Case Presentation 2

Full Name

First NameLast Name

E-mail

Doc #

Patient windent #

Date of submission

Date of presentation

VITAL SIGNS

2-1. blood pressure

2-2. pulse

2-3. respiration rate

EXTRAORAL FINDINGS

2-4. significant extraoral findings

if yes, list significant findings

INTRAORAL FINDINGS

Soft Tissue

2-5. lesions

if yes, list & describe

2-6. oral conditions

if yes, list & describe

Oral Hygiene Description

2-7. OH - status

2-8. OH - summarize findings (plaque, calculus, stain, food impaction, etc.)

Periodontal Description
refer to "Descriptive Terminology" on D3 Case web page

2-9. describe gingiva & significant periodontal findings

2-10. list any significant findings from perio charting

Dentition Description

2-11. teeth - # present

2-12. teeth - state of repair

2-13. list teeth with mobility

2-14. list # of restorations present, types & defects (overview)

Caries Description

2-15. describe clinical appearance of caries

2-16. list teeth with clinically evident caries

2-17. list identified caries risk factors

2-18. list other caries risk assessment findings

Occlusal Analysis

2-19. overview of existing occlusion

2-20. classification of occlusion

RADIOGRAPHIC FINDINGS

Number & Type of Films

2-21. panoramic

2-22. periapicals

if yes, list #

2-23. bitewings

if yes, list #

2-24. other films

if yes, list # and type

Radiographic Characteristics of Bone
refer to "Descriptive Terminology" on D3 Case web page

2-25. describe bone loss, severity, pattern, distribution

2-26. list bony defects, periapical lesions, furcation areas

Radiographic Characteristics of Teeth

2-27. list impactions, number anomalies, crown anomalies

2-28. list attrition, abrasion, trauma

2-29. list abnormal pulp cavity & canal features, abnormal root features

2-30. describe changes in crestal lamina dura, radicular lamina dura, pdl space

2-31. list teeth/surfaces with radiographic evidence of caries

D3 Case Presentation

SECTION 2 CLINICAL & RADIOGRAPHIC FINDINGS