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CASE PRESENTATION/RT

1CASE PRESENTATIONMALIGNANT ULCER INVOLVING RIGHT BUCCAL MUCOSA

PRESENTED BYDr. RAHUL TIWARI

2ND YEAR MDS - PG StudentDEPT. OF ORAL & MAXILLOFACIAL SURGERY

SIBAR INSTITUTE OF DENTAL SCIENCES

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CASE PRESENTATION/RT

2PRELIMNARY DATA Patient name – Ch Anji Reddy Date – 21/03/2016 Age / sex – 48/M O.P.No. – 795376 Occupation – Farmer Religion – Hindi Marital status – Married Socioeconomic status – Fair Address – Pamulluru, Guntur

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CASE PRESENTATION/RT

3PATIENT CHIEF COMPLAINT

Pt c/o swelling in right check region since 20 days

Hardness over check Reduced mouth opening Mild continuous pain visited dentist 1 week back, Under medication for pain subside

and reoccurs

HISTORY OF PRESENT ILLNESS:

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4HISTORY

Past Medical History – NRH Past Dental History – 3 yrs ago for reduced mouth opening, given

medication, increased. Family History –  NRH Personal History – 10 chutta / day, 15 guthkha / day since 8 yrs

Weekly thrice alcohol Brushing- once with pepsodent. Drug History - NRH

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5GENERAL PHYSICAL EXAMINATION

Gait – NADBuilt – thin

Nourishment – Fair Signs of Clubbing – no

Vitals – normalP.I.C.K.L.E. – absent

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7EXTRA ORAL EXAMINATION

Right check- hardness extending ½ cm away from corner of mouth till angle of mandible, superoinferiorly 1 cm away from corner of mouth.

TMJ- NAD 20mm mouth opening LN- palpable right submandibular 1x1cm, hard, immobile, fixed,

tender. No gross facial asymmetry.

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CASE PRESENTATION/RT

8INTRA ORAL EXAMINATION Single Ulcer 1x2cm From distal aspect of 46 till 48 into upper and lower vestibule Erythematous, red in colour, irregular border, floor and surfaces,

indurated edge. Surrounding area- erythematous. No discharge. Mild tenderness Hard consistency DDC-16 45 46, RS-15, GDC- 37,38, MISSING- 36 Wasting diseases- present. Stains & calculus- +++. Gen. brownish intrinsic stains. Gingival bleeding on probing, perio. Pockets, recession- present. Mobile- 41,46,47,31,32,37.

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11INVESTIGATIONS- RADIOLOGICAL

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12DIAGNOSIS

Malignant ulcer involving right buccal mucosa Chr. Irr. Pul. – 15,16,45,46. Moderate flourisis Chr. Periapical abcess- 37,38. Periodontal abcess 47 Chroinic generalized periodontitis Partially edentulous 36

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CASE PRESENTATION/RT

131. ROUTINE BLOOD INVESTIGATIONS AND VIRAL MARKERS.

2. BIOPSY

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