CASE HISTORY -LeukoplaiaBY R0HIT TAYAL

Name VIJAY Age 41 Sex Male

Address Faridabad
Chief complaint Patient complains of sensitivity to hot and cold w.r.t. right lower posterior teeth and presence of greyish white patch on the inner side of the right cheek

 History of Present Illness Patient complains of sensitivity to hot and cold since last 1 month Patient also has got a white patch of about 2-3cm on the on the inner side of the right cheek from past 5-7 years Past Dental History No relevant past dental history

 Past Medical History No relevant history No drug allergy

Personal History Patient cleans teeth using tooth powder with finger once a day Patient is chronic smoker from last 45 years and smokes 15-20 biddis/day Patient is also a tobacco chewer. Patient is a vegetarian, non alcoholic and married.

 General Examination Built/nourishment moderate Pallor absent Icterus absent Clubbing absent Edema absent Pulse rate 74 pulses/min Respiratory rate 15 breaths/min BP 124/88 Temp - Normal

 Extra-oral Examination TMJ no abnormality detected LN non palpable Salivary Glands no abnormality detected Swelling absent Any other abnormality absent

 Intra-oral Examination Hard Tissues

Teeth 30 teeth present

Decayed 45, 47 Missing 18, 48 Filled 26 Supernumerary, retained teeth absent Mobility absent Root stumps absent Attrision & abrasion generalized

Occlusion Class I Deposits stains + calculus +

Soft Tissues

Gingiva

Colour pale pink with generalized melanin pigmentation Size normal Shape normal Contour scalloped Pockets absent Position normal, no gingival recession Bleeding on probing absent Stippling present

Tongue no abnormality detected Buccal mucosa presence of a white patch on the right side of buccal mucosa about 2-3cm in size. Floor of mouth no abnormality detected Frenum no abnormality detected

 Provisional Diagnosis

Caries w.r.t 45 and 47 Leukoplakia of buccal mucosa Lichen planus Nicotina stomatitis Biopsy IOPA w.r.t. 45 and 47 Leukoplakia Caries w.r.t. 45 and 47

Differential Diagnosis

Investigations

Final Diagnosis