1. 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

2. Patient Age Gender Race/ethnic origin
Referred by ? to whom or where? for what?

3. 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

4. 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

5. 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?”

6. 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)

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. Intraoral examination
Special tests:
Crown removal for inspection
Selective anesthesia test
Test cavity for sensitivity
Transillumination for caries and physical defects

14. 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

15. Diagnosis Pulpal and apical periodontal
Other relevant: periodontal, prosthodontic

16. 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

17. 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