How to Write a Dental Case Report

Dental case reports live or die on details general guides skip: which tooth, which classification, how the images were taken, and whether a smile identifies the patient.

Guide · 11 min read · Directive Publications Editorial Team

Why dental case reports need more than a generic template

A dental case report follows the same logic as any clinical case report: one patient, one clear lesson, documented consent, and a discussion that does not claim more than a single case can show. If you have not written a case report before, start with our guide to writing a medical case report with the CARE checklist, which covers the basic structure.

Dentistry then adds problems that general guides skip. The report is about a specific tooth or site, so notation errors make it unreadable. Diagnoses depend on classifications that have changed in the past decade. The evidence is mostly visual: radiographs, cone beam CT (CBCT) slices and intraoral photographs, each of which a reviewer will scrutinise. And the mouth itself can identify a patient in a way a chest X-ray rarely does.

This guide works through those dental-specific issues in the order you will meet them.

Choose the reporting guideline that fits your specialty

There is no single guideline for all of dentistry, so start by deciding which one applies.

PRICE 2020 (Preferred Reporting Items for Case reports in Endodontics) was published in the International Endodontic Journal in 2020. Its developers combined and modified items from CARE and the CLIP principles for clinical images, producing a 47-item checklist and a flowchart. Even if your case is periodontal or restorative rather than endodontic, the PRICE checklist is a useful model, because it spells out details that dental reviewers routinely ask for:

• The words "case report" in the title, plus the area of interest such as the anatomy, disease or treatment
• General intra-oral findings when relevant, such as carious lesions, restorations, periodontal condition and soft tissues
• Diagnostic tests and results for the specific tooth, for example pulp sensibility tests, tenderness, mobility and probing depths
• The diagnostic reasoning, including other diagnoses that were considered
• Any change to the planned treatment, and adverse or unexpected events
• A whole section on image quality, covered below

SCARE was updated in 2025 to add items on the use of AI in patient care and manuscript preparation. If your target journal names a guideline in its instructions, follow that one and upload the completed checklist if asked.

Name teeth, diagnoses and stages in standard terms

Tooth notation

State which notation system you use, once, early in the case description. The FDI two-digit system, standardised as ISO 3950, is widely used internationally; the Universal Numbering System is common in the United States. Mixing systems between the text and a figure legend, or writing "the lower left first molar" in one place and "36" in another without explanation, is a common source of reviewer queries. Many journals specify a system in their author instructions, so check before you write.

Diagnostic terminology

Use a recognised classification and name it, so the reader knows exactly what your label means.

• Endodontics. The American Association of Endodontists' consensus diagnostic terminology gives paired pulpal and apical diagnoses, such as symptomatic irreversible pulpitis with symptomatic apical periodontitis. Give both, and the test results that support them.
• Periodontics and implants. The 2017 classification of periodontal and peri-implant diseases, from the joint AAP and EFP World Workshop, introduced staging (I to IV, by severity and complexity of management) and grading (A to C, by rate of progression) for periodontitis. It also introduced the first classification of peri-implant diseases and conditions, including peri-implant mucositis and peri-implantitis. A case labelled "chronic periodontitis" signals that the authors are working from the older framework.
• Oral pathology. The 5th edition of the WHO Classification of Head and Neck Tumours (2022) revised the odontogenic and maxillofacial bone lesions, adding entities such as adenoid ameloblastoma. Name the edition you used for the diagnosis.
• Oral cancer. The AJCC 8th edition added depth of invasion to the T category for oral cavity cancer. If your case includes staging, state the system and edition and report the measurements that determine it.

If a case was diagnosed under an older system, give the original diagnosis and explain how it maps to the current one rather than silently relabelling it.

Document radiographs, CBCT and photographs to a standard

Images carry most of the evidence in a dental case report, and reviewers read them closely. PRICE 2020's image items are a sound checklist for any dental specialty. For each image, report:

1. How it was acquired. Equipment, software and settings, in the text or legend.
2. Why it was taken and why it is included. A CBCT scan needs a clinical justification, and the reader should see why each image earns its place.
3. How it was viewed and assessed. Who interpreted it and under what conditions.
4. Resolution, magnification and any adjustments. Brightness, contrast, colour balance or smoothing changes must be declared. Undeclared editing of clinical images is exactly what journal image screening looks for.
5. What it shows. An interpretation in the text, and arrows or labels defined in the legend.
6. Where it sits in time. Pre-treatment, intra-treatment or post-treatment, and how follow-up images were standardised.

That last point matters most for outcome claims. Healing of an apical lesion, bone fill after regeneration, or stability after orthodontic treatment is only convincing if the follow-up radiographs or photographs are comparable to the baseline: similar projection, similar angulation, similar framing. If they are not, say so and temper the claim.

Before exporting, remove identifiers. PRICE 2020 requires names and patient numbers to be removed from images. Check burned-in text on radiographs and screenshots, and remember that exported scan files can carry patient details in their file metadata. Export clean image formats from your viewer rather than uploading raw files.

Get consent that covers the mouth, not just the face

The ICMJE Recommendations say identifying information should not be published in descriptions or photographs unless it is essential and the patient, or a parent or guardian, gives written informed consent. They add that an identifiable patient should be shown the manuscript, should be told the material may be available online, and that masking the eye region is inadequate protection.

In dentistry, that last warning is the key one. A smile, a distinctive diastema, a rare anomaly, a gold crown or an unusual restoration can be recognisable to the patient's family, colleagues and other dentists, even with the rest of the face cropped out. Dental records are also used in forensic identification precisely because a dentition is so individual. Treat intraoral and smile photographs as potentially identifying, and get consent for them.

Practical points for dental cases:

• Name the images on the consent form. Consent for "clinical photographs" is weaker than consent that lists the extraoral, smile, intraoral and radiographic images you plan to publish.
• Children. Pediatric and orthodontic cases need consent from a parent or guardian; involving the child in the decision where they are old enough is good practice.
• Consent taken at the chair. A general consent for clinical photography, signed at a treatment visit, usually does not cover open-access publication. Use the journal's own form where one exists.
• De-identification. If you crop or alter images instead, confirm that the change does not distort the clinical meaning, as ICMJE asks.

Our post on patient consent for case reports and images covers consent forms, deceased patients and ethics approval in more detail.

Write the case: a seven-step workflow

1. Pick the guideline and the lesson. Decide whether CARE, PRICE 2020 or SCARE applies, and write one sentence stating what a dentist should learn from the case. If you cannot write it, the case may not be ready.
2. Secure consent for every image. Get written consent on the journal's form, covering the specific photographs and radiographs you plan to use.
3. Fix your notation and terminology. Choose the tooth numbering system and the classifications, and record them in a note you will check the final draft against.
4. Build the timeline. List history, findings, tests, treatment visits and follow-up records in chronological order, using time relative to presentation rather than calendar dates.
5. Write the case and image legends. Report findings and tests for the specific tooth or site, the treatment and any changes to the plan. Write each legend so it stands alone: what the image shows, when it was taken and what the labels mean.
6. Write the discussion and conclusion. Compare the case with published cases, state the limitations, including follow-up length and image standardisation, and finish with a short take-away. Avoid presenting a technique that worked once as a recommendation.
7. Run the pre-submission check. Use the checklist at the end of this post.

Materials, products and support

Dental case reports often name specific materials, instruments, implant systems or devices. Give enough detail for a reader to identify each product and follow the journal's style for manufacturer details. If a company supplied materials, instruments or equipment free or at a discount, declare it: PRICE 2020 counts the supply of instruments and equipment as support that must be acknowledged, alongside funding and any conflicts of interest.

Choose a dental case report journal that fits

The fit question is the same as for any case report, which our guide to choosing where to publish a case report covers in detail. For dental cases, the realistic options fall into four groups:

Two dental-specific checks are worth doing before you submit. First, count your images against the journal's figure limit: a case built on serial radiographs and clinical photographs can easily exceed it, and composite figures may need reformatting. Second, read three recent case reports in the journal and compare their notation, classification and image style with yours. Article types change over time, so confirm in the current author instructions that the journal still accepts case reports.

Pre-submission checklist for a dental case report

1. Title includes "case report" and the anatomy, disease or treatment
2. Guideline named and its checklist completed if the journal asks for it
3. Tooth notation system stated once and used consistently in text, tables and legends
4. Diagnoses use a named, current classification, with supporting test results
5. Every image has acquisition details, timing and any adjustments declared
6. Follow-up images are comparable to baseline, or the limitation is stated
7. Names, numbers and dates removed from radiographs, screenshots and file metadata
8. Written consent covers every identifiable image, including smile and intraoral photographs
9. Supplied materials, funding and conflicts of interest declared
10. Figure count and word count within the journal's case report limits

The detail reviewers notice first

A reviewer reading a dental case report usually goes straight to the images. If the follow-up radiograph is taken at a different angle from the baseline, if the tooth number in the legend disagrees with the text, or if a smile photograph appears without a consent statement, confidence in the rest of the report drops.

Get those three things right, notation, image documentation and consent, and the remaining work is the same careful case writing any clinical report needs. Whichever journal you choose, read its article-type definitions and image requirements before you finalise your figures; Directive Publications sets out its own article types in its author guidelines.