HISTORY TAKING INHISTORY TAKING INPAEDRITIC DENTISTRYPAEDRITIC DENTISTRYBYBYBDS/10/09BDS/10/09
STEPS IN CASE HISTORYSTEPS IN CASE HISTORYTAKINGTAKING
1.PERSONAL INFORMATION1.PERSONAL INFORMATIONa) date;-time of admissiona) date;-time of admissionreference during follow up...
e) sex;-girls mature earlier than boys-require treatmente) sex;-girls mature earlier than boys-require treatmentearlierear...
2.CHIEF COMPLAINT2.CHIEF COMPLAINTAlways record in patient’s own wordsAlways record in patient’s own wordsMention only t...
MEDICAL HISTORYMEDICAL HISTORY
7PREDISPOSING HABITS7PREDISPOSING HABITS-thumb sucking-thumb sucking-type of feeding-bottle of breast-type of feeding-bott...
Mouth breathingMouth breathingmoumouNail biting Tongue thrustingMouth breathing
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION1.General examination: analyze while child entering the clinic1.General examinatio...
EXTRA ORAL EXAMINATIONEXTRA ORAL EXAMINATION
9)Extra oral examination9)Extra oral examination Shape of head- mesocephalic (oval), brachycephalic (short andShape of he...
SALIVARY GLANDLymph nodes
INTRA ORAL EXAMINATIONINTRA ORAL EXAMINATION
10)Intra oral examination10)Intra oral examinationA) soft tissue examinationA) soft tissue examination-lips-sinus ,fistula...
b) Hard tissue examinationb) Hard tissue examination Oral hygiene statusOral hygiene status Restorations-fractures or fa...
Pulpal diseases Faulty restorationsPeriodontal diseasesOcclusaldiscrepanciesDental caries spacing
11)Provisional diagnosis11)Provisional diagnosis A general diagnosis based on the clinical impression without anyA genera...
TREATMENT PLANTREATMENT PLAN
Treatment planTreatment plan Oral hygiene and motivationOral hygiene and motivation A) systemic phase; stabilize the med...
 E) Maintanance phase;3-6 month recallsE) Maintanance phase;3-6 month recalls-review check up of oral health indices-revi...
REFERENCESREFERENCES Text books of pedodontics- Shoba tandonText books of pedodontics- Shoba tandon-Damlae-Damlae-Pinkham...
Thank you….!Thank you….!
HISTORY TAKING, DIAGNOSIS AND TREATMENT PLANNING IN PEDODONTICS BY KEN CARSON
HISTORY TAKING, DIAGNOSIS AND TREATMENT PLANNING IN PEDODONTICS BY KEN CARSON
HISTORY TAKING, DIAGNOSIS AND TREATMENT PLANNING IN PEDODONTICS BY KEN CARSON
HISTORY TAKING, DIAGNOSIS AND TREATMENT PLANNING IN PEDODONTICS BY KEN CARSON
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HISTORY TAKING, DIAGNOSIS AND TREATMENT PLANNING IN PEDODONTICS BY KEN CARSON

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KEN CARSON MOI UNIVERSITY DENTAL SCHOOL

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HISTORY TAKING, DIAGNOSIS AND TREATMENT PLANNING IN PEDODONTICS BY KEN CARSON

  1. 1. HISTORY TAKING INHISTORY TAKING INPAEDRITIC DENTISTRYPAEDRITIC DENTISTRYBYBYBDS/10/09BDS/10/09
  2. 2. STEPS IN CASE HISTORYSTEPS IN CASE HISTORYTAKINGTAKING
  3. 3. 1.PERSONAL INFORMATION1.PERSONAL INFORMATIONa) date;-time of admissiona) date;-time of admissionreference during follow up visitsreference during follow up visitsb) out patient number;-maintaining a record, billing , medico legalb) out patient number;-maintaining a record, billing , medico legalconsiderationsconsiderationsc) name:-to communicate with the patientc) name:-to communicate with the patient-to establish a rapport with the patient-to establish a rapport with the patientd) age:- chronological age (date of birth) should be noted to knowd) age:- chronological age (date of birth) should be noted to knowwhether growth and development is normal or notwhether growth and development is normal or not-occurrence of certain diseases correlated with age-occurrence of certain diseases correlated with ageeg; primary herpetic gingivostomatitis(6months to 6years)eg; primary herpetic gingivostomatitis(6months to 6years)nursing caries-pre schoolersnursing caries-pre schoolers-behavior management techniques also varry according to age-behavior management techniques also varry according to age
  4. 4. e) sex;-girls mature earlier than boys-require treatmente) sex;-girls mature earlier than boys-require treatmentearlierearlier-some diseases shows sex predilection-some diseases shows sex predilectioneg: anorexia-femaleseg: anorexia-femaleshemophilia -maleshemophilia -malesf) race/ethnic origin:-certain religious cultures depends thef) race/ethnic origin:-certain religious cultures depends theetiology of certain diseases.etiology of certain diseases.g) school/class:-to communicate with teacherg) school/class:-to communicate with teacher-to know the IQ level-to know the IQ levelh) address;-communicationh) address;-communication-to chart out appointments for patients from distant-to chart out appointments for patients from distantplacesplaces-to know endemic status of disease in the locality-to know endemic status of disease in the locality
  5. 5. 2.CHIEF COMPLAINT2.CHIEF COMPLAINTAlways record in patient’s own wordsAlways record in patient’s own wordsMention only the chief problem of the present day in the order ofMention only the chief problem of the present day in the order ofseverityseverityFollow the chronological orderFollow the chronological order3)3)HISTORY OF PRESENTING ILLNESSHISTORY OF PRESENTING ILLNESS;-;-it should indicate theit should indicate theseverity and urgency of the problemseverity and urgency of the problem detailed history of the chief complaint-eg; dental paindetailed history of the chief complaint-eg; dental pain-character,-dull, sharp ;throbbing ,constant, pulsating-character,-dull, sharp ;throbbing ,constant, pulsating-quantity, severity, and frequency-quantity, severity, and frequency-location-localized ,diffuse ,referred, radiating.-location-localized ,diffuse ,referred, radiating.-duration of complaint-duration of complaint-onset; spontaneous, on stimulation, intermittent-onset; spontaneous, on stimulation, intermittent-Aggravated by: cold, heat, palpation, percussion-Aggravated by: cold, heat, palpation, percussion-Relieved by ;cold, heat, any medication ,sleepRelieved by ;cold, heat, any medication ,sleep-Associated symptoms e.g headacheAssociated symptoms e.g headache
  6. 6. MEDICAL HISTORYMEDICAL HISTORY
  7. 7. 7PREDISPOSING HABITS7PREDISPOSING HABITS-thumb sucking-thumb sucking-type of feeding-bottle of breast-type of feeding-bottle of breast-tongue thrusting-tongue thrusting-mouth breathing-mouth breathing8. FAMILY-SOCIAL HISTORY8. FAMILY-SOCIAL HISTORY-What born?-What born?-no of siblings…are they well?-no of siblings…are they well?-staying with both parents?-staying with both parents?-occupation of the parents-occupation of the parents-school going or pre skul?-school going or pre skul?-social and plays with others or not-social and plays with others or not-Presence of genetic / inherited abnormalities-Presence of genetic / inherited abnormalities9.REVIEW OF SYSTEMS9.REVIEW OF SYSTEMS-any relevant history-any relevant history10.SUMMERY10.SUMMERY
  8. 8. Mouth breathingMouth breathingmoumouNail biting Tongue thrustingMouth breathing
  9. 9. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION1.General examination: analyze while child entering the clinic1.General examination: analyze while child entering the clinic- built, height ,gait, and posture should be noted,nourishment of the- built, height ,gait, and posture should be noted,nourishment of thechildchild- vital signs like temperature, blood pressure, pulse, respiratory rate- vital signs like temperature, blood pressure, pulse, respiratory rateshould be notedshould be noted-body type-ectomorphic (lean),mesomorphic (normal), endomorphic-body type-ectomorphic (lean),mesomorphic (normal), endomorphic(Obese)(Obese)-pallor, jaundice, dehydration, lymphadenopathy-pallor, jaundice, dehydration, lymphadenopathy
  10. 10. EXTRA ORAL EXAMINATIONEXTRA ORAL EXAMINATION
  11. 11. 9)Extra oral examination9)Extra oral examination Shape of head- mesocephalic (oval), brachycephalic (short andShape of head- mesocephalic (oval), brachycephalic (short andbroad), dolicocephalic (long ,thin ,tapering)broad), dolicocephalic (long ,thin ,tapering) facial form –straight, convex (class II), Concave (class III)facial form –straight, convex (class II), Concave (class III) facial symmetry –bilaterally symmetrical/asymmetricalfacial symmetry –bilaterally symmetrical/asymmetrical Lip competency-competent/incompetentLip competency-competent/incompetent Soft tissue-color ,contour, consistency, temperature ,size ,extendSoft tissue-color ,contour, consistency, temperature ,size ,extendand shapeand shape TMJ-clicking ,deviation ,pain , crepitation should be noted while jawTMJ-clicking ,deviation ,pain , crepitation should be noted while jawmovementsmovements Lymphnodes : size, shape, consistency, number, tender onLymphnodes : size, shape, consistency, number, tender onpalpation, mobility should be notedpalpation, mobility should be noted Salivary glands- Submandibular gland-bimanual palpationSalivary glands- Submandibular gland-bimanual palpation
  12. 12. SALIVARY GLANDLymph nodes
  13. 13. INTRA ORAL EXAMINATIONINTRA ORAL EXAMINATION
  14. 14. 10)Intra oral examination10)Intra oral examinationA) soft tissue examinationA) soft tissue examination-lips-sinus ,fistula ,ulcers, bite marks-lips-sinus ,fistula ,ulcers, bite marks-mucosa-(buccal, alveolar, labial, floor of the mouth); ulcerations, color,-mucosa-(buccal, alveolar, labial, floor of the mouth); ulcerations, color,consistency ,white lesions, trauma etcconsistency ,white lesions, trauma etc-palate:-developmental anomalies, lesions, systemic disorders, growths-palate:-developmental anomalies, lesions, systemic disorders, growths-tongue-growth, development anomalies, ulcers, trauma-tongue-growth, development anomalies, ulcers, trauma-tonsils and adenoids-inflammatory enlargements-tonsils and adenoids-inflammatory enlargements-periodontium-periodontiuma)gingiva- color, contour, consistancy ,size, shape,a)gingiva- color, contour, consistancy ,size, shape,resilience,exudation,resilience,exudation,bleeding on probing, sinus tacks, loss of attachments, plaque andbleeding on probing, sinus tacks, loss of attachments, plaque andcalculuscalculusb)Bone lossb)Bone lossc)Perio pocketsc)Perio pockets
  15. 15. b) Hard tissue examinationb) Hard tissue examination Oral hygiene statusOral hygiene status Restorations-fractures or failures, over extensions.Restorations-fractures or failures, over extensions. Dental caries-per quadrantDental caries-per quadrant Missing teeth-Missing teeth- Discolorations,Discolorations, regressive alterations-attrition ,abrasions, erosionsregressive alterations-attrition ,abrasions, erosions mobility- (grade I-Slight, II-Moderate mobility within a range of 1 mm,mobility- (grade I-Slight, II-Moderate mobility within a range of 1 mm,III-Extensive movement more than 1mm both mesiodistal andIII-Extensive movement more than 1mm both mesiodistal andvertical) recession ,furcation involvement etcvertical) recession ,furcation involvement etc Orthodontic examOrthodontic exam-Class of malocclusion-Class of malocclusion-Crowding, rotations, space loss-Crowding, rotations, space loss-overjet-overjet-overbite-overbite-Coincidence of facial and dental midline-Coincidence of facial and dental midline-type of dentition-type of dentition
  16. 16. Pulpal diseases Faulty restorationsPeriodontal diseasesOcclusaldiscrepanciesDental caries spacing
  17. 17. 11)Provisional diagnosis11)Provisional diagnosis A general diagnosis based on the clinical impression without anyA general diagnosis based on the clinical impression without anylab. Investigationslab. Investigations12)Differential diagnosis12)Differential diagnosisThe process of listing out of 2 or more diseases having similar signsThe process of listing out of 2 or more diseases having similar signsand symptoms of which only one could be attributed to the patient’sand symptoms of which only one could be attributed to the patient’ssufferingsuffering13)Investigations13)Investigationsradiographs, biopsy, $ other testsradiographs, biopsy, $ other tests14)Final diagnosis14)Final diagnosisA confirmed diagnosis based on all available data.A confirmed diagnosis based on all available data.
  18. 18. TREATMENT PLANTREATMENT PLAN
  19. 19. Treatment planTreatment plan Oral hygiene and motivationOral hygiene and motivation A) systemic phase; stabilize the medical condition if any, antibioticA) systemic phase; stabilize the medical condition if any, antibioticprophylaxis, sedation, consentprophylaxis, sedation, consent B) preventive phase: caries risk assessment, personal oral hygiene,B) preventive phase: caries risk assessment, personal oral hygiene,flouride application, pit and fissure sealant, diet counselingflouride application, pit and fissure sealant, diet counseling C) preparatory phase: behavior management, oral prophylaxis,C) preparatory phase: behavior management, oral prophylaxis,caries control, orthodontic consultation, oral surgical procedurecaries control, orthodontic consultation, oral surgical procedure(extractions) ,endodontic therapy(extractions) ,endodontic therapy D) corrective phase: restorative dentistry-permanent fillings,D) corrective phase: restorative dentistry-permanent fillings,stainless steel crownsstainless steel crownsprosthetic rehabilitation-tooth replacements ,jacket crownsprosthetic rehabilitation-tooth replacements ,jacket crownsearly orthodontic intervention;-minor tooth movements,serialearly orthodontic intervention;-minor tooth movements,serialextraction, space managementextraction, space management
  20. 20.  E) Maintanance phase;3-6 month recallsE) Maintanance phase;3-6 month recalls-review check up of oral health indices-review check up of oral health indices-repeat caries activity tests-repeat caries activity tests-reinforcement of home care measures-reinforcement of home care measures-motivation and re-counseling of the parent-motivation and re-counseling of the parent-follow up of treatment procedures-follow up of treatment procedures““Chances only favors trained mind “Chances only favors trained mind “Louis PastureLouis Pasture
  21. 21. REFERENCESREFERENCES Text books of pedodontics- Shoba tandonText books of pedodontics- Shoba tandon-Damlae-Damlae-Pinkham-Pinkham Text book of pediatric operative dentistry-KennedyText book of pediatric operative dentistry-Kennedy text book of oral medicine-Burkettetext book of oral medicine-Burkette Carranza’s periodontologyCarranza’s periodontology Text book of endodontics-GrossmanText book of endodontics-Grossman-Nisha garg-Nisha garg
  22. 22. Thank you….!Thank you….!

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