Case History

CASE HISTORY

DIAGNOSIS, ASSESSMENT AND TREATMENT PLANNING

IN PEDIATRIC PATIENTS

Dr. A. Victor Samuel MDS Dept. of Pedodontics

Contents

• Introduction• Diagnosis• History taking and clinical

examination• Patient information• History taking• General physical examination

• Extra-oral examination• Intra-oral examination A) Soft tissue examination B) Hard tissue examination• Provisional diagnosis• Differential diagnosis• Investigations • Final diagnosis• Treatment planning• Prognosis

Introduction

• The case history enables the patients to communicate symptoms, feelings and fears and the sequence of events leading to the problem for which the patient seeks professional assistance.

• It involves eliciting and recording of relevant information from the patient and parent to aid in the overall diagnosis of the case

• It should be systematic and should follow a definite outline

Gathering this information:• Can be essential in establishing

a correct diagnosis• It allows assessment of the

patient’s mental and behavioral status.

Few terminologies in case history recording

• Diagnosis –The determination of the nature of the disease.

• Symptom –Any morbid phenomena or departure from the normal, in structure, function or sensation experienced by the patient and indicative of a disease.

• Sign –Any abnormality indicative of disease, discovered on examination of the patient (an objective symptom of a disease).

DIAGNOSIS

• Diagnosis is derived from the Greek word dia = by and gnosis = knowledge

• Diagnosis has been defined as

identification of disease. (Donald Kerr and Major Ash 1970)

SPECIFIC DIFFERENCES BETWEEN PEDODONTIC AND ADULT DIAGNOSIS

AND TREATMENT PLANNING

• Physical, Emotional and Psychological differences:

• Consideration of behavior as a integral part of the child’s oral health needs

• Attention to preventive care rather than rehabilitative process

• Acknowledgment of a Dentist-Patient relationship that is triangular rather than linear

• Recognition that the child is a changing person

HISTORY TAKING AND CLINICAL EXAMINATION

I) Personal information

Date

a) It records the time the patient reported.

b) Can be referred back to during the follow- up visits.

Hospital number/Case number

– For the purpose of maintaining record

– For billing the individual– For legal considerations (in view of

Consumer Protection Act)

Patients name

– To establish a better communication with the patient.

– To establish a rapport with the patient.

– Maintenance of record.– To elicit the history properly.– Medico legal purpose.

Age The chronological age (date of birth) should

be noted.1) To compare with other ages (dental,

skeletal) so as to know whether the growth and development is normal in the child.

2) Certain diseases are known to occur frequently at particular ages 3) Depending on the age the behavior management techniques also vary.

Sex

– Girls age faster than boys and

thus their treatment may be required earlier.

– Some diseases are more common in females than in males.

– A combination of age and sex can sometimes give an indication of occurrence of disease

Place of birth

• It gives information about the endemic diseases in the area (particularly fluorosis as relevant to dentistry)

Address

– It is used for all communications even before the first visit.

– By knowing the locality along with the family income and parent’s occupation, the socio-economic status can be assessed.

– If the patient is coming from a far distance, the appointments can be modified to complete treatment in fewer visits.

– It may indicate diseases endemic to the particular areas.

Socio-economic status

a) Treatments can be modified according to the socioeconomic status.

b) Patients background can be understood in a better way.

Languages known

– Mother tongue– To establish better communication

with the patient.– To built a good rapport.

School and class

– To know the economic status.– To communicate with the teacher.– To assess the IQ of the child.– To establish effective

communication at his own IQ level.

Race/ethnic origin

– Some diseases are more common in certain races.

– Oral hygiene practices may be common in some religions or races.

Person accompanying the child

• Child’s family life can be assessed.

• The information which has to be asked can be modified according to it

• The reliability of the information may also be evaluated

Parents name

For better communication with the parents

Parents education:To evaluate their knowledge level

and awareness Parents occupation:To evaluate the socio-economic

status

II) History taking

Chief complaint

It is defined as symptom or symptoms, described in patient own words, related to the presence of an abnormal condition.

• The age of the patient apparently influences the quality of the complaint.

• The parent is often the best historian in younger children.

History of present illness

Chronological account of the chief complaint and associated symptoms from the time of onset to the time the history is taken.

• The most common presenting illness can be

evaluated as, 1) The onset 2) Duration 3) Location 4) The quantity, quality, severity

and frequency of occurrence 5) Aggravating and relieving factors 6) Associated symptoms

Past dental history

a) It gives information about the patients past

dental problems.b) Frequency of dental

visit by the patient which gives an indication of

the patient’s future

behavior.c) Patient’s attitude

towards previous dental treatment.

d) Any untoward complication of dental

treatment.e) To know about any excessive

bleeding in the past dental treatment.f) Reasons for loss of teeth

Medical history• This helps in identifying conditions that could alter, complicate or contraindicate proposed dental procedures.• This should include questions like:• Is the child under the care of physician?• If yes why?• Any Medications taken presently,• Drug name, dosage/duration & indication• Whether the child suffers from any

frequent illnesses (cough, cold etc.)?

• Does your child suffer from any of the

following at present or in the past?• Congenital diseases• Rheumatic fever• Anemia• Bleeding disorders • Asthma• Diabetes• Hepatitis

• Epilepsy• Mental or physical

handicap• Sensory deficits• Speech defects• Kidney disorders• Bone & joint

problems• Growth and

development problems

History of immunization

• DPT vaccine• BCG vaccine• Poliomyelitis• Tetanus vaccine• MMR vaccine

• History of operations, hospitalizations, blood transfusion should be asked

• History of drug allergies is taken such as penicillin, aspirin anesthetic agent etc. the drug should be specified.

Family history

a) It gathers information about diseases that commonly affects more than one member of a family.b) Certain disorders that should be inquired are - Bleeding disorders - Heart disease - Diabetes - Tuberculosis

- Asthma - Allergies - Genetic disorders

-Malocclusionc) Siblings:

Number: Order : Sex :

Social history

• It includes the family situation, the child’s school situation, personality traits, developmental status and the child’s interpersonal relationships.

Prenatal history

• Drug intake during pregnancye.g. tetracycline administration

• Any illness during pregnancy

e.g. hepatitis B infection

• Did the mother suffer from trauma, illness or hospitalization.

• Source of drinking water.

Natal history

• Type of delivery- Normal/C-section/

Forceps Fullterm/Premature • Childs health at birth:

Good/Fair/Poor Specify significant history

Postnatal history

• Method of feeding and duration:

Breast fed/Bottle fed/both

• Does the child sleep with the bottle?

• What are/were the contents of the bottle?

• Is/was a pacifier used-

Type Duration Other details

• Did the child have an erupted tooth at birth or within 30 days after birth?

• At what age did the first tooth erupt in the mouth?

• Which tooth and any associated problems?

• When did the child attain the following developmental milestones?

• Sitting• Standing without

support• Walk • Runs • Speaks in

sentences

Personal history

a) Oral hygiene habits:

• Brushing habits• Method of

cleaning the teeth

• Frequency • Material

• Rinsing habits• At what age was

tooth brushing initiated

• When did the child started brushing on his own?

• Is the child supervised during brushing?

b) Diet:– Patient’s diet

should be assessed.– Number of meals

and in between snacks should be recorded

– If the caries activity is high then diet counseling programs can be employed

c) Oral habits:• Habits such as finger/thumb sucking,

lip biting/sucking, nail biting, mouth breathing, tongue thrusting, bruxism etc. should be recorded.

• The duration of the habit should be noted.

• Also what has been done to make the child stop the habit should be asked.

• Presence of habits such as finger or thumb sucking is considered normal till the age of 3 to 4 yrs beyond that should be considered abnormal.

• Features indicating various habits should be examined

For e.g. a) Finger/thumb

sucking features like anterior proclination and open bite is seen.

b) In case of nail biting presence of clean callus and nails should be examined.

• Minor tooth irregularities such as tooth rotation, wear of incisal edge and minor crowding should be

also noticed.

c) In lip biting habit either of the lips may be involved, with a higher predominance

towards lower lip.• The features are

proclined upper anteriors, retroclined lower anteriors, hypertrophic and

redundant lower lip. Cracking of lips is also

seen.

d) Tongue thrusting: Proclination of anterior teeth,

anterior open bite and bimaxillary protrusion are the common

features. Posterior open bite and posterior cross bite is seen in lateral tongue thrust.

e) Mouth breathing:The features are long and narrow face, narrow nose and nasal passage,contracted upper arch with posterior cross bite, increased overjet

due to flaring of anteriors, anterior marginal

gingivitis and dryness of mouth.

• The various clinical test done to assess mouth

breathing are- Observation Mirror test Butterfly test Water holding test Inductive plethysmography (Rhinomanometry) Cephalometrics

f) In bruxism the patient may have

• Tooth mobility specially in the morning,

• Occlusal wear, • Muscular tenderness,• Headache and • TMJ disorders.

III) General physical examination

• It begins with the first appearance of the child and parents themselves.

a) Built/stature, height and weight: Whether normal for the age. If not

factors responsible should be determined.

b) Gait: An abnormal gait can be associated

with a particular disease.c) Speech: Speech disorders such as aphasia, delayed speech, stuttering,

articulatory speech disorders.

d) Hands: It should be checked for pallor,

cyanosis and icterus. The fingers are checked for

their number (indicative of syndromes), size and shape.

The nails are checked for any clubbing.

e) Skin: It is checked for color and

complexion Any skin lesions, abnormal

texture, color, scars pigmentations, eruptions, marks should be noticed.

f) Hair: Thin and brownish color hair

may be indicative of malnourishment.

• Also texture should be noted

Vital signs

• Temperature: Normal oral temperature is 370C.

• Pulse rate: In children 80-100bpm In adults 70-80bpm• Respiratory rate: In children

16-20/min In adults 12-16/min• Blood pressure: 120/80 mm of Hg

IV) Extra-oral examination

a) Shape of the skull:

• It is classified as

-Brachycephalic -Mesocephalic -Dolichocephalic

b) Shape of the face: Face can be classified in three forms

1) Mesoprosopic- 2) Euryprosopic- 3) Leptoprosopic-

c) Facial symmetry: Gross facial

asymmetries are seen in

-congenital defects, -hemi facial atrophy/hypertrophy, -unilateral condylar ankylosis and hyperplasia.

d) Facial profile: It can be

classified as -straight

-convex

-concave

e) Eyes: The sclera is looked for icterus

and the conjunctiva is looked for pallor.

f) Nose: This can be checked for

deviated nasal septum, position of nostrils and any discharge.

g) Lips: Note lip color,

texture, competence,

surface abnormalities, angular or vertical fissures, lip pits, cold sores, nodules, herpes infection.

h) Paranasal sinuses: Maxillary, frontal, and

ethemoidal are checked for sinusitis.

i) TMJ and function: – Observe for deviations in the path

of the mandible during opening and closing.

– Range of vertical and lateral movement.

– Dislocation – Clicking sound, crepitus

– Tenderness

j) Lymph nodes: The lymph nodes commonly checked are

Submaxillary Submental, and Cervical- Superficial and Deep

– Check for site, size shape and mobility, tenderness, swelling, and lymphadenpathy

– Lymph node palpable is soft –due to infection

hard –carcinoma firm –lymphoma

– No. of lymph node palpable– Diameter – Mobility –mobile in case of infection.

k) Swallow: It can be normal or infantile. The persistence of infantile swallow is

indicated by -protrusion of the tip of the tongue -contraction of perioral muscles during

swallowing -no contact at molar region during swallowing

V) Intra-oral examination

1) Saliva: The flow and viscosity should

be checked for.2) Halitosis: This can occur due to

poor oral hygiene practices or it may be indicative of systemic conditions.

A) Soft tissue examination

1) Labial and Buccal mucosa: Observe for any changes in color,

texture, pigmentations, hyperkeratotic patches, ulcers, swellings, fistulae, and

tenderness.2) Vestibule: Look for the color, texture, swelling

fistulae, and tenderness. Note the frenulum attachment.

3) Tongue: Inspect the

dorsum of the tongue for any swellings ulcers, coating or variation in size.

4) Palate: Inspect for swellings, fistulae,

ulcers, burns, hyperkeratinizations, tenderness, papules, cleft palate & also the depth of the palate.

5) Floor of the mouth:

Character and extent of secretions from the salivary ducts, swellings, ulcers, color, nodules, and patches.

6) Gingiva: The color,

contour, shape, size, consistency, surface texture, and position is checked for.

Any swellings, ulcerations, pus discharge, sinus tracts, erythema is checked for.

7) Frenal attachments: Labial frenum at times can be

thick and may be attached to the incisive papilla which may cause midline diastema.

Blanch test can be used for confirmation

Short lingual frenum can cause ankyloglossia.

8) Tonsils and Adenoids: Enlarged adenoids should be

checked for.

B) Hard tissue examination

1) Teeth present: Number of teeth present in both upper and

lower arch should be noted.2) Type of dentition: Whether primary, permanent or mixed 3) Missing teeth: Note whether the teeth is congenitally

missing or missing following extraction.

4) Caries:

5) Caries with pulp involvement:

6) Root stumps:

7) Filling present:

8) Mobility: Grade of mobility

should be mentioned

9) Fractured teeth:

10) Retained teeth:

11) Erupting teeth:

12) Supernumary teeth:

13) Any wasting diseases: Like attrition, abrasion, and

erosion

14) Hypoplastic teeth

15) Any other dental anomalies:

16) Orthodontic evaluation:

a) Molar relation: b) Terminal plane

relation: c) Canine relation: d) Overbite: e) Overjet:

f) Midline deviation:

g) Crossbite:

h) Space loss:

i) Ectopic eruption:

j) Other significant findings:

17) Deposits: Check for calculus

supragingivally and subgingivally. Stains- Extrinsic Intrinsic

VI) Provisional diagnosis

• A general diagnosis based on clinical impression without any laboratory investigations.

VII) Differential diagnosis

• The process of listing out two or more diseases, having similar signs or symptoms of which only one could be attributed to the patient’s suffering.

VIII) Investigations

• Radiographic investigations:• Radiographs are of two types- 1) Intraoral 2) Extraoral

1) Intraoral radiographs

A) Intraoral Periapical radiographs

B) Bitewing radiograph:

C) Occlusal radiographs:

2) Extraoral radiographs

A) Ortho pantomographs:

B) Cephalographs:

Hematological investigations

• RBC count• Hemoglobin determination• Hematocrit count• Platelet count• Bleeding time• Clotting time• Torniquet test• Prothrombin time• White cell count• Differential count

Bacteriological culture and sensitive tests

• Wound abscess or surgical lesion cultures

• Caries activity tests• Root canal cultures• Fresh moist preparations and

smears

Other tests

• Vitality tests• Biopsy• Photographs• Study models

Advanced diagnostic aids

1) Probes: -Perio temp probe -Fluoride probe -Foster-Miller probe -Toronto automated probe -DNA probe

2) Other aids: -Xeroradiography -CADIA (Computer Assisted Densitometric Image

Analysis system) -Computers -Ultrasonics

IX) Final diagnosis

• A confirmed diagnosis based on all available data.

X) Treatment plan

Phases of treatment planning

• Emergency Phase:

• Systemic phase:

• Preventive phase:

• Preparatory phase:

• Corrective phase:

• Maintenance phase

XI) Prognosis

• It the prediction of the course, duration and termination of a disease and the likelihood of its response to treatment.

References

• Dentistry for child and adolescents- Ralph. E .McDonald

• Clinical Pedodontics- Finn• Textbook of Pedodontics-Shobha

tandon• Oral diagnosis-Donald Kerr,

Major Ash

• Orthodontic- The art and science- I S Bhalaji

• Color Atlas of Oral Diseases in Children and Adolescence

• Pictures from -www.google.com