CASE HISTORY

DIAGNOSIS, ASSESSMENT
AND TREATMENT PLANNING IN
PEDIATRIC PATIENTS
Dr. A. Victor Samuel MDS
Dept. of Pedodontics
 Contents
• Introduction
• Diagnosis
• History taking and clinical examination
• Patient information
• History taking
• General physical examination
• Extra-oral examination
• Intra-oral examination
A) Soft tissue examination
B) Hard tissue examination
• Provisional diagnosis
• Differential diagnosis
• Investigations
• Final diagnosis
• Treatment planning
• Prognosis
Introduction
• The case history enables the patients
to communicate symptoms, feelings
and fears and the sequence of events
leading to the problem for which the
patient seeks professional assistance.
• It involves eliciting and recording of
relevant information from the patient
and parent to aid in the overall
diagnosis of the case

• It should be systematic and should

follow a definite outline
Gathering this information:
• Can be essential in establishing a
correct diagnosis
• It allows assessment of the patient’s
mental and behavioral status.
 Few terminologies in case
history recording

• Diagnosis –The determination of the

nature of the disease.
• Symptom –Any morbid phenomena or
departure from the normal, in
structure, function or sensation
experienced by the patient and
indicative of a disease.
• Sign –Any abnormality indicative of
disease, discovered on examination of
the patient (an objective symptom of
a disease).
 DIAGNOSIS

• Diagnosis is derived from the Greek

word dia = by and gnosis = knowledge

• Diagnosis has been defined as

identification of disease. (Donald Kerr
and Major Ash 1970)
 SPECIFIC DIFFERENCES BETWEEN
PEDODONTIC AND ADULT DIAGNOSIS
AND TREATMENT PLANNING

• Physical, Emotional and Psychological

differences:
• Consideration of behavior as a
integral part of the child’s oral health
needs
• Attention to preventive care rather
than rehabilitative process
• Acknowledgment
of a Dentist-
Patient
relationship that
is triangular
rather than
linear
• Recognition that the child is a
changing person
 HISTORY TAKING AND
CLINICAL EXAMINATION
I) Personal information
 Date
a) It records the time the patient reported.

b) Can be referred back to during the

follow- up visits.
Hospital number/Case number
– For the purpose of maintaining record
– For billing the individual
– For legal considerations (in view of
Consumer Protection Act)
 Patients name

– To establish a better communication

with the patient.
– To establish a rapport with the
patient.
– Maintenance of record.
– To elicit the history properly.
– Medico legal purpose.
 Age
The chronological age (date of birth) should be
noted.
1) To compare with other ages (dental,
skeletal) so as to know whether the
growth and development is normal in
the child.
2) Certain diseases are known to occur
frequently at particular ages
3) Depending on the age the behavior
management techniques also vary.
 Sex

– Girls age faster than boys and thus

their treatment may be required
earlier.
– Some diseases are more common in
females than in males.
– A combination of age and sex can
sometimes give an indication of
occurrence of disease
 Place of birth

• It gives information about the

endemic diseases in the area
(particularly fluorosis as relevant to
dentistry)
 Address

– It is used for all communications even before

the first visit.
– By knowing the locality along with the family
income and parent’s occupation, the socio-
economic status can be assessed.
– If the patient is coming from a far distance,
the appointments can be modified to complete
treatment in fewer visits.
– It may indicate diseases endemic to the
particular areas.
 Socio-economic status

a) Treatments can be modified

according to the socioeconomic
status.
b) Patients background can be
understood in a better way.
 Languages known

– Mother tongue
– To establish better communication with
the patient.
– To built a good rapport.
 School and class
– To know the economic status.
– To communicate with the teacher.
– To assess the IQ of the child.
– To establish effective communication at
his own IQ level.
 Race/ethnic origin
– Some diseases are more common in
certain races.
– Oral hygiene practices may be common
in some religions or races.
 Person accompanying the child

• Child’s family life can be assessed.

• The information which has to be
asked can be modified according to it
• The reliability of the information
may also be evaluated
 Parents name
For better communication with the
parents
Parents education:
To evaluate their knowledge level and
awareness
Parents occupation:
To evaluate the socio-economic status
II) History taking
 Chief complaint

It is defined as
symptom or
symptoms,
described in
patient own
words, related to
the presence of
an abnormal
condition.
• The age of the patient apparently
influences the quality of the
complaint.

• The parent is often the best historian

in younger children.
 History of present illness
Chronological account of the chief
complaint and associated symptoms
from the time of onset to the time
the history is taken.
• The most common presenting illness can be

evaluated as,
1) The onset
2) Duration
3) Location
4) The quantity, quality, severity

and frequency of occurrence

5) Aggravating and relieving factors
6) Associated symptoms
 Past dental history
a) It gives information
about the patients past
dental problems.
b) Frequency of dental visit
by the patient which
gives an indication of the
patient’s future behavior.
c) Patient’s attitude towards
previous dental treatment.
d) Any untoward complication of dental

treatment.
e) To know about any excessive bleeding

in the past dental treatment.

f) Reasons for loss of teeth
 Medical history
• This helps in identifying conditions that
could alter, complicate or contraindicate
proposed dental procedures.
• This should include questions like:
• Is the child under the care of physician?
• If yes why?
• Any Medications taken presently,
• Drug name, dosage/duration & indication
• Whether the child suffers from any
frequent illnesses (cough, cold etc.)?
• Does your child suffer from any of the

following at present or in the past?

• Congenital diseases
• Rheumatic fever
• Anemia
• Bleeding disorders
• Asthma
• Diabetes
• Hepatitis
• Epilepsy
• Mental or physical
handicap
• Sensory deficits
• Speech defects
• Kidney disorders
• Bone & joint problems
• Growth and
development
problems
 History of immunization

• DPT vaccine
• BCG vaccine
• Poliomyelitis
• Tetanus vaccine
• MMR vaccine
• History of operations,
hospitalizations, blood transfusion
should be asked
• History of drug allergies is taken such
as penicillin, aspirin anesthetic agent
etc. the drug should be specified.
 Family history
a) It gathers information about diseases that

commonly affects more than one member

of a family.
b) Certain disorders that should be inquired
are
- Bleeding disorders
- Heart disease
- Diabetes
- Tuberculosis
 - Asthma
- Allergies
- Genetic
disorders
-Malocclusion
c) Siblings:
Number:
Order :
Sex :
 Social history

• It includes the
family situation,
the child’s school
situation,
personality traits,
developmental
status and the
child’s interpersonal
relationships.
 Prenatal history

• Drug intake during

pregnancy
e.g. tetracycline
administration
• Any illness during
pregnancy
e.g. hepatitis B
infection
• Did the mother
suffer from
trauma, illness or
hospitalization.
• Source of drinking
water.
 Natal history
• Type of delivery- Normal/C-section/

Forceps
Fullterm/Premature

• Childs health at birth: Good/Fair/Poor

Specify significant history

 Postnatal history
• Method of feeding
and duration:
Breast fed/Bottle
fed/both
• Does the child sleep
with the bottle?
• What are/were the
contents of the
bottle?
• Is/was a pacifier
used-
Type

Duration

Other details
• Did the child have
an erupted tooth at
birth or within 30
days after birth?
• At what age did
the first tooth
erupt in the mouth?
• Which tooth and
any associated
problems?
• When did the child
attain the following
developmental
milestones?
• Sitting
• Standing without
support
• Walk
• Runs
• Speaks in sentences
 Personal history

a) Oral hygiene
habits:
• Brushing habits
• Method of cleaning
the teeth
• Frequency
• Material
• Rinsing habits
• At what age was
tooth brushing
initiated
• When did the child
started brushing on
his own?
• Is the child
supervised during
brushing?
b) Diet:
– Patient’s diet should
be assessed.
– Number of meals
and in between
snacks should be
recorded
– If the caries
activity is high then
diet counseling
programs can be
employed
 c) Oral habits:
• Habits such as finger/thumb sucking,
lip biting/sucking, nail biting, mouth
breathing, tongue thrusting, bruxism
etc. should be recorded.
• The duration of the habit should be
noted.
• Also what has been done to make the
child stop the habit should be asked.
• Presence of habits such as finger or thumb
sucking is considered normal till the age of
3 to 4 yrs beyond that should be
considered abnormal.
• Features indicating various habits should be
examined
For e.g.
a) Finger/thumb
sucking features
like anterior
proclination and
open bite
is seen.
 b) In case of nail biting
presence of clean
callus and nails should
be examined.
• Minor tooth
irregularities such as
tooth rotation, wear of
incisal edge and minor
crowding should be
also noticed.
c) In lip biting habit
either of the lips may
be involved, with a
higher predominance
towards lower lip.
• The features are
proclined upper
anteriors, retroclined
lower anteriors,
hypertrophic and
redundant lower lip.
Cracking of lips is also
d) Tongue thrusting:
Proclination of
anterior teeth,
anterior open bite and
bimaxillary protrusion
are the common
features. Posterior
open bite and posterior
cross bite is seen in
lateral tongue thrust.
e) Mouth breathing:
The features are long and
narrow face, narrow nose
and nasal passage,
contracted upper arch
with posterior cross
bite, increased overjet due
to flaring of anteriors,
anterior marginal gingivitis
and dryness of mouth.
• The various clinical test done to assess mouth
breathing are-
Observation
Mirror test
Butterfly test
Water holding test
Inductive
plethysmography
(Rhinomanometry)
Cephalometrics
 f) In bruxism the patient may have
• Tooth mobility specially in the
morning,
• Occlusal wear,
• Muscular tenderness,
• Headache and
• TMJ disorders.
III) General physical
examination
• It begins with
the first
appearance of
the child and
parents
themselves.
a) Built/stature, height and weight:
Whether normal for the age. If not
factors responsible should be determined.
b) Gait:
An abnormal gait can be associated with
a particular disease.
c) Speech:
Speech disorders such as aphasia,
delayed speech, stuttering, articulatory
speech disorders.
d) Hands:
It should be checked for pallor,
cyanosis and icterus.
The fingers are checked for their
number (indicative of syndromes), size
and shape.
The nails are checked for any
clubbing.
e) Skin:
It is checked for color and complexion
Any skin lesions, abnormal texture,
color, scars pigmentations, eruptions,
marks should be noticed.
f) Hair:
Thin and brownish color hair may be
indicative of malnourishment.
• Also texture should be noted
 Vital signs

• Temperature: Normal oral temperature is

370C.
• Pulse rate: In children 80-100bpm
In adults 70-80bpm
• Respiratory rate: In children 16-20/min
In adults 12-16/min
• Blood pressure: 120/80 mm of Hg
IV) Extra-oral examination
 a) Shape of the
skull:
• It is classified as
-Brachycephalic
-Mesocephalic
-Dolichocephalic
b) Shape of the face: Face can be
classified in three forms
1) Mesoprosopic-
2) Euryprosopic-
3) Leptoprosopic-
c) Facial symmetry:
Gross facial
asymmetries are seen
in
-congenital defects,
-hemi facial
atrophy/hypertrophy,
-unilateral condylar
ankylosis and
hyperplasia.
d) Facial profile:
It can be classified
as
-straight

-convex

-concave
e) Eyes:
The sclera is looked for icterus
and the conjunctiva is looked for
pallor.
f) Nose:
This can be checked for deviated
nasal septum, position of nostrils and
any discharge.
g) Lips:
Note lip color,
texture,
competence,
surface
abnormalities,
angular or vertical
fissures, lip pits,
cold sores, nodules,
herpes infection.
h) Paranasal sinuses:
Maxillary, frontal, and ethemoidal
are checked for sinusitis.
i) TMJ and function:
– Observe for deviations in the path of the
mandible during opening and closing.
– Range of vertical and lateral movement.
– Dislocation
– Clicking sound, crepitus
– Tenderness
j) Lymph nodes:
The lymph nodes commonly checked are
Submaxillary
Submental, and Cervical- Superficial and Deep
– Check for site, size shape and mobility,
tenderness, swelling, and lymphadenpathy
– Lymph node palpable is soft –due to infection
hard –carcinoma
firm –lymphoma
– No. of lymph node palpable
– Diameter
– Mobility –mobile in case of infection.
k) Swallow:
It can be normal or infantile.
The persistence of infantile swallow is indicated
by
-protrusion of the tip of the tongue
-contraction of perioral muscles during

swallowing
-no contact at molar region during
swallowing
V) Intra-oral examination
1) Saliva:
The flow and viscosity should be

checked for.
2) Halitosis: This can occur due to poor
oral hygiene practices or it may be
indicative of systemic conditions.
 A) Soft tissue examination

2) Labial and Buccal mucosa:

Observe for any changes in color, texture,
pigmentations, hyperkeratotic patches,
ulcers, swellings, fistulae, and tenderness.
2) Vestibule:
Look for the color, texture, swelling fistulae,
and tenderness.
Note the frenulum attachment.
3) Tongue:
Inspect the
dorsum of the
tongue for any
swellings ulcers,
coating or
variation in size.
4) Palate:
Inspect for swellings, fistulae,
ulcers, burns, hyperkeratinizations,
tenderness, papules, cleft palate &
also the depth of the palate.
5) Floor of the
mouth:
Character and
extent of
secretions from the
salivary ducts,
swellings, ulcers,
color, nodules, and
patches.
6) Gingiva:
The color, contour,
shape, size,
consistency, surface
texture, and position
is checked for.
Any swellings,
ulcerations, pus
discharge, sinus
tracts, erythema is
checked for.
7) Frenal attachments:
Labial frenum at times can be
thick and may be attached to the
incisive papilla which may cause
midline diastema.
Blanch test can be used for
confirmation
Short lingual frenum can cause
ankyloglossia.
8) Tonsils and Adenoids:
Enlarged adenoids should be
checked for.
 B) Hard tissue examination
2) Teeth present:
Number of teeth present in both upper and lower
arch should be noted.
2) Type of dentition:
Whether primary, permanent or mixed
3) Missing teeth:
Note whether the teeth is congenitally missing
or missing following extraction.
4) Caries:

5) Caries with pulp

involvement:
6) Root stumps:

7) Filling present:
8) Mobility:
Grade of mobility
should be mentioned

9) Fractured teeth:
10) Retained teeth:

11) Erupting teeth:

12) Supernumary teeth:

13) Any wasting diseases:
Like attrition, abrasion, and erosion

14) Hypoplastic teeth

15) Any other dental anomalies:

16) Orthodontic
evaluation:
a) Molar relation:
b) Terminal plane
relation:
c) Canine relation:
d) Overbite:
e) Overjet:
f) Midline deviation:

g) Crossbite:

h) Space loss:

vii) Ectopic eruption:

j) Other significant findings:

17) Deposits:
Check for calculus supragingivally
and subgingivally.
Stains- Extrinsic
Intrinsic
VI) Provisional diagnosis
• A general diagnosis based on clinical
impression without any laboratory
investigations.
VII) Differential diagnosis
• The process of listing out two or more
diseases, having similar signs or
symptoms of which only one could be
attributed to the patient’s suffering.
VIII) Investigations
• Radiographic investigations:
• Radiographs are of two types-
1) Intraoral
2) Extraoral
 1) Intraoral radiographs
A) Intraoral
Periapical
radiographs

B) Bitewing
radiograph:

C) Occlusal
radiographs:
 2) Extraoral radiographs
A) Ortho
pantomographs:

B) Cephalographs:
 Hematological investigations

• RBC count
• Hemoglobin determination
• Hematocrit count
• Platelet count
• Bleeding time
• Clotting time
• Torniquet test
• Prothrombin time
• White cell count
• Differential count
 Bacteriological culture and
sensitive tests

• Wound abscess or surgical lesion

cultures
• Caries activity tests
• Root canal cultures
• Fresh moist preparations and smears
 Other tests

• Vitality tests
• Biopsy
• Photographs
• Study models
 Advanced diagnostic aids
1) Probes:
-Perio temp probe
-Fluoride probe
-Foster-Miller probe
-Toronto automated probe
-DNA probe
2) Other aids:
-Xeroradiography
-CADIA (Computer Assisted
Densitometric Image Analysis
system)
-Computers
-Ultrasonics
IX) Final diagnosis
• A confirmed diagnosis based on all
available data.
X) Treatment plan
Phases of treatment planning
• Emergency Phase:

• Systemic phase:

• Preventive phase:

• Preparatory phase:
• Corrective phase:

• Maintenance
phase
XI) Prognosis
• It the prediction of the course,
duration and termination of a disease
and the likelihood of its response to
treatment.
 References
• Dentistry for child and adolescents-
Ralph. E .McDonald
• Clinical Pedodontics- Finn
• Textbook of Pedodontics-Shobha
tandon
• Oral diagnosis-Donald Kerr, Major
Ash
• Orthodontic- The art and science-
I S Bhalaji
• Color Atlas of Oral Diseases in
Children and Adolescence
• Pictures from -www.google.com