Physical and oral assessment for the child dental patient

Study objectives

• List the important areas to be assessed in evaluating the health of the child dental patient.

• Identify significant sections of the clerking sheet used in the paediatric dentistry clinic.

• List components of an extra-oral and intra-oral evaluation of the head and neck in children.

Introduction

• It takes many months to become familiar with the

routine questions that must be asked when clerking a patient.

• To be able to make sense out of all the responses your questions generate from the patient, you need to continuously update your knowledge of medicine and dentistry throughout your medical career.

Introduction - 2

• The main reason for oral, physical and radiographic assessment of patients is to identify problems, its cause and then remove and prevent future recurrence.

• Before you make contact with the patients you need to know: o What danger the patient can be to your health?

o What danger you can be to the patient’s health?

Introduction - 3

The patient may have transmissible diseases and so you need to protect yourself by:

o Taking vaccination against hepatitis B

o Observing universal precautions to protect yourself against those diseases that you cannot be immunised against eg hepatitis C and HIV infection.

Introduction - 4

The health of the patient may be at risk from dental procedures either:

o Directly from drug interactions.

o Indirectly from complications arising from disease conditions.

Introduction - 5

• It is important that the information you generate is written out in clear logical manner.

• This is important as the patient may need to be seen by different clinicians. Your clerking notes therefore need to make sense to everyone that reads it.

Introduction - 6

• It is also important to note that your generated NEGATIVE responses are equally as important as your POSITIVE responses.

• Note the response to your questions on your clerking sheet. These notes may save you from future litigations.

Classification of the child

• Infant: 15 months and below

• Toddlers: 15 – 24 months

• Preschool: 2 – 6 years

• Middle year child: 6 – 12 years

• Adolescents: 12 – 19 years

History

Introductory statement

• Your introductory statement should give a summary of the patient’s data (name, age, gender, occupation and residence), the chief complaint(s) and duration of the problem in patient’s own words.

• Each component of the biodata is important in diagnosis and treatment planning.

History of presenting compliant

• Information generated in this section is important. the greater percentage of data to support the diagnosis is found in this section of the history.

• The information should be listed chronologically: start with the initial symptoms and the subsequent symptoms.

History of presenting compliant - 2

• This section often contain lot of important details • The details are important as they help you to start

thinking through the possible diagnosis. • The details should be written CONCISELY, PRECISELY

and ORDERLY.

History of presenting compliant - 3

• Always explore a history of pain o Ask if absent or present

o Nature (dull, sharp)

o Aggravating factor(s)

o Relieving factor(s)

o Recurrent in nature or not

History of presenting compliant - 4

• Ask about any associated bleeding, mobility of drifting of teeth, swelling (duration, where and when, changes in size), halitosis, altered taste (salty or bloody).

Medical history

This is divided into three sections:

• Active medical problems and past medical history

• Specific disease questions

• Systemic enquiry

Medical history - 2

• Before taking the medical history, it is good to

explain to the patient and patient’s guardian exactly what you are about to and why the information is relevant to dental treatment.

• It is YOUR responsibility to find out ALL necessary information that are critical to the successful management of your patient.

Active medical history

• This section generates the core information needed

in the medical history. A quick review of this section should reveal MOST of the relevant medical problems of the patient

Active medical history - 2

• Questions asked include: o Do you have any problem with your health (what

are they)? o Are you attending any hospital or clinic

presently? o Did you have any serious illness in the past (what

and when? What was the outcome?)

Past Medical History

• Have you been admitted in the hospital in the past (what for)?

• Have you had an operation in the past? (what for, when and where? Any associated complications or disability?)

Medication history

• Always note the name, dose and route of administration and frequency of any medication the patient is using. The generic name of the drug should be noted in the case note.

Medication history - 2

• Important questions include: o Are you currently taking any medicines, tablets,

creams, liquids prescribed by the doctor (what for?)

o Are you currently taking any medicines, tablets, creams, liquids or herbal remedies prescribed by someone else (what for?)

Allergy history

This section of the history elicits information that enables you as a dentist to be carefully decide on the choice of medication for the patient when writing prescriptions or using dental products.

Allergy history - 2

You need to ask the patient the following question: • Are you allergic to anything? (what reaction do you

have?)

• Have you ever reacted badly to any medication taken (what effect did it have)?

• Are you allergic to penicillin (what effect does it have)?

Allergy history - 3

• Have you had a bad reaction during dental treatment (to what and what was the effect).

• Note anything the patient claims to react too and note the reactions it produces.

• Many patients may think they react to some medications but these are not true allergy. As a general rule, avoid prescribing such a medication.

Immunisation history

• This is important for the infants and toddlers. It is important that a record of immunisation is obtained from the patient (read up the immunisation dates).

• Measles is a very significant disease in dentistry as there are oral manifestations (Koplik spots) and also a predisposing factor for ANUG.

Specific disease questions

• In this section, you ask patients questions about specific diseases that are relevant to dentistry. Note the response in the patients case note.

Specific disease questions - 2

Questions to be asked include eliciting information about:

o Jaundice

o Rheumatic fever

o Hypertension

o Diabetes

o Thyroid problem

o Epilepsy

o Problems with blood clotting, easy bruising, prolonged bleeding after injury

Systemic review

• This is an opportunity to ask the patient questions

about any problem related to the body systems. It is used as a way of prompting the patient to remember medical problems that they have not disclosed.

Systemic review - 2

• Five systems are evaluated namely:

o Cardiovascular o Respiratory o Gastrointestinal o Urological o Musculoskeletal

Cardiovascular

Ask the following questions:

• Have you had any heart trouble (what and what treatment did you receive)?

• Do you get breathless on exertion (when walking up the stairs)?

Respiratory

Ask the following questions: • Do you have any chest problem (what problem)? • Do you smoke (how many sticks per day, how long

have you being smoking)? • Do you have asthma (how long, current treatment.

Hospital admissions)? • Do you have persistent cough (how long, any sputum

produced, what colour)?

Gastrointestinal

Ask the following questions:

• Any recurrent mouth ulcers (how often, where)? • Do you have problems with swallowing (what? For

how long?) • Do you have problem with abdominal pains,

constipation, diarrhoea? • Is your weight changing (how much, over what

period)? • How much alcohol do you drink in a week?

Urology

Ask the following questions:

• Do you have kidney problem (what, treatment)?

• Do you have difficulty passing urine (how long, treatment)?

• How frequently do you pass urine?

Urology - 2

For a female, it is important to note information about

menstrual cycle:

• Age of onset of menstruation

• Cycle duration – regular or irregular

• Menstrual blood loss – heavy/normal

• Inter –menstrual bleeding

Musculoskeletal

Ask the following questions: • Any skin problem? • Do you use any ointments, creams or lotion on your

skin (what, how long, prescribed?) • Do you have rashes or persistent itching of the skin

(where, how long)? • Any bone or muscle problem? • Any skin problems in the family?

Systemic review

• Note all positive responses.

• For each system reviewed and no anomaly was detected, please note ‘no abnormality detected’.

• It is important to note the specific systems reviewed.

Past dental history

Ask the following questions: • Have you been visited a dental clinic in the past? • Have you had dental treatment in the past? • Have you had any unfavourable reaction to dental

treatment? • Any reaction to local anaesthesia?

Past dental history - 2

Other questions would include: • Use of fluoridated toothpaste • Frequency of toothbrushing • Frequency of refined carbohydrate intake • History of gum bleeding • History of head, facial or dental injury

Family and social history

• The family and social history can elicit information about domestic distress a patient might be going through which may contribute to facial pain and oral ulcers.

• The social history would also help you plan appropriately for dental treatment.

Family history

• The family history covers problems that are hereditary.

• Record all known significant diseases and cause of deaths in the first degree relatives eg diabetes, hypertension, epilepsy, allergies, blood dyscrasia.

• Ask: are there illnesses that run in the family?

Social history

• This section is important as it generates information

about the patient’s environment which may be significant in deciding about patient’s management options.

• Ask the following questions: o Where do you stay? o What is your occupation?

Social history - 2

• For youths, you may want to know how many siblings (s)he has, position in the family and the health of other siblings.

• Ask questions about oral habits as this also has implications for dental care and management eg digit sucking.

Physical examination

• All positive and pertinent negative findings should be recorded. The following are important: o Vital signs (body temperature, pulse and respiratory

rates, blood pressure).

o General appearance (any deformities, gait, respiratory distress or pain, hydration, general nutritional status, mental status - level of consciousness, speech [a pointer to neurological or muscle disease]).

Physical examination – 2

Check the following:

• Weight – catexia in TB, AIDS, malignancy, anorexia

• Hair – alopecia following head and neck radiation or chemotherapy, scanty and thin hair in malnutrition

• Head - abnormal facies, facial symmetry.

Physical examination – 3

• Face – swollen in renal diseases; hyperpigmentation

in Addison’s disease; deviation of facial muscles in facial palsy; butterfly rash in SLE.

Physical examination – 4

• Hands – finger clubbing in cardiovascular diseases;

spincter haemorrhage in infective endocarditis; muscle contracture in cerebral palsy. Examine for rate of nail bed capillary refill to rule out anaemia.

Physical examination – 5

• Eyes – check for ptosis, sclera colour (sclera appears blue in osteogenesis imperfecta and yellow with jaundice). Check conjunctiva for pallor in anaemia, or for heamorrhage associated with zygomatic fractures. Check for strabismus.

Physical examination – 6

• Salivary glands – glands may be swollen when there is mumps, viral or bacterial infection (sialadenitis).

• Lymph node – check if lymph nodes are plapable. If palpable, check for size, texture, location, number, consistency, tenderness.

Physical examination – 7

• Lip – check for lip colour, dryness, appearance of the

commissure (angular stomatitis in anaemia, HIV, candidiasis). Lip may be swollen in Chronn’s disease. Also check for lip competency.

Physical examination – 8

• Jaw relationship – assess the anterior posterior, transverse and vertical relationships. Rule out jaw enlargement as seen in acromegaly, or micrognathia as seen in Pierre Robinson syndrome.

Physical Examination - 9

• There may be the need to do some other physical examinations when you suspect the possibility co-existence of possible physical abnormalities with dental anomalies.

• Do a physical examination on a couch with the patient lying down and only duly exposed. Examine the patient with an assistant present. This is important for litigation purposes.

Extra oral examination

• Function of the TMJ: opening and closing; any jaw

deviation during jaw movement; any sounds during jaw movement; any limitation of mouth opening.

• Muscle and nerve functions: check for the function of the motor and sensory nerves that supply the face.

Intra oral examination

• Soft tissue assessment – examine the oral mucosa, cheeks, lip, tongue, palate, tonsils (size and appearance), floor of the mouth, vestibules. Check if there are ulcers, vessicles, colour changes, swelling, sinus.

Intra oral examination - 2

• Periodontium – check for the colour. Rule out hypertrophy of the gingiva, bleeding, and gingiva recession. Check if there are any pockets.

Intra oral examination - 3

• Teeth – check and rule out anomaly in the number,

shape, size, structure, colour. Also check for tooth mobility. Look out for any carious lesion on the tooth, tooth restorations, attrition.

Intra oral examination - 4

• Oral hygiene – use the oral hygiene index to assess

for oral hygiene status. A quick assessment could be done using this assessment: Good (barely detectable plaque collection), fair and poor (calculus/plaque found on self cleansing tooth surfaces).

Differential diagnosis

• Make a differential diagnosis after you have completed the history taking and examinations.

• Limit your differentials diagnosis to four or five probable diagnosis that can be supported with your history and clinical findings.

Differential diagnosis - 2

• When you make your provisional diagnosis, address everything that is wrong with the patient and NOT just what the patient complains about.

Investigations

• The specific investigations needed would vary with your provision diagnosis. The purpose of your investigation is to rule out or rule in the various provisional diagnoses made – it helps you to objectively assess the lesion.

Investigations - 2

• This may include requesting for intra oral and extra

oral radiographs, full mouth xray using the long cone paralleing technique, chest xrays, laboratory investigations, biopsies, pulp sensibility tests.

• Please always note the results of the investigations in the case notes.

Definitive diagnosis

• This depends on the pertinent information generated from your history and clinical examination and confirmed by the results of your investigation.

• The results of your investigations also helps to rule out other differential diagnosis.

• Multiple diagnosis can also be made in a patient.

Treatment planning

• Draw up a treatment plan for the patient based on

your definitive diagnosis. • Your treatment plan should be the IDEAL thing that

should be done for the patient if all things were equal.

Treatment planning - 2

• Your treatment plan should aim at: o Eliminating disease (managing signs and

symptoms and removing aetiological factors) o Restoring function o Maintaining aesthetics o Ensuring patient satisfaction (this is determined

by patient’s age, health, attitude and aspirations).

Treatment planning - 3

• When you chart your treatment please use acceptable conventions. Use globally accepted charts.

o Primary teeth should be chart as ABCDE

o Permanent teeth should be chart as 12345678

o RCT – root canal therapy

o # - fracture

o Inv – investigation

Treatment

Specific treatment could vary from your treatment plan due to the following:

• Costs

• Availability of materials

• Availability of competent personnel

• Time available to implement treatment

Treatment sequencing

First appointment • Alleviate pain • Start with the least difficult procedure • Always consult when there is a need too

Subsequent visits • Plan sextant dentistry • No bilateral block • Take into account length of appointment

Treatment sequencing - 2

Last visit • Polish all restoration • Apply pit and fissure sealants where indicated. • Recall the patient (once a year for low caries risk

patients, every six months for patients with moderate risk and every 3-4 months for those with high risk for caries).

Philosophy for patient management

• Never guarantee a patient that you would finish

treatment in a certain appointment. • Never guarantee what treatment would be done

next. • Discuss with the patient why the need for treatment

(cause and consequences).

Philosophy for patient management - 2

• Let the patient ask questions.

• Give the patient the opportunity of choosing/taking part in the decision of treatment option. It increases the patient’s responsibility of their individual health.

Philosophy for patient management - 3

• Discuss with the patient at the end of each appointment what has been accomplished.

• Always recall a patient so as to reassess and reinforce instructions.

How much information

Full history • For a new patient attending the clinic for the first

time, you would require ALL the medical information above. Though it may be cumbersome, it is safe!

• When the patient has not attended the clinic in the last one year, take a new comprehensive history.

• When the previous history was not comprehensive.

How much information - 2

Abbreviated history

• When the patient has attended the clinic within the last six months and had a COMPREHENSIVE history previously taken.

• The information required are the medical history, current medication and allergies.

• While taking this history, if you note any significant changes since the last comprehensive history, proceed to take a full history.

How much information - 3

Short history

• This is ONLY taken when the patient is attending clinic for PLANNED routine treatment and the patient had a comprehensive and current full or abbreviated medical history.

• The information collect include history of health problems since last visits or changes in medications.

• If the treatment span more than six months, then take an abbreviated history after six months.

Quiz 1

The order of taking a history for a toddler is:

A. History of presenting complaint, medical history, family and social history, immunisation history, drug history

B. History of presenting complaint, medical history, immunisation history, family and social history

C. Presenting complaint, history of presenting complaint, medical history, immunisation history past dental history

Quiz 2

The aim of your treatment plan is to:

A. Eliminate disease, restore function, maintain aesthetics

B. Eliminate signs and symptoms, restore function, maintain aesthetics

C. Eliminate disease, restore function, maintain aesthetics, ensure patient satisfaction

Quiz 3

When implementing treatment:

A. Treat the patient based on the quadrant

B. Ensure pain is eliminated on the first dental visit

C. Recall all patients once a year

D. Avoid bilateral mandibular infiltration.

Acknowledgement

• Slides were developed by Morenike Ukpong, Associate

Professor in the Department of Paediatric Dentistry, Obafemi Awolowo University, Ile-Ife, Nigeria.

• The slides was developed and updated from multiple materials over the years. We have lost track of the various references used for the development of the slides

• We hereby acknowledge that many of the materials are not primary quotes of the group.

• We also acknowledge all those that were involved with the review of the slides.