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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
– 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
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.
evaluated as,
1) The onset
2) Duration
3) Location
4) The quantity, quality, severity
treatment.
e) To know about any excessive bleeding
• 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
• It includes the
family situation,
the child’s school
situation,
personality traits,
developmental
status and the
child’s interpersonal
relationships.
Prenatal history
Forceps
Fullterm/Premature
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
-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
7) Filling present:
8) Mobility:
Grade of mobility
should be mentioned
9) Fractured teeth:
10) Retained teeth:
g) Crossbite:
h) Space loss:
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
• 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