KEN CARSON MOI UNIVERSITY DENTAL SCHOOL

2. HISTORY TAKING INHISTORY TAKING IN
PAEDRITIC DENTISTRYPAEDRITIC DENTISTRY
BYBY
BDS/10/09BDS/10/09

3. STEPS IN CASE HISTORYSTEPS IN CASE HISTORY
TAKINGTAKING

4. 1.PERSONAL INFORMATION1.PERSONAL INFORMATION
a) date;-time of admissiona) date;-time of admission
reference during follow up visitsreference during follow up visits
b) out patient number;-maintaining a record, billing , medico legalb) out patient number;-maintaining a record, billing , medico legal
considerationsconsiderations
c) 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 patient
d) age:- chronological age (date of birth) should be noted to knowd) age:- chronological age (date of birth) should be noted to know
whether 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 age
eg; 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

5. e) sex;-girls mature earlier than boys-require treatmente) sex;-girls mature earlier than boys-require treatment
earlierearlier
-some diseases shows sex predilection-some diseases shows sex predilection
eg: anorexia-femaleseg: anorexia-females
hemophilia -maleshemophilia -males
f) race/ethnic origin:-certain religious cultures depends thef) race/ethnic origin:-certain religious cultures depends the
etiology 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 level
h) address;-communicationh) address;-communication
-to chart out appointments for patients from distant-to chart out appointments for patients from distant
placesplaces
-to know endemic status of disease in the locality-to know endemic status of disease in the locality

6. 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 of
severityseverity
Follow the chronological orderFollow the chronological order
3)3)HISTORY OF PRESENTING ILLNESSHISTORY OF PRESENTING ILLNESS;-;-it should indicate theit should indicate the
severity 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

7. MEDICAL HISTORYMEDICAL HISTORY

9. 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 breathing
8. 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 abnormalities
9.REVIEW OF SYSTEMS9.REVIEW OF SYSTEMS
-any relevant history-any relevant history
10.SUMMERY10.SUMMERY

10. Mouth breathingMouth breathing
moumou
Nail biting Tongue thrusting
Mouth breathing

11. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
1.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 the
childchild
- vital signs like temperature, blood pressure, pulse, respiratory rate- vital signs like temperature, blood pressure, pulse, respiratory rate
should 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

13. EXTRA ORAL EXAMINATIONEXTRA ORAL EXAMINATION

14. 9)Extra oral examination9)Extra oral examination
 Shape of head- mesocephalic (oval), brachycephalic (short andShape of head- mesocephalic (oval), brachycephalic (short and
broad), 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 ,extend
and shapeand shape
 TMJ-clicking ,deviation ,pain , crepitation should be noted while jawTMJ-clicking ,deviation ,pain , crepitation should be noted while jaw
movementsmovements
 Lymphnodes : size, shape, consistency, number, tender onLymphnodes : size, shape, consistency, number, tender on
palpation, mobility should be notedpalpation, mobility should be noted
 Salivary glands- Submandibular gland-bimanual palpationSalivary glands- Submandibular gland-bimanual palpation

15. SALIVARY GLAND
Lymph nodes

16. INTRA ORAL EXAMINATIONINTRA ORAL EXAMINATION

17. 10)Intra oral examination10)Intra oral examination
A) 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-periodontium
a)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 and
calculuscalculus
b)Bone lossb)Bone loss
c)Perio pocketsc)Perio pockets

19. 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 and
vertical) 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

20. Pulpal diseases Faulty restorations
Periodontal diseases
Occlusal
discrepancies
Dental caries spacing

21. 11)Provisional diagnosis11)Provisional diagnosis
 A general diagnosis based on the clinical impression without anyA general diagnosis based on the clinical impression without any
lab. Investigationslab. Investigations
12)Differential diagnosis12)Differential diagnosis
The process of listing out of 2 or more diseases having similar signsThe process of listing out of 2 or more diseases having similar signs
and symptoms of which only one could be attributed to the patient’sand symptoms of which only one could be attributed to the patient’s
sufferingsuffering
13)Investigations13)Investigations
radiographs, biopsy, $ other testsradiographs, biopsy, $ other tests
14)Final diagnosis14)Final diagnosis
A confirmed diagnosis based on all available data.A confirmed diagnosis based on all available data.

22. TREATMENT PLANTREATMENT PLAN

23. 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, antibiotic
prophylaxis, 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 crowns
prosthetic rehabilitation-tooth replacements ,jacket crownsprosthetic rehabilitation-tooth replacements ,jacket crowns
early orthodontic intervention;-minor tooth movements,serialearly orthodontic intervention;-minor tooth movements,serial
extraction, space managementextraction, space management

24.  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

25. 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

26. Thank you….!Thank you….!