DR. AMINAH M ( POST

GRADUATE )

CASE HISTORY, DIAGNOSIS, TREATMENT PLANNING

Synopsis CONTENTS

• 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

diagnosisTo

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 namePatient registration number and date

Age and date of birth

Address/Phone number

Class /SchoolParents 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 aspectsBilling 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

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 testWISC

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

DENTAL AGE :

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

SMIFISHMAN 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 fluorosisFilariasis

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 painProgression of pain Duration of painMovement 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 period Intermittent

• 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

Referred pain

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 historyQuestions 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 HistoryCondition 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 & palateGerman measles in 1st trimester – cleft lip & palateMaternal rubella, fetal alcohol syndrome

ACCIDENTS / TRAUMA -- Orofacial deformities

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 cooperativeFearful ---considerable support requiredHyperactive---child resorts to screaming and kickingComplaint----whining type of behaviourShy/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 dietNo. of meals/dayCariogenic snacks/dayDoes your child eat everything you prepareDoes your child constantly snack on foodFavourite foodsOther 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)

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

Calorierequired

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 sclerosisBrain tumours,CNS)

(Hip elevation exagerrated, a duck-like walk)Muscle dystrophy

the knees and thighs hittingor crossing in a scissors-likemovement (cerebral strokes, multiple sclerosis)

High stepping, Neuropathic gait

typical of Parkinson's in which,during walking, steps becomefaster 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 disordersSluttering 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 ProfileSymmetry

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

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 lymphnodesSubmandibular

lymphnode

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 syndromeVan der woude’s syndromeMelkersson –Rosenthal syndromeCrusted lips(baelz’s disease)Rhagades ChancreHaemorrhagic 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 syndromeKoplik’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 syndromeOrofacial digital syndromeMelkerson-rosenthal syndrome

Atrophy candidiasisBurning sensationPlummer vinson syndromeIron 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 syndromeVander 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 growthJuvenile periodontitis and inflammatory gingival enlargement

PhenytoinCyclosporineNifidipine

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)

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 RELATIONSHIPBaume (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 analysisModel analysis

• Occlusal radiographs• OPG• CT• Vista scan

Dental caries

IOPA

BITE WING RADIOGRAPH

OCCLUSALRADIOGRAPH

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 traumaExcessive 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

In case of pulp therapy in permanent teeth

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

Emergency treatment – Permanent anterior teeth

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 PIECEMoist 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

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 willoccur in the interval between health supervision visits that includesinformation 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 careAny referral to other health providersConsequences if proposed treatment is refusedAcceptable alternatives

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

“ ACCURATE DIAGNOSIS OF A DISEASE DEPENDS UPON THE ART OF TAKING CASE HISTORY”

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