Case 2

History of the chief complaint: 

BA experienced consistent pain in his lower right back tooth, which disrupted his sleep for two nights. His mother administered Ibuprofen, which reduced the pain but did not fully relieve it. They subsequently visited a dentist, who extracted the affected tooth. The dentist also informed them that BA has other teeth requiring treatment to prevent further progression to the nerve, which could result in pain. These teeth are permanent, and they now seek treatment for them. Currently, BA is not experiencing any pain.

Prenatal history: 

BA's mother had gestational diabetes. Her doctor prescribed Metformin tablets and the standard prenatal supplements. She was also placed on a special diet. Aside from this, she was otherwise healthy. 

Natal history: 

BA was born full-term with no reported neonatal jaundice, birth complications, injuries, or congenital abnormalities. 

Postnatal history: 

BA was breastfed until the age of 9 months and continued to use a bottle until the age of 3 years, consuming formula and sugary juices. The mother described his feeding pattern as "on demand." However, she does not recall wiping BA's teeth after feeding. After weaning, BA transitioned to drinking from a cup. He consumed milk with added sugar and sugary juices, along with water. He also began eating regular family meals. 

Medical history: 

BA is a healthy child with no significant childhood illnesses and is up to date with all his vaccinations. He has no known allergies, although there is a family history of an allergy to diclofenac sodium. 

Dental history and oral hygiene practice: 

BA's last visit to the dentist was a few months ago. During that visit, he had his lower right back tooth extracted due to caries, and he also had a tooth removed from the upper right side because it was rotten and causing pain; his mother does not recall the exact timing of the latter extraction. BA was cooperative during the first extraction, but on his most recent visit, he cried, reporting pain. The dentist proceeded with the extraction despite his distress, which traumatized BA. It took significant effort to convince him to return today. BA brushes his teeth once a day in the morning by himself since he was 6, using adult toothpaste. Although his mother supervises him, it is not done regularly. 

BA is an intelligent child who exhibits signs of anxiety and nervousness. His academic performance is good, and he participates in track and field. He is quite shy, tends to keep to himself, and does not make friends easily. 

His facial appearance was symmetrical and normal, with no palpable lymphadenopathy. The temporomandibular joint was functioning properly, and his muscles were relaxed with no abnormalities detected.

Morphological examination of the face:

BA exhibits a convex facial profile with a prognathic maxilla and slightly retrognathic mandible; lips are competent. 

BA is in the Second Transitional Stage. No abnormalities were found in the tongue, frenum, or mucosa. 

No anomalies or pathologies. The bone and soft tissue anatomy appeared normal, with all permanent teeth except wisdom accounted for. The estimated dental age is 10, corresponding to the second transitional stage. Canines are positioned favourably, and the sequence of eruptions is unfavourable: 13 ahead of the 15, 23 ahead of the 25, 34&35 ahead of the 33, and 44 ahead of the 43. Leeway spaces are compromised in the four quadrants; interproximal caries in 55, earl loss 54, 64, 74 &84.  

BA's attitude was rated as negative on Frankl's Behavior Rating Scale (Shao et al., 2016).

His previous unpleasant dental experience seems to have contributed to noticeable signs of anxiety and nervousness, which will be addressed through desensitization.

To manage BA's behaviour effectively, a combination of techniques will be employed, including modelling, tell-show-do, distraction, enhancing control, and positive reinforcement.

• Modelling Technique: Since BA was accompanied by his older brother, who displayed a positive attitude during his dental visit, BA was given the opportunity to observe his brother's treatment. This modelling approach will help alleviate some of BA's apprehensions by showing him that dental procedures can be completed calmly and positively.

• Tell-Show-Do Technique: BA's previous dental experience involved only extractions, which has led him to fear further extractions. To mitigate this fear, we will explain and demonstrate each step before proceeding. This will help reduce his uncertainty and put him at ease during the treatment.

• Distraction: To keep BA's attention away from discomfort, we will use TV as a distraction tool and engage him in conversation throughout the procedure, minimizing negative or avoidant behaviours.

• Enhancing Control: BA has been instructed to raise his left arm if he feels uncomfortable or needs a break. We will respond promptly to his signal, giving him a sense of control and helping to reduce his anxiety.

Throughout the treatment, we will closely monitor BA's responses, adjusting our approach as necessary to ensure his comfort and cooperation. Our goal is to ensure a positive and successful dental experience for BA.

• As there is no immediate emergency, we will start with the least invasive procedures to build his trust and cooperation before progressing to more complex treatments.

• Preventive Phase:

1/ Oral hygiene education.

2/ Fluoride application: 4 times per year as BA is a high caries risk child.

3/ Diet analysis: A 3-day diary.

4/ Caries control: 26m, 36m, 46m (non-cavitated)

4/Fissure sealant: 14, 24, 34, 35, 44, 45

• Restorative treatment: 16o possible pulp therapy, 55mod, 26od possible pulp therapy 36o, 46o.

• Orthodontics: Consultation regarding the increased overjet.

Overjet reduction:

An increased overjet significantly raises the risk of dental trauma, accounting for 21% globally (Cobourne et al., 2022). The question is whether to recommend early orthodontic treatment for overjet reduction specifically to reduce trauma, given that early class 2 treatment has few real advantages in improving skeletal effects (Cobourne et al., 2022). While early treatment seems logical, it has drawbacks such as longer treatment duration, extended retention periods, potential compliance issues, and higher costs (Cobourne et al., 2022). High-quality evidence on the benefits of early overjet reduction is lacking, as retrospective studies often overstate positive outcomes. However, three major RCTs found no significant long-term differences between early and late treatment of Class II malocclusion (Keeling et al., 1998, O’Brien et al., 2010, O’Brien et al., 2003). However, early treatment showed some reduction in incisor trauma, lowering the risk from 25.5% to 14.2%, though results varied widely across trials (Cobourne et al., 2022). Early intervention may thus be considered, especially if there's a high risk of trauma or social issues like bullying due to prominent teeth (Batista et al., 2018). Decisions about treatment timing should be individualized, balancing the benefits of trauma prevention and potential social advantages against the longer and more burdensome treatment process. Early treatment should not be routinely recommended for all cases based on the expectation of significant facial growth or oral function improvements (Cobourne et al., 2022).

Prosthetics: Mouth guard.

BA's has incompetent lips and increased overjet (8mm). Increased overjet, particularly with dental protrusion, significantly raises the risk of dental trauma, with a global increase in trauma risk of about 21% (Cobourne et al., 2022). Mouth guard Shields teeth from potentially traumatic blows and absorbs/dissipates energy (de Wet et al., 1999). Additionally, BA practices track and field. Even though it is not a contact sport, it still carries the risk of dental trauma. Any activity involving a risk of injury necessitates protective consideration (Polmann et al., 2020; Navarro et al., 2018). 

1. Introduction of measures to lower BA’s caries risk in the long term: A tooth-friendly diet, effective daily tooth brushing, and adequate fluoride usage.

2. Utilize easy, non-invasive treatments like Silver Modified Atraumatic Restorative Technique (SMART) to help KC become familiar with dental care while preventing the progression of caries.

• Rationale:

BA is a high-caries-risk child. Establishing measures to lower his caries risk in the long term allows us to focus on treating the underlying disease process rather than simply addressing the outcomes.

Due to BA’s limited cooperation, he cannot yet tolerate the steps required for adhesive fillings. However, we plan to gradually introduce him to dental care through non-invasive treatments like SMART, with the goal of helping him become more comfortable with dental procedures and eventually being able to tolerate adhesive fillings after successful desensitization.

• First visit:

1/ Diagnosis and treatment plan

2/ Oral Hygiene Instruction and Demonstration:

Active brushing and flossing using a disclosing agent. Even though BA is 9 years old, BA's mom was advised to assist him in brushing his teeth twice a day and flossing until he can do it properly. They should use a disclosing tablet to guide him, as he never learned how to brush properly.

3/ Fissure sealant: 14, 24, 34, 35, 44&45. As BA is a high-caries-risk child and good moisture control was achieved, the resin-based fissure sealant 3M™ Clinpro™ Sealant was selected for its fluoride-releasing, caries-preventive benefits (Simonsen, 2002).

4/ Fluoride application: Because of the controlled swallowing reflex at his age, and he could understand the instructions. Acidulated phosphate fluoride gel ([APF]; 1.23% F, 12,300 ppm F) 4 times per year as he is a high-risk child.

Professionally applied topical fluoride treatments efficiently reduce the prevalence of dental caries. APF has a low pH, enabling it to deliver fluoride faster into enamel (AAPD).

However, in the following visits, 2% Neutral Sodium Fluoride Topical Gel will be applied instead of APF as multiple resin-based restorations are planned. APF should be avoided on teeth with certain dental restorations, such as porcelain crowns or resin-based restorations, as the acidic environment can etch and damage these materials (Shabzendedar et al., 2011).

• 5/ Positive reinforcement: BA was rewarded with a balloon.

• Reiteration of OHI

• 16, 26, 46 Silver Modified Atraumatic Restorative Technique (SMART):

It involves applying 38% SDF to a cavity, followed by the immediate restoration or sealing of the cavity using GIC. This innovative approach combines the benefits of three established principles:

1. SDF effectively halts the progression of caries.

2. For deep lesions that approach the pulp, partial or incomplete removal of caries is performed.

3. A chemically sealed and bonded GIC restoration is properly placed to ensure the best outcome.

By using SMART restorations as ITR, patients can experience the successful elimination of bacteria and the prevention of further caries development while preserving their tooth structure and enhancing pulp vitality. While most research documents the cessation of caries in deciduous teeth, the mechanisms suggested for how silver diamine fluoride (SDF) assists in arresting caries are presumably applicable to permanent teeth as well (Duggal et al., 2022).

ITR may be used in very young patients, uncooperative patients for whom traditional cavity preparation or placement of traditional dental restorations is not feasible or needs to be postponed. Additionally, ITR may be used for caries control in children with multiple open caries lesions prior to definitive restoration of the teeth (AAPD, 2009, APD, 2019).

• 5/ Positive reinforcement: NC was rewarded with a balloon.

BA appeared more relaxed and comfortable, having warmed up to the dental team.

• 55om

Complete caries removal was achieved as the caries were in the D1 stage. Topical anaesthesia was applied to facilitate matrix band placement. Sectional matrix bands were applied. The cavity was filled with compomer Dyract XP, chosen due to BA's cooperation and the good isolation achieved. Given that the cavity was in high-stress-bearing areas and BA is a high caries risk child, Dyract has Higher fracture resistance and toughness than GIC and RMGI; the fluoride-releasing properties of compomer Dyract XP made it the material of choice. Other options included Vitremer, which had similar failure rates; however, the compomer presented superior clinical performance (Pummeret, 2019).

• Positive reinforcement: BA was rewarded with a balloon.

• 16od: It displayed no mobility, was not tender to percussion and had a non-lingering response to cold pulpal sensibility testing (ethyl chloride). On the radiograph, caries extend to the inner third of the dentine (D3), and it is removal risks the exposure of the pulp, which is the definition of a deep carious lesion (DCL). Any cavity that puts the pulp at risk of exposure during excavation should be classified as a DCL (Schwendicke and Innes, 2018). 

This tooth was treated with a selective removal to soft dentin (SRSD) caries removal strategy. SRSD is advocated for treating deep carious lesions in teeth with vital pulps (Schwendicke and Innes, 2018).

Carious lesions can and should be managed conservatively, first and foremost, by controlling those aetiological factors of the carious process. Such strategies include biofilm disruption and hermetically sealing cariogenic biofilm from its nutrient supply (Martignon et al., 2019, ESE, 2019). Therefore, from an operative perspective, selectively excavating carious tissue can be effective without eradicating the entire bacterial population (Schwendicke and Innes, 2018).

In the short term, the non-selective caries excavation approach involves unnecessary overpreparation of tooth structure, resulting in damage to the dentine-pulp complex (ESE, 2019). In the long term, the unnecessary excessive removal of healthy tooth structure tends to compromise the mechanical integrity of the tooth, making it more prone to potentially catastrophic cracks, fractures and their associated sequelae (Schwendicke and Innes, 2018). 

Particularly in the deeper cavity, excessive removal of tooth structure would tend to increase the risk of pulpal exposure, resulting in irreversible damage to the odontoblastic barrier and death of primary odontoblasts (Schwendicke and Innes, 2018). On the other hand, selective caries removal arrests carious lesion activity while simultaneously reducing the risk of pulpal exposure and preserving the odontoblastic barrier, a crucial area that induces the more ordered deposition of reactionary rather than reparative tertiary dentinogenesis (Martignon et al., 2019, Schwendicke and Innes, 2018). It also reduces the risk of bacterial ingress into the pulp, thereby maintaining pulp vitality. This maximises the prognosis of the tooth and should reduce long-term management costs and burden. Although dentine bonding to so-called caries-infected or caries-affected dentine is weaker, this is thought to be clinically insignificant as the appropriately prepared cavity should be surrounded by sound enamel and dentine with which one can consequently achieve high bond strengths and a hermetic seal when methacrylate resin-based adhesives are used (Schwendicke and Innes, 2018).

Reactionary Tertiary Dentinogenesis:

• Definition: Reactionary dentinogenesis refers to the formation of tertiary dentin in response to mild stimuli, such as shallow caries or minor restorative procedures.

• Process: It involves the activation of existing odontoblasts.

• Characteristics: This process generally leads to the deposition of dentin with a similar composition and structure to the primary and secondary dentin. The formed dentin is typically tubular, preserving the continuity of dentinal tubules.

• Function: The main purpose is to protect the pulp from mild injuries by increasing the thickness of the dentin barrier.

• Prognosis: Generally associated with a more favourable prognosis, as it preserves the original odontoblasts, forming a dentin layer that closely resembles the tooth's natural structure and function. This preservation helps maintain normal tooth function and reduces the risk of future complications.

Reparative Tertiary Dentinogenesis:

• Definition: Reparative dentinogenesis occurs in response to more severe stimuli, such as deep caries, trauma, or more invasive dental treatments.

• Process: When the original odontoblasts are damaged or destroyed, new odontoblast-like cells are differentiated from dental pulp stem cells.

• Characteristics: The dentin formed in this process is generally less tubular and more irregular in structure compared to primary and secondary dentin. It often has a more tubular and disorganised appearance, which helps seal off the damaged area and protect the pulp from further injury.

• Function: It serves as a protective mechanism to isolate the pulp from harmful stimuli and prevent further damage (Smith and Lesot, 2001).

Prognosis: While it effectively protects the pulp, the dentin formed is often less organized and more irregular, which may not integrate as seamlessly with the existing tooth structure. This can result in potential weaknesses or vulnerabilities in the tooth over time, potentially affecting its long-term stability (Smith and Lesot, 2001, Farges et al., 2015, Banerjee and Watson, 2015).

• Procedure:

Topical anaesthesia followed by local anaesthesia with 2% lidocaine containing 1:100,000 epinephrine, using one ampule Intraligamentary with the STA system. A rubber dam was applied to ensure isolation. Caries was removed from the margins of the cavity using a round bur in a high-speed handpiece, as cavity margins and peripheral dentine should be caries-free and prepared to sound hard dentine. The dentine situated on the pulpal wall was reduced using a large round bur in a slow-speed handpiece.; Restricting the amount of carious dentin left will ensure that the bonding area is as large as possible, thereby improving the bond strength and sealing the restoration. However, it will also avoid the so-called trampoline effect (Schwendicke et al., 2018).

A close sandwich technique (GIC+composite) was used.

The sandwich technique is highly effective for managing deep cavities, providing essential pulpal protection and enhancing the durability of restorations. The technique shields the pulp by using a glass ionomer cement (GIC) base, which bonds well to dentin and matches the tooth's thermal expansion. The GIC also releases fluoride, which aids in remineralizing the surrounding dentin and prevents secondary caries, making it especially useful for patients at high risk of cavities. Additionally, the strong bond between the GIC and tooth structure minimizes microleakage, a common cause of restoration failure, and is a reliable bonding layer for the overlying composite resin. This GIC layer also helps absorb occlusal stress, reducing the likelihood of fractures in the composite, particularly in areas under high load. In closed sandwich techniques, where the GIC is fully covered by composite, the emphasis is on strengthening the bond and minimizing the risk of microleakage (Shocker and Motea).

• Note: Given the extent of the caries, which had led to the breakdown of part of the distal and palatal walls, I recommended placing a stainless steel crown as an interim restoration. This would protect the tooth until a permanent crown could be completed once growth ceases, or the option of extraction could be considered to utilize the space for overjet reduction. However, BA's mother did not approve it.

• 26odp: The same procedure used for tooth 16 was followed for tooth 26.

However, the tooth was filled with high-strength zinc-reinforced GIC ChemFil Rock, as I planned to use a stainless steel crown at a later date. After further explanation and motivation, BA's mother approved the use of the stainless steel crown. 

36o.

The stamp technique was used to restore the occlusal anatomy.

Topical anaesthesia followed by local anaesthesia with 2% lidocaine containing 1:100,000 epinephrine, using one ampule Intraligamentary with the STA system. A rubber dam was applied to ensure isolation.

The tooth was smeared with Vaseline as a separator. A gingival barrier was placed on the occlusal surface of the 36, and then the micro brush was pressed gently to the gingival barrier and then polymerized for 20 seconds to make a stamp/mould of the tooth's occlusal surface.

After caries removal, 37% phosphoric acid etching was applied. Bonding was applied with a micro brush and polymerized for 20 seconds, and then a packable composite was administered. Each layer was polymerized for 20 seconds. The last incremental layer was covered with Teflon Tape then the stamp made on the microbrush was pressed gently on the plastic. The stamp and plastic were lifted slowly then the excess composite was cleaned with a sharp hand instrument polymerized for 20 seconds, then polished the composite.

• Reiteration of oral hygiene instructions.

• Fluoride application

Due to his controlled swallowing reflex and ability to follow instructions, 2% Neutral Sodium Fluoride Topical Gel was used during this visit. At the previous fluoride application three months ago, Acidulated Phosphate Fluoride (APF) gel (1.23% F, 12,300 ppm F) was applied. However, since multiple resin-based restorations have been placed since then, APF should now be avoided. The acidic environment of APF can etch and potentially damage these restorations (Shabzendedar et al., 2011).

26 Placement of stainless steel crown:

A stainless steel crown would protect the 26 until a permanent crown can be completed once growth ceases or until BA transitions to full permanent dentition, at which point the orthodontist may choose to extract it to utilize the space for overjet reduction instead of extracting healthy premolars.

Schedule appointments every three months and a radiograph every six months as he is a high caries risk.

·       Fluoride application every 3 months

·       monitor the non-cavitated lesions on the 46m (E1).

·       Reenforce oral hygiene instructions 

• In retrospect, I think the treatment plan could have been elaborated better. I did not plan the use of stainless steel crowns on teeth 16 and 26 before starting the treatment. After the orthodontic consultation and their emphasis on saving these teeth, I thought of using stainless steel crowns. Initially, when managing tooth 16, BA's mother did not approve the use of the stainless steel crown, as I only suggested it during the session. However, before starting the management session for tooth 26, I motivated and explained to BA's mother the effectiveness of the stainless steel crown and the importance of saving this tooth, which led her to agree. If I had done this beforehand for tooth 16, she would have likely agreed, providing better protection for that tooth. Additionally, I believe the treatment plan could have been organized more effectively by grouping treatments, allowing the overall process to be completed in fewer sessions.

• AAPD 2009. Policy on interim therapeutic restorations. Pediatric Dent, 31, 38-9.

• APD 2019. Pediatric restorative dentistry. The reference manual of pediatric dentistry. American Academy of Pediatric Dentistry Chicago.

• BANERJEE, A. & WATSON, T. F. 2015. Pickard's guide to minimally invasive operative dentistry, OUP Oxford.

• BATISTA, K. B., THIRUVENKATACHARI, B., HARRISON, J. E. & D O'BRIEN, K. 2018. Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children and adolescents. Cochrane Database of Systematic Reviews.

• BERGAMO, A. Z. N., MIGUEL, L. P., DELGADO, R. Z. R., PALMA-DIBB, R. G., FARAONI, J. J., GATÓN-HERNÁNDEZ, P., SILVA, R., SILVA, L. & NELSON-FILHO, P. 2023. Efficacy of ClinproTMXT Varnish surrounding brackets on the enamel surface of white spot lesion. Braz Dent J, 34, 143-149.

• COBOURNE, M. T., DIBIASE, A. T., SEEHRA, J. & PAPAGEORGIOU, S. N. 2022. Should we recommend early overjet reduction to prevent dental trauma? British Dental Journal, 233, 387-390.

• DUGGAL, M., GIZANI, S., ALBADRI, S., KRÄMER, N., STRATIGAKI, E., TONG, H., SEREMIDI, K., KLOUKOS, D., BANIHANI, A. & SANTAMARÍA, R. 2022. Best clinical practice guidance for treating deep carious lesions in primary teeth: an EAPD policy document. European archives of paediatric dentistry, 23, 659-666.

• ESE 2019. European Society of Endodontology position statement: Management of deep caries and the exposed pulp. International Endodontic Journal, 52, 923-934.

• FARGES, J.-C., ALLIOT-LICHT, B., RENARD, E., DUCRET, M., GAUDIN, A., SMITH, A. J. & COOPER, P. R. 2015. Dental pulp defence and repair mechanisms in dental caries. Mediators of inflammation, 2015, 230251.

• KEELING, S. D., WHEELER, T. T., KING, G. J., GARVAN, C. W., COHEN, D. A., CABASSA, S., MCGORRAY, S. P. & TAYLOR, M. G. 1998. Anteroposterior skeletal and dental changes after early Class II treatment with bionators and headgear. American Journal of Orthodontics and Dentofacial Orthopedics, 113, 40-50.

• MARTIGNON, S., PITTS, N. B., GOFFIN, G., MAZEVET, M., DOUGLAS, G. V., NEWTON, J. T., TWETMAN, S., DEERY, C., DOMÉJEAN, S. & JABLONSKI-MOMENI, A. 2019. CariesCare practice guide: consensus on evidence into practice. British dental journal, 227, 353-362.

• O’BRIEN, K., WRIGHT, J., CONBOY, F., APPELBE, P., DAVIES, L., CONNOLLY, I., MITCHELL, L., LITTLEWOOD, S., MANDALL, N. & LEWIS, D. 2010. Early Treatment for Class II Division 1 Malocclusion with the Twin-Block Appliance: A Multi-Center, Randomized, Controlled Trial1. Informationen aus Orthodontie & Kieferorthopädie, 42, 97-103.

• O’BRIEN, K., WRIGHT, J., CONBOY, F., SANJIE, Y., MANDALL, N., CHADWICK, S., CONNOLLY, I., COOK, P., BIRNIE, D. & HAMMOND, M. 2003. Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 1: dental and skeletal effects. American journal of orthodontics and dentofacial orthopedics, 124, 234-243.

• SCHWENDICKE, F., FRENCKEN, J. & INNES, N. 2018. Caries excavation: evolution of treating cavitated carious lesions, Karger Medical and Scientific Publishers.

• SCHWENDICKE, F. & INNES, N. 2018. Removal strategies for carious tissues in deep lesions. Management of deep carious lesions, 15-35.

• SHAO, A., KAHABUKA, F. & MBAWALLA, H. 2016. Children’s behaviour in the dental setting according to Frankl behaviour rating and their influencing factors. J Dent Sci, 1, 1-12.

• SHOCKER, F. M. & MOTEA, Y. H. Sandwich Technique in restorative dentistry.

• SMITH, A. & LESOT, H. 2001. Induction and regulation of crown dentinogenesis: embryonic events as a template for dental tissue repair? Critical Reviews in Oral Biology & Medicine, 12, 425-437.