WAN NUR AMNI BINTI WAN

AZMI
1312896

YEAR 5 PAEDIATRIC CASE PRESENTATION

DEMOGRAPHIC DETAILS
 Miss Mackenzie
 Female
 Date of first clerking: 7 December 2016
 DOB: 25 March 2008
 8 years old

CHIEF COMPLAIN:
Pain on lower left back tooth
HISTORY OF PRESENTING COMPLAINT:
Pain on lower left back tooth about 1 month ago, throbbing in
nature, no radiation, aggravated by drinking cold water, and
eating hard food, no relieving factor, severity moderate, no
history of fever or swelling
MEDICAL HISTORY:
Patient claimed to be fit and healthy. No signs and symptoms of
systemic disease observed. No allergy. No medication taken.
No history of hospitalization
DENTAL HISTORY:
She was an irregular attender. No history of dental trauma.
PREVENTIVE HISTORY:
Regular toothbrushing, unsupervised, using fluoridated toothpaste
DIETARY HISTORY:
She frequents sweet drinks
SOCIAL HISTORY:
8 year old girl, Standard 2 student at SK Sungai
Talam, the eldest out of three siblings. Father
work as cafe manager, mother work as civil
servant at immigrant office. Lives at Taman
Mahkota Emas. History of bottle feeding
(sweet drinks). No history of thumb sucking
habit.
EXTRAORAL EXAMINATION
TMJ - No clicking, no tendernes, no deviation.
Lymph nodes – Non palpable. Non tender.
Face – Symmetrical.
Lips – Competent at rest
Eye- Normal
INTRAORAL EXAMINATION
 Mucosa – Normal buccal and labial mucosa.
 Tongue & Floor of the mouth – Normal
 Palate – Normal
 Gingiva – Generalized inflammation.
 Teeth – Moderate crowding on upper teeth, and
mild crowding on lower teeth
 Occlusion – Incisor Class I, Right molar Class II, Left
molar Class III.
BPE

1 1 1
1 1 1
DENTAL CHARTING

# #
GI GI GIII GIII
 DIAGNOSIS AND TREATMENT PLAN
DIAGNOSIS:
Caries- 55(MO), 54(DO), 64(MO), 65(D), 26(O), 36(O), 84(DO), 85(O),
46(O&B)
Pulp necrosis- 75
TREATMENT PLAN:
1) OHE & OHI- Mechanical toothbrushing, Diet advice, Fluoride gel therapy,
Fissure sealant on 16
2)INTERMEDIATE-
Amalgam restoration- 84(DO), 85(O)
Composite restoration- 55(MO), 54(DO), 64(MO), 65(D), 26(O), 36(O,
46(O&B)
Extraction- 75, 74, 73
2)LONG TERM-
Review in 2 weeks
Recall in 3-4 months
Refer to orthodontic department for management of crowding
 Date (visit ) Treatment done
7/12/2016 1. END done
2. Early prophylaxis
3. Topical fluoride gel therapy
14/12/2016 1. Amalgam restoration on 84 (DO)
4/1/2017 1. PRR on 36 & 46
2. Extraction of 75
15/2/2017 1. Amalgam Class I on 85
2. Amalgam class II on 84 (DO)
3. Bitewing radiograph right and left was taken
12/3/17 1. PRR on 26
2. Fissure sealant on 16
3. Composite class II on 64 (DO)
29/3/17 1. GIC restoration on 54

19/4/17 1. Stainless Steel Crown on 54

3/5/17 1. GIC on 55 (DO)

24/5/17 1. PRR on 65 (O)

2. Oral prophylaxis
3. Topical fluoride gel therapy
 Date (visit ) Treatment done
20/6/17 1. Review plaque score
2. Completed all treatment. Re-charting done
11/9/17 1. Review charting
2. Review plaque score
3. Tooth 54, 73, 83 exfoliated
4. No new caries noted
5. Final prophylaxis done
6. Topical fluoride gel therapy done.
DISCUSSION
 Patient is very cooperative with Frankl rating
of 4 during all visits for treatment.

 Patient initial plaque score was 100% and her

final plaque score on day of treatment
completion was 37.5 %
THANK YOU