CASE 4

History of the main complaint:

Two years ago, Q sustained blunt force trauma after falling while playing at home, hitting his teeth on a door handle. A very small portion of his front tooth was chipped off, but since there was no bleeding or pain at the time, we did not seek medical attention. However, for the past three months, he has been experiencing occasional pain in both upper front teeth, lasting 10 to 15 minutes. We also noticed a gum boil under his upper lip. After visiting a dentist, he was prescribed antibiotics, which temporarily relieved the pain for about a month. Unfortunately, the pain and gum boil have since returned.

Prenatal history:

Q's mother maintained good health throughout her pregnancy. Apart from the routine pregnancy regimen, which included multivitamins and iron supplements, she did not take any other medications. She followed a regular diet without any special dietary restrictions.

Natal history:

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

Postnatal History:

Q was breastfed until 18 months and did not use a bottle. His mother described his feeding as on-demand and noted that she did not routinely wipe his mouth after feedings. After weaning, Q transitioned to drinking from a cup and primarily consumed milk, rooibos tea with added sugar, and sugary juices. He began eating regular family meals at 8 months old.

Medical history:

Q is a healthy boy with no significant childhood illnesses. He is up to date with all his vaccinations, has no known allergies, and has not had any previous operations.

Dental History and Oral Hygiene Practice:

Q had his first dental visit at age five due to a painful, wiggling bottom front tooth, which was extracted. According to his mother, he was not cooperative during the procedure and cried throughout the extraction. Since age 6, Q has been brushing his teeth independently twice a day using adult toothpaste. He does not floss, and his only fluoride exposure is from toothpaste. He has not undergone any dental treatments under general anaesthesia or sedation. His mother noted that Q brushes regularly without skipping to avoid needing further dental visits.​

Q is an intelligent child who exhibits no signs of anxiety or nervousness. He performs exceptionally well in school and has an excellent academic record. He enjoys swimming and is highly sociable, making friends with ease.

His facial appearance was symmetrical and normal, with no palpable lymph nodes. The temporomandibular joint was functioning normally, and his muscles were relaxed with no abnormalities.

• Molar Classification: Right class I, Left class I

• Midlines:

Maxillary midline: Coincide with the midsagittal plane.

Mandibular midline: No midline shifting at rest or occlusion.

• Open bite: Anterior open bite.

• Crossbite: None

• Habits: He used to suck on his lower lip.

The examination revealed no abnormalities in the tongue or frenum. There were draining fistulae related to teeth 11 and 21.

There is a periapical radiolucency related to the 11 and 12 teeth. The apices are still open despite the patient being 12 years old. However, the trauma occurred two years ago. All the other teeth are sound.

Q's attitude was rated as Definitely Positive on the Frankl Behavior Rating Scale. The planned behaviour management techniques include Tell-Show-Do, distraction, and positive reinforcement, aiming to ensure he has a positive attitude toward dental care. Since this is an emergency, we will start with the emergency root canal treatment. 

• • Preventive Phase:

• 1/ Oral hygiene education.

• 2/ Fluoride application: twice per year as Q is a low caries risk child.

• 3/ Diet analysis: A 3-day diary.

  • Pulp therapy: Emergency root canal treatment 11&12

  • Orthodontics: Consultation regarding the anterior open bite.

First Visit

Emergency root canal treatment via MTA plug.

Topical anaesthesia (labial and palatal) was applied, followed by local anaesthesia using 2% lidocaine with 1:100,000 epinephrine, administered via one ampule infiltration using the STA system. A rubber dam was placed for isolation.

Endodontic access cavities were prepared in teeth 11&21. The working length was determined using an electronic apex locator and confirmed with a periapical radiograph.

Canal debridement was carried out using light instrumentation with H-files, followed by thorough irrigation with 5% sodium hypochlorite to remove necrotic pulp tissue. Irrigation was applied using a side-vented needle to minimize the risk of extruding the irrigant into the periapical area.

Mechanical removal of root dentin was kept to a minimum, as the primary focus was on extensive irrigation with sodium hypochlorite for the removal of necrotic tissue and disinfection of the root canal system (ESE, 2021).

The canals were dried with paper points, and calcium hydroxide was placed as an intracanal medicament for two weeks (ESE, 2021).

The access cavities were then temporized with conventional GIC filling.

• Tooth 21

• Local Anesthesia & Isolation:

Local anaesthesia was administered using one ampule of 2% lidocaine with 1:100,000 epinephrine via the STA system.

A rubber dam was placed for isolation.

• Canal Preparation:

The temporary filling was removed, and the canals were irrigated thoroughly with 5% sodium hypochlorite.

A K-file with a circumferential filing motion was used to remove the calcium hydroxide (CaOH2), followed by final irrigation with 17% EDTA to eliminate the smear layer.

Apical Plug and Backfill:

• MTA Placement: NuSmile NeoMTA2 was mixed according to the manufacturer’s instructions and applied to the canal using the MAP system.

• After placing three layers of MTA, a periapical radiograph confirmed a 4 mm apical MTA plug. The plug was initially 3 mm short of the apex, so it was advanced by 3 mm, followed by another periapical radiograph, which showed it to be 1 mm short. The plug was then pushed 1 mm apically to reach the desired position.

• Sealer Application: A thin layer of bioceramic sealer was applied to the canal walls.

• Thermoplastic Backfill: Following MTA plug placement, a thermoplastic backfill technique was employed using the Gutta-Smart system. As recommended, no master cone was used to avoid the risk of over-extrusion, ensuring the integrity of the MTA plug (Shah et al., 2022). The melted gutta-percha was compacted to create a three-dimensional seal using Gutta-Smart.

• Final Restoration:

• A thin layer of 3M™ Vitrebond™ Light Cure Glass Ionomer Liner/Base was applied followed by composite resin restoratin.

• Tooth 11

• The exact same procedure for the 21 was followed.