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Case 4

The document outlines a case history template for a 23-year-old male patient presenting with sensitivity to sweets, diagnosed with reversible pulpitis. The treatment plan involved the restoration of a carious tooth through a series of clinical procedures including excavation, cavity preparation, and composite filling. Preoperative, operative, and postoperative evaluations are to be attached for comprehensive assessment.

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Faiz UR Rahman
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40 views6 pages

Case 4

The document outlines a case history template for a 23-year-old male patient presenting with sensitivity to sweets, diagnosed with reversible pulpitis. The treatment plan involved the restoration of a carious tooth through a series of clinical procedures including excavation, cavity preparation, and composite filling. Preoperative, operative, and postoperative evaluations are to be attached for comprehensive assessment.

Uploaded by

Faiz UR Rahman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

FELLOWSHIP IN OPERATIVE DENTISTRY AND ENDODONTICS: CASE HISTORY TEMPLATE A

PRE-TREATMENT ASSESSMENT

PATIENT AGE: 23

PATIENT GENDER: mal4

HOSPITAL REG. NUMBER: 3210

DATE: 10/7/24

----------- -----------------------------------------------------------------------------------------------------------------------

TOOTH # (FDI NUMBERING SYSTEM): 36 PROCEDURE CATEGORY:

CHIEF COMPLAINT
Pt presented with chief complaint of sensitivity with sweet

HISTORY OF PRESENTING COMPLAINT

Pt reported with sensitivity to sweets which disappear after few seconds

PAST DENTAL HISTORY


Not significant

MEDICAL HISTORY

Pt was classified as ASA class 1

1
FELLOWSHIP IN OPERATIVE DENTISTRY AND ENDODONTICS: CASE HISTORY TEMPLATE A

CLINICAL EVALUATION (Preoperative, Operative and post operative Radiographs of


the relevant tooth to be attached)

2
FELLOWSHIP IN OPERATIVE DENTISTRY AND ENDODONTICS: CASE HISTORY TEMPLATE A

Diagnostic Procedures

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FELLOWSHIP IN OPERATIVE DENTISTRY AND ENDODONTICS: CASE HISTORY TEMPLATE A

Examination:

(Preoperative, Operative and post operative

Of the relevant tooth to be attached)


Extraoral examination:
there was no significant finding on extraoral examination

Intraoral examination:

Hard tissue examination revealed pit and fissure carries with white spot appearance

PRE-TREATMENT DIAGNOSIS:

Reversible pulpitis

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FELLOWSHIP IN OPERATIVE DENTISTRY AND ENDODONTICS: CASE HISTORY TEMPLATE A

TREATMENT PLAN:

Restoration of carious tooth

CLINICAL PROCEDURES:

Caries was excavated with bur

Cavity was prepared

Bevel margin was created and etched with phosphoric acid

Dentin bonding agent was applied and cured

Cavity was filled with composite and cured

Filling was checked and corrected for over hanging margins and high spot was
checked and filling was finished and polished.

5
FELLOWSHIP IN OPERATIVE DENTISTRY AND ENDODONTICS: CASE HISTORY TEMPLATE A

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