CASE HISTORY-7

Name: DULARA DEVI O.P.D No: 0306/27

Age: 60yrs Occupation: HOUSE WIFE

Religion: Hindu Sex: Male

Date: 05/03/2017 Address: Raipur

Phone no:xxxx

CHIEF COMPLAINT-

Patient complains of oozing of fluid from his right lower post region of oral cavity since 11/2
weeks

HISTORY OF PRESENT ILLNESS-

Patient was asymptomatic 2weeks back than he noticed pus drainage from the oral cavity since
11/2 weeks from lower post rt region. Patient ignored it and took no medicines or treatment for it.
Then after 1week swelling started growing in the region but there was no associated pain.
Swelling has not subsided since then and oozing of fluid continued so patient visited CPGIDS
and hospital for the treatment of same.

PAST DENTAL HISTORY: No relevant past dental history

PAST MEDICAL HISTORY: No relevant past medical history

FAMILY HISTORY- No history of any disease running in family

PERSONAL HISTORY:
Habits-
No ill habits are present
Oral Hygiene habits –

Patient brushes his teeth once a day in morning by toothpaste & toothbrush for 3-4 min

Sleep: normal

Bowel and bladder; normal

GENERAL CLINICAL EXAMINATION

Built- Well built

Gait- Normal
Pulse:- 78/min
BP:- 130/90 mmHg
Respiratory rate:- 16 Cycles/Min
Temperature:- 980 F
Skin -Normal
Nails-Pallor/ Cyanosis/ Shape:- Absent
Conjunctiva- Pallor/ Erythema/ Ecchymosis:- Absent
Sclera- Icterus/Ecchymosis:- Absent

EXTRAORAL EXAMINATION:-

Facial symmetry and Profile:- grossly symmetrical

1. LIPS: Competent
3. TMJ:
 Mouth opening:- 45mm & normal
 Movements- normal
 Sounds-clicking/crepitus:- absent
 Tenderness-absent
 Dislocation- absent
 Sub luxation- absent
4. LYMPHNODES:- Not palpable
5. MUSCLES OF MASTICATION- Normal
6. E/o examination of abnormality,if any- Absent

A. EXAMINATION OF EXTRA ORAL SWELLING /LESION:

SWELLING-
ON INSPECTION:
- An Extraoral diffuse swelling was present on right side of the lower region extending
from corner of mouth to angle of mandible about 3cm backwards to the malar region
size is about 5 x 3 cm. surface is smooth, skin over swelling is normal.
-
- ON PALPATION:-
- All the Inspectory findings are confirmed. Consistency of the swelling is soft. No
tenderness is present. Swelling is not fixed to underlying structures.
B. INTRAORAL EXAMINATION

1. SOFT TISSUES
a. Labial mucosa- Normal
b. Labial vestibule- obliteration is present in lower vestibule region in relation to
34,35,36
c. Buccal mucosa- Normal
d. Buccal vestibule- Normal
e. Tongue- Normal
f. Lips- Normal
g. Hard palate- Normal
h. Soft palate- Normal
i. Floor of mouth- Normal
j. Gingival condition/Periodontium- Normal

2. HARD TISSUE
TEETH
i. Teeth present- 11,12,13,14,,21,22,23,24,,31,32,33,34,,37,41,42,43,,47.

ii. Teeth missing- 15,16,17,25.26,27,36,37,45,46,47

iii. Attrition/ Abrasion/Erosion/ Abfraction- generalised

iv. Caries- Occlusal caries with 16

v. Filled teeth- None

vi. Periodontal condition- pockets:- generalised

vii. Mobility- present

viii. Discoloured teeth/ # teeth- Absent

Area of chief complaint-

Teeth in the area of chief complaint- 44,45,46

 Discolored- Absent
 Caries- present
 Exposure- Absent
 Cracked tooth- Absent
  #tooth- Absent
 Pockets- generalized
 Mobility- present

Inspection:
A diffuse swelling is present front region of maxilla, Size is approx 2x2 ,shape is oval .surface is
smooth , present in the upper vestibular region along 23,23,no sinus is presnt on the surface of
the swelling and no discharge is seen .
Palpation:
Tenderness is present, surface is smooth, border is ill define, on palpation no discharge is seen

PROVISIONAL DIAGNOSIS/CLINICAL DIAGNOSIS-

Choronic irreversible pulpitis 44,45,46

DIFFERENTIAL DIAGNOSIS-

Periapical abscess with 44,45,46

Radicular Cyst with 44,45,46

INVESTIGATIONS-

1. RADIOGRAPH-
 IOPA
 OPG
.

FNAC:- a thick white coloured fluid was seen in the aspirate and sent for Histopath examination.
Report was of infected cyst

RADIOGRAPHIC INTERPRETATION-

IOPA with:- 44,45,46

Teeth completely seen-

Teeth partially seen-

Tooth with maximum pathology/Tooth of interest- 44,45,46

 Periapical region-
 Periapical radiolucency is present with 44,45,46
 Alveolar bone- Normal

OPG:

A well defined radiolucency is seen extending from distal aspect of 44 to mesial aspect of 46,
superoinferiorly it is extending from about 2cm below the lower boarder of mandible. The root
of 44 is displaced distally due to radiolucency. Internal structure is totally radiolucent. The
borders are corticated ..

RADIOGRAPHIC DIAGNOSIS-

RADIOGRAPHIC DIFFERENTIAL DIAGNOSIS-RADICULAR CYST

PERIAPICAL GRANULOMA

FINAL DIAGNOSIS:- RADICULAR CYST

TREATMENT PLAN-

A. Emergency treatment-
B. Planned treatment-

Patient was referred to oral surgery department where enucleation of the cyst was done
along with the extraction of supernumerary teeth

Recall visit--

Patient was recalled after I month and the healing was found to be uneventful.
PRE-OP

OPG
INTRA-OP

SPECIMEN
 POST-OP

BIOPSY REPORT