CASE HISTORY-1

OPD no. 147239/25 Date: o7-Dec-2017

Name: Kelesh Nath Sahu Occupation: Driver

Age: 32 years Sex: Male

Religion: Hindu

Address: Indira Nagar, Lucknow 07305747635

Chief complaint: Patient complains of growth in right upper front region of the jaw related to
gums, and also complains of swelling in gums and bleeding since 15 days.

History of present illness: patient was asymptomatic 15 days back than he noticed small
swelling in right upper front region of the gums; initially swelling was small in size and
gradually increases as present size without pain and discharge. No any history of associated
symptoms.

Past medical history: Not relevant history

Past dental history: Not relevant history

Family history: Not relevant history

Personal history: Gutkha chewing 4-5 pouches per day since 5 years and smoking cigarette 1-2
per day since 2 years

Habits:

Marital status: Married

Diet: Mixed

Sleep: Sound sleep

Bowel and bladder: No abnormality detected

GENERAL CLINICAL EXAMINATION:

Built: Moderate built

Nourishment: Moderate nourishment

Gait: No Abnormality Detected

Skin: No Abnormality Detected

Hair: No Abnormality Detected

Eyes: No Abnormality Detected

Nails: No Abnormality Detected

Vital signs:

Pulse: 70/min Temperature: 98.9o F

Respiratory rate: 21 cycle/ min Blood pressure: 120/80 mmHg

EXTRA ORAL EXAMINATION

Face: asymmetrical

TMJ: No Abnormality Detected

Muscles of mastication: No Abnormality Detected

Lymph nodes: No Abnormality Detected

Lips: Competent

Examination of extra oral swelling:

Inspection: Not significant

Palpation: Not significant

INTRA ORAL EXAMINATION

Soft tissues:

Labial mucosa: No abnormality detected

Buccal mucosa: No abnormality detected

Palate: No abnormality detected

Oropharynx: No abnormality detected

Tongue: No abnormality detected

Floor of the mouth: No abnormality detected

Orifices of the salivary glands: No abnormality detected

Gingiva: Inflammatory growth present i.r.t 13, 14

Hard tissue: No abnormality detected

Teeth present:
11,12,13,14,15,16,17,18,21,22,23,24,25,26,27,28,31,32,33,34,35,36,37,38,41,42,43,44,45,46,47,
48.

Missing teeth: Absent

Dental caries:-

Occlusal: Absent

Proximal: Absent

Cervical: Absent

Dental caries with pulpal involvement: Absent

Root stumps: Absent

Filled teeth: Absent

Attrition/Abrasion/Erosion: Absent

Developmental defects: (number, size, shape and structure of teeth): Absent

Fractured teeth: Absent

Mobility: Absent

Tender on percussion: Absent

Occlusion: Angle’s class 1 molar relationship

Stains: Moderate

Calculus: Mild

AREA OF CHIEF COMPLAIT

Hard tissues:

Dental caries: Absent

Mobility: Absent

Percussion: Absent

Soft tissues:

Gingiva: Inflammatory growth present irt 13,14

Periodontal status: fair

Presence of intra oral sinus: Absent

Examination of intra oral swelling /growth/ulcer/red & white mucosal lesion:

Inspection:

A solitary growth present irt 13and 14 related to gums it extends mesio-distally distal aspect of
13 to distal aspect of 14, covering distally 1/3 crown of 13 and entire coronal surface of 14.
Approximately 02 to 03 cm in size and slightly oval in shape with irregular margin and smooth
and shiny surface, red in color

Palpation: On palpation all inspector findings are confirmed, it is soft and smooth growth
attached with small base and bleeding on probing.

Percussion: non tender

Case summary:

Patient came in the department of oral medicine and radiology with the chief complains of
growth in gums without any other associated symptoms. Growth was small in size initially and
gradually increases as present size 2X 3 cm approximate and sometimes he noticed bleeding
from gums during brushing or own. On examination growth present i.r.t 13 14 attached with
small base pedunculated and pear or oval shaped it extends distal aspect of 13 to distal aspect of
14 that is mesio-distally and superior-inferiorly it extends from attaced gingiva to buccal cusp of
14 (entire coronal portion covered) red in color and no any history of discharge except
sometimes blood. On palpation no raised temperature, it is soft fibrous with smooth surface.
Bleeding on probing present.

Provisional diagnosis: PYOGENIC GRANULOMA

Differential diagnosis:

Giant cell granuloma

Localized gingival hyperplasia irt 13, 14
Gingival polyp irt 14
Investigation:

Radiographs: IOPAR

Blood test: Routine blood examination

Biopsy: Excisional
Histopathological findings: Reveals epithelium overlying an inflamed connective tissue stroma.
Epithelium was stratified squamous in nature and keratinized in nature and exhibiting mild
features of hyperplasia underlying connective tissue was chiefly cellular composed of
proliferating endothelial cells admixed with chronic inflammatory cells within collagenous
background. Numerous budding capillaries and vascular slits were also evident.

Radiographic interpretation:

IOPAR: IOPAR showed no any bony involvement

Final diagnosis: Pyogenic Granuloma

CLINICAL PHOTOGRAPHS

PREOPERATIVE

SPECIMEN & HISTOPATH

POST OPERATIVE