF’S SIGNATURE
 LONG CASE – 06

NAME ;- Mr. Ajith

OP NO ;- 45441 / 24

AGE / SEX ;- 27 / Male

ADDRESS ;- Nallampakkam

OCCUPATION ;- Developer

RELIGION ;- Hindu

CONTACT NO ;- 9884374913

CHIEF COMPLAINT:
Patient gives complaint of sensitivity on consuming chocolates in his upper left back
tooth region for past 6 months.

HISTORY OF PRESENTING ILLNESS:

Patient gives history of sensitivity on consuming chocolates in his upper left back tooth
region for past 6 months. Patient gives no history of pain, food lodgement, sensitivity, malodor,
bleeding while brushing and swelling.

PAST MEDICAL HISTORY:

Patient is a known hypotensive for past 2 years and under not medication. Patient gives
history of sinus for past 18 years and not under any medication.

PAST DENTAL HISTORY:

Patient’s first dental visit.

FAMILY HISTORY:
Patient’s family members are apparently healthy.

MARITAL STATUS ;- Unmarried

NO. OF CHILDREN ;- NIL

DIET ;- Mixed diet

ORAL HYGIENE HABIT ;- Brush once daily with toothpaste and toothbrush

DELETERIOUS HABIT ;- NIL

GENERAL EXAMINATION
APPEARANCE ;- Normal

BUILT ;- Moderate

NOURISHMENT ;- Moderately nourished

ANEMIA ;- Absent

ICTERUS ;- Absent

CYANOSIS ;- Absent

CLUBBING ;- Absent

PEDAL EDEMA ;- Absent

STRUCTURAL ALTERATION ;- No abnormalities detected

VITAL SIGNS
PULSE RATE ;- 76 beats / minutes

BLOOD PRESSURE ;- 110 / 70 mm Hg

RESPIRATORY RATE ;- 15 beats / minutes

TEMPERATURE ;- Afebrile at the time of examination

SYSTEMIC EXAMINATION
Central nervous system:
 No loss of memory
 No vomiting
 No headache

Cardiovascular system:
Patient is known hypotensive for past 2 years & not under medication.

Respiratory system:
History of sinuses for past 18 years and not under medication.
Gastrointestinal system:
 No dysphagia
 No burning sensation while having food
 No loss of taste
 No stomachache

Urogenital system:
 Regular micturition
 No polyuria or discolouration of urine
 No burning sensation
 No abdominal discharge

Skeletal system:
 No spasm
 No stiffness or joints
 No abnormal growth
LOCAL EXAMINATION

EXTRA ORAL EXAMINATION

FACIAL SYMMETRY:
No gross facial asymmetry.

TMJ EXAMINATION:

INSPECTION:
No pain or jaw deviation.

PALPATION:
No deflection, no clicking sound heard upon mouth opening and closing.

LYMPH NODE:
No clinically palpable, abnormal lymph node present in cervicofacial region.

MOUTH OPENING: 45mm (Interincisal distance)

INTRA ORAL EXAMINATION

SOFT TISSUE EXAMINATION
LABIAL MUCOSA ;- No abnormalities detected

BUCCAL MUCOSA ;- No abnormalities detected

ALVEOLAR MUCOSA ;- No abnormalities detected

FLOOR OF MOUTH ;- No abnormalities detected

UVULA ;- No abnormalities detected

SOFT PALATE ;- No abnormalities detected

HARD PALATE ;- No abnormalities detected

TONGUE ;- No abnormalities detected

TONSILAR AREA ;- No abnormalities detected

FRENUM ;- No abnormalities detected

PHARYNX ;- No abnormalities detected

VESTIBULE ;- No abnormalities detected

LIP ;- No abnormalities detected

BUCCAL MUCOSA
INSPECTION:
Diffuse patch like lesion, white in colour in present on dorsal surface of tongue
extending from posterior third to middle third of tongue measuring of size approximately 33
cm with ill-defined margins .The surface texture is smooth in appearance.

PALPATION:
All inspection finding are confirmed by palpation, the patch is soft in consistency.
Upon scraping dorsal surface of tongue, white curd like lesion was leaving an erythematous
band.

GINGIVA
COLOR ;- Red with melanin pigmentation

CONTOUR ;- Rolled out marginal gingiva with blunt interdental papilla

CONSISTENCY ;- Soft and edematous

POSITION ;- At the level of cementoenamel junction

SIZE ;- Altered

SHAPE ;- Altered
SURFACE TEXTURE ;- Stippling Absent

BLEEDING ON PROBING ;- Absent

EXUDATE ;- Absent

POCKET DEPTH ;- Absent

HARD TISSUE EXAMINATION

TYPE OF DENTITION ;- Permanent dentition

NO OF TEETH PRESENT ;- 32

DENTAL CARIES ;- 46, 28

TENDER ON PERCUSSION ;- NIL

MISSING ;- NIL

CALCULUS ;- NIL

STAINS ;- NIL

ROOT STUMP ;- NIL

FILLED ;- NIL

FRACTURED TOOTH ;- NIL

WASTING DISEASE ;- NIL

MOBILITY ;- NIL

GROSSLY DECAYED ;- NIL

PROSTHETIC ;- NIL

OTHERS ;- NIL

SUMMARY
Patient named Mr. Ajith of 28 years old reported to the department of oral medicine and
radiology with chief complaint of sensitivity in his upper left back tooth region on consuming
chocolates for past 6 months. Patient gives history of sensitivity on consuming chocolates in
his upper left back tooth region for past 6 months.

Patient gives no history of pain, food lodgement, sensitivity, malodor, bleeding while
bleeding while brushing. Patient gives medical history of hypotensive for past 2 years and
under not medication. Patient gives history of sinus for past 18 years and not under any
medication

Patient gives personal history of unmarried, on mixed diet, brushes once daily and no
deleterious habit.
No abnormalities detected on general examination, patient’s vital signs and systemic
examination. Patient has a no abnormal finding in facial symmetry, TMJ examination, lymph
node and mouth opening.

On intraoral examination reveals no abnormalities in lip, buccal mucosa, labial mucosa,

alveolar mucosa, floor of mouth, hard and soft palate, uvula, tonsillar area, frenum, pharynx
and vestibule.

On inspection of tongue, diffuse patch like lesion, white in colour in present on dorsal
surface of tongue extending from posterior third to middle third of tongue measuring of size
approximately 33 cm with ill-defined margins. The surface texture is smooth in appearance.
On palpation, all inspection finding are confirmed by palpation, the patch is soft in consistency.
Upon scraping dorsal surface of tongue, white curd like lesion was leaving an erythematous
band.
On examination of gingiva reveals red with melanin pigmentation, rolled out margin
with blunt interdental papilla, soft and edematous in consistency, positioned at the level of
cementoenamel junction, size & shape altered, stippling is absent, absence of bleeding on
probing, exudate & pocket depth.

On hard tissue examination, patient has total of 32 permanent teeth, dental caries -46,
28, moderate calculus and lower anterior attrition.

On correlating the chief complaint, history of presenting illness and intra oral
examination, a provisional diagnosis is Dentinal hypersensitivity irt 16 was arrived.

PROVISIONAL DIAGNOSIS:
Dentinal hypersensitivity irt 16.

OTHER DIAGNOSIS:
1) Pseudomembranous candidiasis
 2) Dental caries in 46, 28
3) Chronic generalized gingivitis

INVESTIGATION: NIL

FINAL DIGNOSIS:
Dentinal hypersensitivity irt 16.

TREATMENT PLAN:
1) Patient advised to use desensitizing toothpaste
2) Patient advised for ultrasonic scaling and oral hygiene instructions for management of
chronic generalized gingivitis and to maintain tongue hygiene
3) Patient advised for restoration for the management of dental caries irt 28 and 47.
4) Patient advised for medication
 Rx - Candid mouth paint 1% by topical means 2 times daily for 1 week (after food).
5) Patient asked to report back after 1 week for review.

STAFF’S SIGNATURE
 LONG CASE – 07

NAME ;- Mr. Saravanan

OP NO ;- 45993/24

AGE / SEX ;- 25 / Male

ADDRESS ;- Thirukazhikundram

OCCUPATION ;- IT Employee

RELIGION ;- Hindu

CONTACT NO ;- 994432297

CHIEF COMPLAINT:
Patient gives complaint of pain & swelling gum in lower anterior teeth region for past
1 week.

HISTORY OF PRESENTING ILLNESS:

Patient gives history of pain & swelling in lower anterior teeth region for past 1 week.
Patient gives history of bleeding while brushing in lower anterior teeth region for past 1 week.
Patient gives no history of food lodgement, sensitivity and bad breath.

PAST MEDICAL HISTORY:

No relevant medical history.

PAST DENTAL HISTORY:

Patient’s first dental visit.

FAMILY HISTORY:
Patient’s mother is known hypothyroid patient for past 4 years and under medication.

MARITAL STATUS ;- Unmarried

NO. OF CHILDREN ;- NIL

ORAL HYGIENE HABIT ;- Brushes once daily with toothpaste and toothbrush

DELETERIOUS HABIT ;- NIL

OTHER HABITS ;- NIL

GENERAL EXAMINATION
APPEARANCE ;- Normal

BUILT ;- Moderate

NOURISHMENT ;- Moderately nourished

ANEMIA ;- Absent

ICTERUS ;- Absent

CYANOSIS ;- Absent

CLUBBING ;- Absent

PEDAL EDEMA ;- Absent

STRUCTURAL AITERATION ;- No abnormalities detected

VITAL SIGNS
PULSE RATE ;- 70 beats/minute

BLOOD PRESSURE ;- 128/80 mmHg

RESPIRATORY RATE ;- 15 breaths/minute

TEMPERATURE ;- Afebrile at the time of examination

SYSTEMIC EXAMINATION
Central nervous system:
 No loss of memory
 No vomiting
 No headache
Cardiovascular system:
 No pain
 No palpitation
  No syncope
Respiratory system:
 No cough
 No breathlessness
 No tuberculosis
Gastrointestinal system:
 No dysphagia
 No burning sensation while having food
 No loss of taste
 No stomachache
Urogenital system:
 Regular micturition
 No polyuria or discolouration of urine
 No burning sensation
 No abdominal discharge
Skeletal system:
 No spasm
 No stiffness or joints
 No abnormal growth

LOCAL EXAMINATION
EXTRA ORAL EXAMINATION
FACIAL SYMMETRY:
No gross facial asymmetry.

TMJ EXAMINATION:
INSPECTION:
No pain or jaw deviation.

PALPATION:
No deflection, no clicking sound heard upon mouth opening and closing.
LYMPH NODE:
No clinically palpable, abnormal lymph node present in cervicofacial region.
MOUTH OPENING : 37mm (Interincisal distance)

INTRA ORAL EXAMINATION

SOFT TISSUE EXAMINATION
LABIAL MUCOSA ;- No abnormalities detected

ALVEOLAR MUCOSA ;- No abnormalities detected

FLOOR OF MOUTH ;- No abnormalities detected

UVULA ;- No abnormalities detected

SOFT PALATE ;- No abnormalities detected

HARD PALATE ;- No abnormalities detected

TONSILAR AREA ;- No abnormalities detected

FRENUM ;- No abnormalities detected

PHARYNX ;- No abnormalities detected

VESTIBULE ;- No abnormalities detected

LIP ;- No abnormalities detected

BUCCUL MUCOSA
INSPECTION:
Multiple swelling like lesion erythematous in colour is present on mandibular anterior
attached gingival region extending mesiodistally from 33 teeth region to 43 teeth region
measuring of size 3×3cm roughly irregular in shape with ill-defined margins. Surface texture
is smooth in appearance.

PALPATION:
On palpation, all inspectory findings are confirmed. The swelling like lesion is soft in
consistency & non scrapable & tender on palpation irt 31, 32, 33, 41, 42, 43. Bleeding on
probing is evident irt 41, 42, 31. The swelling is sessile in nature.
 GINGIVA
COLOR ;- Reddish pink with melanin pigmentation

CONTOUR ;- Rolled out marginal gingiva with blunt end Interdental papilla

CONSISTENCY ;- Soft and edematous

POSITION ;- At the level of cementoenamel junction

SIZE ;- Altered irt 41, 42, 43, 31, 32, 33

SHAPE ;- Altered irt 41, 42, 43, 31, 32, 33

SURFACE TEXTURE ;- Stippling absent

BLEEDING ON PROBING ;- Present irt 41, 42, 31

EXUDATE ;- Absent

POCKET DEPTH ;- Present irt 42

GINGIVAL RECESSION ;- Absent

HARD TISSUE EXAMINATION

Type of dentition ;- Permanent

No of teeth present ;- 32

Dental caries ;- 47

Pit & fissure caries ;- 38, 28

Tender on percussion ;- Nil

Missing ;- Nil

Calculus ;- Moderate

Stains ;- Nil

Root stump ;- Nil

Filled ;- Nil

Fractured tooth ;- Nil

Wasting disease ;- Attrition [Generalized]

Mobility ;- Nil
 Grossly decayed ;- Nil

Prosthetic ;- Nil

Malocclusion ;- Nil

SUMMARY
Patient named Mr. Saravanan, 25 year old, male reported to the department of oral
medicine and radiology with chief complaint of patient gives complaint of pain & swelling
gum in lower anterior teeth region for past 1 week. Patient gives history of pain & swelling in
lower anterior teeth region for past 1 week. Patient gives history of bleeding while brushing in
lower anterior teeth region for past 1 week. Patient gives no history of food lodgement,
sensitivity, and bad breath. Patient gives no relevant medical history. Past dental history
reveals that it is patient’s first dental visit.
Family history reveals that Patient’s mother is known hypothyroid patient for past 4
years and under medication. Patient gives personal history of unmarried, on mixed diet,
brushes once daily.
No abnormalities detected on general examination, patient’s vital signs and systemic
examination. Patient has a no abnormal finding in facial symmetry, TMJ examination, lymph
node and mouth opening.
On intraoral examination of gingiva, on inspection, multiple swelling like lesion
erythematous in colour is present on mandibular anterior attached gingival region extending
mesiodistally from 33 teeth region to 43 teeth region measuring of size 3×3cm roughly
irregular in shape with ill-defined margins. Surface texture is smooth in appearance. On
palpation, all inspectory findings are confirmed. The swelling like lesion is soft in consistency
& non scrapable & tender on palpation irt 31, 32, 33, 41, 42, 43. Bleeding on probing is evident
irt 41, 42, 31. The swelling is sessile in nature.
On examination of gingiva reveals reddish pink with melanin pigmentation, rolled out
margin with blunt end interdental papilla, soft & edematous in consistency, positioned at the
level of cementoenamel junction, size & shape altered irt 42, 43, 32, 33 stippling is absent,
presence of bleeding on probing irt 41, 42, 31 exudate & pocket depth Present irt 42.
 On hard tissue examination, patient has total of 32 permanent teeth, moderate calculus,
no stains, Generalized attrition Dental caries present irt 47 and pit and fissure caries present in
38, 28.
On correlating the chief complaint, history of presenting illness and intra oral
examination, a provisional diagnosis is inflammatory gingival enlargement.

PROVISIONAL DIAGNOSIS:
Inflammatory gingival enlargement.

OTHER DIAGNOSIS:
 Dental caries in 47
 Pit and fissure caries in 28, 38
 Generalized attrition

INVESTIGATION: NIL

FINAL DIGNOSIS:
Inflammatory gingival enlargement.

TREATMENT PLAN:
1) Patient advised for scaling and root planning irt 31, 32, 33, 41, 42, 43.
2) Patient is advised for ultrasonic scaling for the management of chronic generalized
gingivitis.
3) Patient advised for restoration for management of dental caries in 47, 28, and 38.
4) Patient advised for the management of attrition.
5) Patient asked to report back after 1 week for follow up.

STAFF’S SIGNATURE
 LONG CASE – 08

NAME ;- Mrs. Reeta

OP NO. ;- 46410 / 24

AGE / SEX ;- 22 / Female

ADDRESS ;- Selaiyur

OCCUPATION ;- Homemaker

RELIGION ;- Hindu

CONTACT NO ;- 7128522713

CHIEF COMPLAINT:
Patient gives complaint of decayed tooth in her lower left back tooth region for past 2
days.

HISTORY OF PRESENTING ILLNESS:

Patient gives history decayed tooth in her lower left back tooth region for past 2 days.
Patient gives history of sharp, continuous pain, non-radiating in nature, which is nocturnal for
past 2 days.
Patient gives history of sensitivity on consuming hot and cold foods for past 2
days .Patient gives history of food lodgement in lower right back tooth region for past 2 days.
Patient gives history of bleeding while brushing for past 1 day. No history of bad breath.

PAST MEDICAL HISTORY:

No relevant medical history.

PAST DENTAL HISTORY:

Patient’s first dental visit.

FAMILY HISTORY:
Patient’s family members are apparently healthy.
MARITAL STATUS ;- Married

NO. OF CHILDREN ;- Two

ORAL HYGIENE HABIT ;- Brushes once daily with toothpaste and toothbrush

DELETERIOUS HABIT ;- NIL

Gives history of smokeless tobacco (Hans) for past 5
OTHER HABITS ;-
years

GENERAL EXAMINATION
APPEARANCE ;- Normal

BUILT ;- Moderate

NOURISHMENT ;- Moderately nourished

ANAEMIA ;- Absent

ICTERUS ;- Absent

CYANOSIS ;- Absent

CLUBBING ;- Absent

PEDAL EDEMA ;- Absent

STRUCTURAL ALTERATION ;- No abnormalities detected

VITAL SIGNS
PULSE RATE ;- 72 beats / minute

BLOOD PRESSURE ;- 126 / 88 mm Hg

RESPIRATORY RATE ;- 14 breaths/minute

TEMPERATURE ;- Afebrile at the time of examination

SYSTEMIC EXAMINATION
Central nervous system:
 No loss of memory
 No vomiting
 No headache

Cardiovascular system:
 No pain
  No palpitation
 No syncope

Respiratory system:
 No cough
 No breathlessness
 No tuberculosis

Gastrointestinal system:
 No dysphagia
 No burning sensation while having food
 No loss of taste
 No stomachache

Urogenital system:
 Regular micturition
 No polyuria or discolouration of urine
 No burning sensation
 No abdominal discharge

Skeletal system:
 No spasm
 No stiffness or joints
 No abnormal growth

LOCAL EXAMINATION
EXTRA ORAL EXAMINATION
FACIAL SYMMETRY:
No gross facial asymmetry.
TMJ EXAMINATION:
INSPECTION:
No pain or jaw deviation.
PALPATION:
No deflection, no clicking sound heard upon mouth opening and closing.
LYMPH NODE:
No clinically palpable, abnormal lymph node present in cervicofacial region.

MOUTH OPENING: 35mm (Interincisal distance).

INTRA ORAL EXAMINATION

SOFT TISSUE EXAMINATION:
LABIAL MUCOSA ;- No abnormalities detected

BUCCAL MUCOSA ;- No abnormalities detected

ALVEOLAR MUCOSA ;- No abnormalities detected

FLOOR OF MOUTH ;- No abnormalities detected

UVULA ;- No abnormalities detected

SOFT PALATE ;- No abnormalities detected

HARD PALATE ;- No abnormalities detected

TONSILAR AREA ;- No abnormalities detected

FRENUM ;- No abnormalities detected

PHARYNX ;- No abnormalities detected

VESTIBULE ;- No abnormalities detected

LIP ;- No abnormalities detected

BUCCAL MUCOSA
INSPECTION:
A Solitary patch like lesion white in colour is present in maxilla and mandible labial
vestibule extending mesodistally in maxilla from 13to 23 region and in mandible from 31to
33 region. Extending superiorly from labial vestibule to mucogingival junction of each
measuring of size 1.52 cm. The patch is roughly irregular in shape with well-defined margin.
The surface texture is wrinkled in appearance

PALPATION:
All inspection finding are confirmed on palpation, the patch is soft in consistency and
non-scrapable and non-tender and rough and leathery on surface texture.
 GINGIVA
COLOR ;- Pale pink with melanin pigmentation
Rolled out margin with blunt interdental papilla irt 31,
CONTOUR ;-
32, 33, 41, 42, 43
CONSISTENCY ;- Soft and edematous irt 31, 32, 33, 41, 42, 43

POSITION ;- Apical to the level of cemento enamel junction

SIZE ;- Altered irt 31, 32, 33, 41, 42, 43

SHAPE ;- Altered irt 31,32,33,41,42,43

SURFACE TEXTURE ;- Stippling absent

BLEEDING ON PROBING ;- Absent

EXUDATE ;- Absent

POCKET DEPTH ;- Absent

GINGIVAL RECESSION ;- 41, 42, 43, 31, 32, 33

HARD TISSUE EXAMINATION

Type of dentition ;- Permanent

No of teeth present ;- 30

Dental caries ;- 36, 37, 35, 46, 47, 17

Tender on percussion ;- 36, 37

Missing ;- 18, 48

Calculus ;- Moderate

Stains ;- Moderate

Root stump ;- NIL

Filled ;- NIL

Fractured tooth ;- 21 (Ellis class 1)

Wasting disease ;- Attrition (31, 32, 33, 41, 42, 43)

Mobility ;- NIL

Grossly decayed ;- NIL

 Prosthetic ;- NIL

Pit & fissure caries ;- 35, 17, 46, 47

SUMMARY

Patient named Mrs. Reeta, 22 years old female reported to the department of oral
medicine and radiology with chief complaint of decayed tooth in her lower left back tooth
region for past 2 days. Patient gives history decayed tooth in her lower left back tooth region
for past 2 days. Patient gives history of sharp, continuous pain, non-radiating in nature, which
is nocturnal for past 2 days. Patient gives history of sensitivity on consuming hot and cold
foods for past 2 days .Patient gives history of food lodgement in lower right back tooth region
for past 2 days .Patient gives history of bleeding while brushing for past 1 day. No history of
bad breath.

Patient gives no relevant medical history. Patient gives personal history of married and
has 2 children, on mixed diet, brushes once daily and gives history of using smokeless tobacco
for past 5 years.

No abnormalities detected on general examination, patient’s vital signs and systemic

examination. Patient has a no abnormal finding in facial symmetry, TMJ examination, lymph
node and mouth opening.

On intraoral examination reveals no abnormalities in lip, buccal mucosa, labial mucosa,

alveolar mucosa, tongue, floor of mouth, hard and soft palate, uvula, tonsillar area, frenum and
pharynx. On inspection of labial vestibule, a Solitary patch like lesion white in colour is present
in maxilla and mandible labial vestibule extending mesodistally in maxilla from 13 to 23
region and in mandible from 31 to 33 region. Extending superiorly from labial vestibule to
mucogingival junction of each measuring of size 1.52 cm .The patch is roughly irregular in
shape with well-defined margin. The surface texture is wrinkled in appearance. All inspectory
finding are confirmed on palpation, the patch is soft in consistency and non-scrapable and non-
tender and rough and leathery on surface texture.

On examination of gingiva reveals pale pink with melanin pigmentation, rolled out
margin with blunt interdental papilla irt 31, 32, 33, 41, 42, 43, soft and edematuous in
consistency, positioned at the level of cemento enamel junction, size & shape altered, stippling
is absent, absence of bleeding on probing, exudate & pocket depth.
On hard tissue examination, patient has total of 30 permanent teeth, dental caries: 36,
37 missing 18 and 48, moderate calculus & stains and pit & fissure in 35, 46, 47, and 17.

On correlating the chief complaint, history of presenting illness and intra oral
examination, a provisional diagnosis is Dental caries with apical periodontitis irt 36.

PROVISIONAL DIAGNOSIS:
Dental caries with apical periodontitis irt 36.

OTHER DIAGNOSIS:

1) Tobacco pouch keratosis irt maxilla and mandible labial vestibule irt 31 to 23 and 31 to
33
2) Dental caries - 36, 37, 25, 46, 47, 17
3) Grossly decayed – 16
4) Attrition-31, 32, 33, 41, 42, 43
5) Chronic localized periodontitis irt 31, 32, 33, 41, 42, 43

INVESTIGATION:

IOPA reveals radiolucency involving enamel, dentin and approximating pulp with
widening of pdl and loss of lamina dura suggesting of dental caries with apical periodontitis
irt 36 And 37.

FINAL DIGNOSIS:
Dental caries with apical periodontitis irt 36.

TREATMENT PLAN:
1) Patient advised to quit the habit of tobacco chewing and referred to anti-tobacco
counseling.
2) Patient advised for the extraction of grossly decayed 16
3) Patient advised for the management of attrition
4) Patient advised for ultrasonic scaling and management of chronic localized periodontitis
irt 31, 32, 33, 41, 42, 43
5) Patient advised for permanent restoration for management of pit and fissure caries in
relation to 25, 46, 47, 17
6) Patient asked to report back after 1 week for follow up

STAFF’S SIGNATURE
 LONG CASE – 09

NAME ;- Mr. Elumalai

OP NO ;- 4686/24

AGE/SEX ;- 52/Male

ADDRESS ;- Rathinamangalam

OCCUPATION ;- Garden worker

RELIGION ;- Hindu

CONTACT NO ;-

CHIEF COMPLAINT:
Patient gives history of dirt and deposit for past 1 year and wants to clean it.

HISTORY OF PRESENTING ILLNESS:

Patient gives no history of pain, sensitivity, food lodgment, bleeding while brushing and
bad breath.

PAST MEDICAL HISTORY:

Patient gives history of spinal cord surgery due to load fall into him before 1 and ½
years and not under any medication.

PAST DENTAL HISTORY:

Patient underwent extraction in lower left back tooth region for past 1 year and it
uneventful.

FAMILY HISTORY:
Patient’s family members are apparently healthy.

MARITAL STATUS ;- Married

NUMBER OF CHILDREN ;- Two

DIET ;- Mixed diet

BRUSHING HABITS ;- Once daily with toothpaste and toothbrush

OTHER HABITS ;- Patient gives history of smoking for past 37 years

ANY OTHER HABITS ;- NIL

GENERAL EXAMINATION

APPEARANCE ;- Normal
BUILT ;- Moderately built

NOURISHMENT ;- Moderately Nourished

CLUBBING ;- Absent

CYANOSIS ;- Absent

ICTERUS ;- Absent

PEDAL ODEMA ;- Absent

STRUCTURAL ALTERNATION ;- Absent

VITAL SIGNS
HEART RATE ;- 72 beats/minute

RESPIRATORY RATE ;- 20 breaths/minute

BLOOD PRESSURE ;- 120/70 mm hg

TEMPERATURE ;- 98 F

SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM:
 No loss of memory
 No vomiting
 No headache
CARDIOVASCULAR SYSTEM:
 No pain
 No palpitation
  No syncope
GENITOURINARY SYSTEM:
 No dysphagia
 No burning sensation while having food
 No loss of taste
 No stomach ache, constipation, and diarrhoea
RESPIRATORY SYSTEM:
 No cough
 No breathlessness
 No tuberculosis
URINOGENITAL SYSTEM:
 No polyuria
 No burning sensation
 No discharge
 Regular micturition
LOCAL EXAMINATION
EXTRAORAL EXAMINATION:
FACIAL SYMMETRY:
No gross facial asymmetry.

TMJ EXAMINATION:
INSPECTION:
No pain or jaw deviation or deflection detected in right and left TMJ upon opening and
closing of the mouth.

PALPATION:
No crepitus, No clicking sound detected in right and left TMJ upon opening and closing
of mouth.

LYMPHNODE EXAMINATION:
No clinically palpable lymph node detected in cervicofacial region.
MOUTH OPENING: 42 mm (Interincisal distance)

INTRAORAL EXAMINATION

LABIAL MUCOSA ;- No abnormalities detected

ALVEOLAR MUCOSA ;- No abnormalities detected

FLOOR OF THE MOUTH ;- No abnormalities detected

HARD PALATE ;- No abnormalities detected

SOFT PALATE ;- No abnormalities detected

UVULA ;- No abnormalities detected

TONGUE ;- No abnormalities detected

TONSILLAR AREA ;- No abnormalities detected

FRENUM ;- No abnormalities detected

VESTIBULE ;- No abnormalities detected

LIP ;- No abnormalities detected

BUCCUL MUCOSA
INSPECTION:
Diffuse patch like lesion, grayish black in colour present on the right buccal mucosa,
extending anteroposteriorly from retro molar pad region to right commissure of lip measuring
of size approximately 5*4cm. Roughly irregular in shape with well-defined margins.

PALPATION:
On palpation, all inspectory findings are confirmed. A patch is soft in consistency, non-
scrapable, and non-tender on palpation.

PALATE
INSPECTION:
Multiple pinpoint lesion found on the hard palate extending anteroposteriorly from
incisive papilla to junction of hard and soft palate measuring of size approximately 1*2cm.
Roughly irregular in shape with well-defined margins.
PALPATION:
On palpation all inspectory findings are confirmed. The lesion is rough in consistency,
non-tender on palpation.

GINGIVA

COLOUR ;- Pale pink with melanin pigmentation

Rolled out marginal gingiva with knife edged interdental
CONTOUR ;-
papilla irt 31, 41, 42, 23, 24, 26, 16

CONSISTENCY ;- Soft and edematous irt 31, 41, 42, 23, 24, 26, 16

Apical to the level of cemento enamel junction irt 31, 41,

POSITION ;-
42, 23, 24, 26, 16

SHAPE ;- Altered irt 31, 41, 42, 23, 24, 26, 16

SIZE ;- Altered irt 31, 41, 42, 23, 24, 26, 16

SURFACE TEXTURE ;- Stippling absent

BLEEDING ON PROBING ;- Absent

EXUDATE ;- Absent

POCKET DEPTH ;- Absent

GINGIVAL RECESSION ;- 31, 41, 42, 23, 24, 26, 16

HARDTISSUE EXAMINATION
TYPE OF DENTITION ;- Permanent dentition

NO.OF TEETH ;- NIL

DENTAL CARIES ;- NIL

PIT AND FISSURE CARIES ;- NIL

TENDER ON PERCUSSION ;- NIL

MISSING ;- 18, 28, 38, 48

CALCULUS ;- Mild
STAINS ;- Moderate

GROSSLY DECAYED ;- NIL

FRATURED TEETH ;- NIL

ROOT STUMPS ;- NIL

FILLED TOOTH ;- NIL

MOBILITY ;- NIL

WASTING DISEASE ;- Generalized attrition

PARTIALLY ERUPTED ;- NIL

PROSTHETIC CROWN ;- NIL

CERVICAL ABRASION ;- 12, 14, 23

MALOCCLUSION ;- NIL

SUMMARY
Patient named Mr. Elumalai, 57 years old, male patient reported to the department of
Oral Medicine and Radiology, Tagore Dental College and Hospital, with the chief complaint
of dirt and deposit for past 1 year and wants to clean it Patient gives no history of pain,
sensitivity, food lodgment, bleeding while brushing and bad breath. Patient gives history of
spinal cord surgery due to load fall into him before 1 and ½ years and not under any
medication.

Past dental history reveals Patient underwent extraction in lower left back tooth region
for past 1 year and it uneventful and patient’s family history reveals that his family members
are apparently healthy. Patient consumes mixed diet and brushes once daily with toothpaste
and tooth brush.

On General Examination, No abnormalities are detected. Patient’s vital signs are normal
and no abnormalities detected in systemic examination. Extra oral examination reveals no
gross facial asymmetry. No restricted mouth opening. On inspection of TMJ No pain or jaw
deviation or deflection detected in right and left TMJ upon closing and opening of mouth and
on palpation of TMJ No evidence of clicking sound, No crepticus heard upon opening and
closing of mouth with maximum Interincisal distance of 42mm.
 On Intraoral examination, on inspection of Buccal mucosa, Diffuse patch lesion grayish
black in colour is present on the right buccal mucosa, extending anteroposteriorly from retro
molar pad region to the right commissure of the lip, measuring of size approximately 5*4cm.
Roughly irregular in shape with well-defined margins.

On palpation, all inspectory findings are confirmed. The patch is soft in consistency, on
scrapable and non-tender on palpation. On inspection of palate, Multiple pinpoint lesion found
on the hard palate, extending anteroposteriorly from incisive papilla to junction of hard and
soft palate, measuring of size approximately 1*2cm. Roughly irregular in shape with well-
defined margins. On palpation, all inspectory findings are confirmed. The patch is soft in
consistency and non-tender on palpation.

On Hard tissue examination, moderate calculus and stains are present with generalized
attrition and cervical abrasion 12, 14 and 23.

On correlating with the chief complaint, history of presenting illness and intraoral
examination, a provisional diagnosis of chronic generalized gingivitis is arrived.

PROVISIONAL DIAGNOSIS:
Chronic generalized gingivitis with localized periodontitis irt 31, 41, 42, 23, 24, 26
and 16.

OTHER DIAGNOSIS:
1) Smoker’s melanosis in right buccal mucosa.
2) Smoker’s palate
3) Generalized attrition.
4) Cervical abrasion irt 13, 14 and 23.

FINAL DIAGNOSIS:
Chronic generalized gingivitis with localized periodontitis irt 31, 41, 42, 23, 24, 26,
16.
TREATMENT PLAN:
1) Patient is advised to quit the habit of smoking (Cigarette).
2) Later, patient is advised ultrasonic scaling management of chronic generalized
gingivitis with localized periodontitis irt 31, 41, 42, 23, 24, 26 and 16.
3) Later, patient is advised for management of generalized attrition and cervical abrasion
in relation to 12, 14 and 23.
4) Patient is asked to report back after 2 weeks for follow-up.

STAFF’S SIGNATURE
 LONG CASE – 10

NAME ;- Mrs. Devakirubai

OP NO ;- 46910/24

AGE/SEX ;- 49/ Female

ADDRESS ;- Vandalur

OCCUPATION ;- Home maker

RELIGION ;- Hindu

CONTACT NO ;- 9940178208

CHIEF COMPLAINT:
Patient gives a complaint of decayed in lower right back tooth region for past 1 month.

HISTORY OF PRESENTING ILLNESS:

Patient gives a history of pain in lower right back tooth region for past 1 month. Pain
is sharp intermittent, non-radiating, nocturnal in nature and pain aggravates on mastication and
relieves on medication. Patient gives a history of sensitivity on consuming hot food past 2
weeks. Patient gives history of food impaction in that region for past. Patient gives no history
of bleeding gums while brushing and bad breath.

MEDICAL HISTORY:
Patient is a known hypothyroid for past 12 years and is under medication.

PAST DENTAL HISTORY:

Patient underwent extraction before 6 years and it was uneventful.

FAMILY HISTORY:
Patient’s mother is known diabetic for past and is under medication.

MARITAL STATUS ;- Married

NUMBER OF CHILDREN ;- Three

DIET ;- Mixed diet

BRUSHING HABITS ;- Once daily with toothpaste and toothbrush.

OTHER HABITS ;- NIL

ANY OTHER HABIT ;- Nail biting since childhood

GENERAL EXAMINATION

APPEARANCE ;- Normal

BUILT ;- Moderately built

NOURISHMENT ;- Moderately Nourished

CLUBBING ;- Absent

CYANOSIS ;- Absent

ICTERUS ;- Absent

PEDAL ODEMA ;- Absent

STRUCTURAL ALTERNATION ;- Absent

VITAL SIGNS

HEART RATE ;- 73 beats/minute

RESPIRATORY RATE ;- 14 breaths/minute

BLOOD PRESSURE ;- 128/66 mm hg

TEMPERATURE ;- 98 F

SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM:

 No loss of memory
 No vomiting
 No headache
CARDIOVASCULAR SYSTEM:
 No pain
 No palpitation
 No syncope

GENITOURINARY SYSTEM:
 No dysphagia
 No burning sensation while having food
 No loss of taste
 No stomach ache, constipation and diarrhoea
RESPIRATORY SYSTEM:
 No cough
 No breathlessness
 No tuberculosis

URINOGENITAL SYSTEM:
 No polyuria
 No burning sensation
 No discharge
 Regular micturition

LOCAL EXAMINATION
EXTRAORAL EXAMINATION:
FACIAL SYMMETRY:
Gross facial asymmetry is detected.

INSPECTION:
Diffuse swelling present on the right side of the lower face, extending
superinferiorly from maxillary region to the lower border of the mandible and
anteroposteriorly 1cm away from the right commissure of the lip till the ascending ramus,
measuring of size approximately 4*3cm with well-defined margins. The surface is glossy in
appearance.
PALPATION:
On palpation, all inspectory findings are confirmed. The swelling is soft in consistency
and tender on palpation. The swelling was afebrile at the time of examination.

TMJ EXAMINATION:
INSPECTION:
No pain or jaw deviation or deflection detected in right and left TMJ upon opening
and closing of the mouth.

PALPATION:
No crepitus, No clicking sound detected in right and left TMJ upon opening and
closing of mouth.

LYMPHNODE EXAMINATION:
Clinically palpable lymph node detected in the right mandibular region.

MOUTH OPENING: 40 mm (Interincisal distance).

INTRAORAL EXAMINATION

LABIAL MUCOSA ;- No abnormalities detected

ALVEOLAR MUCOSA ;- No abnormalities detected

FLOOR OF THE MOUTH ;- No abnormalities detected

HARD PALATE ;- No abnormalities detected

SOFT PALATE ;- No abnormalities detected

UVULA ;- No abnormalities detected

TONGUE ;- No abnormalities detected

TONSILLAR AREA ;- No abnormalities detected

FRENUM ;- No abnormalities detected

VESTIBULE ;- No abnormalities detected

LIP ;- No abnormalities detected

BUCCAL VESTIBULE ;- Obliteration of vestibule is evident.

BUCCAL MUCOSA
INSPECTION:
No abnormalities detected.

PALPATION:
No abnormalities detected.
GINGIVA

COLOUR ;- Pale pink with melanin pigmentation

Scalloping marginal gingiva with knife edged
CONTOUR ;-
interdental papilla
CONSISTENCY ;- Firm and resilient

POSITION ;- At the level of cemento enamel junction

SHAPE ;- Unaltered

SIZE ;- Unaltered

SURFACE TEXTURE ;- Stippling present

BLEEDING ON PROBING ;- Absent

EXUDATE ;- Absent

POCKET DEPTH ;- Absent

GINGIVAL RECESSION ;- Absent

HARDTISSUE EXAMINATION
TYPE OF DENTITION ;- Permanent dentition

NO.OF TEETH ;- 28

DENTAL CARIES ;- 27, 48

PIT AND FISSURE CARIES ;- NIL

 TENDER ON PERCUSSION ;- 46

MISSING ;- 37, 38, 47, 28

CALCULUS ;- NIL

STAINS ;- NIL

GROSSLY DECAYED ;- 46

FRATURED TEETH ;- NIL

ROOT STUMPS ;- 16

FILLED TOOTH ;- NIL

MOBILITY ;- NIL

WASTING DISEASE ;- Attrition ( lower anterior )

PARTIALLY ERUPTED ;- NIL

PROSTHETIC CROWN ;- NIL

CERVICAL ABRASION ;- NIL

MALOCCLUSION ;- NIL
SUMMARY

Patient named Mrs. Devakirubai, 46 years old, Female, reported to the department of
Oral Medicine and Radiology, Tagore Dental College and Hospital, with the chief complaint
of decayed tooth in her lower right back tooth region for past one month. Patient gives history
of pain in that region for past 1 months. The pain is dull, intermittent, non - radiating and
nocturnal in nature. The pain aggravates on mastication and relieves after medication. Patient
also gives history of sensitivity in that region on consuming hot foods for past 2 weeks.

Patient gives history of food lodgment in that region for past 2 weeks. Patient gives no
history of bleeding while brushing and bad breath. Patient’s medical history reveals that patient
is known hypothyroid for past 12 years and is under medication. Patient’s dental history
reveals that patient underwent extraction before 6 years and it was uneventful. Patient’s family
history reveals that her mother is known diabetic and is under medication. Patient consumes
mixed diet and brushes once daily with toothpaste and tooth brush.
 On General Examination, No abnormalities are detected. Patient’s vital signs are normal
and no abnormalities detected in systemic examination. Extra oral examination reveals gross
facial asymmetry. Local examination reveals clinically palpable lymph nodes, in right
mandibular region. No restricted mouth opening. On inspection of TMJ, No pain or jaw
deviation or deflection detected in right and left TMJ upon closing and opening of mouth and
on palpation of TMJ No evidence of clicking sound, No crepticus heard upon opening and
closing of mouth with maximum Interincisal distance of 40mm.

On inspection, diffuse swelling present on right side of the lower face extending
superioinferiorly from maxillary region till the lower border of mandible and
anteroposteriorly, 1cm away from right commissure of lip till the ascending ramus of the
mandible, measuring of size approximately 4*3cm with well-defined margin. The surface is
glossy in appearance. On palpation, all inspectory findings are confirmed. The lesion is soft in
consistency, Tender on percussion. The swelling was afebrile at the time of examination.

On intraoral examination, obliteration of vestibule is evident.

On Hard tissue examination, dental caries irt 27, 48 is seen, partially edentulous
mandibular arch irt 37, 47 is seen. Mild calculus and moderate stains present. Lower anterior
attrition is present.

On co relating with the chief complaint, history of presenting illness and extraoral
examination, a provisional diagnosis of grossly decayed tooth irt 46 is arrived.

PROVISIONAL DIAGNOSIS:
Grossly decayed tooth in relation to 46.

OTHER DIAGNOSIS:
1) Dental caries in relation to 27, 48
2) Root stump in relation to 16
3) Partially edentulous mandibular arch irt 37 , 47
4) Mandibular anterior attrition.
INVESTIGATION:
IOPA of 46 reveals coronal radiolucency involves enamel, dentin, pulp is seen. An ill-
defined radiolucency is seen in the periapical region of mesial root of 46 suggestive of
Periapical abscess in relation to 46.

FINAL DIAGNOSIS:
Dental caries leading to dentoalveolar abscess irt 46.

TREATMENT PLAN:

1) Patient is advised for Root canal treatment for management of dental caries leading to
Dentoalveolar abscess irt 46.
2) Patient is advised for extraction of root stumps irt 16.
3) Later, patient is advised for prosthesis for management of partially edentulous
Mandibular arch irt 37 and 47.
4) Later, patient is advised for restoration of dental caries irt 27 and 48.
5) Later, patient is advised for management of Lower anterior attrition.
6) Later, patient is advised for ultrasonic scaling.
7) Later, patient is advised the following medications
a. Cap. Amoxicillin 500
b. Tab. Flagil 400 – twice daily- 3 days
c. Tab zerodol .P (6) 1-0-1
d. Tab PAN 40 (3) 1-0-0
8) Patient is asked to report back after 2 weeks for review.

STAFF’S SIGNATURE