Embedded Files
Personal information
Name: MD
DOB: 27/11/2012
Age on presentation: 12 years old
Gender: Male
Accompanied by his mother
Consent signed by his mother
History
History of the chief complaint:
MD has had a lot of dental work done before, but now he's experiencing pain in his lower right back tooth. He's not exactly sure where the pain is coming from, but it's likely from a tooth that has been filled more than once. The pain isn't constant; it comes and goes, sometimes triggered by cold drinks, or when he eats, it lasts for a few seconds, sometimes longer, depending on the trigger. He also occasionally feels pain in his upper left back tooth, which is also sensitive to cold and eating, though it's not as intense as the pain on the bottom.
Prenatal history:
MD's mom was healthy throughout her pregnancy, with no illnesses or medications taken except for the regular prenatal supplements. She did not follow a special diet; her diet was regular.
Natal history:
MD was born full-term with no reported neonatal jaundice, birth complications, birth injuries, or congenital abnormalities.
Postnatal history:
MD was breastfed for one year and did not use a bottle. After weaning, he began drinking water from a regular cup, as well as full-cream milk with added sugar and sugary juice. His mother does not recall wiping his mouth after feeding or practising any oral hygiene care during that time.
Medical history:
MD has a seasonal allergy, which causes his eyes to become dry when he takes antihistamines. He is currently taking antihistamines, eye drops, and an omega-3 supplement. When he was around one year old, he experienced a serious fever, which required an overnight stay in the hospital.
Dental history and oral hygiene practice:
MD had his first dental visit at the age of seven, during which the 36 was extracted due to a large cavity that caused significant sensitivity. According to his mother, the extraction was challenging and left him traumatized. On January 18, 2021, MD experienced severe pain and discomfort in his third quadrant (75), which made eating difficult. The dentist, recognizing his trauma from the previous extraction, referred him to Tygerberg Dental Faculty for extraction under conscious sedation.
January 22, 2021: 75 XLA under conscious sedation
January 28, 2021: 85o; Vitremer and application of fissure sealants on teeth 26 and 84 using Clinpro. Fluoride varnish application
February 8, 2021: 55mo and 54do; Vitremer.
February 16, 2021: 46ob Composite restoration.
February 22, 2021: 16 Indirect pulp capping: Dycal, Vitrebond, and Vitremer.
March 19, 2021: Repair of a fractured filling on 46 with Fuji IX and application of fluoride varnish.
September 3, 2021: Fissure sealant application on teeth 64 and 65 (Clinpro) and fluoride varnish application.
April 4, 2022: Re-do of the restoration on tooth 46 with Dyract.
April 11, 2022: Complaint of discomfort from tooth 46. Occlusion checked and adjusted.
October 10, 2022: Recall visit with fluoride application.
February 24, 2023: Presented with a gum boil on tooth 16; access cavity preparation.
March 2, 2023: 16; Working length determination.
March 30, 2023: 16; canals preparation.
April 12, 2023: 16; canals preparation.
April 26, 2023: 16; canals preparation.
May 4, 2023: 16; obturation and temporary filling.
June 7, 2023: 16mod; composite restoration.
September 15, 2023: 16; XLA.
Throughout these visits, MD was cooperative but frequently experienced pain during treatment. The extraction of tooth 16 was particularly challenging, taking an extended time as the tooth broke into pieces.
MD has been brushing his teeth daily by himself for the past two years using adult toothpaste. Before that, his mother helped him with brushing until he was seven years old and then supervised him for about two years, during which he used age-appropriate toothpaste. MD’s mother says he is very responsible and never skips brushing his teeth. He brushes for an extended period, often more than five minutes, even though sometimes it hurts, to avoid needing dental visits.
Behaviour and temperament
MD is an intelligent child who exhibits signs of anxiety and nervousness. He asks a lot of questions but remains reasonable and agrees to sit in the chair. His academic performance is excellent. He does not participate in sports and prefers indoor activities.
Extra-oral examination:
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.
Orthodontic evaluation:
Morphological examination of the face:
MD has a slightly convex facial profile, with both the maxilla and mandible exhibiting slight prognathism. There is no pronounced chin fold, and his lips are competent.
Occlusal analysis:
Molar classification: not applicable; missing 16&36
The maxillary midline coincides with the midsagittal plane.
Mandibular midline shifting to the left (3mm) at rest and occlusion.
Overjet: 3mm
Overbite: 2mm
No Crossbite
No open bite
No habit.
Intra-oral examination
MD is in the full permanent dentition stage. No abnormalities were observed in the tongue, frenum, or mucosa.
17: Sound
16: Extracted
15, 14, 13, 12, 11, 21, 22, 23: Sound
24, 25: Partially erupted
26: fissure sealant
37: Tilting mesially and rotated
36: Extracted
35, 34, 33, 32, 31, 41, 42, 43, 44, 45: Sound
46: Occlusal filling and fissure sealant applied
Radiographic examination
No anomalies or pathologies. The bone and soft tissue anatomy appeared normal, with all permanent teeth except extracted 16&36 accounted for. The estimated dental age is 12, corresponding to the second transitional stage. Canines have erupted.
Cries Risk Assessment
MD is a High-caries-risk patient. Although MD brushes twice a day, receives professional topical fluoride regularly, has fissure sealant, and a plaque-disclosing gel revealed excellent oral hygiene.
However, despite the placement of fluoride varnish on MIH-affected molars, an increased risk of caries and post-eruptive breakdown (PEB) was still observed (Almuallem and Busuttil-Naudi, 2018). Moreover, while sealants can prevent dental caries on MIH-affected molars, the same protective effect was not observed for PEB (Schraverus et al., 2021). The breakdowns of hypomineralized enamel opacities occurred predominantly in molars, likely due to the influence of masticatory forces on the compromised structures (Almuallem and Busuttil-Naudi, 2018). Hypersensitivity, resulting from increased enamel porosity and bacterial invasion in MIH-affected teeth, leads to subclinical pulpal inflammation. The resulting pain makes it difficult to control the biofilm; so far, MD has been doing an excellent job in this regard. Additionally, enamel breakdown creates niches that harbour the microorganisms and hinder contact with the toothbrush and fluoridated toothpaste, favouring colonization and biofilm formation, which becomes mature and cariogenic quickly. Consequently, the rapid development of carious lesions occurs, rendering MIH-affected ten times more susceptible to dental caries than unaffected ones (Gevert et al., 2024).
Behaviour management and Treatment sequence
MD is an intelligent and very mature 12-year-old who has had several unpleasant dental experiences. He mentioned that despite being anaesthetized, he always felt pain, especially during drilling. He requested brief breaks during procedures to cope with the pain, compose himself, and be informed beforehand about the procedure, materials, and instruments being used.
The Tell-Show-Do behaviour management technique and enhancing control technique were used to address MD's concerns. MD was instructed to raise his left hand if he felt uncomfortable or needed a brief pause in treatment, and I assured him that I would stop.
Distraction Strategy:
TV and Conversation: To divert MD's attention from any discomfort, TV was used as a visual distraction. Engaging him in conversations throughout the procedure further distracted him, minimizing negative or avoidant behaviours. This combination of techniques helped reduce anxiety and discomfort, leading to a smoother treatment experience.
We closely monitored MD's responses throughout the treatment and adjusted our approach as necessary to ensure his comfort and cooperation. Our goal was to provide MD with a positive and successful dental experience.
Since MD's main complaint was pain from tooth 46, we started by addressing that concern.
Diagnosis: MIH affecting the 26 and 46
Treatment plan:
Preventive Phase:
1/Oral hygiene education.
2/Fluoride application: 4 times per year as MD is a high-carrier-risk child, and Tooth mousse to decrease the sensitivity.
3/Diet analysis: A 3-day diary.
Restorative treatment: Redoo the restoration on the 46.
First Visit
The margins of the restoration on the 46 were deteriorated, which is the cause of MD's pain.
Topical anaesthesia, followed by local anaesthesia with 2% lidocaine containing 1:100,000 epinephrine, using two ampule infiltration, inferior alveolar nerve block and intraligamentary with the STA system to ensure proper anaesthesia. A rubber dam was applied to ensure isolation.
The old filling, along with the hypomineralized enamel, was removed. The tooth was then etched with 37% phosphoric acid, followed by deproteinization using 5% sodium hypochlorite. A bonding agent was then applied, and the cavity was restored with a composite filling.
Restoring severe cases of post-eruptive enamel breakdown or cavities with composite resin under rubber dam isolation ensures good moisture control and has high success rates (Lygidakis et al., 2022). Complete removal of hypomineralized enamel until resistance to the bur or probe is achieved is recommended for better adhesion and bond strength (Lygidakis et al., 2022). However, non-invasive approaches for composite restorations in MIH-affected molars have shown poor success rates (Lygidakis et al., 2022).
Clinical investigations have examined pre-treatment with 5% sodium hypochlorite enhanced enamel bonding by removing excess protein, thereby establishing a successful etch pattern (Sönmez and Saat, 2017). However, the evidence thus far does not show substantial improvement in restoration success (Lygidakis et al., 2022).
Md's mother was advised to use CPP-ACP to enhance remineralising and alleviate sensitivity of the 26 and 46.
CPP-ACP enhances calcium and phosphate bioavailability in saliva, promoting remineralisation and desensitisation of MIH teeth. It forms strong bonds with biofilm, stabilises ions, and allows deep penetration into subsurface lesions; unlike fluoride-only products, it improves remineralisation throughout the lesion. A recent study has validated the effectiveness of calcium phosphates, including CPP-ACP, calcium glycerophosphate, and hydroxyapatite, in remineralising teeth affected by MIH. In addition to their remineralisation properties, CPP-ACP and hydroxyapatite have also demonstrated the ability to alleviate tooth sensitivity commonly associated with MIH (Enax et al., 2023).
Follow-Up Plan
Appointments are scheduled every 3 months as MD is a high caries risk.
Application of fluoride treatment at each visit.
Reinforcement of oral hygiene instructions.
Monitoring the restoration on tooth 46, with plans to construct a full coverage crown once growth is complete.
Page updated
Report abuse