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Case Analysis Chart No:: History: Chief Complaint

This document contains a case analysis chart used to record information about a dental patient, including their chief complaint, medical and dental history, examination findings, provisional diagnosis, treatment plan, and case analysis. Key details recorded include the patient's name, age, occupation, address, reason for visit, history of present illness, past dental treatments, medical conditions, oral hygiene habits, family dental history, extraoral and intraoral soft tissue and hard tissue examination findings, periodontal assessment, radiographs, diagnosis, prognosis, and proposed treatment.

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nagamalla rashmitha
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© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
84 views

Case Analysis Chart No:: History: Chief Complaint

This document contains a case analysis chart used to record information about a dental patient, including their chief complaint, medical and dental history, examination findings, provisional diagnosis, treatment plan, and case analysis. Key details recorded include the patient's name, age, occupation, address, reason for visit, history of present illness, past dental treatments, medical conditions, oral hygiene habits, family dental history, extraoral and intraoral soft tissue and hard tissue examination findings, periodontal assessment, radiographs, diagnosis, prognosis, and proposed treatment.

Uploaded by

nagamalla rashmitha
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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CASE ANALYSIS CHART NO:

OP NO: Date:
Discussed with: signature:
Name:
Age /sex:
Occupation:
Address: phone no:

HISTORY:
CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS


Onset:

Duration:

Aggravating / Relieving Factors:

PAST DENTAL HISTORY:

MEDICAL HISTORY:

1
PERSONAL HISTORY:

Diet:
Alcohol:
Smoking:
Pan Chewing:
Biting Habits:
Mouth Breathing:
Bruxism:
Tongue Thrusting:
Thumb Sucking:

Oral Hygiene Practice:


 Type of Brush

 Dentifrice

 Technique

 Duration

 Frequency of Brushing

 Frequency of Changing Brush

 Interdental Aids

 Mouth Rinses

 Tongue Cleaning

 Frequency and nature of periodontal care

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FAMILY HISTORY:

GENERAL EXAMINATION:

EXTRA ORAL EXAMINATION:


Symmetry of face:

TMJ:

Lymph nodes:

Lips:

Others:

3
GENERAL INTRAORAL EXAMINATION:
SOFT TISSUES:
Buccal Mucosa:

Labial Mucosa:

Hard Palate:

Soft Palate:

Floor of Mouth:

Tongue:

Oropharynx:

ORAL HYGIENE STATUS:


ORAL HYGIENE INDEX SIMPLIFIED-O.H. I(S)

DEBRIS INDEX CALCULUS INDEX

16 11 26 16 11 26

46 31 36 46 31 36

TOTAL DI-SCORE TOTAL CI-SCORE

TOTAL SCORE: ORAL HYGIENE STATUS:

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HARD TISSUES:
Teeth present

Teeth missing

Dental caries

Restorations

Plunger cusps

Occlusion

Trauma from occlusion

Wasting diseases

 Attrition

 Abrasion

 Erosion

5
GINGIVAL STATUS
Color

Contour

Consistency

Surface texture

Size

Position

Gingival bleeding

Gingival exudate

ABSCESS

Gingival

Periodontal

Periapical

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RUSSELL’S PERIODONTAL INDEX:

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Periodontal index score = sum of individual scores


No. of teeth present

Assessment:

MUCOGINGIVAL EXAMINATION

Vestibular depth:

Frenal attachment:

Width of attached gingiva:

Gingival recession/extending Mucogingival junction:

PROVISIONAL DIAGNOSIS

INVESTIGATION
Radiographs

Laboratory

DIFFERENTIAL DIAGNOSIS

8
FINAL DIAGNOSIS

PROGNOSIS
Individual

Overall

TREATMENT PLAN

Emergency phase

Phase I/ Etiotropic phase

Phase 2/ Surgical phase

9
Phase 3 / Restorative phase

Phase 4 / Maintenance phase

CASE ANALYSIS

10

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