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 Evaluation

Patient 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 symptoms Drugs the patient is taking: identify possible adverse drug interactions Systemic contraindications to treatment Need for premedication and prophylaxis

Dental 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 stage History of present illness/discomfort An 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 pain

Examination Clinical examination Documentation (photo) 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 cases

Intraoral 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 probing

Intraoral 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 snow

Intraoral examination Thermal pulp tests: Heat test Hot water bath in rubber dam basin Warm gutta-percha

Intraoral examination Electric pulp tests: Electric excitation to stimulate the Aδ sensory fibers within the pulp Does 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 defects

Radiographic 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 pulp

Diagnosis Pulpal and apical periodontal Other relevant: periodontal, prosthodontic

Treatment plan Treatment Prognosis Short term and long term 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

Discussion: Assessment and Evaluation Assessment of the treatment outcome in this particular case Reasons for making the diagnosis and treatment plan Evaluation of the treatment chosen Factors influencing the treatment outcome in this case Was there any alternative treatment? And what would happen if another treatment had been chosen