CASE HISTORY

Demographic Profile

• Date: [DD/MM/YYYY]
• OPD No.: [ ]
• Name: Tanashree
• Nickname: [ ]
• Age/Gender: 7 years/Female
• Accompanying person: [Parent/guardian name and relationship]
• Father’s name: [ ]
• Mother’s name: [ ]
• Occupation of father: [ ]
• Occupation of mother: [ ]
• Contact number: [ ]
• Religion: [ ]

Chief Complaint

History of Presenting Illness

Past Medical History

• No significant medical history.
• No history of hospitalization, systemic illness, allergy, or long-term medication.
• No relevant history of bleeding disorders, asthma, epilepsy, diabetes, cardiac disease, or infectious disease.

Past Family History

• Non-contributory.
• No relevant familial history of systemic illness or dental anomalies reported.

Past Dental History

• History of pulpectomy with respect to 75.
• Details regarding date of treatment, restoration provided, and follow-up status: [to be recorded].
• No other relevant past dental treatment reported.

Prenatal, Natal and Postnatal History

Prenatal History

• Illness during pregnancy: Not contributory/No relevant history.
• Drug therapy during pregnancy: Not contributory.
• Antibiotic intake during pregnancy: Not contributory.
• Blood incompatibility: Absent.
• Fluoride tablet intake during pregnancy: [ask and record].

Natal History

• Type of delivery: [Normal vaginal delivery/Caesarean section]
• Birth cry: [Immediate/Delayed]
• Prematurity: [Absent/Present]
• Congenital anomaly: Absent.
• Neonatal jaundice: [Absent/Present]
• Blood transfusion: [Absent/Present]
• Natal/neonatal teeth: Absent.

Feeding History

• Breastfeeding: [Duration]
• Bottle feeding: [Present/Absent; duration and contents]
• Weaning: [Age and type of food]
• Vitamin/iron supplementation: [Present/Absent]

Postnatal and Infancy History

• Developmental milestones: Reportedly normal for age.
• Immunization status: Reportedly complete for age.
• Childhood diseases: No significant history.
• Medication history: Non-contributory.

Personal History

Oral Hygiene Practices

• Method: [Manual toothbrush]
• Material used: [Fluoridated/non-fluoridated toothpaste]
• Frequency: [Once/twice daily]
• Other oral hygiene aids: [None/Specify]
• Frequency of toothbrush replacement: [Every 3 months/Specify]
• Brushing supervision by parent: [Present/Absent]

Oral Habits

Fluoride History

• Source of drinking water: [Municipal/borewell/filtered water]
• Fluoride tablet exposure: [Absent/Present]
• Ingestion of toothpaste: [Absent/Present]
• Excess use of fluoridated toothpaste: [Absent/Present]

Diet Assessment

24-Hour Diet History

General Examination

• Gait: Normal
• Body type: [ ]
• Posture: Normal
• Built: [Well built/moderately built]
• Height: [ ] cm
• Weight: [ ] kg
• Pulse rate: [ ] beats/min
• Respiratory rate: [ ] breaths/min
• Pallor: Absent
• Icterus: Absent
• Cyanosis: Absent
• Clubbing: Absent
• Lymphadenopathy: Absent
• Edema: Absent

Frankl Behaviour Rating Scale

Extraoral Examination

• Head shape: Normocephalic
• Facial form: [Mesoprosopic/Euryprosopic/Leptoprosopic]
• Facial symmetry: Symmetrical
• Facial divergence: [Straight/Anterior/Posterior]
• Profile: [Straight/Convex/Concave]
• Eyes, nose and ears: No abnormality detected
• Hair and nails: Normal
• Lips: Competent, no abnormality detected
• Lymph nodes: Non-palpable and non-tender
• Temporomandibular joint: No clicking, tenderness, or restriction of movement
• Neck: No abnormality detected

Intraoral Examination

Soft-Tissue Examination

• Lips: Normal
• Buccal mucosa: Normal
• Tongue: Normal in size, shape, and mobility
• Floor of mouth: Normal
• Palate: Normal
• Frenum: Normal
• Tonsils: Normal
• Salivary gland openings: Normal

Gingiva

• Colour: Coral pink
• Contour: Scalloped
• Consistency: Firm
• Texture: Stippled
• Bleeding on probing: [Absent/Present]

Hard-Tissue Examination

• Dentition: Mixed dentition appropriate for chronological age.
• Teeth present: Record in FDI notation after clinical examination.
• 85: Deep carious lesion involving dentin, with clinical features consistent with pulpal involvement.
• 75: Previously treated by pulpectomy. Restoration status to be evaluated clinically and radiographically.
• Other carious teeth: [Record after examination]
• Root stumps: [Absent/Present]
• Tenderness on percussion in relation to 85: [Absent/Present]
• Mobility in relation to 85: [Absent/Present]
• Sinus tract/swelling: Absent clinically [modify if present].
• Developmental anomalies/fluorosis/fracture/attrition: [Absent/Present]

Occlusal Assessment

• Molar relationship: [Flush terminal plane/mesial step/distal step]
• Primate spaces: [Present/Absent]
• Crowding: [Absent/Present]
• Overjet: [ ] mm
• Overbite: [ ] mm
• Midline: [Coincident/Deviated]
• Arch length: [Adequate/Inadequate] in maxillary and mandibular arches.

Caries and Oral Hygiene Indices

• dmft/def score: [ ]
• DMFT score: [ ]
• Debris Index: [ ]
• Calculus Index: [ ]
• OHI-S score: [ ]
• Gingival Index: [ ]

Examination of Area of Chief Complaint

Tooth 85

• Deep carious lesion present in relation to 85.
• History suggestive of spontaneous and/or lingering pain.
• Pulp vitality tests in primary teeth may have limited reliability and should be correlated with symptoms, clinical findings, and radiographic findings.
• Percussion tenderness, mobility, periodontal probing, swelling, sinus tract, and furcal tenderness should be specifically assessed and recorded.

Provisional Diagnosis

Differential Diagnosis

1. Symptomatic reversible pulpitis with respect to 85.
2. Pulp necrosis with respect to 85.
3. Symptomatic apical periodontitis secondary to pulpal inflammation in 85.

Investigations

1. Intraoral periapical radiograph (IOPAR) with respect to 85.
2. IOPAR evaluation of previously pulpectomized 75, if clinically indicated.
3. Clinical assessment of:
   • Extent of caries and restorability
   • Furcation or periapical radiolucency
   • Periodontal ligament space widening
   • Root resorption
   • Status of developing successor, 45
   • Remaining root length of 85
4. Pulp sensibility tests may be attempted but interpreted cautiously in primary teeth.

IOPAR Findings

• Extent of caries in 85: [ ]
• Pulpal involvement: [ ]
• Furcal/periapical radiolucency: [Present/Absent]
• Periodontal ligament widening: [Present/Absent]
• Root resorption in 85: [Physiological/Pathological/Absent]
• Status of follicle/developing successor 45: [ ]
• Radiographic status of pulpectomized 75: [ ]

Final Diagnosis

Treatment Plan

Emergency Phase

• Relief of pain.
• Removal of gross caries and placement of a temporary restoration, if required.
• Analgesic prescription only when clinically indicated.
• Antibiotics are not indicated for uncomplicated pulpitis without systemic involvement, spreading infection, or cellulitis.

Medical Phase

• No medical intervention required, as the child has no significant medical history.

Preventive Phase

• Oral hygiene instructions to child and parent.
• Dietary counselling to reduce frequency of sugary snacks and drinks.
• Age-appropriate supervised toothbrushing twice daily using fluoridated toothpaste.
• Topical fluoride application, if indicated according to caries risk.
• Recall and caries-risk assessment.

Preparatory Phase

• Behaviour management using tell-show-do, positive reinforcement, distraction, and parental communication.
• Oral prophylaxis.
• Caries control and restoration of other teeth as indicated.

Corrective Phase

Endodontic Treatment

• Pulpectomy with respect to 85, provided the tooth is restorable, has adequate remaining root length, and there is no contraindicating pathological root resorption or extensive infection.
• Obturation with a resorbable root canal filling material appropriate for primary teeth.
• Definitive full-coronal restoration with a stainless steel crown after pulpectomy.

Alternative Plan

• If 85 is non-restorable, shows excessive pathological root resorption, or has an unfavourable prognosis:
  • Extraction of 85.
  • Space analysis and consideration of an appropriate space maintainer, based on eruption status of 46 and assessment of the arch.

Maintenance Phase

• Clinical and radiographic follow-up at appropriate intervals.
• Evaluation of the treated 85 for pain, swelling, mobility, restoration integrity, and pathological radiographic changes.
• Monitoring of exfoliation of 85 and eruption of its successor, 45.
• Follow-up of the previously pulpectomized 75.

Treatment Done

History of Presenting Illness:
The patient was apparently asymptomatic until [duration, e.g., 2 days] ago, when she developed pain in the lower right back tooth region. The pain was sudden in onset, spontaneous, sharp/throbbing, and severe in intensity. It was intermittent initially but has become more frequent and persistent.

Pain was aggravated by intake of cold, hot, and sweet food पदार्थs and persisted for several minutes even after removal of the stimulus. It was also aggravated on lying down and disturbed the child’s sleep at night. The pain was non-radiating/radiating to [specify only if reported].

There was no history of swelling, pus discharge, trauma, fever, or difficulty in mouth opening. The parent gave [name/dose if known] analgesic medication, which provided temporary relief. The patient then reported to the department for treatment.

Short exam-style version

A 7-year-old female child reported with acute, severe, spontaneous, throbbing pain in the lower right posterior region since 2 days. Pain was aggravated by hot, cold, and sweet stimuli and lingered after removal of the stimulus. It was worse at night and on lying down, causing sleep disturbance. Analgesics provided only temporary relief. There was no associated swelling, pus discharge, fever, or history of trauma.

The patient was apparently asymptomatic until 2 days ago, when she developed sudden-onset pain in the lower right posterior region.

The pain started 3 days ago, was spontaneous and throbbing in nature, increased in intensity, and disturbed sleep.

24-Hour Diet History

Dental Note

• The child consumes sugar-containing snacks between meals, especially biscuits, chocolates, and sweetened beverages.
• Frequency of sugar exposure: approximately 5 to 6 times/day.
• Bedtime intake of sweetened milk is present.
• The diet is cariogenic, with frequent exposure to fermentable carbohydrates and added sugars.

Inference: The 24-hour diet history reveals frequent consumption of refined carbohydrates and sugar-containing food items between meals, including bedtime sweetened milk. Hence, the child has a cariogenic dietary pattern and is at increased risk for dental caries.

• Pulse rate: 75-115 beats/minute
• Respiratory rate: 18-30 breaths/minute

Pulse rate: 90 beats/minute, regular
Respiratory rate: 22 breaths/minute, normal

• Mandibular central incisors: 31, 41
• First permanent molars: 16, 26, 36, 46

Dentition: Mixed dentition. Permanent teeth erupted were 16, 26, 31, 41, 36 and 46. The remaining teeth present were deciduous.

DMFT/DMFS: 0/0
deft/defs: 2/2
(d = 1 in 85; f = 1 in 75)

Oral Hygiene Index-Simplified (OHI-S): 0.5 - Good oral hygiene
DI-S: 0.5
CI-S: 0.0