Examination and treatment planning for pediatric dental patient

Presenter
Arwa Mohammed Namnakani
2019-2020
R1 SP-PD
1Dr. Arwa Namnakani

- Introduction
- Initial parent contact with the dental office
- First dental visit
- Emergency dental treatment
- Examination and assessment of pediatric patient
- Infant dental care
- Infection control in the dental office
4Dr. Arwa Namnakani

Introduction
Successful dental therapy is predictable on our ability to:
1. Conduct an accurate patient evaluation
2. Establish thorough diagnosis
3. Select an optimal treatment planning to preserve human tissues
5Dr. Arwa Namnakani

1- To distinguish between normal and abnormal.
2- To determine need for professional consultation and referral.
3- To aid in treatment plan.
4- To determine whether the need for delivering the dental care in the hospital.
5- To recognize the need for premedication if indicated
6Dr. Arwa Namnakani

Initial parent contact with the dental office
The information recorded by the receptionist during this
conversation constitutes the initial dental record for the
patient.

First dental visit
• AAPD recommending:
The first visit occur within 6 months of the eruption of the first
primary tooth and no later than 12 months of age.
8Dr. Arwa Namnakani

Emergency dental treatment
• The emergency appointment tends to focus on and resolve a single
problem or a single set of related problems rather than provide a
comprehensive oral diagnosis and management plan.
• Once the emergency problem is under control, the dentist should offer
comprehensive services to the patient.
9Dr. Arwa Namnakani

Is the term often used to describe the
discussion and implementation of
such a plan with the patient and/or
parents
10Dr. Arwa Namnakani

Examination and assessment of
pediatric dental patient

Examination and assessment of
pediatric dental patient
General growth and health
Chief complaint, such as pain
Extraoral soft tissue and temporomandibular
joint evaluation
Intraoral soft tissue
Oral hygiene and periodontal health
Intraoral hard tissue
Developing occlusion
Caries risk
Behavior

Photograph
Radiograph
Pulp vitality testing
Study models
Laboratory tests
Additional Diagnostic Aids

History
Tacking a good history is the key to accurate diagnosis and appropriate
treatment planning.
Its include :
 Personal details
 Chief complaint
 Social history
 Family history
 Medical history
 Dental history

The sequence of case recording:
• Demographic data
Name, age, sex, class and school, parents occupation, address and
telephone number.
• Hospital registration number
• Date
• Name: Real name and nick name
• Age (Juvenile periodontitis and acute herpetic gingiva-stomatitis) (AHGS).
• Sex (Hemophilia in male)
• Hight and Weight
• Class and school
• Parent’s occupation
• Address

Chief complaint
The reason of seeking the dental care must be recorded by parents or child’s
own words.
The history of any current problems include :
• Onset or type of pain present.
• Location.
• Duration.
• Characteristic.
• Aggravating factors.
• Relieving factors. 16Dr. Arwa Namnakani

Family History Oral Habit History
Oral Hygiene History Diet History

General growth and health
➤ Intellectual Development
➤ Gross/Fine Motor Skills
➤ Psychological Development
➤ Physiologic Height
➤ Weight
➤ Vital signs ( Pulse, Respiration, Blood Pressure )

The patient’s hands may reveal information pertinent to a comprehensive
diagnosis.
• The dentist may first detect an elevated temperature by holding the
patient’s hand.
• Cold, clammy hands or bitten fingernails may be 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 a bluish color in the nail beds suggests
congenital heart disease, which may require special precautions during
dental treatment.

Extraoral
Examination
Head and Neck
Examination
Facial
Examination
Intraoral
Examination
Soft Tissue
Hard Tissue
Examination

Head and Neck
Examination

impetigo
Ringworm infection
Head lice
Head and Neck Examination

Thyroid Palpation Lymph nodes Palpation
Head and Neck Examination

Symmetric function
Smooth movement
Absence of pain
Abnormal sounds (crepitus)
Temporomandibular Evaluation

• Observation and palpation of temporomandibular joint function.
Temporomandibular disorders in children can be managed by :
Patient education, mild physical therapy, behavioral therapy, medications, and
occlusal splints.
Temporomandibular Evaluation

Uses
Facial Examination
o Facial symmetry
o Overall facial pattern (Facial Profile)
o Position of the maxilla and mandible
o Vertical facial relationship
o Lip position

Contraindications
FACIAL SYMMETRY

FACIAL PROFILE
• The facial proﬁle is evaluated in the anteroposterior plane
Bridge of the nose
Base of the upper lip
Soft tissue chin

A perpendicular reference line is established beginning at the soft tissue
bridge of the nose.
POSITIONS OF THE MAXILLA AND
MANDIBLE

VERTICAL FACIAL RELATIONSHIP
Vertical facial proportions can be evaluated by dividing the face into
thirds and then comparing the middle third to the lower third.
These thirds are approximately equal, or the lower
third is slightly larger in well-proportioned faces.

LIP POSITON
Tip of the nose
Anterior point on
the soft tissue chin.
3- to 6-year-old child Adolescent

AdvantagesSOFT TISSUE EXAMINATION
Inspection and palpation

3 Cs
Color
Red
White
Blue
Contour
Swelling
Ulcer
Consistency
Soft
Firm
Hard 37Dr. Arwa Namnakani

 Tongue
• Size ,shape, color and movement should be noted.
• Tongue is coated in the febrile state.
• Tongue tie.
 Halitosis
May be due to poor oral hygiene, dehydration, sinusitis, or
GIT disturbances.

 Enlarged tonsils accompanied by purulent exudate may be the
initial sign of a streptococcal infection, which can lead to
rheumatic fever.
 When streptococcal throat infection is suspected, immediate
referral to the child’s physician is indicated.

ORAL HYGIENE AND PERIODONAL HEALH
• The use of the periodontal screening and recording program (PSR) is often
a helpful adjunct when working with children.
• PSR is designed to facilitate early detection of periodontal diseases with a
simplified probing technique and minimal documentation.
• Recommendation:
Initiation of periodontal screening in children following eruption of the
permanent incisors and the first molars.

• High maxillary labial frenal attachment may be responsible for
abnormal spacing between the central incisors.
• Redness and swelling may be associated with inflammation
(gingivitis).
• Draining fistula on the attached gingiva accompanied by a tender
tooth, painful and mobile are usually diagnostic of abscessed
teeth.
• Black color is normal for dark people. 41Dr. Arwa Namnakani

DISCLOSING AGENTS
To increase the patient’s ability to remove plaque, several
agents have been developed to allow for patient visualization
of plaque.

• Simplified Oral Hygiene Index
( Green and Vermillion)
• Six teeth are examined by running the
side of No.5 explorer over the tooth
surface.
• Buccal surface (#16, #26) .
• Lingual surface (#36, #46).
• Labial surface (#11, #31).

AdvantagesHard Tissue Examination
All teeth should be inspected carefully for evidence of carious lesions and
hereditary or acquired anomalies.
 Should be examined :
• Number
• Size
• Shape
• Structure
• Color 48Dr. Arwa Namnakani

Advantages
 Hard tissue status
Decayed, filled, extracted, stained, rotated ,malformed, hypoplastic,
congenitally absent, retained etc.
 Tooth mobility
May be due to periapical infection, periodontal involvement, horizontal root
fracture in middle or coronal one third.
Hard Tissue Examination

AGENESIS OF TEETH
Anomalies of Number
ANODONTIA
HYPODONTIA
(OLIGODONTIA)Supernumerary
Hyperdontia

Anomalies of Size
• Microdontia.
• Macrodontia.
• Fusion.
• Gemination .

Anomalies of Shape
• Dens Envaginatus.
• Dens in Dente.
• Taurodontism.
• Dilaceration.

Anomalies of Structure
Enamel:
Amelogenesis Imperfecta
Enamel hypoplasia
Dentin:
Dentinogenesis imperfecta
Dentin Dysplasia

Anomalies of Color
Extrinsic stains Intrinsic stains

OCCLUSAL EVALUATION
Arch form :
• Mandibular arch is normally U-shaped.
• Maxillary arch can be either U-shape or V shape.
Arch spacing :
Two types of spaces are identiﬁed ideal arch in the
primary dentition:
1-primate space: is located mesial to the maxillary
canine and distal to the mandibular canine.
2- Developmental space : is the space between
the remaining teeth .

ANTEROPOSTERIOR DIMENSION
 primary molar relation :
ﬂush terminal plane, mesial step, distal step.
 Primary cuspid relation
class I, class II, class III or end-to-end.
 Permenant Molar relation:
class I, class II, class III.

ANTEROPOSTERIOR DIMENSION
Overjet:
• Is the measurement between upper incisal edge and the
labial surface of lower incisors.
• Its measured in millimeters.

TRANSVERSE RELATIONSHIP
• Midline discrepancies
• Posterior crossbites
Bilateral crossbite Unilateral crossbite

VERTICAL DIMENSION
Vertical overlap :
The extent of vertical overlap of maxillary
central incisor over the mandibular central
incisor.
Deep bite Anterior
open bite

Advantages
Basic requirements for a tooth-charting system:
Simple to understand and teach
Easy to pronounce in conversation and dictation
Readily communicable in print
Easy to translate into computer input
Easily adaptable to standard charts used in general practice
UNIFORM DENTAL RECORDING
(FDI System)

UNIFORM DENTAL RECORDING
The committee found that
only one system:
(two-digit system) seems
to comply with these
requirements.

Provisional diagnosis:
It is a general diagnosis based on clinical impression
without any laboratory investigation or other tests.

Percussion
-It reveals the status of perodontium and not of pulp.
Positive response to the handle of the mirror may indicate:
-An apical or lateral periodontal abscess.
-Recent high restoration.
-Teeth undergoing orthodontic movement.
Radiographic examination
It gives information regarding the presence or absence of the teeth,
relative state of the teeth development, path of eruption of teeth, shape
and position of teeth, etc. 64Dr. Arwa Namnakani

Pulp testing
Either thermal or electrical
1-Thermal like: gutta-percha (650c), heated instrument tip or cold test like
ethyle alcohol, ice sticks or carbon dioxide.
Response to vitality test:
- Nil= non-vital pulp or false –ve
- Moderate transient= normal
- Painful transient= reversible pulpitis
- Painful lingering= irreversible pulpitis

2-Electricpulp tester
- It is contra-indicated in patient with pacemakers.
- False positive reading is observed with extensive vital restoration
and anxiety.
- False negative reading is observed with recently traumatized
tooth, incomplete root formation, excessive calcification and
partial necrosis

- Study model
To detect arch size and tooth size discrepancy , occlusion, and to compare
pre and post ortho ttt.
- Cephalometric study and X-Rays:
To study growth and development, case diagnosis, and treatment
planning, dictating the prognosis, prediction of growth and as record.
- Final diagnosis
It is a more confirmed diagnosis analyzing all the available data.

Chief complaint, emergencies.
Preventive care.
Restorative treatment.
Surgical treatment.
Orthodontic treatment.
Prosthodontic treatment.
Recall visits, follow up. 69Dr. Arwa Namnakani

It is based on different phases
Medical, systemic, preventive, stabilization, corrective,
maintenance and recall.
Patients at high risk are maintained at 2-3 months recall and
low risk at 6 month recall.

• Medical phase:
Positive medical history should be referred to physician.
• Systemic phase:
It includes any medication given to modify dental ttt like AT prophylaxis,
premedication or ortho consultation
• Preventive phase:
1st phase of ttt and includes ,oral hygiene, prophylaxis, pit and fissure
sealants, fluoride and diet analysis.

• Stabilization:
Where a child has open cavities, a phase of stabilization should precede
the provision of definitive treatment to stop the progression of dental
caries and reduce the bacteria.
- Parents should know that this is not permanent restorations.
• Corrective phase:
Resto, extraction, space M, ortho, prosth.

• Plan efficient use of LA (QUADRANT THERAPY)
• Treat comprehensively with definitive treatment.
• Consider full coverage if using GA

1-Small simple restorations should be 1st
2-Max teeth should be treated before Mand ???? Why?
3-Posterior teeth before anterior ??
4-Quadrant dentistry wherever possible
5-Endodontic ttt should follow simple restorative ttt
6-Extraction should be the last item.

INFANT DENTAL CARE
The 2013 AAPD guidelines on infant oral health care included
the following recommendations:
1. All primary health care professionals should provide
parent/caregiver education on the etiology and prevention of
early childhood caries (ECC)
2. The infectious and transmissible nature of bacteria that
cause ECC and methods of oral health risk assessment,
anticipatory guidance, and early intervention should be included
in the curriculum of all medical, nursing, and allied health
professional programs.

INFANT DENTAL CARE
3. Every infant should receive an oral health risk assessment
from his or her primary health care provider by 6 months of age.
4. Parents or caregivers should establish a dental home for
infants by 12 months of age.
5. Health care professionals and all stakeholders in children’s
health should support the identification of a dental home for all
infants at 12 months of age.

INFANT DENTAL CARE
The examination should begin with a systematic and
gentle digital exploration of the soft tissues without any
instruments.

Dental treatment should be postponed79Dr. Arwa Namnakani

McDonald Pages: 15-16 80Dr. Arwa Namnakani

The dental team is exposed to a wide variety of microorganisms:
hepatitis B and C, herpes viruses, cytomegalovirus….
The goal of infection control in dentistry
is to reduce or eliminate exposure of
patients and dental team members to
microorganisms.
- Use standard precautions - McDonald Page: 15

Conclusion
Be Atraumatic
Work
comprehensively
Be nice

Pediatric Dentistry
Everywhere

References
1- Casamassimo, Paul S., et al. PEDIATRIC DENTISTRY: INFANCY THROUGH
ADOLESCENCE. Elsevier; 2013. Chapter 18: Examination, Diagnosis and
Treatment planning.
2- Dean J, Avery D, McDonald R. McDONALD AND AVERY’S DENTISTRY FOR THE
CHILD AND ADOLESCENT. 10th edition. Elsevier; 2016. Chapter 1: Examination
of the Mouth and Other Relevant Structures.
3- AAPD. "Guideline on periodicity of examination, preventive dental services,
anticipatory guidance/counseling, and oral treatment for infants, children, and
adolescents." Pediatric dentistry (2013). 35.5. 84Dr. Arwa Namnakani

Examination and treatment planning for pediatric dental patient

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