CASE HISTORY, DIAGNOSIS AND TREATMENT PLANNING

CASE HISTORY: Is defined as a planned professional conversation, which

enables the patient to communicate the symptoms, feelings and fears to
the clinician, so that the nature of the real and suspected illness and mental
attitude may be determined.

DIAGNOSIS: The determination of the nature of the 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 patient’s suffering.

PROVISIONAL DIAGNOSIS: A general diagnosis based on clinical impression

without any laboratory investigations.

FINAL DIAGNOSIS: A confirmed diagnosis based on all the available data.

 History is a personal account of patient’s problem. It is the most
important component of clinical diagnosis. The main aim of history taking is
to elicit an accurate account of the symptoms and of clinical problems as a
whole and to set this against the background of patient’s life.

The case history includes following aspects

NAME: The patient’s name should be recorded for communication,

identification of the patient and for official recordings. Further
communication by means of the name has a beneficial psychological effect,
gives a sense of importance & acceptance and initiates rapport with the
patient. (Nick name can be recorded which makes the environment
informal),it also indicates the religion of the patient.

AGE: Patient’s chronological age should be noted to compare with other

ages (Dental, Skeletal) so as to know whether the growth and development
is normal in the child.
 Age considerations help in diagnosis and treatment plan. Certain
developmental changes take place at certain age, which are considered as
normal for that age. For e.g.: Ugly duckling stage, which gets corrected by
itself.

Certain diseases are known to occur frequently at particular ages,

which should be kept in mind. Eg: Primary Herpes Gingivostomatitis from 6
month to 6 years, Nursing caries seen in preschool age group

Behavior management techniques also vary depending on the age.

SEX: is important in treatment planning, as the timing of growth events is

different in males and females. Usually, females precede the males in onset
of growth spurts, puberty & termination of growth and therefore their
treatment may be required earlier. Some diseases are common in males
and some in females. Eg: Hemophilia in males

ADDRESS: Address of the patient is taken for the communication, recalls

and for recording purpose in the office. Living area may indicate diseases
endemic to the particular area (e.g.: Fluorosis). It also indicates
socioeconomic status of the patient.

DATE: It records the time the patient reported to the dental office and can
be referred back to during the follow up visits.
O. P No: For the purpose of maintaining record, billing and for legal
considerations.

OCCUPATION OF THE PARENT&FAMILY INCOME: Helps to evaluate the

socio-economic status of the patient. The education level of the parents
can be understood which influences the treatment planning.

CHIEF COMPLAINT: This gives us the idea of the reason; the patient is
seeking care for. It should be recorded in patients own words, which helps
in identification of priorities and desires of the patient. While recording the
chief complaint, the patient should not be interrupted, and the talk should
be directed to more relevant matters by asking simple questions if needed.

HISTORY OF PRESENTING ILLNESS: This part of history taking comprises of

the chronological account of the development of the problem. The most
common presenting illness can be evaluated as: the onset, duration,
location, quantity, quality, and severity, frequency of occurrence,
aggravating & relieving factors and associated symptoms.

FAMILY HISTORY: The purpose of family history is to provide relevant

information about the social background of the child and, most important,
its family. Such factors as the number of children in the family, the housing
conditions, and the parent’s occupations are important in selecting a
realistic plan for preventive and restorative dental services.

The family history should also include the occurrence of any familial
genetic disorders, oral or general.

PRENATAL HISTORY: Prenatal history (mainly maternal) may disclose

information that can be linked to the present condition. For e.g.: any
positive history of drug therapy during pregnancy can be related to the
staining of teeth. Maternal infections at the time of pregnancy influence
the development of fetus.

NATAL HISTORY: Suggests if any problems were encountered at birth as:

1. Rh incompatibility: may result in the condition termed

‘erythroblastosis fetalis’.The sensitized antibodies of the mother
cross the placental barrier and an immune reaction takes place. The
effects may be seen in dentition as ‘Hump’ on the tooth and the
characteristic blue-green discoloration.

2. Neonatarum Jaundice: The immature RBC’s in an infant are rapidly

destroyed in the spleen. The increased bilirubin cannot be sufficiently
cleared by the liver leading to a transient jaundice in the infants.
Other problems such as Blue baby, Forceps delivery should be recorded in
the history.

POSTNATAL HISTORY:

1. Significance is attached to the amount of time the child was breast

fed, bottle fed, if the bottles were misused, and the type of nipples
used etc.
2. Vaccination status needs to be assessed along with the present
medical illness if any.

3. Presence of any habit, duration, frequency and intensity needs to be

evaluated.

4. The behavior status, a general assessment as to whether the child is

cooperative or uncooperative and if any deep rooted problems are
present, have to be found out.
5. Child’s social and psychological development is important.
Information regarding the child’s learning, behavior and
communicating ability must be gathered.

MEDICAL HISTORY: It is important for the dentist to be familiar with

patient’s medical history. History of child being hospitalized, previous
experience of general anesthesia, surgical procedures should be recorded.
Shaw reported that conditions like this have a traumatic psychological
experience and may sensitize the young child to procedures that will be
encountered later in dental office. When there is indication of acute or
chronic systemic disease or anomaly, consultation with the child’s physician
should be done to understand the condition, prognosis and current
medications for the existing condition.

PAST DENTAL HISTORY: The child’s past experience with dental services
should be reviewed. The kind of dental treatment received, including pain
control measures and acceptance of earlier dental treatment, gives the
dentist important background for evaluation of child’s past behavior.
Factors of importance for future dental health should be identified as part
of dental history, including day to day oral hygiene, dietary and sucking
habits.
DRUG HISTORY: Drug history is essential for identifying drug induced
diseases and avoiding untoward drug interactions, when selecting L.A or
any other medications indicated in dental treatment.

DIET HISTORY: Inquiries into the dietary habits of patient’s are a necessary
basis for advice concerning future changes in diet to prevent dental decay.
It is preferable to take dietary history which is a semi quantitative method
where the patient or his parents record all food consumption during a
specific period of time mostly 3-7 consecutive days, on a form

The patient’s 5 day food diary is analyzed for 1) adequacy of intake of foods
from the food groups and 2) the amount and type of foods sweetened with
sugar and the frequency of eating them.

The patient is asked to do the following:

STEP 1: Circle in red all the foods recorded in the 5 day food diary that are
sweetened with sugar. This means soft drinks, coffee with sugar, cookies,
cakes and pastries; jam, hard candies, cough drops and cough syrup; fruits
canned in syrup and other foods that have an overtly sweet taste. Dried
fruits such as figs, dates, apricots should also be circled, because they are
highly concentrated sweets. However, fresh fruits with high water and fiber
content, such as apples, oranges, or pears are not.
This circling foods in red will point out and separate the protective, non
cariogenic, high nutrient density foods from the empty calorie, cariogenic
types.

STEP 2: The total number of exposures of the teeth to sweets, the form of
the sweets (solid or liquid), and when they are eaten (at meals or between
meals) are to be determined.

STEP 3: The adequacy of the diet in terms of desirable number of servings

of each of the food groups is to be determined.

DIET COUNSELLING: without neglecting the general aspects of nutrition, the

dentist should concentrate his efforts in diet counseling on advice on
consumption of cariogenic products. Thus, dietary counseling concerning
improvement of dental health should be aimed at estimating the patient’s
food habit pattern, the consumption of fermentable carbohydrates, in
particular sucrose, and the intake frequency of snacks, sweetened
beverages and adhesive “sticky” food. Bottle feeding with sucrose
containing fluids, especially at night, is one important factor which may
cause rampant caries in small children. In the dietary counseling it is
important to develop tools that are understandable and will help the child/
family to change their dietary habits.

The approaches to counseling may be directive or non directive. In directive

counseling, the role of the patient is passive and the decisions are made by
the counselor for the patient. In non directive counseling, the counselor’s
role is merely to aid the patient in clarifying and understanding his or her
own situation and to provide guidance so that the patient can make his or
her own final decision as to the type of action that should be taken. The
non directive counseling approach is recommended.

BEHAVIOUR ASSESSMENT

Behavioral scale of Frankel et al with Wright’s modification

RATING FRANKEL’S SCALE WRIGHT MODIFICATION

1 Definitely negative (--)

Refusal of treatment; crying forcefully,

fearful, extreme negativism

2 Negative (-)

Reluctant, uncooperative, limited

negativism, sullen, withdrawn

3 Positive (+)
 Accepts treatment but may be
cautious or reserved, follows
directions

4 Definitely positive (++)

Good rapport, interested in dental

procedures, laughs and enjoys

CLINICAL EXAMINATION

The clinical examination is done at three different steps

1. General examination

2. Extraoral examination

3. Intraoral examination
GENERAL EXAMINATION

The general examination and evaluation of the patient begins with the first
appearance of the child in the dental office. It comprises of general
assessment of the patient’s health status.

HEIGHT & WEIGHT:

Measurement of height and weight should be periodically performed and

compared with norms or standards for that particular chronological age
and sex. Deviations (greater than 2 standard deviations) from normal value
should be confirmed and referred for appropriate medical consultation
(Poole & Macko 1984)

SPEECH:

Speech must be evaluated and compared with the maturational level of the
child.

BUILT:

It is the skeletal structure in relation to age and sex of the individual as

compared to a normal person.
The built of the person is classified as follows;

1. Hypersthenic-short and stocky with constant weight problems.

2. Sthenic-good bone and muscle structure with good body proportion.

3. Hyposthenic-thin with poor muscles because of this they have activities

of more intellectual nature than of physical nature.

4. Asthenic-slight built than hyposthenic.

GAIT:

Severity of a child’s illness, even if oral in origin, may be recognized by

observing a weak, unsteady gait of lethargy and malaise as the patient
walks into the office. Unconscious signals of confidence, distress, anxiety,
depression and other emotions can be learnt by observing the gait.
Abnormalities of gait can be associated with neuromuscular imbalances
which may have dental correlation.

The different types of gaits seen are:

Slapping gait: seen in tabes dorsalis, disease of posterior column of spinal

cord. The patient loses sense of position and walks on a broad base with
legs spread wide apart. Movements of the patient deliberate and patient
look down on ground to be certain the feet land as intended.

Spastic gait or circumduction gait: In this the patient walks on a narrow

base, has difficulty in bending the knees and drags the feet along as if they

were glued to the floor. The foot is raised from the ground, by tilting the
pelvis, and the leg is then swung forwards, so that foot tends to describe
an

arc, the toe scraping along the floor in a circumduction of the leg. This type

of gait is characteristic feature of corticospinal lesions, especially spinal

cord

disease.

Hemiplegic gait: It is essentially a spastic gait in which only one leg is

affected.

Stamping gait-gait in sensory ataxia. In this, the patient raises the foot very

Suddenly often abnormally high and then jerks it forward, bringing it to the

ground again with a stamp and often heel first. By using the eyes in place of

position sense, the patient may succeed in walking fairly steadily, but when

walking in the dark or when eyes closed, there is severe ataxia.

The gait of cerebellar ataxia: It appears drunken or reeling, patient walk on

a broad base, feet planted widely apart and placed irregularly. Ataxia is

severe whether the eyes are open or closed.

Waddling gait: It feature of proximal pelvic griddle muscular weakness,

especially of myopathies and muscular dystrophies. The body is often tilted

backwards, with an increased lumbar lordosis, the feet are planted rather

widely apart and the body sways from side to side as each step is taken.
BODY TYPE: There are three physical patterns (somatotypes) acc to Sheldon

Ectomorph somatotypes have light bone structure and small body mass
relative to length.

Endomorphs are of stocky build with large amounts of soft tissue. They
mature earlier than the ectomorphs.

Mesomorphs exhibit mixed features of both ectomorphs and endomorphs

Their build is more muscular.

HANDS:

The patient’s hands may reveal information pertinent to the

comprehensive diagnosis. The dentist may first detect an elevated
temperature by holding the patient’s hand. Cold, clammy hands or bitten
finger nails are the first indication of abnormal anxiety in the child. A
callused or unusually clean digit suggests a persistent sucking habit.
Clubbing of the fingers or bluish color in the nail beds suggests congenital
heart disease that may require special precaution during dental treatment.

PALLOR: It is the paleness of the skin and mucous membrane as a result of

diminished circulating red blood cells or diminished blood supply. The
causes of are: anemia, shock, and peripheral vascular diseases. The other
sites where anemia can be detected are;
1. Lower palpebral conjunctiva.

2. Tongue.

3. Soft palate.

4. Palms and nails.

CYANOSIS: is the bluish discoloration of the skin or mucous membrane due

to increased amount of reduced hemoglobin (>5mg %) in capillary blood.

The sites where cyanosis is seen are: Palate, Tongue, conjunctiva and lips
inner surfaces, tip of the nose, ear lobule, tip of finger, cheek, nail bed.

The causes of cyanosis are: congenital heart disease: fallots tetrad,

congestive cardiac failure, fibrosis of lung, cold, mitral stenosis.

ICTERUS: Or jaundice is characterized by yellow coloration of tissues and

body fluids due to an increased in bilirubin levels. Normal serum bilirubin
level is 1mg%.

Causes of icterus includes: hereditary spherocytosis, sickle cell anemia,

infections like viral hepatitis, malaria, typhoid, congenital
hyperbilirubinemia in conditions like Dublin Johnson syndrome, rotor’s
syndrome, crigler-najjar syndrome.

VERTEBRAL COLOUMN: In normal upright position it has two anterior-

posterior curves. One with a concavity forward in upper dorsal region and
other with slight convexity forwards in the dorsolumbar region. Normally,
no lateral curvature is seen. Some of the examples seen in deformities of
vertebral columns are;

a.Scoliosis: It is the abnormal lateral curvature of the spine, may be

Congenital, postural, poliomyelitis, rickets etc.,

b.Kyphosis: It is the abnormal anterior-posterior curvature with forward

concavity and dorsal prominence, as seen in congenital wedge shaped

vertebra, tuberculosis, rheumatoid arthritis, osteitis deformans, muscular

dystrophy.

c.Lordosis: It is the abnormal anterior-posterior curvature of spine with

forward.convexity, as seen in pregnancy which is an example of

physiological deformity, secondary to hip disease and congenital

dislocation

of hip, large abdominal tumours, muscular dystrophy.

Recording the vital signs:

TEMPERATURE: Normal temperature is 37’C. It can be measured in mouth,

axilla and rectum.

Normal temperatures recorded in various sites are as;

Oral: 98.6F/37.0'C Auxiliary: 97.6F/36.3'C Rectal: 99.6F/37.7'C

PULSE: It is defined as throbbing caused by the regular contraction and

alternate expansion of an artery as the wave of blood passes through the
vessel, the periodic thrust felt over the arteries in time with the heartbeat.
While examining pulse the following characteristics should be noted

Pulse rate: It is the measure of number of times the pulse beat felt per
minute.

Average Beats per

Minute

The Unborn Child 140 to 150

Newborn Infants 130 to 140

During first year 110 to 130

During second year 96 to 115

During third year 86 to 105

7th to 14 year 76 to 90

14th to 21st year 76 to 85

21st to 60th year 70 to 75

After 60th year 67 to 80

Pulse rhythm: rhythm of pulse can be described as regular, irregular,
regularly irregular and irregularly irregular.

Pulse volume: The carotid artery is measured for the volume of pulse. Pulse
can be classified on this basis into two categories: Hypo kinetic pulse,
Hyperkinetic pulse.

(Thready pulse: pulse rate is rapid and pulse wave is small and disappears
quickly, seen in shock.

Water hammer pulse: the large pounding pulse associated with increased
stroke volume and decreased peripheral resistance.)

RESPIRATORY RATE: Normal respiratory rate is

In infants – 30 – 50 per minute

In children – 18 – 30 per minute

In adults – 8 – 18 per minute

EXTRA ORAL EXAMINATION

HEAD, FACE AND NECK: Important components include an evaluation of

the skin, hair, eyes and ears where structural abnormalities may be related
to certain acquired disorders or developmental conditions.
SKIN: Examination of skin often gives important clues to local and systemic
diseases. The following are noted in skin:

1. Color of skin: like pale flushed, cyanosed, yellow etc."

2. Pigmentation: occurs in certain diseases like Addison’s disease, Cushing’s

disease, pellagra

3. Any hemorrhagic spots like petechiae, purpura, ecchymosis etc

Types of skin:

1. Dry Skin is seen in myxoedema and dehydration.

2. Moist Skin is seen in perspiration as in shock, M.I, pneumonia,

thyrotoxicosis.

3. Thick Skin is seen in myxoedema, acromegaly, and scleroderma.

4. Thin Skin is seen in old people and following wasting diseases.

5. Pinched Skin is seen in dehydration conditions

Dry, parchment like skin is seen in conditions like hereditary ectodermal

dysplasia.

HAIR: condition of hair indicates the nutritional state of the patient.

Excessive hair is seen in conditions like Cushing’s syndrome where as thin,
sparse hair is seen in conditions like hereditary ectodermal dysplasia.

LYMPH NODES: Lymph nodes are palpated to check the following

a. Tenderness of the nodes: The palpable nodes are tender in acute

inflammation .

b. Surface of the nodes: Normally it is smooth. Matted in tuberculosis,

irregular in malignancy and inflammation.

c. Consistency of the nodes: Normally firm. It is rubbery in Hodgkin's

disease, matted in tuberculosis, hard in malignancy.

d. Mobility: Normally are mobile and free from the skin. In malignancy they

are fixed and non-mobile.

FACIAL TYPE

1. Mesofacial

2. Dolicofacial

3. Brachyfacial

SHAPE OF THE HEAD:

1. Mesocephalic: Average

2. Dolicocephalic: Long and narrow

 3. Brachycephalic: Broad and short

ASSESSMENT OF FACIAL SYMMETRY

Facial symmetry is examined to determine disproportion of face in

transverse and vertical planes. Some degree of asymmetry is common

between right and left sides but gross symmetry should be recorded

which may occur as a result of:

i) Congenital defects

ii) Hemifacial atrophy/hypertrophy

iii) Unilateral condylar ankylosis and hyperplasia

iv) Facial space infections.

FACIAL FORM:

- Round/oval/square

i) Mesoproscopic: average or normal face form

ii) Euryproscopic: broad and short

 iii) Leptoproscopic: long and narrow

Facial profile:

Called as "poor man's Cephalometric analysis".

The facial profile is examined by viewing the patient from the side. The
profile is obtained by joining the following two reference lines:

1. A line joining the forehead and the soft tissue point A (deepest point
in curvature of upper lip)

2. A line joining point A and the soft tissue pogonion ( most anterior
point of the chin)

i) Straight profile: the two lines form a nearly straight line

ii) Convex profile: the two lines form an angle with the concavity

facing the tissue. This kind of profile occurs as a result of a prognathic

maxilla or a retrognathic mandible as seen in class II, Division I

malocclusion

iii) Concave profile: the two reference lines form an angle with the
convexity towards the tissue. This type of profile is associated with a
prognathic mandible or a retrognathic maxilla as in class III malocclusion.
FACIAL DIVERGENCE: Is defined as an anterior or posterior inclination of
the lower face relative to the forehead.

1. Anterior Divergence: a line drawn between the forehead and chin is

inclined anteriorly towards the chin.

2. Posterior Divergence: a line drawn between the forehead and chin is

inclined posteriorly towards the chin.

3. Straight or Orthognatic: the line between the forehead and chin is

straight or perpendicular to the floor

FACIAL PROPORTION:

- A well proportioned face can be divided into three equal vertical

 3rds using four horizontal planes

1. At the level of hair line

2. At the supra orbital ridge

3. Base of the nose

4. Inferior border of chin

LIPS

Lips should be evaluated for color, texture, fullness, relative length,

position during rest and swallowing, and evidence of trauma or
pathologic lesions.

Lips are classified into the following 4 types:

a. Competent lips: Slight contact in relaxed state

b. Incompetent lips: Short lip which do not form lip seal in relaxed state.
c. Potentially incompetent lips: are normal lips that fail to form a lip seal

due to proclined upper anteriors

d. Everted lips: are hypertrophied lips with weak muscular tonicity.

TMJ EVALUATION

One should evaluate temporomandibular joint function by palpating the

head of each mandibular condylar and observing the patient while the
mouth is closed (teeth clenched), at rest, and in various open positions.
Movements of the condyles or jaw that are not smoothly flowing or
deviate from the expected norm should be noted. Similarly, any crepitus
that may be heard or identified by palpation or any other abnormal
sounds should be noted. Sore masticatory muscles may also signal TMJ
dysfunction. Such deviations from the normal TMJ function may require
further evaluation and treatment.

INTRA ORAL EXAMINATION

The intraoral examination of a pediatric patient should be

comprehensive.

It includes examination of soft tissues and hard tissues.

 LABIAL AND BUCCAL MUCOSA: Has to be examined for relative height of
frenal attachment, abrasions, traumatic lesions (cheek biting) and
ulcerations.

GINGIVA: Examination of gingiva is very important aspect. Gingivitis in

commonly seen in children and has been exuberated by faulty tooth
alignment. The following things should be noted during the examination
of gingiva. They are:

1. Colour of the Gingiva

2. Surface of the gingiva- stippled or lost

3. Position of gingiva margin

4. Contour of gingiva

5. Consistency

6. Shape and position of interdental papillae

7. Bleeding on probing

8. Periodontal pockets.

TONGUE: Tongue and oropharynx should be closely observed. The dorsum

of the tongue is inspected at rest and protruded. Note any reduced
mobility. Most of the functions of the tongue are well synchronized with
the circum oral muscles and muscles of mastication. Any abnormal function
of one will result in associate abnormal function of the other. The posture
of the tongue is studied in the postural rest position of mandible. Also, the
tongue posture is related to the skeletal morphology, like, in severe Class
III, tongue tends to be below the plane of occlusion. In Class II, tongue
positioned forward due to short mandible and steep mandibular plane.

Other structural abnormalities to be examined are:

a. Macro glossia

b. Micro glossia

c. Tongue-tie.

Few manifestations of diseases on dorsum surface and lateral surface of

tongue are:

i) Fissured tongue

ii) Geographic tongue

iii) Atrophic tongue

iv) Hairy leukoplakia

v) Candidiasis.

vi) Lingual thyroid

EXAMINATION OF FRENAL ATTACHMENT: It is very important to know
the proper frenal attachment. If maxillary frenum is thick fibrous and
attached relatively low, then it may predispose to midline diastema, by
preventing the 2 central incisors from approximation. If mandibular
frenum is abnormal, then it causes recession of gingiva in that area.
Abnormal frenal attachment is diagnosed by Blanch test. In this test, the
upper lip is stretched upwards and outwards for a period to time. The
presence of blanching in the region of interdental papilla is diagnostic of
abnormal frenum.

EXAMINATION OF PALATE: Variation in palatal depth occurs in variations

of facial form. Most of the Dolicocephalic patient's have a deep palate.
Presence of swelling in the palate may be indicative of impacted tooth,
presence of cyst or other bony pathologies. Any mucosal ulcerations and
indentations are the feature of traumatic deep bite. Hard and soft
palates are observed and palpated for clefts and velopharyngeal
incompetence.

ADENOIDS: Enlarged tonsils accompanied by purulent exudates may be

the initial sign of a streptococcal infection, which can lead to rheumatic
fever. When streptococcal throat infection is suspected, immediate
referral to child’s physician is recommended. Inflamed, hypertrophied or
infected tonsils may give rise to altered tongue position mandibular
position during swallowing or breathing reflexes there by upsetting the
 oro-facial balance leading to malocclusions

EXAMINATION OF FLOOR OF THE MOUTH:

Is examined when the tongue is raised floor of the mouth is looked for
any swelling or any abnormalities. Some of the conditions looked for in
the floor of the mouths are:

1. Ranula

2. Salivary gland neoplasm

3. Ludwig's angina.

SALIVA: Abnormal quality and quantity of saliva should be noted.

EXAMINTION OF HARD TISSUE:

The hard tissue examination includes many aspects like

NUMBER OF TEETH PRESENT:

Usually during examination the number of teeth present are counted, as

they may indicate any missing or unerupted teeth for that particular age

group.
TOOTH SIZE , SHAPE AND COLOUR:

Very important to examine all these as size may vary in many

conditions as microdontia/macrodontia. Shape of the tooth should be
noted as per the presence of notched teeth/tapered teeth. E.g. In
congenital syphilis," Hutchinson's" teeth. Also the color of the teeth should
be record which helps to know about the condition of teeth to see any
developmental deformities. Like, enamel hypoplasia, exposure of dentin,
Non-vital teeth, Pink teeth as seen in internal bleeding, Amelogenesis
imperfecta, Dentinogenesis imperfecta

SEQUENCE AND POSITION OF ERUPTING TEETH.

In the developing child the sequence of the eruption of the teeth should be

recorded as some times the teeth may be absent or other teeth may be

present for that particular age. So by recording it carefully the missing

impacted teeth record could be obtained. The position of the erupting

teeth

is very important as it influences the development of normal occlusion or

malocclusion. If any deviated path of eruption is seen early correction as to

be done to prevent the full fledged developing malocclusion.

MOBILITY OF TEETH (MILLERS CLASSIFICATION)

a) Class I: Physiological mobility

b) Class II: upto 1 mm transverse movement

c) Class III: more than 1 mm in any direction

Examination of mobility using 2 probes is called fremitus test. Fremitus is

the term given to non-physiological movement of tooth during function

CARIOUS TEETH: Identification of carious lesions is important in patients of

all ages but is essentially critical in young patients because the lesions may
progress rapidly in early childhood caries if not controlled. During the
clinical examination for carious lesions, each tooth should be dried
individually and inspected under a good light. Eliminating the carious
activity and restoring the teeth as needed will prevent pain and the spread
of infection and also contribute to the stability of the developing occlusion.

FRACTURE:

ELLIS & DAVEY (1960) CLASSIFICATION

CLASS 1: simple fracture of crown involving only enamel with little or no

dentin

CLASS 2: extensive fracture of crown involving dentin but no pulp exposure

CLASS 3: extensive fracture of crown involving considerable dentin with

pulp exposure

CLASS 4: traumatized tooth becomes non vital with or without loss of

crown structure

CLASS 5: teeth lost as a result of trauma or avulsion

CLASS 6: fracture of root with or without loss of crown structure

CLASS 7: displacement of tooth without fracture of crown or root

CLASS 8: fracture of crown enmasse and its displacement

CLASS 9: fracture of deciduous dentition

W.H.O CLASSIFICATION (1993)

873.60 – enamel fracture

873.61 – enamel and dentine fracture without pulp exposure

873.62 – enamel and dentine fracture with pulp exposure

873.63 – root fracture

873.64 – crown-root fracture

873.66 – concussion, luxation

873.67 – intrusion, extrusion

873.68 – avulsion

873.69 – soft tissue injuries

OCCLUSAL ASSESSMENT

MOLAR RELATION:

Class I molar relation: The mesio-buccal cusp of the maxillary first

permanent molar occludes in the buccal groove of mandibular first
permanent molar.

Class II molar relation: The disto-buccal cusp of the upper first permanent
molar occludes in the lower first permanent molar.

Class III molar relation: mesio-buccal cusp of the maxillary permanent first
molar occludes in the interdental space between the mandibular first and
second molars.

MOLAR RELATION IN DECIDUOUS DENTITION

Flush terminal plane: the distal surface of the upper and lower seconds are
in one vertical plane. This is the normal feature of the deciduous dentition.
This type results in an end on molar relation and subsequently class I
relation in permanent dentition.

Mesial step: in this type of relationship the distal surface of the lower
second deciduous molar is more mesial than that of the upper. Thus the
permanent molars erupt directly into class I occlusion. If the differential
growth of mandible in forward direction persists, it can lead to an Angle’s
class III molar relation.

Distal step: this is characterized by the distal surface of the lower second
deciduous molar being more distal to that of the upper. Thus the erupting
permanent molars maybe in Angle’s class II occlusion.

FUNCTIONAL ASSESSMENT:

Respiration

Mouth breathing or interference with nasal respiration have important

effects on craniofacial growth.

Methods of examination

1. Study the patient's breathing unobserved. Nasal breathers usually show

the lips touching lightly during relaxed breathing, whereas mouth breath-
 ers keep the lips apart.

2. Ask the patient to close the lips and take a deep breath through the
nose:

Nasal breathers normally demonstrate a good reflex control of alar

muscles and control the size and shape of the external nares, they dilate
the external nares on inspiration. Mouth breathers, even though they are
capable of breathing through the nose, do not change the size and shape
of the external nares and occasionally even contract the nasal orifices
during inspiration.

3. Mirror test: A double sided mirror is held between the nose and the
mouth. Fogging on the nasal side of the mirror indicates nasal breathing
while fogging towards the oral side indicates mouth breathing. .

4. Cotton test: (Butterfly test): A butterfly shaped piece of cotton is placed

over the upper lip below the nostrils. If the cotton flutters down it
indicates nasal breathing. This test can be used to detect an unilateral
nasal blocking.

5. Water test: The patient is asked to fill his mouth with water and retain it
for a period of time. While nasal breathers accomplish this with ease,
mouth breathers find the task difficult.

Differential Diagnosis:

I. Nasal breathers: lips touch lightly at rest, nares dilate on command

inspiration.

2. Mouth breathers: Lips are parted at rest; nares maintain size/contact on

command inspiration with the lips held together.

Swallowing:

Differential diagnosis of swallowing types

RADIOGRAPHIC EXAMINATION

When indicated, radiographic examination for children must be completed

before the comprehensive oral health care plan can be developed, and
subsequent radiographs are required periodically to allow detection of
incipient carious lesions or other developing anomalies.
Obtaining isolated occlusal, periapical or bite wing films is some times
indicated in very young children because of trauma, toothache, suspected
developmental disturbances or proximal caries. Carious lesions appear
smaller than they really are.

As early as 1967, Blayney and Hill recognized the importance of diagnosing

incipient proximal carious lesions with appropriate use of radiographs. If
the pediatric patient can be motivated to adopt a routine good oral hygiene
supported by competent supervision, many of these initial lesions will be
arrested.

TREATMENT PLANNING

PHASES OF TREATMENT PLANNING

1. Systemic phase:

1. A patient with a medical disease background may require the

condition to be stabilized and then dental treatment to be carried
out. In this respect the patient may have to be referred to the
physician or pediatrician as required.

2. Keeping in mind the systemic condition, pre medication (as in

antibiotic prophylaxis, sedation) needs to be given to the child, again
with the consent of the pediatrician or physician.

2. Preventive phase:
 Caries risk assessment (as described elsewhere) Assessment for various
preventive measures (fluoride application, pit and fissure and sealant,
diet counseling).

3. Preparatory phase:

1. Behaviour management: The child's behavior shaping should start

right from the reception itself.

2. Oral prophylaxis -It presents a clearer view of the caries process which
facilitates its diagnosis. It also gives an idea whether the patient will
cooperate.

3. Caries control - Further progress of carious lesions should be

controlled. Sometimes multiple lesions may need to be temprorized.

4. Orthodontic consultation - Minor orthodontic correction should be

carried out before evaluating the space maintenance program.

5. Oral surgery - Gross caries may necessitate the removal of teeth.

6. Endodontic therapy - Sometimes, a tooth may need to be saved with

endodontic treatment.

4. Corrective Phase:

1. Restorative dentistry - permanent fillings, stainless steel crowns

would be included under this phase.

2. Prosthetic Rehabilitation - tooth replacement, Jacket crowns etc.

3. Early Orthodontic intervention is to be carried out.

5. Maintenance Phase:

Depending on the risk of the individual and his oral hygiene status, a 3-6
month recall visit can be established.