SR.

NO :
DATE :
CASE PAPER NO:
PATIENT NAME :
AGE :
SEX :
ADDRESS :

CLINICAL DAY 0 AT OBTURATION AT 3 AT 6 AT 9

FEATURES MONTHS MONTHS MONTHS
Pain on
percussion
Gingival
swelling or
sinus tract
Purulent
exudate from
gingival margin
Mobility of the
tooth
SUCCESS/
FAILURE

RADIOGRAPHI
C FEATURES
Pathologic
root resorption
Furcation
radiolucency
Periapical
radiolucency
Lamina dura
integrity
SUCCESS/
FAILURE
SR NO. TIME TAKEN
K – FILE PROTAPERS PROFILES
SR AT AT 3 MONTHS AT 6 MONTHS AT 9 MONTHS
NO. OBTURATION
CLINICAL RADIO- CLINICAL RADIOGRAPHIC CLINICAL RADIOGRAPHIC CLINICAL RADIOGRAPHIC
SUCCESS/ GRAPHIC SUCCESS/ SUCCESS/ SUCCESS/ SUCCESS/ SUCCESS/ SUCCESS/
FAILURE SUCCESS/ FAILURE FAILURE FAILURE FAILURE FAILURE FAILURE
FAILURE
 PROFORMA

YMT DENTAL COLLEGE AND HOSPITAL,

KHARGHAR NAVI MUMBAI

Year Month Date

Case paper Number:

Name:

Address:

Date of birth:
Year Month Date

Age in years:
Years Months

Sex (M/F):
 PREPROCEDURAL CLINICAL ASSESMENT
Tooth Type History Duration Pain on Mobi Vita Swellin- Ginigival Pururlent Any
No. of of pain of pain percuss -lity -lity g swelling exudate other
decay -ion or sinus from
tract gingival
margin

PREPROCEDURAL RADIOLOGICAL ASSESMENT

Tooth Periapical radiolucency Lamina dura Furcation
No. integrity radiolucency
 POST PULPECTOMY CLINICAL ASSESMENT
Date Tooth Pain Pain on Mobility Swelling Ginigival Pururlent Success/
No. percussion swelling or exudate Failure
sinus tract from
gingival
margin
Immediately
post
pulpectomy

At 3 months

At 6 months

At 9 months
 POST PULPECTOMY RADIOLOGICAL ASSESMENT
Date Tooth Periapical Lamina Furcation Pathologic Success/
No. radiolucency dura radiolucency root Failure
integrity resorption

Immediately
post
pulpectomy

At 3 months

At 6 months

At 9 months
TIME TAKEN FOR INSTRUMENTATION:

INSTRUMENT FRACTURE:

OBTURATION ASSESSMENT:

ROOT PERFORATION:
1. Form filling
2. Local anesthetic gel application
3. Local anesthesia
4. Rubber dam application
5. Preoperative picture
6. Access opening with airotor and burs (-----------------------)
7. Sodium hypochlorite irrigation
8. Enlarge upto 15 no K- file
9. Take working length xray
10. Start stop watch
11. Perform BMP with K or Profiles or Protapers with intermittent irrigation
12. Last rinse should be of saline
13. Stop the stopwatch after instrumentation
14. Seal with cotton and ZOE
15. Remove rubber dam
16. After 3 days – apply rubber dam
17. Remove dressing
18. Insert H files and barbed broaches 2 remove any remaining tissue with
intermittent irrigation of hypochlorite and saline.
19. Dry the canals with paper points
20. Obturate with ZOE.
21. Take xray
22. Seal with GIC.
23. Remove rubber dam
24. After 1 week select stainless steel crown, contour and crimp it
25. Cement crown with GIC.
26. Recall at 3,6 and 9 months – take iopa, pictures and fill forms.
Materials:
1. Green cloth
2. Tray
3. Waste receiver
4. Cotton holder
5. Syringes and needles
6. Mouth mirror
7. Probe
8. Explorer
9. Tweezer
10.Spoon excavator
11.Round condenser
12.Cement carrier
13.LA gel
14.LA with adrenaline
15.Rubber dam kit
16.Camera
17.Airotor
18.Burs(round , tapered, flame shaped, green lined burs-------------------------)
19.Sodium hypochlorite 3% (60-80ml)
20. K-files
21. Iopa
22. Film holders
23. Stop watch
24. Endodontic motor ( endomate)
25.Protaper
26.Profiles
27. Saline (150-200 ml)
28. Cotton
29. ZOE
30. H files
31. Barbed broaches
32. Paper points
33. Micromotor handpiece
34. Lentulo spirals
35.Reamers
36. Pluggers
37. Gic
38.Agate spatula
39.Vaseline
40.Stainless steel crown
41. Divider
42.Scale
43.Contouring plier
44.Crimping plier