Documente Academic
Documente Profesional
Documente Cultură
2012-20749
CD 41 CASE DISCUSSION
PATIENT WORK-UP
I. PERSONAL INFORMATION
Sex: Male
Address: Block 34, Phase II, Kapalaran St., San Roque, Navotas City
Occupation: unemployed
Phone: 09186340561
The patient’s main concern was to have complete dentures mainly for function. The
patient understands and expects that the treatment will be composed of multiple
appointments.
V. FAMILY HISTORY
The patient stopped smoking 9 years ago, prior to that, patient claims to smoke at
least once a day for 20 years. The patient also stopped drinking alcoholic beverages 9
years ago, and claims to only occasionally drink beer also for 20 years. The patient
does not use recreational drugs.
The patient visits the dentist only when needed. The patient has been previously
exposed to local anesthesia and had no adverse reactions. No complications were also
observed during or after dental procedures.
The patient first had his maxillary central incisors extracted 19 years ago due to
trauma when he fracture his incisors in an accident inside a swimming pool. He first
started wearing a removable partial denture for the maxillary central incisors when 10
years ago. After 3 years, the patient stopped wearing his removable partial denture
when the abutment teeth were also extracted due to caries. Patient recalls his other
teeth being extracted due to caries also. Patient had his last extraction this April in a
dental mission.
Patient claims to have Arthritis and takes Skelan (Naproxen Na) for pain relief as
needed.
Effect in treatment: Naproxen Na has the following known side effects or adverse
reactions; Heartburn, abdominal pain, nausea, constipation, diarrhea, dyspepsia,
stomatitis, flatulence, gross bleeding/perforation, gastric/duodenal ulcer, vomiting,
headache, dizziness, drowsiness, lightheadedness, vertigo, pruritus, skin eruptions,
ecchymoses, sweating, purpura, tinnitus, visual & hearing disturbances, edema,
palpitations, dyspnea, thirst, abdominal renal function, anemia, elevated liver enzyme
levels, increased bleeding time & rashes (Mims, 2017).
In case the patient experiences the following signs and symptoms mentioned, the
clinician must be aware and should determine if the symptoms are caused by dental
treatment or by taking the specified drug.
The patient appears overweight but the gait appears normal and unimpeded. Patient
has no noticeable physical defects.
Structure Remarks
Head/Neck/TMJ No significant findings
Mucosa Bony exostosis observed in buccal of
Quadrant 2
Pharynx No significant findings
Tongue No significant findings
Salivary Glands No significant findings
Lips/Frenum No significant findings
Palate No significant findings
Floor of the mouth No significant findings
Lymph Nodes None were palpated
Thyroid No significant findings
Gingiva N/A
XI. EXAMINATION
Extraoral Examination
Intraoral Examination
1. Arch Size: Medium sized maxillary and mandibular arch
2. Arch Form: tapering maxillary arch
3. Ridges
Maxillary: resorption present but with adequate height remaining and
relatively round crest. Bony exostosis present at the buccal of Quadrant 2
Mandibular: resorption present with uneven ridge height. Elevation at the
anterior ridge (area of canine extracted last April).
4. Palatal vault: Dome-shaped maxillary arch
5. Saliva: Normal in amount and consistency
6. Soft palate drop: approximately 45 degrees
7. Thickness and firmness of underlying soft tissue: Soft tissues are firm, no flabby
ridges or epulis fissuratum observed.
Mandibular cast: The primary stress bearing areas which are the buccal shelf and
retromolar pad is visible from the cast. The buccal shelf is bounded medially by the
crest of residual ridge and posteriorly by the retromolar pad. Limiting structures like
labial vestibule, labial frenum, lingual frenum, buccal frenum, external oblique ridge,
pteryogomandibular raphe, mylohyoid ridge and retromylohyoid fossa can be
observed. Bony undercut is present on the anterior part of the arch.
I. Case Presentation
II. Complete Denture Service and Installation
III. Post-Installation Recall
IV. Alveoloplasty when needed
V. Maintenance