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DR. AMINAH M
( POST GRADUATE
CASE HISTORY,
DIAGNOSIS,
TREATMENT
PLANNING
SynopsisCONTENTS
• Definition
• Introduction
• Guidelines
• Vital statistics
• History
• Examination
• Provisional diagnosis
• Investigation
• Differential diagnosis
• Final diagnosis
• Treatment planning
• Conclusion
• References
DEFINITION
The planned professional conversation that
enables the patient to communicate his/her
symptoms, feelings and fears to the clinician
so as to obtain an insight in to the nature of
patient’s illness and his/her attitude to them.
Bricker
INTRODUCTION
It is a classic form of documentation ranges from clinical
sketches to highly detailed and extended accounts that help in
arriving at a diagnosis and formulation of treatment plan of a
person before treatment. select
a closest
possible choice :
Final diagnosis
Make a differential
diagnosis of all possible
complications
Analyse and interpret the
assembled clues to reach the
provisional diagnosis
Assemble all the available facts
gathered from chief complaint,
medical history, dental history,
diagnostic tests
Tandon S
To distinguish
between normal
and abnormal
condition
To aid in
treatment
plan
To establish
the diagnosis
To determine
the length of
the
appointment
To determine
whether
delivery of
dental care
requires
complex
procedures
To detect
any medical
problem
GUIDELINES
non-clinical
setting
Relaxed,
casual, non
aggressive
questions
Rephrase the
question
Children
under 5 yrs,
parent is
interviewed
Definite
outline
organized,
systematic,
complete
and accurate
BE A GOOD LISTENER
 STATISTICS / Biographical Data
 CHIEF COMPLAINT
 HISTORY----- History of presenting illness
Medical history
Past dental history
Family history
 EXAMINATION------General examination
Extra oral examination
Intra oral examination
 DIAGNOSIS-----Provisional diagnosis
Investigations
Final diagnosis
 TREATMENT PLAN
Statistics/Biographical data
Name & nick name
Patient registration number and date
Age and date of birth
Address/Phone
number
Class /School
Parents name
and
occupation
Gender
Favourite teacher,
subject & activity
Name & Nick name :
 For identification
 For communication
 Record maintenance
 Psychological benefit mainly in
pediatric patients
 Nick name:
 To build a rapport with patient
 To alleviate apprehension
Patient registration no. and Date
 Patient registration number useful for:
Record maintenance
Medico-legal aspects
Billing purposes
 Date:
 Useful for reference
and record maintenance
FEB
07
Age
 As a growth assessment
parameter
 To recognize the
disparities between the
dental – chronological age
 aid in treatment planning
 to calculate the drug
dosage
 Helps in forensic
odontology
In caries :
– Window of
infectivity
– Caries predilection
sites vary distinctly
according to age
(Mejare et al,1999)
In trauma:
– Peak ages
– 2 – 4 yrs 
childhood
– 8 – 10 yrs 
middle– school child
Andearson
Case history, diagnosis and treatment planning
Growth spurts:
 Just before birth
 One year after
birth
Mixed dentition
growth spurt:
 Boys:8-11yrs
 Girls:7-9 yrs
Pre-pubertal growth
spurt:
 Boys:14-16 yrs
 Girls:11-13yrs
Growth spurt are faster in girls than
boys…
MENTAL AGE : IQ X CHRONOLOGICAL AGE
100
IQ Range Classification
Above 145 Genius or near genius
130-145 Very superior
115-130 Superior
85-115 Normal
70-85 Dullness
Below 70 Borderline deficiency
<69 MR
Alfred Bionet
Standford bionet test
WISC
Behaviour management techniques change according
to age
Infant
• Baby needs parents
presence – basic
trust maintained
• Delay in attending
the infants demand
- panic builds up
Toddler(15 mths
– 2 yrs)
• He/ she displays
an ambivalent
nature
Pre-schooler(2 –
6 yrs)
• More effective in
interpersonal
communications
• His/her role is
more role playing
Middle aged
child (6 – 12yrs)
• He/she understands
only what is seen
• An anaesthetic
syringe may poses a
strong threat
• Learns conversation
& his/her thinking
becomes logical and
reversible
CHRONOLOGICAL AGE
(days, weeks, months, or years) : time elapsed from birth
DENTALAGE :
 Determination of dental age was based upon the rate
of development and calcification of tooth buds.
 Dental age estimation was done using Demirjian′s
method.
SKELETAL AGE:
The bone age was assessed by means of
hand-wrist radiograph using
 Bjork, Grave and Brown′s method -9 stages
 Fishman’s skeletal maturity indicator -11 stages
SMI
FISHMAN 1982
Diseases present in children
and young adults :
 Nursing bottle caries
 Juvenile periodontitis
 OSMF
 Fissured tongue
 Eruption cyst
 Dental caries
 Dentigerous cyst
 Pulp polyp
Diseases present in infancy:
 Haemangioma
 Thalassemia
 Palatal cyst of newborn
 Fibrous dysplasia of the
jaw
Diseases present at birth :
 Cleft palate
 Cleft lip
 Micro and macro glossia
 Cleft tongue
 Erythroblastosis fetalis
Diseases present in adults and
older patients:
 Attrition
 Gingival recession
 ANUG
 Lichen planus
 Periodontitis
 Leukoplakia
 Herpes zoster
Gender
• Sex related diseases
like haemophilia, G6PD
deficiency
(causes haemolytic
anaemia)
• As an aid in treatment
planning
– Growth spurts in
girls are ahead of
boys
In trauma:
– Boys sustain more
injuries than girls
– Ratio approx – 2:1
Females :
 Dental caries
 Lichen planus
 MPDS
 Anaemia
 Sjogren’s syndrome
 Juvenile periodontitis
Males :
 Leukoplakia
 Herpes simplex
 Hodgkins lymphoma
 Attrition
Address
 Communication
 Record purpose
 To know certain endemic diseases
 High fluoride content – dental/skeletal fluorosis
 Filariasis
Class/school
• Helps to correlate the patient’s chronological
age with mental age
Parent’s name/occupation
• For communication
• Reflects the socioeconomic status
• (lower socioeconomic status are
much more likely to develop chronic
illness like heart disease, COPD, etc.,)
Favourite teacher, subject
and activity
• To create interest in
communication
• To know the child better
CHIEF COMPLAINT
• Reason which prompted the patient to seek
dental treatment
• Better ask the question first to the child
before involving the parents
 Recorded in child’s own words in a
chronological order
 In kids < 5yrs, Parents – 'Best Historians'.
HISTORY OF PRESENTING ILLNESS
Elaboration/detailed description of
the chief complaint
• Duration
• Mode of onset
• Progression
• Severity
• Nature
• Aggravating/relieving factors
• Postural variation
• Any medications/treatment
received for the same
PAIN
Detailed history of particular symptom
PAIN
Anatomical location (site)
Origin and mode of onset
Intensity of pain
Nature of pain
Progression of pain
Duration of pain
Movement of pain
Effect of functional activity
Pain
• Most common complaint that leads to dental treatment
• According to intensity
Mild pain
• Controlled
by simple
analgesics
Moderate
pain
• Controlled
with narcotic
analgesics
Severe pain
• Cannot
controlled
with
analgesics
• Require
elimination
of cause
According to nature
– Pricking/piercing
– Throbbing
– Lancinating
– Aching
– Dull, boring, gnawing
Localization of pain
Localised when patient can
point to a specific tooth or site
Sharp , piercing and
lancinating pain in a
tooth responds to cold
and is easy to localize
Dull, boring pain is
diffuse and responds
abnormally to heat than
to cold is difficult to
localize.
According to duration
According to onset
• Pain of short duration & seperated by wholly
pain free periodIntermittent
• Pain of longer durationContinuous
• Two or more similar episodes of painRecurrent
• Characterized by regularly recurring episodePeriodic
Spontaneous
• Pain occurs
without
being
provoked
Induced
• Provocation
causes
painful
sensation
Triggered
• When evoked
response is
out of
proportion to
the stimulus
Case history, diagnosis and treatment planning
SWELLING
 SWELLING
 Anatomical location (site)
 Duration
 Mode of onset
 Symptoms
 Progress of swelling
 Associated features
 Secondary changes
 Impairment of function
 Recurrence of swelling
BLEEDING
 Gingivitis
 Periodontal disease
 Allergy
 Deficiency of coagulation factors
 Haemangioma
BURNING SENSATION
 Viral or fungal infection
 Anaemia
 Geographic tongue
 Fissured tongue
 Vitamin deficiency
 Anaemia
 Xerostomia
Loose teeth
 Periodontal disease
 Trauma
 Normal resorption
 AIDS
 Hemangioma
Xerostomia
 Local inflammation
 Autoimmune disease
 Post radiation changes
 Infection of major
salivary gland
Bad taste
 Aging changes
 Poor oral hygiene
 Heavy smoking
 Dental caries
 Periodontal disease
 ANUG
Halitosis
 Poor oral hygiene
 Periodontal disease
 ANUG
 Tobacco use
 Decayed teeth
 Gastric problems
Occlusal problems
Delayed teeth
Social/Family history
Questions to be asked
 Health of his/her parents
 Number and age of siblings and their
health
 Consanguineous marriage
 Any familial conditions / traits exists
Inherited disorders
(diabetes, hemophilia,
G6PD, b-thalassemia,
familial hyperlipidemia,
allergies)
Medical history
Check list of medical history-by Scully and Cawson
-Anemia
-Bleeding disorders
-Cardio respiratory disorders
-Drug treatment and allergies
-Endocrine disorders
-Fits and faints
-Gastrointestinal disorders
-Hospital admissions and surgeries
-Infections
-Jaundice and liver diseases
-Kidney disease
– Ex: juvenile diabetes: increased risk of dental caries
– Asthma and Epilepsy are strongly associated with dental
procedures
Various diseases and functional disturbances predisposes to oral
problems either directly or indirectly. History about
multiple/prolonged hospital admissions
Systemic diseases associated with..
DENTAL CARIES are ,
– Diabetes
– Asthma
– Sjogren’s syndrome
– Scleroderma
– Hereditary ectodermal dysplasia
– Rheumatoid arthritis
Pre-natal History
Condition of mother during pregnancy???
 Disease
 Trauma
 Medications
 Food and habits
 Radiation
 Anomalies scan
 Gene testing
Abnormal fetal position – abnormal pressure on some
part of face ----- FACIAL ASYMMETRY
 Were you on any drug therapy???
 Which??? How long???
 Tetracycline – discoloration of the teeth
DISEASES
Viral infections – cleft lip & palate
German measles in 1st trimester – cleft lip & palate
Maternal rubella, fetal alcohol syndrome
ACCIDENTS / TRAUMA -- Orofacial deformities
Case history, diagnosis and treatment planning
Natal History
• Term of delivery: Full term/ premature
• Patent ductus arteriosus, encephalopathy,
cerebral palsy, respiratory distress
syndrome, kernicterus
• Type: Normal / Forceps / Caesarian
• Forceps delivery ---- injury to TMJ ---
retarded growth of mandible
• Intracranial hemorrhage
Cyanosis at birth : congenital heart defect
Rh incompatibility : erythroblastosis fetalis.
Post natal
 Post Natal
 Feeding history-Duration ,
Weaning?
 Natal or neonatal teeth?
 Vaccinations
 DPT
 BCG
 OPV
 Tetanus
 MMR
• Milestones of development
• Habits
• Childhood diseases
• History of tonsillectomy and adenoidectomy
2015
2015
Milestones Developmental Milestones:
Any delays !!!
 Crawling
 Sitting
 Standing unsupported
 Walking
 Running
 Speaking sentences
Reflexes present at birth
Social/behavioural history
Behavioural Pedodontics:
It is a study of science which helps to
understand development of fear , anxiety , and anger
as it applies to child in the dental situations.
 Which school and class child studying and
performance?
 What is the child’s nature in the school?
 Is your child following you commands?
 How do you discipline your child?
 How does your child react to separation from
you?
 Does he has many friends?
 Preference of games
 Any problems in
learning/reading/understanding
Quite ---cooperative
Stubborn---resists treatment and can be made cooperative
Fearful ---considerable support required
Hyperactive---child resorts to screaming and kicking
Complaint----whining type of behaviour
Shy/Timid---cooperates treatment
Wilson-1975
Frankel behaviour rating scale
Personal
history
Oral hygiene history
– Method of cleaning teeth
– Who brushes the teeth
– Type of brush
– Method of brushing
– No. of times of brushing
– Other oral hygiene aids used like
flossing, rinses
– How often it is changed
– Fluoridated/non fluoridated tooth
pastes
Diet history
It includes recording of the following :
Veg/non-veg/mixed diet
No. of meals/day
Cariogenic snacks/day
Does your child eat everything you prepare
Does your child constantly snack on food
Favourite foods
Other food habits
DETERMINE THE ADEQUACY OF DIET:
Dental health diet score = Food score+ nutrient score
- sweet score
FOOD SCORE:
Milk 3 *8
Meat 2 *12
Fruits & Vegetables 1 *6
Vitamin c 1 *6
Others 2 *6
Breads and cereals 4 *6
FOOD RDA NO OF SERVINGS
NUTRIENT SCORE:
Mark one score for each nutrient consumed
SWEET SCORE:
Liquid : (*5)
Solid and sticky : (*10)
Slowly dissloving : (*15)
ASSESMENT DENTAL HEALTH DIET SCORE:
SCORE RESULT INTERPRETATION
72-96 Excellent Counseling not
required
64-72 Adequate Educate the patient
56-64 Barely adequate Counseling required
56 OR less Not adequate Counseling with diet
modification
Nutritional Status
NUTRITION is the “science
that interprets the
interaction of nutrients
and other substances in
food in relation to
growth, development and
maintenance of an
organism” (WHO)
Case history, diagnosis and treatment planning
STEPS IN DIETARY COUNSELING VISIT:
PURSUE DIARY FOR COMPLETION
DETERMINE DAILY ROUTINE
EXPLAIN THE CAUSE OF DECAY
ISOLATE SUGAR FACTORS
ANALYSE SWEETS INTAKE
DETERMINE ADEQUACY OF DIET
DIET PRESCRIPTIONS AND SUGESSTED MENU
REINFORCEMENT BY FOLLOW-UP REEVALUATION
Diet diary
Recording diet chart for a pediatric patient
How to plan a diet ??
Toddler Pre-school School Adolescent Adult Pregnant
women
Calorie
required
1200-
1500
1500 1800 2500 2800 3200
Protein -
RDA
18-20g 22g 33g 50g 55g 100g
AAPD
 Obesity
 Cachexia
 Anorexia Nervosa
 Bulimia
Nutritional status and its correlation with
dental caries:
-Nutrition affects the teeth during development
and malnutrition may exacerbate periodontal and
oral infectious diseases.
-The most significant effect of nutrition on teeth
is the local action of diet in the mouth on the
development of dental caries and enamel erosion.
Public Health Nutrition
Dental history
 Child’s first dental visit?
 Any unfavourable dental experience?
 How much satisfied was the previous treatment?
 Does your child complain of tooth ache ?
 Has your child suffered any injury to teeth?
 Did he have any fluoride treatment done before?
 Source of drinking water?
 Place of residing for the last few years?
Does your child have any abnormal Oral habits history
 Finger/thumb sucking, nail biting, lip biting, tongue
thrusting, bruxism, mouth breathing
Frequency
Intensity
Duration
EXAMINATION
Clinical examination
General examination:
– Assessment of general appearance should start before the child is
seated in the dental chair
– It includes
1. Child’s stature/ built
2. Weight
3. Height
4. Gait
5. Speech
6. Vital signs
William Sheldon's-1940
 Endomorph
 Mesomorph
 Ectomorph
Body built
Height and weight
 Height and Weight
 Compared with
growth charts
 Stadiometer
 Significance:
 Genetic
 Endocrine
(GH, Thyroid)
 Sotos Syndrome
Gait
(Jerky, uncoordinated)
Multiples sclerosis
Brain tumours,CNS)
(Hip elevation
exagerrated, a
duck-like walk)
Muscle dystrophy
the knees and thighs hitting
or crossing in a scissors-like
movement (cerebral strokes,
multiple sclerosis)
High stepping,
Neuropathic gait
typical of Parkinson's in which,
during walking, steps become
faster and faster with
Progressively shorter steps
Speech
 Aphasia
 Delayed speech
 Sluttering speech
 Cluttering speech
Significance:
-For Management of child in the dental chair
-To know if any systemic diseases associated
Aphasia-CNS disorders
Sluttering speech – parrot like speech (Autism)
Vitals
 Temperature
 Normal Oral
37C/98.6F
 Axillary, Rectal,(>0.5 -1 F)
 Pulse
60-100 beats/min
 BP
120-80 mm Hg
 Heart Rate (general)
<60bpm – Brady
>100bpm – Tachy
 Respiratory Rate (general)
Children – 16-20/min
Adults – 12-16/min
Extra Oral Examination
See
 Head
 Face
 Hair
 Eyes
 Ears
 Nose
 Lips
Feel
 Lymph Nodes
 TMJ
 Swallow
Shape
Profile
Symmetry
Head
Maximum skull width (Transverse dimension)
Cephalic index =
(CI)
Maximum skull length (Anteroposterior dimension)
Martin and Saller (1957)
Head Forms (Cephalic)
Mesocephalic - (76-80.9)
Brachycephalic - (81-85.4)
Dolichocephalic - ( <75.9 )
Hyperbrachycephalic (>85.5)
• It is Brachycephalized Dolichocephalic Crainal
Index
Face
Martin and Saller (1957)
Facial profile
Class II div 1 Class I
Class III malocclusionClass I Class II
Facial Symmetry
Gross Asymmetry of face
can be due to :
 Abscess due to dental
infection
 Parotid enlargement
 Unilateral condylar
hyperplasia
 Unilateral ankylosis of TMJ
Facial divergence
• It is the anterior or posterior
inclination of the lower face
relative to the forehead
FACIAL HEIGHT
UPPER FACIAL HEIGHT
45% of the total facial
height
LOWER FACIAL HEIGHT
55% of the total facial
height
Increased :
• Skeletal open bite
• Long face syndrome
Lowered :
• Growing children
• Skeletal deep bite
• Class II div 2
Lower facial height
Lip Position
 Competent lip
 Incompetent lip
 Potentially incompetent lip
Lip step profile
• Positive lip step
• Normal lip step
• Marked negative lip step
Naso labial angle
• Angle formed between
lower border of nose to the
upper lip(90-110degree)
Increased:
Retrusive maxilla
Decreased :
Proclined maxilla
Mentolabial sulcus
Seen between lower lip and mentalis
muscle
• Normal - class I occlusion
• Deep - class II div 1 occlusion
• Shallow -bimaxillary protrusion
Chin
Chin prominence is related to
mandibular position
• Recessive chin-class II molar
relation
• Prognathic chin-class III molar
relation
• Normal position-class I occlusion
Thank You
Case history, diagnosis and treatment planning
Lymph node examination
Look for:
 Location
 Number
 Size
> 1.5 cm in jugulo diagastric
nodes
> 1.0 cm in other nodes
 Consistency
 Discrete or matted nodes
 Tenderness
 Fixity to the overlying
skin/deeper structures
Texture
 Soft – Infection
 Firm – Granuloma,
Lymphoma?
 Matted - Tuberculous
 Stony hard –
Carcinoma?
Mobility
 Indurated –
Carcinoma?
 Mobile – infection
- Neck lymphnodes are better palpated while standing behind the
patient
- Neck is slightly flexed to that side to relax the muscles
Lymphatic drainage of teeth
Lymphatic
drainage of
teeth
Maxillary teeth
Mandibular
posteriors
Submandibular
lymphnodes
Deep cervical
lymph nodes
Mandibular
anteriors
Submental
lymphnodes
Submandibular
lymphnode
Case history, diagnosis and treatment planning
Case history, diagnosis and treatment planning
Case history, diagnosis and treatment planning
TMJ examination
• Symmetry
• Interincisal opening
• Mandibular movement---Observe path of closure for
deviations,Range of motion(also in lateral
movements)
• Palpation of the joint
– Pretragus palpation
– Intra-auricular palpation
• Auscultation of the joint
– Clicking
– Crepitus
Mouth opening
• Adults:
– Males- 50 – 60 mm
– Females- 45 – 55 mm
• Children:
– 35-45 mm
– Lateral movements- 8 – 12 mm
• Altered path of closure
• Occlusal prematurities
• Lingually or palatally
erupting incisors
• Class II div 1-habitual
• Class III-forward
placement
• Backward or lateral path
of closure
• Discrepancies of TMJ:
• Muscular imbalance
• Deviation/swelling/
redness, trismus or spasm
of muscles
Swallow :
• Infantile swallow (Visceral)
• Adult swallow
Teeth apart swallow : no temporalis contraction
Teeth together swallow : temporalis contraction seen
INTRA ORAL EXAMINATION
Soft Tissue
 Lips
 Mucosa – Labial + Buccal
+ Vestibule
 Frenum
 Tongue
 Floor of mouth
 Palate – Hard + Soft
 Gingiva and periodontium
 Pharynx
 Tonsils
Hard Tissue
Teeth
SOFT TISSUES
Lips
 Check for:
 Color
 Texture
 Any lesions
 Pigmentation Herpes simplex
Cleft lip
Melanotic macule
Diseases of lip
• Double lip
• Congenital lip pits
• Chelitis granulomatosa
• Chelitis glandularis
• Angular chelitis
• Syphilis
• Herpes simplex infection
Ascher’s syndrome
Van der woude’s syndrome
Melkersson –Rosenthal syndrome
Crusted lips(baelz’s disease)
Rhagades
Chancre
Haemorrhagic and matted
Mucosa – Labial + Buccal + Vestibule
 Check for:
 Ulcerations
 Swellings
 Growths
 Pigmentation
 Texture
 lesions
Fordyces granules
leukoedemaLinea alba
Mucocele
Keratotic Patch
Major Apthous Ulcer Capillary Hemangioma
Fibroma
Lichen planus
Diseases
• Lichen planus
• Measles
Grispan syndrome
Koplik’s spots
Frenum
 Check for:
 High labial frenae
 Tongue Tie
 High labial frenae may cause
Midline diastema when
attached highly - to incisal
papilla
 Blanch test confirms
Classification of frenum
Mucosal Gingival
Tongue
Check for...
– Volume
– Colour
– Swelling and ulcer
– Mobility
– Tongue thrusting on
swallowing
 Variations in size
 Macroglossia
 Micoglossia
 Range of movements
Benign migratory glossitis
/Geographic Tongue
Hairy tongue Fissured tongue
Median rhomboid
glossitis
Coated tongue
Foliate papillitis/lingual tonsil
Diseases
• Ankyloglossia
• Bifid tongue
• Fissured tongue
• Median rhombhoid glossitis
• Geographical tongue
• Atropic glossitis
• Depapillation
Oro facial digital syndrome
Orofacial digital syndrome
Melkerson-rosenthal syndrome
Atrophy candidiasis
Burning sensation
Plummer vinson syndrome
Iron defeciency anaemia
Floor of Mouth
 Character and extent of
gland secretions
 Saliva viscosity
and flow
 Swellings(tori)
 Sialoliths
 Tenderness
Palate – Hard & Soft
 Hard Palate
 Clefts
 Fistulae (syphilitic gumma)
 Inflammation
 Swellings
 Pigmentations
 Ulcerations
 Hyperkeratinization
 Soft Palate
Palatal Lesion
• Torus
• Inflammatory papillary hyperplasia
• Denture stomatitis
• Nicotine stomatitis
Diseases
• Necrotising
sialometaplasia
• Stomatitis nicotina
• Cleft palate
• Inflammatory papillary
hyperplasia
Numbness and looseness in the
palate
Dried mud appearance
Pierre robin syndrome
Vander woude’s syndrome
Over ripe berry, cobblestone
appearance
NO SPECIFIC LOCATION
TRAUMATIC ULCER
LEUKOPLAKIAPAPILLOMA
APTHOUS ULCER
Gingiva and periodontium
Child gingiva Adult gingiva
Marginal gingiva is thicker and rounded Marginal gingiva is knife edge margin
Attached gingiva:
• Less stippling
• Less keratinization
• Red in color
• Interdental clefts
• Retrocuspid papillae
Attached gingiva:
• Stippling is common
• Keratinized
• Coral pink
Mostly pyramidal shape interdental
gingiva
Col shape interdental gingiva is common
Gingival and periodontal tissues
– Colour
– Contour
– Consistency
– Surface texture
– Position
– Bleeding
– Ulceration
– Any sinus present
Check for bleeding on probing using probe
Mandibular tori Amalgam tatooPericoronitis
ANUGHerpetic gingivostomatitis Fibromatosis gingiva
• Sturge weber syndrome
• Papillion lefevre syndrome
• Drug induced gingival
enlargement
Massive gingival growth
Juvenile periodontitis and
inflammatory gingival
enlargement
Phenytoin
Cyclosporine
Nifidipine
Periodontal evaluation
• Selective probing of
anterior teeth and
permanent first molars
• Mobility test
• Depressibility test
• Grading of mobility-Miller
• Periodontal pocket evaluation
• Furcation involvement
Periodontal diseases and conditions
• Chronic gingivitis
• Acute pericoronitis
• Acute necrotizing ulcerative gingivitis (ANUG)
• Gingival fibromatosis and hyperplasia
• Prepubertal periodontitis
• Early-onset periodontitis
• Leukemia, Cyclic neutropenia, Hypophosphatasia,
Papillo-Lefevre syndrome, Histocytosis, Down’s
syndrome.
Gingival Index- loe and sillness(1963)
Periodontal index- CPITN(1982)
Pharynx
• Hoarseness of voice
• Any swelling,nodules,adenoid,discharge are
checked
• Airway assessment
Mallampati classification
Tonsil
• Color
• Size
• Any abnormalities
• Airway restriction
• Any discharge
• Tenderness
Tonsils
1. The palatine tonsils or simply referred to as 'the tonsil'- inbetween the
anterior & posterior pillars of oropharynx
2. The Nasopharyngeal tonsils or the adenoids- in the nasopharynx
3. The tubal tonsils- near opening of eustachian tubes.
4. The Lingual tonsils- in the base of the tongue.
Peritonsillar abscess/quinsy
Hockey stick appearance
TEETH
 Caries
 Fractured teeth
 Hypoplastic teeth
 Retained teeth
 Erupting teeth
 Supernumerary teeth
 Any other dental anomalies
 Orthodontic evaluation
HARD TISSUE EXAMINATION
DENTAL CARIES
EROSION ABRASIONFRACTURED TEETH
HYPOPLASTIC TEETH
DMFT INDEX- Klien,Carrole & Knutson(1938)
WHO MODIFICATION -1986
OHI INDEX - Greene and Vermillion(1960)
Case history, diagnosis and treatment planning
Dean’s flurosis index-modified(1942)
Retained teeth
Erupting teeth
PRIMARY TEETH
AAPD
PERMANENT TEETH
Other dental anomalies
Fusion
Hutchinson’s incisor
Supernumerary teeth
Orthodontic Evaluation
• Alignment
• Tooth number
• Tooth structure
• Tooth position
Alignment
TERMINAL PLANE RELATIONSHIP
Baume (1950)
MOLAR RELATIONSHIP IN
PERMANENT TEETH
CANINE RELATIONSHIP-Baume (1950)
• Midline deviation • Cross bite
-Inter arch relationship
• Class II div 1 – more prone for
trauma
• Bimaxillary protrusion
-Presence of crowding/spacing
-Deviations/Displacements
Malocclusion
-Severe skeletal abnormalities
-Overjet and overbite
-Increased overjet – may predispose to
trauma
-Anterior open bite – skeletal problem,
digit sucking habit, tongue thrust
 3mm=abnormal
(Reddy et al 2010)
Instruments used:
Boley gauge (Ravn)
Stainless steel scale(Farsi)
>3mm overlap = abnormal
(Reddy et al 2010)
Number of tooth
Tooth structure
Tooth Position
• Ectopic eruption
• Transposition
• Impaction
• Primary failure of eruption
Provisional diagnosis
 A provisional diagnosis is one that is initially determined to be the
diagnosis, except for the fact that all test results have not been
received and/or analyzed
 Also called Tentative/Working diagnosis
 Arrived after evaluating the case history
and
Clinical examination
Investigations
• Conventional methods
– Visual and tactile
examination
– Radiographs
• IOPA
• Bitewing X-rays
• Non-conventional
methods
– Digital radiography
– Digital subtraction
radiography
– Transillumination
FOTI & DIFOTI
– Fluorescence
– Infrared LASER
Fluorescence(DIAGNOdent)
Dental caries
Investigations
• Pulp tests to assess vitality
– Thermal stimulation
• Ethyl chloride
• Ice
• Dry ice(carbon-di-oxide
snow 78 – 108 ˚F)
– Electric pulp testing
– Test cavity
– Laser doppler flowmetry
– Pulse oximetry
• Radiographs
– Extraoral views
• To exclude facial
fractures
– Intraoral view
• To assess trauma of
individual tooth
• Photographic
documentation is
necessary
Dental Trauma
OTHER INVESTIGATIONS
• Orthodontic treatment
planning:
Cephalometric analysis
Model analysis
• Occlusal radiographs
• OPG
• CT
• Vista scan
Dental caries
IOPA
BITE WING
RADIOGRAPH
OCCLUSAL
RADIOGRAPH
OPG
DIGITAL
Digital
OPG
DIGITAL IMAGING
VISTA SCAN
LIGHT INDUCED FLUORESCENCE
CBCT scan
Cold test
PULP test :
Heat test
False negative responses:
Recently erupted tooth, Recent trauma
Excessive calcifications, Patients on pre-medications
ELECTRIC PULP TESTING
LASER DOPPLER FLOWMETRY
PULP OXIMETRY
FOTI & DIFOTI
DIAGNODENT
USES:
 Helps in
orthodontic
treatment
planning
 Evaluation of
treatment results
 Helps in
predicting the
growth related
changes and
changes
associated with
surgical
treatment.
CEPHALOMETRIC ANALYSIS
DIFFERENTIAL DIAGNOSIS
“Differential diagnosis is
distinguishing a particular
disease or condition from
others that present similar
clinical features”.
Differential diagnosis can be regarded as
implementing aspects of the hypothetico-
deductive method, in the sense that the
potential presence of candidate diseases or
conditions can be viewed as hypotheses that
physicians further determine as being true or
false.
Benign Reactive swelling
Inflammatory
swelling
Posttraumatic
swelling
Hamartoma
Vascular tumors
Myofibroma
Malignant Lymphoma
Soft tissue sarcoma
Rhabdomyosarcoma
Ewing sarcoma
Synovial tumors
Fibrosarcoma
Differential diagnosis of soft
tissue masses/ subcutaneous
swelling in children :
Final/Definitive diagnosis
• Chronologic organization and critical evaluation of the information
obtained from the case history, physical/clinical examination and
the result of radiologic and other
investigative procedures leads
to definitive diagnosis.
• It identifies the chief
complaint first and then the subsidiary diagnosis of other problems
In case of pulp therapy in primary teeth
Case history, diagnosis and treatment planning
Case history, diagnosis and treatment planning
In case of pulp therapy in permanent teeth
Case history, diagnosis and treatment planning
In case of trauma
The goal of treatment for
traumatically injured teeth
is to return the teeth to
acceptable function and
appearance.
Acute treatment:
• There are situations
where treatment within a
few hours can
significantly affect the
outcome.
– Tooth avulsions, alveolar
fractures, extrusive and
lateral luxations, and
possibly root fractures.
– Early repositioning and
stabilization will promote
the best PDL repair
Subacute treatment:
• Treatment within 24 h
after injury allow the
following injuries
proper care
– Concussion,
subluxations, and
intrusive luxation, and
crown fractures with
pulpal exposure.
– Pulpal and PDL
responses do not seem to
be adversely affected by
a delay of 24 h
Delayed treatment:
• Crown fractures without
pulpal exposure appear
to have the same
prognosis whether
treatment is performed
within a few or several
hours
Immediate care :
• It may be initiated with
the emergency
treatment provided,
such as pulp protection
for continued root
formation in developing
teeth with complicated
crown fractures.
In cases of luxation and avulsion injuries, the immediate concern is to stabilize the
tooth in its normal position to allow re-attachment and re-organization of the
periodontal ligament support.
Emergency treatment – Primary anterior teeth
Case history, diagnosis and treatment planning
Emergency treatment – Permanent anterior teeth
Case history, diagnosis and treatment planning
Prognosis
• Prediction of the probable course,
duration and outcome of the disease
based on a general knowledge of the
pathogenesis and the presence of risk
factor of the disease
• Established after the diagnosis is made
and before the treatment plan
TREATMENT PLANNING
Treatment planning
Development of a treatment
plan is the most critical step in
the successful future
management of the child and
parent
5 Phases of the Treatment Plan
 Emergency Phase/ Acute phase
 Systemic Phase
 Preventive OR Preparatory Phase
 Definitive treatment or Corrective Phase
 Maintenance Phase
Acute Phase :
Emergency Treatments
Maxillofacial trauma,
Swelling,
Systemic infection,
Severe pain
Splinting periods
• Extrusive luxation  2 weeks/flexible
• Lateral luxation  4 weeks/flexible
• Intrusive luxation  6-8 weeks/flexible
• Avulsion  1-2 weeks/flexible
Root fracture:
• Cervical third  4 months/rigid
• Middle/apical third  4 weeks/flexible
• Alveolar fracture  4 weeks/flexible
Systemic Phase
 Premedication
 Antibiotic Prophylaxis
 Managing anticoagulants
 Adrenal/Thyroid insuffiency
cases
Preventive Phase
 Caries risk assessment
 Oral hygiene counseling
 Diet counselling
 P&F sealants
 Fluoride application
Preparatory Phase
- Behavioural managment
- Caries control
- Oral Prophylaxis
- Preventive orthodontics
- Extraction of unrestorable teeth
• Pre-prosthetic treatment
MECHANICAL AIDS:
GAUZE PIECE
Moist gauze piece wrapped around finger
for cleaning gum pads in infants
BRUSHING TECHNIQUE Common method :
Circular brushing method (or) Fone’s
technique is used twice daily.
DENTRIFICE
No flouridated tooth paste should be used
till 3years.
Till the child is 7 years of age only pea size
quantity of dentrifice should be dispensed.
POWERED TOOTH BRUSH
Patients who lack manual dexterity
Orthodontic patients
DENTAL FLOSS Waxed dental floss is used in children
Longer handle floss are used
Floss with 8 to 10 vertical strokes
Floss atleast once a day
The important time to floss is before
going to bed
MOUTH WASH:
Chlorhexidine:(rexidin,clohex)
Chlorhexidine(CHX)
Recommended in a
concentration of
0.12% in a range of
5 to 1o ml once
daily.
Not recommended
under the age of 7
years
Case history, diagnosis and treatment planning
Case history, diagnosis and treatment planning
Decision making tree for dental caries(Nyvad & Fejerskov,1997)
Status of the
tooth
Filling
Active lesion
Cavity
Repair/
replacement
No cavity
Non operative
treatment
Inactive lesion No treatment
Defect
Ditching/
Overhanging
No treatment/
reburnishing
Fracture/
Food impaction
Repair/
replacement
No defect No replacement
Lesion
Active
Cavity
Operative
treatment
No cavity
Non operative
treatment
Inactive No treatment
Clinically sound No treatment
Definitve Rx Phase
 Restorative and Pulpal treatment
 Prosthetic rehabilitation
 Orthodontic interventions – serial
extractions, space management,
tooth movements
 Orthognathic surgery
 Periodontal therapy
Maintenance Phase
-3-6 month recalls
-review check up of oral health indices
-repeat caries activity tests
-reinforcement of home care measures
-motivation and re-counseling of the parent
-follow up of treatment procedures
Anticipatory Guidance
 It is defined as pro-active counseling of parents
and patients about developmental changes that will
occur in the interval between health supervision visits that includes
information about daily caretaking specific to that upcoming interval.
 If child is sleeping with a bottle, or if there are incipient white spot lesions, then the dentist
should make recommendations on how to stop the bottle habit or improve oral hygiene.
Informed consent
• Sufficient information must be given by the dentist to the
parent /guardian, so that the parent has a reasonable
understanding of the proposed dental care for the child
• Basic concepts of informed consent (Schultz,1985)
A standard consent form is not a substitute for a dentist parent discussion
Nonremote risks
to care
Any referral to
other health
providers
Consequences if
proposed
treatment is
refused
Acceptable
alternatives
Case history, diagnosis and treatment planning
Scheduling operative treatment
The following are general rules of thumb
• Small, simple restorations should be completed first
• Maxillary teeth should be treated before mandibular teeth
• Posterior teeth should be treated before anteriors
• Quadrant dentistry should be practised
• Endodontic treatment should follow completion of simple
restorative treatment
• Extractions should be the last items of operative care
unless the patient presents with an acute problem.
Conclusion
References
• Pediatric Dentistry: A Clinical Approach by Goran Koch, Sven
Poulsen
• Dental caries by Ole Fejerskov and Edwina Kidd
• Textbook and colour atlas of traumatic injuries of teeth by
J.O.Andreasen and F.M.Andreasen
• Fundamentals of pediatric dentistry by Richard.J.Mathewson
• Pediatric dentistry:principles and practice by M.S Muthu and
N.Sivakumar
• Textbook of pedodontics by Shobha Tandon
• Orthodontics The Art and Science – Balaji
• Oral Diagnosis, Oral Medicine and Treatment Planning –
Bricker & Langlais
• ENLOW AND HANS-facial growth of orthodontics
• Grabers textbook of orthodontics
• Principles and practice of pedodontics-Arathi rao
Case history, diagnosis and treatment planning

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Case history, diagnosis and treatment planning

  • 1. DR. AMINAH M ( POST GRADUATE CASE HISTORY, DIAGNOSIS, TREATMENT PLANNING
  • 2. SynopsisCONTENTS • Definition • Introduction • Guidelines • Vital statistics • History • Examination • Provisional diagnosis • Investigation • Differential diagnosis • Final diagnosis • Treatment planning • Conclusion • References
  • 3. DEFINITION The planned professional conversation that enables the patient to communicate his/her symptoms, feelings and fears to the clinician so as to obtain an insight in to the nature of patient’s illness and his/her attitude to them. Bricker
  • 4. INTRODUCTION It is a classic form of documentation ranges from clinical sketches to highly detailed and extended accounts that help in arriving at a diagnosis and formulation of treatment plan of a person before treatment. select a closest possible choice : Final diagnosis Make a differential diagnosis of all possible complications Analyse and interpret the assembled clues to reach the provisional diagnosis Assemble all the available facts gathered from chief complaint, medical history, dental history, diagnostic tests Tandon S
  • 5. To distinguish between normal and abnormal condition To aid in treatment plan To establish the diagnosis To determine the length of the appointment To determine whether delivery of dental care requires complex procedures To detect any medical problem
  • 6. GUIDELINES non-clinical setting Relaxed, casual, non aggressive questions Rephrase the question Children under 5 yrs, parent is interviewed Definite outline organized, systematic, complete and accurate BE A GOOD LISTENER
  • 7.  STATISTICS / Biographical Data  CHIEF COMPLAINT  HISTORY----- History of presenting illness Medical history Past dental history Family history  EXAMINATION------General examination Extra oral examination Intra oral examination  DIAGNOSIS-----Provisional diagnosis Investigations Final diagnosis  TREATMENT PLAN
  • 8. Statistics/Biographical data Name & nick name Patient registration number and date Age and date of birth Address/Phone number Class /School Parents name and occupation Gender Favourite teacher, subject & activity
  • 9. Name & Nick name :  For identification  For communication  Record maintenance  Psychological benefit mainly in pediatric patients  Nick name:  To build a rapport with patient  To alleviate apprehension
  • 10. Patient registration no. and Date  Patient registration number useful for: Record maintenance Medico-legal aspects Billing purposes  Date:  Useful for reference and record maintenance FEB 07
  • 11. Age  As a growth assessment parameter  To recognize the disparities between the dental – chronological age  aid in treatment planning  to calculate the drug dosage  Helps in forensic odontology In caries : – Window of infectivity – Caries predilection sites vary distinctly according to age (Mejare et al,1999) In trauma: – Peak ages – 2 – 4 yrs  childhood – 8 – 10 yrs  middle– school child Andearson
  • 13. Growth spurts:  Just before birth  One year after birth Mixed dentition growth spurt:  Boys:8-11yrs  Girls:7-9 yrs Pre-pubertal growth spurt:  Boys:14-16 yrs  Girls:11-13yrs Growth spurt are faster in girls than boys…
  • 14. MENTAL AGE : IQ X CHRONOLOGICAL AGE 100 IQ Range Classification Above 145 Genius or near genius 130-145 Very superior 115-130 Superior 85-115 Normal 70-85 Dullness Below 70 Borderline deficiency <69 MR Alfred Bionet Standford bionet test WISC
  • 15. Behaviour management techniques change according to age Infant • Baby needs parents presence – basic trust maintained • Delay in attending the infants demand - panic builds up Toddler(15 mths – 2 yrs) • He/ she displays an ambivalent nature Pre-schooler(2 – 6 yrs) • More effective in interpersonal communications • His/her role is more role playing Middle aged child (6 – 12yrs) • He/she understands only what is seen • An anaesthetic syringe may poses a strong threat • Learns conversation & his/her thinking becomes logical and reversible
  • 16. CHRONOLOGICAL AGE (days, weeks, months, or years) : time elapsed from birth DENTALAGE :  Determination of dental age was based upon the rate of development and calcification of tooth buds.  Dental age estimation was done using Demirjian′s method.
  • 17. SKELETAL AGE: The bone age was assessed by means of hand-wrist radiograph using  Bjork, Grave and Brown′s method -9 stages  Fishman’s skeletal maturity indicator -11 stages SMI FISHMAN 1982
  • 18. Diseases present in children and young adults :  Nursing bottle caries  Juvenile periodontitis  OSMF  Fissured tongue  Eruption cyst  Dental caries  Dentigerous cyst  Pulp polyp Diseases present in infancy:  Haemangioma  Thalassemia  Palatal cyst of newborn  Fibrous dysplasia of the jaw Diseases present at birth :  Cleft palate  Cleft lip  Micro and macro glossia  Cleft tongue  Erythroblastosis fetalis Diseases present in adults and older patients:  Attrition  Gingival recession  ANUG  Lichen planus  Periodontitis  Leukoplakia  Herpes zoster
  • 19. Gender • Sex related diseases like haemophilia, G6PD deficiency (causes haemolytic anaemia) • As an aid in treatment planning – Growth spurts in girls are ahead of boys In trauma: – Boys sustain more injuries than girls – Ratio approx – 2:1 Females :  Dental caries  Lichen planus  MPDS  Anaemia  Sjogren’s syndrome  Juvenile periodontitis Males :  Leukoplakia  Herpes simplex  Hodgkins lymphoma  Attrition
  • 20. Address  Communication  Record purpose  To know certain endemic diseases  High fluoride content – dental/skeletal fluorosis  Filariasis
  • 21. Class/school • Helps to correlate the patient’s chronological age with mental age
  • 22. Parent’s name/occupation • For communication • Reflects the socioeconomic status • (lower socioeconomic status are much more likely to develop chronic illness like heart disease, COPD, etc.,) Favourite teacher, subject and activity • To create interest in communication • To know the child better
  • 23. CHIEF COMPLAINT • Reason which prompted the patient to seek dental treatment • Better ask the question first to the child before involving the parents  Recorded in child’s own words in a chronological order  In kids < 5yrs, Parents – 'Best Historians'.
  • 24. HISTORY OF PRESENTING ILLNESS Elaboration/detailed description of the chief complaint • Duration • Mode of onset • Progression • Severity • Nature • Aggravating/relieving factors • Postural variation • Any medications/treatment received for the same PAIN
  • 25. Detailed history of particular symptom PAIN Anatomical location (site) Origin and mode of onset Intensity of pain Nature of pain Progression of pain Duration of pain Movement of pain Effect of functional activity
  • 26. Pain • Most common complaint that leads to dental treatment • According to intensity Mild pain • Controlled by simple analgesics Moderate pain • Controlled with narcotic analgesics Severe pain • Cannot controlled with analgesics • Require elimination of cause
  • 27. According to nature – Pricking/piercing – Throbbing – Lancinating – Aching – Dull, boring, gnawing Localization of pain Localised when patient can point to a specific tooth or site Sharp , piercing and lancinating pain in a tooth responds to cold and is easy to localize Dull, boring pain is diffuse and responds abnormally to heat than to cold is difficult to localize.
  • 28. According to duration According to onset • Pain of short duration & seperated by wholly pain free periodIntermittent • Pain of longer durationContinuous • Two or more similar episodes of painRecurrent • Characterized by regularly recurring episodePeriodic Spontaneous • Pain occurs without being provoked Induced • Provocation causes painful sensation Triggered • When evoked response is out of proportion to the stimulus
  • 30. SWELLING  SWELLING  Anatomical location (site)  Duration  Mode of onset  Symptoms  Progress of swelling  Associated features  Secondary changes  Impairment of function  Recurrence of swelling
  • 31. BLEEDING  Gingivitis  Periodontal disease  Allergy  Deficiency of coagulation factors  Haemangioma
  • 32. BURNING SENSATION  Viral or fungal infection  Anaemia  Geographic tongue  Fissured tongue  Vitamin deficiency  Anaemia  Xerostomia
  • 33. Loose teeth  Periodontal disease  Trauma  Normal resorption  AIDS  Hemangioma Xerostomia  Local inflammation  Autoimmune disease  Post radiation changes  Infection of major salivary gland
  • 34. Bad taste  Aging changes  Poor oral hygiene  Heavy smoking  Dental caries  Periodontal disease  ANUG Halitosis  Poor oral hygiene  Periodontal disease  ANUG  Tobacco use  Decayed teeth  Gastric problems Occlusal problems Delayed teeth
  • 35. Social/Family history Questions to be asked  Health of his/her parents  Number and age of siblings and their health  Consanguineous marriage  Any familial conditions / traits exists Inherited disorders (diabetes, hemophilia, G6PD, b-thalassemia, familial hyperlipidemia, allergies)
  • 36. Medical history Check list of medical history-by Scully and Cawson -Anemia -Bleeding disorders -Cardio respiratory disorders -Drug treatment and allergies -Endocrine disorders -Fits and faints -Gastrointestinal disorders -Hospital admissions and surgeries -Infections -Jaundice and liver diseases -Kidney disease
  • 37. – Ex: juvenile diabetes: increased risk of dental caries – Asthma and Epilepsy are strongly associated with dental procedures Various diseases and functional disturbances predisposes to oral problems either directly or indirectly. History about multiple/prolonged hospital admissions
  • 38. Systemic diseases associated with.. DENTAL CARIES are , – Diabetes – Asthma – Sjogren’s syndrome – Scleroderma – Hereditary ectodermal dysplasia – Rheumatoid arthritis
  • 39. Pre-natal History Condition of mother during pregnancy???  Disease  Trauma  Medications  Food and habits  Radiation  Anomalies scan  Gene testing Abnormal fetal position – abnormal pressure on some part of face ----- FACIAL ASYMMETRY  Were you on any drug therapy???  Which??? How long???  Tetracycline – discoloration of the teeth DISEASES Viral infections – cleft lip & palate German measles in 1st trimester – cleft lip & palate Maternal rubella, fetal alcohol syndrome ACCIDENTS / TRAUMA -- Orofacial deformities
  • 41. Natal History • Term of delivery: Full term/ premature • Patent ductus arteriosus, encephalopathy, cerebral palsy, respiratory distress syndrome, kernicterus • Type: Normal / Forceps / Caesarian • Forceps delivery ---- injury to TMJ --- retarded growth of mandible • Intracranial hemorrhage Cyanosis at birth : congenital heart defect Rh incompatibility : erythroblastosis fetalis.
  • 42. Post natal  Post Natal  Feeding history-Duration , Weaning?  Natal or neonatal teeth?  Vaccinations  DPT  BCG  OPV  Tetanus  MMR • Milestones of development • Habits • Childhood diseases • History of tonsillectomy and adenoidectomy
  • 44. Milestones Developmental Milestones: Any delays !!!  Crawling  Sitting  Standing unsupported  Walking  Running  Speaking sentences
  • 46. Social/behavioural history Behavioural Pedodontics: It is a study of science which helps to understand development of fear , anxiety , and anger as it applies to child in the dental situations.
  • 47.  Which school and class child studying and performance?  What is the child’s nature in the school?  Is your child following you commands?  How do you discipline your child?  How does your child react to separation from you?  Does he has many friends?  Preference of games  Any problems in learning/reading/understanding
  • 48. Quite ---cooperative Stubborn---resists treatment and can be made cooperative Fearful ---considerable support required Hyperactive---child resorts to screaming and kicking Complaint----whining type of behaviour Shy/Timid---cooperates treatment Wilson-1975
  • 50. Personal history Oral hygiene history – Method of cleaning teeth – Who brushes the teeth – Type of brush – Method of brushing – No. of times of brushing – Other oral hygiene aids used like flossing, rinses – How often it is changed – Fluoridated/non fluoridated tooth pastes
  • 51. Diet history It includes recording of the following : Veg/non-veg/mixed diet No. of meals/day Cariogenic snacks/day Does your child eat everything you prepare Does your child constantly snack on food Favourite foods Other food habits
  • 52. DETERMINE THE ADEQUACY OF DIET: Dental health diet score = Food score+ nutrient score - sweet score
  • 53. FOOD SCORE: Milk 3 *8 Meat 2 *12 Fruits & Vegetables 1 *6 Vitamin c 1 *6 Others 2 *6 Breads and cereals 4 *6 FOOD RDA NO OF SERVINGS
  • 54. NUTRIENT SCORE: Mark one score for each nutrient consumed SWEET SCORE: Liquid : (*5) Solid and sticky : (*10) Slowly dissloving : (*15)
  • 55. ASSESMENT DENTAL HEALTH DIET SCORE: SCORE RESULT INTERPRETATION 72-96 Excellent Counseling not required 64-72 Adequate Educate the patient 56-64 Barely adequate Counseling required 56 OR less Not adequate Counseling with diet modification
  • 56. Nutritional Status NUTRITION is the “science that interprets the interaction of nutrients and other substances in food in relation to growth, development and maintenance of an organism” (WHO)
  • 58. STEPS IN DIETARY COUNSELING VISIT: PURSUE DIARY FOR COMPLETION DETERMINE DAILY ROUTINE EXPLAIN THE CAUSE OF DECAY ISOLATE SUGAR FACTORS
  • 59. ANALYSE SWEETS INTAKE DETERMINE ADEQUACY OF DIET DIET PRESCRIPTIONS AND SUGESSTED MENU REINFORCEMENT BY FOLLOW-UP REEVALUATION
  • 60. Diet diary Recording diet chart for a pediatric patient How to plan a diet ??
  • 61. Toddler Pre-school School Adolescent Adult Pregnant women Calorie required 1200- 1500 1500 1800 2500 2800 3200 Protein - RDA 18-20g 22g 33g 50g 55g 100g AAPD
  • 62.  Obesity  Cachexia  Anorexia Nervosa  Bulimia
  • 63. Nutritional status and its correlation with dental caries: -Nutrition affects the teeth during development and malnutrition may exacerbate periodontal and oral infectious diseases. -The most significant effect of nutrition on teeth is the local action of diet in the mouth on the development of dental caries and enamel erosion. Public Health Nutrition
  • 64. Dental history  Child’s first dental visit?  Any unfavourable dental experience?  How much satisfied was the previous treatment?  Does your child complain of tooth ache ?  Has your child suffered any injury to teeth?  Did he have any fluoride treatment done before?  Source of drinking water?  Place of residing for the last few years?
  • 65. Does your child have any abnormal Oral habits history  Finger/thumb sucking, nail biting, lip biting, tongue thrusting, bruxism, mouth breathing Frequency Intensity Duration
  • 67. Clinical examination General examination: – Assessment of general appearance should start before the child is seated in the dental chair – It includes 1. Child’s stature/ built 2. Weight 3. Height 4. Gait 5. Speech 6. Vital signs
  • 68. William Sheldon's-1940  Endomorph  Mesomorph  Ectomorph Body built
  • 69. Height and weight  Height and Weight  Compared with growth charts  Stadiometer  Significance:  Genetic  Endocrine (GH, Thyroid)  Sotos Syndrome
  • 70. Gait
  • 71. (Jerky, uncoordinated) Multiples sclerosis Brain tumours,CNS) (Hip elevation exagerrated, a duck-like walk) Muscle dystrophy the knees and thighs hitting or crossing in a scissors-like movement (cerebral strokes, multiple sclerosis) High stepping, Neuropathic gait typical of Parkinson's in which, during walking, steps become faster and faster with Progressively shorter steps
  • 72. Speech  Aphasia  Delayed speech  Sluttering speech  Cluttering speech Significance: -For Management of child in the dental chair -To know if any systemic diseases associated Aphasia-CNS disorders Sluttering speech – parrot like speech (Autism)
  • 73. Vitals  Temperature  Normal Oral 37C/98.6F  Axillary, Rectal,(>0.5 -1 F)  Pulse 60-100 beats/min  BP 120-80 mm Hg
  • 74.  Heart Rate (general) <60bpm – Brady >100bpm – Tachy  Respiratory Rate (general) Children – 16-20/min Adults – 12-16/min
  • 75. Extra Oral Examination See  Head  Face  Hair  Eyes  Ears  Nose  Lips Feel  Lymph Nodes  TMJ  Swallow Shape Profile Symmetry
  • 76. Head Maximum skull width (Transverse dimension) Cephalic index = (CI) Maximum skull length (Anteroposterior dimension) Martin and Saller (1957)
  • 77. Head Forms (Cephalic) Mesocephalic - (76-80.9) Brachycephalic - (81-85.4) Dolichocephalic - ( <75.9 ) Hyperbrachycephalic (>85.5) • It is Brachycephalized Dolichocephalic Crainal Index
  • 79. Facial profile Class II div 1 Class I
  • 81. Facial Symmetry Gross Asymmetry of face can be due to :  Abscess due to dental infection  Parotid enlargement  Unilateral condylar hyperplasia  Unilateral ankylosis of TMJ
  • 82. Facial divergence • It is the anterior or posterior inclination of the lower face relative to the forehead
  • 83. FACIAL HEIGHT UPPER FACIAL HEIGHT 45% of the total facial height LOWER FACIAL HEIGHT 55% of the total facial height
  • 84. Increased : • Skeletal open bite • Long face syndrome Lowered : • Growing children • Skeletal deep bite • Class II div 2 Lower facial height
  • 85. Lip Position  Competent lip  Incompetent lip  Potentially incompetent lip
  • 86. Lip step profile • Positive lip step • Normal lip step • Marked negative lip step
  • 87. Naso labial angle • Angle formed between lower border of nose to the upper lip(90-110degree) Increased: Retrusive maxilla Decreased : Proclined maxilla
  • 88. Mentolabial sulcus Seen between lower lip and mentalis muscle • Normal - class I occlusion • Deep - class II div 1 occlusion • Shallow -bimaxillary protrusion
  • 89. Chin Chin prominence is related to mandibular position • Recessive chin-class II molar relation • Prognathic chin-class III molar relation • Normal position-class I occlusion
  • 92. Lymph node examination Look for:  Location  Number  Size > 1.5 cm in jugulo diagastric nodes > 1.0 cm in other nodes  Consistency  Discrete or matted nodes  Tenderness  Fixity to the overlying skin/deeper structures Texture  Soft – Infection  Firm – Granuloma, Lymphoma?  Matted - Tuberculous  Stony hard – Carcinoma? Mobility  Indurated – Carcinoma?  Mobile – infection - Neck lymphnodes are better palpated while standing behind the patient - Neck is slightly flexed to that side to relax the muscles
  • 93. Lymphatic drainage of teeth Lymphatic drainage of teeth Maxillary teeth Mandibular posteriors Submandibular lymphnodes Deep cervical lymph nodes Mandibular anteriors Submental lymphnodes Submandibular lymphnode
  • 97. TMJ examination • Symmetry • Interincisal opening • Mandibular movement---Observe path of closure for deviations,Range of motion(also in lateral movements) • Palpation of the joint – Pretragus palpation – Intra-auricular palpation • Auscultation of the joint – Clicking – Crepitus
  • 98. Mouth opening • Adults: – Males- 50 – 60 mm – Females- 45 – 55 mm • Children: – 35-45 mm – Lateral movements- 8 – 12 mm
  • 99. • Altered path of closure • Occlusal prematurities • Lingually or palatally erupting incisors • Class II div 1-habitual • Class III-forward placement • Backward or lateral path of closure • Discrepancies of TMJ: • Muscular imbalance • Deviation/swelling/ redness, trismus or spasm of muscles
  • 100. Swallow : • Infantile swallow (Visceral) • Adult swallow Teeth apart swallow : no temporalis contraction Teeth together swallow : temporalis contraction seen
  • 101. INTRA ORAL EXAMINATION Soft Tissue  Lips  Mucosa – Labial + Buccal + Vestibule  Frenum  Tongue  Floor of mouth  Palate – Hard + Soft  Gingiva and periodontium  Pharynx  Tonsils Hard Tissue Teeth
  • 102. SOFT TISSUES Lips  Check for:  Color  Texture  Any lesions  Pigmentation Herpes simplex Cleft lip Melanotic macule
  • 103. Diseases of lip • Double lip • Congenital lip pits • Chelitis granulomatosa • Chelitis glandularis • Angular chelitis • Syphilis • Herpes simplex infection Ascher’s syndrome Van der woude’s syndrome Melkersson –Rosenthal syndrome Crusted lips(baelz’s disease) Rhagades Chancre Haemorrhagic and matted
  • 104. Mucosa – Labial + Buccal + Vestibule  Check for:  Ulcerations  Swellings  Growths  Pigmentation  Texture  lesions
  • 106. Keratotic Patch Major Apthous Ulcer Capillary Hemangioma Fibroma Lichen planus
  • 107. Diseases • Lichen planus • Measles Grispan syndrome Koplik’s spots
  • 108. Frenum  Check for:  High labial frenae  Tongue Tie  High labial frenae may cause Midline diastema when attached highly - to incisal papilla  Blanch test confirms
  • 110. Tongue Check for... – Volume – Colour – Swelling and ulcer – Mobility – Tongue thrusting on swallowing  Variations in size  Macroglossia  Micoglossia  Range of movements Benign migratory glossitis /Geographic Tongue Hairy tongue Fissured tongue Median rhomboid glossitis Coated tongue Foliate papillitis/lingual tonsil
  • 111. Diseases • Ankyloglossia • Bifid tongue • Fissured tongue • Median rhombhoid glossitis • Geographical tongue • Atropic glossitis • Depapillation Oro facial digital syndrome Orofacial digital syndrome Melkerson-rosenthal syndrome Atrophy candidiasis Burning sensation Plummer vinson syndrome Iron defeciency anaemia
  • 112. Floor of Mouth  Character and extent of gland secretions  Saliva viscosity and flow  Swellings(tori)  Sialoliths  Tenderness
  • 113. Palate – Hard & Soft  Hard Palate  Clefts  Fistulae (syphilitic gumma)  Inflammation  Swellings  Pigmentations  Ulcerations  Hyperkeratinization  Soft Palate
  • 114. Palatal Lesion • Torus • Inflammatory papillary hyperplasia • Denture stomatitis • Nicotine stomatitis
  • 115. Diseases • Necrotising sialometaplasia • Stomatitis nicotina • Cleft palate • Inflammatory papillary hyperplasia Numbness and looseness in the palate Dried mud appearance Pierre robin syndrome Vander woude’s syndrome Over ripe berry, cobblestone appearance
  • 116. NO SPECIFIC LOCATION TRAUMATIC ULCER LEUKOPLAKIAPAPILLOMA APTHOUS ULCER
  • 117. Gingiva and periodontium Child gingiva Adult gingiva Marginal gingiva is thicker and rounded Marginal gingiva is knife edge margin Attached gingiva: • Less stippling • Less keratinization • Red in color • Interdental clefts • Retrocuspid papillae Attached gingiva: • Stippling is common • Keratinized • Coral pink Mostly pyramidal shape interdental gingiva Col shape interdental gingiva is common
  • 118. Gingival and periodontal tissues – Colour – Contour – Consistency – Surface texture – Position – Bleeding – Ulceration – Any sinus present Check for bleeding on probing using probe
  • 119. Mandibular tori Amalgam tatooPericoronitis ANUGHerpetic gingivostomatitis Fibromatosis gingiva
  • 120. • Sturge weber syndrome • Papillion lefevre syndrome • Drug induced gingival enlargement Massive gingival growth Juvenile periodontitis and inflammatory gingival enlargement Phenytoin Cyclosporine Nifidipine
  • 121. Periodontal evaluation • Selective probing of anterior teeth and permanent first molars • Mobility test • Depressibility test • Grading of mobility-Miller • Periodontal pocket evaluation • Furcation involvement
  • 122. Periodontal diseases and conditions • Chronic gingivitis • Acute pericoronitis • Acute necrotizing ulcerative gingivitis (ANUG) • Gingival fibromatosis and hyperplasia • Prepubertal periodontitis • Early-onset periodontitis • Leukemia, Cyclic neutropenia, Hypophosphatasia, Papillo-Lefevre syndrome, Histocytosis, Down’s syndrome.
  • 123. Gingival Index- loe and sillness(1963)
  • 125. Pharynx • Hoarseness of voice • Any swelling,nodules,adenoid,discharge are checked • Airway assessment Mallampati classification
  • 126. Tonsil • Color • Size • Any abnormalities • Airway restriction • Any discharge • Tenderness
  • 127. Tonsils 1. The palatine tonsils or simply referred to as 'the tonsil'- inbetween the anterior & posterior pillars of oropharynx 2. The Nasopharyngeal tonsils or the adenoids- in the nasopharynx 3. The tubal tonsils- near opening of eustachian tubes. 4. The Lingual tonsils- in the base of the tongue. Peritonsillar abscess/quinsy Hockey stick appearance
  • 128. TEETH  Caries  Fractured teeth  Hypoplastic teeth  Retained teeth  Erupting teeth  Supernumerary teeth  Any other dental anomalies  Orthodontic evaluation HARD TISSUE EXAMINATION
  • 129. DENTAL CARIES EROSION ABRASIONFRACTURED TEETH HYPOPLASTIC TEETH
  • 130. DMFT INDEX- Klien,Carrole & Knutson(1938) WHO MODIFICATION -1986
  • 131. OHI INDEX - Greene and Vermillion(1960)
  • 137. Other dental anomalies Fusion Hutchinson’s incisor Supernumerary teeth
  • 138. Orthodontic Evaluation • Alignment • Tooth number • Tooth structure • Tooth position
  • 139. Alignment TERMINAL PLANE RELATIONSHIP Baume (1950) MOLAR RELATIONSHIP IN PERMANENT TEETH CANINE RELATIONSHIP-Baume (1950)
  • 140. • Midline deviation • Cross bite
  • 141. -Inter arch relationship • Class II div 1 – more prone for trauma • Bimaxillary protrusion -Presence of crowding/spacing -Deviations/Displacements Malocclusion -Severe skeletal abnormalities -Overjet and overbite -Increased overjet – may predispose to trauma -Anterior open bite – skeletal problem, digit sucking habit, tongue thrust  3mm=abnormal (Reddy et al 2010) Instruments used: Boley gauge (Ravn) Stainless steel scale(Farsi) >3mm overlap = abnormal (Reddy et al 2010)
  • 144. Tooth Position • Ectopic eruption • Transposition • Impaction • Primary failure of eruption
  • 145. Provisional diagnosis  A provisional diagnosis is one that is initially determined to be the diagnosis, except for the fact that all test results have not been received and/or analyzed  Also called Tentative/Working diagnosis  Arrived after evaluating the case history and Clinical examination
  • 146. Investigations • Conventional methods – Visual and tactile examination – Radiographs • IOPA • Bitewing X-rays • Non-conventional methods – Digital radiography – Digital subtraction radiography – Transillumination FOTI & DIFOTI – Fluorescence – Infrared LASER Fluorescence(DIAGNOdent) Dental caries
  • 147. Investigations • Pulp tests to assess vitality – Thermal stimulation • Ethyl chloride • Ice • Dry ice(carbon-di-oxide snow 78 – 108 ˚F) – Electric pulp testing – Test cavity – Laser doppler flowmetry – Pulse oximetry • Radiographs – Extraoral views • To exclude facial fractures – Intraoral view • To assess trauma of individual tooth • Photographic documentation is necessary Dental Trauma
  • 148. OTHER INVESTIGATIONS • Orthodontic treatment planning: Cephalometric analysis Model analysis • Occlusal radiographs • OPG • CT • Vista scan
  • 152. VISTA SCAN LIGHT INDUCED FLUORESCENCE CBCT scan
  • 153. Cold test PULP test : Heat test False negative responses: Recently erupted tooth, Recent trauma Excessive calcifications, Patients on pre-medications
  • 154. ELECTRIC PULP TESTING LASER DOPPLER FLOWMETRY PULP OXIMETRY
  • 156. USES:  Helps in orthodontic treatment planning  Evaluation of treatment results  Helps in predicting the growth related changes and changes associated with surgical treatment. CEPHALOMETRIC ANALYSIS
  • 157. DIFFERENTIAL DIAGNOSIS “Differential diagnosis is distinguishing a particular disease or condition from others that present similar clinical features”. Differential diagnosis can be regarded as implementing aspects of the hypothetico- deductive method, in the sense that the potential presence of candidate diseases or conditions can be viewed as hypotheses that physicians further determine as being true or false. Benign Reactive swelling Inflammatory swelling Posttraumatic swelling Hamartoma Vascular tumors Myofibroma Malignant Lymphoma Soft tissue sarcoma Rhabdomyosarcoma Ewing sarcoma Synovial tumors Fibrosarcoma Differential diagnosis of soft tissue masses/ subcutaneous swelling in children :
  • 158. Final/Definitive diagnosis • Chronologic organization and critical evaluation of the information obtained from the case history, physical/clinical examination and the result of radiologic and other investigative procedures leads to definitive diagnosis. • It identifies the chief complaint first and then the subsidiary diagnosis of other problems
  • 159. In case of pulp therapy in primary teeth
  • 162. In case of pulp therapy in permanent teeth
  • 164. In case of trauma The goal of treatment for traumatically injured teeth is to return the teeth to acceptable function and appearance.
  • 165. Acute treatment: • There are situations where treatment within a few hours can significantly affect the outcome. – Tooth avulsions, alveolar fractures, extrusive and lateral luxations, and possibly root fractures. – Early repositioning and stabilization will promote the best PDL repair Subacute treatment: • Treatment within 24 h after injury allow the following injuries proper care – Concussion, subluxations, and intrusive luxation, and crown fractures with pulpal exposure. – Pulpal and PDL responses do not seem to be adversely affected by a delay of 24 h
  • 166. Delayed treatment: • Crown fractures without pulpal exposure appear to have the same prognosis whether treatment is performed within a few or several hours Immediate care : • It may be initiated with the emergency treatment provided, such as pulp protection for continued root formation in developing teeth with complicated crown fractures. In cases of luxation and avulsion injuries, the immediate concern is to stabilize the tooth in its normal position to allow re-attachment and re-organization of the periodontal ligament support.
  • 167. Emergency treatment – Primary anterior teeth
  • 169. Emergency treatment – Permanent anterior teeth
  • 171. Prognosis • Prediction of the probable course, duration and outcome of the disease based on a general knowledge of the pathogenesis and the presence of risk factor of the disease • Established after the diagnosis is made and before the treatment plan
  • 173. Treatment planning Development of a treatment plan is the most critical step in the successful future management of the child and parent
  • 174. 5 Phases of the Treatment Plan  Emergency Phase/ Acute phase  Systemic Phase  Preventive OR Preparatory Phase  Definitive treatment or Corrective Phase  Maintenance Phase
  • 175. Acute Phase : Emergency Treatments Maxillofacial trauma, Swelling, Systemic infection, Severe pain
  • 176. Splinting periods • Extrusive luxation  2 weeks/flexible • Lateral luxation  4 weeks/flexible • Intrusive luxation  6-8 weeks/flexible • Avulsion  1-2 weeks/flexible Root fracture: • Cervical third  4 months/rigid • Middle/apical third  4 weeks/flexible • Alveolar fracture  4 weeks/flexible
  • 177. Systemic Phase  Premedication  Antibiotic Prophylaxis  Managing anticoagulants  Adrenal/Thyroid insuffiency cases
  • 178. Preventive Phase  Caries risk assessment  Oral hygiene counseling  Diet counselling  P&F sealants  Fluoride application
  • 179. Preparatory Phase - Behavioural managment - Caries control - Oral Prophylaxis - Preventive orthodontics - Extraction of unrestorable teeth • Pre-prosthetic treatment
  • 180. MECHANICAL AIDS: GAUZE PIECE Moist gauze piece wrapped around finger for cleaning gum pads in infants BRUSHING TECHNIQUE Common method : Circular brushing method (or) Fone’s technique is used twice daily. DENTRIFICE No flouridated tooth paste should be used till 3years. Till the child is 7 years of age only pea size quantity of dentrifice should be dispensed.
  • 181. POWERED TOOTH BRUSH Patients who lack manual dexterity Orthodontic patients DENTAL FLOSS Waxed dental floss is used in children Longer handle floss are used Floss with 8 to 10 vertical strokes Floss atleast once a day The important time to floss is before going to bed
  • 182. MOUTH WASH: Chlorhexidine:(rexidin,clohex) Chlorhexidine(CHX) Recommended in a concentration of 0.12% in a range of 5 to 1o ml once daily. Not recommended under the age of 7 years
  • 185. Decision making tree for dental caries(Nyvad & Fejerskov,1997) Status of the tooth Filling Active lesion Cavity Repair/ replacement No cavity Non operative treatment Inactive lesion No treatment Defect Ditching/ Overhanging No treatment/ reburnishing Fracture/ Food impaction Repair/ replacement No defect No replacement Lesion Active Cavity Operative treatment No cavity Non operative treatment Inactive No treatment Clinically sound No treatment
  • 186. Definitve Rx Phase  Restorative and Pulpal treatment  Prosthetic rehabilitation  Orthodontic interventions – serial extractions, space management, tooth movements  Orthognathic surgery  Periodontal therapy
  • 187. Maintenance Phase -3-6 month recalls -review check up of oral health indices -repeat caries activity tests -reinforcement of home care measures -motivation and re-counseling of the parent -follow up of treatment procedures
  • 188. Anticipatory Guidance  It is defined as pro-active counseling of parents and patients about developmental changes that will occur in the interval between health supervision visits that includes information about daily caretaking specific to that upcoming interval.  If child is sleeping with a bottle, or if there are incipient white spot lesions, then the dentist should make recommendations on how to stop the bottle habit or improve oral hygiene.
  • 189. Informed consent • Sufficient information must be given by the dentist to the parent /guardian, so that the parent has a reasonable understanding of the proposed dental care for the child • Basic concepts of informed consent (Schultz,1985) A standard consent form is not a substitute for a dentist parent discussion Nonremote risks to care Any referral to other health providers Consequences if proposed treatment is refused Acceptable alternatives
  • 191. Scheduling operative treatment The following are general rules of thumb • Small, simple restorations should be completed first • Maxillary teeth should be treated before mandibular teeth • Posterior teeth should be treated before anteriors • Quadrant dentistry should be practised • Endodontic treatment should follow completion of simple restorative treatment • Extractions should be the last items of operative care unless the patient presents with an acute problem.
  • 193. References • Pediatric Dentistry: A Clinical Approach by Goran Koch, Sven Poulsen • Dental caries by Ole Fejerskov and Edwina Kidd • Textbook and colour atlas of traumatic injuries of teeth by J.O.Andreasen and F.M.Andreasen • Fundamentals of pediatric dentistry by Richard.J.Mathewson • Pediatric dentistry:principles and practice by M.S Muthu and N.Sivakumar • Textbook of pedodontics by Shobha Tandon • Orthodontics The Art and Science – Balaji • Oral Diagnosis, Oral Medicine and Treatment Planning – Bricker & Langlais • ENLOW AND HANS-facial growth of orthodontics • Grabers textbook of orthodontics • Principles and practice of pedodontics-Arathi rao