Chief Complaint 1. What is the problem? History of Complaint/ Present Illness 1. When did it happen? 2. How it happened? 3.

When was this treatment done? 4. Is there any pain associated with it (chief complaint?) if yes, a.) Ask questions related to pain like, how, when, where, duration, intensity, exacerbating and relieving factors, continuous or intermittent, referred anywhere, etc. 5. Duration of the problem? Past history of dental illness / Dental History 1. What r your oral hygiene practices? (Plaque control) 2. What r your dietary habits 3. Any oral Habits or Para functional habits? (Bruxism, clenching, nail biting), If the patient is kid, ask about oral habits like thumb sucking, lip sucking, nail biting , etc. 4. Have u undergone any dental treatment earlier also? If yes, any incidence of reported allergy to medication or L.A , or any bleeding disorder or any other complication? 5. Any past history of dental of maxillofacial trauma 6. Any other problem or symptom other than chief complaint like tooth pain, sensitivity, gingival bleeding, or halitosis, or tooth mobility. Medical history 1. h/o of Diabetes, HTN, Asthma, any heart problem, epileptic disorder, any bleeding disorder, allergy, any medication she is taking for any chronic diseases, any chronic diseases she is suffering, any history of previous surgery, any complication associated with it, pregnancy. Family History 1. Family history of Diabetes, HTN , asthma, cardiac problems, bleeding disorder Personal history 1. Any history of smoking, alcohol, or drug abuse etc. Occupational history 1. Is she working or not? if yes, what business or job she is in ? any occupational hazard associated ?

Extra oral Examination-----under 4 categories---Inspection, Palpation, Percussion, Auscultation. 1. Any swelling or asymmetry on face or any extra oral sinus any abnormality, 2. Palpation of Lymph Nodes For Dry mouth or xerostomia. 1. Palpation of salivary glands For TMJ Problem or Occlusal Problem 1. Palpation of Masticatory muscles. 2. Palpation of TMJ 3. Assessment of Range of Mandibular Movement Intra oral examination 1. Soft Tissue examination like oral hygiene, any gingival or mucosal swelling and any discharge blood or pus associated with it, oral mucosal lesion or abnormality, red or white lesion, torus, any overgrowth, or ulcer, palate, gingival condition. 2. Hard tissue examination like of the teeth which include any DMF tooth, any prosthetic appliance like RPD or FPD and also the: --a. Periodontal evaluation i. Hygiene, plaque, calculus, any gingival or mucosal swelling and any discharge blood or pus associated with it, inflammation or swelling of gums, bleeding, pocket, recession, mobility, any drifting or TFO. b. Endodontic evaluation i. caries, Any pain, if yes, ask history related to pain. ii. Pulpal condition using history, inspection, like swelling, pus discharge, sinus, palpation, Percussion, thermal tests, electric pulp tests, radiograph, iii. Assessment of previous root filling, periapical condition of RC treated teeth, c. Prosthodontics evaluation ---i. any prosthetic appliance like RPD or FPD or CD ii. Resistance form of the tooth, (condition of any filling or post endodontic restoration) iii. Retentive form of the tooth, (clinical crown height, including post and core) iv. Occlusion ---availability of Interocclusal Space for restoration v. Aesthetic and functional considerations or demands of the patient.

vi. Look for ICP, RCP, vii. Any interference during protrusive or lateral excursions, guidance teeth, vi. Any wear facets d. Pedodontic evulation i. Look for oral habits like thumb and digit sucking, tongue thrusting, mouth breathing, bruxism, nail biting, etc.

Provisional Diagnosis

Investigation 1. General Investigations like Pulse, BP, Temp., Resp. Rate, Blood Analysis, Urinalysis, virology immunology, blood cultures, biopsy, cytology, etc. 2. Specific Investigations like Heat test, Test cavity, Percussion, palpation, mobility test, biting on gauze, L.A, etc. 3. Radiology like IOPA, OPG, etc. Differential Diagnosis Specific Investigations Final Diagnosis

Treatment options

Treatment Plan

Treatment