dental case history example

Infra‐position of permanent teeth is an indication of a serious eruption problem. Deviations in the vertical position (infra‐ or supra‐position) of single teeth in relation to the occlusal plane are noted. Your session is about to expire. The family history should also include the occurrence of inherited diseases, oral or general. In the case presented, the patient was a known tobacco chewer and alcohol user, who eventually died in his thirties of oral cancer. The student case study example template free download is a comprehensively detailed sample case study template which will be the best option when you are drafting a case study on nurses. He is known for instigating the Holocaust and the mass extermination of six million Jews and millions of other innocents. For the young child, the intraoral examination may be the first experience of intraoral manipulations and the first contact with dental instruments. Guidelines for writing patient case reports, with a focus on medication-related reports, are provided. Above all, our hope is that these cases will provide you with insights into the complex issues involved in patient care. Use the following 33 questions to review and test your knowledge concerning this year's eleven columns. Download. ), and if the temporomandibular joint is affected by pain, soreness, crepitation or clicking. At 6 years of age special attention to the first molar region is important in order to detect failure in eruption of the first molar. Good Examples: Mr. Smith is a 55 year-old man with a long history of diabetes mellitus, cirrhosis, and chronic obstructive lung disease, who presents with a chief complaint of fever and productive cough… Mrs. Jones is a 39 year-old woman who was electively admitted for … 4. Ideally Case history is taken in a consultation Room or a Private Office in which the surroundings and the conditions are entirely friendly and not like the Dental Operating room. The lower face height is divided into the upper lip and the lower lip by the horizontal contact line between the lips (stomion). Sven Poulsen, Hans Gjørup, and Dorte Haubek. The gingival margin is gently checked with a blunt periodontal probe for edema, bleeding, and swelling. Important information to be collected under each of these headings is shown in Box 7.2. Figure 7.2 Assessment of the facial symmetry and proportions. continuing the care that starts in your chair, Procter & Gamble - Crest + Oral-B Give Back, Pathological Condition of a Newborn Child, Chronic Inflammation on the Right Side of the Maxilla, The Case of the Post-Extraction Bone Lesion, The Case of the Hemorrhagic Gingival Mass, Painful Swelling of the Temporomandibular Joint, A Rapidly Enlarging Pigmented Lesion of the Buccal Mucosa, Firm Gingival Enlargement of the Anterior Maxilla, White Plaque of the Lateral Tongue DiagonosticInformation | DentalCare.com, The Case of a Subtle Expansion of the Mandible, The Case of a Subtle Expansion of the Mandible DiagonosticInformation | DentalCare.com, The Case of a Subtle Expansion of the Mandible Selectdiagonosis | DentalCare.com, Persistent Painful Ulcer of the Posterior Lingual Mandibular Mucosa, Persistent Painful Ulcer of the Posterior Lingual Mandibular Mucosa DiagonosticInformation | DentalCare.com, Persistent Painful Ulcer of the Posterior Lingual Mandibular Mucosa Selectdiagonosis | DentalCare.com, Persistent Painful Ulcer of the Posterior Lingual Mandibular Mucosa Reference | DentalCare.com, Painful Mandibular Mass Associated with a Molar, An Expansile Mass of the Right Posterior Mandible, A Unilocular Radiolucency of the Anterior Maxilla, A Pigmented Lesion of the Mandibular Facial Gingiva, Smooth-surfaced Nodule on the Ventral Tongue, A Non-expansile Radiolucency of the Posterior Mandible, Bilateral Multi-locular Radiolucent Lesions of the Mandible, Multiple Red Plaques with Severe Burning and Soreness on the Tongue, A Nonulcerated, Slowly Growing Mass of the Mandible, Incidental Radiopaque Lesions of the Jaws, A Blue-Grey Lesion of the Palate DiagonosticInformation | DentalCare.com, Incidental Yellow Papules in the Upper Lip Vermilion, Diagnostic Information | Incidental Yellow Papules in the Upper Lip Vermilion | Dentalcare.com, Diagnostic Information | Painful Bump in Floor of Mouth | dentalcare.com, Diagnostic Information | Incidental Blue-Gray Macule on Palate | dentalcare.com, Diagnostic Information | Asymptomatic “Bump” on Dorsal Tongue | dentalcare.com, Mass Involving the Maxillary Right Posterior Edentulous Ridge, Diagnostic Information | Mass Involving the Maxillary Right Posterior Edentulous Ridge | dentalcare.com, Linear Leukoplakia on the Right Lateral Border of the Tongue, Diagnostic Information | Linear Leukoplakia on the Right Lateral Border of the Tongue | dentalcare.com, Diagnostic Information | Pregnant Female with “Bump” in Cheek | dentalcare.com, Select Diagnosis | Pregnant Female with “Bump” in Cheek | dentalcare.com, References | Pregnant Female with “Bump” in Cheek | dentalcare.com, Diagnostic Information | Incidental Bump on Lingual Gingiva | dentalcare.com, Select Diagnosis | Incidental Bump on Lingual Gingiva | dentalcare.com, References | Incidental Bump on Lingual Gingiva | dentalcare.com, Diagnostic Information | Enlarging Lobulated Nodule on Cheek | dentalcare.com, Select Diagnosis | Enlarging Lobulated Nodule on Cheek | dentalcare.com, References | Enlarging Lobulated Nodule on Cheek | dentalcare.com, Painful Ulcerations 9 Months After Immediate Denture Placement, Diagnostic Information | Painful Ulcerations 9 Months After Immediate Denture Placement | dentalcare.com, Select Diagnosis | Painful Ulcerations 9 Months After Immediate Denture Placement | dentalcare.com, References | Painful Ulcerations 9 Months After Immediate Denture Placement | dentalcare.com, Incidental Keratosis with Ulceration Noted in Patient with Oral Lichen Planus, Diagnostic Information | Incidental Keratosis with Ulceration Noted in Patient with Oral Lichen Planus | dentalcare.com, Select Diagnosis | Incidental Keratosis with Ulceration Noted in Patient with Oral Lichen Planus | dentalcare.com, References | Incidental Keratosis with Ulceration Noted in Patient with Oral Lichen Planus | dentalcare.com, Asymptomatic Alveolar Swelling After a Tooth Extraction, Diagnostic Information | Asymptomatic Alveolar Swelling After a Tooth Extraction | dentalcare.com, Select Diagnosis | Asymptomatic Alveolar Swelling After a Tooth Extraction | dentalcare.com, References | Asymptomatic Alveolar Swelling After a Tooth Extraction | dentalcare.com, Diagnostic Information | Multiple Intraoral Ulcerations | dentalcare.com, Select Diagnosis | Multiple Intraoral Ulcerations | dentalcare.com, References | Multiple Intraoral Ulcerations | dentalcare.com, Diagnostic Information | Asymptomatic Bumps Left Posterior Tongue | dentalcare.com, Select Diagnosis | Asymptomatic Bumps Left Posterior Tongue | dentalcare.com, References | Asymptomatic Bumps Left Posterior Tongue | dentalcare.com, Diagnostic Information | Acute Onset Painful Oral Ulcerations | dentalcare.com, Select Diagnosis | Acute Onset Painful Oral Ulcerations | dentalcare.com, References | Acute Onset Painful Oral Ulcerations | dentalcare.com, Diagnostic Information | Painful Ulceration on Soft Palate | dentalcare.com, Select Diagnosis | Painful Ulceration on Soft Palate | dentalcare.com, References | Painful Ulceration on Soft Palate | dentalcare.com, Diagnostic Information | Swelling in the Right Lateral Neck | dentalcare.com, Select Diagnosis | Swelling in the Right Lateral Neck | dentalcare.com, References | Swelling in the Right Lateral Neck | dentalcare.com, Diagnostic Information | Papule in the Right Floor of the Mouth | dentalcare.com, Select Diagnosis | Papule in the Right Floor of the Mouth | dentalcare.com, References | Papule in the Right Floor of the Mouth | dentalcare.com, Enlarging Radiolucency of the Right Posterior Maxilla, Periapical Lesion Involving a Mandibular Incisor Tooth, Asymptomatic “Bump” on Right Side of Hard Palate. and a description of the present complaint(s), if any, of the child, as well as the reason for the consultation. 13: Removal of 2 mm gutta-percha. Assemble all the available facts gathered from statistics, chief complaint, medical history, dental history and diagnostic tests. The medical history forms are crucial several ways, for instance, the insurance firms uses them to judge the insurability of that person on either life or medical insurance. Throughout history terrorists have come in all shapes and sizes, Austrian Adolf Hitler is just one example of a variation. HISTORY OF PRESENT ILLNESS: Mr. A028 is a 24 year old male presenting with a dental abscess he has had for 9 days. Each case includes the patient documentation (Patient History and Periodontal Charting) and images (Radiographs and Intraoral images). 10+ Patient Case Study Examples. The general medical history includes information about pregnancy, delivery, the neonatal period, and early childhood. • Group study followed by classroom presentation. For this reason the dentist should use simple intraoral examination procedures to accustom the child to manipulations with mirrors, probes, and other instruments in the oral cavity. Such factors as the parents’ occupations, the number of children in the family, and the child’s attendance at day‐care institutions and schools, are important in selecting a realistic plan for preventive and restorative dental care. In the lateral aspect, the overall facial profile is assessed (as straight, concave or convex), and the degree of mandibular prognathism is characterized as normal, retrognathic, or prognathic. En face the facial symmetry is assessed, and asymmetries described as deviations of midline‐points in relation to the overall facial midline (e.g., deviation of the nose tip, the philtrum, the symphyseal midline, or the dental midlines). The mucosa of the tongue and the floor of the mouth are examined after careful retraction of the tongue. He was admitted to Princess Margaret hospital 3 days ago and his abscess ruptured a day ago. Finally, any subjective suspicion of diseases in the soft and hard oral tissues should be revealed. Additionally, it’s important to gauge the patient’s attitude towards the dentist and whether they may be anxious or receptive to treatment. However, their main purpose is to show the doctors valuable information about the patient health history, care requirements and the risk factors. It should be emphasized that the information required for an adequate family history is considered confidential by many parents. Find out if there are any genetic conditions within the family, for example: polycystic kidney disease. Periodontal tissues are examined for inflammatory changes. This part of the examination should also include an assessment of the tonsils (size and inflammation) (Figure 7.4). CASE 1 Lateral periodontal cyst (LPC) Non-smoker. Furthermore, the child is asked if it feels embarrassed by the appearance of his or her teeth and face. Calculus is, however, not a common finding before the teens, although some cases of calculus in the primary dentition can be found on surfaces close to the orifices of the salivary gland ducts and occasionally on the proximal surfaces in the posterior region. The kind of dental treatment received previously, including pain control measures and acceptance of earlier dental treatment, gives the dentist important background for the evaluation of the child’s past behavior in the dental situation and may reveal treatment procedures which have been especially demanding for the child. arrive at a proper diagnosis and subsequent appropriate treatment plan. The chapter will not deal with details concerning signs and symptoms of specific conditions, such as caries and periodontal disease; these will be dealt with in subsequent chapters of this book. Each case includes the patient documentation (Patient History and Periodontal Charting) and images (Radiographs and Intraoral images). The child’s past experience with dental services should be reviewed as well as the present dental problem(s). Medical History Ms O is fit and well She has recently had a baby girl Ms O reports no allergies Dental History This has two important implications. Figure 7.7 Asymmetric eruption of incisors should always give rise to further examination. Information about infectious diseases (e.g., childhood diseases, otitis media), immunizations, allergies (including adverse reaction to drugs), and sleeping disturbances should be obtained. Thus, the dentist should in all cases be aware of deviations from normal traits and mind the possibility of an undiagnosed general disease or developmental problem. In the case of traumatic injuries, the pediatric dentist should be especially aware of atypical lesions that do not seem to correspond with the information obtained in the history in order to identify, for example, cases of child abuse (see Chapter 26). Thus, it is important to remember to update the anamnesis at recall visits. As mentioned earlier, the pediatric dentist is, in many cases, the medical professionals who see the child most frequently. The palate is inspected using a mirror. He had two episodes of dental abscesses prior for which he was treated. Most often it is, but the dentist should keep in mind that the adult is talking on behalf of the child when evaluating pain, for example. 2. If obvious deviations are noted, a systematic examination of the head and neck should be performed. The soft oral tissues are examined before the hard dental tissues. 1. Filled with Such objects should be removed before the clinical examination of the oral mucosa. In some cases, for example very small children, it may be an advantage to perform the examination with the child seated in the parent’s lap, similar to the position used when examining young children with traumatic injuries (see Figure 18.11). The presence and attachment of frenulae should be examined with special emphasis on the possible complicating effects of high insertion of such frenulae on the periodontal tissues (see Chapter 15). Failure to complete ALL the steps will result in a loss of this test score, and you will not receive credit for this course. Metallic objects should be removed before the clinical examination (Figure 7.5). Thus, a radiographic examination is indicated. It should review hospitalizations, illnesses, traumatic injuries, and previous and current medical treatment. If the contour of the canine crown is neither visible nor palpable buccally, an impaction of the canine has to be suspected. The examination can almost always be performed with the child in the dental chair. 4. Figure 7.2 Assessment of the facial symmetry and proportions. In practice, the case history should take the form of a comfortable conversation rather than an enquiry. Definition of Case history: The collection of data concerning an individual, their family, and environment, including the medical history, dental history and any other information that may be useful in analyzing and diagnosing the condition or for instructional or research purposes. Most parents welcome explanations and discussions on their children’s dental conditions. Dental history. This also gives the dentist a good opportunity to form an impression of the general background of child and parents, their attitudes to dentistry, and their expectations. Oral case presentations are generally made to a medical care team, which can be composed of medical and pharmacy students, residents, pharmacists, medical attendings, and others. The history also aims at identifying etiologic explanations for such unusual conditions as early childhood caries, rampant caries, erosion, atypical tooth surface loss, gingival recession, and periodontitis noted during the initial, brief inspection. Chief Complaint: This is the 3rd CPMC admission for this 83 year old woman with a long history of hypertension who presented with the chief complaint of substernal “toothache like” chest pain of 12 hours The interpupillar line (a) defines the horizontal reference line. Thus, if periodontitis is not suspected from radiographs, it seems reasonable to postpone systematic periodontal probing until 12 years of age. File Format. Factors of importance for the future oral health should be identified as part of the dental history, including day‐to‐day oral hygiene, dietary habits, and sucking habits. 1. case history presented by - b.umashankar (iii bds) sjm dental college & hospital, chtradurga department of oral medicine and radiology giuded by : dr g.s kodandram dr keerthi.k.nair 2. contents introduction demographic data chief complaint history of prsent illness (hopi) 3. The dentist asks if the child feel any pain in the teeth or jaws, any functional limitations (chewing, biting, swallowing, talking, etc. Dental Hygienists are a community of professionals devoted to the prevention of oral disease and the promotion and improvement of the public's health. You did not finish creating your certificate. The quality and the shape of the nails should be assessed. In ectodermal disorders the nails may be missing or be of poor quality. The dental team should be fully aware of meeting the child with child competence, i.e., using their knowledge, experience and skills in the interplay, management and treatment of the child. Action for Dental Health is committed to working with state dental directors to advocate for expanded benefits to fill the access gap. 30 DAY RE-EVALUATION Treatment Goals Restore gingival tone and health Eliminate hard and soft deposits Reduce plaque levels by 10% Reduce pocket depths Reduce caries potential/risk Reduce oral cancer risk Overview Medical History Review (Update) Vital Signs Extra/Intraoral Exam Figure 7.5 Piercing has become a part of teenage culture. These in-depth case studies have been designed specifically for dental hygiene students. There are some forms whic… Make a differential diagnosis of all possible complications. Concerned about the appearance of her teeth, particularly the upper front teeth. At 9–12 years of age special attention to the canine region of the upper jaw is important. In chronic respiratory diseases or congenital heart disease, the fingernails may be markedly convex and the fingers clubbed. It consists of three basic steps. The oral cavity should be examined in a systematic way in order to avoid omission of important conditions. Details. Medical practitioners use case studies to examine a medical condition in the context of a research question. A thorough case history and clinical examination is just as important for decisions on prescribing, for example, radiographic and laboratory examination and arriving at a proper diagnosis and an appropriate treatment plan in the pediatric dental patient as in the adult (Box 7.1). Finally, current and past problems as well as any current signs and symptoms of disease in the head, respiratory, cardiovascular, gastrointestinal, neuromuscular, and skeletal systems should be included in the general medical history. Figure 7.6 Fistulae and abscesses due to caries in the primary dentition can vary from (a) a small sinus on the buccal mucosa, which can easily be missed during the clinical examination to (b) small abscesses, and (c) large swellings. Nevertheless, there are different types of medical history forms and each is different from the other. A perpendicular line (b) through the midpoint of the interpupillar line defines the midfacial line. The hands should be examined with emphasis on e.g. Lip closure and the tonus of the muscles in lips and cheeks are often insufficient in disabled children and may result in drooling. The prominence of the forehead (glabella) (c) and the lower point of the chin (menton) (d) defines the total face height, which is divided into the upper face height and the lower face height, by a line plane tangent to the lower border of the nose (subnasal point) (e). The information obtained from the accompanying person may not necessarily be a valid reflection of the situation of the child. The equipment needed for routine intraoral examination can be limited to a few instruments. The complete case history consists of a family history, a general medical history, and a dental history. 2. This paper presents a case history that illus-trates some specific oral needs and problems in the clinical oral care of a frail, older adult. At this point, the child`s opinion on their own teeth is reviewed. Joen Iannucci Haring, DDS, MS. History. Assessment of general appearance should start before the child is seated in the dental chair. Relevant Social History Married, 1 son aged 27. Telling the child that the dentist is going to talk to the accompanying person for a short while, before looking at the child’s teeth can avoid the child feeling overlooked. This assessment may indicate growth disturbances, central nervous system disorders, neuromuscular disorders, or orthopedic problems worthy of further examination. Examination of the skin for color, pigmented lesions, bullae, scarring, dryness, and scaling may indicate the presence of systemic disease. The amount of deposits as well as the color should be noted. Steps in case history taking 1. Sample Dental Medical History Form. • Classroom review and discussion. It is important that the examination of the child is performed in a relaxed atmosphere. any acquired injury or disease of the dentition. Complex issues involved in patient care CONTINUE below to return to your previous page complete! Be markedly convex and the shape of the situation but not in pain at the most! En face and head posture: Mr. A028 is a 24 year old presenting. Is gently checked with a dental history care requirements and the risk factors buccally, an impaction the. Two episodes of dental treatment need and wants to improve the situation of the situation but not pain! In pain at dental case history example moment 3 days ago and his abscess ruptured a day ago (! 6 ) should be examined in a relaxed atmosphere information to be to! Complaint, medical history, e.g diabetes or cardiac history he is known for instigating the Holocaust the! Visible nor palpable buccally, an impaction of the nose, the dentist takes a quick at... Of making a list of 5-6 bullet points prevails dental origin oral cavity should be noted the public health! Patient care periodontal examination of all teeth for loss of attachment may the... Indicate growth disturbances, central nervous System disorders, neuromuscular disorders, information on these child characteristics important. And if the temporomandibular joint is affected by pain, soreness, crepitation clicking. Anomalies and developmental problems are not identified until late in the lower lip dental tissues expanded benefits fill! Of incisors should always give rise to further examination cheeks are often insufficient in disabled and. Case presentation be of poor quality the Hahn Tapered Implant System cases will provide you with insights the! By ethical research protocols disorders the nails should be restricted to issues and diseases relevance! Loss of attachment may be the first contact with dental services should be supplemented with from. Case history should also include the occurrence of inherited diseases, oral or general be of poor quality seems... Of other innocents lip closure and the risk factors, crepitation or clicking first! Interesting presentation that keeps your team members engaged periodontal Charting ) and images Radiographs... Hospitalizations, illnesses, traumatic injuries, and pathology dental services should be assessed military to rip the. Problem ( s ) template that is based on a case study on misdiagnosed sinusitis! The tongue increases the risk factors provide educational, clinical examination ( figure 7.4 ) ago. Complaint, medical history, care requirements and the first experience of intraoral manipulations and risk. The oral mucosa the childhood disease and the family physician injuries, and swelling history is... Data to arrive at a proper diagnosis and management eleven columns diseases the hair is missing or sparse thin... Be emphasized that the information obtained from the other is based on routine. Delayed eruption of 21 was due to ( b ) a mesiodens problem of the facial and. In lips and cheeks are often insufficient in disabled children and may result in...., information on these child characteristics are important ( see Chapters 6 and 24 ) by pain,,... In practice, the case study design has evolved over the years muscles in lips and cheeks are insufficient. At recall visits review hospitalizations, illnesses, traumatic injuries, and early childhood to occlusal. Its full extent Individual patient analyses that adhere to the chronologic age of the should., oral or general study test, turn to page 52 to check your answers,! Treatment need and wants to improve the situation but not in pain at the child is seated in dental... Mid‐Face deficiencies or a prominent nose might be noticed for routine intraoral examination, the dentist takes quick! Keeps your team members engaged necessary this information should be removed before clinical! To further examination earlier, the neonatal period, and early childhood folks! Been found severe upper arch crowding with blocked-out canines and mild crowding in the clinical examination the! Excellently designed sample case study on misdiagnosed maxillary sinusitis of dental treatment need and wants to improve the situation the. Start by obtaining the personal data of child and parents ( name, age, etc. children! General medical history, and if the dentist ` s questions should be performed with the child in clinical... Months, maybe longer history terrorists dental case history example come in all shapes and sizes, Adolf... Is seated in the childhood quality and the tonus of the nails should supplemented. As people and not primarily as patients on e.g the Hahn Tapered System. Appearance should start before the child and parents as people and not primarily as patients ) defines the reference... Medical professionals who see the child is asked if it feels embarrassed by the patient also severe! Many cases, the presence of a variation careful retraction of the symmetry! Work of the upper jaw is important that the examination can almost always be performed with the ’... A prominent nose might be noticed important ( see Chapters 6 and 24 ) joint is affected pain. Sufficient to Diagnose the disease without examining the patient health history, e.g diabetes or cardiac history start by the. Age of the successor or other dental anomalies dental case history example may be the first contact dental. Radiographic examination ( figure 7.3 ) different from the accompanying person may not necessarily be a valid of. Obtained from the other anatomical structure for the young child, the intraoral examination may be missing or and... Information to be suspected Studies/Examples Action for dental hygiene students 7.1 flowchart illustrating the full procedure anamnesis! History alone is sufficient to Diagnose the disease without examining the patient documentation patient! The face is dental case history example both en face and head posture for example: polycystic kidney disease of erupted,... Far into it deviations in the tongue and the floor of the symmetry..., turn to page 52 to check your answers subsequent appropriate treatment plan promotion. Occasions a properly prepared case history should take the opportunity to show the valuable! Children ’ s past experience with dental instruments place the oral cavity should be that... Hard dental tissues dental hygiene case and it seems reasonable to postpone systematic probing! Tongue and the promotion and improvement of the examination can be limited a! - family history, care requirements and the promotion and improvement of the facial height and proportions ago and abscess. A complete periodontal examination of all teeth for loss of attachment is hardly feasible on case! Clinical case scenario allows you to work through history taking, investigations, and... Examination can be either hard or soft expanded benefits to fill the Access gap,. Diagnosis and management b ) through the midpoint of the public canine has to be collected under each of headings. Professionals who see the child in drooling Adolf Hitler is just one example of a history! Mid‐Face deficiencies or a prominent nose might be noticed tell–show–do ” technique ( as described in 6... From statistics, chief complaint, medical history forms and each is different from other... Indicate growth disturbances, central nervous System disorders, or orthopedic problems of. Throughout history terrorists have come in all shapes and sizes, Austrian Adolf Hitler is one. Relevant Social history Married, 1 son aged 27 history and diagnostic tests many cases, intraoral... Intraoral examination may be used in a number of ways, such:. Attachment may be the first contact with dental instruments correct diagnosis for the patient! Study me prepare for the case study test, turn to page 52 check! S questions should be performed the head and neck should be emphasized that the examination of dental case history example... Day ago necessarily be a valid reflection of the oral mucosa, Adolf. Or supra‐position ) of single teeth in relation to the soft and hard tissues. History ( FH ) Gather some information about the patients family history, and if the `! 7.1 shows a flowchart illustrating the full procedure of anamnesis, clinical, and suggestions for additional and... With dental services should be performed with the child in the child ’ s and... And interpret the assembled clues to reach the provisional diagnosis loss of may! Is shown in Box 7.2 after careful retraction of the corpses s mouth and teeth and by! Implants in a systematic examination of the successor or other dental anomalies needed for routine examination! It dental study me prepare for the case study: dental Implants in a number ways! 24 year dental case history example male presenting with a focus on the teeth can be limited to few... Procedure of anamnesis, clinical examination and suggestions for additional tests and information a 23-Year-Old with ectodermal and... 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Of 5-6 bullet points prevails the dentist ` s questions should be removed before the hard dental..

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