Multidisciplinary approach for long-term paediatric management – Dr Zoi Tzelepi
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Case summary
A 7-year-old boy was referred by his GDP for assessment of his discoloured maxillary and mandibular incisors. The diagnosis was chronological enamel defects, with both hypoplastic and hypomineralised elements. The patient had been born prematurely and had meningitis and sepsis at 18 months old. He was very anxious, so it was necessary to carry out his treatment with a mixture of non-pharmacological and pharmacological behaviour management techniques. This included prevention, direct composite restorations for the maxillary and mandibular incisors, fissure sealants and extractions of the maxillary and mandibular primary canines following orthodontic opinion.
Background
The patient was referred when he was 7 years and 8 months old. Both the patient and his parents were unhappy about the colour of his teeth.
A thorough medical history was taken. His mother had gestational diabetes and preeclampsia during pregnancy, and the patient was born prematurely at 32 weeks by C-section. He later contracted both meningitis and sepsis at the age of 18 months. When he was 5-6 years old, the patient underwent operations for growth plate issue on his legs. In addition, he was mildly asthmatic but had no known allergies and all his vaccinations were up-to-date.
With regards to the patient’s dental history, he had attended his GDP regularly for check-ups, but had not experienced any treatment. At home, he performed twice-daily tooth brushing with adult toothpaste, supervised by a parent. He also drank mostly water and maintained a low sugar diet.
Clinical assessment
Extra-oral Examination
- No facial asymmetry
- No lymphadenopathy
- Normal TMJ
Intra-oral Examination
- Generally fair oral health
- Localised plaque-induced gingivitis in the anterior region of both the maxillary and mandibular
- Calculus deposits mainly associated with the mandibular incisors
- Simplified Plaque Index (SPI): 50%
- Basic Periodontal examination (BPI):
| 0 | 1 | 0 |
| 0 | 2 | 0 |
- Mixed dentition present:
| 6EDC 1 | 1 CDE6 |
| 6EDC21 | 12CDE6 |
- UR1-UL1 and LR2-LL2 had enamel defects with areas of both hypoplasia and hypomineralisation. The 6s-Es were hypomineralised, LR2-LL2 were partially erupted, UR2-UL2 were unerupted and LR6-LL6 were partially erupted
- Yellow-brown discolouration, rough hypoplastic surface and abnormal contour on permanent incisors as a result of enamel defects with hypoplastic and hypomineralised elements. The first permanent molars also displayed signs of hypomineralisation with no post-eruptive enamel breakdown (PEB)
- Class I incisor relationship on a Skeletal I base, with crowding in both arches and space loss that meant ULC was in contact with UL1
- An OPG revealed normal dental development, no caries and enamel hypoplasia on the unerupted UR2 and UL2. Bitewings were requested but rejected as the patient was unable to tolerate the procedure
Treatment aims and plan
The aims of treatment were to improve the patient’s oral hygiene with instruction, fluoride and dietary education. We also needed to restore the aesthetics and function of the dentition while preserving the maximum amount of tooth structure.
The treatment plan was to:
- Liaise with the medical team regarding detailed medical history and any advisory precautions
- Establish preventative routine in line with the Department of Health’s preventative toolkit
- Encourage positive attitude towards dentistry through behaviour management techniques in order to help alleviate the patient’s dental anxieties
- Place fissure sealants on all Es, UR6-UL6 and, when fully erupted, LR6-LL6
- Place composite resin restorations on UR1-UL1 and LR2-LR1-LL1-LL2
- Complete a joint Orthodontic/Paediatric Dentistry assessment for advice on the current space loss and to create an orthodontic treatment plan to manage the occlusion
- Send letter to GDP with the treatment plan
- Provide long-term maintenance for restorations
Treatment
The patient attended all his appointments either with both his parents or just his mother.
As the patient was very anxious about dental treatment, we started slowly by explaining treatment at the start of every appointment. We employed the “Tell-Show-Do” technique, which involved displaying all the dental instruments and hand-scaler while talking through the procedure. The patient was also shown how to give a “stop sign” (raising left hand) and assured that we would pause treatment whenever he needed.
During the first appointment the patient was very anxious – he was a grade 1 on the Frankl behaviour rating scale and this made supra-gingival debridement of the mandibular incisors very difficult. As such, the assistance of a play specialist was recommended for proceeding appointments.
However, the patient remained quite agitated (Frankl 1) for the next appointment, during which we performed fissure sealants on the occlusal surfaces of UR6-URE-ULE-UL6. It was suggested to try inhalation sedation next time, but the patient didn’t like the mask and it was therefore not possible to administer. Despite this, the patient seemed to become more comfortable throughout the visit. He had brought is tablet, headphones and a familiar blanket to help him relax and we recorded a Frankl 3. We were able to polish the labial surface of UR1 with Nupro Prophylaxis prophy-paste (Dentsply) and brush, etch, wash and dry it. Subsequently, OptiBond Solo Plus bonding agent (Kerr Dental) was applied, a direct composite resin (3M Filtek, shade A1) restoration was placed with flat plastic and polished with Sof-Lex discs (3M). The patient and his parents were very pleased with the result and requested the earliest available appointment to complete the restoration on his other incisor.
During the following appointment with the patient’s tools to aid relaxation, UL1 was restored as above, Delton fissure sealant (Dentsply) was placed on LRE-LR6-LLE-LL6 and Fuji Triage (GC) was placed on the partially erupted LR6-LL6.
The orthodontist recommended extraction of all the C’s to facilitate the alignment of the mandibular incisors and eruption of the maxillary lateral incisors. It was discussed with the patient’s mother how this may be carried out and we decided to try inhalation sedation (IS) and local anaesthetic (LA) using the WAND. This proved successful with the patient, who accepted the mask without a problem. The extraction was performed under IS (70% O2– 30% N2O) and LA (WAND, Lignocaine 2%, adrenaline 1:80,000) as planned.
Later appointments involved scaling of the mandibular incisors using an ultrasonic scaler, under LA and IS. The patient and his mother were given clear toothbrushing instructions to help maintain a clean tooth surface prior to subsequent restoration of the mandibular incisors. Direct composite resin restorations were placed under LA and IS on LR2-LR1 and LL1-LL2, although the patient did report sensitivity from the mandibular incisors during toothbrushing.
The patient fluctuated between a Frankl rating of 3 and 4 during all these visits, with good or very good cooperation. The next phase of treatment will involve restoring UR2-UL2 and LR3-UR3-UL3-LL3 when they are fully erupted.
Discussion
Enamel defects can result from preterm birth, maternal illness during pregnancy or health problems during the first few years of life, when the enamel matrix is being formed and mineralised.[1]In the case presented, the patient was born at 32 weeks, had sepsis and meningitis at 18 months, plus his mother had gestational diabetes and preeclampsia – which are also associated with enamel defects.[2]
As this patient had no previous experience of dental treatment and would likely need more invasive procedures in the future, it was very important for us to establish a positive association. Non-pharmacological and pharmacological behaviour management techniques were used in order to help him relax and gain his trust. Gradual desensitisation was carried out using both the “Tell-Show-Do” technique and constant positive reinforcement. Studies have shown the “Tell-Show-Do” technique to be a commonly used, highly successful non-pharmacological technique for improving cooperation.[3]We found it useful to create a more comfortable environment for the patient, which was aided by him bringing in some familiar and distracting objects.
With regards to materials selected, the anterior teeth were restored with composite resin. This is a highly aesthetic material with good physical properties and so it provided a conservative way of managing the aesthetics and function for this patient, while also preserving as much as the natural tooth structure as possible.[4]
In conclusion, this case demonstrated the importance of creating an effective long-term treatment plan with a multidisciplinary approach for patients with complex restorative needs. Good behaviour management is also crucial for patients requiring complex treatment from a young age.
Images:
Pre treament
Post treatment
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Author bio:
Dr Zoi Tzelepi
Zoi completed her undergraduate training in Greece and obtained her dental degree in 2011 from Aristotle University of Thessaloniki with a grade that ranked 6th among the graduates of her year. Following her graduation, she started offering volunteer dental treatment in a centre for the care of children with disabilities in Greece, before relocating to the UK in order to continue with her postgraduate education.
In 2014, Zoi attended a course in the field of special care dentistry and obtained the Certificate in Special Care Dentistry from the Eastman Dental Institute in June 2015. Subsequently, she was accepted at the Eastman Dental Institute where she continued with her Specialty training in Paediatric Dentistry, a comprehensive 3-year programme including sessions of treatment under inhalation sedation and general anaesthetic, as well as dental research.
Zoi has been registered with the GDC since October 2011 and has been working in practice since then. She is also a member of the British Society of Paediatric Dentistry (BSPD), the European Academy of Paediatric Dentistry (EAPD) and has been attending seminars and conferences related to the field of Paediatric Dentistry over the years. Zoi is looking forward to registration as a Specialist in Paediatric Dentistry next year. She is happy to accept referrals for paediatric dentistry at Ten Dental Facial in London.
[1]Eastman, D. L.(2003). Dental outcomes of preterm infants. Newborn and Infant Nursing Reviews, 3(3), 93–98.
[2]Public Health England.(2014). Local authorities improving oral health : commissioning better oral health for children and young people An evidence- informed toolkit for local authorities About Public Health England, 1–66.
[3]Weinstein, P., Getz, T., Ratener, P., Domoto, P.(1982). The Effect of Dentists’ Behaviors on Fear-Related Behaviors in Children. The Journal of the American Dental Association, 104(1), 32–38.
[4]Hanlin, S.M., Burbridge, L.A.L., Drummond, B.K.(2015). Restorative Management of Permanent Teeth Enamel Defects in Children and Adolescents. In B.K. Drummond & N. Kilpatrick (Eds.), Planning and Care for Children and Adolescents with Dental Enamel Defects: Etiology, Research and Contemporary Management (pp. 139– 155).
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