Clinician: Ruedas, Rainier S.

2012-20749

CD 41 CASE DISCUSSION
PATIENT WORK-UP

I. PERSONAL INFORMATION

Patient Name: Jonathan Rosit

Age: 52 years old

Sex: Male

Address: Block 34, Phase II, Kapalaran St., San Roque, Navotas City

Occupation: unemployed

Educational Attainment: College graduate

Birthdate: November 5, 1965

Civil Status: Married

Mobile Number: 09127142839

Person to notify in case of emergency: Edith Rosit (wife)

Phone: 09186340561

Initial Visit: September 15, 2017

II. CHIEF COMPLAINT

“Nahirapan ako kumain dahil wala akong ngipin”

III. HISTORY OF PRESENT ILLNESS

Patient claims to experience difficulty in masticating food, which started when he

became partially edentulous around more than 10 years ago. Patient became
completely edentulous last April. 19 years ago, the patient first had his upper centrals
extracted due to fracture caused by trauma. The remaining teeth were extracted due to
caries. 10 years ago, patient had an upper removable partial denture which he wore
for 3 years. Patient stopped wearing his upper removable partial denture when the
abutment teeth became carious and were extracted. At present, patient cuts his food
 into small pieces and most of the times can not chew it so he just swallows the
manually cut small pieces of food.

IV. PATIENT’S MAIN CONCERN AND EXPECTATIONS

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

Review of family history reveals no significant findings.

VI. SOCIAL 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.

VII. DENTAL HISTORY

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.

VIII. MEDICAL HISTORY

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.

IX. PHYSICAL ASSESSMENT

The patient appears overweight but the gait appears normal and unimpeded. Patient
has no noticeable physical defects.

X. SOFT TISSUE ASSESSMENT

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

1. The patient has no lesions or scars

2. General Facial symmetry is observed

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.

XII. FINDINGS ON DIAGNOSTIC CAST

Maxillary cast: Maxillary limiting structures such as the maxillary tuberosity,

hamular notch, buccal vestibule, buccal frenum, labial vestibule, labial frenum,
incisive papilla, median palatine raphe, crest of residual ridge, and rugae, can be
observed on the cast. Meanwhile, the fovea palatina can not be observed. A bony
exostosis on the buccal of Quadrant 2 can be also be observed. The findings from the
intraoral examination can be verified on the maxillary cast. The arch form tapering.
The palatal vault is dome-shaped which is favorable to retention. The height of the
residual ridge is adequate and its form is generally round. An undercut is present in
the anterior segment and underneath the bony exostosis 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.

XIII. TREATMENT PLAN

I. Case Presentation
II. Complete Denture Service and Installation
III. Post-Installation Recall
IV. Alveoloplasty when needed
V. Maintenance