Overall Layout of Case Presentation (CPD Review of Everything)

What this document is

A self-contained, reusable per-case template for the DMD3S1 Clinical Dental Practice (CDP) case portfolio. The sample presentations are essentially a direct cut-and-paste from the case portfolio — so the goal is to assemble a complete case portfolio first, then build the PowerPoint from it. Work top-to-bottom through one patient, then duplicate the whole template for the next case. Model layouts: Sample Portfolio 1 and Sample Portfolio 2 (both backlinked with their PDFs); formatting and assessment rules: Some Tips and Suggestions for Case Portfolio.

General treatment-planning sources: T1 Treatment Planning, T2 Treatment Planning, T3 exam and diagnostic steps_formatted, T4 Diagnostic, L6 Developing the Treatment Plan, Diagnosis and Treatment Planning in Dentistry TOC.

Canonical section sequence:

1. Presenting complaint + history of presenting complaint
2. Medical history (+ ASA)
3. Dental history
4. Oral hygiene
5. Social history + diet
6. Examination (extra-oral → intra-oral → occlusion → charting → periodontal → special tests → radiographs → tooth wear → prosthetic)
7. Problem list
8. Diagnoses
9. Prognosis (individual + overall)
10. Treatment options
11. Management plan (phased)
12. Treatment delivery (before & after)
13. References

Portfolio Assembly Guide

How to use this template

This is a reusable per-case template. Duplicate the whole block once for each case in your portfolio (the cohort standard is a two-case portfolio). Work through the numbered sections for one patient, then duplicate and repeat for the next. When every case is complete, assemble the cases in order, export to a single document, and cut/paste the finished content into PowerPoint for presentation. Two model submissions are available to benchmark against: Sample Portfolio 1 and Sample Portfolio 2. Submission rules and the assessment rubrics live in Instruction - CPE 011 and Comprehensive Exam 011.

Before you finalise, check every item below — these are the formatting and academic standards examiners assess against.

• Auto-numbered headings — Use Microsoft Word’s Headings and Styles function so sections number themselves as 1., 1.1, 1.1.1. Never type numbers by hand; let the style hierarchy do it so renumbering stays consistent across cases.
• Per-case headers/footers — Add a header or footer on every page identifying the specific patient. Use section breaks between cases so each case can carry its own header/footer.
• Uniform terminology — Pick one term and stay with it across all cases (e.g. always “caries”, never “decay”). Use formal classifications throughout, such as the Kennedy-Applegate Classification for partially dentate patients.
• Single PDF, under 25 MB — Submit the whole portfolio as one PDF. Compress it to keep the file size below 25 MB, and back up to OneDrive or cloud storage as you go.
• Image handling — Use the Tables function to lay out images in a grid. Crop, rotate, or flip every image to remove distracting elements (lips, retractors). Date every photograph and radiograph.
• Referencing — Vancouver, EndNote, per case — Use the Vancouver style, catalogued in EndNote for a consistent format. Place a reference list AFTER EACH CASE, not one combined list at the end of the portfolio (duplicated references across cases are expected and acceptable). Avoid casual or incomplete citations — never write things like “lectures Loh 2019”.
• Justify every decision — Back every treatment decision with academic sources (journals and textbooks). Examiners hold high expectations of your theoretical knowledge regardless of how far the clinical case progressed; where information is missing, prepare a justification for its absence.

Sources: Some Tips and Suggestions for Case Portfolio

Presenting Complaint

Record why the patient has presented, in their own words, alongside the baseline photographic record captured before any treatment.

Pre-treatment photo set

Insert the baseline extra-oral (EO) and intra-oral (IO) photograph series here, laid out in a table. Crop/rotate to remove lips and retractors, and date each image. Suggested IO views: anterior in occlusion, upper occlusal, lower occlusal, right and left buccal segments; EO views: full-face (rest and smile), profile.

‹EO full-face›	‹EO smile›	‹EO profile›
‹IO anterior›	‹IO upper occlusal›	‹IO lower occlusal›
‹IO right buccal›	‹IO left buccal›	‹date all images›

• The patient’s chief complaint, verbatim: “‹patient’s exact words here›”
• Additional concerns in the patient’s own words (if any): ”‹…›”, ”‹…›”

Sources: Instruction - CPE 011, Sample Portfolio 1, Sample Portfolio 2

History of Presenting Complaint

Explore each complaint systematically. Use the SOCRATES framework for any pain or symptom so nothing is missed.

SOCRATES prompts

Work through each axis below for the presenting symptom. Not every axis applies to every complaint (e.g. an aesthetic concern has no “radiation”) — record those as N/A.

• Site — where is it? ‹tooth/region/quadrant›
• Onset — when did it start, and how (sudden / gradual)? ‹…›
• Character — what does it feel like (sharp, dull, throbbing, sensitivity)? ‹…›
• Radiation — does it spread anywhere? ‹yes/no — where›
• Associations — anything accompanying it (swelling, bleeding, bad taste, food impaction)? ‹…›
• Timing — constant or intermittent? Lingering or fleeting? ‹…›
• Exacerbating / relieving factors — what makes it worse or better (hot, cold, sweet, biting, analgesics)? ‹…›
• Severity — patient-rated intensity (e.g. /10) and impact on daily function/aesthetics: ‹…›
• Patient’s attitude and motivation for seeking treatment now: ‹…›

Sources: Instruction - CPE 011, Sample Portfolio 1, Sample Portfolio 2

Medical History

Document the patient’s full medical and medication history so treatment can be modified safely.

Review, update, sign every visit

A signature is not the same as comprehension — confirm the patient understands each question and verify unclear answers. Health changes over time, so the medical history must be reviewed, updated and re-signed by the patient at every visit.

Conditions	Medications
‹condition — relevance/control›	‹drug, dose, frequency — purpose›
‹…›	‹…›
‹…›	‹…›
‹…›	‹…›

Screen for the conditions and agents below (closed yes/no questions are efficient for medical history); flag any positive finding for its dental implications:

• Cardiovascular — hypertension, heart disease, valve replacement, pacemaker, rheumatic fever: ‹…›
• Bleeding / clotting disorders — von Willebrand, anticoagulants/antiplatelets, anaemia, excessive bruising or bleeding: ‹…›
• Endocrine — diabetes (control, last HbA1c, hypoglycaemia risk), thyroid disorder: ‹…›
• Neurological — epilepsy/seizures (last episode, control): ‹…›
• Respiratory — asthma, COPD, sleep apnoea: ‹…›
• Renal / hepatic — kidney or liver disease, hepatitis (drug-prescribing implications): ‹…›
• Bone-modifying agents — bisphosphonates or denosumab (MRONJ risk): ‹…›
• Cancer / radiotherapy — head and neck irradiation (osteoradionecrosis risk): ‹…›
• Psychological — anxiety, depression, dental phobia: ‹…›
• Infectious disease — TB, hepatitis, HIV: ‹…›
• Allergies — medications (esp. penicillin), latex, foods, materials — and the nature of each reaction: ‹…›
• Pregnancy / breastfeeding (if applicable), due date: ‹…›
• Past operations / hospitalisations and any complications: ‹…›

ASA Physical Status

Assign and record an American Society of Anesthesiologists (ASA) Physical Status to summarise overall systemic fitness for treatment.

ASA	Descriptor
I	Healthy patient, no systemic disease
II	Mild systemic disease, no functional limitation
III	Severe systemic disease, definite functional limitation, not incapacitating
IV	Severe systemic disease that is a constant threat to life
V	Moribund patient not expected to survive without the operation
VI	Declared brain-dead patient (organ donor)

• Assigned status: ‹select ASA I–VI›

Source — ASA Physical Status Classification

Hendrix JM, Garmon EH. American Society of Anesthesiologists Physical Status Classification System. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441940/. (Primary source: American Society of Anesthesiologists. ASA Physical Status Classification System. Schaumburg (IL): ASA House of Delegates; approved 1962, last amended 2020.) needs-source-link

Sources: L10 Medical and Drug History 2025_formatted_text, MOC Pharmacology, Instruction - CPE 011

Dental History

Capture the patient’s past dental experiences and attitudes — patients often recall useful detail not visible on examination.

Field	Patient response
Frequency of visits	‹regular / irregular — last visit›
Attitude to dental care	‹motivated / neglectful / anxious — describe›
Dental anxiety	‹none / mild / moderate / severe — triggers›
Local anaesthetic experience	‹previous LA — tolerated / problems›
Bleeding (gums / post-operative)	‹yes/no — detail›
Caries experience	‹low / moderate / high — history of restorations, extractions›
Periodontal history	‹prior gum treatment, scaling, surgery, tooth mobility/loss›
Existing prostheses	‹dentures / bridges / implants — type, age, satisfaction›

Sources: Instruction - CPE 011, Comprehensive Exam 011, L10 Medical and Drug History 2025_formatted_text

Oral Hygiene

Record the patient’s current home-care regimen as reported — this informs caries and periodontal risk.

Field	Patient response
Toothbrushing	‹frequency/day, manual or electric, technique›
Toothpaste	‹brand — fluoride ‹ppm› (standard 1450 ppm / high-fluoride 5000 ppm)›
Flossing	‹yes/no — frequency›
Interdental aids	‹interdental brushes / picks / floss — size, frequency›
Mouthwash	‹brand/type — fluoride, chlorhexidine, alcohol; frequency›

Sources: Instruction - CPE 011

Social History

Document social circumstances and lifestyle factors that influence oral health and treatment planning.

Field	Patient response
Marital status	‹…›
Children / dependents	‹number, ages›
Occupation	‹role — note any oral-health relevance, e.g. stress/bruxism, acid/sugar exposure›
Smoking	‹current / ex / never — product, quantity, duration; ‹pack-years››
Alcohol	‹type, amount per day/week, duration; ‹standard drinks/week››
Recreational drugs	‹substance, frequency; recent / >1 yr ago›

Diet History

Record dietary intake as reported by the patient. (Caries-risk and dietary analysis is completed in a later section — capture intake history only here.)

Field	Patient response
Water consumption	‹… L/day; fluoridated supply yes/no›
Soft drink consumption	‹type, amount, frequency›
Fruit juice consumption	‹type, amount, frequency›
Tea / coffee consumption	‹cups/day; added sugar yes/no›
Snacking frequency & timing	‹number of intakes/day; between-meal / bedtime exposures›

Sources: Instruction - CPE 011, L10 Medical and Drug History 2025_formatted_text

Examination

Document all clinical findings from the systematic patient examination here. Place the relevant clinical photographs in the subsection they belong to — full-face/profile/smile photos in Extra-Oral, the intra-oral photo set in Intra-Oral, and articulating-paper/excursion photos in Occlusion.

Extra-Oral Examination

Record the extra-oral findings working systematically from general appearance inward, supported by standardised photographs.

How to capture and work through it

• Take a standard photo set: full-face at rest, full-face smiling, and profile (natural head position, relaxed lips for rest views).
• Examine systematically from the outside in: general/facial appearance → symmetry → skeletal pattern → glands/nodes → muscles → TMJ → lips → smile analysis.
• Smile analysis is mini-esthetics — assess tooth display at rest and on smiling.

Item	Finding
General facial appearance	‹findings›
Facial symmetry (frontal)	‹within normal limits / asymmetric — location ‹…››
Skeletal pattern / profile	‹Convex (Class II) / Straight (Class I) / Concave (Class III)›
Vertical facial proportions	‹normal / long face / short face›
Thyroid gland	‹findings›
Lymph nodes (cervical chains)	‹findings›
Muscles of mastication (masseter, temporalis, pterygoids)	‹tenderness / hypertrophy / nil›
TMJ	‹clicks / crepitus / deviation / deflection›
TMJ range of motion	opening ‹mm› (normal 40–50), lateral ‹mm›, protrusive ‹mm›
Upper lip	‹findings›
Lower lip	‹findings›

Smile analysis (record against optimal displays):

Item	Optimal / reference	Finding
Maxillary incisor display at rest	usually 2–4 mm	‹mm›
Maxillary incisor display on smile	75–100% crown shown (slightly below gingival margin)	‹% / mm›
Gingival display on smile	≤ ~2–3 mm	‹mm — OK / excess›
Smile arc	consonant (lower-lip curve matches maxillary incisal contour)	‹consonant / non-consonant / flat / excessive›
Buccal corridor	M 15–24 mm, F 10–17 mm	‹OK / too little / too much›
Dental & facial midline	coincident (off-centre noticeable > ~3 mm)	‹coincident / deviated ‹mm››
Occlusal plane cant	level	‹level / canted ‹side››

Frontal (full-face) analysis

How to assess

Examine the patient from the frontal (full-face) view on both rest and smile photos in natural head position (relaxed face). Orient the patient with a vertical facial centreline drawn through the midpoint of the ears and nose, then evaluate symmetry, transverse and vertical proportions, and tooth display against the reference lines below.

Reference line / proportion	What to draw	Normal / ideal	Conclusion (‹finding›)
Midsagittal (facial centreline)	Vertical line through midpoint of ears and nose	Face roughly symmetric; right side often slightly larger than left (normal)	‹symmetric / asymmetric — location›
Interpupillary / transverse line	Horizontal line connecting the pupils	Level; canting suggests vertical asymmetry	‹level / canted›
Vertical facial thirds	Horizontal lines: hairline → glabella (bridge of nose) → subnasale (base of nose) → menton	Three thirds approximately equal; lower third usually slightly longer in modern populations	‹balanced / increased / decreased lower third›
Lower-third subdivision	Subnasale → mouth, and mouth → menton	Subnasale-to-mouth ≈ 1/3; mouth-to-menton ≈ 2/3	‹proportionate / disproportionate›
Facial fifths	Five equal vertical sections across face width	Each fifth ≈ equal; eye width = intercanthal distance; nose width ≈ intercanthal distance (central fifth); mouth width = interpupillary distance; mandibular (gonial) width ≈ width across the eyes	‹equal / unequal fifths›

Symmetry thresholds (conclusions to state):

• Mandibular / chin deviation: up to ~3 mm not readily noticed; ≥4 mm likely noticed and a potential problem. (Over 80% of noticeable facial asymmetry involves the mandible.)
• Dental midline deviation: maxillary dental midline off the facial midline becomes noticeable at ~3 mm (a deviation of 1–2 mm is not noticed).
• Buccal-corridor norms (transverse smile width): males 15–24 mm, females 10–17 mm. ‹OK / too little / too much›

Profile analysis

How to assess

Assess on a true-profile photo with the Frankfort horizontal levelled and the patient in natural head position. Soft-tissue contours reflect the underlying hard tissue, so the profile predicts jaw and tooth positions before any radiograph is taken.

Line / plane	Landmarks	Normal value / range	Conclusion (‹finding›)
Frankfort horizontal (FH)	Porion → orbitale	Reference plane (levelled)	‹reference›
3-line convexity method	Glabella/bridge of nose → subnasale (base of upper lip) → pogonion (chin)	Straight = Class I (ideal); convex = Class II; concave = Class III	‹straight / convex / concave›
Nasion perpendicular	True vertical through nasion to Point A and Point B	Point A ≈ +2 mm (range 0–4); Point B ≈ −2 mm (range −4 to 0); A–B difference should not exceed ~4 mm	‹jaw position — Class I / II / III›
Ricketts E-line	Pronasale (tip of nose) → soft-tissue pogonion	Upper lip ≈ −4 mm, lower lip ≈ −2 mm behind the line (lips ~2–4 mm behind in Caucasians)	‹retrusive / normal / protrusive lips›
Nasolabial angle	Columella–subnasale–upper lip (Cm-Sn-Ls)	~90–110°	‹incisor inclination / lip support›
Mandibular plane angle (clinical)	Mandibular plane vs true horizontal (FH)	~32°; >35° = steep, <25° = flat	‹steep / moderate / flat — vertical growth pattern›

Vertical pattern — long-face vs short-face

Vertical jaw relationship

Vertical disproportion shows in the middle/lower facial thirds and predicts the bite. Confirm clinically (mandibular-plane mirror-handle test) and on the lateral view.

Feature	Long face	Short face
Lower face height (LFH)	Increased	Decreased
Mandibular plane angle	Steep	Flat
Mandibular rotation	Downward–backward	Upward (forward)
Incisor / gingival display	Excess gingival display	Reduced incisor display
Bite tendency	Open-bite (skeletal open bite)	Deep-bite (skeletal deep bite)

Vertical pattern conclusion: ‹long face / normal / short face›

Cephalometric norms (confirmatory)

Role of the ceph

The lateral cephalogram is used to confirm and quantify the clinical soft-tissue findings — it does not replace them. Trace landmarks on a true lateral ceph, then compare angular/linear values against reference norms to give a dento-skeletal diagnosis.

Measurement	Caucasian norm	Interpretation
SNA	~81°	Maxilla A-P position relative to cranial base. ‹value› ‹normal / prognathic / retrognathic›
SNB	~78° (78.2°)	Mandible A-P position relative to cranial base. ‹value› ‹normal / prognathic / retrognathic›
ANB	~2–3° (2.8°)	Inter-jaw discrepancy: >4° → Class II, <0° → Class III. ‹value› ‹I / II / III›
MMPA / MP-SN	~32° (high-angle >35°, low-angle <25°)	Vertical skeletal pattern. ‹value› ‹high / average / low›
Interincisal angle (U1–L1)	~131°	Combined incisor inclination. ‹value› ‹increased / normal / decreased›
L1–NB	~25° / 4 mm	Lower incisor inclination and prominence. ‹value› ‹retroclined / normal / proclined›
U1 inclination (U1–NA / U1–SN)	U1–NA ~22° / 4 mm (U1–SN ~103°)	Upper incisor inclination relative to maxilla/cranial base. ‹value› ‹interpretation›
Wits appraisal	A–B perpendicular to occlusal plane (≈ 0 ± 1 mm)	Jaw discrepancy independent of cranial base. ‹value› ‹I / II / III›

Note: norms above are for Caucasians; reference standards vary by ethnicity (e.g. SNA ~84.7° and SNB ~79.2° in Black populations, ANB ~5.5°).

The HTML table below is the orthodontic facial-dimension checklist from Contemporary Orthodontics — work through each item and record findings against each during the clinical examination.

Table 6.5 — Checklist of Facial Dimensions to Evaluate During Clinical Examination

Frontal at Rest	Frontal Smile	Frontal Widths	Profile
To Midsagittal Plane Nasal tip Maxillary dental midline Mandibular dental midline Chin (midsymphysis) <strong>Vertical</strong> <ul> <li>Lip separation (lips relaxed)</li> <li>Lip vermilion display</li> <li>Maxillary incisor display (lips relaxed)</li> <li>Lower face height</li> <li>Philtrum length</li> <li>Commissure height</li> <li>Chin height</li> </ul> </td> <td> <ul> <li>Maxillary incisor display</li> <li>Maxillary incisor crown height</li> <li>Gingival display</li> <li>Smile arc</li> <li>Occlusal plane cant?</li> </ul> </td> <td> <ul> <li>Alar base</li> <li>Nasal tip</li> <li>Buccal corridor</li> </ul> </td> <td> <strong>Lower Face</strong> <ul> <li>Maxillary projection</li> <li>Mandibular projection</li> <li>Chin projection</li> <li>Lower face height</li> </ul> <strong>Nose</strong> <ul> <li>Nasal radix</li> <li>Nasal dorsum contour</li> <li>Nasal tip projection</li> <li>Nasolabial angle</li> </ul> <strong>Lip</strong> <ul> <li>Lip fullness</li> <li>Labiomental sulcus</li> </ul> <strong>Throat Form</strong> <ul> <li>Chin–throat angle</li> <li>Throat length</li> <li>Submental contour (fat pad)</li> </ul> </td> </tr>

Source — Orthodontic diagnosis & smile analysis

Fields HW, Larson BE, Sarver DM, Proffit WR. Contemporary Orthodontics. 7th ed. St. Louis (MO): Elsevier; 2025. Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: part 1. Evolution of the concept and dynamic records for smile capture. Am J Orthod Dentofacial Orthop. 2003;124(1):4-12. needs-source-link

Sources: L2 Facial Form Analysis, Level II Unit B Summary, L4 Level II Unit B, R1 Cephalometric Tracing, Contemporary Orthodontics (sixth edition) TOC, Instruction - CPE 011

Intra-Oral Examination

Record intra-oral findings soft-tissue-first, in a systematic order, before moving to the dentition (charted in a later section).

How to work through it

• Examine in a consistent order so nothing is missed: labial mucosa → buccal mucosa → sulci → frena → palate → oropharynx → ridges → tongue → floor of mouth → saliva → gingivae → OH status.
• Capture the standard intra-oral photo set (frontal in occlusion, left & right buccal, maxillary & mandibular occlusal mirror views) — insert here: ‹IO photo set›.

Site / item	Finding
Labial mucosa	‹findings›
Buccal mucosa	‹findings›
Sulci (buccal/labial vestibules)	‹findings›
Frena	‹findings — classify per Kotlow below›
Hard palate	‹findings›
Soft palate	‹findings›
Oropharynx / tonsils	‹findings›
Alveolar ridges	‹findings›
Tongue	‹findings›
Floor of mouth	‹findings›
Saliva (pooling / quality)	‹findings — detailed saliva testing in Special Tests›
Gingival tissues	‹colour / contour / consistency / biotype›
OH status	‹findings — plaque/calculus distribution›

Kotlow classification — maxillary labial frenum attachment (apply to the frenum row above):

Class	Attachment level	Description
Class I	Mucosal	Frenum fibres attach to the mucogingival junction
Class II	Gingival	Frenum fibres attach within the attached gingiva
Class III	Papillary	Frenum fibres extend into the interdental papilla
Class IV	Papilla-penetrating	Frenum fibres penetrate through the papilla into the anterior palatine papilla

#needs-source-link — Kotlow classes presented from the standard maxillary labial frenum classification; confirm exact wording against a cited source before finalising.

Sources: Instruction - CPE 011, Sample Portfolio 2

Mucosal Lesion Description

Any mucosal lesion or swelling found on examination is described systematically here, using a standardised framework, before forming a differential. A structured description ensures accurate communication (especially when photographs are unavailable) and prevents vague descriptions that could lead to a missed diagnosis.

CLOTHS

Letter	Captures	Finding
C — Colour	Red; white; speckled; pigmented	‹colour›
L — Location	Lesion in relation to anatomical site + landmarks	‹site / relation to landmarks›
O — Outline	Well demarcated; diffuse	‹outline›
T — Texture	Ulcerated; indurated; granular; smooth; flat; raised; verrucous	‹texture›
H — History	Onset; duration; symptoms; any change	‹onset / duration / symptoms / change›
S — Size	Length × Width × Depth (mm)	‹L × W × D mm›

Supplementary descriptors (complete the description before moving to the differential):

Feature	Options	Finding
Consistency / palpation	Soft; firm; hard; indurated; fluctuant	‹consistency›
Base	Sessile (broad base) vs pedunculated (stalk)	‹base›
Mobility	Fixed (tethered) vs mobile	‹mobility›
Number	Single vs multiple	‹number›
Surrounding tissue	e.g. normal; erythematous; inflamed	‹surrounding tissue›
Regional lymph nodes	Palpable / enlarged (>1 cm suspicious) vs impalpable	‹lymph node status›
Tenderness	Tender vs non-tender	‹tenderness›

Descriptor glossary

Term	Definition
Macule	Circumscribed discoloured flat lesion not raised above the surrounding mucosa
Papule	Circumscribed elevated solid lesion <5 mm in diameter
Nodule	Circumscribed elevated solid lesion >5 mm in diameter
Plaque	Slightly elevated area of mucosa with a flat surface
Vesicle	Fluid-filled elevated lesion <5 mm in diameter
Bulla	Fluid-filled elevated lesion >5 mm in diameter
Ulcer	Break in continuity of the mucosa due to full-thickness loss of epithelium, exposing underlying connective tissue, usually coated by a white/yellow membrane
Erosion	Partial loss of the surface epithelium not extending through the full thickness
Sessile	Exophytic lesion attached to the underlying tissue by a broad base
Pedunculated	Exophytic lesion attached to the underlying tissue by a stalk
Indurated	Hardening of soft tissue, usually due to chronic inflammation or malignancy
Fluctuant	A “waterbed” sensation indicating fluid content (e.g. abscess, mucocele)
Exophytic	A lesion that grows outwards from the surface epithelium
Endophytic	A lesion that grows inwards into the underlying tissue

Red flags

Refer urgently to an oral medicine specialist if any of the following are present:

• Oral ulcer persisting >2–3 weeks (or recurrent / non-healing)
• Red, white, or mixed red-and-white lesion of unknown origin, especially with induration, ulceration with rolled margins, or fixation to underlying tissue
• Lesion in a high-risk site — lateral / ventral tongue, floor of mouth, soft palate
• Facial or oral paraesthesia / numbness with no clear cause
• Lumps or swellings, including lymphadenopathy
• Persistent mucosal discomfort with no obvious cause

Sources: 3. Soft Tissue Examination, L4 OPMDs

Occlusion

Record both the static occlusal relationship (in MIP) and the dynamic contacts (in excursions), noting articulating-paper marks and the guidance scheme.

How to record it (from L5)

• Static: mark contacts in maximum intercuspation (MIP); note posterior support and articulating-paper marks.
• Dynamic: guide the patient through protrusive and left/right lateral excursions; identify the guidance scheme (canine guidance vs group function) and any interferences.
• Interferences: centric (premature contact on closure), working/non-working (non-working are particularly destructive), and protrusive (premature posterior contacts on forward movement).

Static occlusal measures:

Measure	Finding
Incisor relationship	‹Class I / II div 1 / II div 2 / III›
Overjet	‹mm›
Overbite	‹% / mm›
Anterior crossbite	‹present (teeth) / nil›
Posterior crossbite	‹present — unilateral/bilateral / nil›
Anterior open bite	‹present (teeth) / nil›
Posterior open bite	‹present / nil›
Molar relationship (Angle)	‹Class I / II div 1 / II div 2 / III›
Canine relationship	‹Class I / II / III›
Skeletal class	‹I / II / III›
Dental midlines (upper/lower)	‹coincident / deviated ‹mm››
Facial midline relationship	‹coincident / deviated ‹mm››

Angle’s classification reference (molar/canine criteria):

Class	Molar relationship	Notes
Class I	MB cusp of maxillary 1st molar occludes in the buccal groove of mandibular 1st molar	Normal A-P molar relationship; malocclusion may still exist (crowding, etc.)
Class II div 1	Mandibular 1st molar distal to Class I (maxillary MB cusp anterior to buccal groove)	Proclined maxillary incisors, increased overjet
Class II div 2	Same molar relationship as div 1	Retroclined maxillary central incisors, deep overbite
Class III	Mandibular 1st molar mesial to Class I	Edge-to-edge or reverse overjet; anterior crossbite common

Canine (Angle): Class I = maxillary canine occludes between mandibular canine and 1st premolar; Class II = maxillary canine mesial to this; Class III = maxillary canine distal to this.

Dynamic occlusion:

Movement	Finding
Protrusive guidance	‹anterior guidance / posterior contacts›
Lateral guidance scheme	‹canine guidance / group function› ‹…›
Working-side contacts	‹…›
Non-working-side contacts	‹present / nil›
Interferences (centric / working / non-working / protrusive)	‹present ‹where› / nil›

Source — Occlusal examination & TMD

Okeson JP. Clinical Management of Temporomandibular Disorders and Occlusion. 9th ed. St. Louis (MO): Elsevier; 2026. needs-source-link

Sources: L5 Clinical Examination of Occlusion, Level II Unit B Summary, MOC Occlusion, Sample Portfolio 1

Tooth Charting / Odontogram

Record the status of every tooth and surface to build the baseline dental picture that feeds the Problem List, Prognosis grid, and treatment plan.

Chart each quadrant in an odontogram (e.g. an Excel or Titanium chart). For every tooth record: existing restorations (material + surfaces), missing teeth, caries (with ICDAS code), non-carious tooth surface loss/wear, and any provisional per-tooth prognosis. The full prognosis grid (periodontal / restorative / endodontic / occlusal dimensions) lives in the later Prognosis section — here just flag teeth as questionable for follow-up there.

ICDAS caries classification (codes 0–6) — score the most advanced lesion per surface after 5 s air-drying:

Code	Classification	Visual / clinical change
0	Sound	No change in translucency after 5 s air drying.
1	Initial (first visual)	No change when wet; opacity/discolouration visible only after air drying.
2	Initial (distinct)	Opacity or brown discolouration visible when wet; wider than the pit/fissure.
3	Moderate (breakdown)	Localised enamel breakdown; no visible dentine; loss of surface integrity.
4	Moderate (shadow)	Dark shadow (grey, blue or brown) from the underlying dentine, with/without enamel breakdown.
5	Extensive (cavity)	Distinct cavity with visible dentine; cavitation involving < half a surface.
6	Extensive (deep)	Extensive deep/wide cavity; dentine clearly visible on walls and base (≥ half surface).

• Also note lesion activity (active = matt/opaque, rough, plaque-stagnation site; inactive = shiny, hard, smooth) — this drives the caries-risk synthesis below.

Charting / restoration legend (mirrors the case-portfolio colour key — adapt to your odontogram software):

Finding	Suggested colour code	Example fill-in
Caries	Dark brown / orange	‹tooth/surface: ICDAS code›
Root stump	Black	‹tooth›
Unsatisfactory restoration (with caries)	Maroon	‹tooth/surface›
Unsatisfactory restoration (other reason)	Red / green	‹tooth/surface›
Non-carious tooth surface loss (NCCTSL) / tooth wear	Pink	‹tooth/surface›
Sound restoration	Yellow (composite/GIC), grey (amalgam)	‹tooth/surface: material›
Missing tooth	—	‹tooth›

NCCTSL / tooth wear

Record erosion, attrition, abrasion and abfraction here, then score severity formally in the Tooth Wear (BEWE) subsection below. Note occlusal trauma / excessive occlusal force (parafunction, heavy contacts, non-working interferences) as a contributing aetiology to capture for the wear and prognosis assessments.

Source — ICDAS

Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, et al. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol. 2007;35(3):170-8. needs-source-link

Sources: ICDAS, Sample Portfolio 1

Periodontal Assessment

Screen the whole mouth, then chart and diagnose any disease, so the periodontal status can be staged, graded, and slotted into the step-wise treatment plan.

Workflow

Start with the PSR (one code per sextant, worst site recorded with a WHO probe). If any sextant scores 3 in two or more sextants, or any sextant scores 4 or *, proceed to a full 6-point periodontal chart. A single isolated code 3 → chart that sextant only.

PSR codes (worst finding per sextant):

Code	Finding
0	No bleeding or calculus; black band fully visible.
1	Bleeding on probing; black band fully visible; no calculus.
2	Calculus or defective restoration margin; black band fully visible.
3	Black band partially visible (probing depth 3.5–5.5 mm).
4	Black band disappears (probing depth > 5.5 mm).
*	Added to any code for furcation involvement, mobility, mucogingival problem, or recession extending beyond the black band (> 3.5 mm).
X	Edentulous sextant or < 2 teeth present.

Full 6-point chart — fields to record per tooth (6 sites: MB, B, DB, ML, L, DL):

• PPD (mm) ‹6 sites/tooth›
• Gingival margin / recession (mm) ‹›
• CAL (= PPD + recession) ‹›
• BOP % ‹___ %›
• Plaque % ‹___ %›
• Furcation (grade I–III) ‹tooth: grade›
• Mobility (grade I–III) ‹tooth: grade›
• Suppuration ‹sites›

Diagnosis

Apply the EFP clinical decision tree. First determine periodontal health (Chapple 2018: BoP < 10%, no PPD ≥ 4 mm on an intact or reduced periodontium) and, around any implants, peri-implant health (Berglundh 2018) — assess these regardless of periodontitis status. Confirm periodontitis (interdental CAL at ≥ 2 non-adjacent teeth, not from local causes), then assign extent (localised < 30% of teeth / generalised ≥ 30% / molar-incisor pattern), stage I–IV, and grade A/B/C.

Staging (I–IV) — severity (interdental CAL at worst site, radiographic bone loss, tooth loss) + complexity:

Stage	Interdental CAL	Radiographic bone loss	Tooth loss (periodontal)	Complexity highlights
I	1–2 mm	< 15% (coronal third)	None	Max PPD ≤ 4 mm; mostly horizontal bone loss.
II	3–4 mm	15–33% (coronal third)	None	Max PPD ≤ 5 mm; mostly horizontal bone loss.
III	≥ 5 mm	Mid-third of root or beyond	≤ 4 teeth	PPD ≥ 6 mm, vertical defects ≥ 3 mm, furcation II–III; moderate ridge defect.
IV	≥ 5 mm	Mid-third of root or beyond	≥ 5 teeth	Stage III complexity plus masticatory dysfunction, < 10 occluding pairs, bite collapse, drifting/flaring, severe ridge defect.

Grading (A/B/C) — use bone loss % ÷ patient age (no prior records) or 5-year progression (with records):

Grade	BL% ÷ age	Direct evidence (5-yr progression)	Risk-factor modifiers
A (slow)	< 0.25	No bone/CAL loss over 5 yr	Non-smoker; no diabetes.
B (moderate)	0.25–1.0	< 2 mm over 5 yr	Smoker < 10 cig/day; diabetic HbA1c < 7.0%.
C (rapid)	> 1.0	≥ 2 mm over 5 yr	Smoker ≥ 10 cig/day → grade C; diabetic HbA1c ≥ 7.0% → grade C.

• Diagnosis statement: ‹Extent› ‹Stage I–IV› ‹Grade A–C› periodontitis (modified by ‹smoking/diabetes›), plus periodontal/peri-implant health status.

Treatment

Follows the EFP S3 step-wise protocol via the OCHWA protocol: Step 1 — behaviour change, OHI, risk-factor control, supra-gingival biofilm/PMPR; Step 2 — subgingival instrumentation (± adjuncts); Step 3 — re-evaluate residual pockets, repeat/refer for surgical access where needed; Step 4 — supportive periodontal therapy (SPT) maintenance, with recall interval set by a Periodontal Risk Assessment (PRA).

Sources: Periodontal Screening and Records (PSR), EFP Periodontitis - Clinical decision tree for staging and grading, Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline, OCHWA DMD PERIO Treatment Protocl, MOC Periodontology, Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions, Peri‐implant diseases and conditions Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions, Periodontal Risk Assessment (PRA) for Patients in Supportive Periodontai Tiierapy (SPT)

Pulp Sensibility & Special Tests

Test pulpal and periapical status of symptomatic and suspect teeth to support a vitality/endodontic diagnosis. Always compare against a healthy adjacent or contralateral baseline tooth.

Test	Normal pulp	Reversible pulpitis	Irreversible pulpitis	Necrotic / non-vital
Cold (CO₂ / EndoFrost)	Responds, settles quickly	Responds; sensation lingers, sometimes heightened	Heightened and lingering response	No response
EPT (electric)	Responds within normal range	Responds	Responds (may be altered)	No response — confirms necrosis; useful in heavily restored/calcified teeth
Percussion	Not tender	Usually not tender	± tender if periapex involved	Tender if apical periodontitis present
Palpation (buccal/apical)	Normal	Normal	± tenderness	Tenderness/swelling if periapical pathology
Mobility	Physiological (grade 0)	Physiological	Physiological	May increase with periapical/perio involvement

• Heavily restored teeth may give a slow or absent cold response despite vitality — corroborate with EPT.
• Fill-in: ‹tooth: cold response | EPT | percussion | palpation | mobility› vs baseline tooth ‹tooth: response›.

Sources: T4 Diagnostic

Radiographs

Take the minimum number of films needed to answer the clinical question — justify each exposure, expose only when diagnostic yield outweighs dose, and report each film systematically (keep the written report succinct — ideally ≤ one page). Bitewings are the standard for interproximal caries and crestal bone; an OPG gives a low-dose (≈ two to three bitewings) overview but has poor spatial resolution (≈ 10 lp/mm vs ≈ 20 lp/mm intraoral) and is not accurate for caries (gross lesions only); take periapicals when apical, endodontic, or root detail is needed.

Justification & quality

Justify each film

State a rationale / justification (ALARA) for every film — expose only when the clinical examination cannot supply the diagnostic information and the yield outweighs the dose. The OMFR teaching is justification + optimisation, not fixed recall intervals: set bitewing frequency by individual caries risk and OPG/periapical use by clinical need (e.g. pre-surgical assessment, referral). Where a numeric review interval is quoted, cite a current radiographic selection-criteria guideline (e.g. FGDP/SDCEP), not these lectures.

Assess film quality and positioning before interpreting — a non-diagnostic film can hide or mimic pathology. A good intraoral film shows clear molar cusps, distinct enamel and pulp chambers, open interproximal spaces, and non-overlapping contacts (contacts may overlap legitimately where teeth are crowded).

Error	Appearance	Acceptable? / retake
OPG — chin too high (Frankfort up)	Condyles cut off; flat occlusal plane or “reverse smile” (frown); blurred/magnified Mx incisors	‹acceptable? / retake›
OPG — chin too low (Frankfort down)	Exaggerated “smile” (joker line); condyles project high; blurred Mn incisors with short-appearing roots	‹acceptable? / retake›
OPG — patient too far forward (in front of focal trough)	Anterior teeth appear narrow; spine visible on film	‹acceptable? / retake›
OPG — patient too far back (behind focal trough)	Anterior teeth magnified/widened; ramus not fully captured	‹acceptable? / retake›
OPG — head rotation (off midsagittal)	Asymmetric magnification of rami/posterior teeth; side farthest from receptor enlarged, nearest reduced; contact overlap	‹acceptable? / retake›
OPG — head tilt	Facial asymmetry — one side projected more inferiorly	‹acceptable? / retake›
OPG — tongue not to palate	Palatoglossal air shadow superimposed as a radiolucent band over the maxillary root apices	‹acceptable? / retake›
OPG — spine not straight / neck extension	Cervical spine ghost as linear radiopacity in the midline	‹acceptable? / retake›
OPG — swallowing	Soft palate lifted to nasopharynx; hyoid elevated	‹acceptable? / retake›
OPG — ghost shadows	Mirror of a real object (ramus, hyoid, spine, earrings) projected to the opposite side, higher and blurred/magnified	‹acceptable? / retake›
OPG — foreign objects	Radiopaque artefacts (earrings, necklace, denture in situ, lead apron)	‹acceptable? / retake›
BW — horizontal overlap	Overlapping interproximal contacts hide approximal surfaces	‹acceptable? / retake›
BW — cone-cut	Unexposed (clear) edge where the beam missed the receptor	‹acceptable? / retake›
BW — elongation / foreshortening	Teeth appear too long / too short from vertical angulation error	‹acceptable? / retake›

Systematic OPG report

Work through the taught 6-step zonal sequence — a checklist ensures every area is reviewed even if not all is written into the final (ideally one-page) report:

1. Technical errors / artefacts — positioning faults, ghost/double images, foreign objects, focal-trough errors: ‹findings›
2. Primary clinical concern — address the presenting site/question first (e.g., site of pain): ‹findings›
3. Dentoalveolar — count teeth (note missing/retained deciduous/ectopic/impacted), caries (gross only — confirm on BW/PA), periapical lesions, periodontal bone loss (generalised vs localised, horizontal vs vertical). For impacted third molars classify the angulation (Winter’s: mesioangular / distoangular / horizontal / vertical) and depth/ramus relationship: ‹findings›
4. Maxilla & mandible — abnormal radiolucencies/opacities, trabecular pattern (healthy = even “honeycomb”; altered ground-glass / empty spaces may indicate pathology), cortical borders, fractures/asymmetry: ‹findings›
5. Maxillary sinuses & TMJ/condyles — sinus floor and walls (thin, corticated), mucosal thickening; condyles for gross morphology, fracture, or asymmetry only: ‹findings›
6. Soft tissues & other — airway/pharynx, tonsilloliths, styloid process, cervical spine, soft-tissue calcifications: ‹findings›

Bitewing report

Bitewings best record the coronal third and early crestal bone changes (beam more perpendicular than a PA). Report every intraoral film (BW/PA) against the OMFR 6-point intraoral checklist: 1 periodontal · 2 restorations · 3 caries · 4 resorption · 5 periapical (periapicals only) · 6 other findings.

• Periodontal — crestal bone level — normal alveolar crest is 0.5–2 mm from the CEJ and appears radiopaque, smooth, horizontal. Pattern: horizontal vs vertical (angular); estimate % of root length lost (mild < 33%, moderate 33–66%, severe > 66%); distribution localised (< 30%) vs generalised (> 30%); plus calculus (interproximal radiopaque spurs), furcation (“inverted-J”), lamina dura, PDL space: ‹findings›
  • Caveat: radiographs underestimate bone loss versus probing and show only historical (past) destruction; an intact lamina dura suggests health but its absence does not confirm disease.
• Restorations — margins, overhangs, ledges, deficient margins, voids; identify material radiodensity (amalgam very radiopaque vs composite): ‹findings›
• Caries grading — for each lesion classify depth:
  • Confined to enamel (outer/inner enamel only): ‹findings›
  • Extending to the enamel–dentine junction (EDJ): ‹findings›
  • Extending into dentine: ‹findings›
  • Plus occlusal (radiolucency in fossa, no obvious enamel shadow), root/cervical, and secondary/recurrent caries adjacent to existing restorations: ‹findings›
• Resorption — external (blunted/shortened roots) vs internal (lucency within the canal): ‹findings›
• Periapical (periapicals only) — PDL widening, periapical radiolucency/radiopacity: ‹findings›
• Other findings — retained roots, foreign bodies, incidental radiopacities: ‹findings›

Abnormal-finding analysis (if a lesion is seen)

Five-step lesion analysis (White & Pharoah, Box 17-1)

1. Localise — anatomic position / epicentre; localised vs generalised; unilateral vs bilateral; single vs multifocal: ‹…›
2. Periphery & shape — well-defined (punched-out / corticated = thin white line / sclerotic = fuzzy dense border / soft-tissue capsule) vs ill-defined (blending / invasive); shape circular, scalloped, or irregular: ‹…›
3. Internal structure — totally radiolucent, totally radiopaque, or mixed (describe pattern; note denticles/amorphous masses): ‹…›
4. Effect on adjacent structures — root resorption / displacement, lamina dura (effacement), PDL space, mandibular canal / mental foramen, maxillary antrum, cortical borders, periosteal reaction, trabecular pattern: ‹…›
5. Interpretation / DDx — categorise with the OMFR image-analysis algorithm (normal vs abnormal → developmental vs acquired → cyst / benign neoplasm / malignant neoplasm / inflammatory / bone dysplasia / metabolic / vascular / trauma), then apply a surgical sieve (see the Diagnoses section) and list the differential ordered most → least likely: ‹…›

Films taken & findings

Films taken & findings:

• ‹OPG — date›: ‹findings›
• ‹Bitewings (R/L) — date›: ‹findings›
• ‹Periapicals ‹region› — date›: ‹findings›

Source — Radiographic interpretation

Mallya SM, Lam EWN, editors. White and Pharoah’s Oral Radiology: Principles and Interpretation. 8th ed. St. Louis (MO): Elsevier; 2019. needs-source-link

Sources: L6 Intraoral Radiograph Interpretation, L7 Intraoral Radiographic Interpretation Part 2, L8 Panoramic Radiography, L2 Intraoral Radiography, L2 Radiography in Periodontology, W4.1 Oral Radiography Workshop, MOC Radiography

Saliva, Plaque & Diet Analysis

Synthesise salivary, plaque, and dietary data into an objective caries and erosion risk picture that the Problem List and Prognosis sections draw on.

Saliva analysis — resting (unstimulated) and stimulated parameters:

Parameter	Phase	Normal / healthy	At-risk band	Result
Hydration (time to droplet)	Resting	< 60 s	≥ 60 s (low flow)	‹___ s›
Viscosity / consistency	Resting	Clear, watery	Sticky / frothy	‹›
Resting pH	Resting	6.8–7.8	5.0–5.8 (acidic)	‹›
Stimulated quantity (5 min)	Stimulated	≥ 3.5 mL	< 3.5 mL (low)	‹___ mL›
Stimulated pH	Stimulated	6.8–7.8	< 6.8	‹›
Buffering capacity (0–12)	Stimulated	High (≥ 10)	Low (0–5)	‹___ /12›

Plaque score:

• Method ‹O'Leary plaque control record / other› → ‹___ %›
• Interpretation: ‹good < 10% | fair | poor›; use as OHI baseline and re-assess at review to demonstrate improvement.

Dietary analysis (references the Diet History collected earlier):

• Cariogenic risk: frequency and timing of fermentable carbohydrates / sugars — ‹frequency, snacking pattern, between-meal exposures›
• Erosive risk: frequency and timing of dietary/intrinsic acids — ‹acidic drinks, reflux, timing relative to brushing›

Caries-risk synthesis

Saliva, plaque, and diet findings feed the caries-risk assessment (CAMBRA) synthesised in the Problem List / Prognosis sections (disease indicators + risk factors + protective factors → overall low / moderate / high risk and recall interval).

Source — Caries risk assessment (CAMBRA)

Featherstone JDB, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10):703-7, 710-13. needs-source-link

Sources: T4 Diagnostic, Sample Portfolio 2

Tooth Wear (BEWE)

Score erosive/tooth wear objectively per sextant and convert the cumulative score into a risk level that guides monitoring and management.

BEWE scoring (per surface; record the most severely affected surface):

Score	Criteria
0	No erosive tooth wear.
1	Initial loss of surface texture.
2	Distinct defect; hard-tissue loss < 50% of the surface area (dentine often involved).
3	Hard-tissue loss ≥ 50% of the surface area (dentine often involved).

• Record the highest score per sextant (S1 17–14, S2 13–23, S3 24–27, S4 37–34, S5 33–43, S6 44–47), then sum the six scores. ‹S1›+‹S2›+‹S3›+‹S4›+‹S5›+‹S6› = ‹sum›

Cumulative-score risk levels & management (Bartlett 2008):

Risk level	Cumulative score	Management
None	≤ 2	Routine maintenance and observation; repeat ~3-yearly.
Low	3–8	Oral hygiene + dietary assessment and advice; routine maintenance; repeat ~2-yearly.
Medium	9–13	OH + dietary assessment/advice; identify and eliminate main aetiological factor(s); fluoride / surface-resistance strategies; avoid restorations where possible and monitor with casts/photos/silicone; repeat 6–12-monthly.
High	≥ 14	As medium, plus special care that may involve restorations, especially in severe progression; repeat 6–12-monthly.

Sources: Basic Erosive Wear Examination (BEWE) a new scoring system for scientific and clinical needs

Prosthetic Assessment

Evaluate any existing prostheses, classify the edentulous arches, and assess the biomechanical and biological factors that drive removable-prosthesis design and prognosis.

Existing-prosthesis evaluation

Criterion	Finding
Type & age	‹acrylic/CrCo F/P, upper/lower, age›
Stability	‹stable / rocks under function›
Retention	‹adequate / loses retention; adhesive use›
Support	‹tooth / mucosa / tooth-tissue borne›
Occlusion (centric, lateral, protrusive)	‹even contacts? interferences?›
Aesthetics	‹shade, set-up, midline, smile line›
Phonetics	‹speech with appliance›
Extension / border	‹under/over-extended, post-dam, flange›
Tissue health	‹denture stomatitis, ulceration, hyperplasia›
Patient satisfaction	‹comfort, function, appearance›

Be wary of the chronically dissatisfied patient

A patient presenting with multiple “unsatisfactory” dentures, or with neuroticism/hypercritical traits, is difficult to treat successfully. A clinician may judge a prosthesis satisfactory while the patient finds it unsuitable — patient perception drives true success. Old acrylic dentures frequently harbour candidiasis / denture stomatitis; relining with a soft-tissue conditioner plus antifungal restores tissue health before definitive impressions, because inflamed tissue changes contour as it heals.

Classification & support

Kennedy classification (the most posterior edentulous area determines the class; the lowest class number takes priority):

Class	Description
Class I	Bilateral distal-extension (free-end) edentulous areas
Class II	Unilateral distal-extension (free-end) edentulous area
Class III	Unilateral bounded edentulous area with teeth both anterior and posterior to it
Class IV	Single anterior edentulous area crossing the midline (no modifications permitted)

• Each additional edentulous area is a modification space, designated by number (extent is not counted) — e.g. Class II Modification 2.
• Applegate’s rules: classify after all planned extractions; teeth not being replaced (e.g. an absent, non-replaced third molar) are excluded; the most posterior edentulous area always determines the class; additional spaces are “modifications” counted by number; there is no modification in Class IV.
• Maxilla: ‹Kennedy class + modifications› — Mandible: ‹Kennedy class + modifications›

Support type — characterises how masticatory load reaches the foundation:

Support type	Load path	Prognosis / note	Select
Tooth-supported (tooth-borne)	All load to abutment periodontium; no occlusal load on ridge mucosa	Best prognosis — patients rarely report mucosal pain. All Kennedy Class III are this type	‹select›
Tooth-and-tissue-supported	Distal-extension cases. Cat A: load shared, greater share through teeth. Cat B: load transmitted mainly to mucosa	Free-end saddle compresses mucosa; needs rest distal-to-space design + altered cast	‹select›
Tissue-supported	All load to mucosa	Complete denture; ridge-borne only	‹select›

Biomechanical movement classification:

Type	Definition	Select
Intercalated	Bounded edentulous area limited by teeth; no free-end saddle	‹select›
Levered	Free-end (distal-extension) edentulous area acting as a lever arm	‹select›
Combined	Both a free-end saddle and an intercalated bounded modification — complex force distribution	‹select›

Never design a unilateral free-floating appliance

A framework replacing a single tooth must extend bilaterally across the arch. A unilateral design supports vertical biting but lacks stability against dislodging forces — sticky food can lift it, creating a swallowing / aspiration risk.

Abutment tooth evaluation

Assess the prognosis of every strategic abutment on periodontal, endodontic, and restorative grounds before committing to a design.

Tooth	Periodontal (mobility / furcation / attachment)	Endodontic	Ferrule	Rest-seat capability
‹tooth: …›	‹mobility grade, furcation, probing/attachment loss›	‹filled + no apical periodontitis? symptomatic to percussion? partially filled?›	‹360° / partial buccolingual / inadequate›	‹sound tooth / restoration ≥1 mm beneath seat / needs survey crown›

• Periodontal: angular/vertical bone loss and infra-bony defects carry a poor prognosis; teeth with Grade III mobility or furcation involvement requiring extraction are excluded from the classification (or classified present with a noted questionable prognosis). An RPD without a rest near the saddle overloads the abutment and causes vertical bone resorption beneath the saddle.
• Endodontic: a completely filled canal with no apical periodontitis and no symptoms to percussion/palpation is acceptable; signs of apical periodontitis, partial filling, or positive percussion indicate active infection. OCHWA guidance: if the RCT was not done in-house and the tooth will receive a crown or serve as an RPD abutment, retreatment is often offered as the first option to secure prognosis. Allow up to 1 year for bone formation before finalising; provide an interim denture meanwhile.
• Restorative / ferrule: a 360° ferrule is ideal; a partial (buccolingual) ferrule still indicates restorability. Rest seats in amalgam need ≥1 mm of material beneath the seat, with margins kept within the restoration to avoid secondary caries.

Edentulous ridge & soft-tissue assessment

• Resorption phase: Immediate (3–6 months) — rapid remodelling; definitive prosthesis contraindicated. Stabilisation (~12 months) — contours stabilise, though slow lifelong resorption continues.
• Ridge height: ‹high (AB=AC>BC) / normal (AB=AC=BC) / low (AB=AC<BC)›
• Ridge form: ‹knife-edge / flabby (flat anterior) / tori / exostoses / undercut›
• Denture-bearing area (reduces with resorption): dentate arch ≈ 45 cm² → edentulous maxilla ≈ 23 cm² → edentulous mandible ≈ 12 cm² — the mandible offers the least support; bases must extend to maximum landmarks (e.g. retromolar pads) to distribute load.
• Soft-tissue undercut (governs retainer choice): ‹measure depth› — <3 mm → infrabulge clasp (I-bar / T-bar), requiring ideally ≥3 mm of attached gingiva from the free gingival margin to the top of the undercut, crossing the gingival margin at 90°; >3 mm → suprabulge clasp to avoid tissue impingement.

Surveying & path of insertion

The 7-step survey/design sequence (done on study casts before mouth prep)

1. Preliminary visual assessment — occlusal view: Kennedy class, fulcrum line(s), candidate rest seats, indirect-retention need, problem teeth (tilted/conical molars).
2. Path of insertion — Roach/three-point or bisector technique; Applegate convenience tilt (lateral tilt balances undercuts between abutments; AP tilt sets guide planes with minimal tooth reduction).
3. Height of contour — mark survey lines (side of carbon marker) dividing retentive from non-retentive areas.
4. Rest position — control rotation: rest adjacent to a bounded space, but distal to / away from a free-end saddle to resist tissueward rotation.
5. Desired undercut — 0.25 mm gauge for CoCr; only the terminal third of the retentive arm engages.
6. Framework outline — rests, grid (≈⅔ of ridge), clasps, major/minor connectors.
7. Adjust guide planes / height of contour — simulate tooth modification on the cast; plan survey crowns where conservative recontouring cannot create adequate guide planes, undercut, or rest seats.

• Survey crowns indicated when tooth morphology cannot be modified conservatively (insufficient undercut, over-erupted molars exposing dentin, tilted abutments needing guide planes/rest seats built in).

Indirect retention & fulcrum (Kennedy I / II)

• Fulcrum line: axis of rotation connecting the most posterior rests on each side of the arch — ‹note teeth defining it›
• Indirect retainer placement: rests/components positioned perpendicular to and far from the fulcrum line (on teeth anterior to it — canines/premolars) to resist lift-off of the distal-extension base when sticky food engages it — ‹indirect retainer location›
• Rotation control: place the rest mesial to the terminal abutment so occlusal load does not open the distal gap — ‹terminal abutment + rest position›

Complete denture / jaw relations (if applicable)

• Ridge assessment for CD: height, form, denture-bearing area, sulcus depth, frena, posterior palatal seal, palate shape, inter-ridge space and ridge relation — ‹findings›
• Retention–stability–support triad: ‹retention (seal/saliva) · stability (resistance to horizontal forces) · support (load-bearing area)›
• OVD = RVD − freeway space (~3 mm): record RVD (Willis gauge / extra-oral nose-to-chin reference), subtract freeway space — ‹OVD value›
• Centric relation record: leaf gauge (200 µm/leaf) for asymptomatic patients (anterior jig/splint if TMD); confirmative (MIP) vs reorganised — ‹CR record method›
• Closest speaking space: sibilant (“Mississippi”) check, ~2–3 mm between incisors, more consistent than freeway space — ‹phonetic check›
• Prior-denture critique: ‹OVD, stability, retention, extension, occlusion, aesthetics, phonetics›

Combination syndrome (Kelly's syndrome)

Occurs when a maxillary complete denture opposes a mandibular Kennedy Class I RPD or anterior natural teeth. The classic changes are: anterior maxillary bone loss, tuberosity hyperplasia (overgrowth), extrusion of the mandibular anterior teeth, and posterior mandibular ridge resorption beneath the RPD bases — with loss of prosthetic space complicating future rehabilitation. Prevent it by replacing the mandibular posterior teeth and achieving bilateral balanced occlusion.

Source — Fixed prosthodontics

Rosenstiel SF, Land MF, Walter R, editors. Contemporary Fixed Prosthodontics. 6th ed. St. Louis (MO): Elsevier; 2022. needs-source-link

Sources: McCracken’s Removable Partial Prosthodontics - E-Book Annotations, L2 Components and Classifications, L7 Survey and Design, L8 Mouth preparation for RPD, L9 Clinical Sequence, L1 Complete Dentures Overview, MOC Prosthodontics, MOC Dentures

Problem List

Synthesise every abnormal finding from the examination into a single prioritised list — this becomes the spine of your diagnoses, prognosis, and plan.

How to build it

• Work systematically through the examination (EO → IO soft tissue → perio chart → hard tissue/charting → occlusion → radiographs → risk assessment) and convert each finding into a discrete problem.
• Group problems by category so nothing is missed: patient-level/host, pathological (active disease), structural/morphological, functional/occlusal, aesthetic.
• Lead with the presenting complaint(s) — examiners want to see the patient’s own concern explicitly captured and tracked through to delivery.
• State a brief aetiology/contributing factor for each — it justifies your later management.

#	Problem	Category	Aetiology / Notes
1	‹presenting complaint, in patient’s words›	‹aesthetic / functional / pain›	‹driving factor for treatment›
2	‹high caries risk (CAMBRA)›	Patient-level / host	‹cariogenic diet, xerostomia, low fluoride, plaque score ‹…›%›
3	‹high periodontal risk›	Patient-level / host	‹smoking, OH, BoP ‹…›%, BL/age ratio ‹…››
4	‹relevant medical condition(s)›	Patient-level / host	‹systemic modifier — e.g. xerostomia, healing, bleeding›
5	‹active dental caries — teeth ‹…››	Pathological	‹frank cavitation / radiographic lesions›
6	‹periodontitis / gingivitis›	Pathological	‹stage ‹…› grade ‹…› extent ‹…››
7	‹pulpal / periapical pathology — teeth ‹…››	Pathological	‹necrosis, P/ap radiolucency, TTP+›
8	‹mucosal lesion ‹…››	Pathological	‹differential ‹…›; review interval›
9	‹tooth loss / root stumps / unrestorable teeth ‹…››	Structural / morphological	‹caries, fracture, NCTSL›
10	‹defective restorations — teeth ‹…››	Structural / morphological	‹recurrent caries, marginal breakdown›
11	‹tooth wear / NCTSL›	Structural / morphological	‹erosion, attrition, abrasion — identify aetiology›
12	‹occlusal problem / parafunction / TMD›	Functional / occlusal	‹loss of posterior support, OVD, bruxism›
13	‹partial edentulism — Kennedy class ‹…››	Functional / occlusal	‹arch(es) affected›
14	‹aesthetic concern ‹…››	Aesthetic	‹discolouration, smile arc, buccal corridors›

Sources: T2 Treatment Planning, L6 Developing the Treatment Plan, Sample Portfolio 1, Sample Portfolio 2

Diagnoses

State a definitive diagnosis (or justified differential) for each active problem, grouped by domain. Each diagnosis should map to one or more problems above.

Surgical sieve for differential diagnosis

For any lesion or swelling of uncertain cause, apply one surgical sieve consistently and work through every category — this ensures no diagnostic category is overlooked. Select a single sieve (such as VITAMINS CDE) and use it for every case rather than mixing frameworks.

Letter	Category	Oral example(s)
V	Vascular	Haemangioma, vascular malformations
I	Infective / Inflammatory	Odontogenic or non-odontogenic infection (e.g. tonsillitis)
T	Trauma	Mucocele, polyps
A	Autoimmune	Pemphigus vulgaris, mucous membrane pemphigoid
M	Metabolic	Hyperparathyroidism (associated with large mandibular tori)
I	Idiopathic / Iatrogenic	Thermal or chemical burns, lacerations, sodium hypochlorite extrusion causing necrotic ulceration
N	Neoplasia	Including oral potentially malignant disorders
S	Socio-cultural	Paan / betel-nut chewing → oral submucous fibrosis
C	Congenital	Exostoses
D	Degenerative / Drug-related	Gingival overgrowth from calcium channel blockers
E	Endocrine / Exocrine	Pleomorphic adenoma

Alternative mnemonic: ACTIVE MINDS — Autoimmune, Congenital, Trauma, Infection, Vascular, Endocrine, Metabolic, Inflammatory, Neoplasia, Degenerative / Drugs, Safety (Iatrogenic).

Source — surgical sieve & lesion description

Moore R, Dave M, Stocker J, et al. Simplifying differential diagnoses of orofacial conditions — a guide to surgical sieves and red flags. Br Dent J. 2021;230(5):289-293. Patel J, Tyers C, Sandhu P. Refer with CLOTHS. Br Dent J. 2020;228(3):137. needs-source-link

• Caries / restorative: ‹e.g. active dental caries (teeth ‹…›); unrestorable teeth / retained root stumps (‹…›); defective restorations (‹…›); NCTSL (‹…›)›
• Periodontal: ‹e.g. Periodontitis Stage ‹I–IV› Grade ‹A–C›, ‹localised / generalised / molar-incisor› extent — record current periodontal status and the staging/grading rationale from the perio section; or gingivitis on an intact/reduced periodontium›
• Endodontic: ‹e.g. symptomatic/asymptomatic irreversible pulpitis (‹…›); pulp necrosis with chronic/acute apical periodontitis (‹…›); previously treated, technically inadequate RCT with persistent apical periodontitis (‹…›)›
• Prosthodontic / edentulism: ‹e.g. partially dentate maxilla — Kennedy Class ‹…› Mod ‹…›; partially dentate mandible — Kennedy Class ‹…› Mod ‹…›; edentulous ‹arch›; unsatisfactory existing prosthesis›
• Occlusal / TMD: ‹e.g. loss of posterior support; ‹increased/decreased/acceptable› OVD; parafunction; TMD diagnosis ‹…›; skeletal/dental classification ‹…››
• Mucosal / pathological: ‹e.g. denture stomatitis; recurrent aphthous ulceration; ‹lesion› pending review/biopsy›
• Orthodontic: ‹e.g. malocclusion Class ‹…›; crowding/spacing; tilted/over-erupted teeth ‹…››

Sources: Sample Portfolio 1, Sample Portfolio 2, Some Tips and Suggestions for Case Portfolio

Prognosis

Individual Tooth Prognosis

Assign each tooth a relative prognostic value, then carry these into the treatment plan (which teeth to save, restore, or extract).

Use the Samet & Jotkowitz (2009) comprehensive approach

Each tooth is evaluated against four criteria — periodontal/alveolar support, restorability (remaining sound coronal tooth structure), endodontic condition, and occlusal plane/tooth position — plus two compromising factors (anatomic irregularities, iatrogenic factors). Three analysis steps:

1. Step 1 — score each tooth on all four criteria; the single most severe criterion determines the tooth’s class.
2. Step 2 — drop one class for anatomic and/or iatrogenic compromising factors (more than two such findings may drop it further).
3. Step 3 — drop one class for all teeth when considerable patient-level risk factors are present (reassessed over time; class can rise if modifiable factors improve).

Class	Prognosis	Brief criteria (worst of the four domains)
A	Good	80–100% bone support; 80–100% sound coronal structure; straightforward/sound endo; correct occlusal plane (≤ minimal enameloplasty). Minimal risk of loss.
B	Fair	50–80% bone support (maintainable, treatable defects/furcation); 50–80% sound structure (adequate ferrule, acceptable C:R); predictably retreatable or difficult primary endo; correctable occlusal position. Low risk of loss.
C	Questionable	30–50% bone support (cleansability difficult); 30–50% sound structure (ferrule compromises C:R/adjacent teeth); endo difficult to predictably retreat; needs multiple procedures for occlusal correction. Medium risk of loss.
D	Compromised	<30% bone support with active disease; <30% sound structure (no adequate ferrule); non-retreatable failing endo; severely malpositioned/reduced C:R. High risk of loss — external/patient factors decide approach.
X	Non-salvageable	Cannot be cleansed without acute outbreaks; no supragingival sound structure; vertical root fracture or repeatedly failed endo; un-restorable position. Indicated for extraction.

Tooth	Prognosis (A/B/C/D/X)	Key determining factors
‹17›	‹A–X›	‹worst domain + any anatomic/iatrogenic drop›
‹…›	‹…›	‹…›
‹…›	‹…›	‹…›
‹…›	‹…›	‹…›

Chart it

Record prognoses on the periodontal/hard-tissue chart with a colour/letter legend (e.g. Good / Fair / Questionable / Poor / Hopeless / Extraction), mirroring the sample portfolios, so the grid above and the charting agree.

Overall / Dentition Prognosis

Patient-level factors modify every tooth’s prognosis and set the realistic ceiling for the whole case.

• Biologic / medical: ‹immune/healing impairment, salivary flow, systemic disease, family history›
• Periodontal risk: ‹BoP%, residual disease, bone loss, smoking›
• Caries risk (CAMBRA): ‹diet, fluoride exposure, S. mutans/Lactobacillus, plaque›
• OH / compliance / behavioural: ‹motivation, attendance, ability to maintain, dental IQ›
• Parafunction / occlusal load: ‹bruxism, loss of posterior support›
• Financial / personal: ‹resources, willingness, aesthetic expectations — may drive extraction of an otherwise savable tooth›

Overall dentition prognosis: ‹favourable / guarded / poor›, because ‹integrate the worst individual prognoses with the modifying patient-level factors — state whether modifiable factors are being controlled›.

Sources: Classification and prognosis evaluation of individual teeth—A comprehensive approach, L7 Prognosis of Periodontally Involved Teeth, Periodontal Prognosis at OCHWA

Treatment Options

For each problem (or logical group of problems) present the realistic spectrum of options — always including no treatment — with balanced pros and cons, then document the shared decision.

How to present options

• Span the spectrum: preventive → restorative → prosthodontic → surgical, and always list no treatment / monitor as a genuine option with its consequences.
• For each option give: description, advantages, disadvantages, expected prognosis, and approximate cost/time.
• Record informed consent and shared decision-making: what the patient was told (risks, benefits, alternatives), their values/priorities, and that consent was obtained.
• Conclude each group with rejected options + reason and the selected option + rationale (mirror Sample Portfolio 1).

Problem / group: ‹e.g. management of unrestorable anterior teeth + tooth replacement›

Option	Description	Advantages	Disadvantages	Prognosis	Cost / time
A	‹e.g. extraction + immediate removable prosthesis›	‹aesthetics, disease reduction, lower cost›	‹resorption, relines, transition›	‹…›	‹…›
B	‹e.g. fixed / implant-supported replacement›	‹stability, function, bone preservation›	‹cost, surgical risk, time›	‹…›	‹…›
C	‹e.g. attempt to retain + restore›	‹tooth preservation›	‹questionable prognosis, recurrence›	‹…›	‹…›
D	No treatment / monitor	‹no intervention required now›	‹progression of pain/infection, further tooth loss, worsening aesthetics›	‹declining›	‹nil›

• Rejected option(s): ‹option ‹…›› — because ‹reason: cost, prognosis, patient refusal, biological compromise›.
• Selected option: ‹option ‹…›› — rationale: ‹aesthetics, disease control, cost, patient goals, predictability›.
• Informed consent: ‹risks/benefits/alternatives discussed; patient priorities; consent obtained ‹date›.›

Source — Evidence-based dentistry & informed consent

Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-2. Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-7. needs-source-link

Sources: Sample Portfolio 1, Sample Portfolio 2

Management Plan

Sequence the agreed care into the standard phases (Sturdevant / UWA GDP model). Boundaries are flexible — but disease control and the patient’s goals are always established first.

Sequencing logic

Move from stabilising the patient and halting disease, through re-evaluation, to definitive rehabilitation, and finally long-term maintenance. A procedure’s phase can shift with context (e.g. an extraction may be acute or definitive). Obtain/confirm informed consent before each definitive procedure.

Phase 1 — Systemic

• ‹Consult patient’s physician / specialist re: ‹condition››
• ‹Premedication (e.g. antibiotic prophylaxis) if indicated›
• ‹Stress / anxiety / fear management›
• ‹Modifications for systemic disease (bleeding, healing, drug interactions)›
• ‹Referrals: ‹…››

Phase 2 — Acute / Emergency

• ‹Manage pain — tooth ‹…››
• ‹Control acute infection / swelling›
• ‹Address the urgent component of the chief complaint where possible›
• ‹Provisional comfort / temporary aesthetics if needed›

Phase 3 — Disease Control (Stabilisation)

• Education / OHI: ‹brushing, interdental, denture hygiene; motivation›
• Periodontal (non-surgical): ‹supra/subgingival debridement, SRP, control of contributing factors — defective restorations, smoking cessation support›
• CAMBRA caries management: ‹fluoride (high-strength toothpaste/varnish), diet counselling, saliva measures, antibacterial regime per individual risk›
• Caries removal / provisional restorations: ‹determine restorability; temporise teeth ‹…››
• Extractions: ‹remove hopeless / Class X teeth ‹…›; provisional replacement if needed›
• Endodontics: ‹RCT for pulpal/periapical pathology — teeth ‹…››
• Holding phase — re-evaluation: ‹re-assess at ‹…› weeks: plaque/BoP, PPDs, caries activity, motivation; confirm prognoses before progressing›

Phase 4 — Definitive

• ‹Advanced/surgical periodontal therapy if required›
• ‹Stabilise occlusion / OVD; occlusal adjustment›
• ‹Orthodontics if indicated›
• ‹Definitive restorations — teeth ‹…› (incl. ETT — cuspal coverage)›
• ‹Definitive endodontic restorations / post-cores›
• ‹Prosthodontics — fixed / removable; implants ‹…››
• ‹Informed consent re-confirmed prior to each definitive procedure›

Phase 5 — Maintenance

• Recall interval: ‹e.g. 3 / 6 months, risk-based›
• Supportive periodontal therapy: ‹debridement, monitoring PPDs/BoP›
• Preventive regime: ‹fluoride, diet, OH reinforcement›
• Monitoring: ‹restorations, prostheses (relines), caries activity, mucosal lesions, prognosis reassessment›

Sources: T2 Treatment Planning, L6 Developing the Treatment Plan, OCHWA DMD PERIO Treatment Protocl, MOC GDP

Treatment Delivery

A chronological record of what was actually done — appointment by appointment — with clinical photographs and structured reviews.

What to capture

• Log each visit with date, procedure, and outcome; note any deviation from the plan and why.
• Include before / after clinical photographs (cropped to remove retractors/lips, dated) and laboratory phases where relevant.
• Document the standard review sequence: 24-hour, 1-week, 3–4 week (repeat as needed), and periodontal re-evaluation.
• Finish with a clinical reflection — link outcomes back to your planning and the evidence.

Date	Visit / Procedure	Notes / Outcome
‹date›	‹e.g. emergency — pain relief tooth ‹…››	‹…›
‹date›	‹OHI + debridement / SRP›	‹plaque ‹…›%, BoP ‹…›%›
‹date›	‹extractions ‹…› / immediate prosthesis›	‹…›
‹date›	‹caries management / restorations ‹…››	‹…›
‹date›	‹endodontics ‹…››	‹…›
‹date›	‹definitive restorative / prosthodontics›	‹shade ‹…›, try-in, delivery›
‹date›	‹24-hour review›	‹occlusion checked, post-op reinforced›
‹date›	‹1-week review›	‹healing, sore spots adjusted›
‹date›	‹3–4 week review›	‹reline / adjustment / satisfaction›
‹date›	‹periodontal re-evaluation›	‹PPDs, BoP, attachment levels›

Before treatment: ‹before clinical photograph(s)› After treatment: ‹after clinical photograph(s)›

Clinical reflection

‹Reflect: Did the outcome meet the patient’s chief complaint and your predicted prognosis? What worked, what would you do differently, and what does the evidence say about expected longevity/maintenance?›

Sources: Sample Portfolio 1, Sample Portfolio 2

References

Referencing standard

Use Vancouver style, managed in EndNote. Provide a reference list after each case (not one combined list at the end) — duplication across cases is acceptable and expected. Cite textbooks and journals, not lectures (avoid casual citations such as “lectures Loh 2019”). The flagged #needs-source-link sources embedded throughout this template (ASA, ICDAS, CAMBRA, Okeson, Rosenstiel, Contemporary Orthodontics, White & Pharoah, evidence-based dentistry / consent) are ready-formatted starting points to add to your library.

1. ‹reference›
2. ‹reference›
3. ‹reference›
4. ‹reference›
5. ‹reference›

Sources: Some Tips and Suggestions for Case Portfolio