CASE HISTORY -5

OPD no. 624021/195 Date: 21-12-2013

Name: Bhallaram Occupation : Farmer

Age: 60 years Sex: Male

Religion: Hindu Address: Sandila

Chief Complaint: Patient complains of pain in the left upper and lower back teeth since one
week.

History of Present Illness: Pain is continuous, insidious in onset, throbbing type and severe
intensity, radiates to whole of left side of face, aggravates on chewing food, relieved by taking
tablets. Sleep is disturbed. Patient has burning sensation on taking spicy food since one year.
Patient also has altered taste sensation since six months. And also there is decreased salivation.

Past Medical History: Patient under medication for hypertension since 10 years

Tab Betatrop (atenolol 50mg + nifedipine 20mg)

Past Dental History:

Patient got his lower front teeth removed due to mobility about 4yrs back.

Patient had visited private practitioner three days back due to pain.

• Tab Cifran CT (Ciproflaxacin 500mg + Tinidazole 600mg)

• Tab Imol (Ibuprofen 400mg + Paracetamol 333mg)

Diet: mixed

Bowel and bladder: regular

GENERAL CLINICAL EXAMINATION:

Built: moderately built

Nourishment: moderately nourished

Gait: no abnormality detected

Skin: no abnormality detected

Hair: no abnormality detected

Eyes: no abnormality detected

Nails: no abnormality detected

Vital signs:

Pulse: 72/min Temperature: 98. 90 F

Respiratory rate: 18 cycle/min Blood pressure: 120/80 mmHg

EXTRA ORAL EXAMINATION

Face: Asymmetrical (due to swelling in right upper back region of the jaw)

TMJ: No abnormality detected

Muscles of mastication: no abnormality detected

Lips: competent

Extra Oral Examination lesion:

Inspection: Fissures present on right and left commissure of mouth which are erythematous and
has tendency to bleed on opening the mouth.

Palpation: On palpation dry, creaky, slightly tender and bleed

Intra Oral Examination: Soft Tissue Examination:

Soft tissues: no abnormality detected

Labial mucosa: no abnormality detected

Buccal mucosa: White pseudomembranous lesion interspersed with red areas present on right
and left buccal mucosa extending from retromolar area to retrocommissure area with ill defined
borders. These lesions are scrappable, non tender, no tendency to bleed.

Palate: no abnormality detected

Oropharynx: no abnormality detected

Tongue: Diffuse curdy white areas present on dorsal and ventral surface of tongue, extending to
entire dorsal surface with depapillated areas and ill defined borders. These lesions are scrappable,
non tender and has no tendency to bleed.

Floor of the mouth: no abnormality detected

Orifices of the salivary glands: no abnormality detected

Vestibular mucosa: A solitary diffused swelling was seen on right side of the buccal vestibule

Gingiva: marginal gingival inflamed

• Generalized attrition of teeth

• Cervical abrasion irt 16, 17, 25, 26, 27, 36, 37, 46, 47.

• Tender on percussion 25, 26, 27, 36, 37.

• Gr II Mobility irt 14, 12, 22, 24

• Clinically missing 18, 28, 41, 42

Case Analysis:

A male patient aged 60yrs visited Career Post graduate Institute of Dental Sciences and Hospital,
complaining of pain in upper and lower left back teeth since one week. Pain is continuous,
insidious in onset, throbbing type and severe intensity, radiates to whole of left side of face,
aggravates on chewing food, relieved by taking tablets. Sleep is disturbed. Patient has burning
sensation on taking spicy food since one year. Patient also has altered taste sensation since six
months. And also there is decreased salivation. Patient’s medical history reveals that patient is
known hypertensive since ten years and is taking medicine, Tab Betatrop, once daily. Patients
dental history reveals that patient had got his lower front teeth removed four years back due to
mobility and has visited private practitioner three days back and tablets were prescribed. Tab
Cifran CT and Tab Imol. Personal history reveals that patient is married and is blessed with five
children, patient is on mixed diet, cleans his teeth daily with tooth brush and tooth paste daily in
horizontal direction. Has the habit of chewing pan with tobacco three to four times daily since
15yrs and keeps it in right and left buccal vestibule for 15mins and then spits it. On lymph node
examination, left submandibular lymph nodes enlarged measuring 1cm X 1cm, palpable, single,
mobile, nontender, firm in consistency. On extra oral examination, fissures present on right and
left corner of mouth which has tendency to bleed on opening the mouth. On intra oral
examination, Buccal Mucosa, White pseudomembranous lesion interspersed with red areas
present on right and left buccal mucosa extending from retromolar area to retrocommissure area
with ill defined borders. These lesions are scrappable, non tender, no tendency to bleed. Tongue,
diffuse curdy white areas present on dorsal and ventral surface of tongue, extending to entire
dorsal surface with depapillated areas and ill defined borders. These lesions are scrappable, non
tender and have no tendency to bleed. Hard Tissue Examination: Generalized attrition of teeth,
Cervical abrasion irt 16, 17, 25, 26, 27, 36, 37, 46, 47, Tender on percussion 25, 26, 27, 36, 37, Gr
II Mobility irt 14, 12, 22, 24, Clinically missing 18, 28, 41, 42.

Provisional Diagnosis:

Pseudomembranous candidiasis involving tongue and buccal mucosa

Chronic Generalised Periodontitis with Chronic Periapical Abscess 46, 47

Differential Diagnosis:

 Aphthous Stomatitis
 Lichen Planus
 Dermatologic Manifestations of oral leukoplakia
Investigations:

BLOOD TEST:

• Hemoglobin – 14.4gms

• HIV 1and 2 – negative

• HBsAg - negative

• Post prandial blood sugar – 110mg%

CYTOLOGY:

• Smear taken from buccal mucosa and tongue.

• Three PAS stained smears reveal presence of epithelial squames, numerous chronic
inflammatory cells and cellular debris. Abundant number of hyphae forms and spores of
candidal hyphae are evident.
Final Diagnosis:

Acute Pseudomembranous Candidiasis

Treatment:

Antibiotics and Analgesics prescribed were asked to continue.

• Clotrimazole 1% topical application 3 to 4 times daily

cap becosules

• Thiamine mononitrate 10mg

• Riboflavin 10mg

• Pyridoxine 3mg

• Vit B12 15mcg

• Niacinamide 100mg

• Folic acid 1.5mg

Patient advised to come after 3-4days.

Later, patient was reviewed.

Burning sensation was reduced to 50%

Lesions on tongue and buccal mucosa reduced completely.

Patient was referred to department of Periodontics and to Conservative and Endodontics.

EXTRA-ORAL

INTRA-ORAL
POST TREATMENT