Case: Gingivitis
Abstract: A 40 y/o man come to your dental clinic cause he has pain in the lower 1 st and
2nd molars. He works at the cement factory for 20 years.
Doctor
Hi there, Im Dr… What is your name?
How old are you?
What’s your job?
How long have you been doing that job?
How can I help you? / What bring you
here today?
Can you tell me more about your
problem?
Using SOCRATES:
Where do you feel the pain come from?
When did the pain begin?
Is this the first time it happened?
Is it constant or intermittent?
How long does it last, and how often does
it occur?
Does the pain spread elsewhere?
Are there any other symptoms that seem
Patient
My name is William Richardson
40
I’m a worker at the cement plant.
About 20 years, I think so
.
I feel the pain right here (point at the
gingivitis area).
I’ve been suffering from the pain for 5
years. At first the pain was short in
duration when food got stuck in the gum’s
area so I don’t think it’s worth to go the
hospital. But lately, the pain’s severe has
increased bit by bit and now it hurts badly
and the duration was longer.
Its around these teeth: point at the lower
1st and 2nd molars
It was last month when the pain has
became worse and I barely can touch the
gum or eating with these teeth..
It has happened like 5 years ago.
It’s intermittent.
Before, I feel hurt when stuff got stuck
into the area, it occurs quickly and goes
away when there is none food got stuck..
Now, it hurt even when i dont eat, just
occur when something touch it.
I think it’s a no. It only hurt this area.
I see the bleeding from the gums when
associated with the pain?
How has the pain changed over time?
Does anything make the pain better? Does
anything make it worse or trigger it?
On a scale of 0-10, how severe is the pain,
if 0 is no pain and 10 is the worst pain
you’ve ever experienced?
What do you think your problem is?
What’s your number one concern
regarding this problem at the moment?
What were you hoping I’d be able to do
for you today?
How would you rate your health? Based
on level from 1 to 10, tell me a number.
Do you have any medical conditions?
How well do you control the disease?
Have you ever previously undergone any
operations or procedures?
Have you carried any medical devices
inside your body?
Are you allergic to latex or any other
substance or materials?
Do your family members have any
physiological disease or genetic disorder?
Are you smoking?
brushing, also my breath has bad smell
lately.
When it first come out at 5 year ago, I
don’t feel much but now it hurts a lot.
It hurts when something touch the gum
but i dont know for sure ì there are
anything make it feel better or worse..
I think it might be 7-8..
I think my gum is under the inflamation
for the long time and now I’ve started to
feel the pain.
Can it be cured?
I want to have my pain eased as much as
possible.
6/10
Yes, I just was diagnosed with diabetes
type 2 5 years ago.
I had been treated with Glucophage for 5
years.
No
No
Im not allergic to latex but I’m allergic to
the alcohol.
No.
Yes.
How many times a day do you smoke?
Do you drink alcohol frequently?
When was the last time you visited a
dentist?
I do the smoking at free time… About 10
pieces of tobacco a day.
No, I can’t drink it cause of the allergy.
It has been 3 years. Back then I need to
have my teeth filled.

When was the last time you visited a It has been 3 years. Back then I need to
dentist? have my teeth filled.

How often do you see a dentist? Not frequently. I only go to the dentist for
treatment.
Have you had any dental treatment in the I had my tartar removal 3 years ago. The
past? same time I have my teeth filled.

How many times do you brush your teeth Twice per day.
in a day?

How do you brush your teeth? Brushing left to right along my teeth 

Do you have interdental cleaning? No

Do you have any bad habits? Such as: I think I like chewing ice cubes.
Chewing ice cubes.
Biting your nails.
Eating too much snack.
Brushing too hard.
Using your teeth as an utensil.
Grinding or clenching your teeth/Especial
in anger or sleeping.

Thank you for your cooperation, now I

have to examinate your mouth for more
information.
Relax and open your mouth!