Dental And Oral Health - Case Study 50

Patient Profile: 

Patient is a 5-year-old Asian male. He is 42.5 inches (107.9 cm) tall and weighs 40 pounds (18 kg). He lives at home with parents and will be entering Kindergarten in 3 months.

Chief Complaint: 

Parents are worried about the dark discoloration of the teeth. Mother further mentions that “the teeth seem to be dissolving.”

Medical History: 

According to mother (verbal) and written medical history, the patient sees a local pediatrician and is up to date for all inoculations. No known allergies. No physical or mental issues. Patient has one older sister. Father has type II diabetes.

Dental History: 

New patient to this pediatric dental office. Prior to this dental visit, the patient has received mostly emergency care for fractured enamel on mandibular deciduous molar teeth.

Supplemental Information: 

Child seems happy, is alert and inquisitive. He is not a patient management problem in the dental environment. Mother brushes his teeth with a manual brush and “lots of toothpaste” but doesn’t remember what kind of toothpaste – “I buy whatever is on sale.”

Mother admits to high carbohydrate diet, e.g., lots of pastas, noodles, sugar in tea, etc. She also states that he was frequently put to bed with a bottle of warm milk when a baby. He now likes to drink cool aid (but from a glass).

Extraoral Examination: 

No palpable lymph nodes. No facial skin lesions. Frontal view of the face is bilaterally symmetrical. Eye movement is normal. Overall, head and neck examination was negative for any significant findings.

Intraoral Examination:

Visual examination reveals generalized dental caries. Caries involving the facial surfaces of the maxillary teeth is particularly severe. Soft tissue examination was negative for periodontal disease.

Bleeding Index: 

Did not do periodontal charting

Plaque Score: 

20% (16/80 surfaces)

% Carious Surfaces: 

35% (28/80 surfaces)