final year dds paedodontics case

CASE HISTORY

DATE OF EXAMINATION: April/May, 2013

CANDIDATE NUMBER: [808100046]

PATIENT INITIALS: [T.G]

CASE SUMMARY

T.G is a 3 year old female patient of African descent that presented to the UWI Child Dental

Health Unit with dental pain and a history of dental trauma and localized soft tissue swelling.

She was diagnosed as having early childhood caries and a possibly non-vital primary central

incisor. She was treated with conservative therapy including both palliative and definitive

restorations.

THE UNIVERSITY OF THE WEST INDIES

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Contents SECTION 1. PRE-TREATMENT ASSESSMENT.......................................................... 3

PATIENT DETAILS ...................................................................................................... 3

PATIENT COMPLAINT ................................................................................................ 3

EXPECTATION OF THE PARENT .............................................................................. 3

HISTORY OF PRESENTING COMPLAINT ................................................................. 3

MEDICAL HISTORY .................................................................................................... 4

SOCIAL HISTORY ....................................................................................................... 4

DENTAL HISTORY ...................................................................................................... 4

TRAUMA HISTORY ..................................................................................................... 5

ORAL HYGIENE PRACTICES .................................................................................... 5

DIET HISTORY............................................................................................................ 5

BEHAVIOURAL HISTORY .......................................................................................... 5

PRE-TREATMENT PHOTOGRAPHS: EXTRA-ORAL ................................................ 6

CLINICAL EXAMINATION: EXTRA-ORAL FEATURES .............................................. 7

PRE-TREATMENT PHOTOGRAPHS: INTRA-ORAL ................................................. 8

CLINICAL EXAMINATION: INTRA-ORAL FEATURES ............................................ 10

CROWDING/SPACING ............................................................................................. 10

OCCLUSAL FEATURES ........................................................................................... 11

PRE-TREATMENT RADIOGRAPHS and RADIOGRAPHIC REPORTS ................... 12

DIAGNOSTIC SUMMARY ......................................................................................... 15

PROBLEM LIST......................................................................................................... 15

AIMS AND OBJECTIVES OF TREATMENT ............................................................. 15

TREATMENT PLAN .................................................................................................. 16

ALTERNATIVE TREATMENT PLAN ......................................................................... 17

KEY STAGES IN TREATMENT................................................................................. 18

MID TREATMENT PHOTOGRAPHS ........................................................................ 19

POST TREATMENT PHOTOGRAPHS ..................................................................... 20

CASE DISCUSSION .................................................................................................. 22


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CONCLUSION ........................................................................................................... 32


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SECTION 1. PRE-TREATMENT ASSESSMENT

PATIENT DETAILS Initials: TG

Sex: Female

Date of birth: 16/06/08

Age at start of treatment: 3yrs

Date at presentation: 30/04/12

PATIENT COMPLAINT TG complained of pain in the lower left quadrant that was spontaneous in nature.

EXPECTATION OF THE PARENT To investigate infected tooth and remaining dentition.

HISTORY OF PRESENTING COMPLAINT

TG’s mother noticed that TG was feeling unwell and developed a diffuse left facial swelling that

affected the entire side of her face and became worse after three days. At its worst TG became

febrile and was hardly eating. At that time she was taken to the Arima Health Care Facility

(emergency department) where she was referred to the Arima dental clinic (within the same

facility). Here she received a prescription for Amoxicillin and Paracetemol syrup and a referral to

the Eric Williams Medical Sciences Complex (EWMSC) Dental Hospital. Upon taking this

medication the fever and swelling subsided. However over a short period of 3 weeks, the same

symptoms returned. She was then taken to the EWMSC Dental hospital and was prescribed the

same medication and given an appointment to return for treatment of the tooth. However, the

hospital repeatedly cancelled her appointments and treatment for the tooth was subsequently

sought at the UWI Dental School, Child Dental Health Unit.


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MEDICAL HISTORY Asthma (cold/flu, last attack; October of 2012)

Was hospitalized for a week for severe vomiting –

Blood sugar was found to be elevated. Diagnosis of Diabetes Mellitus was not given but

mother monitors it regularly to ensure that it remains within normal limits.

Skin rash on left ear

Drugs

1. Ventolin® (Albuterol sulphate)

2. Beclamethasone spray (50ug)

-Both drugs are only for symptomatic use

3. Micogel® (Miconazole)

4. Bonjela®

No known allergies

Pre-natal Within normal limits (no illnesses during pregnancy)

Peri-natal Vaginal delivery

Post-natal Jaundice as a neonate

SOCIAL HISTORY TG is a preschooler who resides with both parents and four siblings (three sisters and one

brother). Her eldest sister requires orthodontic treatment. Her mother is a seamstress and her

father is a carpenter.

DENTAL HISTORY No dental history prior to the emergency visit to address the soft tissue abscess.


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TRAUMA HISTORY Approximately a month ago (from date of presentation) she fell and hit her front tooth in

presence of her siblings, mother still hasn’t gotten a full account of the incident.

ORAL HYGIENE PRACTICES TG’s mother brushes her teeth (with much protest from TG) twice daily with a soft bristled

toothbrush and children’s Aquafresh®. Flossing or use of mouthwash was not a part of her daily

oral hygiene routine.

DIET HISTORY

The following is typical of weekday and weekend eating habits Breakfast

o Fruit, Bread/Bake, milk in the bottle

Lunch

o Cooked food; starches and a protein

Dinner

o Cereal/cooked meal

Between meals

o Homemade juice without sugar added

Breastfed at night (mother commented that TG would take out the breast herself at

night) and bottle-fed (Dairy Dairy) up until time of presentation.

BEHAVIOURAL HISTORY None to report


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PRE-TREATMENT PHOTOGRAPHS: EXTRA-ORAL (02/7/12)

Figure 1: Frontal view

No gross facial asymmetry

Figure 2: Profile view

Skeletal features Anteroposterior: Class 1

Vertical

o Lower face height:

Average

o Maxillary-Mandibular

Plane angle: Average

Transverse

o Bimaxillary Proclination:

Mild

Lips: Competent

Naso- labial angle: Reduced


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Figure 4: Rotated view

On smiling, discolored #51 is

distinctly visible

CLINICAL EXAMINATION: EXTRA-ORAL FEATURES All findings were within normal limits. Right and left non – tender, mobile submandibular lymph

nodes were palpated.


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PRE-TREATMENT PHOTOGRAPHS: INTRA-ORAL (02/7/12)

Figure 5: Frontal view

Discolored #51 can be noted

Upright and spaced upper

incisor, lower incisors are

minimally spaced

Decreased overbite

Figure 6: Right buccal view

Primate space mesial to #5.3

is evident in this view

Figure 7: Left buccal view

Primate space mesial to #6.3

is evident in this view


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Figure 8: Upper occlusal view (Not first presentation; taken after #5.4 was temporized)

Temporary restoration

visible on the occlusal

aspect of #5.4

Evidence of caries on

posterior teeth but true

extent cannot be

ascertained from this

view

Figure 9: Lower occlusal view (Not first presentation; taken after #7.4 was temporized)

Temporary restoration

visible on the occlusal

surface of #7.4

All other posterior teeth

showing occlusal caries

with worse affected teeth

being the #7.5 and #8.5

(see charting under

general dental condition)


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KEY__ Absent

•. Caries

Discolored

5 4 3 2 1 1 2 3 4 5

5 4 3 2 1 1 2 3 4 5

CLINICAL EXAMINATION: INTRA-ORAL FEATURES

Soft tissues: A soft tissue swelling, well circumscribed in nature on the buccal mucosa over #7.5

was noted.

Oral hygiene: Plaque deposits were found on the occlusal surfaces of all posterior teeth and on

the gingival one third of all labial and

buccal surfaces.

General dental condition:

Findings: #5.5: Occlusal caries

# 5.4: Occlusal caries

With large cavitation

#5.1: Grey discoloration

#6.4: Occlusal caries



#7.4 occlusal caries with large cavitation, nil to percussion and palpation to the

best of TG’s awareness



CROWDING/SPACING Maxillary arch: Spacing that is expected in the functional primary dentition including

primate spacing9999999

Mandibular arch: Primate Spaces are minimal in the lower arch


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OCCLUSAL FEATURES

Incisor relationship: Class I

Overjet (mm): 2 2

Overbite: Normal

Centrelines: Upper coincident to the face, lower to the left

Left buccal segment relationship: Distal step

Right buccal segment relationship: Distal step

Crossbites: Nil

Displacements: Nil

Other occlusal features: Nil


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PRE-TREATMENT RADIOGRAPHS and RADIOGRAPHIC REPORTS

Figure 10 Right bitewing (taken with a Snap-a Ray instrument on 25/05/12)

5.4 shows occlusal caries into dentine

and possibly involving the pulp

# 8.5 shows occlusal caries into

dentine

Figure 11 left bitewing (taken with a Snap-a Ray instrument on 25/05/12 after temporization of #7.4)

Overlap between #6.4 and # 6.5 and

#7.4 and #7.5 renders these areas

non- diagnostic

Intermediate restoration into the pulp

chamber of #7.4


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Figure 12: Lower left Periapical (taken with a Snap-a Ray instrument on 25/05/12 after temporization of #7.4)

Caries into pulp of # 7.4

Intermediate restoration within the

pulp chamber of #7.4

Developing successors to primary

molars seen (#3.4, #3.5)

Developing permanent first molar

seen (3.6)

Figure 13: Lower left Periapical (taken on 12/09/12 after temporization of #7.4)

Similar findings to above radiograph

with the exception of lost portion of

the temporary restoration


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Figure 14: Upper Right Periapical (taken on 12/09/12 after temporization of #5.4)

Caries involving the pulp of # 5.4

#5.4 also appears as extensive root

resorption however this view does not

allow accurate assessment of this

Figure 15: Upper Right Vertical Bitewing (taken on 16/03/13

Roots are indeed intact and fully

formed

Intermediate restoration within the

pulp chamber of #5.4

Crown of successor (#1.4) is evident

Film fault: Emulsion scratched

Figure 16: Upper Periapical (taken on 12/09/12)

#5.1 has a comparatively wider root

canal and slightly wider and less

distinct periodontal ligament space.

The periapical areas were not readily

diagnosed due to overlap with the

forming permanent successors (#1.1,

#2.1). Portions of #1.2 and #2.2 can

be seen as well


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DIAGNOSTIC SUMMARY TG is a 3 year 10 month old female of African descent with early childhood caries. She has a

history of the most severe sequelae of ECC (resulting in spread of infection to the soft tissues)

and a traumatized primary central incisor. She has been facilitated by her parent in prolonged

ad libitum (on demand) breastfeeding practices and prolonged bottle feeding habits.

PROBLEM LIST 1. Poor oral hygiene

2. Poor feeding habits

3. Caries (including grossly affected teeth)

4. Traumatized primary central incisor

AIMS AND OBJECTIVES OF TREATMENT 1. Establish a “Dental Home” by fostering mutually enriching and beneficial dentist-

patient (and parent) relationship based on trust.

2. Minimize anxiety and institute the use of appropriate behavior management

modalities.

3. Manage immediate pain and open cavities.

4. Introduce age appropriate oral hygiene practices.

5. Introduce age appropriate feeding practices while removing those negatively

affecting TG’s general dental condition.

6. Attain optimal therapeutic control of dental infection.

7. Ensure that traumatized tissues remain healthy and/or detect possible sequelae.

8. Ensure that her overall general dental condition remains in a healthy state.


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TREATMENT PLAN 25/05/12 1. Oral hygiene instruction

2. Dietary and childhood feeding advice

3. Temporization of open cavities (#5.4 and #7.4)

4. Restore

i. #5.5 occlusal

ii. #6.4 occlusal

iii. #6.5 occlusal

iv. #7.5 occlusal

v. #8.4 occlusal

vi. #8.5 occlusal

5. Pulpectomy and stainless steel crown on #7.4

6. Pulpectomy and stainless steel crown on #5.4(modified on 16/01/13)

7. Monitor traumatized #5.1 radiographically and clinically for signs and symptoms of

infection, resorption or canal obliteration


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ALTERNATIVE TREATMENT PLAN 1. Oral hygiene instruction

2. Dietary and childhood feeding advice

3. Temporization of open cavities (#5.4 and #7.4) for the sake of introduction to dental

surgery.

4. Restore

i. #5.5 occlusal

ii. #6.5 occlusal

iii. #7.5 occlusal

iv. #8.5 occlusal

5. Extract

i. #5.4

ii. #6.4

iii. #7.4

iv. #8.4

6. Pulpectomy of #5.1 and permanent restoration


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KEY STAGES IN TREATMENT

30/04/12 First visit and temporization of #7.4

21/05/12 Further treatment planning and

temporization of #5.4

15/06/12 Prophylaxis with tooth brush at chair side and

then with slow speed

16/07/12 First restoration (upper tooth), without local

anesthetic

23/07/12 First restoration (lower tooth), with local

anesthetic

12/09/12 Pulpectomy of #7.4

15/10/12

Stainless steel crown placement


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MID TREATMENT PHOTOGRAPHS (12/09/12)


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POST TREATMENT PHOTOGRAPHS (31/10/12)


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POST TREATMENT PHOTOGRAPHS (31/10/12)


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CASE DISCUSSION

Caries Risk Assessment

Caries risk factors unique to infants and young children include perinatal considerations,

establishment of oral flora and host defense mechanisms, susceptibility of newly erupted teeth,

dietary transition from bottle or breastfeeding to cups, and childhood preferences. (Preventive

oral health intervention for pediatricians, 2008). In the light of this statement, the following points

of assessment can be discussed from TG’s presenting condition. TG had not yet given up either

drinking in a bottle and on demand breastfeeding. In addition on the broader scope of caries risk

factors, the family’s socio-economic status may also play a role. I had the opportunity to visit

the home and in my humble opinion, there was need for structural improvement around the

home and immediate environment. While not wanting to venture far beyond my role as clinician

and further comment about these observations, and as will be discussed further, there may be

an association between the income of the family and the occurrence of ECC.

Fostering mutually enriching relationships

TG was a preschooler who had never visited a dentist in a formal fashion. Thus the

opportunities for assessing her caries risk at an early stage and establishing infant oral health

aimed at prevention were missed. Therefore, treatment commenced with introducing her to the

dental setting. The first attempt at this was aimed at ensuring that her mother felt comfortable

with the dental setting including avoidance of instilling guilt for her daughter’s dental condition.

Through the process of primary socialization, children become aware of normal modes of

behavior from their parents and the slightest upset in mothers can easily be detected by young

children. It was appreciated that any child at this age, with guidance from the parent (and those

around them by way of imitation), would need to let down their guard to begin building a trusting

relationship with the dentist (Jean Paiget, Erik Erikson). Thus with this in mind, a “second care

taker” approach was taken towards TG. The aim was to allow her to be comfortable with the

practitioner intruding as it were, and sharing the responsibility of doing no harm but remain firm

when needed, with her mother. This began with constant rapport with TG at the start of her

visits through to the end. Interestingly enough this proved to bring out her true talkative


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personality that was not so evident at preliminary visits. TG was also visited at home to allow

interaction to take place outside of the dental setting.

Minimizing anxiety, behavior management

Non pharmacological behavior management refers to the means by which the dental health

team effectively performs treatment for a child, aiming to instill positive dental attitudes (Wright).

The concept of behavior shaping and positive reinforcement was utilized in this case. Behavior

shaping involves teaching the patient small steps towards an ideal behavior. This is even more

significant for first time attenders such as TG. Positive reinforcement includes eliciting pleasant

reactions to the completion of these steps or display of behavior in order to increase the

likelihood of displaying the behavior again. The steps performed are highlighted in the key

stages in treatment in the earlier section of this report. The Tell-Show-Do technique was also

used. As the name implies the three phases represents an explanation, demonstration and

quick follow through of the procedure. This was done at each step (procedure), combined with

positive reinforcement for compliant behavior. TG responded well to these techniques initially,

starting with the acceptance of the slow speed and high speed handpieces as slow and fast

versions of her toothbrush. She graduated to tolerance of local anesthesia for one restoration.

However, she was intolerant of the same at the appointment for pulp therapy of #74 and

stainless steel crown application. This being later stage but vital treatment, the behavior

management technique employed at that visit was one of distraction to complete administration

of the local anesthetic with the help of a colleague. Although this method may have worked at

this appointment, it did not serve well for the following one. There may have been an unpleasant

element of surprise that caused TG to fully object to treatment of#54. Her behavior deteriorated

to the point of holding her hands over her mouth, coming of the chair and ignoring instructions

including those given my her mother. The procedure was subsequently aborted until further

notice.


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Management of pain and open cavities

Open cavities are sources of high bacterial load and pain. Stabilization of cavities such as these

was performed in TG in order to slow the progression of caries in these teeth, minimize future

bouts of pain and to allow behavior shaping with more preventive measures before placing

permanent restorations. Only one tooth (#7.4) was permanently restored after this phase. The

intermediate restoration on #5.4 is still in place.

Preventive Care

Upon presentation TG had already been affected by caries. In fact her presentation can be

described as early childhood caries (to be discussed further). Thus, the strategy employed was

one of secondary prevention. Caries can be described as a disease process resulting in the

demineralization of tooth structure as a result of bacterial action. The process itself is a dynamic

one involving both demineralization and remineralization. The extent of the disease depends on

the balance between these two. The four pillars of caries prevention are plaque control/

toothbrushing, diet, fluoride, and fissure sealing. The balance between causative and protective

mechanisms comes into play. With the exception of fissure sealing, these pillars were the

central building blocks of TG’s preventive care.

Plaque control

Brushing technique appropriate for TG’s age (Fones technique for 2-3mins) was demonstrated

and both mother and child were asked to mimic and execute the technique at the sink in the

unit. The use of a mirror was encouraged. Advice given included:

Twice daily brushing with a soft toothbrush especially last thing before bedtime.

Amount of toothpaste should be restricted to a pea sized amount.

Always assist TG when brushing (the mother already demonstrated effective positioning

behind TG for this.

Avoid excess rinsing.

TG was already using appropriate toothpaste.

Evidently caries cannot be prevented by toothbrushing (removal of cariogenic bacteria) alone

but is an important vehicle for delivering fluoride to tooth surfaces.


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Fluoride use

The naturally occurring element that is fluoride has been pivotal in the prevention of caries. Its

applications include both topical and systemic delivery. Toothbrushing delivers it topically and a

summary of its preventive mechanisms are as follows:

1. Inhibits the glycolytic pathway in cariogenic bacteria, affecting acid production.

2. Encourages remineralization while inhibiting demineralization when present at the

surface.

3. Forms fluoroapatite crystals during remineralization which is harder and more resistant

to attack.

4. Can lower the critical pH which results in dissolution from 5.5 to 4.5.

Other mechanisms of action apply to its systemic use.

Nutrition and diet

TG is normally kept on a low sugar diet due to the tentative diabetes mellitus diagnosis and as

such, nutrition advice more so than dietary advice was given. TG’s breastfeeding and bottle

feeding habits were already mentioned and this will be discussed as a background to her caries

management.


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Caries management

Caries management includes all of the following:

1. Prevention (in the absence of caries, already discussed)

2. Arrest caries

3. Treat operatively

a. Caries removal and restoration

b. Pulp therapy and restoration

4. Extraction

The carious lesions discovered after examination were not amenable to arresting measures

such as diet modification, fluoride application and oral hygiene. The lesions present represented

a more advanced state of demineralization.

Early childhood caries (ECC) is an all-encompassing term that is used to describe the

presentation of dental caries in the primary dentition of young children (Welbury) or more

closely, in preschool children at the age of 2 years to 5 Years 11 months. The most frequent

presentation includes caries affecting the upper incisors and first primary molars and lower

molars with sparing of lower incisors. This severe form is associated with the frequent drinking

of sweetened liquids held in nursing bottles or reservoirs. Thus, the term nursing caries or bottle

mouth caries was coined to describe this. However ECC can also present in the slightly older

child (coinciding with TG’s age of 3-4 years) with multiple carious teeth. All of TG’s molars were

in fact carious two of them being grossly affected. Challenges to her treatment planning

included bitewing radiography. TB found difficulty in biting down on the soft pliable paper bite

tabs. To solve this problem, a Snap- a Ray instrument was used to provide a hard biting surface

as the bitewing film holder proved to be too big for her small oral cavity.

The etiology of ECC has been attributed to poor nutrition habits as earlier mentioned. In addition

to frequent bottle-feeding (cow’s milk), TG also breastfed at night while her mother slept. In

general, lactose (extrinsic milk sugar) is less cariogenic or acidogenic than sucrose, glucose or

fructose and is present in both cow’s milk and breast milk (4%). Some circumstantial evidence

suggest that prolonged on demand breastfeeding contributes to early childhood caries. The

proposed association suggested that prolonged breastfeeding is more frequent in low-income

populations (Rogus, Emmet, & Golding, 1997) (Dini, Holt, & Bedi, 2000) and that a high


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prevalence of ECC was observed in low income populations (Finlayson & Ismail, 2006). By

linking the two this suggests an association between prolonged breastfeeding and ECC.

With this in mind TG’s mother was firmly advised against:

1. Bottle-feeding: TG is without a doubt past the age for drinking in a bottle and can drink

from a cup.

2. On demand breastfeeding: The nutritional benefits of breastfeeding are no longer

substantial for TG and only serve as comfort. Furthermore TG’s sleeping patterns

require stern attention to curb the habit.

TG’s mother appeared to agree with the advice and would often repeat it to the child at the visit.

She has subsequently bought a “Sippy” cup which is still not ideal but shows that some effort is

being made. With respect to the breastfeeding, up to last appointment date, TG still has not

curbed the habit. Other positive dietary practices were further reinforced with emphasis on a

well-balanced diet. The use of beclamethasone was noted but TG is not on long term use and

as such it was not considered as a contributory factor in her caries presentation.

Operative treatment

Caries Removal and restoration

Tenets of caries removal include:

1. Removal of soft infected dentine

2. Retention of hard but discolored dentine in the base of the cavity

3. Preservation of as much tooth structure as possible

4. Avoidance of unnecessary pulp damage

5. Improvement of esthetics

As part of the behavior shaping tool, TG was introduced to the slow speed handpiece and

tungsten carbide bur during the stabilization of open cavities and rubber cup prophylaxis. In

moving to the next step, a minimally (relatively) carious upper molar was chosen for placement

of the first definitive restoration (#5.5O) It was performed without local anesthetic solution while

keeping constant communication with TG for indications of pain. TG often fell asleep at the

restoration phase of the procedure, making it somewhat easier to complete the procedure.

TG’s first restoration with the use of local anesthetic was performed on a lower second molar

(#8.5). It was administered during caries removal when TG appeared uncomfortable (without


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alarm, crying). The remaining caries was then removed and the tooth restored. The

administration of local anesthetic for the first time should have been ideally done on an upper

tooth.

Pulp therapy

In the light of TG’s presentation of rampant caries, it is no surprise that two of the eight carious

teeth were pulpally involved. This is due to the small size of the teeth, relatively large pulp

chambers, rapid caries progression and early onset combined with failure to diagnose and treat.

Alternatives to pulp therapy, as suggested included extraction of these teeth (as well

contralateral teeth) as a result pulp therapy is preferred.

Indications included:

1. Cooperation (Initially)

2. Avoidance of general anesthesia

3. Age of the patient

TG is too young to extract #54 and #74 as a primary option. The permanent successors

are present but they are due to erupt between 10 and 12 years.

4. Space maintenance

For the same reason as above, her natural teeth would act as space maintainers for the

first premolars.

Teeth #7.4 and #5.4 required pulpectomy (endodontic treatment involving removal of necrotic

pulp tissue by gentle instrumentation and filling the root canal systems with a filling material that

will resorb along with the tooth) as the treatment modality of choice. Treatment planning for

these teeth was flawed in that adequate radiographic assessment was not made. Due to

difficulties in obtaining bitewing radiographs, the provisional treatment plan was made based on

the clinical history of these teeth. Subsequently, upon consultation, periapical radiographs were

requested. With particular mention of #5.4, the roots appeared to be resorbed in this view and

the treatment plan that followed dictated that #5.4 be left alone for natural exfoliation. However,

further reassessment with vertical bitewings revealed two fully formed, intact roots. This

oversight proved to an obstacle in the complete appreciation of TG’s treatment needs. This

option is not preferred as the infected tooth would be given opportunity to cause suffering over

medium to long term.


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Pulpectomy is indicated in a cooperative child and carries a treatment success rate of over 90%.

Clinical features include:

1. Exposure of a non-bleeding pulp

2. Symptoms or signs of irreversible pulpitis, periapical periodontitis or acute abscess

3. Absence of facial swelling

The root canals were dressed with CaOH. Other dressings include iodoform paste and zinc-

oxide-eugenol. A mixture of CaOH and iodoform paste may have been preferable to CaOH

alone as a success rate defined by resolution of pain, inflammation and swelling after the first

6months recall, was reported to be 100% with the use of CaOH and iodoform paste (Walkhoff’s

Master Formula) (Mendoza, Reina, & F, 2012). Challenges experienced during this procedure

included hesitancy to receive local anesthesia. This resulted in non-ideal use of cotton roll

isolation as opposed to rubber dam and clamp during the procedure. The definitive restoration

for grossly carious teeth that are void of two or more surfaces is the stainless steel crown. This

was applied at a subsequent visit. Review of this pulp treated tooth is required within one year.

Traumatic Injury

Traumatic injuries to the dentition are fairly common in young children with the central incisors

being most commonly affected. It is thought to be the third main cause for the mortality of the

tooth that is affected. In the absence of emergency presentation, trauma to TG’s #5.1 was

diagnosed clinically and to a lesser extent radiographically. There are two main possible of

injuries that may have occurred:

1. Concussion: No clinical loosening of the tooth. At time of injury, the tooth is severely

tender to percussion in both a horizontal and vertical direction.

2. Subluxation: Abnormal mobility in a horizontal direction and sensitive to percussion and

occlusal forces.

No treatment in either case is indicated in primary teeth.


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Dental materials

Resin Modified Glass Ionomer Cement (RMGIC)

TG’s #5.5, #8.4 and # 8.5 were restored with (RMGIC)

RMGIC is the restorative material of choice in restoration of primary teeth. This material is a

modified version of Conventional Glass Ionomer Cement (CGIC) and it improves the

disadvantages CGIC. Properties of this material include:

Its ability to bond to enamel

Fluoride release

Ability to absorb fluoride from the oral cavity and serve as a fluoride reservoir for later

release.

Aesthetics – considered a tooth coloured material and is available in different shades,

however exact match is not possible all the time.

Improved wear characteristics when compared to CGIC

Less brittle than CGIC

Improved fracture toughness when compared to CGIC

Less erosion from acid attack

Can be used where moisture control is difficult unlike CGIC

The ease of use of this material was priceless as it allowed for a short appointment time for

TG.

Composite resin

Resin composite by definition contains four structural components: polymer matrix, filler

particles, a silane coupling agent and an initiator. The polymer matrix is usually Bisphenol-A-

glycidyl methacrylate and the filler particle some type of glass. Setting of the material is based

on the polymerization of the resin. Composite resin was used to restore #6.4, #6.5 and #7.5.

These cavities were barely into dentine however, the choice to use this material was primarily

due to preference of the supervising instructor. RMGIC would have been a better choice for the

reasons listed above especially less leakage. These restorations were then sealed along with

the remaining fissure system.


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Stainless Steel Crowns

These are pre-fabricated crowns with very high success rates that are placed on primary teeth

and sometimes permanent teeth as a result of:

Extensive loss of tooth structure as a result of decay

Restoring a primary teeth following pupil treatment

Restoring teeth that are affected by genetic conditions.

Stainless steel was used as the definitive restoration of #7.4 following pulpectomy.

Cresophene

Cresophene is combination of two antiseptic agents including a powerful bactericide,

parachlorophenol with a corticosteroid dexamethasone. The antiseptics includes: thymol, and

camphor. It has low irritant properties and is used as a desensitizing agent in pulpal treatment.

Cresophene was used in the temporization of#7.4 and #5.4. To avert the symptoms that were

experienced on this tooth prior to temporization a better choice of medicament may have been

ledermix or foromocresol, knowing that pulpectomy was already planned.

Non setting Calcium Hydroxide

This material was used in the pulpectomy technique to fill the root canal systems of #7.4. It is

completely, resorbable as well as radioopaque.

Intermediate Restorative Material (IRM)

IRM is a zinc oxide eugenol based material that is used as an interim material until a permanent

material can be placed. It is considered the least irritating of all dental materials due to its

sedative effect on the pulp. Its component includes a powder and a liquid. The liquid consist of

eugenol which is bactericidal while the powder consists of zinc oxide. IRM was used as a

temporary restoration on tooth #7.4 until definitive treatment could be completed and permanent

filling material place. It was left in situ in tooth #5.4 which would be replaced at appropriate

intervals until exfoliation.


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Future treatment

Another attempt to treat #54 accordingly will be made. TG’s risk factors will be continuously

monitored and anticipatory advice given. In about two years she will be introduced to topical

professionally applied fluoride and sealing of her first permanent molars.

Critical appraisal

Formulation of the association between prolonged breastfeeding and ECC underscores

common practice and certainly probably best practice. However the history elicited from TG’s

mother did not document the occurrence of ECC in her other siblings (although she commented

vaguely that TG was the only one) as well as the practice of prolonged breastfeeding with them.

In addition one study found that without making adjustments for confounding factors such as

child’s age, nocturnal breastfeeding, infant formula, and daily sucrose consumption between

meals, the association should not be believed to be strong. (Nunes, et al., 2012) However TG

did breastfeed at nights and there was the confounding factor of bottle-feeding. Thus, while

giving advice more emphasis should have been placed on the parents instituting and enforcing

rules about co-sleeping. There may have been some limitation for this as TG’s parents are only

now expanding the home to accommodate all five children.

Prognosis

TG’s caries activity has decreased. However prognosis will be improved once her mother

stands firm to cease breastfeeding especially at night time.

CONCLUSION The management of early childhood caries requires careful consideration of the factors

involved. While the factors for dental caries as a whole may be well known, management of the

preschooler presents additional challenges for the clinician. This case report highlighted the fact

that prevention is better than cure.


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REFERENCES

Preventive oral health intervention for pediatricians. (2008, June). Pediatrics, pp. 1387-1394.

Dini, E., Holt, R., & Bedi, R. (2000). Caries and its association with infant feeding and oral-health

related behaviors in 3-4 year old Brazillian childrem. Community Dentistry and Oral

Epidemiology, pp. 241-248.

Finlayson, T., & Ismail, A. S. (2006). Psychosocial factors and early childhood caries among low-

income African America nchildren in Dtroit. Communiy Dentistry and Oral epidemiology, pp.

25-35.

Mendoza, A., Reina, J., & F, G.-G. (2012, January). Pulpectomy of Necrotic Primary Teeth may be

an Effective Tool in Managing the Primary Dentition. Journal of Evidence Based Dental

Practice, pp. 39-40.

NG, M. W., & Chase, I. (2013, January). Early Childhood Caries: risk based disease prevention and

management. Denatl Clinics of North america, pp. 1-16.

Nunes, A., Alves, C., Araujo, F., Ortiz, T., Ribeiro, M., Silva, A., et al. (2012, Dec). Association

between prolonged breast-feeding and early childhood caries: a hierarchical approach.

Community Dentistry and Oral Epidemiology, pp. 542-549.

Rogus, I., Emmet, P., & Golding, J. (1997). The incidence and duration of breastfeeding. Early

Human Development, pp. 45-47.

Welbury, R., Duggal, M., & Hosey, M. (2005). Paediatric Dentistry. Oxford: Oxford.

final year dds paedodontics case

Documents

dental history

trauma history

history of dental trauma

medical history

social history

diet history

behavioural history

oral features