CASE HISTORY

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Department of PEDODONTICS : 

Department of PEDODONTICS CASE HISTORY

History : 

History Clinical history of the child is done with the logical and orderly sequence of observations and examinations procedures and in a smiling, kindly manner. This art and science of patient evaluation is the key to treatment planning.

SEQUENCE OF CASE RECORDING : 

SEQUENCE OF CASE RECORDING VITAL STATISTICS CHIEF COMPLAINT HISTORY EXAMINATION ORAL HABITS CLINICAL EXAMINATION OCCLUSAL RELATIONSHIP ANALYSIS DENTAL CARIES EVALUATION PROVISIONAL DIAGNOSIS INVESTIGATION FINAL DIAGNOSIS TREATMENT PLANNING

VITAL STATISTICS : 

VITAL STATISTICS NAME For indentification To maintain records Communication To build rapport Recording nicknames is useful SEX Certain diseases are common in one sex such as haemophilia in males or juvenile periodontitis in females Timing of eruption sequence earlier in females Variation in timing of growth spurts.

AGE : 

AGE The chronological age should be compared with other ages (dental, skeleton) so as to know whether growth and development is normal Certain diseases occur in certain age groups like juvenile periodontitis, acute herpetic gingival stomatitis To relate eruption and exfoliation Behavior management techniques may vary

VITAL STATISTICS : 

VITAL STATISTICS HOME ADDRESS Communication Some areas might be endemic to certain diseases Assessing parent occupation and socio economic status Helpful to co-relate patients chronological age with mental age Indicates about socio economic background SCHOOL ADDRESS Helpful to co-relate patients chronological age with mental age Indicates about socio economic background

CHIEF COMPLAINT : 

CHIEF COMPLAINT Reason which prompted the patient to seek dental treatment. Might be referred by another dentist Recorded in patients own words

HISTORY : 

HISTORY History of present illness Type of pain (sharp, dull, continous, intermitent, mild, etc). History of current problems should be carefully documented, which includes the onset, nature & intensity, duration,location,relieving &exacerbating factors, associated symptoms

TYPE OF PAIN : 

TYPE OF PAIN Sharp pain – Reversible pulpitis Shooting pain – Irreversible pulpitis Momentary pain – Exposure of dentin from a leaking restoration or open lesion. Persistent pain – Wide spread inflammation of the pulp

Past dental history : 

Past dental history Previous treatment-how the child has coped with other forms of treatment. If any preventive treatment has been undertaken. History of previous bad experience needs careful handling

PAST MEDICAL HISTORY : 

PAST MEDICAL HISTORY Medical history should be taken in a systematic fashion, covering all the systematic areas in the body. systemic problems, major areas include CVS,CNS,endocrine,GIT,respiratory tract. Allergies Past operations or treatment/medications Immunization eg:BCG, polio, DPT, hepatitis B

HISTORY : 

HISTORY FAMILY HISTORY Any history of serious illness. Attitude of parents towards oral hygiene, health and dentistry. Hereditarily influenced development of the patient.

PERSONAL HISTORY : 

PERSONAL HISTORY

PERSONAL HISTORY : 

PERSONAL HISTORY ORAL HABITS HISTORY INCLUDES RECORDING FREQUENCY,INTENSITY,DURATION OF HABITS LIKE DIGIT SUCKING,TONGUE THRUSTING,NAIL BITING,BRUXISM,MOUTH BREATHING.

BEHAVIORIAL HISTORYFrankel’s rating scale : 

BEHAVIORIAL HISTORYFrankel’s rating scale

CLINICAL EXAMINATION : 

CLINICAL EXAMINATION HEIGHT-Normal,too short, too tall WEIGHT-Over weight or under weight BUILD-endomorph, ectomorph, mesomorph. Nourishment-well nourished or under nourished

Clinical examination : 

Clinical examination GAIT MOST COMMON-weak, unsteady gait of lethargy & malaise in ill patients. Others-waddling, equinus, scissors, hemiplegic, wobbly, staggering & ataxic gaits. SPEECH DISORDERS CAN BE ASPHASIA DELAYED SPEECH STUTTERING OR REPITITIVE SPEECH CLUTTERING ARTICULATORY SPEECH DISORDERS.

EXTRA ORAL EXAMINATION : 

EXTRA ORAL EXAMINATION FACIAL SYMMETRY/DEFORMITIES FACIAL ASYMMETRY CAN BE PATHOLOGICAL ABNORMAL INTRA-UTERINE PRESSURES,FIBROUS DYSPLASIA,CRANIAL NERVE PARALYSIS OR PHYSIOLOGICAL EYES Observation includes-action of lids,presence or absence of inflammation,swelling or puffiness around the eyes,conjunctivitis,abnormal lancination Inflammation>maxillary teeth>orbital region>swelling>conjunctivitis

SKIN : 

SKIN Number of primary &secondary skin lesions may be found on the face Postponed dental visit for child who has large painful herpes lesions or other type of sore on lip or face

LIPS : 

LIPS Lips can be competent/incompetent Ulcers,vesicles,fissures&abrasions are frequently seen in lips Lips protect teeth from trauma>frequent site of contrusions in child Nutritional &allergic reactions>cause changes

LYPMH NODES : 

LYPMH NODES Submandibular, sub mental lymph nodes are once commonly involved during dental infections Cervical lymph nodes & others in the head and neck should be checked in routine procedure Sub maxillary nodes enlarge>respiratory infection Palpable nodes>oral infection or neoplasms

TMJ EXAMINATION : 

TMJ EXAMINATION Diagnostic method Dentist places his finger in the area of tmJ >child opens &closes his mouth slowly>from closed centric>have him move into the lateral motions>askin him to chew slowly on his back teeth This shows the discrepancies of the tmj,muscular imbalances &anatomic deviation from the mid line Trismus or spasm of the masticatory muscles>infection >following and permanent molar extraction

INTRA ORAL EXAMINATIONSSOFT TISSUE EXAMINATION : 

INTRA ORAL EXAMINATIONSSOFT TISSUE EXAMINATION CHEEKS/VESTIBULE/LABIAL/BUCCAL MUCOSA Any lesions or changes in the color or consistency should be evaluated Any ulcerations,pallor, growth may indicate anaemia Yellowish discoloration>jaundice Koplik’s spots >onset of measels Lesions associated with HSV Palate Childs head tips slightly backwards for correct observation Scars on palate>evidence of past trauma or surgical repair of anomalies Color changes>neoplasms, infections of systemis disease,trauma or chemical agents

GINGIVA : 

GINGIVA High maxillary labial frenal attachment >abnormal spacing between central incisors Redness or swelling >gingivitis Draining fistulae>attached gingiva >tenderness,pain,&some tooth mobility>abscessed teeth As tooth eruptes>overlying gingiva>swollen, painful

TONGUE : 

TONGUE Dryness of tongue >dehydration Pathologic enlargement> cretinism, mongolism,cyst,neoplasm Desquamation> avitaminosis , anaemia Short lingual frenum >tongue tie Tongue is coated in febrile state

HARDTISSUE EXAMINATION : 

HARDTISSUE EXAMINATION Teeth present Determined and noted using FDI coding For both primary and permanent teeth Number of decayed ,missing & filled teeth is noted

STAINS : 

STAINS Stains may be intrinsic or extrinsic Extrinsic stains >chromogenic bacteria Generalised discolorations of enamel and dentine >intrinsic factors (blood dyscrasias, amelogenesis & dentinogenesis imperfecta, internal resorption and drugs) Check for plaque & calculus

OCCLUSAL RELATIONSHIP ANALYSIS : 

OCCLUSAL RELATIONSHIP ANALYSIS Molar relationship (Angle’s class 1,2&3 for permanent teeth) For primary teeth based on Baumes terminal plane relationship into flush terminal plane , mesial step &distal step terminal Canine relationship(1,2&3) Incisal relationship (overjet &over bite) Midline: normal or deviated Archlength :adequate/inadequate Also check for crossbites, supernumerary teeth/congenitally missing teeth

DENTAL CARIES EVALUATION : 

DENTAL CARIES EVALUATION BLACKS CLASSIFICATION WITH MODIFICATION

PROVISIONAL DIAGNOSIS : 

PROVISIONAL DIAGNOSIS It is a general diagnosis formulated for every patient based on clinical impression without any lab diagnosis It influences the final diagnosis and treat ment planning

INVESTIGATIONS : 

INVESTIGATIONS Percussion reveals the status of periodontium and not of the pulp Percussed first lightly with index finger followed by the handle of the mouth mirror Palpation Mobility Radiographic examinations(IOPA,bitewing,OPG,lateral ceph) Other investigations if any

FINAL DIAGNOSIS : 

FINAL DIAGNOSIS The art or act of recognizing the presence of disease from its signs or symptoms, and deciding as to its character; also, the decision arrived at. Lab diagnosis is also considered

TREATMENT PLANNING : 

TREATMENT PLANNING Treatment planning can be divided into four phases Emergency phase( treatment of emergencies) Preparatory phase (preventive phase) Corrective phase (restorative phase) Recall and maintenance

EMERGENCY PHASE : 

EMERGENCY PHASE Extraction of grossly decayed painful tooth or a tooth that is severely mobile. Management of Trauma. Endodontic treatment of painful tooth Developing Cross bite correction.

PREPARATORY PHASE : 

PREPARATORY PHASE Oral Prophylaxis Temporary restorations Topical Flouride Application Pit & Fissure Sealants Diet Counselling Patient Education & motivation

CORRECTIVE PHASE : 

CORRECTIVE PHASE Permanent restorations Orthodontic appliances & Treatment

RECALL &MAINTAINECE : 

RECALL &MAINTAINECE Evaluation of effectiveness of the preventive programme Evaluation of Restorative care Evaluation of tooth guidance treatment