Jordan University of Science and Technology
Faculty of Dentistry
Dent 521-522 Comprehensive Dental Care II & III
Clinical Case Portfolio
130144 Mohammad Alzubi
Dent 521-522 Comprehensive Dental
Care II & III
Clinical Portfolio Report for case No. 1
Clinical case Portfolio Report
Student ID 130144
Student Name Mohammad Saleh Alzubi
Patient Name امل محمود عيد العمري
Patient ID at DTC 174561
Patient ID at JUST clinics 54216
Outline
Demographic Data • Medication use
• Tobacco use
Patient selection • Family History
Examination, • Dental History
Diagnosis, and • Continue to the end
formulation of
treatment planning
• Chief Complaint
• History of Chief
complaint
• Medical History
• Allergy
Demographic data
Age 57
Gender Female
Nationality Jordanian
Occupation Not working
Marital statue Married
Smoking status Non-smoker
Attitude Cooperative
Patient selection
The age of the patient is 57 years and he has multiple dental needs
including dental restorations, root canal filling, periodontal treatment
and teeth extractions
The patient have a positive attitude after proper communication and
description of timing and commitment during treatment course and he
signed the consent form of treatment
The patient have 22 remaining teeth or roots
Examination, Diagnosis, and formulation of treatment
planning
Chief complaint
I have pain in this tooth ( pointed to 27)
History of Chief complaint
Pain started 2 months ago lasting from seconds to minutes, and it was
precipitated by cold drinks and sweets and relieved by paracetamol
She came to emergency clinic and they did pulp extirpation followed by
temporary filling
Patient reported that she had car accident which led to fracture in her lower jaw
Examination, Diagnosis, and formulation of treatment
planning
Medical history
Gastroesophageal reflux disease (GERD)
Allergy
Nothing she knows about
Medication use
1. Digestyl: dietary supplement 1 capsule daily
2. Gasec: a drug of combination of 2 medications, acetaminophen and an
antihistamine. 40 mg once daily
3. Aspirin: 80 mg daily. Self prescribed.
Examination, Diagnosis, and formulation of treatment
planning
Tobacco use
None smoker. None user of hubble-bubble
Family history
Unremarkable
Examination, Diagnosis, and formulation of treatment
planning
Dental history
1. Habits: Brushes once in a while
2. Last visit: 2 months ago for pulp extirpation of 27
3. Previous treatment:
Fillings
Endo treatment
Extractions
4. Complication: No complication reported
Examination, Diagnosis, and formulation of treatment
planning
Clinical Examination
Extra oral examination:
Intraoral Examination
Extra oral examination
Value Notes Inserted by
Facial symmetry Normal symmetrical
Skin Normal acne
Temporalis Normal NAD
Masseter Normal NAD
TMJ Normal NAD
Jaw movements Normal NAD
Lymph nodes Normal NAD
Neck Normal NAD
Salivary glands Normal NAD
Upper lip Normal dryness and fordyce granules
Lower lip Normal dryness and Fordyce granules
Extra oral photographs
Put photographs here
Intra oral examination
Value Notes Inserted by
Upper labial mucosa Normal feral tag
Lower labial mucosa Normal NAD
Right buccal mucosa Normal NAD
Left buccal mucosa Normal NAD
Hard palate Normal NAD
Soft palate/oropharynx Normal NAD
Intra oral examination
Value Notes Inserted by
Saliva Normal NAD
Dorsal tongue Normal NAD
Lateral tongue Normal NAD
Ventral tongue Normal NAD
Floor of mouth Normal NAD
abscess and racial
Gingiva Normal
pigmentation
Alveolar mucosa Normal NAD
Intra oral photographs
Intra oral photographs
Intra oral photographs
Intra oral photographs
Intra oral photographs
Diagnosis
Restorative diagnosis
Finding from the upper dental arch
Restorative diagnosis
Finding from the lower arch
Detailed restorative diagnosis
Tooth Diagnosis
18 Missing
17 Occlusal caries
16 Occlusal caries
15 Amalgam
restoration
14 Remaining root
13 Missing
12 DL caries
11 Erosion
Detailed restorative diagnosis
Tooth Diagnosis
18 Missing
17 Occlusal caries
16 Occlusal caries
15 Amalgam restoration
14 Remaining root
13 Missing
12 DL caries
11 Erosion
Detailed restorative diagnosis
Tooth Diagnosis
21 Erosion
22 PFM crown
23 Missing
24 Mesial caries
25 Missing
26 Remaining root
27 MO caries
28 Missing
Detailed restorative diagnosis
Tooth Diagnosis
21 Erosion
22 PFM crown
23 Missing
24 Mesial caries
25 Missing
26 Remaining root
27 MO caries
28 Missing
Detailed restorative diagnosis
Tooth Diagnosis
41
42 Attrition + wearing
fascet
43
44 Distal caries
45 Caries into root
46 Missing
47 Remaining root
48 Missing
Detailed restorative diagnosis
Detailed restorative diagnosis
Tooth Diagnosis
38 Missing
37 PFM crown
36 Amalgam restoration
35 Remaining root
34 DO caries
33
Attrition + wearing fascet
32
31 Missing
Detailed restorative diagnosis
Tooth Diagnosis
38 Missing
37 PFM crown
36 Amalgam restoration
35 Remaining root
34 DO caries
33
Attrition + wearing fascet
32
31 Missing
Endodontic diagnosis
35 Negative Negative Negative Negative Necrotic Asymptomatic apical
periodontitis
Periodontal diagnosis
Generalized Plaque induced periodontitis
Etiology and risk factors:
Plaque
Calculus
Caries
Remaining roots
Defective restorations
Overhang restoration
Periodontal diagnosis
Treatment Plan
Treatment Plan
The Systemic Phase
The Acute Phase
The Disease Control Phase
The Definitive Phase
Treatment plan –
The Systemic Phase
Refer patient for further medical evaluation to a gastroenterologist to be evaluated
for GERD
Usually no need to alter treatment unless there are other medical problems, such
as recent MI or stroke
Frequent chewing of sugar-free antacid and xylitol will help to improve salivary flow
rates
Instruct patient to rinse the mouth with water, sodium bicarbonate, and a fluoride
mouthwash immediately after a significant acid challenge
Treatment plan –
The Systemic Phase
Decrease the consumption of carbonated and acidic beverages
Patient must be informed not to brush their teeth immediately after an acid
challenge and not to use strongly abrasive toothpastes
Fluoride varnish should be applied every three months. Prescription fluoride
toothpaste should be recommended for daily use
Treatment plan –
The Acute Phase
Pulp extirpation of 27 followed by intracanal medicament and temporary
restoration
Treatment plan –
The Disease Control Phase
Patient education & motivation
Oral hygiene instructions:
Modified stillman technique
Scaling & root planing
Extraction of remaining roots 14, 26, 35, 45, 47
Provisional restorations
Re-evaluation after 4-6 weeks
Treatment plan –
The Definitive Phase
Periodontics
Restorative
Endodontic
Prosthodontics
Periodontics
After re-evaluation
Improvement No improvement
Keep on maintenance Move to surgical phase
Restorative
Tooth Diagnosis Treatment Alternative
17 Occlusal caries Class I
Amalgam
16 Occlusal caries Composite
Remove
caries and
12 DL caries assess -
restorability
and CRR
Class II
24 Mesial caries Amalgam
Composite
Restorative
Tooth Diagnosis Treatment Alternative
Class II
34 DO caries Amalgam
Composite
Endodontic
Percussio Treatment
Tooth Cold test EPT Diagnosis
n plan
Symptomatic
Lingering Positive irreversible
27 Tender RCT
pain >5 sec response pulpitis with
SAP
12 NA Normal - Endo treated Retreatment
Percussio Treatment
Tooth Cold test EPT Diagnosis
n plan
Prosthodontics
1st option:
implant for 14, 3rd option
13, 23, 25, 26, 35, 2nd option: 3-unit (preferable):
Fiber post and 45-47(implant bridge for (12-15), removable
core for 12 supported bridge) (34-46) denture for upper
•Need to regain inter- and lower jaws
occlusal space
Records of treatment
Records of treatment
Records of treatment
Records of treatment
Records of treatment
Appendix
Add all relevant radiographs, photographs, consent form, tests etc.
