Fa

cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e

St
uden
tna
me:
Gro
up:

Lo
gBo
ok

2020-2021

1
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e

Temp
lat
efo
rca
ses
tudywr
iti
ng
Ti
tle
Au
tho
rs:

Abs
tra
ct:br
iefs
umma
ryo
fyo
urc
aser
epo
rt(
max
imu
mof1
50 wo
rds
)

Keywo
rds
:Li
stt
her
elev
antk
eywo
rdso
rph
ras
est
hatc
oul
dbeu
sedi
nan
i
nter
neto
rPu
bMeds
ear
cht
ofi
ndyo
ura
rti
cle(
limi
toff
ive)

I
ntr
odu
cti
on:
Pr
ovi
dea
nov
erv
iewa
bou
tth
eto
pic
.

Ca
seRep
ort
:
In
trodu
cto
rysent
ence:e.g
.Th i
s25yea
roldf emalepres
ent
edf o
rt hetrea
tmento
f
….
.
Desc
rib
et hees
sent
ialnatur
eo ft
heco
mpl
ain
t,i n
cludi
ngloc
ati
on,in
tens
ityand
a
sso
cia
tedsymptoms
………..

Fu
rth
erdev
elopmen
tofhi
sto
ryincl
udin
gdet
ail
soft
imea
ndc
irc
ums
tan
ceso
fon
set
,
andt
hec o
urseoft
hecompl
ain
t…..

Des
cri
ber
eli
evi
nga
nda
ggr
ava
tin
gfa
cto
rs,i
ncl
udi
ngr
esp
ons
est
oot
hert
rea
tmen
t….
.

I
ncl
udeo
therh
eal
thh
ist
ory,i
frel
eva
nt….

I
ncl
udef
ami
lyh
ist
ory,i
frel
eva
nt….
.

Summari
zeex ami
nati
onfindi
ngs
(Generalobs
ervat
ion,ex
traor
alex
ami
nat
ion
,In
tra
ora
lex
ami
nat
iona
ndt
hro
ugh
exa
mina
tionoft helesi
on)

La
bor
ato
ryf
indi
ngs
,ifr
elev
ant
….

Th
epa
tien
twa
sdi
agn
osedwi
th……

Man
agementandOu t
come:
Des
cri
bea sspecifi
call
ya spos
sib
lethetrea
tmentpro
vided,i
ncl
udi
ngt
hen
atu
reo
f
thetreat
men t
,a ndthefreq
uencyan
ddu rat
iono
fc are.
Ifpos
sib
le,refertot heres
ultsoffo
llowup.

Di
scu
ssi
on:
Summari
zet
hec
ase,di
ffer
ent
ialdi
agn
osi
s,t
rea
tmen
tpl
ann
inga
nda
nyl
ess
ons
lear
ned:

Ref
eren
ces
:(us
ingVa
nco
uvers
tyl
e)e.
g.

2
 Fac
ultyofDentist
ry
Depar
tmentofOralMedi c
ine
GrapMJ,Mu n
roCL,El swi
ckRK Jr,Sessl
erCN,WardKR.Du¬r
ati
onofact
iono
fa
si
ngl
e,earlyora
la ppli
cat
ionofchlo
rhexi
dineonor
almi
crob
ialfl
orai
n
mech
anic
allyvent
ilat
edp ati
ent
s:ap i
lotstu
dy.Hea
rtLun
g2004;33:83-91
.

Leg
ends
:(t
abl
es,f
igu
reso
rima
gesa
ren
umb
ereda
cco
rdi
ngt
oth
eor
deri
nwh
ich
th
eya p
pearint
het
ext
.)e.
g.
Figu
re1:…..

Di
scl
aimer
s
St
atemen
tth
atp
ati
entc
ons
entwa
sob
tai
ned

I
.Ca
seSt
udyAs
ses
smen
tFo
rm

Ca
ses
tudyt
itl
e

Dateofthe
pr
esen
tat
ion

Gr
ade Co
mmen
ts
Cr
iter
ia

1 FOCUS ( s
ubstant
ial
inf
o r
mat i
on/in
sightrelevanttot he
case)( 6marks)
2 REP ORT
(detail
eddes cr
ipti
ono ft hecase)
(7marks)
3 LANGUAGE,& FORMATTI NG
(li
ttlet on osentence-str
uctur
e
Problems).(4ma r
ks)
4 DOCUMENTATI ON ( Cit
ationisclear
andCo rrect)(3ma r
ks)
Fi
nalAs
ses
smen
tRes
ult /4
/
20

Eva
lua
torsi
gna
tur
e
1
. …. .

2. ….
.

3
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e

Facul
tyofDen t
ist
ry
Or
almedic
ineDepartment
Or
alPres
ent
ati
on- Ev
aluati
onf o
rm

Ti
tle:
Pr
esent
ati
onNo
:1

4
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
As
ses
smen
tCr
iter
ia
Gr
ade

1 - Or
igi
nal
itya
ndCr
eat
ivi
ty
/1

2 - Orga
niz
ati
on(Log
ica
l 1
. Objecti
ves
/go
a
p
res
entat
ionofidea
s) l
sareclea
rly
s
tat
ed. 1
/

2.Th ou
ght
sand
ideasfl
owina
logi
calman
ner

3 - Or
alp
res
ent
ati
on 1
. Exhi
bit
sg oo
d
bo
dyp ost
ure

2.Maint
ainsgood
eyec on
tact
wit
ha udien
ce /1

3.Gooddict
ion
;
go
od
ar
tic
ula
tio
n

4 - Kno
wledgeo
fMa t
eria
l 1
. Exhibit
s
(
Fami
lia
rit
ywiths
ubjectma
tter
) knowledgeof
su
bj ectmat
ter

2. Answers 3/
qu
es t
ion
swi t
h
co
nf i
dence

To
tal
/6 /
6

Ev
alu
ato
rs i
gna
tur
e
1
. …. .

2. ….
.

Pa
tien
t’sDi
agn
ost
icRec
ord(
1)

Pa
tien
t’si
den
tif
ica
tio
nda
ta

5
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
Name: Ag e:
M: F: Mar
ita
ls t
atu
s
Bir
thDa te:
Address:
Tel:..
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:
Occupation:. .
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Physi
cia n’
sNa me:. .
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. Phys
ici
an’
steleph
oneNo :..
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Dateo fLa stVi sit:. .
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.Rea
.
. s
onofLa s
tVisittoPh ys
ician:..
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ChiefCo mp l ain:. ..
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Histo
r yo fCh iefCo mp la in:
Onset..
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Severit y..
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o n.
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Precipit atin gf a cto rs.
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Rel iev ingf ac tors..
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Associat eds ymp toms ..
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Anyp rev iouss el f -t rea tmen to rp res
cri
bedt
rea
tmen
t.
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Medi
calHi
sto
ry:
Haveyouhadheartproblems?Orhypertension?
Areyoudiabetic?
Haveyouhadanyliverproblems?
Haveyouhadanykidneyproblems?
Haveyouhadanylungproblems?
Haveyouhadanythyroidproblems?
Iffemale,areyoupregnant?
Areyoutakinganymedications?Whichones?
Haveyouhadanyprevioussurgeriesorhospitalization?
Haveyoueverfaintedindentaloffice?
Haveyouhadprolongedbleedingfromacutetoothextractionorotherinjury?
Areyouallergictoanesthetics,antibiotics,otherdrugs?
Doyouhaveanydiseaseorconditionnotlistedabove?
Fa
mil
y& So
cia
lHi
sto
ry:
……………………………………………………………………………………………………………………………………………………………………

6
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
…….
.

Den
talHi
sto
ry
Sensitivity(hot/cold/sweet)
Toothpainordiscomfortwithchewing
Bleeding,swollenorirritatedgums
Ulcersorsores
Foodcatchbetweenyourteeth
Headaches,earachesorneckpains
Jawjointpain,noise
Grindingorclenchingteeth
Teethorfillingsbreaking
Mobileteeth
Badbreathorbadtasteinmouth
Drymouth
Doyouh aveorh av
eyo uha
dan
yoft
hef
oll
owi
ng:
Extractedteeth/why?
Bridge/Filling
Partialdentures/Fulldentures
Braces
Problemsassociatedwithpreviousdentaltreatment
Wh
enwasyo
url
astden
talappoi
ntment(appr
oxda t
e):____
___
____
Wh
atwa
sdoneatth
attime?_________
_____
_____
_____
___
Wh
endi
dyoulas
thavedenta
lx -raystak
en( a
pproxdate)
:____
____
__

Doyousmokeorchewta
b a
cco
?Y/ N
Ifyes
:Howmu c
h/manyperday:_
____
___
___
_an
dsi
ncewh
en?
___
___
____
___

Co
mmen
ts:
___
___
___
___
___
___
___
___
__

7
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
CLI
NICAL EXAMI
NATI
ON
Pa
tien
t’sa
ppr
ais
ala
ndg
ener
alh
eal
th

Ex
tra
-or
alex
ami
nat
ion

Skull
 Face
 Eyes,Ea rs& No
se
Skin
,h ai
r,
handa n
dn ails
TMJ
Neck
Sali
varyg lan
ds
 Lymphn odes

I
ntr
a-o
ralex
ami
nat
ion

Labialmu cosa
Buccalmucos a
Gingiva
Al veo l
arr i
dge
Vestibule
Tongue
Flooro ft hemo u
th
Hardp ala
te
Softpal atea n
du vula& o
rop
har
ynx
Teeth
1.Mi ss
ed/Extrac
ted
2.Fi l
led
3.Decayed
4. Dis
color
ed
5.Mal pos
ed

Co
mmen
ts………………………………………………………………………………………………………

8
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
Per
iodo
nta
lEx
ami
nat
ion
.
.
……………………………………………………………………………… Hyg
ien
e:
Pl
aque Hea
vy Medi
um – De
Li
ght
……………………………………………………………………………………………………
.
Ca
lcu
lus
–Su
rpa
gin
giv
al Hea
vy Medi
um
Li
ght
.
……………………………………………………………………………………………………
Su
bgi
ngi
val Hea
vy Medi
um
Li
ght
…………………………………………………………………………………………………………

:
Gin
giv
a
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or:
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.
. i
ze:
………………………………………………………………………………………………Sha
pe:
……………………………………………………………………………………C
. on
sis
ten
cy:
……………………………………………………………………………………………Te
. x
tur
e:
……………………………………………………………………………R
.
. ec
ess
ion(
Clef
ts)
:
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.
. leedi
ngo
nPr
obi
ng:
……………………………………………………………………S
. up
pur
ati
on/
Exu
dat
es:

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cat
ion(
Pro
be)
:
………………………………………………………………Mu
.
. cog
ing
iva
lPr
obl
ems
:
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.
. un
cti
ona
lRel
ati
ons
:
.
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.…………………………………………………………………………………………Fremi
tus
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.……………………………………………………P
.
. ar
afu
nct
ion
al:

Pa
pil
lar
yBl
eedi
ngI
ndex

7 6 5 4 3 2 1 1 2 3 4 5 6 7

Sco
re Bleedi ngong entl
ep r
obing
0 Nob leedi
ng.
1 Onlyo neb l
eedingp oi
nta ppeari
ng.
2 Sev eralis
o l
atedb leedingpo i
ntsorasmallbl
oodareaappea
rin
g.
3 In
t erdentaltrian
glef ill
edwi thb lo
odso
onafterprobi
ng.
4 Prof u
s ebleedin
gwh enprobing,blo
odsp
reads
towar
dst hemargi
nal
gi
ng iva.

9
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e

Per
iodo
nta
lEx
ami
nat
ion(
con
tin
ued)

Key
1.Res t
o r
atio
n( black)
2.Mi ss
ingt ooth( x-out)
3.En dodonti
ca l
ly-t r
eated( “Endo”)( bl
acklinesinroot
s)
4.Ret ain
edr oots(x-outc rown)
5.Ma lposi
tio
n edt ooth( dra
wa rr
owi ndirec
t i
on)
6.Openc ont
act( para
llell i
nesb etweenteeth)
7.Fo odi mpaction( a
rrowt owardsc on
tactarea)(r
ed)
8.Mo bili
ty( writec lassinRo mann umeralonr o
ot)
9.Recessi
on( drawo u
tline)
10.Fu
rcationin v
olvement( Vi nt
of urcawithc l
assindi
cated)

1
0
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e

Diff
erentia
lDia gno
sis
:
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
………………………………………………………
Radiogra
phicEx a
m:
…………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………
Laborat
oryinvesti
gati
on
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………
Defin
itiveDia
gn os
is
……………………………………………………………………………………………………………………
……………………………………………
TreatmentPlan:
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………
Da
te Pr
ocedu
re Staf
f
s
ign
ature

1
1
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e

Pa
tien
t’sDi
agn
ost
icRec
ord(
2)

Pati
ent ’
si den tif icatio nda ta
Name: Ag e:
M: F: Mar
ita
ls t
atu
s
Bir
thDa te:
Address:
Tel:..
.
..
.
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.
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.
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mail
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Occupation:. .
.
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Physi
cia n’
sNa me:. .
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. Phys
ici
an’
steleph
oneNo :..
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Dateo fLa stVi sit:. .
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.Rea
.
. s
onofLa s
tVisittoPh ys
ician:..
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ChiefCo mp l ain:. ..
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Histo
r yo fCh iefCo mp la in:
Onset..
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Severit y..
.
..
.
..
..
.
..
.
..
..
.
..
..
.
..
.
..
..
.
..
.
..
..
Distr
ib ut i
o n.
..
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..
.
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
.
Precipit atin gf a cto rs.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
.
Rel iev ingf ac tors..
..
.
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.
..
..
.
..
.
..
..
.
..
.
..
..
.
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.
..
Locatio na ndr adi at ion..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
.
.
Associat eds ymp toms ..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
.
Anyp rev iouss el f -t rea tmen to rp res
cri
bedt
rea
tmen
t.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..

Medi
calHi
sto
ry:
Haveyouhadheartproblems?Orhypertension?
Areyoudiabetic?
Haveyouhadanyliverproblems?
Haveyouhadanykidneyproblems?
Haveyouhadanylungproblems?
Haveyouhadanythyroidproblems?
Iffemale,areyoupregnant?
Areyoutakinganymedications?Whichones?
Haveyouhadanyprevioussurgeriesorhospitalization?
Haveyoueverfaintedindentaloffice?
Haveyouhadprolongedbleedingfromacutetoothextractionorotherinjury?

1
2
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
Areyouallergictoanesthetics,antibiotics,otherdrugs?
Doyouhaveanydiseaseorconditionnotlistedabove?
Fa
mil
y& So
cia
lHi
sto
ry:
……………………………………………………………………………………………………………………………………………………………………
…….
.

Den
talHi
sto
ry
Sensitivity(hot/cold/sweet)
Toothpainordiscomfortwithchewing
Bleeding,swollenorirritatedgums
Ulcersorsores
Foodcatchbetweenyourteeth
Headaches,earachesorneckpains
Jawjointpain,noise
Grindingorclenchingteeth
Teethorfillingsbreaking
Mobileteeth
Badbreathorbadtasteinmouth
Drymouth
Doyouh aveorh av
eyo uha
dan
yoft
hef
oll
owi
ng:
Extractedteeth/why?
Bridge/Filling
Partialdentures/Fulldentures
Braces
Problemsassociatedwithpreviousdentaltreatment
Wh
enwasyo
url
astden
talappoi
ntment(appr
oxda t
e):____
___
____
Wh
atwa
sdoneatth
attime?_________
_____
_____
_____
___
Wh
endi
dyoulas
thavedenta
lx -raystak
en( a
pproxdate)
:____
____
__

Doyousmokeorchewta
b a
cco
?Y/ N
Ifyes
:Howmu c
h/manyperday:_
____
___
___
_an
dsi
ncewh
en?
___
___
____
___

1
3
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
Co
mmen
ts:
___
___
___
___
___
___
___
___
__

CLI
NICAL EXAMI
NATI
ON
Pa
tien
t’sa
ppr
ais
ala
ndg
ener
alh
eal
th

Ex
tra
-or
alex
ami
nat
ion

Skull
 Face
 Eyes,Ea rs& No
se
Skin
,h ai
r,
handa n
dn ails
TMJ
Neck
Sali
varyg lan
ds
 Lymphn odes

I
ntr
a-o
ralex
ami
nat
ion

Labialmu cosa
Buccalmucos a
Gingiva
Al veo l
arr i
dge
Vestibule
Tongue
Flooro ft hemo u
th
Hardp ala
te
Softpal atea n
du vula& o
rop
har
ynx
Teeth
1.Mi ss
ed/Extrac
ted
2.Fi l
led
3.Decayed
4. Dis
color
ed
5.Mal pos
ed

1
4
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
Co
mmen
ts………………………………………………………………………………………………………

Per
iodo
nta
lEx
ami
nat
ion
.
.
……………………………………………………………………………… Hyg
ien
e:
Pl
aque Hea
vy Medi
um – De
Li
ght
……………………………………………………………………………………………………
.
Ca
lcu
lus
–Su
rpa
gin
giv
al Hea
vy Medi
um
Li
ght
.
……………………………………………………………………………………………………
Su
bgi
ngi
val Hea
vy Medi
um
Li
ght
…………………………………………………………………………………………………………

…………………………………………………………………………………………… :
Ging iv
a
.
..
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
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..
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..
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..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.……………………………………C
.
. olor:
.
..
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.………………………………………………S
. ize:
………………………………………………………………………………………………S hape:
……………………………………………………………………………………C
. ons
ist
en cy:
……………………………………………………………………………………………Te
. xture:
.
.……………………………………………………………………………R ecessi
on( Clefts)
:
.
..
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.…………………………………………………B
. leedin
go nPr o b
ing:
……………………………………………………………………S
. uppur
ation
/Exuda tes
:

.
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.……………………………………………………Fur
cat
ion(
Pro
be)
:
………………………………………………………………Mu
.
. cog
ing
iva
lPr
obl
ems
:
.
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.………………………………………………F
.
. un
cti
ona
lRel
ati
ons
:
.
.
.…………………………………………………………………………………………Fremi
tus
:
.
.
..
.
..
.
..
.
..
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..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.……………………………………………………P
.
. ar
afu
nct
ion
al:

Pa
pil
lar
yBl
eedi
ngI
ndex

7 6 5 4 3 2 1 1 2 3 4 5 6 7

Sc
ore Bl
eedi
ngo
ngen
tlep
rob
ing

1
5
 Fac
ultyofDen t
istr
y
Depar
tmento fOr alMedicine
0 Nob leeding
.
1 Onlyo neb l
eedingp oi
nta p
peari
ng.
2 Severalisola
tedb leedin
gp oi
ntsorasmallbl
oodareaappea
rin
g.
3 In
terdentalt r
iang
lef il
ledwi t
hb lo
odso
onafterprobi
ng.
4 Profusebleedingwh enprobi
ng,blo
odsp
reads
towar
dst hemargi
nal
gi
ngiva.

Per
iodo
nta
lEx
ami
nat
ion(
con
tin
ued)

Key
1
1.Res
torat
ion(black)
1
2.Miss
ingt o
oth(x-o u
t)
1
3.Endodont
ical
ly-treated( “En
do”)(
bla
ckl in
esinr
oot
s)
1
4.Retain
edr oot
s( x-outc ro
wn)
1
5.Malpos
iti
onedt o
oth( dr
awa rro
windirec
tion
)

1
6
 Facultyo fDen t
istr
y
Departmento fOr alMedi c
ine
1
6.Openc ont
act( par
a l
lell i
nesb et
weent eet
h)
1
7.Fo odi mpact
ion( ar
rowt owardsconta
cta r
ea)(r
ed)
1
8.Mo bili
ty( wri
tec lassinRo mann u
meralonroot)
1
9.Recess
ion( dra
wo utline)
20.Fur
cationinvol
vement( Vi n
tof urc
awi thcla
ssindi
cat
ed)

Diff
erentia
lDia gno
sis
:
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
………………………………………………………
Radiogra
phicEx a
m:
…………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………
Laborat
oryinvesti
gati
on
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………
Defin
itiveDia
gn os
is
……………………………………………………………………………………………………………………
……………………………………………
TreatmentPlan:
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………
Da
te Pr
ocedu
re St
affs
ign
atu
re

1
7
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e

Pa
tien
t’sDi
agn
ost
icRec
ord(
3)

Pati
ent ’
si den tif icatio nda ta
Name: Ag e:
M: F: Mar
ita
ls t
atu
s
Bir
thDa te:
Address:
Tel:..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
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.
..
.
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.
.. E.
mail
:
Occupation:. .
.
..
.
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.
..
.
..
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
Physi
cia n’
sNa me:. .
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
. Phys
ici
an’
steleph
oneNo :..
.
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.
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.
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..
.
..
..
Dateo fLa stVi sit:. .
..
.
..
.
..
.
..
.
..
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.
..
.
.Rea
.
. s
onofLa s
tVisittoPh ys
ician:..
.
..
.
..
..
.
..
.
..
.
..
.

ChiefCo mp l ain:. ..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
.
Histo
r yo fCh iefCo mp la in:
Onset..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
..
.
..
.
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Course..
.
..
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.
..
.
..
..
.
..
.
..
..
.
..
..
.
..
.
..
..
.
..
Severit y..
.
..
.
..
..
.
..
.
..
..
.
..
..
.
..
.
..
..
.
..
.
..
..
Distr
ib ut i
o n.
..
..
..
.
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
.
Precipit atin gf a cto rs.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
.
Rel iev ingf ac tors..
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
Locatio na ndr adi at ion..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
.
.
Associat eds ymp toms ..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
..
..
.
..
.
.
Anyp rev iouss el f -t rea tmen to rp res
cri
bedt
rea
tmen
t.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..

Medi
calHi
sto
ry:
Haveyouhadheartproblems?Orhypertension?
Areyoudiabetic?
Haveyouhadanyliverproblems?
Haveyouhadanykidneyproblems?
Haveyouhadanylungproblems?
Haveyouhadanythyroidproblems?
Iffemale,areyoupregnant?

1
8
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
Areyoutakinganymedications?Whichones?
Haveyouhadanyprevioussurgeriesorhospitalization?
Haveyoueverfaintedindentaloffice?
Haveyouhadprolongedbleedingfromacutetoothextractionorotherinjury?
Areyouallergictoanesthetics,antibiotics,otherdrugs?
Doyouhaveanydiseaseorconditionnotlistedabove?
Fa
mil
y& So
cia
lHi
sto
ry:
……………………………………………………………………………………………………………………………………………………………………
…….
.

Den
talHi
sto
ry
Sensitivity(hot/cold/sweet)
Toothpainordiscomfortwithchewing
Bleeding,swollenorirritatedgums
Ulcersorsores
Foodcatchbetweenyourteeth
Headaches,earachesorneckpains
Jawjointpain,noise
Grindingorclenchingteeth
Teethorfillingsbreaking
Mobileteeth
Badbreathorbadtasteinmouth
Drymouth
Doyouh aveorh av
eyo uha
dan
yoft
hef
oll
owi
ng:
Extractedteeth/why?
Bridge/Filling
Partialdentures/Fulldentures
Braces
Problemsassociatedwithpreviousdentaltreatment
Wh
enwasyo
url
astden
talappoi
ntment(appr
oxda t
e):____
___
____
Wh
atwa
sdoneatth
attime?_________
_____
_____
_____
___
Wh
endi
dyoulas
thavedenta
lx -raystak
en( a
pproxdate)
:____
____
__

1
9
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e

Doyousmokeorchewta
b a
cco
?Y/ N
Ifyes
:Howmu c
h/manyperday:_
____
___
___
_an
dsi
ncewh
en?
___
___
____
___

Co
mmen
ts:
___
___
___
___
___
___
___
___
__

CLI
NICAL EXAMI
NATI
ON
Pa
tien
t’sa
ppr
ais
ala
ndg
ener
alh
eal
th

Ex
tra
-or
alex
ami
nat
ion

Skull
 Face
 Eyes,Ea rs& No
se
Skin
,h ai
r,
handa n
dn ails
TMJ
Neck
Sali
varyg lan
ds
 Lymphn odes

I
ntr
a-o
ralex
ami
nat
ion

Labialmu cosa
Buccalmucos a
Gingiva
Al veolarridge
Vestibu
le
Tongue
Flooro ft h
emo u
th
Hardp alate
Softpal atea n
du vula& o
rop
har
ynx
Teeth
1.Mi ssed/Extrac
ted

20
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
2.Fil
led
3.Decayed
4.Dis
colored
5.Malposed

Co
mmen
ts………………………………………………………………………………………………………

Per
iodo
nta
lEx
ami
nat
ion
.
.
……………………………………………………………………………… Hyg
ien
e:
Pl
aque Hea
vy Medi
um – De
Li
ght
……………………………………………………………………………………………………
.
Ca
lcu
lus
–Su
rpa
gin
giv
al Hea
vy Medi
um
Li
ght
.
……………………………………………………………………………………………………
Su
bgi
ngi
val Hea
vy Medi
um
Li
ght
…………………………………………………………………………………………………………

…………………………………………………………………………………………… :
Ging iv
a
.
..
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.……………………………………C
.
. olor:
.
..
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.………………………………………………S
. ize:
………………………………………………………………………………………………S hape:
……………………………………………………………………………………C
. ons
ist
en cy:
……………………………………………………………………………………………Te
. xture:
.
.……………………………………………………………………………R ecessi
on( Clefts)
:
.
..
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.…………………………………………………B
. leedin
go nPr o b
ing:
……………………………………………………………………S
. uppur
ation
/Exuda tes
:

.
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.……………………………………………………Fur
cat
ion(
Pro
be)
:
………………………………………………………………Mu
.
. cog
ing
iva
lPr
obl
ems
:
.
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.………………………………………………F
.
. un
cti
ona
lRel
ati
ons
:
.
.
.…………………………………………………………………………………………Fremi
tus
:
.
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.……………………………………………………P
.
. ar
afu
nct
ion
al:

21
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
7 6 5 4 3 2 1 1 2 3 4 5 6 7

Pa
pil
lar
yBl
eedi
ngI
ndex

Sco
re Bleedi ngong entl
ep r
obing
0 Nob leedi
ng.
1 Onlyo neb l
eedingp oi
nta ppeari
ng.
2 Sev eralis
o l
atedb leedingpo i
ntsorasmallbl
oodareaappea
rin
g.
3 In
t erdentaltrian
glef ill
edwi thb lo
odso
onafterprobi
ng.
4 Prof u
s ebleedin
gwh enprobing,blo
odsp
reads
towar
dst hemargi
nal
gi
ng iva.

Per
iodo
nta
lEx
ami
nat
ion(
con
tin
ued)

22
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e

Key
21.Restorati
on( black)
22.Mi ss
ingt ooth( x
-o ut)
23.En dodonti
ca l
ly-treated( “Endo”)( bl
acklinesi nroot
s)
24.Ret ain
edr oot
s( x-outc rown)
25.Ma lposi
tionedt oo
th( dra
wa rr
owi ndirec
t i
on)
26.Openc onta
ct( parallell i
nesb etweenteeth)
27.Fo odi mpactio
n( arrowt owardsc on
tactarea)(red)
28.Mo bili
ty( writec la
s sinRo mann umeralonr oo
t )
29.Recessi
on( drawo utline)
30.Furca
tioninv o
lvement( Vintof u
rcawi thclassindic
ated)

Di
ffer
ent
ialDi
agn
osi
s:

23
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
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Radi
ographi
cEx a
m:
…………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………
Labo
rator
yi nvesti
gat
ion
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………
Defi
niti
veDi a
gn os
is
……………………………………………………………………………………………………………………
……………………………………………
Trea
tmentPl an:
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………
Da
te Pr
ocedu
re St
affs
ign
atu
re

Pa
tien
t’sDi
agn
ost
icRec
ord(
4)

Pa
tien
t’si
den
tif
ica
tio
nda
ta

24
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
Name: Ag e:
M: F: Mar
ita
ls t
atu
s
Bir
thDa te:
Address:
Tel:..
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cia n’
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Anyp rev iouss el f -t rea tmen to rp res
cri
bedt
rea
tmen
t.
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Medi
calHi
sto
ry:
Haveyouhadheartproblems?Orhypertension?
Areyoudiabetic?
Haveyouhadanyliverproblems?
Haveyouhadanykidneyproblems?
Haveyouhadanylungproblems?
Haveyouhadanythyroidproblems?
Iffemale,areyoupregnant?
Areyoutakinganymedications?Whichones?
Haveyouhadanyprevioussurgeriesorhospitalization?
Haveyoueverfaintedindentaloffice?
Haveyouhadprolongedbleedingfromacutetoothextractionorotherinjury?
Areyouallergictoanesthetics,antibiotics,otherdrugs?
Doyouhaveanydiseaseorconditionnotlistedabove?
Fa
mil
y& So
cia
lHi
sto
ry:
……………………………………………………………………………………………………………………………………………………………………

25
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
…….
.

Den
talHi
sto
ry
Sensitivity(hot/cold/sweet)
Toothpainordiscomfortwithchewing
Bleeding,swollenorirritatedgums
Ulcersorsores
Foodcatchbetweenyourteeth
Headaches,earachesorneckpains
Jawjointpain,noise
Grindingorclenchingteeth
Teethorfillingsbreaking
Mobileteeth
Badbreathorbadtasteinmouth
Drymouth
Doyouh aveorh av
eyo uha
dan
yoft
hef
oll
owi
ng:
Extractedteeth/why?
Bridge/Filling
Partialdentures/Fulldentures
Braces
Problemsassociatedwithpreviousdentaltreatment
Wh
enwasyo
url
astden
talappoi
ntment(appr
oxda t
e):____
___
____
Wh
atwa
sdoneatth
attime?_________
_____
_____
_____
___
Wh
endi
dyoulas
thavedenta
lx -raystak
en( a
pproxdate)
:____
____
__

Doyousmokeorchewta
b a
cco
?Y/ N
Ifyes
:Howmu c
h/manyperday:_
____
___
___
_an
dsi
ncewh
en?
___
___
____
___

Co
mmen
ts:
___
___
___
___
___
___
___
___
__

26
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
CLI
NICAL EXAMI
NATI
ON
Pa
tien
t’sa
ppr
ais
ala
ndg
ener
alh
eal
th

Ex
tra
-or
alex
ami
nat
ion

Skull
 Face
 Eyes,Ea rs& No
se
Skin
,h ai
r,
handa n
dn ails
TMJ
Neck
Sali
varyg lan
ds
 Lymphn odes

I
ntr
a-o
ralex
ami
nat
ion

Labialmu cosa
Buccalmucos a
Gingiva
Al veo l
arr i
dge
Vestibule
Tongue
Flooro ft hemo u
th
Hardp ala
te
Softpal atea n
du vula& o
rop
har
ynx
Teeth
1.Mi ss
ed/Extrac
ted
2.Fi l
led
3.Decayed
4. Dis
color
ed
5.Mal pos
ed

Co
mmen
ts………………………………………………………………………………………………………

27
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e
Per
iodo
nta
lEx
ami
nat
ion
.
.
……………………………………………………………………………… Hyg
ien
e:
Pl
aque Hea
vy Medi
um – De
Li
ght
……………………………………………………………………………………………………
.
Ca
lcu
lus
–Su
rpa
gin
giv
al Hea
vy Medi
um
Li
ght
.
……………………………………………………………………………………………………
Su
bgi
ngi
val Hea
vy Medi
um
Li
ght
…………………………………………………………………………………………………………

…………………………………………………………………………………………… :
Ging iv
a
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.
. olor:
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.………………………………………………S
. ize:
………………………………………………………………………………………………S hape:
……………………………………………………………………………………C
. ons
ist
en cy:
……………………………………………………………………………………………Te
. xture:
.
.……………………………………………………………………………R ecessi
on( Clefts)
:
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.…………………………………………………B
. leedin
go nPr o b
ing:
……………………………………………………………………S
. uppur
ation
/Exuda tes
:

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.……………………………………………………Fur
cat
ion(
Pro
be)
:
………………………………………………………………Mu
.
. cog
ing
iva
lPr
obl
ems
:
.
.
..
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.………………………………………………F
.
. un
cti
ona
lRel
ati
ons
:
.
.
.…………………………………………………………………………………………Fremi
tus
:
.
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.……………………………………………………P
.
. ar
afu
nct
ion
al:

Pa
pil
lar
yBl
eedi
ngI
ndex

7 6 5 4 3 2 1 1 2 3 4 5 6 7

Sco
re Bleedi ngong entl
ep r
obing
0 Nob leedi
ng.
1 Onlyo neb l
eedingp oi
nta ppeari
ng.
2 Sev eralis
o l
atedb leedingpo i
ntsorasmallbl
oodareaappea
rin
g.
3 In
t erdentaltrian
glef ill
edwi thb lo
odso
onafterprobi
ng.
4 Prof u
s ebleedin
gwh enprobing,blo
odsp
reads
towar
dst hemargi
nal
gi
ng iva.

28
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e

Per
iodo
nta
lEx
ami
nat
ion(
con
tin
ued)

Key
31.Restorati
on( black)
32.Mi ss
ingt ooth( x
-o ut)
33.En dodonti
ca l
ly-treated( “Endo”)( bl
acklinesinroo
ts)
34.Ret ain
edr oot
s( x-outc rown)
35.Ma lposi
tionedt oo
th( dra
wa rr
owi ndirec
t i
on)
36.Openc onta
ct( parallell i
nesb etweenteeth)
37.Fo odi mpactio
n( arrowt owardsc on
tactarea)(r
ed)
38.Mo bili
ty( writec la
s sinRo mann umeralonr o
ot)
39.Recessi
on( drawo utline)

29
 Fac
ultyofDentis
try
Depar
tmento
fOr alMedici
ne
40.
Furca
tio
ninvo
lvement(
Vi nt
ofu
rcawi
thc
las
sin
dic
ated)

Diff
erentia
lDia gno
sis
:
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
………………………………………………………
Radiogra
phicEx a
m:
…………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………
Laborat
oryinvesti
gati
on
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………
Defin
itiveDia
gn os
is
……………………………………………………………………………………………………………………
……………………………………………
TreatmentPlan:
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………
Da
te Pr
ocedu
re Staf
f
s
ign
ature

30
 Fa
cultyofDen
tis
try
Depa
rtmen
tofOralMedi
cin
e

31