Dental Charting & Notation
MawiaBatayneh Saleh Mutlaq 7 – 7 7 – 2015 2015
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Some notes : .All slides are included & .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 t he first tooth is erupted in his/her mouth . And usually it will be between 6th – 7th months , it 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 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 patient’s 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; Mum health during pregnancy Any complications, trauma, infection, drugs taken Gestational age (premature birth) Delivery (O2 deprivation)
Neonatal; Birth weight, birth height Birth defect, jaundice, Rhesus incompatibility, any need for special medical care
Perinatal/postnatal Bottle or breast fed, bottle content
Immunization
Childhood illnesses
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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
.................. 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 patient’s 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 patient’s 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 patient’s 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 further coaxing.
this child is likely to hop into the chair for a check-up without
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 atient .
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 child’s legs straddle
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the parent’s 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 child’s head positioned in the parents arm’s. 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: Height is the child very tall or very small for their age? In a fe w cases, it may be appropriate to take an accurate height measurement and plot data on a standard growth chart. Weight could 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). Skin look for any notable bruising or injury on exposed arms or legs.
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Hands assess 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: Head note size, shape (abnormalities may be seen in certain syndromes), and any facial asymmetry. Hair note if sparse, quality and quantity Eyes is there any visual impairment or abnormality of the sclera? Ears record any abnormal morphology or presence of hearing aids. , birthmarks and be Skin document any scars, bruising, lacerations, pallor aware of contagious infections, such as impetigo ( ) . : Temporomandibular joint is there any pain, crepitus, deviation, or restricted opening. Muscle of mastication must also be examined. Lymph nodes palpate for enlarged submandibular or cervical lymph nodes (bear in mind that lymphadenopathy is not uncommon in children, due to frequent viral infections). Lips note 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 medicolegal 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
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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 we’ll 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.
In the oral debris index : #0= No debris or stain present.
Disclosing agent: an agent used to detect the presence of plaque on the tooth.
#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 (Löe, 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 years⎯at 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 bite associated with localized gingival recession of lower incisor . Anterior open bite which 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) years at 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 us e alphabets and numbers , but actually we don’t 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 teeth :
Palmer notation for a normal child full set of 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 patient’s 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, we’ll draw a large cavity (circle) on the chart .
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*The “X” sign we put it for recently extracted teeth only, we don’t use it for normally exfoliated teeth.
. . . . . . . . . . . . . . .. *This part of lecture will talk about the sheet that you’re going to fill during dental examination.
Now we’ll talk about each part of it in details
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*So you’ll 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 , you’ll give it to the parents and ask specific question , then you’ll review it and write the summery in the gap here . *Then you’ll ask about dental history and social & family history.
*Here you’ll write the extra- and intra-oral findings . *Remember that we use the Löe 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 teeth’s 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 we’ll see if there’s caries, cavities, restoration (and type of it) , partially erupted teeth, remaining roots and write down these finding .
*Then you’ll do the radiographic report, so you’ll put which type of radiograph you took. *put what you find in the radiograph: caries , periapical involvement , root resorption … etc *Finally you’ll reach the diagnosis, e.x : the patient had caries , periodontal problem , orthodontic problem , any kind of infection
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*Then you’ll reach the treatment plan, so you’ll 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 and never to forget to write the prevention treatment plan for each 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 3 rd quadrant the lower left 5th visit same but on the 4th quadrant the lower right . *6th visit is the referral visit where the patient is checked if he need to be referred to an orthodontist or 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 didn’t mention what to do in the 6 th and 8th visits but in most times they are left for the first checkout after therapy is done and after the referral is finished
Don’t forget to write your name and the staff name and the date and sign , because if u didn’t do that then it will not be taken in consideration as a finished work
Done By : Saleh Mutlaq Corrected By : Ahmad Fawzi
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