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A 19 year white man was examined because of ill " defined pain in all of his teeth.
     CURRENT ILLNESS-The patient said that he had generalized pain of a proxysmal nature in all of his teeth but primarily in his mandibular teeth. The pain was so intense that it prevented him from sleeping at night. The initial onset of the facial pain was three months before the examination. The patient also occasionally had intermittent and recurring preauricular pain there was no history of facial swelling or asymmetry. Previously, there had been episodes of severe abdominal pain and arching of the arms and legs. The pain in the patient' s legs was much worse when he walked.
     Medical HISTORY - the patient had had the usual childhood disease; he had had no serious injures, no allergies, and was not taking any medication other than a nonnarcotic analgesic occasionally. While he was in a hospital for treatment of pneumonia at the age of 10, an obstruction of the lower segment of the left urethra and hydronephrosis on the left side was diagnosed. When he was between the age of 10 and 15 he underwent a series of urology procedure to correct the obstruction; finally, a nephrectomy was on the left side. Chronic pyelonephritis and hydronephrosis on the right side developed subsequently. The patient also had benign hepatomegaly and bilateral conductive loss of hearing.
     FAMILY HISTORY - the patient was one of nine children, none of whom had similar manifestation. Both parents were in good health.
     PHYSICAL EXAMINATION - The patient was a slender person who appeared younger than 19 years of age. His vital signs were as follows: blood pressure, 104/68; pulse rate, 80 with regular rhythm and intensity; respiration, 16/min; and temperature, 99ºF, orally. He was 5 feet l inch tall and weighted 95 lb.
     The patient' s head was slightly dolichocephalic and appeared disproportionately large. There were reddish – purple macular lesions involving the low lip and the skin between the chin and low lip. The face was extremely pale. Facial hair was thin and soft in texture, giving the impression that the patient did not shave. The voice was high pitched.
     The eyes had tortuous, engorged veins at the periphery of the cornea. There were no apparent corneal abnormalities on slit - lamp examination; there was no evidence of abnormalities of the lenses. The pupils were round, equal, and reaction to light and accommodation. The extraocular movements were intact. The fundus demonstrated tortuous retinal veins with evidence of arteriovenous nicking. The disk was flat, yellowish in color (the same color as the surrounding retina), and without distinct boards, which made them difficult to distinguish.
     The dental arches were extremely wide with a very shallow maxillary palatal vault. The teeth were small and wide spaced; some teeth were incompletely erupted and rotated. The buccul mucosa, tongue, floor of the mouth, and palatal mocosa were without abnormalities. The left maxillary lateral incisor was congenitally missing. The patient had had extensive restorative dentistry. His oral hygiene was suboptimal with a generalized, moderate marginal gingivitis. The patient had minimal carious lesions. He had severe malocclusion with very little tooth contact.
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