FELLOWSHIP IN OPERATIVE DENTISTRY AND ENDODONTICS: CASE HISTORY TEMPLATE A
PRE-TREATMENT ASSESSMENT
PATIENT AGE: 52
PATIENT GENDER: female
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TOOTH # (FDI NUMBERING SYSTEM): 36 PROCEDURE CATEGORY:
CHIEF COMPLAINT
pt presented with cc of sharp pain in lower molar area
HISTORY OF PRESENTING COMPLAINT
Slight pdl widening
MEDICAL HISTORY
Pt was classified
ASA CLASS 1
CLINICAL EVALUATION (Preoperative, Operative and post operative photograph the relevant tooth
to be attached)
Extraoral examination :
Extraoral finding did not reveal any significant finding
Intraoral examination
Intraoral examination reveal slight swelling of gingiva adjacent to tooth # 36
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FELLOWSHIP IN OPERATIVE DENTISTRY AND ENDODONTICS: CASE HISTORY TEMPLATE A
Diagnostic tests
Tooth #36 #37
Percussion +ve -ve
Palpation -ve -ve
Mobility No No
Probing depth WNl WNl
Radiographic Interpretation: (Preoperative, Operative and Post operative
radiographs to be attached) widening of pdl
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FELLOWSHIP IN OPERATIVE DENTISTRY AND ENDODONTICS: CASE HISTORY TEMPLATE A
PRE-TREATMENT DIAGNOSIS:
Irreversible puulpitis with symptomatic apical periodontitis
TREATMENT PLAN:
Emergency: Non
Definitive:Non-surgical root canal treatment
Alternative: Extraction
CLINICAL PROCEDURES:
Visit 1 informed consent was obtained
Endodontic evaluation and treatment plan was discussed with patient
LA was administered
Accesss cavity was established
Canal was negociated with patency files
Radiograph was taken for working length determination
Cleaning and shaping was performed by step back tech
Irrigation was done
Canal was dried and medicated with ca(oh)
Access was sealed with cavit
Visit 2
pt reported that his condition has improved cavit was removed pulp chamber was irrigated with sodium
hypochloride
Working length was reestablished canal was dried and obturated with lateral condensation tech And tooth was
restored with permanent restoration
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FELLOWSHIP IN OPERATIVE DENTISTRY AND ENDODONTICS: CASE HISTORY TEMPLATE A
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FELLOWSHIP IN OPERATIVE DENTISTRY AND ENDODONTICS: CASE HISTORY TEMPLATE A