Name

Age

CC

HOPI

MH

Medical Condition (Congenital heart defect, Asthma/breathing issues, born prematurely,

learning/communication problems, anemia, abnormal bleeding issues etc.)

Medications (Dose, Frequency of Use)

Allergies

Surgery or Hospitalization (When, Reason)

DH

Last visit to dentist

Last treatment

How was the child behaviour

Has patient had an injury to the mouth, teeth or jaw. Explain

Was/Is patient breastfed or bottle fed

Until what age – Breastfed Bottle fed

How often does patient brush teeth

With or without help

Toothpaste

Toothbrush

Does patient

 Suck Thumb Fingers

 Use Pacifier
 Bite/Chew Finger Nails
 Have speech issue
 Clench/Grind teeth
 Mouth Breathing

Diet
Clinical Examination

E/O

Patient’s Size, Stature, Gait or involuntary movements

Sign of Malnutrition

Hands

 Elevated temperature
 Cold clammy hands or bitten fingernails (sign of anxiety)
 Clubbing
 Callused or unusually clean digit (persistent sucking habits)

Hair (headlice, ringworm, impertigo)

Head, Face, Neck (size, shape, symmetry, function)

TMJ

I/O

Buccal Mucosa

Palate & Oropharynx

Tongue & Floor of Mouth

Gingivae & Periodontium

Hard Tissue

Number of Teeth

 Primary Teeth
 Permanent Teeth

Mobility of Primary Teeth

Presence

 Congenital missing teeth

 supernumerary teeth
 carious lesions
 restorations
 ectopic eruptions

Plaque Score

Caries Risk Assessment

Occlusal Review

Facial Profile

 Class I – Normal
 Class II – Retrognathic
 Class III – Prognathic

Arch Length – Adequate/Inadequate

Molar Relationship

Primary (Terminal Plane) R L

 Straight
 Mesial Step
 Distal Step

Space/Non-spaced Dentition –

Primate Space R L

 Max (btw B&C)

 Mand (btw C&D)

Incisors Relationship

 Overjet mm
 Overbite mm (normal 2-3mm)
 Openbite mm

Fluoride Varnish Instructions

 not to eat or drink for 30 minutes following the procedure.

 eat soft food for the rest of the day
 advise that teeth should not be brushed that day but toothbrushing with fluoride toothpaste
should resume the following morning

OHI

 Brush teeth and gums at least twice daily, in the morning and last thing at night.
 Use toothpaste containing at least 1000 ppm (parts per million) fluoride.
 Children should be supervised until the age of 7 and encouraged not to swallow toothpaste
while brushing.
 ‘Spit, don’t rinse’ after brushing – this gives the toothpaste time to work to protect teeth.
 Keep food and drinks containing sugar to mealtimes only. Reduced frequency and amount of
sugary food and drinks
 Plain milk and tap water are the safest drinks for teeth.
 Visit the dentist every 6 months for review – apply fluoride varnish to teeth twice a year
Amount of paste

0-3 years – smear of toothpaste

3-6 years – pea size of toothpaste