History of chief complaint: 

NC’s toothache started two weeks ago during the holidays, affecting the bottom right side. The pain occurred mostly at night, lasting 10-15 minutes over three days. Panado was initially given, but it didn’t help. Ibuprofen was then administered, which relieved the pain. Although the pain has subsided, his mother wants the tooth extracted to prevent future discomfort. 

Prenatal History: 

NC's mother was healthy throughout her pregnancy. She did not take medications other than the standard prenatal supplements and maintained a regular diet without any special dietary restrictions. 

Natal History: 

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

Postnatal History: 

NC was breastfed for the first two months and then transitioned to bottle-feeding for two and a half years, during which only formula was given by the bottle. Starting at 9 months, he also consumed water and sugary juice from a regular cup. He began eating regular family meals. His mother described the feeding as on-demand and did not wipe his mouth after feeding.

Medical History: 

NC is generally a healthy child with no significant childhood illnesses. He has received all his vaccinations and has no known allergies. At the age of 3, NC experienced an ear infection requiring an overnight hospital stay. He is not taking any medications and has not undergone any surgeries. 

Dental History and Oral Hygiene Practice: 

NC's first dental visit was at 7 years old for the extraction of tooth 54, which was severely decayed and causing pain. During the procedure, the tooth broke into pieces, and NC became distressed and refused to open his mouth. The dentist informed the family that a small fragment remained, which would likely resorb naturally. Last year, tooth 75 was also extracted due to decay. Four months ago, teeth 64 and 65 were extracted after NC experienced swelling that resolved after two days. 

NC has been brushing his teeth once a day by himself since the age of 4, using adult toothpaste. Before that, his mother was responsible for brushing his teeth. He does not floss and has not received professionally applied fluoride treatments. 

NC is a smart and sociable boy who makes friends easily, though he has shown signs of anxiety and nervousness. His academic progress is excellent; he is currently in Grade 3 and enjoys playing rugby. 

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

NC has a slightly convex facial profile with both the maxilla and mandible slightly retrognathic. There is no pronounced chin fold, and the lips are competent. 

• Molar Classification: Right class I, Left class I 

• Midlines: Maxillary midlines coincide with the midsagittal plane

Mandibular midlines shift to the lift by 1.5mm at rest and occlusion. 

• Overjet: revers 

• Open Bite: no open bite 

• Crossbite: 11, 21, 22. 12 partially erupted palatally behind the 11 

• Buccal canine bulges: palpable  

• Habits: None. 

No abnormalities were found in the tongue, frenum, or mucosa. However, visible plaque was observed on his posterior teeth. 

• 12: Partially erupted palatally. 

• 11, 21, 22: In crossbite. 

Radiographic examination revealed no anomalies or pathologies. The bone and soft tissue anatomy appeared normal, with all permanent teeth accounted for. The estimated dental age is 8 years, corresponding to the first transitional stage. The canines are positioned favourably, and the sequence of eruptions is also favourable. However, leeway space is compromised in all four quadrants.

Maxilla/Mandible

Molar classification: Class I on both sides

Anterior crossbite (12, 11, 21, 22)

According to Frankl's Behaviour Rating Scale, NC's attitude was classified as negative (Shao et al., 2016). Behaviour management focused on desensitization due to his previous unpleasant dental experience, which I believed had contributed to his anxiety and nervousness.

The tell-show-do technique was implemented to reduce uncertainty. NC's previous dental experience had involved only extractions, leading him to fear that more extractions might follow. By clearly explaining and demonstrating each step before performing it, we aimed to reassure him and help him feel more at ease.

We used the TV to distract him and engaged him in conversation throughout the procedure. This diverted his attention from any discomfort and minimized negative or avoidant behaviours.

We also employed the enhancing control technique. NC was instructed to raise his left arm if he felt uncomfortable or needed a break, and we responded immediately. This gave him a sense of control, reducing his anxiety and contributing to a more positive experience.

We closely monitored NC's responses throughout the treatment and adjusted our approach to ensure his comfort and cooperation, aiming for a successful and positive dental visit.

Given the urgency of NC's situation, we started with the emergency procedure (XLA 85), followed by the least invasive procedures. This approach was designed to build NC's trust and cooperation before progressing to more complex treatments.

• First Visit

• Emergency XLA 85.

Topical anaesthesia followed by LA (Block)  one ampule of 2% lidocaine with 1:100,000 epinephrine via the STA system.

• Positive Reinforcement: NC was rewarded with a balloon.

• Motivational Interviewing: 

I first met NC in December at a service rendering, where he came with the same complaint of toothache and swelling that resolved in a few days. The 64 and 65 were extracted, and I asked his mom to bring him to the faculty in February as he had multiple carious lesions. However, they did not come until June for another extraction. 

Given NC's current high caries risk, it is essential to address the causes of being a high-risk child. 

NC's parents share a common misconception that primary teeth don't require much attention because permanent teeth will eventually replace them. This belief is a primary reason why children like NC can develop significant dental problems, such as the multiple carious lesions that led to extractions in his case (Setty & Srinivasan, 2016).

According to the study by Setty and Srinivasan (2016), many parents do not fully understand the importance of primary teeth. 

Changing NC's parents' attitude towards dental care for his primary teeth is crucial, as it is one of the primary causes of NC's dental problems. Understanding the significance of maintaining healthy primary teeth can help prevent further decay, avoid the need for more extractions, and support NC's overall oral health.

I spent the rest of the session explaining to NC's parents the importance of maintaining healthy primary teeth. These teeth play critical roles in maintaining proper nutrition and speech development and in holding space for permanent teeth to erupt correctly. When primary teeth are neglected and cavities go untreated, it can lead to early tooth loss, which may cause adjacent teeth to shift. This shifting can result in the misalignment of permanent teeth, leading to more complex and costly orthodontic issues later in life. Additionally, untreated cavities can cause pain and infection and negatively impact a child's overall health and well-being (Setty & Srinivasan, 2016).

I also explained that their concerns about misaligned teeth would only be addressed if NC's oral hygiene improves, as orthodontic appliances are not recommended for high caries risk patients. Additionally, I emphasized that their active involvement and understanding of the treatment plan are key to NC's successful dental journey. They expressed that they were unaware of this and are now motivated to follow the instructions and the treatment plan. NC's mother asked if this was why his teeth were misaligned, and the lower teeth were in front of his upper teeth. I explained to her that his being Class 3  is most likely genetic, as her teeth also occlude similarly. However, I also mentioned that early extraction certainly complicates it.

1/ Diagnosis and treatment plan.

2/ Oral Hygiene Instruction and Demonstration:

Active brushing and flossing using a disclosing agent. Even though NC is 9 years old, NC'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: 16, 26, 36&46. As NC 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 are efficacious in reducing 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.

• 53d&63d

3M™ Vitremer™ Core Buildup/Restorative B2.

Motivation for using Vitremer:

•Command set(light cured) saves time

•Fluoride release equals that of GIC

•Higher fracture resistance and fracture toughness  than GIC 

•High moisture resistance

•Good handling properties Less technique sensitive than conventional GIC and Dyract.

Another option is Dyract XP, both with similar failure rates (Pummeret, 2019).

• Reinforcement of OHI.

• Positive reinforcement.

 NC's parents were motivated. They brought NC's two younger siblings, aged 3 and 4, for a check-up and asked if they should follow NC's OHI for them.

• 55op (D2)

3M™ Vitremer™ Core Buildup/Restorative B2. (same motivation as above).

• Impression for the orthodontic study models.

• Reinforcement of OHI

• Positive Reinforcement.

NC's mom was informed that the restorative phase of the treatment plan has been completed. They must maintain good oral hygiene and follow the instructions, and come every three months for follow-up.

During the 3-month follow-up, NC maintained good oral hygiene. He and his mom were excited to begin interceptive orthodontic treatment. After consulting with the Orthodontic department, the treatment plan was to correct the anterior crossbite using an anterior expansion screw and to place a lower lingual arch to hold the 36 and 46 in a class 1 position.

The upper appliance was to be constructed first. The aim was to introduce the upper appliance initially, ensuring he could maintain good oral hygiene. Then, the lower lingual arch would be introduced afterwards to avoid overwhelming him with two appliances simultaneously.

Appliance Design: Reverse labial bow, Adam's clasp on 16&26, Posterior bite block

The treatment plan was discussed and agreed upon by NC and his mom.

An impression for the construction of the upper removable appliance was taken.

• Reinforcement of OHI

• Fluoride gel application Neutral pH (NaF).

 It is recommended for patients with ceramic or resin-based restorations (Shabzendedar et al., 2011).

• This was a routine monthly follow-up to activate the expansion screw. 

NC maintained good oral hygiene throughout.

• The upper expansion screw was activated by 4 turns, equivalent to 1 mm. 

• An impression was also taken for the construction of the lower lingual arch.

• Oral hygiene instructions were reinforced to ensure continued compliance.

This was a routine monthly follow-up to activate the expansion screw. 

NC continued to maintain good oral hygiene.

The upper expansion screw was adjusted by four turns, corresponding to a 1 mm expansion. 

The lower lingual arch was cemented using Riva Luting GIC cement.

Oral hygiene instructions were reinforced to ensure continued compliance.

• The 11 and 12 have successfully been corrected out of crossbite (edge-to-edge), while the 22 and 12 remain in crossbite.

Once the 11 and 12 have fully moved out of the crossbite, the acrylic behind these teeth will be trimmed away to prevent further forward movement. This will allow the expansion screw to selectively apply force to the 22 and 12 during subsequent activations.

• The next appointment is scheduled in one month for expansion screw activation and reinforcement of oral hygiene practices. 

NC's case underscored the importance of addressing misconceptions about primary teeth and ensuring parental involvement in his dental care. By utilizing motivational interviewing, I successfully engaged NC’s parents, helping them understand the significance of maintaining healthy primary teeth to prevent further decay and complex orthodontic issues. Their newfound commitment to following the treatment plan reflects a positive shift in their attitude, which is crucial for NC’s long-term oral health.

Initially, NC's attitude was rated as negative according to Frankl's Behaviour Rating Scale, likely due to his previous unpleasant dental experience, which contributed to his anxiety and nervousness. However, through desensitization, he is now excited to visit the dental surgery. I take pride in the progress that both he and his parents have made. Being part of this positive transition is rewarding, and I am confident it will have a lasting impact on NC and his younger siblings.