final year dds paedodontics case
TRANSCRIPT
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
DD 5330
1
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
2
CONCLUSION ........................................................................................................... 32
THE UNIVERSITY OF THE WEST INDIES
DD 5330
3
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
4
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
5
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
6
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
7
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
8
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
9
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)
THE UNIVERSITY OF THE WEST INDIES
DD 5330
10
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
#6.5: Occlusal caries
#7.5: Occlusal caries
#7.4 occlusal caries with large cavitation, nil to percussion and palpation to the
best of TG’s awareness
#8.4: Occlusal caries
#8.5: Occlusal caries
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
11
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
12
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
13
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
14
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
15
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
16
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
17
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
18
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
19
MID TREATMENT PHOTOGRAPHS (12/09/12)
THE UNIVERSITY OF THE WEST INDIES
DD 5330
20
POST TREATMENT PHOTOGRAPHS (31/10/12)
THE UNIVERSITY OF THE WEST INDIES
DD 5330
21
POST TREATMENT PHOTOGRAPHS (31/10/12)
THE UNIVERSITY OF THE WEST INDIES
DD 5330
22
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
23
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
24
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
25
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
26
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
27
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
THE UNIVERSITY OF THE WEST INDIES
DD 5330
28
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
29
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
30
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
31
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
32
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.
THE UNIVERSITY OF THE WEST INDIES
DD 5330
33
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.