LONG CASE(Oral Sub Mucous Fibrosis) Presented By : Fatema Mithaiwalla ( Intern )
General InformationPATIENT’S NAME: Mr. Ayaz BaigAGE/SEX :25 yrs/ MaleADDRESS : Bhawani peth, PuneOCCUPATION : ServiceOPD NO : 25504H
CHIEF COMPLAINT: Patient complains of restricted mouth opening and burning sensation in the mouth on consumption of hot and spicy foodstuff since 1-2 months HISTORY OF PRESENT ILLNESS: Patient complains of restricted mouth opening and burning sensation in the mouth on consumption of hot and spicy foodstuff since 1-2 months. Patient was asymptomatic 2 months back,after which he began experiencing burning sensation in the mouth on consumption of hot and spicy foodstuffs. Initially the burning sensation was very mild and localised to the buccal mucosa region only but now it has increased in intensity and become more severe and generalised. Patient also noticed stiffness on opening the mouth which was mild initially but gradually increased in severity to the present state due to which the patient has difficulty in eating and speaking.
MEDICAL HISTORY: No relevant medical history. No history of any drug allergy. FAMILY HISTORY : No relevant family history. PAST DENTAL HISTORY : No relevant past dental history. PERSONAL HISTORY: HABIT : Chewing Tobacco 5 - 6 times daily since 7-8 years. Patient also gives history of chewing “Ghutka” 6-7 times a day which he stopped 6 months back. Oral hygiene : Patient cleans his teeth once a day in morning with tooth brush and toothpaste.
EXTRAORAL EXAMINATION: On extra oral examination the patient was of moderate built, had a normal gait. Face was apparently symmetrical Had a convex profile. Lips are competent. Lymph nodes non palpable and non tender. No abnormality detected in left and right TMJ. Mouth opening is 27 mm
INTRA ORAL EXAMINATION:1) TEETH: Teeth Present : 87654321 12345678 87654321 12345678 Teeth missing : No teeth Absent. Caries : Occlusal caries involving enamel,dentin and pulp with 6 Proximal caries involving dentin with 6 Pit and fissure caries with 78 6 Restoration : Absent Tenderness on Percussion : Absent Mobility/Discolored : Absent Attrition/Abrasion/Erosion : Absent Calculus/Stains : Gen. Calculus & Stains ( grade III) Occlusion : Angle’s Class I occlusion on both sides. Overjet & Overbite : Normal
SOFT TISSUE EXAMINATION Tongue/Lips : No abnormality detected. Hard and soft palate : No abnormality detected. Floor of mouth : No abnormality detected. Buccal mucosa : Fibrous Bands that are blanched seen on theright & left buccal mucosa extending from the commissure of themouth to the Pterygomandibular raphae. Gingival condition : Generalized marginal and papillary gingival inflammation seen.
DETAILED EXAMINATION Of THE Area of Chief Complaint:Examination of the Right & Left Buccal Mucosa On Inspection :Inflamed buccal mucosa on both left and right sides. There are no lesions on the labial vestibule and soft palate. Fibrous Bands seen on the right & left buccal mucosa. The mucosa appears blanched extending from the commissure of mouth to Pterygomandibular raphae . On Palpation :All findings of inspection are confirmed on palpation.mouth opening is reduced and tongue protrusion.Fibrous bands are felt on the right and left buccal mucosa. There is stiffening of the buccal mucosa in that area. The cheek flexibility is reduced The mucosa appears blanched. The surface is rough and leathery in texture .
INTRAORAL PHOTOGRAPHSRight Buccal view Left Buccal view
FINAL DIAGNOSIS Oral Sub mucous Fibrosis bilaterally (Stage III) Pit and fissure caries with 7 67 Chronic Gen. Marginal and papillary Gingivitis
TREATMENT PLANEMERGENCY TREATMENT: Not RequiredPLANNED TREATMENTI ] PREPARATORY PHASE : Stoppage of Tobacco chewing Habit immediately. Oral prophylaxis and polishing. Patient education and motivation. Going on bland food, free from chillies and peppers.Nutritional support: Iron supplements like Cap.Fefol Z Cap. Becosules 30..Intralesional Injections : Inj Hydrocortisone HCl 3 times a week (by multiple puncture method) Inj Placentrix Inj BetnesolII ] SURGICAL PHASE : Not required.III] RESTORATIVE PHASE : Excavation of caries followed by Silver Amalgam restoration forIV ] MAINTAINANCE PHASE: Cleaning teeth twice a day using tooth brush and fluoridated tooth paste. Use of dental floss for interdental cleaning. Use of tongue cleaner for cleaning tongue. Gum massaging with finger. Use of 0.2% chlorhexidine mouth wash three times a day for 15 days. Recall after one week.