final year

1. History Sheet
Department of Oral Diagnosis
North Bengal Dental College & Hospital
Sushrutanagar, Darjeeling
Date: 21.09.16 Ticket No: N-0261561
PARTICULARS OF PATIENT
 NAME; Mr. DhirendraNath Roy
 AGE: 62 years
 SEX: Male
 RELIGION: Hinduism
 OCCUPATION: Farmer
 ADDRESS: Jalpaiguri
 CHIEF COMPLAINT:Patient complains of continuous pain and swelling in the lower front
teeth region of mouth since last four months.
 HISTORY OF PRESENT ILLNESS:History dates back to four months since when the patient
noticed a gradual swelling which occured following trauma on lingual aspect of anterior
mandibular teeth region with continous throbbing pain.
 Patient also complains of burning sensation on taking spicy food since last four months.
PERSONAL HISTORY
 ADDICTION OR ORAL HABIT:Pateint gave history of betel quid chewing 5times daily since
last 50 years.
 FAMILY HISTORY:No relevant family history was given by the patient.
 MAINTANENCE OF ORAL HYGIENE:Patient gave history of brushing his teeth with tooth
powder by finger in irregular motion in the morning.
 PAST MEDICAL HISTORY:No significant past medical history.
 PAST DENTAL HISTORY:Extraction of 41 was done one month ago.
GENERAL EXAMINATION
 PHYSICAL EXAMINATION
 LEVEL OF CONCIOUSNESS: Alert, conscious, co-operative and totally associated with
time and space.
 BUILT: Average,
 NUTRITION: Normal,
 PALLOR: Not present,
 ICTERUS: Not present,
 CYANOSIS: Not present,
 CLUBBING: Not present,
 OEDEMA: Not present,
VITAL SIGNS:
 PULSE: 80 beats/min with normal rate
and rhythm and regular volume,
 BLOOD PRESSURE: 116/78 mm of Hg,
 RESPIRATORY RATE: 17 breaths/min,
 TEMPERATURE: Not measured.

2.  ORAL EXAMINATION
 INSPECTION
 EXTRA ORAL: No facial asymmetry was present. Mouth opening was normal.
 INTRA ORAL: A growth present on both facial and lingual aspect of gingiva in relation
to 31, 32 & 41, 42 teeth region.
 The lesion appears as round,lobulated,smooth surfaced mass which is pinkish red in
colour and approximately(3×2)cm in size.
 PALPATION: All the inspectory findings were confirmed.
 EXTRA ORAL: sub mandibular lymph node of right side is palpable and tender, was
normal, no clicking sounds were heard during mouth opening.
 INTRA ORAL: On palpation, the tumor like growth is firm in consistency with smooth
surface & sessile base. Tenderness present on palpation. There is no rise in
temperature on the elevated area.
 PERCUSSION: Tenderness present on vertical percussion in 31 and 42.
 DIAGNOSIS &TREATMENT PLANNING:
 PROVISIONAL DIAGNOSIS:Pyogenic Granuloma of the gingiva in relation to the 31,32 and
41,42 region.
 DIFFERENTIAL DIAGNOSIS:
1. Periapical abcess 2. Fibroma,
3. Peripheral ossifying fibroma, 4.Peripheral Giant Cell Granuloma.
 INVESTIGATION:
1. Intra-oral Periapical Radiograph of 31,32and41,42region.
2.Blood Tests for BT, CT, TC, DC,ESR, Hb gm% and Blood glucose for fasting and PP.
Histopathological examination of the biopsy specimen showed-
I. Intact Epithelial Lining of normal thickness,
II. Small and large endothelium lined channels filled with RBCs,
III. Chronic Inflammatory cells were present.
IV. Areas of fibrous change were noticed.
 FINAL DIAGNOSIS:Pyogenic Granuloma of the gingiva in relation to the 31,32 and 41 42
region.
 TREATMENT PLANNING:
1.Stoppage of all oral habit.
2.Surgical excision of the lesion.
3.extraction of mobile teeth.
4.Fabrication.