CASE HISTORY DIAGNOSIS AND T/T PLANNING part1

Case History, Diagnosis & Treatment Planning: 

Case History, Diagnosis & Treatment Planning CHETANA BINDRANI First Year M.D.S

BOOK SEMINAR: 

BOOK SEMINAR List of books referred: Richard Mathewson [3] Mcdonald & Avery [9] Jimmy Pinkham [4] Braham & Morris Sidney Finn [4] Coleman and Nelson’s principles of oral diagnosis. Stephen Wei Burkets Oral Medicine & Diagnosis

CASE-HISTORY : 

CASE-HISTORY DEFINITION – Classic form of documentation which ranges from clinical sketches to highly detailed & extended accounts that help in arriving diagnosis & t/t plan of person under study American Association of Pediatric Dentistry,1993: To provide quality care the patient’s record should include: Complete Dental, Medical &Family histories Clinical assessments Physical & Behavioural – Patients physical appearance & behaviour at onset of t/t be recorded.

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OCCLUSAL –The developing occlusion and growth & development of the orofacial complex be accessed. HARD TISSUES-Dental caries and any hard tissues abnormalities be evaluated SOFT TISSUES-Initial oral hygiene with plaque &gingival scores/indices; Prevention needs of patients; Parents attitude be recorded. RADIOGRAPHIC-Enables the diagnosis of dental caries and sequence, oral pathoses & other anomalies.

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LABORATORY DIAGNOSIS CONSULTATION with other health providers, both verbal & written DIAGNOSIS & T/T PLAN – It is formulated from the clinical assessments. T/t plan should be Logical step-by-step process to treat dental health needs A mean to prioritize the needs of patients.

Recording Case History: 

Recording Case History A self-administered questionnaire cane be great value. Ideally, the parent can complete such a form in the waiting room in the initial visit. The pedodontist needs only to glance over the completed questionnaire to spot significant finding Affirmative answers can be elaborated upon further questioning of the parent & patient Special notations are made of this additional information in the patients records. [FINN]

How to present Q’s during diagnostic interview?: 

How to present Q’s during diagnostic interview? OPEN ENDED QUESTIONS CLOSED ENDED QUESTIONS LEADING QUESTIONS CONTRADICTION QUESTIONS INDIRECT QUESTIONS [Coleman & Nelson]

VITAL STATISTICS: 

VITAL STATISTICS Hospital Registration No Record Includes File Keeping , Billing and Legal Purposes Date Records Patient’s First Visit which can be referred back to Name To build rapport with Child Communication Record Purpose Medico Legal Issues

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Nickname Children are at ease when referred to by the same name as they referred at home Age (Chronological Age) To chose behavior management techniques To relate the eruption and exfoliation sequence of teeth To compare dental age and chronological age and if needed to initiate any preventive or interceptive methods of treatment.

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Growth Assessment Parameters To recognize disparities between dental, mental, chronological, skeletal age To correlate dental, mental, chronological, skeletal age To Aid in treatment Planning Growth Modification by means of functional and orthodontic appliances during growth spurts Age Related Diseases Certain Oral Findings like absence of stippling of Gingiva below 3 yrs is a normal Finding

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Sex Sex Specific Disease Hemophilia in males and Juvenile Periodontitis in females Timing of Eruption sequence is slightly earlier in females Variation in timing of growth spurts Behavior Management Techniques Differ Parents Name & Occupation Communication Understanding the socio-economic status

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Address Communication Record Purpose Medico legal Issues To rule out Endemic conditions Eg . Flourosis Chid’s physician / Pediatrician’s name & contact no:

CHIEF COMPLAINT: 

CHIEF COMPLAINT DEFINITION: Symptom or Symptoms described in the patients own words related to presence of an abnormal condition. Concerned about what made the patient visit the dentist Supposed to be recorded in patients/parent’s own words Patients Priority Medico legal Purposes It must be recorded in Chronological Order

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Children often have difficulty characterizing pain or even locating it to a single quadrant Historian is present usually mother. Adolescents have a sense of time & vocabulary that permit characterization of problems

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Questions should be open ended requiring more than a simple “Yes” or “No” answer Patient should not be led to answers, but asked to characterize the trouble as fully as possible.

History Of Present Illness: 

History Of Present Illness Location of Pain: to identify offending tooth or teeth Inception: Pain that started few days/ hours ago Acute Pain present for many days/Months Chronic Provoking/Aggravating factors Pain Increased in lying down : - Pulpal Hyperemia Pain Present only while eating maybe due to deep Caries or reversible pulpitis Spontaneous pain without any provoking factors indicates wide involvement of pulp Attenuating/Relieving Factors Pain that is relieved by removal of stimuli indicates reversible pulpitis

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Duration: Pain following a stimulus for a short period indicates reversible pulpitis Pain that begins on provocation and lingers even after removal of stimulus indicates irreversible pulpitis Intensity and Quality Sharp lancinating pain Acute Condition Dull Gnawing pain Chronic condition Radiation Pain can be radiated to other teeth or tissues this makes it difficult to identify the diseased tooth or teeth Pain in Pulp is difficult to localize as it does not contain proprioceptive fibers unlike the pain of periodontium [BURKET’S OMD]

Dental History: 

Dental History It provides clues about ATTITUDE of patient towards dentistry. First Visit Yes/No MCTIGUE (1984) points that potentially uncooperative behavior may be related to fear sustained through past unpleasant dental experience. Questionnaire should elicit if the child is previously seen by ANOTHER DENTIST and if so the what the OUTCOME was in term of behavior displayed. Also if the parent was not satisfied with the previous dentist the knowledge of WHAT CAUSED THE DISSATISFACTION may lead to better dentist-child-parent relationship.

Medical History: 

Medical History list of medical history-by Scully and Cawson - A nemia - B leeding disorders - C ardio respiratory disorders -Drug treatment and allergies - E ndocrine disorders - F its and faints - G astrointestinal disorders -Hospital admissions and surgeries - I nfections - J aundice - K idney disease antibiotic prophylaxis needed in case of bacterial endocarditis

Infant Oral Health History: 

Infant Oral Health History It should be diagnostic pointing to existing diseases, symptoms of disease or problems that the child has experienced. It should be prognostic providing the dentist with an impression of success of past professional intervention and parental involvement. [B&M]

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Risk elements recommended by American Academy of Pediatric Dentistry Parental health history Diet & Nutrition Fluoride Adequacy Oral habits Oral Development Oral hygiene Injury Prevention & Trauma

PARENTAL HISTORY: 

PARENTAL HISTORY Dental History Parents attitude towards Dentistry & their experiences Have you ever been to dentist before? Nature of treatment? Any unpleasant experience or complication? Reason for dissatisfaction in previous visit/complication? To rule out certain hereditary disorders E.g. Amelogenesis imperfecta Do you or your spouse have a decayed disordered fractured, worn-out or soft teeth?

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To understand parents anxiety or fear Mother-child inter-dependency that initiates infancy and builds well in to pre-school period(4 to 5 yrs) MOTHER’S ANXIETY due to her own dental encounters Anxiety is TRANSMITTED to off-springs creating phobia of dentistry [Mathewson]

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Medical history Hereditary disease Consanguineous marriage Consanguinity : amount of shared DNA, the genetic material Percentage of Consanguinity between two cousins increases FOUR FOLD. [HGC] Latin American Collaborative Study Association between Consanguinity and hydrocephalus, polydactyly & bilateral oral and facials Clefts. Also 50/1000 births Congenital Heart Diseases

Prenatal History: 

Prenatal History It often provides clues to the origin of abnormal color & structure of deciduous & permanent teeth. The pedodontist sees the effects of DRUGS & METABOLIC DISTURBANCES which occurred during the formative stages of teeth Q:Did you take any antibiotics during pregnancy? Certain drugs cross the placental barrier & have adverse effects on dentition of the fetus

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Q:Did you take any flouride supplements ? Excess ingestion of flouride can affect the ameloblasts during the tooth formation stage and cause dental flourosis or mottled enamel. Levy & colleagues observed Flourosis of primary teeth in 12.1% of 504 children, based on their estimates of fluoride ingestion prenatally and during first year of life.

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Q: Is there any Rh incompatibility between you and your spouse? ERYTHROBLASTOSIS FETALIS: Bluish green discoloration of teeth and a ‘hump’ on tooth appearance.

Natal History : 

Natal History Low BIRTH WEIGHT children are predisposed to increased risk of dental caries since they receive special diet [Burt BA,Pais Dental Edu 65:1024-1027,2001] Also PREMATURE BIRTH are associated with hypoplastic dentitions [ Lseow VJK:Effects of premature birth on oral growth &development, Aust Dent J 42:84-90,1997] NATURE OF DELIVERY gives an idea about trauma to TMJ during forcep delivery

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History of Jaundice: Immature RBCs in an infant are rapidly destroyed in the spleen, this increased bilirubin cannot be sufficiently cleared by the liver leading to a transient jaundice in the child known as NEONATRORUM JAUNDICE. BLUE BABY OR CYANOSED BABY is a term used to describe newborns with cyanotic conditions such as Tetralogy of Fallot .

MEDICAL: 

MEDICAL VACCINATIONS Indian Academy of Pediatrics Committee on (immunization, 2006) Birth BCG, OPV, HBV 6 weeks OPV1, DPT1, HBV1 10 weeks OPV2, DPT2, HBV2 14 weeks OPV3, DPT3, HBV3 9 months Measles Vaccine 15-18 months MMR, OPV4, DPT, HBV 2 yrs Typhoid Vaccine 5 yrs OPV5, DPT5 10 yrs TT 16 yrs TT

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Vaccination Schedule for Adolescents Tetanous Toxoid Boosters 10 & 16 yrs Rubella Vaccine or MMR vaccine 1 dose at 12-13 yrs (if not given earlier) Hep B Vaccinne 0,1 and 6 months (if not given earlier) Typhoid vaccine Every 3 years

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Development Milestones 6-9 months 12-23 months 24 months Intellectual Development Opts for spoon, imitates action of adults Copies sound & action, understands simple commands 3-4 word sentences, puts toys in group Gross/Fine Skills Rolls over, able to sit independently Stands with handheld, sits without support Scribble /draws shapes, throw balls Psychological Development Laughs and squeals with delight, screams if annoyed Shows affection to Adults, fears of strangers and separation Changeable feelings, recognizes emotions

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FLUORIDE ADEQUAUCY Fluoride adequacy refers to the adequacy of drinking water to provide optimal fluoride but also address the proper role of dentifrice in reducing likelihood of flourosis . Fluoride supplements orally or fluoridated drinking water.

Diet History: 

Diet History Feeding during Infancy Inadequate Breast feeding and early introduction of bottle feeding is an indication of low muscular activity which may result into developing Malocculusion . [ Karjalainen , 1999] Persistence of substantial nonnutritive sucking habits beyond 3 yrs reflects a psychological disturbance suggestive of inability to manage stress or anxiety.

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Dietary Habits to be Noted Snacking between the Meals: Stephen’s curve states that the pH of the plaque drops and remains below a critical level at which enamel decalcification can occur for an average of 20 mins after the introduction of sucrose into the mouth. Adequacy of diet/balanced diet US Department of Agriculture, March 1999 recommended a food guide pyramid.

Diet Diary/Chart: 

Diet Diary/Chart 24 Hr recall or a 5 day history is recommended Particular attention to the number of exposures to CHO per day Every Exposure to a food containing refined CHO, specially one that adheres to the teeth and dissolves slowly produces acid in and around plaque [Pinkham] More than 3 Exposures to sugar per day places the child in a higher Caries risk category [AAPD Reference Manual, 25:54, 2003]

History Related to Oral Hygiene Measures: 

History Related to Oral Hygiene Measures Certain Questions are asked which enable the dentist to develop an effective dental disease prevention programme Q: How does you child clean his teeth? How many times a day does he/she clean the tonque ? Which Dentifrice do you use(Fluoride/ Non Fluoride) ? Does your child use any Mouthrinse ? Does his/her gums bleed easily?

History Related to Swallowing Type: 

History Related to Swallowing Type NORMAL Infantile Swallow: Tongue lies between the gum pads and the mandible is stabilized by obvious contraction of facial muscles especially buccinator muscles MATURE Swallow Pattern: Appears gradually with eruption of the primary incisors. The Child tends to swallow with teeth brought together by masticator muscles action without a tongue thrust. RETAINED infantile swallowing: Persistence of infantile swallowing pattern even after arrival of permanent teeth. One thrusts the tongue between the teeth in front and on both the sides, Noticeable contraction of buccinator

History Related to Teething: 

History Related to Teething Teething history is recorded since it is most likely the first postnatal oral issue that parents confront. The timing of eruption is a frequent source of parental anxiety [J Pinkham] Some infants exihibit signs of systemic distress including a rise in temperature, diarrhea, dehydration, increased salivation and gastrointestinal disturbances [Tooth eruption symptoms: a survey of parents and Health Professionals. J. Dent Child 69:148- 150,2002] [Teething and tooth eruption in infants: A Cohort study Pediatrics 106,2000]

History Related to Oral Habits: 

History Related to Oral Habits Non-nutritive sucking: Digit/Thumb sucking Pacifiers use? Sugar coated/non-sugar coated? Mouthbreathing Bruxism Tobacco (in case of adolescents)

Social and Behavioral History: 

Social and Behavioral History Today the aim and scope of effective patient management evolves from the study of child’s psychology and sociologic involvement. The socio cultural and inter personal aspects of pediatric patients are important part of the expanding pre-doctoral curriculum of behavior dentistry. [ Mathewson] Q: Does he/she make friends easily and mixes with people? Which games does your child prefer?

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Older siblings sabotage a child’s adaptive behaviour willingly or unwillingly A child will model older sibling’s behaviour , Good or Bad [Mathewson] Fear and/or anxiety of patient should be recorded Q: Is he/she afraid of visiting Dentist? Do you know why?

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Frankl’s Rating Can also be extended to include pets and hobbies Rating No. 1 Definitely Negative (- -) Refuses T/T Cries Forcefully Extremely Negative, Associated Fear Rating No. 2 Negative(-) Reluctant to accept T/T Displays slight Negativism Rating No. 3 Positive (+) Accepts Treatment Tense Cooperative Behavior Rating No. 4 Definitely Positive(++) Unique Behavior Looks Forward Understands importance of Good Preventive Care

CLINICAL EXAMINATION: 

CLINICAL EXAMINATION The four main functions of examination of child Identification of unknown or undiagnosed disease Recognition and determination the extent and implication s of known disease Corroboration or interpretation of historical information Establishment of baseline data for behavioral management [B raham and Morris]

Vital Signs: 

Vital Signs The role of Vital Signs in the general appraisal is twofold: To identify Abnormalities To satisfy the Medico Legal role of providing Baseline health data in Emergency situations. The standard of care now demands that the dentist be able TO MANAGE EMERGENCIES, both in routine and when medication is being used in conjunction with dental treatment. Critical to emergency management are baseline data on height, weight, BP, pulse and respiration. [ Braham and Morris]

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BP, Pulse, Respiration may be put off until the child has become accustomed to the environment but before any drugs are administered. AGE PULSE RESP B.P. 6-9 Mnths 120 30 105/67 22-23 Mnths 120 28 105/69 24+ 110 25 106/68 3 Yrs 105 30 100/60 4 Yrs 100 28 100/60 5 Yrs 100 26 100/60 6 Yrs 100 23 105/60 9 Yrs 90 20 110/65 12 Yrs 85 18 115/65

Height and Weight: 

Height and Weight Height recorded using a stadiometer together with weight serves as an index of physical development It also helps in determination of Drug doses

Gait: 

Gait As the child walks into the dental office, the examiner can quickly ascertain whether the gait is normal or affected. Abnormal Gait includes Spastic Gait Trendelenburg Gait Magnetic gait Scissor Gait Limping

Speech: 

Speech Speech retardation can be considered if the child does not speak upto the age of 3 [ Causes: Hearing loss, Intellectual Retardation, Genial Development Retardation] Articulatory disorders Lisping: Substitution of “ th ” sound for “s” Interdental lisping Dental lisping Phonemic Disorders:

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Voice Disorders Apraxia: Rearranging of sounds in a word Stuttering: Repetition of words Cluttering Aphasia: Loss of speech , secondary to CNS, rare .

Hands: 

Hands By taking the child’s hand in his, the dentist not only establishes a warm communication but also is afforded an opportunity to further appraise the general health Increased moisture many indicate sweating due to anxiety All primary and secondary skin lesions such as macules , papules, vesicles, ulcers can be observed here Number, shape of child’s fingers

Nails: 

Nails Spoonshaped Pitted Absent Bitten & Short Extremely Clean Nails with Callous Deposition Clubbing Cyanosis A hand radiograph can be used to access the skeletal age of the child to co-relate with chronological age. A 5” x 7” radiograph of left hand can be taken with dental x-ray machine to determine the skeletal age.

LOCAL EXAMINATION: 

LOCAL EXAMINATION Extra-oral Examination Shape of Head Cephalic Index = Transverse dimension/ Anteroposterior dimension Martin & Saller Classification [ 1957] Mesocephalic : Avg CI= 76-80.9 Dolicocephalic : Long & Narrow CI=<75.9 Brachycephalic : Broad & short CI=>81

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Dolicocephalic Mesocephalic Brachycephalic

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Shape of Face Morphological Facial Index= Morphological facial ht/ Bizygomatic Width Martin & Saller Classification [ 1957] Mesoprosopic : Average, square, MFI= 84-87.9 Dolichoprosopic : Long and narrow, Oval, MFI= 88-92.9 Euryprosopic : Broad and Short, Round, MFI= 79-83.9

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Dolichoprosopic Euryprosopic Mesoprosopic

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Facial Profile Straight- Nasion , point A & Pogonion are in same vertical plane Convex- Point A is ahead or Pogonion is behind. Concave- Point A is behind or Pogonion is ahead.

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Facial Symmetry Can be Physiological or Pathological Infant sleeping habits particularly in children born at less than full term have been shown to affect the shape of face permanently Pathological Facial Symmetry Infections, Trauma, Cranial Nerve paralysis, Intra Uterine pressure, Unilateral condylar hyperplasia, unilateral ankylosis of TMJ, parotid enlargement

Hair and Skin: 

Hair and Skin A number of primary and secondary skin lesions may be found on the face The careful dentist may wish to postpone a dental visit for the child who has a large, painful herpes lesion on the lip or face. A discreet round area edged by a raised, indurate, inflamed line is diagnostic of ring worm. Alopecia or hirsutm should be noted Hair :- Quality, Thickness Colour :- Dryness and premature graying in malnourishment Also check for child abuse, chemotherapy

Temporo-Mandibular Joint: 

Temporo-Mandibular Joint While standing at back of the child the dentist may place his hand in front of tragus and ask the child to open and close his mouth slowly. Notation should be done of any clicking sound is heard crepitus is felt or tenderness. To check for the deviation, a 15-18 inches piece of dental floss is pressed against his face in the mid-line connecting forehead, point of nose and chin point, And the patient is asked to open and chew on his back teeth [ Burket’s OMD]

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Examination of TMJ

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Common Causes In children Infection following a mandibular permanent molar Extraction Eruption of lower permanent molar Crepitus : Cartilage around the joint has eroded and joints rub against each other

Ears: 

Ears Diagnostic technique: Visualization, palpation, assessment of hearing. Abnormal findings: Malformed ears Eg . Treacher Collins Syndrome tenderness on palpation can be due to radiating pain from the oral cavity. Acute otitis media (PACIFIER USE)

Eyes: 

Eyes Diagnostic technique: Visualization, Assessment of vision Abnormal Findings : Pallor Icterus Infection Hypertelorism Coloboma Blue sclera photophobia

Nose: 

Nose Diagnostic technique : Visualization Abnormal Findings : Malposition & Malformation ( eg median facial cleft) Saddle Nose

Lymph nodes: 

Lymph nodes Submandibular & Submental Lymph Nodes: The patient is asked to look down & slight flex towards the side on which lymph nodes is examined.The operator stands behind the patient & palpates with the pulp of fingers. 3 to 6 in number placed in the submaxillary triangle Enlargement of cervical group of lymph nodes in absence of infection suggests systemic diseases such as syphillis TB, Leukemia, lymphoma.

Examination of Lymph nodes: 

Examination of Lymph nodes