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Name:Gurprabal Singh Sex:Male Age:5years OPD NO:18202 Date: Source of Information- Patient's parent(mother)

CHIEF COMPLAINT
Patient's mother complains of bad appearance of decaying upper front teeth from 3 years.

HISTORY OF PRESENT ILLNESS:


History dates back to 3 years not accompanied by any pain or

discomfort. One year back they consulted a practitioner. When the appearance was better but were adviced no treatment. So they came to Govt. Dental College for checkup.

PAST HISTORY: PAST MEDICAL HISTORY: - No H/O Diabetes - No H/O Tuberculosis - Patient's mother gives a H/O jaundice 2 years post birth that lasted 5-7 days and treated by medication. - Patient had intermittent stomach ache 5-6 months back, relieved by medication,

no problem at time of reporting. PAST DENTAL HISTORY:No


dental treatment in the past

DRUG HISTORY:
- No drug on regular basis. - No known drug allergy.

ALLERGY: none PRENATAL HISTORY:


- No H/O prenatal trauma - Delivery: premature (8 months) cesarian section

FAMILY HISTORY: Lives with


mother, father and a younger sister - Father and mother are known

Hypertensive - No H/O diabetes in the family.

PERSONAL HISTORY:
He consumes a vegetarian diet.

DIET CHART:
Morning: tea/milk with 1 teaspoon sugar with 2 bread slices. Tiffin: 1 prantha with vegetable. Lunch: 2 chapati with curd and vegetable/pulse Evening: 1 bread sandwich with butter. Dinner: 1 chapati and a pulse. Bed time: milk, 1 cup with 1 teaspoon sugar and half teaspoon bournvita. Chocolates and toffees 1/2 per day

Brushing: - He brushes once daily with colgate paste and pedobrush. - Uses horizontal scrub method. - Employs 2-3 min to brush.

EXAMINATION
General Physical Examination - Vitals: Normal - No sign of edema or lymphadenopathy

EXTRA ORAL EXAMINATION

Symmetry of face: normal Nose: normal Eyes: normal Lip seal: Competent Lymph nodes: not palpable Ears: normal INTRA ORAL EXAMIINATION
HARD TISSUE TOTAL TEETH PRESENT= 20 FDI Notation 55 54 53 52 51 61 62 63 64 65 85 84 83 82 81 71 72 73 74 75 - 52, 51, 61, 62 teeth are

hypoplastic. - Incisal edges lack enamel cover. - Dentin visibilty clear. - Hypoplasia involves the incisal third and extends upto middle third of crown. TOP+ve - none Carious - 64, 74, 75

SOFT TISSUE - Tongue: normal - Buccal mucosa: normal - Labial mucosa: normal - Floor of the mouth: normal - Gingiva: normal - Palate: normal

PROVISIONAL DIAGNOSIS
Enamel Hypoplasia w.r.t teeth 52, 51, 61, 62

DIFFERENTIAL DIAGNOSIS
1. Arrested Caries 2. Amelogenesis Imperfecta 3. Turner's teeth 4. Fractured tooth

FINAL DIAGNOSIS
Enamel Hypoplasia w.r.t 52, 51, 61, 62

TREATMENT ADVISED
1. Complete build up of crowns of 52, 51, 61, 62 2. Restoration of caries on 64, 74, 75 with Glass Ionomer Cement or Composite. 3. Maintenance of Oral Health. 4. Advised 2 times Brushing.