Jordan University of Science & Technology

Faculty of Dentistry Dental Teaching Center

Initial Examination Form

Name: Leen DOB: 16/7/1980 Gender: Female File number: 44728
Occupation: Secretary Marital status: married
Chief Complaint (C/C): Pain in the upper right quadrant after an old restoration has fallen.
History of C/C:

Relevant Medical History (MH):

Serious illness Yes No Details of MH:
Previous hospitalization/blood transfusion √
Hypertension
Diabetes mellitus √
Bleeding tendency
Cardio-respiratory diseases (MI) √
Gastro-intestinal diseases
Renal and urinary tract diseases
Psychiatric disorders
Allergies (strawberry, skin rash) √
Pregnancy
Others Dental History (state any complications): Last dental visit was 1 year ago
for routine dental care (scaling). Rarely brushes, no floss use.
Parafunctional habits: pen biting on anterior teeth, habitual cheek biting in right side
Tobacco use: 1. Smoking: No Quantity: Duration:
2. Nargileh: No
Extra-oral examination: Intra-oral examination:
General, eyes, nails, hair WNL Upper labial mucosa Frenal tag
Skin of Face and neck WNL Lower labial mucosa WNL
Facial symmetry, profile, lip Symmetrical, convex profile, lips Right buccal mucosa Keratosis (Morsicatio
competence competent buccarum)
TMJ Slight tenderness Left buccal mucosa WNL

Jaw movements WNL Hard palate WNL

Temporalis Slightly tender Soft palate/oropharynx WNL
Masseter Slightly tender Saliva WNL
Lymph nodes WNL Dorsal tongue White coat
Neck, thyroid gland WNL Lateral tongue WNL
Salivary glands WNL Ventral tongue WNL
Lip vermilion borders WNL Floor of mouth WNL
Gingivae Edema, recession
Alveolar mucosa WNL
Maxilla and Mandible WNL

Course Coordinator: Prof. Rima Safadi

 Jordan University of Science & Technology
Faculty of Dentistry Dental Teaching Center

Teeth: 1. Surface by surface examination, tenderness to percussion

Teeth: 2. General Examination:

Calculus in the lower anterior region, tooth surface loss in (11,41), cavity because of fallen restoration on 16
INVESTIGATIONS: (1. Pulp vitality: 16; slightly elevated in strength lasting 8 seconds, 35: negative response). TTP: 35: slight
tenderness to vertical percussion.
2. Radiographic findings: 2 Bitewings, 1 PA for 35
G = Gross, M = Mesial, O = Occlusal/Incisal, D = Distal, F = Facial, L= Lingual/Palatal, I = Incipient, RE = Recurrent, RO= Rarefying osteitis (abscess, cyst, granuloma), SO = Sclerosing
osteitis, H = Hypercementosis, E = Enostosis, X = External resorption, O = Other findings (see below).

M Re, M D M M
(Generalized horizontal bone 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Loss) 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
M D RO

Course Coordinator: Prof. Rima Safadi