Pedia clinical examination and diagnosis


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Pediatric Dentistry I
Forth Year

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Pedia clinical examination and diagnosis

  1. 1. Patient Records • Health history, signed & dated; update area • Examination record • Treatment plan • Progress notes • Parental or guardian consent Clinical examination
  2. 2. Patient Records • Should include: – Developmental status and existing pathosis – Record of each exam or procedure – Facial and occlusal status – Oral hygeine and periodontal status – Prevention – Charting system • Primary and permanent dentition • Developmental profile
  3. 3. Diagnosis • Recognize problem--cc • Treatment depends upon diagnosis • Depends upon complete health history, extraoral and intraoral exam and additional diagnostic aids – X-rays – Lab tests – Medical consult
  4. 4. Medical History • Completed by parent or legal guardian • Signed • Dated • Update on recall • Contact physician regarding concerns or unclear information • Do not ask child for any confirmation • Determine need for antibiotic prophylaxis A thorough knowledge of medical conditions (physical and psychological) that may predispose the patient to development of a problem will prevent the majority of emergency situations.
  5. 5. Medical History • Should include – Any medical or dental conditions, past or present – Allergies – Hospitalizations – Medications – Heart problems – Familial history – Etc. • Interview parent or guardian to clarify any questions
  6. 6. Caries Risk Assessment • Fluoride History • Dietary Habits • Sleep time Habits • Medications • Nonnutritive sucking habits • Family History • Oral Hygiene Habits
  7. 7. Fluoride History • Dosage • Frequency • Source • Water • Supplements • Rinses • Dentifrices
  8. 8. ADA Recommended Supplemental Fluoride Dosage Schedule
  9. 9. Family History Dental history Dental attitude
  10. 10. New patient 1st visit • Complete Pediatric clinical chart • Forming necessary radiographs • Prophylactic fluoride application • Patient & parent advices or education • Diet analysis
  11. 11. New patient 1st visit • Assessment of child behavior • Communication with the child • Assessment of caries risk • Instructions for home hygiene care
  12. 12. Clinical Examination: • Visual Inspection – pain source is usually evident. • Palpation – sensitivity over apex of tooth suggests periapical inflammation. Firm or fluctuant swelling consistent with abscess. • Percussion – pain/sensitivity consistent with periapical inflammation. Percussion of each cusp helps locate incomplete fracture.
  13. 13. • Mobility – check horizontal and vertical. • Periodontal Probing – evaluate periodontal status. Aids in decision regarding retaining or extracting. • Thermal Sensitivity – tests pulpal status. Cold (ethyl chloride) is test of choice. – Normal / reversible pulpitis: not prolonged – Irreversible pulpitis: prolonged response – Necrotic pulp: no response – Heat test not usually done, difficult Clinical Examination:
  14. 14. • EPT – pulp is responsive (vital) or it is not (nonvital). False (+) and false (-). • Translumination – helps detect enamel and pulpal floor fractures. • Radiographs: – Panorex – overall survey – PAs – provide definition of PA areas, caries, fxs – BWs – bone level and interproximal caries – Occlusal – buccal / lingual and floor of mouth – Water’s – maxillary sinuses • Selective Anesthesia – infiltration, blocks, TPIs • Test Cavity – prep suspected tooth with no
  15. 15. Examination • Comprehensive exam: clinical & radiographic • Systematic exam • General appraisal – Physical status – Behavioral assessment* • Head & Neck exam – Extraoral evaluation – Soft tissue evaluation* • Orthodontic evaluation
  16. 16. Extraoral Evaluation • Cranium – Inspect for sores, flaking, inflammation, swelling & symmetry • Neck – Thyroid gland-palpate/inspect for swelling – Musculature-inspect/palpate for suppleness – Lymph nodes-palpate for lymphadenopathy • Hair – Inspect for thickness, color, dryness, consistency • Ears – Inspect for normal appearance, cartilaginous defects, pits and cutaneous lesions
  17. 17. Extra oral Evaluation s Eyes – Eyeball-inspect for inflammation, deviation or exophthalamos – Eyelid-inspect for ptosis, inflammation s Nose – Evaluate potency, note any discharge s Perioral – Inspect for inflammation, scarring, eruptions, ulcerations
  18. 18. Soft Tissue Evaluation s Gingiva – Inspect for inflammation, bleeding s Mucosa – Inspect for inflammation, palate for swelling; inspect parotid duct opening for function s Pharynx – Inspect for inflammation, test gag reflex s Tonsils – Inspect for size, inflammation Palate Inspect for deviation, integrity Tongue Inspect for inflammation; coating, observe range of motion, inspect for atrophy and deviation Lips Inspect for chapping, ulcers and cheilitis Teeth Inspect for development, morphologic appearance, color, integrity, mobility, hygiene
  19. 19. Occlusion Summary • Alignment – Arch categorization--U-shaped or V-shaped – Ideal arch in primary dentition has spacing between the teeth • Two types: Primate space and developmental space – Tooth size-arch length discrepancy • Anterior segment • Posterior segment – Space loss – Rotations – Alignment – Missing or supernumerary teeth – Eruption abnormalities – Ankylosis
  20. 20. Occlusion Summary • Anterior-Posterior* – Relation of mx and md arches to each other – Primary molar relation--flush terminal plane, mesial step and distal step – Permanent molar relation--Class I, II, III – Primary and permanent canines--Class I, II, III or end-to-end – OJ (mm)--horizontal overlap of mx and md central incisors – Lip posture (vertical, everted, tight, loose, mentalis strain – Tongue thrusting (swallow)
  21. 21. Occlusion Classification Primary Dentition
  22. 22. Occlusion Summary • Transverse – Midline discrepancies – Posterior cross-bite – Facial type – Facial asymmetry – Md displacement – Mx midline diastema--frenum
  23. 23. Occlusion Summary • Vertical – Overbite (%)--vertical overlap of the primary incisors based on total height of md incisor crown • Approx. 2 mm or 20% in the primary dentition – Open bite (mm)--absence of vertical overlap – Habitual lip posture (closed, open) – Lip length (mx lip), relation to mx incisors (md lip) – Tongue size, shape and position – Skeletal lower face height (55% of total face height) – Frankfort-md plane angle (approx. 26o )
  24. 24. Dental charting
  25. 25. Treatment plan form • Indicate sequence of care • Progress note indicates what was done • Phase I:- o Prophylactic treatment o Oral Hygiene instruction &education o Fluoride application, fissure sealant • Phase II:- o Restorations o Pulpotomy, St st crown o Extraction • Phase III:- o space maintainer & orthodontic consultation • Phase IV:- o Maintenance & recall
  26. 26. Treatment plan form
  27. 27. The process of diagnosis • Existence of an abnormal state • Determination of cause • Alternatives or options to correct the problem • Anticipated benefits, immediate and long term • Problems or requirements for accomplishing treatment • A problem list helps to separate those abnormalities that are in need of management from those that are simply identified. • Identification of the cause of the abnormality is critical to determine short and long-term treatment.
  28. 28. Treatment plan • No single treatment plan is ideal. A variety of alternatives must be considered • TP based on the child's health, cooperation, parental finances, and the benefits • The behavioral plan is critical to the success of the treatment plan to be used must be included in the treatment plan. • The sequencing of be behavior management, consent for medications, and reasonable alternatives to recommended procedures should be discussed with the parents.
  29. 29. • Acute infection and pain are managed first. • Hopelessly involved teeth should be extracted • This "first aid" approach reduces the chance of decay progression with resultant pain and reduces the difficulty in cleaning, reducing the deleterious oral flora. • The infiltration • Injections are easiest for the patients to tolerate. Treatment plan
  30. 30. Patients with Special Health Care Needs • Knowledge of the medical elements of conditions , such as congenital heart disease • Knowledge of oral health implications of conditions, such as precocious periodontal disease in Down syndrome or gingival overgrowth in transplantation patients • Essential management skills to communicate with, stabilize, and manage patients in the care setting • Awareness of the social, therapeutic, and cultural milieu of those with special healthcare needs
  31. 31. Problem of special need pt • Fear or difficulty in connection. • Chronic or short-term medical problems that are acquired during their life 1. Accessibility 2. Psychosocial 3. Financial 4. Communication 5. Medical 6. Mobility and stability 7. Preventive 8. Treatment planning 9. Continuity of core
  32. 32. Early caries detection techniques • Electrical conductivity measurements (ECM) • Laser fluorescence using the Diagnodent unit (KaVo-IR) • Ultrasound measurements (UM) • Quantitative light fluorescence (QLF) • Optical coherence tomography (OCT) • Fiberoptic transillumination (FOTI) • Digital imaging fiberoptic transillumination (DIFOTI) • Direct digital radiography (DDR)
  33. 33. • Birth-12 Months • 12-24 Months • 2 - 6 Years • 6 - 1 2 Years • 12-18 Years Examination and Oral Treatment for Children
  34. 34. Examination and Oral Treatment for Children Birth-12 Months • Complete the clinical oral assessment and appropriate diagnostic tests to assess oral growth and development and/or pathology. • Provide oral hygiene counseling for parents, guardians& caregivers. • Remove supra- and subgingival stains or deposits. • Assess the child's systemic and topical fluoride status (type of infant formula used, fluoridated toothpaste). Prescribe systemic fluoride supplements if indicate after assessment of total fluoride intake. • Assess appropriateness of feeding practices (bottle feeding and breast-feeding). • Provide dietary counseling related to oral health.
  35. 35. Birth-12 Months • Provide age-appropriate injury prevention counseling for orofacial trauma. • Provide counseling for non-nutritive oral habits (e.g., digit, pacifiers). • Provide diagnosis and required treatment and/or appropriate referral for any oral diseases or injuries. • Provide anticipatory guidance for parent/guardian. • Consult with the child's physician as indicated. • Based on evaluation and history, assess the patient's risk for oral disease. • Determine interval for periodic reevaluation. Examination and Oral Treatment for Children
  36. 36. 12-24 Months 1. Repeat birth to 12-month procedures every 6 months or as indicated by patient's needs/ susceptibility to disease. 2. Review patient's fluoride status, including any child care arrangements that may affect systemic fluoride intake and provide parental counseling. 3. Provide topical fluoride treatments every 6 months or as indicated by the individual patient's needs. Examination and Oral Treatment for Children
  37. 37. 2 - 6 Years 1. Repeat 12- to 24-month procedures every 6 months or as indicated by patient's needs/susceptibility to disease. Provide age-appropriate oral hygiene instructions. 2. Complete a radiographic assessment of pathology and/or abnormal growth and development. 3. Scale and clean the teeth every 6 months or as indicated by the individual patient's needs. 4. Provide topical fluoride treatments every 6 months or as indicated by patient's needs. Examination and Oral Treatment for Children
  38. 38. 2 - 6 Years 5. Provide pit and fissure sealants for primary and permanent teeth as indicated by patient's needs. 6. Provide counseling and services (athletic mouth guards) as needed for or orofacial trauma prevention. 7. Provide assessment/treatment or referral of developing malocclusion as indicated by patient's needs. 8. Provide diagnosis and required treatment and/or appropriate referral for any oral disease, habits, or injuries as indicated. 9. Assess speech and language development, and provide appropriate referral as indicated. Examination and Oral Treatment for Children
  39. 39. 6 - 1 2 Years • Repeat 2- to 6-year procedures every 6 months or as indicated by patient's needs/susceptibility to disease. • Provide substance abuse counseling (e.g., smoking, smokeless tobacco). Examination and Oral Treatment for Children
  40. 40. 12-18 Years 1. Repeat 6- to 12-year procedures every 6 months or as indicated by patient's needs/susceptibility to disease. 2. At an age determined by the patient, parent, and dentist, refer the patient to a general dentist for continuing oral care. Examination and Oral Treatment for Children
  41. 41. Examination and Oral Treatment for Children • A thorough medical history (questions about medications, current illnesses, hepatitis, weight loss, lymphadenopathy, oral soft tissue lesions, or other infections. • Clean all reusable instruments in an ultrasonic cleaner or washer/disinfector. Wear heavy rubber gloves, mask, and protective clothing and eyewear to protect against puncture injuries and splashing.
  42. 42. E M E R G E N C Y D E N T A L T R E A T M E N T • 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 for the patient.
  43. 43. Early examination To prevent oral pain and infection, To prevent the occurrence and progress of dental caries, To prevent the premature loss of primary teeth, the loss of arch length, and To prevent the development of an association between fear and dental care.