Case Presentation
Patient (demographics) Medical History (general anamnesis) Dental History & Chief Complaint (special anamnesis) Examination (status presens) Clinical examination Radiographic examination Diagnosis Treatment plan Treatment Prognosis Assessment and EvaluationPatient
Age Gender Race/ethnic origin Referred by ? to whom or where? for what?Medical History
Systemic conditions that may produce or affect the patient’s symptomsDrugs the patient is taking: identify possible adverse drug interactionsSystemic contraindications to treatmentNeed for premedication and prophylaxisDental History & Chief Complaint
What prompted the patient to consult a dentist in the first place (in the patient’s own words)No diagnosis should be included at this stageHistory of present illness/discomfortAn interview process during which the dentist attempts to evaluate the patient’s symptoms accurately, completely, and objectively, avoiding the temptation to make a premature diagnosis
Dental History & Chief Complaint
Open-ended, non-leading questions”Tell me about the problem””I understand you have been experiencing cold sensitivity in your upper front teeth for several weeks, is that correct?”Dental History & Chief Complaint
Specific questions about the nature of the symptoms experienced: Inception (When the first time) Frequency and cource (How often) Intensity (Mild, moderate, or severe: medication, home from work) Quality (Sharp, dull, stabbing, throbbing)Dental History & Chief Complaint
Location (Pointing to the tooth that hurts) Provocation factors (heat, cold, momentary or last longer) Spontaneous (without provocation)? Attenuating factors (Anything relieving the painExamination
Clinical examination Extraoral examination Intraoral examination Documentation (photo) Frontal view of dentition Occlusal or lingual (for front teeth) view Others as necessary for highlighting aspects Radiographic examination Dental periapical Orthopantomogram in special cases CT in special casesIntraoral examination
Any alterations of the color, texture, consistency, or contour of the soft tissue and should be noted The tooth/teeth in question should be inspected for color changes, caries and restorative status Palpation test Percussion test Mobility test Periodontal examination: gentle probingIntraoral examination
Thermal pulp tests: Cold test Cold water bath in rubber dam basin Ice sticks Compressed gasses: ethyl chloride; 1,1,1,2 tetrafluoroethane (Endo-Ice) Carbon dioxide snowIntraoral examination
Thermal pulp tests: Heat test Hot water bath in rubber dam basin Warm gutta-percha
Intraoral examinationElectric pulp tests:Electric excitation to stimulate the Aδ sensory fibers within the pulpDoes not provide any information about the health or integrity of the pulp; it simply indicates that there are vital sensory fibers present within the pulp
Intraoral examination
Special tests: Crown removal for inspection Selective anesthesia test Test cavity for sensitivity Transillumination for caries and physical defectsRadiographic examination
Diagnostic radiography should be used only after the history is recorded and the clinical examination is accomplished Limitations Provides a two-dimensional portrayal of a three-dimensional reality Cannot be used to determine the status of the health and integrity of the pulpDiagnosis
Pulpal and apical periodontal Other relevant: periodontal, prosthodonticTreatment plan Short term and long term Treatment Immediate and permanent Documentation (photo) As necessary for highlighting aspects of treatment Final: occlusal or lingual (for front teeth) view of restored tooth Prognosis Endodontic and dental Success rate for the relevant diagnosis and treatment selected