Pre-Operative Assessment

A. Chief Complaint:
“Sumakit ung ngipin ko.” (Referring to tooth no. 71)
B. History of Present Illness:
Six months prior to consultation, the patient told her mother that the tooth no. 71 is
slightly moving. She was eating junk food at that time. The patient didn’t experience any
pain. There was no discoloration. No treatment was given and they didn’t seek advice
from the dentist.
Three months prior to consultation, the patient told her mother that the tooth was
moving and they tried to pull it with a thread but wasn’t able to pull it out. The patient
experienced sharp pain on tooth no. 71 when eating solid foods and it lasted for 2-
3seconds. The pain was localized. The patient rated the pain 4/10 with 10 being most
painful. The patient put a little pressure on her tooth to remove the pain. The patient did
not take any medication.
On the day of the consult, the patient’s mother wants the tooth no. 71 to be removed.
The patient explained that she still feels pain whenever she eats solid foods and put
pressure to subside. There’s still no discoloration and didn’t take any medication.
C. Medical History:
 No history of allergy
 There’s a history of hospitalization last 2015 due to dehydration
 The patient has asthma that was diagnosed by a pediatrician. The asthma attacks
sometimes occur only when the patient played all day. It happened when she was 5
years old. Her mother uses Salbutamol Inhaler, which is prescribed by her doctor, to
her during asthma attacks.
 DPT and MMR Immunization are up to date
 No Dengvaxia Vaccine
D. Dental History:
 Discontinued bottle feeding at the age of 4 years old
 Eats a lot of sweets
 Brushes three times a day using fluoridated toothpaste
E. Family/Social History
 Family Illnesses:
 Father: Maneclang, Edinel- No known history of systemic disease
 Age: 33 years old
 Mother: Maneclang, Catherine- No known history of systemic disease
 Age: 33 years old
  Siblings:
 Maneclang, Justin- No known history of systemic disease
 Age: 8 years old
 Maneclang, Cathynhyl- No known history of systemic disease
 Age: 10 months old
 Name of School: Francisco Balagtas Elementary School, Manila
 Grade: One (1)
 Hobbies & Interests: Playing cellphone games and on the street with her
siblings and friends. She wants color blue. She likes to watch paw patrol.
F. Diet
 Her favorite foods are hotdog and egg together with rice and ketchup.
 She is fond of eating sweets like candies, and chocolates.
 Photographic Description (Extra-Oral)

I. FRONT STRAIGHT VIEW:

 Face is symmetrical
 Absence of swelling
 Lips are in normal condition, no cracks or ulcer

II. FRONT VIEW SMILING:

 Face is symmetrical
 Maxillary anterior teeth are in midline

III. LATERAL VIEW:

 Straight facial profile

IV. THREE QUARTER VIEW:

 Lips are competent
 Eyes in line with each other
 Straight facial profile
Problem List
A. Treatment Objectives
 To improve the oral hygiene of the patient
 To restore carious teeth and prevent progressing to the pulp
 To prevent spread of caries in the nearby teeth
 To maintain vitality of the teeth
 To maintain arch integrity
 To restore the normal function, esthetic, and occlusion of teeth.

B. Treatment Plan

Q5/Q1 Problem List Treatment

55 Root fragment Extraction

54 Unrestorable carious lesion Extraction
53 Distal caries Pulpotomy, Stip off crown
52 Mesial caries Class IV M- Composite
51 Mesial and Distal caries Strip off Crown
16 Sound Pits and Fissure sealant
Q6/Q2 Problem List Treatment

65 Mesial and Distal caries Stainless Steel Crown

64 Mesial and Distal caries Stainless Steel Crown
63 Root fragment Extraction
62 Mesial caries Class IV M- Composite
61 Mesial and Distal caries Strip off Crown
26 Sound Pits and Fissure sealant

Q7/Q3 Problem List Treatment

75 Unrestorable carious lesion Extraction

74 Large Disto-occlusal caries Extraction
73 Distal caries Class III- Composite
72 Sound No treatment
71 Mobile tooth Extraction
 36 Incipient occlusal caries Preventive Resin Restoration
31 Sound No treatment

Q8/Q4 Problem List Treatment

85 Mesio- occlusal caries Class II M- Amalgam

84 Large Disto- occlusal caries Extraction
83 Distal caries Class III- Composite
82 Sound No treatment
81 Sound Extraction
46 Sound Pits and fissure sealant
41 Sound No treatment