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comprehensive case history recording in pediatric dentistry



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comprehensive case history recording in pediatric dentistry

  1. 1.  ‘re-vision’
  2. 2. No mobiles……..plz ,,,,, as it distracts and only 30 min time allotted Questions will be asked as a rapid fire
  3. 3. Definition of pediatric dentistry??????
  4. 4. It is your first touch with patient ….the beginning of a long bonding
  5. 5. Pediatric dentistry is an incredible subject that includes all specialties under one banner ---so we need to be clear on diagnosis or else the growing child will be messed up physically ,mentally ,emotionally and dentally.
  6. 6. to know what is normal  what know what is abnormal  to diagnose the child's disease To assess the main hurdle ;the child and maternal anxiety and to tailor-make behaviour management strategy  to diagnose the medical conditions To plan treatment in a systematic way
  7. 7. The planned professional conversation that enables the patient to communicate his/her symptoms, feelings and fears to the clinician so as to obtain an insight in to the nature of patient’s illness and his/her attitude to them  Bricker
  8. 8. Data gathering;
  9. 9.  STATISTICS / Biographical Data  CHIEF COMPLAINT  HISTORY----- History of presenting illness Medical history Past dental history Family history  EXAMINATION------General examination Extra oral examination Intra oral examination  DIAGNOSIS-----Provisional diagnosis Investigations Final diagnosis  TREATMENT PLAN
  10. 10. Name & nick name Patient registration number and date Age and date of birth Address/Phone number Class /School Parents name and occupation Gender Name of his pet Favourite cartoon teacher, subject
  11. 11. Communication is the mainstay of paediatric dentistry ad has to e very well programmed as it is the foundation for a building a relation with child patient;
  12. 12.  To assess the growth spurt  For calculation of drug dosage  Exfoliation, Eruption and delay of dentition  To plan endodontic treatment of young permanent teeth  To understand the cognition and psychological limitations of age  Chronological age v/s dental age v/s skeletal age and planning of treatment of interceptive orthodontics DIAGNOSIS
  13. 13. Very important to know the level of psychological growth specially cognition ;to plan the behaviour management; so the stage of the level of cooperation can be anticipated and child is not taxed.
  14. 14.  Diseases present in children : Early childhood caries  Haemangioma  Palatal cyst of newborn  Fibrous dysplasia of the jaw  Nursing bottle caries  Juvenile periodontitis  Eruption cyst  Dentigerous cyst  Pulp polyp  Herpetic gingiva stomatitis  Hand foot and mouth  disease
  15. 15. Females :  Dental caries  Lichen planus  MPDS  Anaemia  Sjogren’s syndrome  Juvenile periodontitis MALES  Leukoplakia  Herpes simplex  Hodgkins lymphoma  Attrition • Sex related diseases like haemophilia, G6PD deficiency  (causes haemolytic  anaemia) • As an aid in treatment planning – Growth spurts in girls are ahead of boys  In trauma: – Boys sustain more  injuries than girls – Ratio approx – 2:1
  16. 16.  Communication  Record purpose  To know certain endemic diseases High fluoride content – dental/skeletal fluorosis Filariasis  Is an excellent link to grow rapport  To do parental counselling to use It as a reinforce in child management  To teach few things through apps like diet and caries  To teach the child oral hygiene instructions  To book appointments PHONE NUMBER
  17. 17. • For communication • Reflects the socioeconomic status • (lower socioeconomic status are much more likely to develop chronic illness like heart disease, COPD, etc.,)
  18. 18. Is the reason for the patient’s visit to the clinic Should be recorded in patient’s own words and in a chronological order of their appearance and severity Helps to Understand patient’s underneath mental status, anxiety, irritation or depression This aids in diagnosis and treatment planning and hence should be given utmost priority In kids less than 5 years, parents should be questioned Helps to categorically place child and parent under different strata
  19. 19. ‘Pulp is a small tissue with a big issue’
  20. 20. Why is dental pain sooooo painful??????
  21. 21. INTRAPULPAL PRESSURE Normal pulp 10mm Hg Reversible pulpitis 13mm Hg Irreversible pulpitis 34.5mm Hg Necrosis 36 mm hg
  22. 22.  It is covered by a non complaint chamber of hared enamel and dentine which does not expand in due course of inflammation and infection and the pressure within causes severe pain.
  23. 23. Why is pulpal diagnosis important??????
  24. 24. How many of you believe…. it is not a big deal to over diagnose a tooth with just a deep caries as a irreversible pulpitis?????
  25. 25. Each manifestation of pulp has a clear indication of the pathology underneath directing towards a clear treatment plan it is clinicians judgement to do the most conservative procedure like a ipc than an aggressive pulpectomy if it is justified.
  26. 26.  activity which induces the pain should be taken in consideration.  sudden / gradual • Pain occurs without being provoked Induced • Provocation causes painful sensation Triggered • When evoked response is out of proportion to the stimulus SPONTANEOUS
  27. 27. Mild pain • Controlled by simple analgesics Moderate pain • Controlled with narcotic analgesics Severe pain • Cannot controlled with analgesics • Require elimination of cause
  28. 28. –Pricking/piercing – acute irreversible pulpitis –Throbbing – furcal abscess –LancinatingAching,Dull, boring, gnawing – furcal abscess
  29. 29. • Pain of short duration & seperated by wholly pain free periodIntermittent • Pain of longer durationContinuous • Two or more similar episodes of painRecurrent • Characterized by regularly recurring episodePeriodic
  30. 30. Aggravating or relieving factors- Hot/cold/sweet food, eating, biting etc. Pain aggravating to sweet and cold food – reversible pulpitis Pain aggravating to hot food and relieves to cold – irreversible pulpitis Nocturnaldiurnalpostural variations- if pain on turning the head , lying down – acute irreversible pulpitis
  31. 31. PHYSIOLOGY OF PULPAL PAIN HYPERALGESIA – spontaneous pain decreased pain threshold (allodynia) An increased response to painful stimuli spontaneous pain - irreversible pulpitis or pulpal necrosis
  32. 32.  Not a disease, but a symptom that last for a couple of seconds  Causes a sharp, quick hypersensitive responses  Momentary painful response to thermal change that subsides as soon as the stimulus is removed  Does not involve an unprovoked pain REVERSIBLE PULPITIS
  33. 33. IRREVERSIBLE PULPITIS The AAE has suggested dividing this classification into the subcategories of symptomatic irreversible pulpitis- acutely inflamed asymptomatic irreversible pulpitis- chronically inflamed .
  34. 34. SYMPTOMATIC IRREVERSIBLE PULPITIS The sensitivity to temperature changes is more intense and with a longer duration  Rapid exposure of teeth in this category to dramatic temperature changes (especially to heat stimuli) will elicit heightened and prolonged episodes of pain  even after the thermal stimulus has been removed. may extend for minutes or even longer usually dose not respond to pain killers the pain in these cases may be sharp, lingering, spontaneous
  35. 35. With advanced irreversible pulpitis a thickening of the periodontal ligament may become evident on the radiograph, by virtue of extensive pulp chamber and root canal space calcification. Typically, when symptomatic irreversible pulpitis remains untreated, the pulp will eventually become necrotic.
  36. 36. increases venous return from all tissues below the level of the heart increasing cardiac output transient increase in systemic blood pressure stimulates baroreceptors decrease sympathetic vasoconstriction to all vascular beds increases peripheral blood flow. Increased pulpal pressure
  37. 37. ASYMPTOMATIC IRREVERSIBLE PULPITISPulp Necrosis after degeneration;due to death of the nerves and blood vessels as a response to long standing irritation of toxins and inflammatory response the tooth becomes nonvital and leads to infection With pulp necrosis, the tooth will not respond to electric pulp tests or to cold stimulation. However, if heat is applied for an extended period of time, the tooth may respond to this stimulus. This response could possibly be related to remnants of fluid or gases in the pulp canal space expanding and extending into the periapical tissues.  Pulpal necrosis may be partial or complete and it may not involve all of the canals in a multirooted tooth.
  38. 38. After the pulp becomes necrotic, bacterial growth can be sustained within the canal. When this infection the bacterial toxins from this infection extends into the periodontal ligament space, the tooth may become symptomatic to percussion or exhibit spontaneous pain Radiographic changes may occur, ranging from a thickening of the periodontal ligament space  appearance of a periapical radiolucent lesion. The tooth may become hypersensitive to heat, even to the warmth of the oral cavity, and is often relieved by
  39. 39. Provisional diagnosis
  42. 42. Reversible pulpitis Irreversible pulpitis Pain with stimulus (cold or sweet) and subsides on removal of stimulus Pain continues after removal of stimulus Quick, sharp , hypersensitive response Spontaneous pain No pain at night Pain at night No pain on lying down Pain on lying down Stimulation of A delta fibres Stimulation of C fibres
  43. 43. PARENTAL HISTORY Pedodotic treatment triangle
  44. 44. Maternal attitude ( Bayley and Schaefer) Behaviour of child Over protective •Shy ,submissive , anxious • Cooperative patient Over indulgent •Aggressive ,demanding ,display temper tantrum •Usually not anxious, demands dentists attention Under affectionate •Usually well behaved, may be unable to cooperate, shy , may cry •Often respond to surrogate who will give emotional support and needed affection. Rejecting •Aggressive ,overactive ,disobedient •He will usually resort to any behaviour to gain attention Authoritarian Dawdling and evasive
  45. 45.  Hemifacial microsomia  Ectodermal dysplasia  Enamel hypoplasia  Cleft lip / cleft palate  Down syndrome EFFECTS OF CONSANGUINEOUS MARRIAGES ON ORAL AND CRANIOFACIAL STRUCTURES: A STUDY ON DENTAL PATIENTS IN NORTH INDIA , Annals and Essences of Dentistry – Dec. 2010
  46. 46. Oral cavity is a insuperable part of body ;thanks to the anatomy so we get a privilege to be called as doctors
  47. 47.  CNS  CVS  Hematopoietic and lymphatic system  Respiratory system  GI system  Endocrine system  Genitourinary system  Skin  Extremities  Allergies  Medications or treatment taken  Hospitalization MEDICAL HISTORY
  48. 48. cvs
  49. 49. Irrespective of the type, they share certain clinical characteristics and oral manifestations which includes, Cyanotic gingivitis & stomatitis Glossitis
  50. 50. Delayed tooth eruption Increased caries activity INCREASED STRUCTURAL DEFECTS OF ENAMEL Intrinsic dyschromia (medication and/or blood byproduct deposition.
  51. 51. CARDIA C PACEMAK ERS principally usedfor atrio- ventricular defects and sympotamatic sinus node disease in children
  53. 53. • Soft tissue findings include : Metastatic calcifications (altered CaPo4 metabolism) Noted in maxillary sinus and around the oral cavity Chronic marginal gingivitis Uremic gingivostomatitis Uremic stomatitis,whitish- gray pseudomembrane on the tongue. White keratotic lesion which mimics leukoplakia.
  54. 54. • Uremic osteodystrophy of bones Loss of lamina duraGround glass appearance Large bony lesions Retarted growth resulting in malocclusion Hypoplasia – characteristic Incremental defect Tetracycline staining
  55. 55.  Blood investigation – BLEEDING DISORDERS parameter Normal value Moderate risk High risk INR 1-1.5 >1.5 PT 12-18 sec 18-27 sec >30 sec a - PTT 22- 28 sec 50 – 55 sec >55 sec
  56. 56. Procedure Decision recommended Reason Pulpally involved teeth Endodontic therapy Lowers bleeding LA administration *Infiltration preferred over block * PDL and intrapulpal useful Accidental pricking of bv results in hematoma No bleeding risk Number of appointments Reduced to 2 , consecutive days highly appropriate Factor VII infusion need not be repeated Treatment mode Split mouth technique – one quadrant in one appt. Or full mouth treatment under GA Decreases frequency of factor VII infusion. Minor surgical procedures. Electrocautery or laser preferred No risk of bleeding
  57. 57.  . Complete blood count with platelet count < 20,000- prophylatic platelet transfusion before treatment ANC- <1000/cubic mm- elective dental treatment should be delayed. Pulp therapy and RCT contraindicated. Donot prescribe aspirin related analgesics.
  58. 58. • Hypopituitarism The craniofacial manifestations include Circumoral paraesthesia, Spasm of the facial muscles, Hypodontia Oral candidiasis thickened lamina dura Enamel hypoplasia Delayed / arrested tooth eruption
  59. 59. • • • • A familial X-linked dominant disease in which there are adequate parathyroid hormone levels but inadequate response to parathyroid hormone. Boys are more severely affected than girls. • Treatment focuses on maintaining serum calcium through medication, diet supplementation and vitamin D therapy. Hypoplastic enamel and pitting Delayed eruption of teeth Incomplete closure of apical area of teeth
  60. 60. Inherited autosomal recessive disease It produces dentin defects in both the primary and the permanent dentition. Enlarged pulp-chambers and extension of the pulp horns into the cusp tips also appear.
  61. 61. THYROID DISEASES Oral manifestations include : • Hypothyroidism:  Macroglossia & poor periodontal health  Pronounced lips, altered tooth morphology  Delayed tooth eruption with malocclusion  Long-term effect : impaction of mandibular 2ndmolar. • Hyperthyroidism:  Early loss of primary teeth with subsequent rapid eruption of permanent teeth(young children)  Lymphoid tissue hyperplasia- tonsillar & oropharynx (Grave’s disease)  Burning mouth syndrome, Sjogren′s syndrome  Maxillary & mandibular osteoporosis  In Graves disease, thyroid may be enlarged or noticeably palpable. in a supine position in the dental chair. ShaluChandna, ManishBathla etal.Oral mani f es t at i ons ofthyroid disorders and i t s management .IndianJournalofEndocrinology andMetabolism, Vol. 15,2011,
  62. 62. Ten-year-old child suffering from hypothyroidism with delayed eruption and exfoliation Anterior open bite Eight-year-old child suffering from hyperthyroidism with early eruption of premolars and second molars Macroglossia observed in child with congenital hypothyroidism
  63. 63. More severe periodontal disease Xerostomia angular chelitis Burning tongue - associated with candidiasis Multiple abscess
  64. 64. Comprehensive medical history along with screening test essential. Dental procedure – short , stress free, atraumatic Early morning appt, normal breakfast Conscious sedation preferred LA –excess adrenaline – increase blood glucose level Prophylactic antibiotics before surgical procedures Fixed or removable applince- depends on periodontal health. Nonvital tooth with evidence of infection- extraction Pulp capping and pulpotomy- questionable
  65. 65. Oral manifestations include, Soft tissue lacerations of the tongue or buccal mucosa Facial fractures Trauma to the teeth Recurrent apthous like ulceration
  66. 66. GINGIVAL HYPERPLASIA Cervical lymphadenopathy
  67. 67. A condition in which a person's airways become inflamed, narrow and swell and produce extra mucus, which makes it difficult to breathe.
  68. 68. Semi-supine / upright position may be better for treatment in such patients. Avoid use of rubber dam in severe diseases
  69. 69. Sickle cell Anemia VIT D Resistent Rickets Herpes zoster DISEASES CAUSING SPONTANEOUS PULPAL DEGENERATION
  70. 70. Nutritional diseases Stress Corticosteriod Theray DISEASES WHICH REDUCES PULPAL HEALING AND REPAIR
  71. 71. Condition of mother during pregnancy???  Disease  Trauma  Medications  Food and habits  Radiation  Anomalies scan  Gene testing
  72. 72.  Cytomegalovirus infections- microcephly, hydrocephaly , mental retardation  HSV – microcephaly, micropthalmia , mental retardation  Rubella – congenital heart disease, defeness, microphalmia, cleft lip and palate  Treponema pallidum- Hutchinsons teeth and bones , mental retardation, congenital deafness. DISEASES IN MOTHER
  73. 73. • Term of delivery: Full term/ premature • Type: Normal / Forceps / Caesarian • Forceps delivery ---- injury to TMJ --- retarded growth of mandible • Intracranial hemorrhage Cyanosis at birth : congenital heart defect Rh incompatibility : erythroblastosis fetalis.
  74. 74. Rh incompatibility - may result in the condition termed as ‘erythroblastosis fetalis’. Rh hump on the tooth and the characteristic blue – green discoloration. ABO incompatibility Hemolytic anemia when mother is Blood Type 0 and the infant is Blood Type A or B, with A being more antigenic.
  75. 75.  Post Natal  Feeding history- Duration , Weaning?  Natal or neonatal teeth?  Vaccinations  DPT  BCG  OPV  Tetanus  MMR • Milestones of development • Habits • Childhood diseases
  77. 77.  Child’s first dental visit?  Any unfavourable dental experience?  How much satisfied was the previous treatment?  Does your child complain of tooth ache ?  Has your child suffered any injury to teeth?  Did he have any fluoride treatment done before?  Source of drinking water?  Place of residing for the last
  79. 79.  Compared to cow milk, breast milk has low mineral content but high lactose content favouring caries.  High calcium and casein levels in cows milk also helps in reducing caries by remineralisation. • Breast feeding greater than 7 times daily after 12 months of age is associated with increased risk of ECC. AAPD GUIDELINES 2013
  81. 81. Do make a note of previous unpleasant dental episode so you can frame strategies to modify that phobia
  82. 82.  Acrodynia  Cherubism  Cyclic neutropenia  Hypophosphasesia  Histocytosis X  Juvenile diabetes  Papillon LeFevre syndrome  Progeria
  83. 83. Frequency Intensity Duration
  84. 84. Each child is different; there is no one size fits all, so important to clearly and categorically understand child's nature
  85. 85. Definitely negative- refuse treatment, cries forcefully Negative- reluctant to accept treatment, display evidence of slight negativism. Positive- accepts treatment, if bad experience during treatment becomes uncooperative Definitely positive – good rapport with dentist and accepts treatment
  87. 87.  To decide on the behavior management mainly desensitization is usefull
  88. 88.  Cooperative behaviour: Cooperative behaviour- Lacking Cooperative behaviour- young child , disabled child Potentially Cooperative behaviour- has potential to cooperate, because of inherent fear child doesn’t cooperate
  89. 89.  Un Cooperative behaviour Uncontrolled behaviour- preschool children at their first dental visit, refuses to cooperate. Obstinate behaviour- spoilt and stubborn child Timid behaviour- shy but cooperative Tense Cooperative behaviour- do not resist treatment, but tensed at mind Whining behaviour- allows for procedure ,but complains throughout treatment. Stoic behaviour- cooperative and accepts treatment without any facial expression
  90. 90. Fearful –resist entering room , cries , accepts treatment with a state of fear Timid – enters cautiously , do not look at the staff when talked to. Spoiled- enters clinics with arrogent and proud behaviour, neglects treatment , gives orders. Aggressive- screams ,does not open mouth, neglects treatment Adopted- combination of spoiled and fearful. Handicapped- all children with physical and mental handicapping condition. Cooperative- cooperate with treatment
  91. 91. 0-1 year 1- 2 years 2- 6 years 6-12 years
  92. 92. So empathy is the main ethics
  93. 93. Oral hygiene history – Method of cleaning teeth – Who brushes the teeth – Type of brush – Method of brushing – No. of times of brushing – Other oral hygiene aids used like flossing, rinses – How often it is changed – Fluoridated/non fluoridated tooth pastes
  94. 94. It includes recording of the following : Veg/non-veg/mixed diet No. of meals/day Cariogenic snacks/day Does your child eat everything you prepare Does your child constantly snack on food Favourite foods Other food habits
  95. 95. DETERMINE THE ADEQUACY OF DIET: Dental health diet score = Food score+ nutrient score - sweet score
  96. 96. Milk 3 *8 Meat 2 *12 Fruits & Vegetables 1 *6 Vitamin c 1 *6 Others 2 *6 Breads and cereals 4 *6 FOOD RDA NO OF SERVINGS
  97. 97. 72- 96 = excellent 64 – 72 = adequate 56 – 64 = barely adequate  < 56 = not adequate Score 60-100 is acceptable, and diet counseling is given only at patient request. If 56 or less ,then dietary counseling is both recommended and indicated as a part of preventive program.
  98. 98. Day Meat group Milk group Veg/fruit group Bread cereal Detergent Sugar equivalents 1 - 2 x (8) 1 banana x 5 2 chapatis Rice x 6 - Biscuits -5 Tofee-2 2 - 2 x (8) 2 slice melon x 5 One cup rice x 6 - Biscuits-5 Chocolate-2 3 Fish 1 x 12 2 x (8) Carrot half Pulses x 5 One cup rice x 6 - Icecream – 1 Tofee- 1 4 - 2 x (8) Mix veg x 5 Chpatis 1 cup rice x 6 - Biscuits – 4 Chips 5 Eggs 1x 12 2 x (8) Banana 1 Mango 2 slice x 5 3 bread slices 2 chapatis x 6 Peanuts Chocolate – 1 Biscuits- 6 6 7 - Chicken 1 x 12 2 x (8) - apples x 5 1 cup rice Noodles x 6 Chapatis Rice x 6 - Chocolate-2 Biscuits- 6 Biscuits - 2
  99. 99. Sweet Group Score  Sweetened liquid – 5  Sweetened solid – 10  Slowly dissolving – 15 Sweet Score Inference 5/<5 = excellent 10 = good 15/>15 – watch out
  100. 100.  Prefered positions: • Parental presence is mandatory for clinical examination of infants • Dental chair is not always necessary for examination
  101. 101.  Dental arches- edentulous/ tooth bulges  Frenula- high placement on alveolus  Palate- prominent median raphe / rugae  Gingiva – pink hydrated
  102. 102. Riga Fede disease Neonatal teeth
  103. 103. Bhon’s nodules and epstein pearls
  104. 104. Eruption cyst Congenital epulis
  105. 105. – Assessment of general appearance should start before the child is seated in the dental chair – It includes 1. Child’s stature/ built 2. Weight 3. Height 4. Gait 5. Speech 6. Vital signs
  106. 106. William Sheldon's-1940  Endomorph  Mesomorph  Ectomorph
  107. 107.  Aphasia  Delayed speech  Sluttering speech  Cluttering speech Significance: -For Management of child in the dental chair -To know if any systemic diseases associated Aphasia-CNS disorders Sluttering speech – parrot like speech (Autism)
  108. 108.  Pulse  Normal pulse rate is 60-80beeats/min  Average pulse is 72 beats/min  Physiologic increase in infants, afterexertion.  Pathologic increase in fever, cardiopulmonarydisea  Temperature  normal temp is 98.6 degree F or 37 degreecelsius.  Measured by thermometer.  Respiratoryrate  Adult rate–16-24 breaths perminute  Observe  Feel for chestmovement  Auscultate
  109. 109.  Blood pressure  Systolic- 110-140 mm Hg  Diastolic-60-90 mm of Hg  Measured by Sphygmomanometer.
  110. 110.  Includes examination of  Head  Face  Hair  Eyes  Ears  Nose  Lips  Lymph Nodes  TMJ  Swallow
  111. 111. Cephalic index =maximum skull width ( transverse dimension) (CI) Maximum skull length (Anteroposterior dimension) Cephalic index Mesocephalic 75-79.9 Brachycephalic 80 – 84.9 Dolichocephalic <74.9
  112. 112.  abnormal intrauterine pressure,  cranial nerve paralysis,  fibrous dysplasia,  familial developmental disturbances.  Infections  Trauma  Hemifacial atrophy  Hemifacial hypertrophy  Unilateral condylar hypoplasia  TMJ disorders
  115. 115.  Upper facial height:  45% of the total facial height  Lower facial height:  55% of the total facial height
  116. 116. Increased : • Skeletal open bite • Long face syndrome Lowered : • Growing children • Skeletal deep bite • Class II div 2
  117. 117. • Angle formed between lower border of nose to the upper lip(90-110degree) Increased: Retrusive maxilla Decreased : Proclined maxilla
  118. 118. Seen between lower lip and mentalis muscle • Normal - class I occlusion • Deep - class II div 1 occlusion • Shallow -bimaxillary protrusion
  119. 119. Chin prominence is related to mandibular position • Recessive chin- class II molar relation • Prognathic chin- class III molar relation • Normal position-class I occlusion
  120. 120. Pigmentations Skin of face – primary or secondary skin lesions (ulcerations , scars) Edema / cellulitis- renal disorder Redness/ allergic response Dryness/ dehydration, ectodermal dysplasia Ulceration , infectious disease.
  121. 121. bruising – child abuse cafe- au-lait spots PIGMENTATION
  123. 123. • Symmetry • Interincisal opening • Mandibular movement---Observe path of closure for  deviations,Range of motion(also in lateral movements) • Palpation of the joint – Pretragus palpation – Intra-auricular palpation • Auscultation of the joint – Clicking – Crepitus
  124. 124. MOUTH OPENING • Adults: –Males- 50 – 60 mm –Females- 45 – 55 mm • Children: – 35-45 mm –Lateral movements- 8 – 12 mm
  125. 125. Lymphatic drainage of teeth Maxillary teeth Mandibular posteriors Deep cervical lymph nodes Mandibular anteriors Submental lymphnodes Submandibular lymph nodes
  126. 126. SOFT TISSUE EXAMINATION 1. Breath 2. Lips and buccal mucosa 3. Saliva 4. Gingiva 5. Tongue and sublingual area 6. Palate 7. Teeth
  127. 127. Compound nevus on the vermillion border of maxillary lip MUCOCEL HERPIS LABIALIS
  128. 128. MUCOSA – LABIAL + BUCCAL + VESTIBULE  Check for:  Ulcerations  Swellings  Growths  Pigmentation  Texture  lesions
  129. 129. Fordyces granules leukoedemaLinea alba Mucocele
  130. 130. Fibroma Keratotic Patch Lichen planus Major Apthous Ulcer
  131. 131.  Check for:  High labial frenae  TongueTie  High labial frenae may cause Midline diastema when attached highly - to incisal papilla  Blanch test confirms
  132. 132.  Dorsum Check for... – Volume – Colour – Swelling and ulcer – Mobility – Tongue thrusting on swallowing  Variations in size  Macroglossia  Micoglossia  Range of movements
  133. 133. Coated tongue Apthous ulcer on tongue tip Coated tongue
  134. 134. Benign migratory glossitis Median rhomboid glossitis
  135. 135.  FLOOR OF MOUTH
  136. 136.  Floor of mouth  Swelling – mucocele, sialolith  Ulceration- aphthous , abuse
  137. 137. FREE TONGUE 16 mm Kotlow's classification Class I: Mild ankyloglossia: 12 to 16 mm, Class II: Moderate ankyloglossia: 8 to 11 mm, Class III: Severe ankyloglossia: 3 to 7 mm, Class IV: Complete ankyloglossia: Less than 3 mm.
  138. 138.  Hard Palate  Clefts  Fistulae (syphiliticgumma)  Inflammation  Swellings  Pigmentations  Ulcerations  Hyperkeratinization  Soft Palate
  139. 139. Erythematous candidiasis
  140. 140. ANUG Herpetic gingivostomatitis
  141. 141. Mandibular tori Fibromatosis gingiva
  142. 142. Pericoronitis
  143. 143. Primary examination technique for evaluating teeth include: Visual inspection Transillumination Probing Palpation Percussion
  145. 145.  Syndromes associated:  Aperts syndrome  Cleidocranial dysplasia  Gardner syndrome  Downs syndrome  Struge weber syndrome
  146. 146. HYPODONTIA :  Ectodermal dysplasia  Chondroectodermal dysplasia  Achondroplasia
  147. 147. Microdontia- hemifacial microsomia - downs syndrome( peg laterals) - chondroectodermal displasia - Ectodermal displasia
  148. 148.  Macrodontia  – hemifacial hypertrophy - fusion - gemination
  149. 149. DENS IN DENTE- OEHLERS CLASSIFICATION Dens invaginatus. Part 1: classification, prevalence and aetiologyInternational Endodontic Journal 2008
  150. 150.  Amelogenisis imperfecta  Enamel hypoplasia  Dentinogenisis imperfecta  Dentine displasia  Regional odontodisplasia
  151. 151.  Dental caries
  152. 152.  PROBING
  153. 153. Inspection of the offending tooth and surrounding structures
  154. 154. Examination of the exposed pulp for size .type of bleeding and any pus discharge and the type of surrounding dentin is sound or carious
  155. 155. If large carious lesion – check for percussion sensitivity Pain on lateral percussion – apical periodontitis Done by tapping the tooth lightly with a mirror handle
  156. 156.  Radiograph provide information about hard tissue Helpful in detecting  Caries  Periapical pathology  Bony structures of face , jaw and dental anomalies
  159. 159. BITE WING
  161. 161.  Fibro Optic Transilluminator.  Digital Fibro Optic Transilluminator.  DIAGNOdent -
  162. 162.  Pulp testing is often referred to as vitality testing.  It assess the integrity of the nerve supply in the pulp while it is the blood supply that maintains the pulp health. PULP VITALITY TESTS
  163. 163.  Testing should never be limited just to tooth in question.  Surrounding and contralateral tooth should be tested Various types of pulp tests  Thermal test  cold test  heat test  Electric pulp testing  Test cavity  Anesthesia  Bite test
  164. 164. COLD TEST
  166. 166.  Exaggerated brief  Pulp is vital but inflamed.  Pulpits may be reversible.  Exaggerated, Prolonged - Pulp is vital and inflamed.  Pulpitis likely to be irreversible.  Negative response  Pulp is non vital necrotic or root canals are sclerosed.
  167. 167.  UNRELIABLE IN DECIDUOUS TEETH AND IMMATURE PERMANENT TEETH BECAUSE  RELATIONSHIP BETWEEN ODONTOBLASTS AND NERVE FIBERS OF THE PULP HAS YET TO DEVELOP  LACK OF DEVELOPMENT OF RASCHKOW PLEXUS  IN DECIDUOUS TEETH, NERVE FIBERS ARE THE LAST TO DEVELOP AND FIRST TO DEGENERATE Dr. Grossman in 1940, stated that the electric pulp tester is not delicate enough to differentiate diseases of the pulp although it does give a gross indication of the vitality or non-vitality of the pulp. Gopakumar R, Gopakumar M. Diagnostic aids in pediatric dentistry. International journal of clinical pediatric dentistry. 2011 Jan;4(1):1.
  168. 168.  Increase in the threshold for pain due to systemic medication narcotic analgesics etc.  Extensive calcifications in the pulp Teeth with extensive restorations and a pulp protecting base.  Recently traumatized teeth.  Recently erupted teeth with incomplete root formation.  Patients with an unusually high pain threshold.  Defect in the EPT that is used.
  169. 169.  Accidental contact of the electrode with a large metal restoration in the tooth. It may conduct that electric impulse to the attachment apparatus.  The pulp cavity containing fluid, i.e., in case of moist gangrenous pulp in a root canal.  In case of multi rooted teeth with partially necrotic pulp with some nerve fibers still vital in one or more of the root canals.  Inadvertent spreading of the conducting medium on to the marginal gingiva.  Over anxious patient may give an exaggerated response.
  170. 170. PULSE OXIMETRY It depends on the absorbance characteristics of haemoglobin in the red and infra-red range. Oxygenated hemoglobin and deoxygenated hemoglobin are different in color and therefore absorb different amounts of red and infrared light.
  171. 171. EMERGENC Y PHASE
  172. 172.  Referral to physician MEDICAL PHASE
  173. 173. SYSTEMIC PHASE  Premedication  Antibiotic Prophylaxis  Managing anticoagulants  Adrenal/Thyroid insuffiency cases
  174. 174. REGIMEN FOR DENTAL PROCEDURE situation Agent Adults children oral Amoxicillin 2g 50 mg /kg IV/IM Ampicillin Cefazolin or Ceftriaxone 2g 1 gm 50 mg /kg 50 mg /kg Allergic to Penicillin or Ampicillin Oral Cephalexin or Clindamycin or Azithromycin or Clarithromycin 2g 600 mg 500 mg 50 mg /kg 20 mg/kg 15 mg/kg IV/IM Cefazolin or Ceftriaxone or Clindamycin 1 gm 600 mg 50 mg /kg 20 mg /kg AAPD guidelines
  175. 175. PREPARATOR Y PHASE (Preventive and interceptive phase)
  177. 177.  INDICATIONS:  Patients requiring full mouth rehabilitation.  Uncomplicated vital teeth.  Patients in whom sedation is required.  Fractured anterior or bicuspid teeth where esthetics is the concern.  Teeth with accidental/mechanical pulp exposure.  Non vital teeth with sinus tract  Medically compromised patients who require antibiotic prophylaxsis  Physically compromised patients who cannot come to dental clinics frequently  CONTRAINDICATIONS  Patients having severe pain on percussion suffering from acute apical periodontitis.  Teeth with anatomic anomalies for e.g. calcified and curved canals.  Acute alveolar abscess cases with pus discharge.  Patients who are unable to keep mouth open for long duration for e.g. TMJ disorders.  Teeth with limited access.
  178. 178. OLIET'S CRITERIA FOR CASE SELECTION Oliet's criteria for case selection include 1. Positive patient acceptance, 2. Sufficient available time to complete the procedure properly, 3. Absence of acute symptoms requiring drainage via the canal and of persistent continuous flow of exudate or blood, and 4. Absence of anatomical obstacles (calcified canals, fine tortuous canals, bifurcated or accessory canals) and procedural difficulties (ledge formation, blockage, perforations, inadequate fills). Oliet S: Single-visit endodontics: a clinical study, J Endod 9:147,1983.
  179. 179. Final diagnosis is ;like a jigsaw puzzle …..we come to a final diagnosis by bringing together all the collected information's of chief compliant, signs and symptoms.


  • Slow and avoiding
  • Downs syndrome
    Epidermolysis bullosa
    Fanconi syndrome
    Hunters syndrome
    Hurlers syndrome
    Struge weber syndrome
    Turners syndrome
    Trechercollins synd
    Vitamin D resistant rickets
  • Hemifacial microsomia: It is the second most common birth defect after clefts and refers to underdevelopment of one side of the face along with maldevelopment of the ear.
    Ectodermal dysplasia:There is a classical triad of hypodontia, hypohydrosis (diminished sweating )and hypotrichosis (condition of abnormal hair patterns - predominantly loss or reduction).

  • Respiratory sys- mouth breathing
  • Most common in children are hemophilia A and thrombocytopenia. VWD is less common.
    Deficiency of factor VIII- normal – 95-100% , increase in CT

  • WBC- 4,500-10,000 white blood cells per microliter
    PLATELET – 1,50,000 - 400,000 platelets per microliter (
    Absolute neutrophil count -(1,500 to 8,000/mm3).
    Filiform papillae – ant: 2/3 rd ,fine hair like. Fungiform papillae – sparse and scattered, larger round shape , deep red in color . Circumvallate papillae – 8-12 prominent flat mushroom shaped @ junction of ant2/3rd n post 1/3rd .
    Terminal sulcus – shallow groove posterior to circumvallate papillae, separates body from root of tongue.
    Foramen cecum- circular opening in centre of terminal sulcus- remnent of thyroglossal duct.
    Foliate papillae- lateral surface of tongue – leaf like projections – some taste buds.
  • Tongue &sublingual space- size, shape color and movement, desqumation, lingual freenum , tongue habits, swelling on floor

    Adolescence – alcohol consumption
  • candidiasis
  • Shiney and blood vessels are visible.
    Lingual frenum –thin sheet of tissue at midline that attaches undersurface of tongue to floor of the mouth.
    Tongue tie – restricted tongue movements- gingival recession and subsequent periodontal problems.
    Plica fimbriata
  • The term free-tongue is defined as the length of tongue from the insertion of the lingual frenum into the base of the tongue to the tip of the tongue. Clinically acceptable, normal range of free tongue is greater than 16 mm. The ankyloglossia can be classified into 4 classes based on Kotlow's assessment as follows; 2 Class III and IV tongue-tie category should be given special consideration because they severely restrict the tongue's movement. The difficulties in articulation are evident for consonants and sounds like “s, z, t, d, l, j, zh, ch, th, dg”[10] and it is especially difficult to roll an “r”. Localization of the frenum insertion on the gingiva seemed to be of importance for gingival sequelae because insertion of the lingual frenulum in the area of the papilla had the highest association with gingival recession. 
  • r process next to premolars and molars.
    Palatine rughae- palatal tissue elevations just posterior to anterior teeth- 2 imp functions
    Tactile sensation of food
    Proper tongue placement for production of sppech sound.
  • Syatematic observation of entire dentition as a unit
    Stages of dentition- primary
    - mixed
    - permanent
  • Supernumerary teeth are less common in the deciduous dentition with a reported incidence of 0.3–0.6 percent of the population
  • Type I: An enamel-lined minor form occurring within the confines of the crown not extending beyond the cemento-enamel junction.Type II: An enamel-lined form which invades the root but remains confined as a blind sac. It may or may not communicate with the dental pulp. Type III A: A form which penetrates through the root and communicates laterally with the periodontal ligament space through a pseudo-foramen. TYPE III B: A form which penetrates through the root and perforating at the apical area through a pseudoforamen. The invagination may be completely lined by enamel, but frequently cementum will be found lining the invagination.
  • Pit and fissure caries
    Smooth surface caries – early stages incipient lesion – dry tooth
    Interproximal lesion
    Large carious lesion with pain on probing
    Also check for intact margins of restorations , fractured restorations
  • Checked by attempting to move the tooth with 2 rigid instruments, mouth mirror handles.
    In pediatric cases – preshedding mobility , due to abscess.
  • A child should be exposed to dental ionizing radia-tion only after the dentist has determined the radio-graphic
    requirement, if any, to make an adequate diagnosis for the individual child at the time of the appointment
  • FILM SIZES- SIZE 0 – 22*35mm, size 1 – 24*40 mm, size 2 – 31*41mm,size 3 – 27*54mm
  • FOTI- decayed tooth lower index of light transmission- darkened shadow.
    DIFOTI- captured by camera.
    DIAGNOdent – fluoresent light- carious lesion absorbs and emit light of higher spectra than non carious lesion.
  • Should only be used to assess the vital or non vital pulp as they do not quantify the disease nor do they measure the health .
  • Non invasive electro optical technique
    Detect viscosity of red blood cells
    First used by Gazelius et al in 1986
    Uses a Laser beam of known wave length directed through the crown of the tooth to the blood vessels within pulp.
    The moving red cells causes the laser beam to be Doppler shifted and scattered back.
    This beam is detected by photo cell on the tooth surface which is proportional to number and velocity of R.B.C

  • a noninvasive oxygen saturation monitoring device widely used in medical practice for recording blood oxygen saturation levels during the administration of intravenous anesthesia. T
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