Department of Pedodontics and Preventive

dentistry,
Dasmesh Institute of Research and Dental
sciences, Faridkot

Case history
Montek singh 12/M

Dr.Sirjanapreet Kaur
/2012

DEPARTMENT OF PEDIATRIC &

PREVENTIVE DENTISTRY
CASE HISTORY
DATE: 28-06-12

PATIENTS NAME:- MONTEK SINGH

OPD NO:-12742
AGE/SEX:- 12y/M
BIRTH:05-03-2000
FATHERS NAME:-Mr.Gurmeet Singh
Mrs.Kulwinder Kaur
FATHERS OCCUPATION:-Serviceman

DATE OF
MOTHERS NAME:-

SCHOOL:-P.K.S.International School,Bathinda
CONTACT NO:9417237445

CLASS:- 7th
ADDRESS:Bathinda

1. NAME OF ATTENDING DOCTOR:-Dr.Sirjanapreet Kaur

2. CHIEF COMPLAINT:- Patients mother complains of thumb
sucking habit of patient and wants it to correct.

3. HISTORY OF PRESENT ILLNESS: patient has history of thumb

suc
4. PAST DENTAL HISTORY: no relevant past dental history.
5. Family History: (Medical & Dental):
MEDICAL HISTORY:- no relevant medical history
6 .Natal & Prenatal History: no relevant history of any
complication.
Delivery / Type : Normal
7.

Post Natal History:

Bottle fed upto 2yrs

(a) Introduced at the age : at 2 months of age

(b) Duration : 15-20 mins
(c) Frequency: 2-3 times per day
8.
(a)

Mile stones of Development:

Started Sitting at:6-7mon

(b)

Started Crawling at: 7.5mon

(c) Started Standing at:9mon

(d)

Started Walking at:15-16mon

(e) Started talking words at:18mon

(f)

Started talking sentences:2yr

8. Childhood Diseases: no relevant childhood diseases

Time

Type of food

Quantity

10:00am

Custard

1bowl

8:00am

Bread

2 Slices

6:00am

Tea

1 cup

9:00pm

Maggi

plate

8:00pm

Mango

4:00pm

Tea

2:00pm

Chapatti,pickle

12.00

chips

1 packet

Method
of
Preparation

Quantity
of Sugar
Added
2 tsp sugar
2tsp sugar

Yesterday

9. Oral Habits: none

10.

DIET CHART

CLINICAL EXAMINATION
General Physical Examination:
Built:- Aesthetic
Body Type:- Mesomorphic
1. Extra Oral Examination :
Shape of the Head:- Mesocephalic
Facial form:- Mesoprosopic
Facial Profile:- Straight

2tsp sugar

Facial Symmetry:- Symmetrical

Lip Posture & Tonicity:- Competent
2.Functional Examination :
Breathing :Normal

Mastication:Normal

Postural Real Position:Normal

Speech: Normal

Deglutition: Normal

TMJ:Normal

INTRA ORAL EXAMINATION

Soft tissue examination
1. Oral vestibule/ Buccal mucosa normal
2. Gingiva
Color- coral pink
Consistency-firm
Contour - Scalloped

Hard tissue examination no of teeth present-20

FDI Notation:55 54 53 52 51 61 62 63 64 65
75 74 73 72 71 81 82 83 84 85

Visual Examination:

Carious teeth 51,52,61,62,54,64,74,84,71,72,73,81,82,82

Grossly carious none
def-14(high risk patient)
Mobile -none
Filled teeth none

ARCH ANALYSIS
Shape:
U Shaped
asymmetry
Arch Alignment: normal

Arch Symmetry:

Molar relationship: Primary: flush terminal

Midline: coincide
Canine Relationship:Class I
Incisor relationship:normal overjet and overbite
Crossbite: not present

Investigation :
IOPA: Iopa showing 75,74

Final diagnosis:-Early Childhood Caries

TREATMENT PLAN:- 1)Preliminary Phase/Emergency Phase: Access

opening
2)Preventive Phase: Brushing demo Given, Dietary Counselling ; fluoride
application
3)Prepratory phase: BMP
4)Corrective phase: obturation and stainless steel crown.
5)Maintainance Phase: follow up
PATIENTS CONSENT FOR THE TREATMENT
The undersigned give my full consent to operate on me/ my wife/ my child
and to do any investigation as necessary and under any kind of
anaesthesia.

Signature of patient/
parent/ guardian

Date

TREATMENT DONE
Visit
First visit

Date
11-6-12

Treatment done

Next

History taken, salivary ph

appointment
12-6-12

checked, brushing demo,

behaviour management and
2nd Visit

12-06-12

restoration 53

14-6-12

Composite 84 and A/O irt

51,52,61 fluoride application
3rd visit

14-6-12

21-6-12
Pulpectomy 84 & omega loop

4th visit

21-6-12

build up done 51,52,61

11-7-12

Pulpotomy 74
5th visit

11-7-12

18-7-12
Stainless steel crown-74

18-7-12
6th visit

16-8-12
Post obturation 75

16-8-12
7th visit

A/o- 63

MEDICATION PRESCRIBED:
Signature H.O.D

Preoperative

Omega loops in 51,52,61

ZOE Obturation-51,52,61

Omega loops -51,52,61

Postoperative

Postoperative

Pulpotomy -74

Stainless steel crown -74