Ibin Hayan Univ. College / DentistryDept.
Lecture # - 1 & 2 - Pediatricdentistry 5th
. Dr Sami Malik Abdulhameed
Examinationand Treatment Plan in PediatricDentistry:
• The student should learn:
• Departmental charting conventions Real world treatment planning for pediatric dentistry
& Communication of treatment plan to staff
Examination and Treatment Plan of Pediatric Patient:
Dentist is traditionally taught to perform a complete oral examination of the patient and to
develop a treatment plan from the examination findings. Then the dentist makes a case
presentation to the patient or parents, outlining the recommended courseof treatment. This
process should include the development and presentation of a prevention plan that outlines an
ongoing comprehensive oral health care program for the patient .
The plan should include recommendations designed to correct existing oral problems (or halt
their progression) and to prevent anticipated future problems.
Anticipatory guidance: is the term often used to describe the discussion and implementation of
such a plan with the patient and/or parents.
The major difference between the treatment of children and adults is the relationship. Treating
adults generally involves a one to one relationship (dentist- patient), while treating children
relies on a one to two relationship (dentist – pediatric patient- parents).
It is a classic form of documentation ranges from clinical sketches to highly detailed and
extended accounts that help in arriving at a diagnosis and formulation of treatment plan of a
Steps in case history taking
Step 1;assemble all the available facts gathered from chief complaint, medical history,
dentalhistory ,diagnostictests and investigations
Step 2:analyseand interpret the assembled clues to reach the provisional diagnosis
Step3 :make a differential diagnosisof all possible complications
Step4 ;select a closest possible choice-final diagnosis
Guidelines for taking case history;
Questions should be open ended (encourage a detailed explanation). No ‘yes’ or ‘no’
Avoid leading questions
Infants under 5yrs parent is interviewed
The questions should be clear and should touch various aspects ofthe disease
Symptoms are described by patient should record in his own words
Doctor should be an empathetic listener
Behavior Shaping of pedo patient should be started from casehistory taking or even before
Case history taking;
a) date;-time of admission reference during follow up visits
b) out patient number;-maintaining a record, billing , medico legal considerations
c) name:-to communicate with the patient -to establish a rapport with the patient
d) age:- chronological age (date of birth) should be noted to know whether growth and
development is normal or not -occurrenceof certain diseases correlated with age
eg; primary herpetic gingivostomatitis (6months to 6years) nursing caries-pre schoolers
-behavior management techniques also varry according to age
e) Gender :- girls mature earlier than boys, so require treatment earlier
-some diseases shows sex predilection eg: anorexia-females hemophilia -males
f) race/ethnic origin:-certain religious cultures depends the etiology of certain diseases.
g) school/class:-to communicate with teacher -to know the IQ level
h) address;& phone # -communication
-to chart out appointments for patients from distant places
-to know endemic status of disease in the locality
i] socio economic status-to know about the nourishment, hygiene, & payment capacity of the
Always record in patient’s own words
Mention only the chief problem of the present day in the order of severity
Follow the chronological order
3)History of the present illness;-it should indicate the severity and urgency of the problem
detailed history of the chief complaint-eg; dental pain
-quality,-dull, sharp ;throbbing ,constant
-quantity, severity, and frequency
-location-localized ,diffuse ,referred, radiating.
-duration of complaint
-onset; spontaneous, on stimulation, intermittent
-Aggravated by: cold, heat, palpation, percussion
- Relieved by cold, heat, any medication ,sleep
Preliminary medical and dental history:
It is important for the dentist to be familiar with the medical and dental history of the pediatric
patient. Familial history may also be relevant to the patient s oral condition and may provide
important diagnostic information in some hereditary disorders.
Medical history includes:
1-Family history from the parents or child s physician.
2-Informations regarding child s social and psychological development.
3-Previous hospitalization or general anesthetic and surgical procedures.
4-Child current physical condition, such as blood pressure, bodytemperature, heart sounds,
height and weight, pulse and respiration.
5- Certain laboratory tests
6- Infectious conditions.
Check list of medical history
-Cardio respiratory disorders
-Drug treatment and allergies
-Fits and faints
-Hospital admissions and surgeries
* antibiotic prophylaxis needed in cases to prevent bacterial endocarditis
5) Dental history includes:
a- Previous dental treatment.
b- Child behavior.
c- Patient current oral hygiene and habits.
d-Previous fluoride exposure
Past dental history
History of dental treatment undergone by the patient ,along with patients experience
before, during and after the dental treatment
History of complications experienced by the patient
To know about parental attitude towards the child and towards the dental treatment
Presence of genetic / inherited abnormalities
Prenatal history: maternal history of nourishment, usage of drugs etc eg; tetracycline
staining of teeth phenytoin sodium –cleft lips in child
Natal history: birth injuries –forceps deliverypremature baby, low birth weight baby
neonatal jaundice-due to rapid destruction of immature RBCs in liver Rh incompatibility
–rh+ father and Rh –ive mother
-type of feeding-bottle or breast feeding
-presence of any habit along with its onset, duration ,frequency and intensity should be
noted-mouth breathing, thumb sucking ,tongue thrusting etc
-behavioral status-co-operative or not, - diet chart, - physical and emotional development of
-oral hygiene status of the child-type, method and frequency of brushing
8)General examination: analyze while child entering the clinic
built, height ,gait, and posture should be noted nourishment of the child
vital signs like temperature, blood pressure, pulse, respiratory rate should be noted
bodytype-ectomorphic (lean),mesomorphic (normal), endomorphic (obese)
Dental care for children has been designed primarily to:
1- Prevent oral pain and infection.
2- Prevent the occurrence and progress of dental caries.
3- Prevent the premature loss of primary teeth, the loss of arch length.
4- Prevent the development of an association between fear and dental care.
The goals of pediatric dental care therefore are primarily preventive
Most facts needed for a comprehensive oral diagnosis in the young patient are obtained by a
thorough clinical and radiographic examination.
Extra oral Examination includes:
1- The patient`s size, stature, gait, or involuntary movements as he walks into the office.
3- Attention to the patient`s hair, head, face, neck, and hands should be among the first
observations made by the dentist after the patient is seated in the chair.
4- 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 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 that may require special
precautions during dental treatment.
5- Inspection and palpation of the patient`s face, head and neck are also indicated for the
presence of any contagious diseases like hair lice, ring warm and impetigo. Further treatment
should be postponed until the contagious condition is controlled.
6- Variations in size, shape, symmetry, or function of the head and neck structures should be
7- Temporomandibular joint (TMJ) evaluation while the mouth closed (teeth clenched), at rest,
and in various open positions
8- The extraoral examination continues with palpation of the patient s neck and submandibular
A) soft tissue examination
-lips-sinus ,fistula ,ulcers, bite marks
-mucosa-(buccal, alveolar, labial); ulcerations, color, consistency ,koplik’s spots in measles
,white lesions, trauma etc
-hard and softpalate:-developmental anomalies,lesions, systemic disorders, growths etc
-gingiva- color, contour, consistancy ,size, shape, resiliency, exudation etc
-Toungue- growth, developmental anomalies, ulcers and lesions, speechpattern ,trauma
-floor of the mouth-ulcers and lesions, growth etc
-tonsils and adenoids:-inflammatory enlargements
-salivary orifice-flow of saliva,inflammation,exudation
b) Hard tissue examination
Oral hygiene status
Restorations-fractures or failures, over extensions.
regressive alterations-attrition ,abrasions, erosions
Periodontal status-bleeding from gums ,mobility (grade I-Slight, II-Moderate mobility
within a range of 1 mm, III-Extensive movement more than 1mm both mesiodistal and
vertical) recession ,furcation involvement etc
Class of malocclusion
Crowding, rotations, spaceloss
Eruption status and development of jaws and teeth
Retained deciduous teeth etc
The intraoral examination of a pediatric patient should be comprehensive. It includes:
1- The dentist should first evaluate the condition of the oral softtissues and the status of the
2- look first for obvious carious lesions.
3- Any unusual breath odors and abnormal quantity or consistency of saliva should also be
4- The bucket tissues, lips, floor of the mouth, palate, and gingivae should be carefully
inspected and palpated.
5- The use of the periodontal screening and recording program (PSR)is often a helpful adjunct
6- The tongue and oropharynx should be closely inspected.
7- Enlarged tonsils accompanied by purulent exudate may be the initial sign of a streptococcal
infection, which can lead to rheumatic fever. When streptococcalthroat infection is suspected,
immediate referral to the child s physician is indicated.
8- After thoroughly examining the oral softtissues, the dentist should inspect the occlusion and
note any dental or skeletal irregularities.
9- Monitoring of the patient s facial profile and symmetry; molar, canine, and anterior segment
relationships; dental midlines; and relation of arch length to tooth mass should be routinely
included in the clinical examination.
10- Diagnostic cast and cephalometric analyses may be indicated relatively early in the mixed
dentition stage and sometimes in the primary dentition.
11- Morphologic defects and incomplete coalescenceof enamel at the base of pits and fissures
in molar teeth can often be detected readily by visual and explorer examination after the teeth
have been cleaned and dried.
12- Finally, the teeth should be inspected carefully for evidence of carious lesions and
hereditary or acquired anomalies and supernumerary or missing teeth.
Note: Dentist may always start in the upper right quadrant, work around the maxillary arch,
move down to the lower left quadrant, and end the examination in the lower right quadrant.
Identification of carious lesions is important in patients of all ages but is especially critical in
young patients because the lesions may progress rapidly in early childhood caries if not
controlled. 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.
In patients with severe dental caries, caries activity tests and diet analysis may contribute to the
diagnostic process byhelping to define specific etiologic factors.
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
Obtaining isolated occlusal, periapical, or bite-wing films is sometimes indicated in very young
children (even infants) becauseof trauma, toothache, suspected developmental disturbances, or
Carious lesions appear smaller on radiographs than they actually are.
Before making a diagnosis and developing a treatment plan, the dentist must collect and
evaluate the facts associated with the patient s or parents chief concern and any other identified
problems that may be unknown to the patient or parents.
On the other hand, a comprehensive diagnosis of the entire patient s problems or potential
problems may sometimes need to be postponed until more urgent conditions are resolved. For
example, a patient with necrotizing ulcerative gingivitis or a newly fractured crown needs
immediate treatment, but the treatment will likely be only palliative, and further diagnostic and
treatment procedures will be required later.
Diagnostic methods include:
• Medical and dental history taking.
• Vitality tests.
• Study casts.
• Laboratory tests.
10)Provisional diagnosis A general diagnosis based on the clinical impression without any
The process oflisting out of 2 or more diseases having similar signs and symptoms of which
only one could be attributed to the patient’s suffering
12)Investigations . radiographs, biopsy, & other tests
13)Final diagnosis; Aconfirmed diagnosis based on all available data
A) systemic phase; stabilize the medical condition if any, antibiotic prophylaxis, sedation,
B) preventive phase: caries risk assessment, personal oral hygiene, flouride application,
pit and fissure sealant, diet counseling
C) preparatory phase: behavior management, oral prophylaxis, caries control, orthodontic
consultation, oral surgical procedure(extractions) ,endodontic therapy
D) corrective phase: restorative dentistry-permanent fillings, stainless steel crowns
prosthetic rehabilitation-tooth replacements ,jacket crowns , early orthodontic
intervention;-minor tooth movements,serial extraction, spacemanagement
• Symbols and abbreviations:
– PFS = pit and fissure sealant
– PT/PE= pulpotomy/pulpectomy
– LLHA/BLS = Spacemaintenance
– C/S = composite/sealant
– Diag = diagnostic excavation
– RCT = root canal treatment
– RF = rootfragment
– Always ParentConsult
– Consults (i.e. ortho, endo, O.S., etc.)
– Retake ofnondiagnostic x-rays
– Possible prescriptionfor topical/systemic fluoride
– Start with easyoperative, if possible, usually maxillary arch
– Plan for sextantdentistry
– Take into accountlength of appointment (90 min.)
– No bilateral blocks
– Last appointment : Polishes ; PFS ; Recall(usually 6 months)
– Compose treatment plan
• Use treatment planning sheet (not the actualpatient record)
• Eachprocedure has a separate line
• Skip one line betweenappointments
• Note restorative material to be used (i.e. SA, C, SSC, C/S, GIC)
– Review plan with faculty
• be prepared to answerquestions regarding procedures
– Faculty approves and grades treatment plan
– Give approved treatment plan to your dental assistant
• DA will enter TP on the permanent patient recordand will write
– TP for the worst
• Extended time interval betweenexam and treatment
• Costestimate is a worstcase scenerio
• Public relations issues
– Rampant caries
• Considergross caries removaland temporization
• Discuss baby bottle syndrome if the patient is young
• Considerdiet history and extended oral hygiene instructions with
• Considerfluoride supplementation, either systemic or topical
• Always treat the area that is painful to the patient, regardless of
treatment plan order
• Neverlet a patient leave in pain!
– Talking to parents
• Neverguarantee that we will finish in a certain number of appointments
• Neverguarantee what treatment we will do next
• Don't give encounter forms to parents
• Relayparental concerns to the faculty
– In reviewing caseswith parents, always discuss three main areas:
• Restorative needs
• Orthodontic evaluation ( posteriorocclusion, overbite/overjet,
• Preventive needs
– Discuss with the parent WHY the patient needs the care we are proposing
– Discuss with the parent after eachappointment what was accomplishedand
patient cooperation(be as positive as possible)
• Maintanance phase;3-6 month recalls
-review check up of oral health indices
-repeat caries activity tests
-reinforcement of home care measures
-motivation and re-counseling of the parent
-follow up of treatment procedures