Outline patients key characteristics and conditions

My patient is a seven year old male. He was originally referred in to the

paediatric department of Royal London Hospital on 31/01/2012. He had
presented with intermittent pain, which was also associated with a temperature,
the mother had given paracetamol to relieve the pain and reduce the
temperature. The pain affected the patients normal eating and sleeping habits.
The pain was sharp in nature and was prescribed amoxicillin by his GDP. I saw
this patient for the first time on the 3/12/12 and the patient presented with the
same problem. The mother had said the last time the pain occurred it relieved
after he completed the course of antibiotics. However the pain had flared up
again, however the pain was localised to the lower left quadrant. The pain had
taken a toll on him physically as the mother reported he had lost weight and he
has not been eating as usual. Parcetamol was given to bring down the pain. He
consumes a balanced diet, however the mother had owned up to his habit of
frequent sugar intake and is currently taking action to reduce sugar intake. He is
a middle child of three siblings. He is a healthy looking child and his growth and
development is consistent with his age group. He is fit and well and has no
known allergies to food , medicines or other substances. He is co-operative and
he has two sisters and is the middle child. He brushes twice a day and is
occasionally supervised by his mother. He uses fluoride toothpaste (colgate)
revieves 1350ppm fluoride. On examination no abnormal disorders extra orally.
Intra-orally there was an abscess on the buccal sulcus adjacent to the LLE, there
was no pus discharge. The tooth in question was the LLE. It had a large medialocclusal cavity and the lingual GIC restoration. It was TTP and sensitive to cold
air.
During the 3rd appointement with this patient he once gain presented with pain.
The pain was constant and sharp in nature; it was from the top right quadrant.
The pain was difficult to localise. There were no abnormalities extra-orally and
the tonsils were slightly inflamed intra0orally. The teeth in question were the
URD and URE. URD had a DO cavity which was carious and sensitive to cold air
and was slightly TTP. URE had a mesial occlusal cavity which was carious and
again was slightly TTP.

Identify the special features/features of this case that make it

interesting.

What makes this case interesting is that the patient presented twice in pain, which had to be
treated as an emergence. The patient also requires a variety of different treatments. This
meant that I was able to see the patient for many appointments and improve my skills in
paediatric dentistry. The patient was also in a mixed dentition which meant I had the
responsibility of ensuring we preserve his permanent dentition and enforce prevenative
measures in order to so. On the first appointment the patient was quiet and reserved so I had
to use my communication skills effectively to build the patients trust and confidence in me.
Also this case outlined to me despite offering patient the best treatment or treatment which

the guidelines recommend may not necessary results in the parents or

guardians accepting such plans.. Therefore this conversation with the mother
again reinforced to me the importance of communcaition skill and the need to
respect the patient and the carers autonomy for her son.The patient was
advised that multiple extractions under GA was the most suitable action however
after having his upper incisors extracted under GA at the age of 2 the mother
was very sceptical and objected to the idea. She felt it would affect his selfesteem as he already has missing teeth and the permanent incisors yet to
exfoliate. She also was aware of the risk of malocclusion later on in his
permanent dentition. It was decided by me, Dr Giwa and the mother that such a
number of restorations will only be possible if the child can show a level of
cooperation and compliance to such a vast treatment plan. We had also
discussed to the mother about the length of time it would take to complete the
treatment

Describe the overall planned approach (including preventive plan) to

treat this patient
The treatment was varied, involving preventive measures, multiple restorations,
a pulpotomy, a stainless steel crown and an extraction. Since the patient
presented with pain, the first stage of the treatment plan was to relieve patient
from pain. The LLE was carious, unrestorable and causing infection to spread into
the buccal space. It was decided to extract the LLE, verbal consent was gained
from the mother and tooth was extracted under LA. The next stage of treatment
involved preventive measures. OHI was given through demonstrations and I

advised the patient to brush last thing at night and continue using fluoridated toothpaste (1350
ppm), and that he should spit out after brushing instead of rinsing The patient has a mixed
dentition so it is essential he keeps these teeth clean and develops good oral hygiene habits.
The patients sugar consumption was a cause for concern, a diet sheet was given but is yet to
be completed. However I have, advised the mother that the frequency and amount of sugary
foods and drinks should be limited to meal times. Next we planned to fissure seal or place
preventive resin restorations on all four permanent first molars. Multiple restorations were
also planned these included, URED, LRE,ULE and a pulpotomy was to be done on the LLD
a stainless steel crown to be placed if asymptomatic. As mentioned above on his 3rd visit, he
had presented with pain again, the plan had to be altered, and a pulpotomy was done of the
URE and a IRM temporary restoration placed to relieve the patient of pain.
What difficulties did you encounter and how did you overcome them?
In my first consultation with patient the patient did not really co-operate and
was slightly anxious. To compound to this anxiety the patient presented with
pain. While taking the history I ensured I engaged my patient as much as
possible. I asked about his school life, his siblings , the sports he likes and what
cartoons he likes. Once the patient was eased into the new surroundings there
was a change in theco-operation levels.

In this first appointment I would have to do and extraction which is was

a great challenge. Whilst talking to the patient he told me of his
admiration for spiderman. This was utilised to deliver a succesfful ID
block. No terminology was used and the anesthetic was referred to as
sleepy juice and that it would work best if his eyes were closed. He
was also told to think about spiderman. Topical anesthesia on the soft
tissue was used and a successful ID block was administeres along with
a long buccal infiltration. The patient was fully co-operative and despite
being aware of the extraction was showing very good levels of cooperation.
Another huge challenge which I faced was mosisture control, whilst fissure
sealing the lower first permanent molars. The patient had a strong reactive
tongue, making it an arduous task to achieve dry conditions to place a resin
based fissure seal. Although me and my nurse altered our technique and fully
followed all precautions required to achieve moisture control such as effective
suction changing cotton rolls once damp despite it making a huge difference it
was still not sufficient moisture control for a resin based fissure seal. It was then
decided to use GIC as a fissure seal which although requires moisture control is
more forgiving than a resin based fissure seal.
Also another difficulty faced was the unpredictability of fissure caries and just
realising how deep it may go. Initially I was very reserved used when exploring
suspect fissures with a bur and did not anticipate how far the decay had spread
when doing a PRR for the LR6. Finally another difficulty faced when the patient
present with sharp constant pain forms the upper right region.

Critical review of benefits and risk of materials used

The thre materials used so far for this patient is GIC,IRM (Zinc oxide Eugenol),
ferric sulphate and resin based fissure sealant. GICs have a high level of fluoride

release which is incorporated in the apatitie crystal structure of enamel to form fluorapatite
which is less soluble in acid and hence inhibits demineralisation. This is fluoride uptake has
been shown to resuce the risk of caries. It is also aesthetic and the thermal expansion
coefficient is similar to enamel, meaning there is no shrinkage. IRMIRM
Ferric Sulphate was also used whilst performing a pulpotomy. Ferric sulphate is
the preffered mode of medicament for pulp therapy. It is a haemostatic agent
which allows for the sealing of blood vessels. Ferric sulphate

Ferric Sulphate

(15.5%, Astringedent)

liquid/gel

haemostatic agent

forms ferric ion-protein complex

seals blood vessels

Resin based fissure sealantz

Describe the outcomes of the patient of your care/treatment
The treatment for this patient is still on going and we are aiming to complete the
full course of treatment before the end of the summer term. However the initial
signs of treatment leads me to believe the treatment we provide will have an
overall positive outcome.
After the extraction of the LLE, the mother had reported his eating had returned
to normal as the pain disrupted his normal eating habits and his sleep was not
disturbed which was very good to hear. The outcome we hope for is for the
patient to be completely pain free.

During the course of treatment my patient became more compliant and helped me gain the
trust of the patient and his mother. My patient also has a greater understanding of the
importance of oral hygiene and is determined to ensure he never gets a toothache with his
permanent dentition.

Describe the outcomes of this case to you

This case has given me an insight into the importance of communication and the
need to adapt and tailor your skills between speaking to the child and the parent.
It has also allowed me to gain the ability to manage the behaviour of a child
patient and through positive and negative reinforcement, how we are able to
transform the change in attitude the child has towards the dental chair. More
importantly I have hugely improved in my clinical skills and I feel far more
competent in treating and relieving a child patient who presents with dentally
related pain. Above all I feel I have built a good rapport with the patient and the
parent .