INTERDISCIPLINARY

DIAGNOSIS AND
TREATMENT PLANNING
A case presentation
Submitted to : Dr.Borja

Submitted by:
Dr.Amithbabu.c.b.
MSD-ENDODONTICS,U.E.
DECEMBER 8 2009
 IDENTIFICATION DATA OF THE
PATIENT
 NAME OF THE PATIENT : xx
 AGE - 19 YEARS OLD
 SEX - FEMALE
 DATE OF BIRTH -02/09/1990
 RELIGION - CHRISTIAN ROMAN
CATHOLIC
 CIVIL STATUS -SINGLE
 CULTURAL STATUS - ASIAN
 ADDRESS :
 CHIEF COMPLAINT

“I have pain on the right front tooth”

(TOOTH # 11)
 HISTORY OF PRESENT ILLNESS
 The patient came to the graduate school on
December 08 2009 with a complaint of pain in the
upper front tooth. patient started experiencing
pain 3 weeks prior to consultation. History reveals
that the patient noticed caries on that tooth
6months prior to consultation. the patient is
having pain while having hot and cold food liquids.
The pain was intermittent and discontinuous in
nature. Patient took medicine to relieve from the
pain( mefanamic acid 500 mg for 3 days for every 6
hours).the patient was relieved of pain.
MEDICAL HISTORY
No systemic diseases, no known allergy to
penicillin or other medications, no known
allergy to any food, no history of
hospitalization in the past 2 years.

FAMILY HISTORY
Patient’s parents, grandparents and siblings
do not suffer from any known medical
conditions.
PERSONAL HISTORY
 Patient is not a smoker
 Patient doesn’t have the habit of drinking
 Patient brushes once daily

DENTAL HISTORY
 Patient’s first visit to the dentist
 REVIEW OF SYSTEM
 Respiratory System– Patient has no difficulty in
breathing, coughing, night sweats, nocturnal
dyspnoea or wheezing
 Cardiovascular System – Patient does not have
chest pain, dyspnoea, hypertension, palpitations,
weakness, or swelling of extremities
 Gastrointestinal System – Patient has no nausea,
vomiting, diarrhoea and constipation. She has a good
appetite.
 Hematopoietic System– There is no spontaneous or
excessive bleeding, pallor or anaemia.
 REVIEW OF SYSTEM
 Excretory system – No change in the colour of
urine. Frequency of urination is normal with no
pain or urgency.

 Genital Tract – Menstrual cycle is normal. There

is no discharge, pain or discomfort. No history of
venereal disease.

 Skeletal System – No limitation of function or

deformity. No pain with movement.
 REVIEW OF SYSTEM
 Nervous System – No history of dizziness,
seizures, tremor, ataxia and difficulty in speaking.
She never experienced paresthesia

 Endocrine System – No tremors, palpitations,

intolerance to heat or cold, polyuria, polydipsia,
polyphagia, exopthalmos or goitre present.
 GENERAL EXAMINATION
 Healthy looking
 Body build : Moderate build
(mesomorphic)

 Gait : Heel to toe type

 Posture & movement : Balanced posture, no

abnormal tremors observed, no signs of twitching,
no un-coordinated muscle movements
 GENERAL EXAMINATION

 Psychological Status – No nervousness,

instability, depression, phobia, insomnia,
night terrors, memory loss or
disorientation.

 Speech : No slurring of speech (dysarthria),

no difficulty in accomplishing proper verbal
expression (aphasia)
 VITAL SIGNS

 Blood pressure : 116 / 78 mm of Hg

 Heart rate : 86 beats / min
 Respiration rate : 19 breaths / min
 Temperature : 36.2oC
 Height : 5 feet 1 inches
 Weight : 54.5 Kgs
 EXTRA ORAL EXAMINATION

 Facial symmetry: Symmetrical

 Eyes : No signs of Cataract,

Conjunctivitis, Strabismus, diplopia

 Nose : No deviation in shape and

position of nose, no deviation of the septum,
nasal fractures, nasal polyps, nose bleeds or
rhinitis
 EXTRA ORAL EXAMINATION

 Ear : No signs of any developmental deformity,

no difficulties in hearing, no signs of any swelling or
inflammation of the ear

 Hair : Black colour, no signs of Alopecia, Hair

shaft disorders

 Skin : No signs of acne, Cellulitis, Erysipelas,

Folliculitis, Skin Abscesses, any patches of
discolouration
 EXTRA ORAL EXAMINATION

 Lymph node : No palpable lymph nodes

 T.M.J : No Shifting of mandible to left or

right when opening the mouth, no asymmetry, no
abnormal range of motion, can open the mouth
wide, no clicking sounds, no crepitus on
auscultation, no tenderness on palpation

 Facial Profile : straight

 INTRA ORAL EXAMINATION
 Lips : No cracks, lesions, irregular vermilion border angular
cheilitis were observed
 Labial /buccal mucosa : No changes in colour, texture, no
tenderness upon palpation, no signs of any other intra oral
lesions were observed
 Palate
 Hard Palate : Firm, High palatal vault, No torus
palatinus present, prominent rugae present in
anterior region
 Soft Palate : Compressible, No ulcerations
present, Vibrating line vibrates when patient says
“ah”, Uvula is not deviated
 INTRA ORAL EXAMINATION
 Oro-pharyngeal area : No changes in colour, no
signs of tonsillitis, no signs of sore throat or
discomfort when swallowing
 Tongue
 Dorsal surface : Presence of papillae, No signs of
dryness, fissured tongue, geographic tongue,
macroglossia, or hairy tongue
 Ventral surface : No signs of ankyloglossia (can move
the tongue freely and no difficulty when speaking) were
observed
 Lateral surface : No signs of ulcers or coatings
 INTRA ORAL EXAMINATION

 Tongue position : Not deviated

 Floor of mouth : No change in color,
texture, mucocele, no lingual varicosities no tori
were seen observed on the lingual surface of the
mandible
 Gingival colour : Reddish
 Consistency of gingiva :firm and resilient
 Occlusion : Class I Type I
PATIENT CHART
Data from Patient’s Chart

 Caries Tooth
#17,16,15,14,12,11,21,22,24,25,26,27,37,35,34,35,4
1,4244,45,47,48
 Missing Tooth #46,36

 Sound Tooth Tooth #13,23,33,43,48

 PATIENTS RADIOGRAPH

Widening of
Periodontal ligament

caries involving mesial suface

Of 21 and distal of 11
 DIAGNOSIS

 TOOTH #11 - SYMPTOMATIC

IRREVERSIBLE PULPITIS WITH ACUTE
APICAL PERIODONTITIS
 TREATMENT PLAN
 PULPECTOMY IN 11

 ROUTINE ENDODONTIC TREATMENT -11

 SCALING AND ORAL PROPHYLAXIS
 RESTORATION OF-
#17,16,15,14,12,11,21,22,24,25,26,27,37,35,34,35,4
1,4244,45,47,48
 REPLACEMENT OF MISSING TEETH-46,36
 RECALL
THANK YOU ALL