DEPT. OF CONSERVATIVE DENTISTRY AND ENDODONTICS C.K.S. TEJA INSTITUTE OF DENTAL SCIENCES AND RESEARCH, TIRUPATI
CASE RECORD Doctors Name:
Occupation: Marital Status: Married / Single Address / Ph. No.: DENTAL HISTORY: Chief Complaint:
History of Present Illness:
Past Dental History:
PAST MEDICAL HISTORY: ANY RELATED DISEASES TO : Cardiovascular Respiratory Gastrointestinal Neural
: : : :
Yes/No Yes/No Yes/No Yes/No
Hepatic Renal Endocrine (Diabetes)
: : :
Yes/No Yes/No Yes/No
If yes, give details: ALLERGIC TO: Have you been hospitalized / Operated: If Yes, give details: Do you have any history of abnormal bleeding with trauma or: dental procedures. If yes, give details: Are you pregnant? I TRIMESTER
Yes / No Yes / No Yes / No
CLINICAL EXAMINATION: I.INTRA ORAL EXAMINATION: A.HARD TISSUE EXAMINATION: No of teeth present : Missing teeth : Filled teeth : Fractured teeth : Discoloured teeth : Wasting diseases : Mobility : Crowding/spacing : Molar occlusion : B.SOFT TISSUE EXAMINATION: Swelling : Sinus opening : •
II.EXTRA ORAL EXAMINATION: Swelling : Lymphnode enlargement: Sinus opening : PROVISIONAL DIAGNOSIS:
PULP VITALITY TEST: – Cold Thermal Test: Normal
No response – Heat
Electric Pulp Test: Control tooth response to No.: Test tooth response at No.: PERCUSSION TEST:
OTHER TESTS: LAB INVESTIGATIONS: FINAL DIAGNOSIS: PROGNOSIS: Good / Fair / Poor / Doubtful. TREATMENT PLAN:
Patient Motivation: Highly / Moderately / Poorly Signature POST OPERATIVE EVALUATION & FOLLOW UP 1 Month 3 Months 6 Months 1 Year
CONSENT FORM 1.
The doctor has explained my dental condition, the proposed procedure, I understand the probable out come of the procedure including that which are specific to me.
The doctor has explained relevant treatment options and their associated risks. The doctor has explained my prognosis the procedure.
I understand that photographs or video footage may be taken during the procedure out of academic interest. (You shall not be identified in any photograph / Video footage).
I Understand the details of the procedure and in case of any unexpected complication during or subsequent to treatment, will not hold either the treating doctor or the hospital authority responsible.
I am willing to undergo the treatment.
Signature (Parent / Guardian, if minor
PAYMENTS AND RECEIPTS Bill No.
ENDODONTIC CASE RECORD
Tooth Number: Access Cavity Preparation and Pup Extripation:
Bio-Mechanical Preparation: Length determination:
Instruments used: Irrigants used: H2O2 / Saline/NaOCl/Metrogyl/Chlorhexidine Obturation: Complete / Sectional Mastercone size: Sealer used: Condensation technique: Lateral / Vertical / Thermal Post Operative X-Ray: Apical Seal: Lateral Condensation:
Post Endodontic Restoration:
Post Operative Follow up:
No. of Teeth present: Existing Restorations: Rediographic pulp exposure: Lamina dura: Periapical rediolucency: a. No of teeth involved b. Size and Shape c. Nature of radiolucency Periodontal Status: a. Periodontal space widening b. Interdental bone loss Name of root canal in the involved teeth: a. No. of canal b. Shape c. Anatomical variations d. Patency e. Presence of calcified structures, resorption, closure of apical portion Previous endodontic treatment: a. Status of root canal filling b. Status of retrograde filling Fracture of teeth: a. Crown b. Root Any other abnormalities: