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Case Presentation

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.

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Case Presentation

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  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 • 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 andapical periodontal Other relevant: periodontal,prosthodontic

  16. Treatment 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

  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

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