case history diagnosis and treatment planning in pediatric dentistry

PRESENTED BY

DR. SWATI MANOHAR(PAPPULWAR)

PG STUDENT PEDODONTICS

CASE HISTORY EXAMINATION AND TREATMENT PLANNING IN PEDIATRIC

DENTISTRY

INTRODUCTION

• Successful dental care for children is best achieved after thorough examination, thoughtful diagnosis and formulation of a proper treatment plan.

• Pediatric dentist has a specific skills in management, diagnosis and treatment planning of a child which are different from those experience with adult patients.

IMPORTANCE OF RECORDING CASE HISTORY

PERSONAL INFORMATION • Name

• Age: diseases seen in infancy, childhood and young adult

- to determine exfoliation and eruption sequence

- determine treatment plan

- behavior management technique

- child drug dose

- growth assessment parameter

• Gender

• Address

• Language known

• Date birth

• Name of accompanying person

• Patient’s name and education

• Contact number

• Chief complaint of the patient

HISTORY OF PRESENT ILLNESS

• Information should be collect by asking various questions

include:

Mode and duration of onset

Cause of onset

Duration and progress

Any treatment done

Any medication taken

DETAILED HISTORY OF PAIN

History of pain should be elicited in detail which include • Location of pain• Origin or mode of onset• Intensity of pain• Nature• Progression

• Duration• Radiation of pain• Effect of functional activity• Association with any systemic effects

DETAILED HISTORY OF SWELLING

• Mode of onset• Progress of swelling• Symptoms• Associated features• Secondary changes• Impairment of function• Any medication

PAST MEDICAL HISTORY

• Child under any physician care

• Medication and allergy

• Hospitalization

• Blood transfusion

• Immunization status of child

IMMUNIZATION SCHEDULE

FAMILY HISTORY • Siblings

• Socioeconomic status

- B.G PRASAD SCALE

- PAREEK CLASSIFICATION

- KUPPUSWAMY SCALE

PRENATAL, NATAL AND POST NATAL HISTORY

• Health of mother during pregnancy

• Diseases to mother

• Accident/ trauma during pregnancy

• Abnormal fetal position

Natal History :

Trauma, childhood disease Developmental mile stones :

Importance

Developmental milestones for infants- toddlers, 3- 6 years and 6- 12 years

Post natal history:

Feeding habit : breast feeding or bottle

SOCIAL/ BEHAVIORAL HISTORY

• School• Performance at school• Fear • Learning, concentrating, reading, co operating

and understanding problem: IQ of the child

PERSONAL HISTORY

• Habits • Tooth brushing techniques

Duration , frequency, technique• Tooth paste – fluoridated and non

fluoridated

DIET HISTORY

• Diet diary • 24 hour recall period

DENTAL HISTORY

• 1st dental visit • Tooth ache, trauma in past • Fluoride treatment

EXAMINATION OF THE PATIENT

• General examination – its importance in detail

Stature

Gait

Speech

Hands

Cyanosis

Icterus

Nails

Extra oral examination

• Shape of head• Skin on the face• Shape of face• Facial profile & symmetry• Ears • Eyes • Nose • Neck

• Lymph nodes- its examination

• TMJ & function- its examination

BEHAVIOR RATING

• Behavior rating scale: frankel classification

• Behavior management : verbal and non verbal communication

PRESENTED BY

DR. SWATI MANOHAR

PG STUDENT

CASE HISTORY EXAMINATION AND

TREATMENT PLANNING

• Protruding ears (also called prominent ears): Ears that, regardless of size, stick out more than 2 cm from the side of the head

• Constricted ears : A variety of ear deformities where the helical rim is either folded over (also called lop ear), wrinkled, or tight

• Microtia : Underdeveloped external ear• Anotia : Total absence of the ear• Stahl's ear : Ears that have a pointy shape and an extra cartilage

fold (crus) in the scapha portion of the ear

• Ear tags: Also known as an accessory tragus or a branchial cleft remnant, ear tags consist of skin and cartilage

• Earlobe deformities: earlobes with clefts, duplicate earlobes, and earlobes with skin tags Cauliflower ear: Abnormal cartilage forms on top of the normal cartilage, resulting in bulky misshapen ears

• Ear keloids: Caused by excessive scar tissue formation after minor trauma, most commonly after ear piercing

• Ear hemangiomas: Most common benign tumor of infancy, can occur anywhere on the body, including the external ear and the salivary gland in front of the ear.

INTRA ORAL EXAMINATION IN CHILDREN

• Examination in infants and toddlers: differs form other age group

• Lip and labial/ buccal mucosa • Tongue,• Palate, • Floor of mouth,

GINGIVA

• Color , size, contour, shape, consistency, surface texture, position.

• Stippling • Bleeding on probing

FRENUM

• TYPES OF FRENUM

Type 1- mucosal attached frenum

Type 2- gingival frenal attachment

Type 3- papillary frenal attachment

Type 4 papillary penetrating frenal attachment

Gingiva in children

Reddish in color Thinner epithelium, a lesser degree of keratinization, and greater vascularity

Gingiva in adults

Coral pink, due to thickness and degree of keratinization , vascularity and pigmented cells

Lack of stippling: Shorter and flatter papillae from the lamina propria.

Stippling is present: it is a form of adaptive specialization or reinforcement for function. Degree of keratinization and prominence of stippling appear to be related

Rounded and rolled gingival margins:Hyperemia and edema that accompanies eruption. Pronounced cervical ridge of the crown in deciduous teeth

Knife edge margins

Consistency is flaccid and retractable: immature connective tissue composition, immature gingival fibres system, increased vascularization

Firm and resilient: increase in collagenous nature of the lamina propria and its contiguity with mucoperiosteum of alveolar bone

• Gingiva:

The connective tissue has comparatively less well-developed net of collagen fibres than in adults. The surface of the col was said to be covered by an odontogenically-derived epithelium that is atrophic, (four cell-layers thick) and has a diminished proliferative activity.

• Alveolar Bone:

The lamina dura is thinner; there are fewer trabecular and larger marrow spaces. There is a smaller amount of calcification greater blood and lymph supply and the alveolar crest appears flatter.

• Periodontal Ligament: It is wider, has fewer and less dense fibers per unit area and has increased hydration with a greater blood and lymph supply than in adults. During eruption the principal fibres are parallel to the long axis of the teeth. The bundle arrangement occurs after the teeth encounter their functional antagonists

• Cementum: It is often thinner and less dense than of adults. It shows a tendency to hyperplasia of cementoid apical to the epithelial attachment. Before the tooth reaches the occlusal plane, a cellular cementum is formed

• Williams periodontal probe is marked in millimeters at the following distances from the probe tip. 1, 2, 3, 5 then 7, 8, 9 and 10 millimeters. The spaces between the 3 and 5 millimeter marking and between the 5 and 7 millimeter marking are to avoid confusion in the reading of the measurement.

• Probing depth is recorded for all teeth on each of six locations (buccal, lingual, mesio-buccal, mesio-lingual, disto-lingual, disto-buccal).

• The probe should be inserted parallel to the long axis of the tooth and walked around each surface of each tooth to detect the depth of pocket at each -surface. A probing force of 25 grams (0.75 Newtons)

• Tonsils and adenoids

• Openings of salivary gland ducts

INTRA ORAL HARD TISSUE EXAMINATION

• Examination of teeth:

Number, size, color and malformation of teeth

Nomenclature : universal system, Zsigmondy's, and palmer method, FDI (Fédération Dentaire Internationale system of nomenclature

Retained teeth Dental anomaliesSupernummery teethDental caries and oral hygiene status ( calculus and stains)

ORTHODONTIC EVALUATION

• Classification

Molar and canine relationship and classification

• Open bite is defined as a condition where a space exists between the occlusal or incisal surfaces of the maxillary and mandibular teeth in the buccal or anterior segments when the mandible is brought into a habitual or centric occlusion (Graber).

• Cross bite is a condition where one or more teeth may be abnormally malposed buccal or lingually or labially with reference to opposing teeth.

• Deep bite: condition of excessive overbite where the vertical measurements between maxillary and mandibular incisal margins is excessive when mandible is brought into habitual centric occlusion

• Primate space:

• Leeway space is the size differential between the primary posterior teeth (canine, first and second molars labeled C, D and E in the picture), and the permanent canine and first and second premolar (labeled 3, 4 and 5)

• Incisor liability:

• Space loss: criteria by owen ( Mac Donald's)

PROVISIONAL DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

INVESTIGATIONS

• Types Of Film

• Intra Oral Radiographs-

Bitewing

Periapical

Occlusal Radiograph

EXTRA ORAL RADIOGRAPHY

APPLICATIONS OF CBCT IN DENTISTRY• Investigate the exact location and extent of jaw

pathologies and assess impacted or supernumerary teeth and the relationship of these teeth to vital structures

• CBCT imaging is a useful tool for diagnosing periapical lesions

• CBCT is used widely for planning orthognathic and facial orthomorphic surgeries,

• Detect root resorption (external or internal) and cervical resorption, it can also identify the extent of a lesion

• It can be used to determine the number and morphology of roots and associated canals (both main and accessory), establish working lengths, and determine the type and degree of root angulation

• Hematological investigation

Coagulation factor deficiencies

Congenital Hemophilia A and B von Willebrand’s disease Other factor deficiencies (rare) Acquired Liver disease Vitamin K deficiency, warfarin use Disseminated intravascular coagulation

Platelet disorders Quantitative disorder (thrombocytopenia) Immune-mediated: Idiopathic ,Drug-induced, Collagen vascular disease, Sarcoidosis Non-immune-mediated: Disseminated intravascular coagulation Microangiopathic hemolytic anemia Leukemia Myelofibrosis Qualitative disorder Congenita:l Glanzmann thrombasthenia von Willebrand’s disease Acquired : Drug-induced Liver disease Alcoholism

Vascular disorders Scurvy, Purpura, Hereditary hemorrhagic telangiectasia, Cushing syndrome, Ehlers-Danlos syndrome

Fibrinolytic defects S Streptokinase therapy, Disseminated intravascular coagulation

• Histo pathological investigation it refers to the microscopic examination of tissue in order to study the manifestations of disease- oral diseases such as cyst, tumors etc

FINAL DIAGNOSIS

• It usually identify the diagnosis for the patients primary complaint first with subsidiary diagnosis of concurrent problems

• Their may be possibility that more than one disease may be present at the same time.

• Most important in an unusual cases consultation with other specialist or general physician is necessary before a final diagnosis.

TREATMENT PLANNING

Practitioner needs an organized approach to diagnose correct and prevent problem with a proper treatment planning.

Advantages of treatment planning:

• General outline suggested by FINN

1. Medical treatment

Referral to physician

2. Systemic treatment

Premedication

Therapy for oral infection

3. Preparatory treatment

Caries control

Oral prophylaxis

Orthodontic consultation

Oral surgery

Endodontic therapy

4. Corrective treatment

Operative dentistry

Prosthodontic correction

Orthodontic correction

5. periodic recall examination and maintenance treatment

ACC TO STEPHEN WEI

1. Preventive phase:

Caries stabilization

Oral hygiene instruction

Dietary analysis and advice

Prophylaxis, Topical fluoride application, Pit and fissure sealants

2. Surgical phase:

Extraction of teeth with poor prognosis

Surgical exploration of desirable teeth

Extraction of undesirable teeth and for orthodontic reasons

3. RESTORATIVE PHASE:

Composite restoration

GIC restorations

Pulp therapy procedure

Stainless steel crown cementation

4. ORTHODONTIC PHASE:

Space management

Removable appliance therapy

Functional appliance therapy

Fixed appliance therapy

ACC TO BARBER AND LUKE

• Four basic areas of concern in diagnosis and treatment planning are

1. Oral medical problem

2. Periodontal consideration for long term

3. Dental caries- restorative

4. Occlusion – craniofacial growth and development

ACC TO BRAHAM MORRIS

1. Systemic phase: premedication, medical consultation

2. Preparatory phase: preventive therapy, orthodontic consultation, endodontic therapy

3. Corrective phase: prosthodontic correction, orthodontic corrections, stainless steel crown cementation

4. Maintenance phase: recall for preventive and orthodontic visits.

CONCLUSION