CHECKLIST FOR HISTORY AND EXAMINATION OF

A PARTIALLY DENTATE PATIENT

Before appointment - Read notes
for important information regarding:
previous treatment
latest treatment plan (see consultant
letter)
medical history

radiographs

Dental history ask about;

history of attendance (regular attender?)
previous dentures (type/ number/ how
often replaced?/ likes & dislikes/ previous
problems?)
other treatment (restorative/ periodontal/
other)

Also, tidy notes. Put day sheets in date

order, followed by medical history sheets.

Medical history
At appointment
Introduce yourself to patient
Check notes present & correct
Update contact details

All information must be recorded on MH

sheet (for future reference).
Record subsequent changes on a new
line with date (never alter previous entries!)
Keep medical history sheets together, at
end of day sheets for easy reference.

Who referred patient ?

Social history

- ask about:

Patient complaint record patients

smoking

own words, and ask questions about the

following to fill in the gaps:

family circumstances

alcohol consumption
occupation

appearance
function (speech & mastication)
comfort

Extra-oral examination
- include information about:
TMJ

History of present
complaint how
long has patient
experienced problems?

Lymph nodes

lips (& lip support ) (angular

cheilitis)
facial height

facial symmetry

mandibular deviation on
opening/closing

Handout available on CE6 in Prosthodontics and Occlusion Module, January 2009

Intra-oral examination
- SOFT TISSUES
(a) Mucosa (eg. tori/ Candida/ denture

Special investigations
(x-rays, mounted study casts, vitality
tests, blood tests, bacteriology)

trauma)

(b) Periodontium
(c) Saliva
- HARD TISSUES
(a) Teeth (do charting).

Record existing
Restorations/ their need for replacement,
as well as tooth prognosis. Also, include
caries, mobility/ wear/ vitality/ over-eruption/
drifting/ retained roots/ periapical lesions, etc

(b) Occlusion (stable ICP? Use RCP? FWS

Diagnosis List your findings

(this makes it easier to devise a
treatment plan). Include soft tissue,
hard tissue & denture problems:
1.
2.
3. etc

measurment? Observe occlusal plane)

(c) Bony ridges - Describe the following, and

.

any likely problems:

Shape (rounded/knife-edged/ undercuts)
Size (height/ width/ amount of resorption)
Consistency (firm or flabby?) (tender
areas?)

Aims of treatment Then

make a list of what you need to do to
manage these problems:
1.
2.
3. etc

Inter-alveolar space (sufficient for

denture?)
Skeletal classification (I, II or III)

Treatment options Outline

Dentures

- Describe upper and lower denture

separately, and include the following:
material (acrylic/ CoCr)

denture hygiene

appearance (eg tooth colour/ size/ position etc)

previous modifications, eg.repairs or relines

different ways of treating problems,

and discuss advantages and
disadvantages with patient. For
example; a missing tooth could be
replaced with a bridge/ denture OR
implant. An existing denture could
be modified OR a new one made etc.

retention (test by pulling denture away from

supporting tissues)
clasps (do they work?)
stability (test by pressing down on occlusal
surfaces of denture teeth)
support (is it sufficient ?)
PLUS..Draw design(s) for future reference !

Treatment plan List exactly

what you are going to do (in a logical
order, and in order of priority):
1.
2.
3. etc

Handout available on CE6 in Prosthodontics and Occlusion Module, January 2009