Erin, 5year old, female, has attending a dental visit today for a check up, has never been to the dentist before and mother has no concerns. She reports brushing 2x daily,  no flossing mentioned and uses a toothpaste from the supermarket. She likes mint. She has an Anaphylaxis allergy to peanuts (Epipen at school), has hayfever, but otherwise is in good health. She enjoys juice and mum says she is “always eating at the moment”. She attends the local kindergarten in Albury and lives with her 3 sisters, 2 brothers and both parents. Her dad is currently unemployed and her mother works casually when she can. Erin enjoys reading, maths and horses.

Clinical Notes

C/C: patient has attending today for a check up, mother has no concerns

MHx: Anaphylaxis, allergy to peanuts. Epipen at school, not bring with him. Hayfever, doesn’t mention about taking any tablet for that., no asthma, no other medications, no heart conditions

DHx: First time at the dentist, never been to the dentist before.

OH:. Brushing 2x daily, no flossing, uses a mint toothpaste

SHx: She attends the local kindergarten in Albury. There are 6 people in her family: both parents, 3 sisters, 2 brothers and herself. Dad is unemployed, mother works casually when possible.

Diet: like drinking juice

Consent: Consent given for a comprehensive examination and BWs.

E/O (Extra Oral):

Musculature of head and neck, Lymph, TMJ, Sinuses, Thyroid and Larynx: NAD

Adequate speech, nil difficulties understanding

Straight profile (Nil asymmetries)

I/O (Intra Oral):

Soft tissue – Nil significant findings

Deposit assessment – generalised soft deposits mainly gingival margins and buccal surfaces

Occlusal assessment:

Class I primary dentition, postures class III

Non-carious lesion 51I, 52I, 61I, 62I

PSR (Periodontal Screening and recording): 010 101

Odontogram/Hard Tissues: Full dental charting completed – Primary dentition.

Additional diagnostic tests/investigations required (if any):

Need to investigation about what toothpaste pt uses. Is it kid toothpaste or adult toothpaste, how much percentage of the fluoride in the toothpaste.

Diet: how often does he take juice daily? How consuming?

CO2 test required for all 5’s

Mobility test

O’leary plaque index: using disclosing tablets

Saliva test (visual examination, resting pH or Flow and buffering capacity)

Percussion tender test (TTP) for all 5’s

X-rays : PA’s or OPG

Diet analysis

Caries risk assessment

Presumptive Diagnosis:

Caries 55O, 65O, 75O, 74DO, 84D, 85O

Generalised plaque- induced gingivitis

NCTL: 51I, 52I, 61I, 62I

Treatment Plan:

First visit: full examination and x-ray, photos

OHI:

• Demonstrate modified bass technique on a demonstration model, patient to demonstrate technique on model as well.
• Advise a soft toothbrush or electric toothbrush with supervision
• Use fluoride toothpaste when brushing at night

Dietary advice:

• Limit Juice consumption

Take OPG to investigate the apical of 55,75,85,65 to get further information.

 

Second visit:

Check the hygiene with disclosing GIC gel

Prophylaxis to remove plaque debridement of calculus.

• Flossettes to clean interproximally
• Use ToothMousse twice a day at

Isolate 55 using cotton rolls. Class I caries removal 55O. restore with resin modified GIC.

Third visit:

65O using resin modified GIC.

Put elastic between 74,75 and 84,85

Four visit

Stainless steed crown for 75,85

Recall 3 months because high-risk caries

N/V: whole mouth debridement and OPG