CLINICAL PEDIATRIC DENTISTRY I 2
CH.1
EXAMINATION & DIAGNOSIS OF THE
MOUTH AND OTHER RELEVANT
STRUCTURES. McDonald, Avery, Dean. Dentistry For The Child And Adolescent, 8th Ed. Page: 1-22
Wednesday, November 05, 2014 1 OTHMAN AL-AJLOUNI
Lecture outline:
INITIAL PARENTAL CONTACT WITH THE DENTAL OFFICE
THE DIAGNOSTIC METHOD
PRELIMINARY MEDICAL AND DENTAL HISTORY
CLINICAL EXAMINATION
TEMPOROMANDIBULAR EVALUATION
UNIFORM DENTAL RECORDING
RADIOGRAPHIC EXAMINATION
EARLY EXAMINATION
INFANT DENTAL CARE
DETECTION OF SUBSTANCE ABUSE
Etiologic Factors In Substance Abuse
Specific Substances And Frequency Of Use
SUICIDAL TENDENCIES IN CHILDREN AND ADOLESCENTS
INFECTION CONTROL IN THE DENTAL OFFICE
Biofilm
EMERGENCY DENTAL TREATMENT
to develop a treatment plan.
T.P. 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.
Each pediatric patient should be given an opportunity to
receive complete dental care. If parents reject a portion
or all of the recommendations, the dentist has at least
fulfilled the obligation of educating the child and the
parents.
Guidelines on Periodicity of Examination, Preventive Dental
Services, Anticipatory Guidance, and Oral Treatment for
Children, Revised M a y 2 0 0 0
•Birth-12 Months
•12-24 Months
•2 - 6 Years
•6 - 1 2 Years
•12-18 Years
Birth-12 Months
1. Complete the clinical oral assessment and appropriate diagnostic tests to assess oral growth
and development and/or pathology.
2. Provide oral hygiene counseling for parents, guardians, and caregivers, including the
implications of the oral health of the caregiver.
3. Remove supra- and subgingival stains or deposits as indicated.
4. Assess the child's systemic and topical fluoride status (including type of infant formula
used, if any, and exposure to fluoridated toothpaste), and provide counseling regarding
fluoride. Prescribe systemic fluoride supplements if indicated, following assessment of total
fluoride intake from drinking water, diet, and oral hygiene products.
5. Assess appropriateness of feeding practices, including bottle feeding and breast-feeding,
and provide counseling as indicated.
6. Provide dietary counseling related to oral health.
7. Provide age-appropriate injury prevention counseling for orofacial trauma.
8. Provide counseling for non-nutritive oral habits (e.g., digit, pacifiers).
9. Provide diagnosis and required treatment and/or appropriate referral for any oral diseases or
injuries.
10. Provide anticipatory guidance for parent/guardian. 1 1. Consult with the child's physician
as indicated.
12. Based on evaluation and history, assess the patient's risk for oral disease.
13. Determine interval for periodic reevaluation.
12-24 Months
1. Repeat birth to 12-month procedures every 6 months or as indicated by the individual 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.
2 - 6 Years
1. Repeat 12- to 24-month procedures every 6 months or as indicated by the individual 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, as indicated
by the individual patient's needs.
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 the individual patient's needs.
5. Provide pit and fissure sealants for primary and permanent teeth as indicated by the individual 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 the individual
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.
6 - 1 2 Years
1. Repeat 2- to 6-year procedures every 6 months or as indicated by the individual patient's
needs/susceptibility to disease.
2. Provide substance abuse counseling (e.g., smoking, smokeless tobacco).
12-18 Years
1. Repeat 6- to 12-year procedures every 6 months or as indicated by the individual patient's
needs/susceptibility to disease.
2. At an age determined by the patient, parent, and dentist, refers the patient to a general dentist for
continuing oral care.
INITIAL PARENTAL CONTACT WITH THE DENTAL OFFICE
The parent usually makes the first contact with the dental office
by telephone. This initial conversation between the parent and
the office receptionist is very important. It provides the first
opportunity to attend to the parent's concerns by pleasantly and
concisely responding to questions and by offering an office
appointment. The receptionist must have a warm, friendly voice
and the ability to communicate clearly. The receptionist's
responses should assure the parent that the well-being of the
child is the chief concern.
The information recorded by the receptionist during this
conversation constitutes the initial dental record for the patient.
Filling out a patient information form is a convenient method of
collecting the necessary initial information.
THE DIAGNOSTIC METHOD
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. Some pathognomonic signs may lead to an
almost immediate diagnosis.
They provide a diagnosis only for a single problem area. On the other hand, a
comprehensive diagnosis of all the patient's problems or potential problems
may sometimes need to be postponed until more urgent conditions are
resolved.
THE DIAGNOSTIC METHOD
• Medical and dental history taking
• Inspection
• Palpation
• Auscultation
• Exploration
• Radiography
• Percussion
• Transillumination
• Vitality tests
• Study casts
• Laboratory tests
• Photography
PRELIMINARY MEDICAL AND DENTAL HISTORY
Familial history: information in some hereditary disorders.
The child's social and psychologic development: a child's learning, behavioral, or
communication problems.
Remember to keep the questions age appropriate to the child.
Hospitalized previously for general anesthetic and surgical procedures: a
Traumatic psychologic experience and the child's fear of strangers in clinic attire.
Strengthens the confidence of the parents.
Systemic disease or anomaly, the dentist should consult the child's physician to learn
the status of the condition, the long-range prognosis, and the current drug therapy.
Current illnesses: consulting the child's physician.
Laboratory tests.
Special precautions.
Communicable infectious conditions.
Current recommended childhood immunization schedule.
Dental patients with special medical, physical, or behavioral problems.
Medical history
Dental history
Current oral hygiene habits and previous.
Current fluoride exposure.
CLINICAL EXAMINATION
Examining the structures in the oral cavity, patient's size, stature, gait, or
involuntary movements.
Clinical examination, whether the first examination or a regular recall
examination, should be all inclusive. 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.
The patient's hands: temperature, cold, clammy hands or bitten fingernails,
anxiety, sucking habit. Clubbing of the fingers or a bluish color in the nail
beds suggests congenital heart disease.
Inspection and palpation of the patient's head and neck
Hair or skin: lice, ringworm, or impetigo
Referral: contagious.
Variations in size, shape, symmetry, or function of the head and neck
structures should be recorded. Abnormalities of these structures may indicate
various syndromes or conditions associated with oral abnormalities.
TEMPOROMANDIBULAR EVALUATION
One should evaluate temporomandibular joint (TMJ) function by palpating
the head of each mandibular condyle and observing the patient while the
mouth is closed (teeth clenched), at rest, and in various open positions.
TMJ disorders in children managed effectively by the following conservative
and reversible therapies: patient education, mild physical therapy, behavioral
therapy, medications, and occlusal splints.
Extraoral examination: palpation of the patient's neck and submandibular
area, tenderness or enlargement.
Speech: positions of the tongue, lips, and paraoral musculature during
speech, while swallowing, and while at rest.
Intraoral examination: First evaluate the condition of the oral soft tissues and
the status of the developing occlusion, charting carious lesions, breath odors
and saliva.
The buccal tissues, lips, floor of the mouth, palate, and gingivae, periodontal
screening and recording program (PSR). Initiation of periodontal screening
in children following eruption of the permanent incisors and the first molars.
The tongue and oropharynx: rheumatic fever, immediate referral, throat
culture specimen.
Occlusion. 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.
Finally, the teeth should be inspected carefully for evidence of carious lesions
and hereditary or acquired anomalies, counted and identified individually,
supernumerary or missing teeth. During clinical examination for carious
lesions each tooth should be dried individually and inspected under a good
light.
alert to signs and symptoms of child abuse and neglect.
RADIOGRAPHIC EXAMINATION
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 anomalies. A child should be
exposed to dental ionizing radiation only after the dentist has determined the
radiographic requirement, if any, to make an adequate diagnosis for the
individual child at the time of the appointment. Obtaining isolated occlusal,
periapical, or bite-wing films is sometimes indicated in very young children
(even infants) because of trauma, toothache, suspected developmental
disturbances, or proximal caries. Carious lesions appear smaller on
radiographs than they actually are.
As early as 1967, Blayney and Hill recognized the importance of diagnosing
incipient proximal carious lesions with the appropriate use of radiographs. If
the pediatric patient can be motivated to adopt a routine of good oral hygiene
supported by competent supervision, many of these initial lesions will be
arrested.
EARLY EXAMINATION
Historically, dental care for children has been designed primarily to prevent
• Oral pain
• Oral infection,
• Occurrence and progress of dental caries,
• Premature loss of primary teeth,
• Loss of arch length,
• Development of an association between fear and dental care.
• Goals of pediatric dental care therefore are primarily preventive.
Some dentists, especially pediatric dentists, like to counsel expectant
parents before their child is born, good nutrition during pregnancy,
medication, her all carious lesions restored, high levels of
Streptococcus mutans can lead to transmission by the mother to the
infant, reinforce good nutritional recommendations provided by
medical colleagues.
INFANT DENTAL CARE
Oral examination, anticipatory guidance including preventive education, and appropriate
therapeutic intervention for infant enhance opportunity for a lifetime of freedom from
preventable oral disease.
RECOMMENDATIONS:
1. Infant oral health care begins ideally with prenatal oral health counseling for
parents. An initial oral evaluation visit should occur within 6 months of the eruption
of the first primary tooth and no later than 12 months of age.
2. At the infant oral evaluation visit, the dentist should do the following:
a. Record a thorough medical and dental history, covering the prenatal, perinatal, and
postnatal periods.
b. Complete a thorough oral examination
c. Assess the patient's risk of developing oral and dental disease, and determine an
appropriate interval for periodic reevaluation based on that assessment
d. Discuss and provide anticipatory guidance regarding dental and oral development,
fluoride status, nonnutritive oral habits, injury prevention, oral hygiene, and effects of
diet on dentition
3. Dentists who perform such services for infants should be prepared to provide
therapy when indicated or should refer the patient to an appropriately trained
individual for necessary treatment.
INFANT DENTAL CARE
infant of any age, even a newborn,
at least 1 year of age.
It is not always necessary to conduct the infant oral examination in the dental
operatory, but it should take place where there is adequate light for a visual
examination.
direct observation and digital palpation. gently restrain the child and that it is
normal for the child to cry during the procedure. The infant is held on the lap
of a parent, usually the mother. provides emotional support to the child and
allows the parent to help restrain the child. lighting for visibility and gauze
for drying or debriding tissues. Sometimes a tongue depressor and a soft-
bristled toothbrush are also useful. a systematic and gentle digital exploration
of the soft tissues without any. If hand instruments are needed, the dentist
must be sure to have a stable finger rest before inserting an instrument into
the child's mouth.
regular recall examinations often contribute to the youngsters' becoming
excellent dental patients without fear at very young ages.
Obtaining accurate data in a child is very difficult,
whyɁɁ
1. Required data obtained from parents or guardian
2. Not reliable
3. Different behaviour of the children
4. Inaccurate data from parents
5. Parents forget to mention minor findings
Chief Complaint
• Common reasons for seeking treatment includes: pain, swelling, to improve esthetics or referred from other practitioner
• Record it in chronological order what appeared first should be mentioned first.
Pain of 4 days duration
Swelling of 2 days duration
Fever of 1 day duration
Intraoral examination
• Search for signs of: 1. Caries 2. Toothbrush abrasion 3. Darkened teeth 4. Observable swelling 5. Fractured teeth 6. Defective restorations 7. Attrition 8. Cervical erosion 9. Developmental defects 10. Occlusal discrepancies
11. Any unusual alterations of the soft tissues
Case History, Examination, Treatment planning
1. Patient evaluation
2. Vital statistics
3. Chief complaint
4. History
5. Examination
6. Provisional diagnosis: is the art of identifying a disease from its signs and symptoms followed by thoughtful interpretation of the data.
Provisional diagnosis: is a general diagnosis based on clinical impression without any
laboratory investigation.
Investigations:
1. - Percussion
2. - Radiographic examination
3. - Pulp testing
4. - Study models & model analysis
5. - Photographs
6. - Cephalometric study
7. - Supplemental Diagnostic aids
Radiographic examination
• Although radiographs are arguably the single most useful diagnostic tool at the dentist’s
disposal , they are also the most misused.
• The two-dimensional shadow is misinterpreted, which may cause a diagnostic error and thus improper treatment
• Radiographs are only an adjunct to diagnosis --- used only after the history is recorded and the clinical examination is accomplished
Case History, Examination, Treatment planning
1. Patient evaluation
2. Vital statistics
3. Chief complaint
4. History
5. Examination
6. Provisional diagnosis
7. Investigation
8. Final diagnosis: it is a more confirmed diagnosis analyzing all the available data including the results of investigation.
Case History, Examination, Treatment planning
1. Patient evaluation
2. Vital statistics
3. Chief complaint
4. History
5. Examination
6. Provisional diagnosis
7. Investigation
8. Final diagnosis
9. Treatment planning
Case History, Examination, Treatment planning
Treatment planning:
is the orderly or sequentially arrangement of the various treatment needs of the patient to provide
maximum benefit to the patient as a whole.
Case History, Examination, Treatment planning
Advantages of Treatment planning:
1. Re-diagnosis is avoided
2. Serial appointments can be given on the 1st day
3. Instruments can be prepared well in advance
4. Total fee estimation can be done
PHASES OF TREATMENT PLANNING:
1. Medical phase
2. Systemic phase
3. Preventive phase
4. Corrective phase
5. Maintenance and recall
PHASES OF TREATMENT PLANNING:
1. Medical phase:
In patients with +ve medical history are referred to pediatrician for evaluation and consent.
PHASES OF TREATMENT PLANNING:
1. Medical phase
2. Systemic phase:
any medication given to modify dental treatment such as premedication for behavior management or antibiotic prophylaxis to a child with congenital cardiac defect.
PHASES OF TREATMENT PLANNING:
1. Medical phase
2. Systemic phase
3. Preventive phase: is the first phase of dental treatment, aimed to prevent or minimize dental disease including:
- Oral prophylaxis and fluoride treatment
- Pit and fissure sealant application
- Oral hygiene counseling
- Diet counseling
- Orthodontic consultation
PHASES OF TREATMENT PLANNING:
1. Medical phase
2. Systemic phase
3. Preventive phase
4. Corrective phase: includes providing treatment or management of the disease process:
- Extractions
- Restorations
- Minor surgical procedures
- Space maintainers
- Minor orthodontic corrections
- Prosthetic rehabilitation
PHASES OF TREATMENT PLANNING:
1. Medical phase
2. Systemic phase
3. Preventive phase
4. Corrective phase
5. Maintenance and recall:
as a preventive measure for early detection of disease and also for biannual topical fluoride application. Patients at high-risk are maintained at 2-3 months recall and low-risk at 6 months recall.
PHASES OF TREATMENT PLANNING:
Modification in Treatment planning:
1. Estimation of cooperation from the patient and parent
2. Assessment of the condition of the teeth and the oral hygiene
3. Whether extraction is needed or not
4. Nature of tooth movement and type of appliance required
Remember, if it is not written down
– it did not happen.
Consider this example of a
complete treatment note:
Thank You
