GOOD AFTERNOON

CASE HISTORY , DIAGNOSIS

AND TREATMENT PLANNINg
Submitted to : Submitted by :
The department of Pedodontics Kamalpreet kaur
BDS Prof IV
INTRODUCTION
The first step towards treating a patient is to
achieve an accurate diagnosis for which
comprehensive history taking and thorough
clinical examination is essential.
DEFINITIONS
CASE HISTORY - It is a classic form of documentation ,
which ranges from clinical sketches to highly detailed
and extended accounts that help in arriving at a
diagnosis and formulation of treatment plan of the
person under study.

DIAGNOSIS It is the process of identifying a disease
by its signs , symptoms and result of various diagnostic
procedure.



SYMPTOMS It is the subjective evidence of a disease
perceived by the patient

SIGNS Any abnormality indicative of disease ,
discovered on examination of the patient ( an objective
symptom of disease).

DIFFERENTIAL DIAGNOSIS The process of listing
out two or more diseases , having similar signs and
symptoms of which only one could be attributed to the
patients suffering.
PROVISIONAL DIAGNOSIS A general diagnosis
based on clinical impression without any laboratory
investigation.
FINAL DIAGNOSIS - A confirmed diagnosis based
on all available data.

ANTICIPATORY GUIDANCE - It is the term often used
to describe , discuss and implement diagnosis
and treatment plan with the patient and / or
parent.
HISTORY TAKING
It includes :-
A ) Personal information
B ) Chief complaints
C ) Medical History
D) Dental history
E ) Parent History
F ) Prenatal History
G) Birth History
H) Postnatal History

PERSONAL INFORMATION

Date
Name of the patient
Age
Sex
Hospital number / Case number
School and Class
Address

DATE
It includes the time the patient reported and can
be referred back to during the follow-up visit.

NAME OF PATIENT
Asking the name is verbal communication which
establishes the rapport with the patient.
Give a sense of importance and acceptance to
the patient.



AGE

The chronological age ( date of birth ) should be
noted to compare with other ages (dental ,skeletal)so as
to know whether growth and development is normal in
the child.
Certain diseases are known to occur frequently at
particular ages .
eg :- primary herpetic gingivostomatitis - 6 months to 6
years.
Nursing caries is seen in preschool age group only.



SEX
Girls mature faster than boys and thus their treatment
may be required earlier.
Some diseases show specific sex predilection.
eg :- anorexia is more common in females while
hemophilia may be found exclusively in males.
A combination of age and sex can sometimes give an
indication of the occurrence of a disease.
eg :- pubertal gingivitis in adolescent females

HOSPITAL NUMBER / CASE NUMBER
For the purpose of maintaining a record , billing
the individual and for legal considerations.

SCHOOL AND CLASS
To know economic status and to communicate
with the teacher .
It also help in assessing the IQ of the child .

ADDRESS
Use for all communications
Socio-economic status can be assessed
If the patient coming from a far distance , the
appointments can be modified to complete
treatment in fewer visits.

CHIEF COMPLAINTS
Detailed information of the chief complaints helps in
establishing the diagnosis.
Always recorded in patients own word.
Most common presenting illness can be evaluated
under:
1. The onset
2. The duration
3. The location
4. The quantity , quality , severity and frequency of occurrence.
5. Aggravating and relieving factors.
6. Associated symptoms.
MEDICAL HISTORY
It helps to identify conditions relevant to the patients
dental health or which could have an impact on how
treatment is carried out.
eg : conditions which require antibiotic prophylaxis or
prescription of certain drugs.
History of child being hospitalized , previous general
anesthesia and surgical procedures , are traumatic
psychological experiences and may sensitize the young
child to dental procedure.
DENTAL HISTORY






Patients previous dental history should be recorded.
eg : history of previous treatment and its duration.
Patients present oral hygiene habits and fluoride exposure
should be recorded.


PARENT HISTORY
A dental visit and treatment performed would point towards
the attitudes of the parents.
Any genetic / inherited abnormalities should be interviewed
into.


PRENATAL HISTORY
It may disclose information that can be linked to
the present condition.
eg: tetracycline stains on teeth.
Accident / trauma of the mother during pregnancy.
Eg : Trauma may result in orofacial deformity.





BIRTH HISTORY
If any problem were encountered at birth :
Rh incompatibility - may result in erythroblastosis
fetalis.
Effects may be seen in dentition as HUMP on the
tooth and characteristic BLUE-GREEN
discolorations.
Other problems :-
1. Neonatorum jaundice
2. Cyanosed or blue baby
3. Trauma due to forceps delivery
4. Premature delivery

POSTNATAL HISTORY
It includes the amount of time the child was
breast fed , bottle fed , if the bottle was misused
and type of nipple used etc.
Vaccination status need to be assessed along
with the present medical illness, if any.
Presence of any habit and its duration ,
frequency and intensity need to be evaluated.
CLINICAL EXAMINATION
1.General examination
2. Extraoral examination
3.Intraoral examination
GENERAL EXAMINATION

Childs stature, gait gives the overview of the
nutrition , general health and neuromuscular
coordination and development etc.
EXTRAORAL EXAMINATION
Head
TMJ
Lymph nodes

SHAPE OF THE HEAD
Cephalic index (CI) = maximum skull width
maximum skull length
Based on the classification by Martin and Saller (1957),
shape of the head can be classified as :
Mesocephalic average , cephalic index (CI) is 76.0-
80.9
Dolichocephalic long & narrow , CI is < 75.9
Brachycephalic broad & short , CI is 81.0-85.4
Hyperbrachycephalic CI is > 85.5

TEMPOROMANDIBULAR JOINT

TMJ function is evaluated by palpating the head
of the mandibular condyle extraorally
and observing the patient while the
mouth is closed and in various
positions of mouth opening.

Any abnormalities detected such as
trismus ,deviation of mandible to
one side , clicking of the joint and
symptoms of pain during mouth
opening should be recorded.




Examination of TMJ during
the act of opening and
closing
LYMPH NODES
Palpation of commonly involved lymph nodes
( submental and submandibular ) shows an acute
or chronic infection.







Examination of submandibular
lymph node
Examination of cervical
lymph node



INTRAORAL EXAMINATION

It includes : -
a. Oral soft tissues
b. Oral hard tissues








Oral soft tissues EXAMINATION
SKIN / LIPS :- for presence of any sinus / fistula etc.
MUCOSA :- any ulceration , growth ,pallor of
mucosa indicating anemia , yellowish
discoloration.
PALATE :- the hard and soft palate are inspected for
any developmental anomaly like clefts and
manifestations of systemic diseases.
GINGIVA :- normal gingiva in child is different from
an adult. Inflamation of gingiva and
accumulation of the plaque on the teeth
are seen by respective indices.

TONGUE :- should be examined for developmental
anomaly , lesion and swallowing pattern.
TONSILS / ADENOIDS :- oropharynx should be closely
examined for any enlargement or purulent exudate.









Examination of buccal mucosa



The teeth present have to be recorded so that
the dental age can be assessed along with the
stage of development of the dentition.



ORAL HARD TISSUE
EXAMINATION
FDI Scoring System

It is one of the commonly used numbering systems.
Quadrants are alloted initial numbers as:
upper right upper left
Primary 5 6
8 7

upper right upper left
Permanent 1 2
4 3

Then the tooth in each quadrant is numbered as:
Primary
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75

Permanent
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

INDICES

Commonly used indices are :-
1. Caries index (Palmer & Knutson, 1938 )
2. Plaque index ( Silness and Loe ,1964)
3. Gingival index ( Loe and Silness , 1967)


CARIES INDEX
W.H.O (1987) criteria for primary and permanent teeth
Permanent tooth code condition/status primary tooth code
0 Sound A
1 Decayed B
2 Filled, with decay C
3 Filled, no decay D
4 Missing as a result of caries E
5 Missing due to any other reason -
6 Sealant, Varnish F
7 Bridge abutment or special crown G
8 Unerupted tooth -
9 Excluded tooth -


PLAQUE INDEX
(Silness and LOE,1964)
PLAQUE has been defined as a specific, highly selective
entity resulting from a sequential colonization of
microorganisms on the surface of the teeth, soft tissues,
restorations and appliances.

Rather than examining the whole dentition, a few Index
teeth are selected:
Permanent dentition - 16, 12, 24, 36, 32, 44
Primary dentition - 55, 52, 64, 75, 72, 84
Mixed dentition - 16, 52, 64, 36, 32, 84

Scoring Criteria:

0 -No plaque in the gingival area
1 - A film of plaque adhering to the free gingival margin
and adjacent area of the teeth. Only running a probe
across the teeth surface may recognize the plaque.
2 - Moderate accumulation of soft deposits within the
gingival margin and/or adjacent tooth surface that can
be seen with naked eye.
3 - Abundance of soft matter within the gingival pocket
and/or the gingival margin and adjacent tooth surface.
Calculations
A. Plaque index for a tooth =
Add scores from 4 areas of tooth
--------------------------------------------------
4
B. Plaque index for a individual =
Add scores for each tooth
---------------------------------------------
No. of teeth examined

INTERPRETATION SCALE
1. 0.0 - Excellent
2. 0.1-0.9 - Good
3. 1.0-1.9 - Fair
4. 2.0-3.0 - Poor
GINGIVAL INDEX
(Loe and Silness, 1967)
It has been developed for the purpose of assessing the
severity of gingivitis and its location in four possible
areas of an individual tooth.
Same teeth are examined as in plaque index.
Each tooth is divided into four parts:
1. Distofacial papilla
2. Midfacial papilla
3. Mesiofacial papilla
4. Entire lingual gingival margin
Score Criteria
0 - Normal papilla
1 - Mild inflammation, slight change in color, slight
edema; No bleeding on probing.
2 - Moderate inflammation, redness, edema, and
glazing; Bleeding on probing
3 - Severe inflammation, marked redness and edema,
ulcerations; Tendency for spontaneous bleeding

CALCULATIONS
Gingival index score per tooth =
Total score
---------------------------
4
Gingival index score for a person =
Total of all scores
--------------------------------------
No. of teeth examined

INTERPRETATION
1. 0.1-1.0 Mild
2. 1.1-2.0 Moderate
3. 2.1-3.0 Severe
PROVISIONAL DIAGNOSIS
On the basis of history and clinical examination , one
should arrive at a provisional diagnosis.

DIFFERENTIAL DIAGNOSIS
The list of most likely and probable diagnosis based on
the available information is called differential diagnosis.
It distinguishes one disease from several other diseases
with similar signs and symptoms by identifying their
differences.
DIAGNOSTIC AIDS

Before arriving at a diagnosis , investigations such as
radiographs
Blood and urine examination
Biopsy
Should be carried out to confirm the diagnosis.


TREATMENT PLANNING
After completion of diagnosis , treatment planning
requires careful considerations of the information
assembled after examining the patient , study models
and radiographs.

ADVANTAGES
o Re-diagnosis at every visit is avoided.
o Instruments can be prepared well in advance.
o Total fee estimation can be done.
PRESENTATION OF TREATMENT PLAN TO
PARENTS

Good communication is important
Relaxed environment and informal attitude
Use of visual aids
CONTENTS OF PRESENTATION

Includes :-
Dental need of their child
Restorative procedure required
Amount of time required to perform the treatment
Total cost
Preventive measure necessary

History and examination
Assessment of treatment needs
VS
Likely patient / parent co-operation
DISCUSSION
Parent patient medical / dental specialist
Management of acute dental problems
INITIAL TREATMENT
Acclimatization Preventive advice Stabilization
DISCUSSION
Parent Patient

DEFINITIVE TREATMENT
Restoration / Extraction Prevention Aesthetic
considerations
Recall according to risk assessment
THANK
YOU