This patient presented with pain from UR3. He had not been for 2 years. The patient’s personal details and medical history was checked. A dental history was taken which revealed that the patient’s irregular attendance was due to a fear of treatment. Further open-ended questions by Dr Muzzafar Zaman revealed that the patient had a phobia of experiencing pain during treatment. Even after local anaesthetic had been administered the patient still said that he used to feel pain during procedures. An extraoral examination, soft tissue check, charting, occlusal examination, periodontal assessment including BPE scores, and oral hygiene assessment was recorded. As part of an intraoral soft tissue exam, a mouth cancer screening was carried out. Bitewing radiographs and a periapical of UR3 were taken. Their justification and grading were recorded. The radiographs were reported. A diagnosis was recorded and a suitable treatment plan made. This was agreed with the patient and included a discussion of all options including no treatment and advantages and disadvantages of possible solutions. The patient consented for the filling of UR3 which had buccal caries. In view of the patient’s nervous disposition and the discomfort he was suffering, an appointment was made first thing the next morning. The patient was also suitably reassured that he would not feel any pain during treatment and was told simply to put his hand up in case he wanted to stop at any time. The patient returned the next morning and was given an opportunity to ask further questions. Dr Zaman gave an infiltration using Articaine and in addition, gave an intraligamentary injection due to the patient’s previous bad experiences with pain during treatments. The local anaesthetic’s batch numbers, amount and expiry dates were recorded. A note was made that the necessary post-operative instructions were given both verbally and in writing. A scale and polish were also carried out and a suitable recall period was made for the patient and he was happy to continue to see Dr Zaman again. In view of the patient’s previous bad experiences with dental treatment, Dr Zaman instructed a staff member to ring the patient the next day and everything was fine. At the following visit, a treatment plan was formulated for this patient’s long term care which included several other carious cavities,
moderate periodontal disease and missing teeth.
Another Case Study
