DIAGNOSIS and

TREATMENT PLANNING

for
pediatric dental patient
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 DIAGNOSIS AND
TREATMENT PLANNING
diagnosis :
Requires the collection of an adequate database of
information about the patient
= pertinent data is Collected in a systemic manner to
help in identifying the nature and cause of the
problem.
Requires distillation from that database a
comprehensive but clearly stated list of the patients
problem.
Should be on sound scientific knowledge combined
with clinical experience and common sense
(practical judgment).

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 Cont
Both the patients perceptions and the doctors observations are
needed in formulating the problem list.
Diagnosis must be done scientifically; for all practical purposes,
Then the task of treatment planning is to synthesize the possible
solution to the specific problems into a specific treatment
strategy that would provide maximum benefit for this particular
patient.
Treatment planning cannot be science alone. Judgment by the
clinician is required to:
Prioritize the problems
Evaluate alternative treatment possibilities.

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 Cont

There are a series of logical steps in carrying out diagnosis and

treatment planning.
1. Development of an adequate diagnosis database (organized
information).
2. Formulation of a problem list - the diagnosis from the database.
Both pathological and developmental problems may be present
3. Planning of treatment based on a problem list.
Pathologic problems should be separated from the developmental ones
so that they can receive priority for treatment not because they are
more important but because pathologic processes must be under
control before treatment of developmental problems begins.

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 Cont
diagnosis involves development of a comprehensive
data base of pertinent information derived from
three major sources.
1. Patient questioning
2. Clinical examination of the patient includes:
Extra oral examinations.
Intra oral examinations.
3. Evaluation of diagnostic records including:
Radiographs
Photographs
Dental casts

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Cont

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 Obtaining Patients database

Two types of Data

1. Subjective data(case hx)
Information given by the patient , the family or close
relatives who accompany the patient
2. Objective data(clinical examination)
Information derived from physical examination and
laboratory tests/ diagnostic records

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 I. Patient questioning

Recording of a comprehensive data base of pertinent

information from the patient or parents .
Recording of a comprehensive and relevant informations from
the patient or parents that might be necessary to examine,
diagnose and plan the treatment is called case history/ Patient
history. = Subjective data
Case history / Patient history should be recorded in the patients
or parents own words or sentences.
It is important not to ask any leading questions.
Case history should be a written record.= Legal Document
Case history usually made up of a medical history and dental
history.

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The essential elements of a patient history/
Case history
1. Personal details/ information
2. Chief complaint
3. History of the present illness (HPI)
4. Dental history
5. Past medical history
6. Family history
7. Personal, Social & Behavioral history
8. Review of systems
9. General Clinical Examination

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 1. Personal details / information
We should start the case history by recording:
Name: For identification &communication
Age:
To identify certain transient conditions that occur during
development that are considered as normal for that age:
e.g.: the ugly duckling stage.

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 Cont
Sex
Females usually precede males in growth spurt,
puberty and termination of growth.
Address and occupation
Helps in evaluation of the socio-economic
status of the patient and parents.

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 2. Chief complaints

The chief complaint is the reason that the patient seeks

care, as described in the patients own words.

This helps the clinician in identifying the priorities and

desires of the patients.

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 3. History of the present illness (HPI)

The HPI is a chronologic description and elaboration of the

patients symptoms and should include information about
1-Onset of the problems
2-Aggravating/exacerbating factors
3-Alleviating/relieving factors -cold or hot things.
4-Duration,
5- Frequency : How often, how long, what time day or
night.
6-Location,
7-character, and intensity: how would the pain described

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 4. Dental History
Elements that should be included in the dental history
are:
1. Past dental visits:
The patient's past dental history should include:
The nature of previous dental treatment how the child coped
with other form of treatment.
What preventive treatment has been undertaken.
Eruption times
Details relating to Extractions, Restorations,
complications
The reason for present consultation.

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 Cont
The nature, extent and frequency of previous dental
treatment together with the level of patient
cooperation should be recorded.
If treatment was abandoned, the patient must be
questioned carefully for the reasons.
History trauma
2. Oral hygiene practices

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 Cont
3. Oral symptoms
- including tooth pain or
- sensitivity,
- gingival bleeding or pain,
- gum recession, alveolar bone loss
- tooth mobility,
- halitosis, and
- abscess formation
4. Past dental or maxillofacial trauma

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 Cont
5. Any history of temporomandibular joint symptoms
including pain, muscle tenderness or difficulty with
mouth opening.
6. Habits related to oral disease, such as
thumb sucking,
tongue trusting, bruxing,
clenching, and
nail biting.

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 6. Medical history

Helps to identify the medical conditions of the patient.

Should also include information on drug usage.
Elements that need to be included in the medical
history are:
Birth weight and length of confinement
Current status of the patients general health
History of hospitalizations
Medications
Allergies

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 7. Family histories

Why is the family history of interest to the dentist?

The family history often provides information about
diseases of genetic origin or diseases that have a familial
tendency. Examples include
Hemophilia
Clotting disorders,
Atherosclerotic heart disease,
Psychiatric diseases, and
Diabetes mellitus.

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8. Personal , Social & Behavioral History

Patients personal history include details of :

1. Pre-Natal History
Include details of :
Nutritional disorders,
Drugs taken,
Disease and
Accidents of the mother during pregnancy.
Drug induced deformities like thalidomide can lead
to orofacial deformities.

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 Cont
German measles during first trimester of
pregnancy can cause cleft lip/ cleft palate.
Injury at the time of birth particularly to the jaws
affects the growth.
Injury to TMJ either due to intra uterine pressure
or pressure due to the forceps delivery can result in
ankylosis.

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 Cont
2. Post-Natal history
Includes information on
The type of feeding
The presence of habits
Fracture of the jaws or teeth
The milestone of normal development which include
Time of Crawling,
Time of eruption, shading of the deciduous teeth,
Time of Walking and
Time of Talking.

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 Cont
Patients Social history includes
Child's learning, behavioral and communication problems.
Concern of the parents and patients will helps in
assessing the extent of cooperation that can be expected
from them during the treatment.
The distance at which the family lives; and an estimate
of traveling time to and from potential appointments
should be noted.

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 Cont
Access to transport, the ease with which a responsible
adult can accompany the child patient, together with
information relating to forthcoming events that may
influence attendance, are important.
Patients motivation for treatment,
What he or she expects as a result of treatment, and
How cooperative or uncooperative the patients is likely
to be.

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 Cont
Motivation for seeking treatment can be classified as
external or internal.
1. External motivation
Is that pressure supplied by another individual, as
with a reluctant child who is being brought for
orthodontic treatment by a determined parents or an
older patient who is seeking alignment of incisor
teeth because her boy friend( or his girlfriend) wants
the teeth too look better.

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 Cont
2. Internal motivation
Pressure comes from within the individual and is
based on his or her own assessment of the situation
and desired for treatment.
Quite young children can encounter difficulties in
their interaction with others because of their dental
and facial appearance, which sometimes produces a
strong internal desire for treatment.

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 9. Review of systems

Asking series of questions going from head to toe.

The Review of Systems questions may uncover problems
that the patient has overlooked (not taken into account) ,
particularly in areas unrelated to the present illness.

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 9. General Clinical Examination
General physical examination involves:
Inspection
Palpation
Percussion
Auscultation

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 Cont

Pediatric dental patient clinical examination

comprises assessment of the patient
Extra orally
Intra orally
General body system.

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2. Clinical examination of
the patient includes

I. Extra Oral Examination

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 Cont..

In addition to examining the structures in the oral

cavity, the dentist may in some cases wish to note
the patient's size,
stature, gait, or
involuntary movements.
The first clue to malnutrition may come from
observing a patient's abnormal size or stature.
Variations in size, shape, symmetry, or function of
the head and neck structures should be recorded.

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Stature of child:
General survey of a child done quickly as the child
enters the reception room or dental operatory.
The 1st observation is whether the child is overall tall or
short for his particular age.
The child can be classified in following categories:
Normal height for his age.
Too short height for his age.
Too tall height for his age.
Gait of child:
As child walks into the dental operatory,
Pedodontist can quickly ascertain whether
the gait (manner of walking) is normal or
affected.
Abnormal gait is usually seen with sick
child.
 Cont
Skin colour and appearance
The extraoral examination continues with palpation
of the patient's neck and submandibular area .Again,
deviations from normal, such as
unusual tenderness or
enlargement, should be noted and follow up tests
performed or referrals made as indicated.

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Figure: Palpation of the neck and
submandibular areas.
 G. Assessment of Temporomandibular Joints

Standing behind/ infront of the patient the site of the condyles

is palpated while the patient opens and closes their mouth.
Joints are examined for tenderness and clicking or crepitus on
opening and closing.
The maximum mouth opening is determined by measuring the
distance between the maxillary and mandibular incisal edges with
the mouth wide open.
The normal inter incisal distance is 40 - 45mm.
In cases of TMJ pain dysfunction cases the inter-incisal distance
increases during the initial stages due to hypermobility of the
TMJ; eventually the mouth opening is limited, thereby the inter-
incisal distance decreases.

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Figure: Observation and palpation of
temporomandibular joint function
 Cont

II. INTRA- ORAL EXAMINATION

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 cont.

Equipment required in patient assessment are:

A mirror,
Probe,

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One method of positioning a child for
an oral examination
 II. Intra- oral examination

Intra oral examination of the patient should begin by

examining the following details:
A. Evaluation of Oral Health status.
The hard and soft tissue of the oral cavity must be
assessed.
Breath: The breath of a healthy child is usually
pleasant and even sweet.
Bad breath or HALITOSIS may be attributable to
either local or systemic factors.

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 Cont
This includes
Medical problems,

Dental caries,

Oral mucosal lesions

Pulpal pathology and

Periodontal disease.

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 B. Gingiva

The gingiva should be examined for:

Interdental (interproximal ) Papilla
Free Gingiva (Marginal gingival)
Attached gingiava
Gingival sulcus - evaluated using graduated probes.
Inflammation - Presence of poor oral hygiene is usually
associated with generalized marginal gingivitis.
Bleeding
Recession

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 Cont
Muccogingival lesions - ANUG
Hyperplastic gingiva seen in patients who take
phenytoin.
Epulis or pyogenic granuloma or pregnancy tumor
Traumatic occlusion

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 c. Oral Mucosa

Look for
Color
Ulcers
Patches
Nodules

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 D. Frenum

The maxillary labial frenum at times be thick, fibrous

and attached relatively low.
Such an attachment prevents the two maxillary central
incisors from approximating each other thereby
predisposing the midline diastema.
Upper labial frenum low attachment associated with
median diastema.
Abnormal frenal attachment are diagnosed by a blanch
test where the upper lip is stretched upwards and
outwards for a long time.

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 Cont
The presence of blanching in the region of the inter-
dental papilla is diagnostic for abnormal frenum.
Lower lingual frenum attachment is examined by asking
the patient to protrude the tongue.
If the patient is unable to protrude the tongue it is due to
abnormal lingual frenum and is called as tongue tie or
ankyloglosia.

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 E. Tongue

Abnormalities of the tongue can upset the muscle

balance and equilibrium leading to malocclusion.
Presence of an excessively large tongue is indicated
by the presence of imprints of the teeth on the lateral
margins of the tongue giving it scalloped appearance.
The lingual frenum should be examined for tongue
tie.
Tongue thrusts are usually adaptive, i.e. the tongue is
placed forward between the teeth to achieve an
anterior oral seal during swallowing.

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 F. Palate

Look for the depth and width of the plate (Deep &
Narrow palate ) and any other developmental
abnormalities like:
Torous palatinous
Palatal cysts
Cleft palates
Adenomas (Pleomorphic Adenomas ).
Gummas

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Tertiary syphilis; gummas of the palate.

Necrosis in the centre of

the palate has caused
perforation of the bone
and two typical round
punched-out holes.

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 G. Teeth
- Check for
size,
form,
structure and
number

- For

Maxillary

mandibular teeth

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 Cont
5. Number of teeth- Assess for
Teeth present
Teeth under erupted
Teeth missed
Teeth impacted
Supernumerary
Mesodens
Anodontia -Congenitally missing teeth
6. Variation in tooth size
Microdontia
Macrodontia
Peg shape laterals

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 Cont
Hutchinsons incisors:
Results of prenatal syphilis; screw driver shaped
incisors broad cervically and narrowing incisally.
Mulberry molars:
Multiple tiny tubercles with poorly developed
indistinguishable cusps.

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 Cont
8. Tooth Wear-Assessment of tooth wear
Abrasion Wear of dental tissue by mechanical processes
Erosion Wear of dental tissue by chemical processes
Attrition - Wear of dental tissue by physiological processes

9. Vitality, carious, restoration ,fracture, discoloration, mobility,

hypoplasia , malformation of the tooth, veneers, crowns and
bridges .
- Mild to sever fluorosis is resistance to etching .

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 Cont
FLUOROSIS
Mild Form: - mild form of mottling, exhibiting
white opaque flecks near the incise edges with the
surface remaining smooth and intact.
Moderate Form: - Moderate form of fluoride
mottling with ridges of hypoplasia; white and
brownish enamel.
Severe Form: - Severe form of fluoride-induced
hypoplasia and discoloration with associated
cracking and chipping of enamel.

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 Focal enamel Hypoplasia
Focal enamel Hypoplasia
Local or focal enamel hypoplasia involving only
one or two teeth is relatively common.
Cause is unknown (Idiopathic) .
A common form of focal enamel hypoplasia of
known cause is Turner Tooth which results from
localized inflammation or trauma during tooth
development.

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 Cont
10. Carious cavity- Assessment of decayed tooth
Class I- Class I Cavity includes those cavity originated in pit or
fissure surfaces.
Class II- Class II cavity originating on proximal surfaces of
posterior teeth that is molar and Premolar teeth.
Class III- Is a smooth surface lesion that is found in the
proximal surface of anterior teeth but not including the incisal
edge of the tooth.
Class IV -Involves the proximal surface of the anterior teeth
including the incisal edge.
Class V- Involves the cervical one third of the buccal and lingual
surface of any tooth.

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 Cont
11. Fractured Tooth- Assessment of fractured tooth:
Ellis classification
Class I: Fracture within the enamel.
Class II: Fracture of enamel - dentine.
Class III: Fracture involving pulp.
Class IV: Fracture involving the roots.

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 Cont
12. Tooth Injury- Assessment of tooth injury:
Concussion: Injury to supporting tissues of tooth, without
displacement.
Subluxation: Partial displacement, but commonly used to describe
loosening of a tooth without displacement.
Luxation: Displacement of tooth (laterally, labially, or palatally).
Intrusion: Displacement of tooth into its socket. Often
accompanied by fracture of alveolar bone.
Extrusion: Partial displacement of tooth from its socket.
Avulsion: Traumatic removal of the tooth from its socket.

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 Cont
13. Tooth Mobility - Assessment of tooth mobility
The continuous loss of the supporting tissues in progressive
periodontal disease may result in increased tooth mobility.
- Faciolingual mobility
- Mesiodistal mobility
- Alveolo-occlusal (Vertical ) mobility
Tooth mobility may be classified in the following way:
Degree 1: Mobility of the crown of the tooth 0.2 - 1 mm in
horizontal direction
Degree 2: Mobility of the crown of the tooth exceeding 1 mm in
horizontal direction.
Degree 3: Mobility of the crown of the tooth in vertical direction
as well.
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 INVESTIGATIONS
Radiograophs
Laboratory- stool, blood, microbial
Pathology

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 Special tests
Pulp vitality testing: Thermal, Electrical
Palpation and percussion
Mobility
Transillumination

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 Definitive diagnosis
The final diagnosis is based on examination and
history and determines the treatment plan.

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 Treatment plan
Emergency care and relief of pain
Preventive care
Surgical treatment
Restorative treatment
Orthodontic treatment

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THE END