DEPARTMENT OF
PERIODONTOLOGY
CASE HISTORY
OPD NO………………………………………………………………..DATE…………….
NAME…………………………………………………………………..AGE/SEX…..........
ADDRESS..................................................................................................................
PHONE NO…………………………… OCCUPATION………………………………….
NAME OF TRAINEE………………………..………………………………………………
1. CHIEF COMPLAINT:
2. HISTORY OF PRESENT ILLNESS :
3. PAST DENTAL HISTORY:--
4. MEDICAL HISTORY:
5. FAMILY HISTORY:
6.ALLERGY / DRUG ALLERGY :
7.HABITS:
8.ORAL HYGIENE MEASURES:
CLINICAL EXAMINATION
1).EXTRA ORAL EXAMINATION:
a)TMJ:
B) Lymph Nodes:
c)Facial Symmetry:
d)Lip Seal:
e)Halitosis :
2). INTRA ORAL EXAMINATION:
I. SOFT TISSUES
a)Mouth breathing:
b)Tongue thrusting:
c)Lip Mucosa :
d)Buccal/Labial Mucosa :
e)Palatal Mucosa :
f)Floor Of Mouth :
g)Vestibule :
h)Tongue :
i)Any other :
j)Frenum Attachment:
k)Tension Test :
II.HARD TISSUE:
a)Caries:
b)Pulpal problem:
c)Non-vital teeth:
d)Crowding:
e)Stains:
f)Developmental abnormality :
g)No. of missing teeth :
5. GINGIVAL STATUS :
MAXILLARY ARCH RIGHT ANTERIOR LEFT POSTERIOR
POSTERIOR
COLOR
CONTOUR
CONSISTENCY
STIPPLING
SIZE
POSITION
EXUDATION
BLEEDING ON
PROBING
SPONTANEOUS
BLEEDING
PIGMENTATION
ENLARGEMENT
MANDIBULAR RIGHT ANTERIOR LEFT POSTERIOR
ARCH POSTERIOR
COLOR
CONTOUR
CONSISTENCY
STIPPLING
SIZE
POSITION
EXUDATION
BLEEDING ON
PROBING
SPONTANEOUS
BLEEDING
PIGMENTATION
ENLARGEMENT
EVALUATION OF ORAL HYGEINE STATUS
AT BASELINE
a) PLAQUE INDEX (P.I.)
{LOE.H & SILNESS. J}
D M D M D M
16 12 24
SCORE=
44 32 36
b) GINGIVAL INDEX (G.I.)
{LOE.H & SILNESS. J}
D M D M D M
16 12 24
SCORE=
44 32 36
AT 3 MONTHS
a) PLAQUEINDEX (P.I.)
{LOE.H & SILNESS. J}
D M D M D M
16 12 24
SCORE=
44 32 36
b) GINGIVAL INDEX (G.I.)
{LOE.H & SILNESS. J}
D M D M D M
16 12 24
SCORE=
AT 6 MONTHS
a) PLAQUE INDEX (P.I.)
{LOE.H & SILNESS. J}
D M D M D M
16 12 24
SCORE=
b) GINGIVAL INDEX (G.I.)
{LOE.H & SILNESS. J}
D M D M D M
16 12 24
SCORE=
PERIODONTAL STATUS
Periodontal Studies (Pre-operative)
Mucogingival
Problems
Pathological Migration
Furcation involvement
Mobility
Loss of B
Attachment P
Pocket Depth P
B
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
Pocket Depth B
L
Loss of L
Attachment B
Mobility
Furcation involvement
Pathological Migration
7. OCCLUSAL ANALYSIS:
a) TRAUMA FROM OCCLUSION :
b) FOOD IMPACTION :
c) PLUNGER CUSP :
d) ANY OTHER :
8. INVESTIGATIONS :
a. RADIOGRAPHIC INVESTIGATION:
IOPA / OPG:
HORIZONTAL
BONE LOSS
VERTICAL
BONE LOSS
ENDODONTIC
TREATMENT
PERIAPICAL
PATHOLOGY
PDL SPACE
LAMINA
DURA
CROWN
ROOT RATIO
TOOTH NO. 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 2
8
TOOTH NO. 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 3
8
HORIZONTAL
BONE LOSS
VERTICAL
BONE LOSS
ENDODONTIC
TREATMENT
PERIAPICAL
PATHOLOGY
PDL SPACE
LAMINA
DURA
CROWN
ROOT RATIO
b. BLOOD INVESTIGATIONS :
c. BLOOD PRESSURE:
d. URINE EXAMINATION :
e. SPECIAL INVESTIGATIONS :
1. BIOPSY :
2. BACTERIAL SMEAR :
PHOTOGRAPHS / MODELS :
9. Diagnosis:-
10. Differential Diagnosis:-
11. Prognosis:-
a) Overall prognosis:-
b) Individual Tooth prognosis:-
12. TREATMENT PLAN:-
a) Emergency phase:
b)Phase –I :-
c) Phase-II :-
d) Phase-III :-
e) Phase-IV :-
13. CASE ANALYSIS :-
CONSENT: .
I CERTIFY THAT I HAVE READ AND UNDERSTOOD THE ABOVE. I ACKNOWLEDGE THAT MY
WUESTIONS , IF ANY ABOUT INQUIRIES SET FORTH ABOVE HAVE BEEN ANSWERED TO MY
SATISFACTION WILL NOT HOLD MY DENTIST OR ANY OTHER MEMBER OF HIS/ HER / STAFF ,
RESPONSIBLE FOR ANY ACTION THEY TAKE OR DO NOT TAKE BECAUSE OF ERRORS OR
OMISSIONS THAT I MAY HAVE MADE IN THE COMPLETION OF THE FORM..
………………………………………………………………………. ……………
SIGNATURE OF PATIENT/LEGAL GUARDIAN DATE
DATE TREATMENT DONE STAFF
SIGNATURE
