Dental Student Case History Template
Sections in the order expected by most academic departments. The generator uses this exact structure; if your department requires a specific format, upload it as a template.
- 1General patient data
Age (not date of birth), gender, occupation/profession (omit organization name), date and time of admission, department, referral source/delivery method, referring facility diagnosis, admission diagnosis. Do not include full name, address, or document numbers: use "Patient N."
- 2Complaints
Chief complaints with details (localization, character, intensity, radiation, duration, triggers, and relieving factors) along with general symptoms; complaints upon admission and at the time of examination.
- 3History of the present illness (Anamnesis morbi)
Onset and progression, initial symptoms, clinical course, previous medical consultations, prior diagnostic tests and treatments before admission along with their efficacy, as well as the reason and circumstances of hospitalization.
- 4Past Medical History (Anamnesis vitae)
- Brief biographical data, living conditions, and dietary habits
Birthplace and upbringing, education, housing and living conditions, dietary habits, physical activity.
- Past medical history, surgeries, injuries
Childhood infections, chronic diseases, surgeries, trauma, tuberculosis, viral hepatitis, STIs, blood transfusions (with reactions).
- Bad habits
Smoking (duration, pack-years), alcohol (frequency, quantity), illicit drug use.
- Medication history
Regular medications taken by the patient (name, dose, frequency).
- Allergic history
Drug, food, and household allergen intolerance; type of reaction.
- Epidemiological history
Contact with infectious patients, travel outside the region/country over the past 6 months, parenteral interventions, bites, dietary history, contact with animals.
- Family history
First-degree relatives' medical history (CVD, diabetes mellitus, oncology, tuberculosis, psychiatric conditions).
- 5Dental Status
- General physical examination
Briefly: general condition, consciousness, body temperature, concomitant diseases.
- External examination of the maxillofacial region
Facial configuration and symmetry, skin and vermilion border of the lips, regional lymph nodes, temporomandibular joint (movements, clicking, pain), mouth opening.
- Inspection of the vestibule and oral cavity proper
Mucous membrane of the lips, cheeks, gingiva, palate, tongue, floor of the mouth; frenula and vestibule depth; excretory ducts of the salivary glands, saliva characteristics.
- Dental formula
WHO two-digit system (FDI) with designations: caries, filling, pulpitis, periodontitis, root, missing tooth, crown, artificial tooth, mobility (grade).
- Occlusion and condition of the dentition
Type of occlusion, dentition defects (Kennedy classification: for prosthetic dentistry), existing orthopedic appliances and their condition.
- Oral hygiene and periodontal status
Hygiene indices (Fedorov–Volodkina, Greene–Vermillion), DMFT, periodontal indices (PMA, CPITN), periodontal pockets, recession, bleeding.
- Local status (causative tooth or area)
Inspection, probing, percussion, palpation along the mucobuccal fold, thermal testing, pulp vitality testing (EPT), mobility; for surgery: lesion area, edema, fluctuation.
- 6Preliminary diagnosis and its rationale
Identify syndromes based on complaints, history, and objective data, justify each; formulate a preliminary diagnosis.
- 7Examination plan
Additional methods with the purpose of each: radiography (periapical, orthopantomography, CBCT), EPT, thermal testing, laboratory tests as indicated.
- 8Results of laboratory and instrumental studies
All available results with dates (in a table where appropriate) and interpretation: what is normal, what is abnormal, and what it means. Unperformed/missing studies should be listed as "no data".
- 9Differential diagnosis
At least 2–3 diseases with a similar presentation: for each, common features and differences used to rule it out (based on this patient's data).
- 10Clinical diagnosis and its rationale
Formulation according to ICD-10 (classes K00–K14) with code, if necessary according to the department's clinical classification; main diagnosis and concomitant dental diseases; rationale.
- 11Etiology and pathogenesis
Etiology and pathogenesis of the disease in general and applied to this patient (risk factors, mechanisms of syndrome development).
- 12Sanation and Treatment Plan
Sequence of stages: therapeutic, surgical, periodontal, orthopedic; anesthesia, materials and methods with rationale, hygiene recommendations.
- 13Treatment and its rationale
Completed treatment by stages: anesthesia, preparation/intervention, materials, drug prescriptions (INN, dose, frequency) with reference to clinical guidelines; Latin prescriptions for 1–2 drugs if prescribed.
- 14Visit Log
Date, complaints, objective data, performed manipulations, anesthesia, materials, prescriptions.
- 15Stage (discharge) epicrisis
Briefly: patient, age, date of admission, reason for admission, main examination results, clinical diagnosis, treatment performed and its effect, condition at the end of curation, recommendations.
- 16Prognosis and recommendations
Prognosis for the tooth and dentognathic system, hygiene recommendations, follow-up examination and dispensary observation schedule.
- 17References
formatted according to GOST R 7.0.100-2018.
How a Dental Case History Differs from Other Disciplines
The general part is shorter here than in internal medicine: complaints, anamnesis, and somatic status are written briefly, but without omissions. The main bulk consists of external examination, oral cavity inspection, dental formula, indices, additional methods, and radiographs. The focus depends on the department: in conservative (therapeutic) dentistry, it is caries, pulpitis, periodontitis, and periodontal disease; in oral surgery, status localis, anesthesia, and intervention protocol; in prosthodontics, occlusion, dentition defects, and selection of the construction.
What Departments Check Most Strictly
- Pre-intervention anamnesis. Tolerance to local anesthetics, allergies, use of anticoagulants and antiplatelet agents, diabetes mellitus, cardiovascular diseases. This determines the choice of anesthesia and pre-treatment or tooth extraction steps.
- External and oral cavity examination. Facial configuration, skin, regional lymph nodes, mouth opening, vermilion border of the lips, vestibule (depth, frenula), mucous membrane, gingiva, tongue, occlusion.
- Dental formula. WHO international two-digit system (FDI): the first digit indicates the quadrant (1–4 for permanent teeth, 5–8 for deciduous), the second indicates the tooth number from the midline. For example, 36 is the mandibular left first molar. Letter designations (C caries, P pulpitis, Pt periodontitis, F filling, R root, M missing, Cr crown) should be verified with the department guidelines.
- Indices. DMFT (sum of decayed, missing, and filled permanent teeth), Fedorov-Volodkina and Greene-Vermillion hygiene indices (OHI-S), PMA and CPITN periodontal indices. Always supplement the number with a conclusion: hygiene level or degree of gingival inflammation.
- Additional methods. Probing, percussion, thermal testing, EPT with results in µA, periapical radiograph or orthopantomogram with description: periodontal ligament space, destruction foci, root canal filling.
- Diagnosis. Tooth according to the formula, clinical form according to the classification adopted at the department, and ICD-10 code. In conservative dentistry in Russia, ICD-DA (International Classification of Diseases for Dentistry and Stomatology based on ICD-10) is often used, where categories are detailed with additional signs. Check with your department if it is required.
What to Add by Dental Specialty
Therapeutic: hygiene and periodontal indices, differential diagnosis based on thermal testing, EPT (electric pulp testing) and radiographs, oral rehabilitation plan and hygiene instruction. Surgical: type of anesthesia, drug and dosage, surgical procedure (tooth extraction, abscess incision), post-operative instructions. Orthopedic: type of bite, Kennedy classification of dental arch defect, tooth mobility, rationale for prosthesis selection. The general workflow is covered in the article on medical histories with neural networks.
Dental Case History Example: Chronic Apical Periodontitis
Excerpts from a model case history in conservative dentistry. The patient is fictional, and the data are for educational purposes.
Local Status (Excerpt)
Patient N., 34 years old, complains of discoloration of tooth 36 and food impaction in it. About a year ago, this tooth had severe spontaneous nocturnal pain, which subsided after a few days; the patient did not consult a physician. The face is symmetrical; submandibular lymph nodes are not enlarged, painless. Mouth opening is free. DMFT = 9 (D 2, F 6, M 1).
Tooth 36: on the occlusal and mesial surfaces, there is a deep carious cavity with softened pigmented dentin, communicating with the pulp chamber. Probing, including root canal orifices, is painless. No reaction to cold. Vertical percussion is slightly painful. The mucous membrane over the projections of the roots is unchanged, no fistulous tract. EPT of tooth 36: over 100 µA. Periapical radiograph: at the apex of the mesial root of 36, there is a round bone destruction focus with clear contours, about 3 mm in size; root canals are unfilled.
Justification of the diagnosis
No reaction to cold, painless probing, EPT over 100 µA: pulp is necrotic. The destruction focus at the root apex indicates periapical tissue involvement, and the absence of pronounced pain and mucosal changes indicates a chronic course. The focus is round with clear contours, which corresponds to the granulomatous form according to I. G. Lukomsky's classification. Differential diagnosis is made with chronic granulating periodontitis (blurred margins of the focus, often a fistula) and radicular cyst (definitively differentiated histologically).
Diagnosis: Chronic apical periodontitis of tooth 36 (chronic granulomatous periodontitis according to I. G. Lukomsky).
ICD-10 Code: K04.5 (Chronic apical periodontitis).
Concomitant: Dentin caries of tooth 46 (K02.1), chronic catarrhal gingivitis (K05.1).
If there were a fistulous tract over the root projection, the diagnosis and code would be different: periapical abscess with fistula is coded as K04.6. The code must match the formulation.
Treatment Plan
- Endodontic treatment of tooth 36 in multiple visits: rubber dam isolation, canal access, working length determination using an apex locator with radiographic control, mechanical preparation and irrigation with sodium hypochlorite solution, temporary root canal filling with calcium hydroxide preparation.
- Permanent root canal filling with gutta-percha and sealer, control radiograph.
- Crown restoration: considering the extent of destruction, prosthodontist consultation (inlay or crown).
- Sanation: caries treatment 46, professional oral hygiene, oral hygiene instruction.
- Long-term radiological follow-up to assess bone tissue regeneration.
Common mistakes in the dental case history
- Teeth are designated by name or using another system when the department requires the FDI two-digit system; the tooth number is inconsistent between the dental chart, status, and diagnosis.
- Indices are calculated without showing the formula or using the wrong teeth: for example, the Fedorov-Volodkina index calculated without using the six lower anterior teeth.
- Thermal test, percussion, and EPT are missing, although they are key to differentiating pulpitis from periodontitis.
- Radiograph is mentioned but not described: the state of the periodontal ligament space, the size and borders of the lesion are not specified.
- Diagnosis without tooth number and clinical form, clinical classification mixed with ICD-10, code does not match the wording.
- Surgical case history lacks the type of anesthesia, drug used, surgical procedure, and post-extraction instructions.
- Orthopedic case history lacks bite classification and Kennedy classification of the defect, and the appliance design is chosen without justification.
- Allergy and drug history not taken: tolerance to anesthetics, anticoagulant therapy.
- The identification section contains the patient's real full name, date of birth, or address instead of anonymized data.
Compile your dental case history
The patient can be simulated for a specific condition, or you can upload your own clinical notes (text, handwritten photos, audio). Cross-checked with clinical guidelines, ICD-10 coding, and export to Word and PDF. 2 case histories per month for free.
Frequently asked questions
How to write a dental case history?
Start with complaints, history of present illness, and brief somatic status, then describe general inspection and oral cavity examination, fill out the dental chart, and calculate indices. Next, provide data from additional diagnostic methods and radiographs, substantiate the diagnosis, assign the ICD-10 code, and outline the examination and treatment plan. Conclude with daily notes, epicrisis, and references, if required by the department.
How to maintain a dental patient's case history during a clinical rotation?
Record findings on the day of examination using the FDI tooth numbering system, index values, and EPT results, and describe radiographs immediately. Reflect what was done during each visit in the daily notes: treatment stage, medications, filling material, patient reaction. This way, you won't have to reconstruct data from memory for the final paper.
How do case histories in therapeutic, surgical, and orthopedic dentistry differ?
In therapeutic dentistry, the focus is on indices, differential diagnosis of caries, pulpitis, and periodontitis, and the sanation plan. In surgical dentistry, status localis, anesthesia, and the surgical procedure are described in more detail. In orthopedic dentistry, occlusion, Kennedy's classification of the dentition defect, and the rationale for the choice of appliance are determined.
How to record a dental chart in the case history?
According to the international FDI two-digit system: the first digit indicates the quadrant, the second the tooth number from the midline. Permanent teeth are numbered in quadrants 1–4, primary teeth in quadrants 5–8, for example, 36 is the lower left permanent first molar. Letter designations of the tooth condition adopted by the department are placed above or below the number.
Where to get a template or example of a dental case history?
A model example for chronic apical periodontitis is discussed above: local status, rationale, diagnosis with ICD-10 code, and treatment plan. The generator compiles a case history according to the dental outline, and if the department has its own outline, its template can be uploaded or borrowed from other students. Handing in someone else's finished case history is risky: during defense, you will be asked about your patient.
Can a dental case history be written using AI?
You can use AI to understand the structure and compile a draft, but you will defend the work yourself. The generator compiles a student dental case history according to the dental outline or your department's template based on clinical records (text, file, photo of handwritten notes, audio), assigns the ICD-10 code, and marks missing data as "not specified" rather than inventing a dental chart. Do not include the patient's real full name, date of birth, address, and insurance policy in the prompt: this violates medical confidentiality (Art. 13 of Federal Law No. 323-FZ) and personal data regulations (152-FZ). 2 case histories per month are available for free on any account, plus 5 more on the "Maximum" tier.
Case histories for other subjects
How the generator works and how to check its output: case history with AI. All tools: AI for medical professionals.