Dental Charting & Notation

MawiaBatayneh
Saleh Mutlaq
7 7 2015
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Some notes :
.All slides are included & bolded
.The exam will be held on 21-7-2015 , three lectures are included in it

Pediatric dentistry : is the section of dentistry that deals with pediatric patients
The first dental examination should follow the eruption of the first primary tooth and
no later than 12 months of age.
Usually the first dental visit for pediatric patient should be once the first tooth is erupted in
his/her mouth . And usually it will be between 6th 7th months , it should not be after the
12th month .
Significance of the first dental visit :
For child :
Introduce the child to the dental environment
establish communication with the child by directing the questions to them when
possible
to desensitize (make less sensitive) the child to the fearful procedure by starting with
simple ones
Motivation for the child by developing a positive attitude to dental care.

For parents :
establish good relation with the parent
Emotional support of the patient.
Higher success rate when involving the parents. Recent studies has shown that when
the parents are involved in the treatment of the child, the successful rate will be high.
For the dentist :
To diagnose and make treatment plan best for the patient

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 Component of history taking :
Chief Compliant: it is the reason of attendance to the clinic (routine checkups, referral,
and toothache, pain, swelling and aesthetic).
History of Chief Compliant: If the chief compliant was pain , then you should know
these information about this pain; location, onset, duration, nature, frequency,
aggravating factors, relieving factors, awake from sleep, day or night, severity,
radiation to other parts, temperature?
Medical history ; systemic review
You should make a systematic evaluation for the patients medical history, so you will ask a
question by question about each system in the body, like:
CVS; congenital heart disease, risk of bacterial endocarditis
Respiratory; asthma, hay fever, infections
Hematological; anemia, bleeding, bruising
Gastrointestinal; hepatitis, jaundice
Endocrine; diabetes
CNS; epilepsy, mental and physical handicap
Uroginital; renal disease
Skin; thin, fragile

Also, you should check these things:

Immunization
Medication
Hospitalization; age, cause of admission, if he had an operation, if he took GA
(general anesthesia), blood transfusion
Allergies; Mainly in dentistry we check the allergy for latex (rubber material) specially
if this is the first visit of the patient.

Also, you should check the Birth details:

Prenatal, neonatal and perinatal / postnatal periods:

Prenatal; Neonatal; Perinatal/postnatal

Mum health during Birth weight, Bottle or breast
pregnancy birth height fed, bottle content
Any complications, Birth defect,
Immunization
trauma, infection, drugs jaundice, Rhesus
taken incompatibility, Childhood illnesses
Gestational age any need for
(premature birth) special medical
Delivery (O2 deprivation) care 2
And you should check the:
Growth ; Height, weight, growth charts
Family history

Dental history
Previous dental visits, dental checkups, treatment, LA
Brushing history; age of start, frequency, type of toothpaste
Fluoride history; water, mouth rinse, tablets
Additional oral hygiene measures
Oral habits
Diet history; diet sheet

Social history ;Address, live with parent, siblings, school, friends, SES (socioeconomic status)

Behavior; Good, moderate, poor

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EXAMINATION
Importance of Examination :
To introduce the child to a simple treatment procedures
To obtain information for diagnosis and treatment plan
To explain treatment needs to the child and parents

First impressions
An initial impression of the child's overall health and development can be gained as soon
as he or she is greeted in the waiting room or enters the surgery.
In particular, it is useful to note:
General Health/ does the child looks well?
Overall physical and mental development/ does it seem appropriate for the child's
chronological age?
Weight/ is the child grossly under- or overweight?
Co-ordination/ does the child have an abnormal gait or obvious motor impairment?
Attention to the patients 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 dentist may first detect an elevated temperature by holding the patients hand.
Cold, clammy hands or bitten fingernails may be the first indication of abnormal
anxiety in the child.
A callused or unusually clean digit suggest
Persistent sucking habit.

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 Clubbing of the fingers or a bluish color in the
nail beds suggest congenital heart disease that
may require special precautions
during dental treatment.

Variation in the 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

While the history is being taken, the clinician should also be making an 'unofficial
assessment of the child's likely level of co-operation in order that the most
appropriate approach for the examination can be adopted. So We can assess the
patients behavior and cooperation while we are asking questions during history taking .

prospective young patients may fall into one of the following categories:

Happy and confident this child is likely to hop into the chair for a check-up without
further coaxing.
A little anxious or shy but displaying some rapport with the dental team this child
will probably allow an examination after some simple acclimatization and
reassurance (if the child is very young, the option of sitting on the mother's knee
could be given).
Very frightened, crying, clutching their parent, avoiding eye contact, or not
responding to direct questions this child is unlikely to accept a conventional
examination at this visit (though the child may allow a brief examination while sitting
on a non-dental chair, perhaps even in the waiting room); further acclimatization will
be required before a thorough examination can be undertaken.

Severe behavioral problem or learning disability in a few cases, this may preclude
the child from ever voluntarily accepting an examination; restraint (with or without
pharmacological management) may be indicated to facilitate an intraoral
examination .in this case we might need to use sedation or general anesthesia in order
to be able to examine the patient .

Techniques of examination of children :

Depend on patient age and behavior:
For infant and toddlers (less than 2 years old):
the dentist and the parent are seated face to face with their
knees touching (knee-to-knee position). Their upper legs form
the examination table for the child . The childs legs straddle
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the parents body, which allow the parent to restrain the
child legs and hands.

For young children (2-6 years old):

The parents sit in the dental chair and the child lies across
her or his lap. The childs head positioned in the parents arms.

For older children (>6 years old)

Child sit on the dental chair.

Examination under sedation or GA , as we said we use this when we have a child

with Severe behavioral problem or disability :

Extra oral examination :

1. General examination
Before carrying out a detailed examination of the craniofacial structures, a more general
physical assessment should be undertaken. Valuable information about a child's overall
health, development, or even habits can often be determined by noting:
Heightis the child very tall or very small for their age? In a few cases, it may be
appropriate to take an accurate height measurement and plot data on a standard
growth chart.
Weightcould there be an underlying eating disorder? Is general anesthesia
contraindicated due to the child's obesity? Is there an underlying endocrine
problem?
After we had these measurements, we compare it with the standard growth chart, and see
where the patient lie on the growth chart (look at the pictures below).
Skinlook for any notable bruising or injury on exposed arms or legs.
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 Handsassess for evidence of digit sucking or nail biting, warts, finger clubbing,
abnormal nail, or finger morphology.

*Most of the children will be

between 25 and 75 percentiles
*If the patient lie below or more
than that, this means he needs a
medical intervention

2. The head and neck

During the examination of the head and neck, the following structures should be briefly
assessed:
Headnote size, shape (abnormalities may be seen in certain syndromes), and any
facial asymmetry.
Hairnote if sparse, quality and quantity
Eyesis there any visual impairment or abnormality of the sclera?
Earsrecord any abnormal morphology or presence of hearing aids.
Skindocument any scars, bruising, lacerations, pallor, birthmarks and be
aware of contagious infections, such as impetigo ( : ).
Temporomandibular jointis there any pain, crepitus, deviation, or restricted
opening.
Muscle of mastication must also be examined.
Lymph nodespalpate for enlarged submandibular or cervical lymph nodes (bear in
mind that lymphadenopathy is not uncommon in children, due to frequent viral
infections).
Lipsnote the presence of cold sores, swelling, or abnormal coloring

Any positive findings should be recorded carefully. Clinical photographs or annotated

sketches may be very helpful for future reference, particularly with respect to medico-
legal purposes, or in cases of suspected child physical abuse.
When the child presents with a specific problem, such as a facial swelling, a more
thorough examination of the presenting condition is needed.

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 3. Facial examination
Usually we do facial examination as part of orthodontic evaluation .
We can do the evaluation in three spatial planes: anterioposterior, vertical, and transverse.
Anterio-posterior-relation includes :
Description of the overall facial pattern, the position of the maxilla and mandible,
and the vertical facial relationship.
The position of the lips (competent or incompetent). Facial symmetry and maxillary
dental midline is located relative to the facial midline.

Facial profile can be examined by drawing

Line connecting:
Midpoint between eyebrows + Base of the nose +
Lowest point of the chin
Facial profile classify into:
straight profile : in patient with class I occlusion
convex profile with retrognathic mandible and\or protracted maxilla with class II
malocclusion
concave profile with retrognathic maxilla and\or protracted mandible with class III
malocclusion

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Vertical relation
Vertical component of the facial profile
should be evaluated for the steepness
of The mandibular angle (angle between
Frankfort and mandibular plane ).
A large mandibular angle indicates a long
lower face height, while small angle
indicate short lower face height.

Usually the face is divided into three

thirds, they should be the same.
Depending on the mandibular angle,
we can say that the patient has a long
or short lower face height.
In case of short lower face height, the
patient will have deep anterior bite.
In case of long lower face height, the
patient will have open anterior bite.

Transverse relation
Refers to the presence of cross-bite and evident as a deviation in the mandible in some
cases.

4. Assessment of speech
Assess the ability to talk and pronounce letters properly, no marked lisp .
Especially in patients withClift, down syndrome, mentally retarded and deaf
patients.

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 Intraoral examination
A systematic approach should be adopted for the intraoral examination in order not to
miss anything. The following is a suggested order for examination:
Soft Tissues
Gingival And Periodontal Tissues
Teeth
Occlusion.

Now well talk about each one in details :

Soft tissues
An abnormal appearance of the oral soft tissues may be indicative of an underlying
systemic disease or nutritional deficiency.
In addition, a variety of oral pathologies may be seen in children. It is therefore
important to carefully examine the tongue, palate, throat, and cheeks, noting any
color changes, ulceration, swelling, or other pathology.
It is also sensible to check for abnormal frenal attachment or tongue-tie, which may
have functional implications (speech, chewing and eating).
An overall impression of salivary flow rate and consistency should also be gained.

Tongue ulcers Lip swelling Tongue tie

The presence of abscess

or sinus tract indicates
that the adjacent tooth
is non vital

Gingival and periodontal tissues

A visual examination of the gingival tissues is usually
all that is indicated for young children, as periodontal
disease is very uncommon in this age group.
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 The presence of color change (redness), swelling,
ulceration, spontaneous bleeding, or recession
should be carefully noted, and the aetiology sought.
The presence of profound gingival inflammation in the
absence of gross plaque deposits, lateral periodontal
abscesses, prematurely exfoliating teeth, or mobile
permanent teeth may indicate a more serious underlying
problem(like systematic diseases or syndromes) ,
warranting further investigation
During inspection of the gingival tissues, an assessment of oral cleanliness should
also be made, and the presence of any plaque or calculus deposits noted.

A number of simple oral hygiene indices have been developed to provide an objective
record of oral cleanliness. One such index, the oral debris index (another name: Green
and Vermillion index, 1964), requires disclosing prior to an evaluation of the amount of
plaque on selected teeth (first permanent molars, and upper right and lower left
central incisors), so we ask the patient to wash his mouth with the disclosing agent,
thenthe plaque will get discolored, and now you can evaluate it. We use this for six teeth
as mentioned above, not all teeth.
Disclosing agent: an agent used to detect
In the oral debris index : the presence of plaque on the tooth.
#0= No debris or stain present.
#1= Soft debris covering not more than one third of
the tooth surface being examined or the presence
of extrinsic stains without debris regardless of
surface area covered .
#2= Soft debris covering more than one-third but
not more than two-thirds of the exposed tooth surface .
#3= Soft debris covering more than two-thirds of the exposed tooth surface.

Another type of indices is the Gingival Index (Le, 1967), it was created for the
assessment of the gingival condition and records qualitative changes in the gingiva. It
scores the marginal and interproximal tissues separately on the basis of 0 to 3 :
#0= Normal gingiva

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#1= Mild inflammation slight change in color and slight edema but no bleeding on
probing;
#2= Moderate inflammation redness, edema and glazing, bleeding on probing;
#3= Severe inflammation marked redness and edema, ulceration with tendency to
spontaneous bleeding

Systematic periodontal probing is not routinely practiced in young children, unless

there is a specific problem. However, it is prudent to carry out some selective
probing for teenagers (especially when the permanent incisors and first molars start
to erupt) in order to detect any early tissue attachment loss, which may indicate the
onset of adult periodontitis.

Teeth
Following assessment of the oral soft tissues, a full dental charting should be
performed.
A thorough knowledge of eruption dates for the primary and permanent dentition
is essential as any delayed or premature eruption may alert the clinician to a
potential problem. However, simply recording the presence or absence of a tooth is
not adequate: closer scrutiny of each tooth's condition, structure, and shape is also
required.
During the clinical examination for carious lesions each tooth should be dried
individually and inspected under good light.
A definite routine of examination should be established. For example, a dentist may
always start in the upper right quadrant, work around the maxillary arch, move
down to the lower left quadrant, and end the examination in the lower right
quadrant.
*So after we finish evaluation of soft tissue and gingiva , we move to the teeth , and its
important to follow a systematic approach for teeth assessment , it is better to do it
clockwise ; starting from upper right quadrant , evaluate each tooth separately , then move
to upper left then lower left and finally lower right .
Features to note are:
Caries/ is it active/arrested, restorable/ not restorable? Check for the presence of
a chronic sinus associated with grossly carious teeth.
Restorations/ are they intact/deficient?
Fissure sealants/ are they intact/ deficient?
Tooth surface loss/ note any erosion/attrition, site, extent.
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 Trauma/ note extent, site, or signs of loss of vitality.
Tooth structure/ record any enamel opacities/hypoplasia (are defects localized/
generalized?)
Tooth shape/size/ note presence of double teeth, conical teeth, macrodontia
/microdontia, talon cusps, deep cingulumpits.
Tooth number/any missing/extra teeth?
Tooth mobility/ is it physiological or pathological?
Tooth eruption/ are there any impactions, infra-occluded primary molars, or
ectopically erupting first permanent molars?

Occlusion
Clearly, a full orthodontic assessment is not indicated every time a child is
examined. However, tooth alignment and occlusion should be briefly considered, as
these may provide an early prompt as to the need for interceptive orthodontic
treatment.
It is certainly worth noting:
Severe skeletal abnormalities.
Over jet and overbite.
First molar relationships.
Presence of crowding/ spacing.
Deviations/ displacements.

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 There are also two key stages of dental development, when the clinician should be
particularly vigilant in checking tooth eruption and position:
1. Age 8-9 yearsat this stage usually the patient has an eruption of upper permanent
incisors, so we check for:
increased over jet/because it may predispose to trauma
Cross-bite/ need for early intervention?
Traumatic biteassociated with localized gingival recession of lower incisor .
Anterior open bitewhich may indicates skeletal problem, digit-sucking habit, or
tongue thrust.
Failure of eruption may be because of presence of a supernumerary, crown/root
dilacerations, retained primary incisor, congenitally missing lateral incisors .

2. Age 10+ (or more) yearsat this stage usually the patient has aneruption of upper
permanent canines, so we should note this:
The permanent canines are palpable buccaly/if not, they may be heading in a palatal
direction.
The primary canines are becoming mobile / if not, the permanent canines may be
ectopic.

Radiographic examination
Comprehensive clinical guidelines for radiographic assessment of children have
been proposed by the European Academy of Pediatric Dentistry (2003).
Routine radiographic screening is certainly not indicated for children.
However, radiographs may be indicated in order to facilitate:
Caries diagnosis.
Trauma diagnosis.
Orthodontic treatment planning.
Identification of any abnormalities in dental development.
Detection of any bony or dental pathology.

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 Charting and notation system
Several different dental notation systems are used for associating information with a
specific tooth. The notation system is the names that we give for the teeth in order to
communicate with the patient or with other dentists.
The three most common systems are:
The FDI system
Universal Numbering system
Palmer notation system

Universal Numbering System

This system of marking permanent teeth uses the
numbers 1 to 32, beginning with the upper right
third molar (No. 1) and progress around the arch
to the upper left third molar (No. 16), down to the
lower left third molar (No. 17), and around the arch
to the lower right third molar (no. 32)
The primary teeth are identified in the universal
system by the first 20 letters of the alphabet ;
from A to T.
Orientation of the chart is traditionally "patient's view",
i.e. patient's right corresponds to notation-chart right.
The designations "left" and "right" on the chart
correspond to the patient's left and right, respectively.
*In the patient mouth, it will be clockwise,
but on the sheet it will be counter-clockwise .
*Important: the difference between this system and the other two systems is that here
the Orientation of the chart is the patient's view (the upper right of the patient will be
your left and the left of the patient will be your right) .

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 This is an alternative notation system for pediatric patient, in which we use alphabets
and numbers , but actually we dont use it .

Palmer notation
The Palmer notation consists of a symbol () designating in which quadrant the
tooth is found and a number indicating the position from the midline.
Adult teeth are numbered 1 to 8, with deciduous teeth indicated by a letter A to E.
Hence the left and right maxillary central incisor would have the same number "1", but
the right one would have the symbol "" underneath it, while the left one would have
"".
The easiest system in the clinic, but it is not used widely because it's hard to reproduce
these symbols () on the computer during communicating with the staff .
Orientation of the chart is traditionally "dentist's view", i.e. patient's right corresponds
to notation chart left.

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 Palmer notation for a normal adult full set of Palmer notation for a normal child full set of
teeth : teeth :

FDI World Dental Federation notation

This notation system is widely used by dentists internationally to associate information
to a specific tooth. Developed by the FDI World Dental Federation.
Orientation of the chart is traditionally "dentist's view", i.e. patient's right corresponds
to notation chart left.
We will usethis system in pediatric clinic , while in
The other clinics usually we will use palmar system.
FDI notation is a two digit system :
The first digit indicate the quadrant and the
second digit the type of the tooth within
the quadrant.
The quadrants are allotted the digits 1 to 4 for
the permanent teeth and 5 to 8 for the primary
teeth in a clockwise sequence, starting at the
upper right side.
Teeth within the same quadrant are allotted the
digits 1 to 8 (primary teeth from 1to 5)from the midline
backward. The digits should be pronounced separately.

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*this is a summary :

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DENTAL CHARTING
A chart is a diagrammatic representation of the teeth showing all the surfaces of the
teeth. The charts in the examination will be used to show:
which teeth present
which teeth missing
What's the work to be carried out
What's the work to be completed
Surfaces with cavities and restorations etc.
When charting, the mouth is looked on as being a flat line. The diagram is viewed, as
you would examine the patients mouth.
Tooth surfaces :

Incisal the biting edge of the incisors and canines

Occlusal the biting surfaces of premolars and molars

Mesial the surface of any tooth nearest to the mid-line of the arch

Distal the surface of any tooth furthest from the mid-line of the arch

Buccal the surface facing the cheeks (molars and premolars)

Labial the surface facing the lips (incisors and canines)

Palatal the surface facing the palate of all upper teeth

Lingual the surface facing the tongue of all lower teeth

Cervical the part of the tooth next to the gingival margin

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*In anterior teeth we have four surfaces (buccal , lingual , mesial , distal)
*In posterior teeth we have five surfaces (occlusal , buccal , lingual , mesial , distal)

These are the symbols that we use for dental charting :

cavity

restoration

Extracted tooth X

Un-erupted tooth U

Partially erupted tooth PE

.
Recurrent (secondary caries)

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 Fracture #

Remaining roots ++

Fissure sealant FS

Stainless Steel Crown SSC

*Here are some examples:

The size of the cavity

(circle) we draw on the
chart should be
comparable with that of
the patient mouth .so
when we have a large
cavity on the tooth, well
draw a large cavity (circle)
on the chart .

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*The X sign we put it for recently extracted teeth only, we dont use it for normally
exfoliated teeth.
. . . . . . . . . . . . . . ..
*This part of lecture will talk about the sheet that youre going to fill during dental
examination.

Now well talk about each part of it in details

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*So youll start by history taking ;
asking the patient about his name
/ address / birthday date / date of
examination / with whom is the
patient coming / chief complaint
(why the patient is here) and
history of it ... etc .
*Then you will ask about relevant
medical history, there is a
separate sheet for medical history
, youll give it to the parents and
ask specific question , then youll
review it and write the summery
in the gap here .
*Then youll ask about dental
history and social & family history.

*Here youll write the extra- and

intra-oral findings .
*Remember that we use the Le
Index (Gingival index) , for the
assessment of the gingival
condition

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*This part of the paper will be about dental charting .In our clinic (pediatric clinic) as we said we use
FDI notation system .Here are the teeths numbers , there is another number for the quadrant we fill
it according to the patient teeth : if it deciduous teeth , the second number will be from 5 to 8 ,
if it permanent teeth , the second number will be from 1 to 4.
*But here see that its always filled because teeth #6 + #7 is from permanent teeth.
*Then well see if theres caries, cavities, restoration (and type of it) , partially erupted teeth,
remaining roots and write down these finding .

*Then youll do the radiographic

report, so youll put which type of
radiograph you took.
*put what you find in the
radiograph: caries , periapical
involvement , root resorption etc
*Finally youll reach the diagnosis,
e.x : the patient had caries ,
periodontal problem , orthodontic
problem , any kind of infection

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*Then youll reach the treatment plan,
so youll fill what you have done in each
visit :
*1st visit as we said we do the
examination, history taking,
radiographic report and sometime we
do simple preventive treatment like
fissure sealants, fluoride application and
write it where it should be written in the
forum.
*2nd visit we do the treatment plan for
other teeth . In pediatric dentistry we do
what we call a quadrant therapy then in
the tooth column we write the name of
the tooth using FDI system , so if we are
talking about upper right E then we
write 55 and we put what it needs either
restoration or any other thing and , then
we move to other tooth in the quadrant Dont forget to write your name and the staff name
and never to forget to write the and the date and sign , because if u didnt do that then
prevention treatment plan for each it will not be taken in consideration as a finished work
tooth .
**in each visit we should always talk
about the oral hygiene instruction and
diet instruction if there was a need for
that .
*3rd visit we do same as in the second
visit but on the second quadrant which is
the upper left and just do the same start
from the first teeth that erupt which is
the 6th and go forward
*4th visit do the same but on the 3rd A smile a day keeps the wrinkles away =)
quadrant the lower left
5th visit same but on the 4th quadrant the
lower right .
*6th visit is the referral visit where the Done By : Saleh Mutlaq
patient is checked if he need to be
referred to an orthodontist or Corrected By : Ahmad Fawzi
endodontisit and also we write about
the caries risk and how much time we
need to make sessions for the patient to
follow up with him .
*The dr didnt mention what to do in the 6th and 8th

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visits but in most times they are left for the first
checkout after therapy is done and after the referral is
finished