case history

CASE HISTORY DIAGNOSIS, ASSESSMENT

AND TREATMENT PLANNING INPEDIATRIC PATIENTS

Dr. A. Victor Samuel MDSDept. of Pedodontics

Contents •Introduction•Diagnosis•History taking and clinical examination•Patient information•History taking•General physical examination

•Extra-oral examination•Intra-oral examinationA) Soft tissue examination B) Hard tissue examination • Provisional diagnosis• Differential diagnosis•Investigations•Final diagnosis•Treatment planning•Prognosis

Introduction

•The case history enables the patients

•It involves eliciting and recording of

•It should be systematic and shouldfollow a definite outline

Gathering this information: •Can be essential in establishing acorrect diagnosis •It allows assessment of the patient’smental and behavioral status.

Few terminologies in case history recording •Diagnosis –The determination of thenature of the disease. •Symptom –Any morbid phenomena or

•Sign –Any abnormality indicative of

DIAGNOSIS

•Diagnosis is derived from the Greekword dia = by and gnosis = knowledge •Diagnosis has been defined asidentification of disease. (Donald Kerr and Major Ash 1970)

•Physical, Emotional and Psychologicaldifferences: •Consideration of behavior as aintegral part of the child’s oral health needs •Attention to preventive care ratherthan rehabilitative process

•Acknowledgment

•Recognition that the child is a

changing person

HISTORY TAKING AND CLINICAL EXAMINATION

I) Personal information

Date a) It records the time the patient reported. b) Can be referred back to during the follow- up visits.

Hospital number/Case number –For the purpose of maintaining record– For billing the individual–For legal considerations (in view ofConsumer Protection Act)

Patients name – To establish a better communicationwith the patient. –To establish a rapport with thepatient. – Maintenance of record.–To elicit the history properly.– Medico legal purpose.

Age The chronological age (date of birth) should be noted.

management techniques also vary.

Sex – Girls age faster than boys and thustheir treatment may be required earlier. –Some diseases are more common infemales than in males. – A combination of age and sex cansometimes give an indication of occurrence of disease

Place of birth •It gives information about the

Address

–It is used for all communications even beforethe first visit. – – If the patient is coming from a far distance,the appointments can be modified to complete treatment in fewer visits. – It may indicate diseases endemic to theparticular areas.

Socio-economic status b) Patients background can be understood in a better way.

Languages known –Mother tongue– To establish better communication withthe patient. –To built a good rapport.

School and class –To know the economic status.– To communicate with the teacher.–To assess the IQ of the child.– To establish effective communication athis own IQ level.

Race/ethnic origin –Some diseases are more common incertain races. – Oral hygiene practices may be commonin some religions or races.

Person accompanying the child •Child’s family life can be assessed.•The information which has to beasked can be modified according to it •The reliability of the informationmay also be evaluated

Parents name For better communication with the

II) History taking

Chief complaint

•The age of the patient apparently

influences the quality of the complaint. •The parent is often the best historianin younger children.

History of present illness

•The most common presenting illness can be

Past dental history c) Patient’s attitude towards

previous dental treatment.

d) Any untoward complication of dentaltreatment. e) To know about any excessive bleeding in the past dental treatment. f) Reasons for loss of teeth

Medical history • This helps in identifying conditions thatcould alter, complicate or contraindicate proposed dental procedures. •This should include questions like:• Is the child under the care of physician?•If yes why?• Any Medications taken presently,•Drug name, dosage/duration & indication• Whether the child suffers from anyfrequent illnesses (cough, cold etc.)?

•Does your child suffer from any of thefollowing at present or in the past? Congenital diseasesRheumatic feverAnemiaBleeding disordersAsthmaDiabetesHepatitis

• Epilepsy • Mental or physical handicap • Sensory deficits • Speech defects • Kidney disorders • Bone & joint problems • Growth and

development problems

History of immunization DPT vaccineBCG vaccine Po lio myelitis• Tetanus vaccine•MMR vaccine

•History of operations,hospitalizations, blood transfusion should be asked •History of drug allergies is taken suchas penicillin, aspirin anesthetic agent etc. the drug should be specified.

Family history a) It gathers information about diseases thatcommonly affects more than one member of a family.b) Certain disorders that should be inquired

- Ast hm a

- Allergies - Genetic disorders -Malocclusion c)Siblings::

Social history • It includes the

Prenatal history

• Drug intake during•Any illness duringpregnancye.g. hepatitis B infection

•Did the mother•Source of drinkingwater.

Natal history •Type of delivery- Normal/C-section/Forceps Fullterm/Premature •Childs health at birth: Good/Fair/PoorSpecify significant history

Postnatal history •Method of feedingand duration: Breast fed/Bottle fed/both •Does the child sleepwith the bottle? • What are/were thecontents of the bottle?

•Is/was a pacifierused-

•Did the child have

•At what age didthe first tooth erupt in the mouth? • Which tooth andany associated problems?

•When did the child•Sitting•Standing withoutsupport • Walk•Runs• Speaks in sentences

Personal history

a) Oral hygiene habits: • Brushing habits•Method of cleaningthe teeth • Frequency•Material

•Rinsing habits•At what age wastooth brushing initiated •When did the childstarted brushing on his own? • Is the childsupervised during brushing?

b) Diet: – Patient’s diet shouldbe assessed. – Number of meals–If the caries

c) Oral habits:

•Habits such as finger/thumb sucking,•The duration of the habit should benoted. •Also what has been done to make thechild stop the habit should be asked.

•Presence of habits such as finger or thumb•Features indicating various habits should beexamined

For e.g. is seen.

•Minor toothalso noticed.

towards lower lip. • The features areredundant lower lip. Cracking of lips is also

d) Tongue thrusting: Proclination of

•The various clinical test done to assess mouth

f) In bruxism the patient may have

•Tooth mobility specially in themorning,

Occlusal wear,Muscular tenderness,Headache andTMJ disorders.

III) General physical

examination

•It begins with

a) Built/stature, height and weight:

Whether normal for the age. If not factors responsible should be determined. b) Gait: An abnormal gait can be associated with a particular disease.

speech disorders.

d) Hands: It should be checked for pallor, cyanosis and icterus.

The nails are checked for any clubbing.

color, scars pigmentations, eruptions,

marks should be noticed.

f) Hair:

Thin and brownish color hair may be indicative of malnourishment. •Also texture should be noted

Vital signs • Temperature: Normal oral temperature is370C. •Pulse rate: In children 80-100bpmIn adults 70-80bpm • Respiratory rate: In children 16-20/minIn adults 12-16/min • Blood pressure: 120/80 mm of Hg

IV) Extra-oral examination

a) Shape of the skull: • It is classified as

b) Shape of the face: Face can be

c) Facial symmetry:

-congenital defects, -hemi facialatrophy/hypertrophy,

d) Facial profile:

-convex -concave

e) Eyes: f) Nose:

g) Lips:

h) Paranasal sinuses: Maxillary, frontal, and ethemoidalare checked for sinusitis.

i) TMJ and function: – Observe for deviations in the path of themandible during opening and closing. –Range of vertical and lateral movement.– Dislocation–Clicking sound, crepitus–Tenderness

j) Lymph nodes:

The lymph nodes commonly checked are Submaxillary Submental, and Cervical- Superficial and Deep –Check for site, size shape and mobility,tenderness, swelling, and lymphadenpathy – Lymph node palpable is soft –due toinfectionhard –carcinoma firm –lymphoma

No. of lymph node palpableDiameterMobility –mobile in case of infection.

-protrusion of the tip of the tongue

-contraction of perioral muscles during swallowing -no contact at molar region during swallowing

V) Intra-oral examination

1) Saliva:The flow and viscosity should be checked for.

.

A) Soft tissue examination

3) Tongue:

4) Palate:

5) Floor of the

mouth:

6) Gingiva:

7) Frenal attachments: Blanch test can be used for

confirmation Short lingual frenum can cause ankyloglossia.

8) Tonsils and Adenoids:

Enlarged adenoids should be checked for.

B) Hard tissue examination 2) Teeth present: Number of teeth present in both upper and lower arch should be noted. 2) Type of dentition: Whether primary, permanent or mixed 3) Missing teeth: Note whether the teeth is congenitally missing or missing following extraction.

4) Caries: 5) Caries with pulp involvement:

6) Root stumps: 7) Filling present:

8) Mobility:Grade of mobility should be mentioned 9) Fractured teeth:

13) Any wasting diseases: Like attrition, abrasion, and erosion 14) Hypoplastic teeth 15) Any other dental anomalies:

16) Orthodontic

Stains- Extrinsic Intrinsic

VI) Provisional diagnosis

•A general diagnosis based on clinicalimpression without any laboratory investigations.

VII) Differential diagnosis

•The process of listing out two or more

VIII) Investigations

•Radiographic investigations:•

1) Intraoral radiographs

A) IntraoralPeriapical radiographs B) Bitewing radiograph: C) Occlusalradiographs:

2) Extraoral radiographs A) Ortho pantomographs: B) Cephalographs:

Hematological investigations RBC countHemoglobin determinationHematocrit countPlatelet countBleeding timeClotting timeTorniquet testProthrombin timeWhite cell countDifferential count

Bacteriological culture and

sensitive tests •Wound abscess or surgical lesioncultures Caries activity testsRoot canal culturesFresh moist preparations and smears

Other tests

• Vitality tests•Biopsy• Photographs• Study models

Advanced diagnostic aids

Densitometric Image Analysis

IX) Final diagnosis

•A confirmed diagnosis based on allavailable data.

X) Treatment plan

Phases of treatment planning

Emergency Phase:Systemic phase:Preventive phase:Preparatory

phase:

•Corrective phase:

•Maintenancephase

XI) Prognosis

•It the prediction of the course,

References

•Dentistry for child and adolescents-Ralph. E .McDonald •Clinical Pedodontics- Finn•Textbook of Pedodontics-Shobhatandon •Oral diagnosis-Donald Kerr, MajorAsh

•Orthodontic- The art and science-I S Bhalaji •Color Atlas of Oral Diseases inChildren and Adolescence•Pictures from -www.google.com