PRO SIMPLE CASE REPORT

PATIENT NAME
MEDICAL RECORD NO
AGE
SEX
OCCUPATION
ADDRESS
MARITAL STATUS
RELIGION
DATE OF EXAMINATION
STUDENT NAME
DIAGNOSIS

: MISS RARA AMELIA

: 2015-00199
: 21 YEARS OLD
: FEMALE
: STUDENT
: JL. CIHAELANG BARU
: SINGLE
: ISLAM
: 16 JANUARY 2015
: MUNIRAH BINTI MOHD AMIR (160110103007)
: CHRONIC GENERALIZED MARGINAL GINGIVITIS

Chief Complaint:
Patient complained of calculus on the tooth and now wants the calculus to be
removed.
Anamnesis:
Patient has not done any dental treatment for the few years back. Patient does not
suffer from any medical problems. She does not have any oral bad habits, and she doesnt
smoke.
Etiologiy:
Bacterial plaque, calculus, tooth crowding
Treatment planning:
1. Preliminary phase:2. Initial phase:
Dental health education/ oral hygiene instructions
Plaque score
Pro scaling for upper and lower jaw
Control after 1week and 1month
Re-evaluation after phase 1 therapy : reprobing and re examination of all
patient findings ( gingival inflammation, plaque, calculus, pocket depth and
mobility)
3. Surgical phase:4. Final Restoration Phase:5. Maintenance phase:
Oral hygiene instruction, home care and recall after 6 months to evaluate
plague score, calculus, gingival condition, pocket depth, mobility and
occlusion.
6. Pocket depth measurement

1st visit on 16th January 2015

18

17

16

15

14

213

1ST
PALAT
AL

TOOTH
FACIAL

212

48

47

46

312

1ST
LINGU
AL

312

13

12

11

21

22

23

21
1
21
2

11
1
11
1

11
1
11
1

11
1
11
2

11
1
11
1

11
1
11
1

24

45

44

43

42

41

31

32

33

34

11
2
11
2

22
1
21
1

11
1
11
1

11
1
12
1

11
2
11
2

11
1
11
1

12
1
21
1

11
1
11
1

11
1
11
1

25

26

27

11
1
11
2

21
1
32
2

21
1
32
2

35

36

37

Missing teeth

TOOTH
FACIAL

7. Patient preparation
Provide information about the procedure that will be carried out, the
prognosis, limitations, communication and results after treatment
Explain that the procedure will be carried out step by step
Observe patients personal condition: emotional status, occupation, and give
empathy towards patients personality
8. Instrument and material
Basic instruments: mouth mirror, explorer, excavator, periodontal probe.
other instruments:
o Hand gloves
o Face mask
o Suction tube
o Sterile gauze, cotton rolls and cotton pallets
o Sterile napkin
o Instruments tray
o Universal scaler
o Interdental scaler
First visit
Examination date: 16th January 2015

8
6

7
7

6
8

28

38

7
5

6
6

5
7

Percentage (%):

Second visit
Examination date: 23rd January 2015

8
6

7
7

6
8

7
5

6
6

4
5

3
4

2
3

1
2

1
1

2
1

3
2

4
3

5
4

Percentage (%):

Third visit
Examination date:

8
6

7
7

6
8

7
5

6
6

4
5

3
4

2
3

Intraoral examination:
Gingival:
Shape
Colour
Consistency
Pitting test

: edematous
: dark red
: soft
: positive

1
2

1
1

2
1

3
2

4
3

5
4

Stippling
: positive
Recession
: negative
Interdental papilla
: blunt
Frenulum
: high
Percussion
: negative
Mobility
:negative
Occlusion
Premature contact : negative
Facet
Attrition
: positive on the anterior mandible region
Abrasion
: negative
Erosion
: negative
Mal-alignment
: positive (37)

Acknowledge by,
..............................................