ORAL DIAGNOSIS

CASE PRESENTATION
Rommel Jerard B. Caratiquit
DEN 162
◦
EXTRA ORAL
INTRA - ORAL
 PATIENT’S INFORMATION
Patient’s name: Roldan Jose Jeremie Atienza
Age: 22
Sex: Male
Birthday: October 2, 1996
Address: 32 Katipunan St., Bambang, Taguig
Marital status: Single
Religion: Roman Catholic
Height: 5’8
Weight: 100kg
CHIEF COMPLAINT

“Gusto kong ipabunot yung extrang ngipin

(supernumerary tooth) ngipin ko.”
HISTORY OF PRESENT ILLNESS
 PHYSICAL ASSESSMENT & VITAL SIGNS
WITHIN NORMAL LIMITS
 Gait
Appearance
DEFECTS
- None

Blood pressure Pulse rate Respiratory rate Temperature

130/70 70 bpm 21 cpm 37⁰C

 SOFT TISSUE EXAMINATION
PALATE NORMAL (NO TORUS)
GINGIVA INFLAMED
LIPS COMPETENT
HEAD AND NECK NO PALPABLE MASS
PHARYNX NO PALPABLE MASS
FLOOR OF THE MOUTH WITHIN NORMAL LIMITS
TONGUE WITHIN NORMAL LIMITS
LYMPH NODES NO PALPABLE MASS
SALIVARY GLANDS NO PALPABLE MASS
THYROID NO PALPABLE MASS
 SOCIAL HISTORY & HABITS
YES NO WHAT KIND? HOW OFTEN? FOR HOW MANY
YEARS?

TOBACCO 

CIGARETTES 

BETEL NUT 

ALCOHOLIC  BEER OCCASIONALLY SINCE 2010

BEVERAGES

DRUGS FOR 
RECREATIONAL/
NON – THERAPEUTIC
PURPOSES

PARAFUNCTIONAL  Nail biting When under stress Since childhood

HABITS
 DENTAL HISTORY
FREQUENCY OF DENTAL 2x a year

DATE OF LAST DENTAL VISIT Last week (August 15, 2018)

PROCEDURE/S DONE ON LAST DENTAL Extraction on tooth 37

VISIT
EXPOSURE AND RESPONSE TO LOCAL Normal
ANESTHESIA
COMPLICATIONS DURING AND/OR none
AFTER DENTAL PROCEDURES
 DENTAL HISTORY
YES NO I DON’T KNOW OTHER RELEVANT
INFORMATION
Do your gums bleed when 
you brush?
Have you ever had 
experienced tooth
extraction?
Have you bled too much 
after extraction procedure?
Have you ever had  8 years ago
orthodontic treatment?
Are your teeth sensitive to 
cold, hot, sweets, and/or
pressure?
Have you had any 
periodontal/gum problems?
Do you wear any denture? If 
yes what type of denture?
 MEDICAL HISTORY
YES NO I DON’T KNOW OTHER RELEVANT
INFORMATION
Under physicians 
care
Hospitalization  dengue
Allergies 
Illness 
Medications  Antibiotic
(amoxicillin)
Pregnant 
Childhood disease  Allergies on
history vitamin C
 FAMILY HISTORY
YES NO
DIABETES 
HEART DISEASES 
BLEEDING DISORDER 
CANCER 
NEUROLOGIC PROBLEMS 
TUBERCULOSIS 
RESPIRATORY PROBLEMS 
 ALLERGIES
YES NO I DON’T KNOW WHAT IN
PARTICULAR?

DRUGS 

FOOD 

RUBBER 

OTHERS 
RADIOGRAPHIC INTERPRETATION
 TREATMENT PLAN
Tooth # Clinical findings Radiographic findings Diagnosis Treatment plan

18 Impacted Radiographically sound Impacted tooth Odontectomy

17 Caries Radiographically sound Class I caries Restoration

16 Caries Radiographically sound Class I caries Restoration

15 Sound Radiographically sound None Sound tooth

14 Sound Radiographically sound None Sound tooth

13 Sound Radiographically sound None Sound tooth

12 Sound Radiographically sound None Sound tooth

11 Sound Radiographically sound None Sound tooth

Tooth # Clinical findings Radiographic findings Diagnosis Treatment plan

28 Sound Radiographically sound None Sound tooth

27 Sound Radiographically sound None Sound tooth

26 Sound Radiographically sound None Sound tooth

25 Sound Radiographically sound None Sound tooth

24 Sound Radiographically sound None Sound tooth

23 Sound Radiographically sound None Sound tooth

22 Sound Radiographically sound None Sound tooth

21 Sound Radiographically sound None Sound tooth

TOOTH # CLINICAL RADIOGRAPHIC DIAGNOSIS TREATMENT PLAN
FINDINGS FINDINGS
38 Sound Radiographically sound None Sound tooth

37 Missing None None Implant

36 Caries Radiographically sound Class I caries Restoration

35 Caries Radiographically sound Class I caries Restoration

34 Sound Radiographically sound None Sound tooth

33 Torsiversion Radiographically sound None Sound tooth

32 Sound Radiographically sound None Sound tooth

31 Sound Radiographically sound None Sound tooth

TOOTH# CLINICAL RADIOGRAPHIC DIAGNOSIS TREATMENT PLAN
FINDINGS FINDINGS
48 Sound Radiographically sound None Sound tooth

47 Composite restored None None

46 Caries Radiographically sound Class I caries Restoration

45 Caries Radiographically sound Class I caries Restoration

44 Sound Radiographically sound None Sound tooth

43 Sound Radiographically sound None Sound tooth

42 Sound Radiographically sound None Sound tooth

41 Sound Radiographically sound None Sound tooth

 TREATMENT PLAN
◦ Patient Education
◦ Oral prophylaxis
◦ Class I restorations on tooth #s 16,17,35,36,45,46
◦ Implant on tooth #37
◦ Odontectomy on tooth #18
◦ Orthodontic treatment on mandibular
◦ Extraction of the supernumerary tooth between tooth #s 35 and 36
 TIME TABLE
1ST Appointment 2nd Appointment 3rd Appointment 4th Appointment 5th Appointment 6th Appointment

Approval for Scaling and Class I Implant on tooth Extraction of Orthodontic

oral rehab case polishing: restoration on # 37 supernumerary treatment on
assessment of tooth #’s tooth mandibular
periodontium 16,17,35,36,45,4
6