Essentials of Pedodontics T.N. Tilakraj
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Clinical Examination of Mouth and Associated StructuresCHAPTER 1

Successful dentistry for children depends not only upon the dentists technical skill but also upon his ability to acquire and maintain a child's cooperation. The initial visit for the pedodontic patient is critical from both a diagnostic and behavior standpoint. It should be the beginning of a pleasant relationship between the dentist and the patient. One that can lead to the patients desiring and learning to achieve optimal dental health.
The stage for this first appointment should actually be set when the parent calls the office to make the first appointment for the child. The conversation should be pleasant and informative. Information obtained at this time from the parent can be very helpful when seeing the child on the first appointment. Information obtained from the parents can make the first appointment for the child, the parents and the dental staff more comfortable and less threatening. A form can be placed next to the appointment phone to serve as a helpful reminder for the type of information needed from the parent as well as the type to be given to the parent concerning office matters. If sufficient time is available between the initial phone call and the scheduled appointment, additional information can be sent to the parent about the dental office and future treatment.
When the child arrives for the first appointment, a thorough history and examination should be completed. This will assist in a definite diagnosis and allow for logical preventive and treatment objectives to be developed with the parent and the child.
A systematic approach to examination, diagnosis and treatment planning can be done, but it is not advised. Such an approach doesn't lend itself to the meaningful interpersonal relationships between patient and doctor that are necessary in a successful private practice. Therefore, the following outline serves only as a guide for the type of information that should be obtained.
 
INTERVIEW
The interview should be a fact-finding session.
  1. Obtain statistical information.
    1. Date
    2. Name (also get child's nickname)
    3. Sex
    4. Age and birth date
    5. 2Address
    6. Phone number
    7. Parent's name
    8. Child's primary physician
  2. Obtain written consent and other legal documents necessary to provide dental treatment.
    1. Treatment consent—parental consent for dental treatment is necessary when a child is under legal age and should be obtained in accordance with the local law.
    2. Photographs for patient records and publication – may be indicated for several reasons:
      1. Instant recall of patient when photograph is attached to record – especially helpful when discussing patients dental treatment when patient is not present as well as giving visual record of patient before an appointment.
      2. Record of preoperative appearance of patient when an alteration is expected following treatment—especially important in the areas of orthodontics, periodontics, prosthodontics, and oral surgery.
      3. Specific consent from parent to publish photograph of child in a journal or book – best if obtained prior to treatment.
    3. Any other data such as graphs or charts that may be desired for patient documentation.
  3. Determine reason for child's appointment (what is primary concern)
    1. Routine dental examination
    2. Emergency appointment
      1. Traumatic injury
      2. Pain
      3. Swelling or enlargement (soft or firm?)
      4. Inflammation (intraoral sores or ulcers?)
      5. Intraoral bleeding
      6. Chewing difficulty
        NOTE: When the appointment is for emergency treatment, take a short history adequate to cover the emergency situation, then treat the emergency as atraumatically as possible. Reschedule the patient for follow-up care as needed.
    3. Consultation
      1. Occlusion problems (maligned teeth, overbite, overjet, open bite, crossbite, and so on)
      2. Bruxism (or temporomandibular joint problems)
      3. Malformed discolored, or congenitally missing teeth
  4. Review patient's dental and medical history
    1. Dental history
      1. Any previous preventive experience
        1. Home care instructions
        2. Fluoride treatments
        3. Instructional information
      2. 3Any previous dental problems
        1. Disease (dental caries, periodontal disease, pulpal involvement)
        2. Any traumatic injuries to face and teeth
        3. Any prior dental surgery
        4. Any known occlusion problems (abnormal growth and development, missing teeth, habits, and so on)
        5. Any discrepancy between chronological and dental age.
    2. Medical history
      1. Present health status
      2. Childhood illness and hospitalization.
      3. Congenital-hereditary interactions.
      4. Prior surgical experience (type of surgery)
      5. Medication and therapeutic precautions
      6. Allergies and immunopathies
      7. Idiopathic reactions
      8. Behavioral-learning experiences.
It is important to update the medical history on the child periodically. Sometimes even between recall visits a child may develop a significant medical problem. This should be noted in the record.
 
EXAMINATION
Begin observation of the patient from the first moment of the appointment. Continue unobtrusive observations systematically. Record this information in the patient's record.
Table 1.1   General physical examination
Type of observations
Examples of abnormalities
State of health
Acute pain, chronic pain, illness
Stature
Discrepancy in length of extremities, obese, thin, frail, short
Motor activity
Slowed in depression, tremor, paralysis, altered gait
Skin appearance
Pallor, jaundice, pigmentation, eruptions, elevated temperature
Speech, hearing and sight
Fast speech, dysphasia, conductive or sensory hearing loss, nystagmus, comprehension
State of awareness
Uncooperative or uncommunicative state
Vital signs
  1. Blood pressure
  2. Pulse
  3. Respiration
  4. Temperature
Baseline for determining deviations, for example, body temperature rises with infection, creating a greater demand for oxygen; also difficulty in breathing, facial form or expression, fidgety movements, and moist skin may be signs of anxiety, pain or distress
Personal hygiene
Odors, systemic disease
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PHYSICAL EXAMINATION WITH EMPHASIS ON THE HEAD AND NECK
Cranium: Observe size, shape, hair pattern and type
Face: Observe features, color, skin-muscle tone, symmetry, skin excoriations, pigmentations
Neck: Observe symmetry, any enlargements, salivary glands, thyroid gland, vascular structures, and then palpate nodes.
Eyes: Observe periorbital structures, movement, surface, deviations.
Nose: Observe size, location, and relation to other structures
Temporomandibular joint: Observe degree and deviation of opening, palpate for tenderness, and listen for abnormal sounds when opening and closing mouth.
 
Intraoral Examination
Observe and record any abnormal, diseased, congenital, hereditary, or altered structures.
Buccal mucosa: Observe color, elevations, depressions, salivary ducts
Vestibule: Observe frenula and depth of vestibule
Alveolar ridges: Observe size, clefting, contour.
Palate: Observe size, arch, firmness (high, low, asymmetric) clefts, uvula (length, shape)
Gingiva: Observe inflammation, enlargements, ulcerations, swelling, recessions
Pharynx: Observe swelling, enlargement, tonsilar crypts, lymphoid tissue
Lips: Observe color, fissures, pits, clefts, posture
Teeth: Observe number size, anatomy, stage of development and eruption, malocclusion, mobility, accumulation (pellicle, plaque, calculus, and so on)
Saliva and salivary glands: Observe saliva consistency, palpate salivary glands, examine minor salivary glands
Floor of mouth: Observe color, elevations, salivary ducts
Bone structures: Observe tori, micrognathia, macrognathia, defects
Tongue: Observe size, mobility, swelling, fissuring, clefting.
 
EXAMINATION OF YOUNG CHILD
It has been reported that the average 2-year-old child has two carious lesions and in fact caries can develop as early as the nursing years. Therefore, if the dental disease is to be prevented the child must be examined early in life.
First dental examination before the first birthday is recommended.
An examination of the infant at this age enables the dentist to evaluate the mouth and to determine if any variations from normal exists. When major abnormalities are 5present that will require treatment at a later time, the parent can be informed and reassured. This may be helpful in preventing unnecessary anxiety for them. The importance of preventive dentistry and early treatment concepts can also be reinforced at this time.
Examination of the young child is accomplished as follows in Figure 1.1).
zoom view
Fig. 1.1: Position of dentist, parent, and child during examination of very young child
 
Position of Dentist, Parent or Assistant and the Child
  1. Use two straight back chairs
  2. Dentist or auxiliary and parent sit facing one another
  3. Parents holds young child, facing child, with child's legs straddled around parents waist.
  4. Child's head is lowered back onto dentist's lap for examination.
  5. Parent holds child's hand and controls child's legs with elbows.
  6. Dentist can separate his legs slightly to cradle head of resistant child.
  7. Perform a detailed examination of child as outlined earlier in this chapter.
NOTE: Positioning the parent in this approach allows the parent to be in an ideal position to observe examination of the child. Home care instructions can be given. Also the parent and dentist can reverse positions, allowing the parent to perform the oral hygiene under the dentists supervision.
 
Supplemental Diagnostic Data
  1. Diagnostic casts to study arch dentition discrepancies, cleft palate, or other aberrations of dental development.
  2. Profile records such as lateral cephalometric radiographs, photographs, or moulage to study congenital anomalies and orthodontic problems.
  3. Pulp tests to determine vitality of any teeth in question
  4. Oral hygiene index
  5. Salivary tests:
    1. pH determination using litmus paper.
    2. Caries activity tests – modified synder test.
  6. 6Special laboratory tests for oral tissue
    1. Exfoliative cytology
    2. Biopsy.
  7. Clinical pathology tests (may be indicated when there is suspicion of systemic problems. They should be completed by or coordinated with patients primary physician. Significant variations from normal should be carefully studied, and the treatment plan altered accordingly. Coordinate treatment through the patient's physician):
    1. Complete blood count.
    2. Hemoglobin and hematocrit.
    3. Blood culture.
    4. Partial thromboplastin.
    5. Platelet count.
    6. Urinalysis.
 
Diagnosis
 
Correlation of Data
After the data-gathering interview, examination, and necessary special tests are completed, the information obtained should be assembled and studied to determine an accurate diagnosis. Only after proper diagnosis can a logical treatment plan be established for the child.
 
Consultation
When the child is suspected of having a medical problem, the primary physician should be consulted prior to any dental treatment. Describe the treatment plan for the patient to the physician to coordinate treatment through him. Dental consultations may also be needed and should be done in the same fashion.
NOTE: Always write the consultation note in the patients chart along with any pertinent orders.
 
Treatment Plan
When all the information has been obtained and assembled concerning the patient and diagnosis is confirmed, treatment can then be planned in a logical manner. Some suggestions to consider when planning treatment follow.
 
Amount of Dental Disease Present
If several teeth are pulpally involved, then they should logically receive treatment priority. This may prevent further destruction of the child's teeth and allow the dentist more time to complete the comprehensive dental treatment needed. On the other hand, if caries are minimal and periodontal problems are exaggerated, the periodontium should be treated first.
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Behavior of Patient
When a child is fearful of the dental situation it is best to gradually introduce the different procedures. Therefore, it may be better to perform a simple procedure at first until the child's confidence is gained. Also try to make the child's last restorative appointment as easy as possible. This appears to lessen anxiety prior to placing the child on the first recall appointment and makes the return easier. After a couple of routine checkups with only cleaning and fluoride treatments the child may become more relaxed.
 
Finances
Treatment planning modifications may also be indicated when parents express financial difficulties. People who are financially depressed may also become emotionally depressed as the financial burden increases. A treatment plan alternative may give them some relief and at same time help the child. Sedative dressings can be placed in the involved teeth, which will help control the dental caries process and allow more time to accomplish treatment.
NOTE: Always write the treatment plan in the chart and have the patient's sign, accepting the plan. This may avoid considerable confusion as treatment progresses.
 
Progress Notes
Accurate records concerning the progress of treatment are also important. Although the plan of treatment is determined for convenience and orderly progression, it cannot be adhered to at all times. Progress notes provide a means of keeping a record of treatment as it is provided. It may also serve to identify other aspects, such as behavior of the patient on a particular appointment, amount of analgesia needed if it is used, amount of anesthetic needed for satisfactory anesthesia or any other data deemed important.
BIBLIOGRAPHY
  1. Avery DR: Integrated dental treatment in children: diagnosis. Quintessence Int 2:59-62, 1980.
  1. Moskow BS, Barr CE: Examination of the patient. In Goldman HM and others (Eds): Current Therapy in Dentistry, CV Mosby Co.,  St. Louis:  Vol.4: 1970.
  1. OepFerd SJ: Infant oral health: A rationale. J Dent Child 534:257-60, 1986.
  1. Shaq O: Dental anxiety in children. Br Dent J 18a: 134-39, 1975.
  1. Weddell JA, Klein AI: Socio-economic correlation or oral disease in six to thirty-six month children, Pediatr Dent 3:306-10, 1981.