case history in pediatric dentistry, a overview in detail

1. Case History
in paediatric
dentistry
Presented by
Hrishikesh Joshi

2. Biographical data
 Name
 Age
 Sex
 Date of birth
 Gender
 Phone number
 Address

3. Chief Complaint
 The chief complaint is the symptom or symptoms in patients(parents)
own words.
 The recording of symptom in patients own words is of importance for
medico-legal purposes
 Factors that are to be taken in consideration while recording the history
are as follows:
1. Young patients may not exactly able to express what they feel
2. Fear my cause disguise a problem

4. History of Present Illness
It is the chronological account of patients chief complaint
The HOPI may be Qualitative or Quantitative( Qualitative
means –the pain can be described as sharp, lancinating,
dull or throbbing; and Quantitative may be described as
the time for which the pain lasts; for example the pain
lasts for 3-4 hours.

5. Questions to be asked in HOPI
 ABOUT PAIN
1. When did it start?
2. How did it start?
3. What is the character and nature of pain?
4. Location of pain?
5. Aggravating & reliving factors?
6. Is the pain associated with any other activity?

6. Types of pain
1. Intermittent sharp pains
2. Dull aching pain
3. Throbbing pain
4. Tender on percussion
5. Diffused pain

7. Types of pain refer to?

9. Past medical history
I. Any infections during pregnancy?
This is of importance because many infections can pass through the
mother to the foetus, this kind of infections are known as trans-
placental infections and may cause foetal abnormalities.
One of the disease in our concerns is SYPHILLIS
In congenital syphilis the features seen are MULBERRY MOLARS AND
SCREWDRIVER shaped incisors.

10. Any trauma during pregnancy?
– History of trauma during pregnancy is important because
it can give us idea about many disorders, for example;
Forceps delivery can cause trauma to the TM Joint which
can lead to ANKYLOSIS of the joint.

11. Drug intake during pregnancy?
– The word TERATOGENIS comes in mind when asked this question
Teratogenesis means ability of a drug to induce foetal abnormalities
For example
Tetracycline is known to cause YELLOW staining of and reduction in
height of long bones.
Diazepam is known to cause CLEFT LIP.

12. Examples of teratogenic drugs are as follows;
– ACE( Angiotensin converting Enzymes)
– Isotretinoin( an acne drug) [it is also prescribed in cases of
leucoplakia] it is derivative of Retinoic acid.
– Alcohol
– Lithium
– Phenytoin
– Warfarin

13. Natal history
1. Was the child born premature/term/post-term?
Asking this question gives us an idea about the periodontal
condition of the mother, PERIODONTITIS in pregnant ladies
can cause low weight babies and premature and preterm
deliveries.

14. 2. History of uncontrolled DIABETIES?
PERIODONTITIS is to be known to be associated with
diabetes so, this gives us a idea about the periodontal
condition of the patient.

15. – Type of delivery?
The type of delivery gives us an idea gives us an idea about
the joint disorders
For example
Forceps delivery can cause trauma to the TMJ which can
lead to TMJ ankylosis.

16. – Blue /yellow baby?
This tells us that was the baby cyanotic or jaundiced at the
time of delivery.

17. H/O of allergy to any drugs or
food?
– Is the child allergic to any food or drug?
– This question tells us about the allergic conditions of the
child(patient).

18. Is the child on any prescription or
non-prescription drugs
– This thing is important for the treatment planning
of the patient.

19. Past Dental History
– The past dental history tells us about any previous
exposure of patient to the dental environment.
– This thing is important for management of the patient
according to the previous exposure of the patient.
– Plus, it also tells us about the history of any exposure of
the patient to the local anaesthetic agents, which tells
about any allergy to local anaesthetic agents.

20. Personal History of the Patient
This primarily includes about the habits of the child
1. Thumb or digit sucking- this gives rise to mal occlusions
with anterior crowding
2. Mouth breathing- this also gives rise to the
malocclusions.

21. Diet History
– A complete diet chart is drawn with the timing and meals, with the in-
between food intake.
– The sugar in solid medium and sugar in liquid medium is also recorded.
– The frequent sugar intake can result into the Ph of the saliva dropping
below 5.5 which concludes with the demineralization of the enamel
which makes it more susceptible for caries.
– The sugar in solid medium takes time to dissolve into the oral cavity,
because of which he Ph is more below 5.5 ultimately making it more
prone to caries.

22. Oral Hygiene History
– How the patient brushes his/her teeth?
– How many times a day?
These are the questions, which are the primary concern when it
comes to oral hygiene history. This provides us with the idea of the
oral hygiene of the child.

24. Habits
– Dental habits
Does the child has any following habits;
1. Finger/thumb sucking
2. Nail biting
3. Lip biting
4. Tongue thrusting
5. Mouth breathing
6. Bruxism/teeth grinding

25. – All of the habits are of prime importance when it comes
to diagnosis & treatment planning.
– These habits lead certainly to mal-occlusions, which
when diagnosed early and treated early can prevent the
mal-occlusions.

26. Examination
General physical examination
1. Facial symmetry
2. Physical and body proportions
3. Posture & Gait

27. – Changes noticed in any of the mentioned general examinations
can indicate
1. Cerebral palsy
2. Polio
3. Orthopaedic problems
4. Dwarfism/ Gigantism

28. – Head : shape, size & symmetry may be evaluated( which
when abnormal may indicate Hydrocephalus,
Microcephalus, sleeping on the side, etc)
– Eyes: Checked for hyper or hypo-telorism
– Nose : Deviated nasal septum(DNS)

29. Extraoral Examination
– Shape of head
1. Dolichocephalic – Head is longer than normal
2. Mesocephalic –Head is neither too long nor short
3. Brachycephalic – Shorter head than normal

30. Facial Form
– Leptoproscopic – Having a long narrow face
– Mesoproscopic – Having a face of average facial
width
– Euryproscopic - having a short and broad face

31. Facial symmetry
– Asymmetrical – seen in cases of any swelling or tumour
– Symmetrical – seen normal cases

32. Lateral profile
– Convex – Seen class 2 mal- occlusions
– Concave – seen in class 3 mal-occlusions
– Straight – Seen in class 1 mal-occlusions

33. Lips
– Competant
– In-competant
– Partially competant

34. Lymph Node Examination
– Consistency of lymph node
1. Soft – Usually seen in infectious conditions
2. Hard – Seen in Malignancies
3. Matted – Seen in chronic inflammatory
conditions such as Tuberculosis

35. Methods of examination of
lymph nodes

40. Intraoral Examination
– Intraoral examination includes any soft tissue related
lesions and any hard tissue lesions( Jaws and Teeth).
– In the examination, the teeth are recorded in FDI system.
– The intraoral examination gives us an idea about dental
age, type of dentition present, decayed, missing and
filled teeth & the present oral hygiene status.

41. Soft Tissue Examination
Lips
Buccal mucosa
Labial mucosa
Soft palate
Hard palate

42. Tongue
Floor of mouth
Frenum
Gingiva

43. 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

44. Gingiva in children Gingiva in adults
Reddish in color Thinner epithelium, a
degree of keratinization, and greater
vascularity
lesser Coral pink, due to thickness and degree of
keratinization ,
cells
vascularity and pigmented
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
Lack of stippling: Shorter and flatter papillae Stippling is present: it is a form of adaptive
from the lamina propria. specialization or reinforcement for function.
Degree of keratinization and prominence of
stippling appear to be related
Rounded and rolled gingival margins: Knife edge margins
Hyperemia and edema that accompanies
eruption. Pronounced cervical ridge of the
crown in deciduous teeth

45. Hard Tissue Examination
– Teeth Present
– Chronological Age/Dental Age
– Carious Teeth
– Oral Hygiene

46. 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

47. Eruption and Shedding timings
of Deciduous Dentition

48. Eruption timings of permanent
Dentition

49. Orthodontic Evaluation of the
Dentition

50. – Class 1 malocclusion: In this the mesio-buccal cusp of 1st maxillary
permanent molar occludes in the buccal groove of 1st mandibular
permanent molar.
– Class2 mal-occlusion: In this the disto-buccal cusp of 1st maxillary
molar occludes in the buccal groove of 1st mandibular molar.
– Class 3 mal-occlusion: In this the mesio-buccal cusp of 1st maxillary
molar occludes in the interdental area between 1st and 2nd
mandibular molar.

51. Primary molar relationship
– Flush or straight terminal plane: If the distal surfaces of both upper
& lower primary molars are in one line with each other, when the
primary teeth are in occlusion then it is known as flush terminal
plane.

52. – Mesial step: If the distal surface of lower primary molar
is mesial to the distal surface of upper second primary
molar in occlusion.

53. – Distal step: If the distal surface of the lower primary
molar is distal to the distal surface of upper 2nd primary
molar in occlusion then it is termed as distal step
occlusion.

55. Pulpal Diagnosis
– Anatomical differences in in pulp of primary teeth & permanent teeth-
1. Pulp horns of primary teeth are proportionately larger than the pulps of
permanent teeth, with the pulp horns coming close to the cusps.
2. The thickness of primary teeth dentin is less than that of permanent
teeth.
3. There are increased number of accessory canals as compared to the
permanent teeth.

56. Pulpal Pain
– Provoked Pain- It is stimulated by thermal, chemical
& mechanical irritants & is reduced or eliminated
when the stimulus is removed.
– This frequently indicates sensitivity due to deep
carious lesion or faulty restoration.
– This condition is usually seen in reversible pulpitis.

57. – Spontaneous pain- It is throbbing, constant type of pain
that can keep patient awake at night.
– This indicates extensive degeneration of pulp, which
extends towards the root canals.
– This usually refers to a diagnosis of irreversible pulpitis.

59. Fibres responsible for pain
conduction in pulp
– The cell bodies of the sensory neuron of the pulp are
located in the trigeminal ganglion.
– The nerve fibres enter through the apical foramen,
where they reach the coronal pulp and form the plexus
of Raschkow .
– There they anastomose and terminate into free nerve
endings into odontoblastic process.

60. – The two types of nerve fibres in the pulp are myelinated A
fibres (A-delta fibres & A- beta fibres) & non-myelinated C
fibres.
– 90% of the fibres are A-delta fibres which are located near
pulp-dentin border of the coronal pulp & are concentrated in
the pulp horns, the C horns are located in the core of the
pulp or pulp proper & extend till the cell free zone till the
odontoblastic layer.

61. Clinical implications for intra-
pulpal sensory nerve fibres
– The A-delta fibres have a smaller diameter therefore slower conduction
velocity than the other types of A fibres, but are faster than C fibres.
– The A fibres transmit pain directly to the thalamus, generating a fast, sharp
pain that is easily localised, the C fibres are modulated by the interneurons
hence a slow effect.
– The A fibres respond to various stimuli like probing, drilling, etc through
hydrodynamic effect.
– The location of the C fibres in the core of the pulp may explain the diffused
pain or which is called also as referred pain.

62. – The C fibres may survive in hypoxia which may explain
the pain during the root canal treatment.

63. Provisional Diagnosis
– It is tentative diagnosis which is not fully worked out,
concluded or agreed upon.
– This is based upon medical & dental history taken & also
by the examination done.
– This is used till the final diagnosis is worked out based on
the investigations.

64. Differential Diagnosis
– It is a process of identifying a condition by differentiating
all the pathologic processes or conditions that may
produce similar lesions.
– Otherwise it is termed as distinguishing between
diseases of similar character by comparing their signs
and symptoms.

65. Investigations
– Investigations that may be carried out are as follows
– Radiographs like
1. IOPA
2. OPG
3. PA Mandible
4. CT
5. MRI

66. Final Diagnosis
– This is achieved by all investigative data collected
– The diagnosis may be categorised in any of the following
headings
1. Medical
2. Behaviour
3. Growth
4. Oral hygiene

67. 5.Caries Risk
6.Restorative
7.Endodontic
8.Orthodontic
9.Surgical or any other

68. Treatment Planning
– The treatment planning is always stepwise, rational, evidence
based ordered sequence in which the treatment is necessary for
child’s well being will be carried out.
– While making a treatment plan these factors are taken into
consideration
1. The emergency needs should be treated urgently( like trauma,
dento-alveolar abscess, etc)
2. Patients with medical history like leukaemia & haemophilia.
3. Patients coming from long distance
4. Parental attitude towards the dentistry.

69. 5. Prognosis of the tooth.
6. Anticipated benefits of the patient.
7. Need for importance of preventive dentistry.

70. The Treatment may be executed
in following order
1. Immediate phase- Refers to attending the immediate
needs of the patient.
– Relieving the pain & mental agony of the patient..
– Attending the trauma or the deep carious lesions causing
agonising pain to the patient.
– Some may work along with the action of prescription
drugs like analgesics, antibiotics, anxiolytics, etc

71. Systemic Phase
– In this phase a reference from physicians should be taken
in consideration in case of any medical conditions.
– This is necessary before starting any dental procedures.

72. Preparatory Phase
– It includes preventive measures like oral prophylaxis, pit
& fissure sealants, etc.
– Premedication plus health education given to the patient
& their parents.

73. Corrective Phase
– Includes step by step planning of restorative, surgical,
endodontic, orthodontic & prosthetic rehabilitation
procedures.

74. Maintenance Phase
– It includes the instructions given for the maintenance
after the dental procedures are completed.