DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY

BABU BANARASI DAS COLLEGE OF DENTAL SCIENCES, LUCKNOW

UG CASE HISTORY SHEET
OPD NO. – 27043 DATE- 22/06/23

NAME OF PATIENT – SHARIQUE AGE- 30yrs

GENDER – MALE MARITAL STATUS- MARRIED

ADDRESS – BARABANKI CONTACT NO.- 9369533266

CHIEF COMPLAINT – Pt. complains of broken tooth in right lower back region of jaw since 1.5
months.
HISTORY OF PRESENT ILLNESS – Pt. gives history of sensitivity on taking cold beverages on the right
lower back region of jaw which relieves on taking warm water.
PAST MEDICAL AND SURGICAL HISTORY – No relevant history
COVID VACCINATION – Both have taken
DRUG ALLERY – No known drug allergy
PAST DENTAL HISTORY – Pt. visited dental clinic 1 month back for the same and was not satisfied .
FAMILY HISTORY – Patient’s mother is hypertensive and diabetic .
PERSONAL HISTORY –

1. Abusive habits- Pt. smokes cigarette occasionally since 20yrs . He also consumed Kamla
Pasand 5-6 packets /day since 20 years.
2. Para functional habits – no any such habits.
3. Dietary habits - mixed
4.Oral hygiene - Pt. brushes his teeth once a day with tooth brush and toothpaste .
GENERAL PHYSICAL EXAMINATION
Built – Mesomorphic
Nourishment – Well nourished
Mental state – Well oriented to time, place and person
Gait – normal Menstruation – not required
Pallor – absent Cyanosis – absent
Icterus – absent Clubbing – absent
VITAL SIGNS
Blood pressure – not recorded Pulse – 76 beats/min
Temperature – afebrile Respiratory rate – 16 breath/min
EXTRAORAL EXAMINATION
Facial symmetry – bilaterally symmetrical
Facial profile – straight
Lymph nodes – non palpable
Temporomandibular joint – bilaterally smooth and synchronised movement
Muscles of mastication – no abnormality detected
Mouth opening – reduced (36mm)
INTRAORAL EXAMINATION

1. Hard tissue examination

Teeth present – Missing

Color, shape, size – yellowish white in colour with normal shape and size

Attrition , abrasion , erosion – localised attrition is seen in lower arch

Occlusion – angle’s class 1 molar relation

Others – fractured cusp w.r.t 46

T.O.P w.r.t 46
2. Soft tissue examination
Lips – competent
Labial and buccal mucosa –
Non scrapable greyish white patch present on the buccal
mucosa (bilaterally) with wrinkled appearance.
- Presence of fibrotic band (bilaterally) on buccal mucosa.
- Blanching present on upper labial mucosa.
Vestibule – no abnormality detected
Tongue – greyish white patch present on left side of lateral border of tongue.
Palate – no abnormality detected
Other findings – shrunken uvula is seen
3.Gingival and Periodontal status
Color – pale pink
Contour – scalloped
Consistency – firm and resilient
Surface texture – stippling present
Recession – localised recession in lower anteriors
Bleeding on probing – absent
Pocket – present in relation to 37,38
Stains – severe
Calculus – moderate
LOCAL EXAMINATION: w.r.t 46

A) Soft tissue:
1. Inspection – gingiva is pale pink with scalloped borders
2. Palpation – gingiva is firm and resilient with no bleeding on probing
B) Hard tissue:
1. Inspection – fractured cusp w.r.t 46, wrinkled appearance
2. Palpation – Inspectory findings confirmed
tenderness on percussion in vertical direction w.r.t 46

C) Buccal and labial mucosa:

- Inspection – Greyish white patch present bilaterally on buccal mucosa
- presence of fibrotic band bilaterally on buccal mucosa
- blanching present on upper labial mucosa
- Palpation – lesion is non scrapable, rough in texture,
bilaterally vertical band is palpable on buccal
mucosa and non-tender.
PROVISIONAL DIAGNOSIS

- Chronic generalised periodontitis

- Chronic apical periodontitis w.r.t 46
- Homogenous Leukoplakia on right buccal mucosa and left lateral border of the tongue

DIFFERENTIAL DIAGNOSIS
 A) w.r.t oral submucous fibrosis :
- trismus
- localised scleroderma
- radiation induced fibrosis
B) w.r.t leukoplakia :
- candidiasis
- hairy leukoplakia
- tobacco pouch keratosis

C) w.r.t apical periodontitis :

- chronic periapical abscess
- chronic periapical cyst
- chronic periapical granuloma
INVESTIGATIONS AND REPORT

FINAL DIAGNOSIS

- Oral sub mucous fibrosis grade 2

- Leukoplakia

TREATMENT PLAN

1. Counselling of patient for cessation of smoking and kamla pasand.

2. Emergency phase :
Medication – ointment cinort 0.1% topical application 3-4 times daily before/after meals
( composition : triamcinolone Acetonide 0.1% w/w )
-capsule S.M. fibro – BD for 15 days
-capsule Densomin – OD
-capsule sentrum G4 – OD
-B-mine(benzodiazamine) mouthwash
3. Elective phase :
- oral prophylaxis
- root canal treatment w.r.t 46
4. Patient is recalled on follow up after 15 days