TAGORE DENTAL COLLEGE AND HOSPITAL

DEPARTMENT OF PEDIATRIC AND PREVENTIVE DENTISTRY

CASE SHEET

NAME OF THE DOCTOR : Janisha.M

DATE: 28/9/21
NAME OF THE PATIENT: Master.Philip
CASE NO : 28153/21
DATE OF BIRTH : 15/04/2014
AGE/SEX. : 7YEAR/Male
LANGUAGE KNOWN : Speak: Tamil
Read: Tamil
Write: Tamil
ADDRESS : No.84, Kalaingner Street, Rathinamangalam,
Chennai
TELEPHONE NO. : 9546872477
PERSON ACCOMPANYING THE CHILD: Mrs. Manasa
(RELATIONSHIP) : Mother
CHIEF COMPLAINT : Patient complaints of mild tooth decay in the upper
and lower front and back tooth region for the past 6 months.
HISTORY OF PRESENT ILLNESS: Patient’s mother gives a history of tooth decay in
upper and lower jaw for past 6 months, with a history of sensitivity No history
of pain
PAST MEDICAL HISTORY: No history of medical history reported
PAST DENTAL HISTORY: Patient has visited dentist one week before.
FAMILY HISTORY : No relevant family history reported. All are apparently
healthy.
PARENTAL HISTORY : Both are apparently healthy
PRENATAL HISTORY : Mother was apparently healthy, no history of
gestational diabetes mellitus, any infection . Mother was vaccinated . Mother
was not on any medications.
NATAL HISTORY : Normal delivery. Born after 10 months(Full term). No
history of natal teeth . Child was normal at time of birth . No medical issues
reported .
POSTNATAL HISTORY : Normal developmental milestones
Breastfeeding upto 1 year. Bottle feeding upto 2 years.
History of night feeding practice is reported.
H/O ORAL HABITS
HABITS INTENSITY
DURATION FREQUENCY
NIL NIL NIL NIL

FRANKEL’S BEHAVIOUR RATING SCALE

RATING INTERPRETATION
RATING – 1 Refusal of treatment , crying
forcefully , fearful.
DEFINITELY NEGATIVE Extreme negativism.

ORAL HYGIENE MEASURES :

MATERIALS USED : Toothbrush and toothpaste
METHOD OF CLEANING : Horizontal method
FREQUENCY OF CLEANING: Once daily
DURATION OF BRUSHING : 1 minute
DIETARY HABITS :
● Fully weaned child ,
● Refined carbohydrate exposure,
● Bottle feeding – Milk supplements (Pediasure),
● Duration of bottle feeding – For 2 years
GENERAL EXAMINATION :
WEIGHT 15 kg
GAIT Normal
BUILT Moderately built
Mesomophic
PALLOR No signs of pallor
noted
TEMPERATURE Afebrile at the time of
examination
HEIGHT 90 cm
RESPIRATORY RATE 26 breaths / min
BLOOD PRESSURE 100/50mmHg

EXTRA ORAL EXAMINATION :

FACE : No gross facial asymmetry detected.
MAXILLA :No abnormalities detected
MANDIBLE : No abnormalities detected
TMJ : No abnormalities detected
MOUTH OPENING : Normal
LIPS :Competent lips
LYMPH NODES : No clinically palpable lymph nodes
PERIORAL MUSCLE ACTIVITY : No abnormalities detected
INTRA ORAL EXAMINATION :
SOFT TISSUE : no redness , swelling , ulcer, vesicles detected
LABIAL MUCOSA : no abnormalities detected
BUCCAL MUCOSA : no abnormalities detected
PALATE : no cleft, abscess, petechiae detected
FLOOR OF THE MOUTH : no abnormalities detected
VESTIBULE : no abnormalities detected
FRENUM : normal frenal attachment
GINGIVA : no bleeding, redness, sinus or discoloration detected
HARD TISSUE :
TEETH IDENTIFICATION (FDI) :
16 55 54 53 52 11 21 62 63 64 65 26
46 85 84 83 82 41 31 72 73 74 75 36

DMFS / Defs Index

DMFS Score = Ds + Ms+ Fs = 18+0 +0 = 18

OHI INDEX
DEBRIS INDEX
16 11 26
1 - 1

1 1 1

46 31 36
D.I = 5/5 = 1 (Fair)
CALCULUS INDEX
16 11 26
1 - 0

0 1 1

46 31 36
C.I = 3/5 = 0.6= Good
OHI-S = D.I + C.I = 0.8 + 0.5 = 1.3 (Fair)

DECAYED TEETH 55,54,11,21,64,65,75,74,84,85

FILLED TEETH -
MISSING TEETH -
SUPERNUMERARY -
CONGENITAL -
ABNORMALITY
FRACTURED TEETH -
TEXTURE OF TEETH -
ANY OTHER -

OCCLUSION PRIMARY PERMANENT

 RIGHT LEFT RIGHT LEFT
MOLAR RELATION FTP FTP
CANINE RELATION Class I Class I

INCISOR RELATION :
OVER JET : NORMAL – 2mm
OVER BITE : DEEPBITE – 5 mm
PROVISIONAL DIAGNOSIS :
DENTAL CARIES – 21,54,55,11,64,65,74,75,84,85
IOPA reveals radiolucency involving enamel, dentin on occlusal and proximal
surfaces
DIFFERENTIAL DIAGNOSIS : nil
FINAL DIAGNOSIS : mild early childhood caries
TREATMENT PLAN:
EMERGENCY: nil
PREVENTIVE :
● Fluoride dentrifice
● Diet counselling for parents and child,
● Oral hygiene instructions,
● Parent oral hygiene screening,
● Proper brushing technique demonstration
RESTORATIVE :
● Glass Ionomer restoration of decayed tooth in relation to
21,54,55,11,64,65,74,75,84,85
CORRECTIVE : nil
MAINTENANCE : Patient recalled once every 1 month for review.