The Management of Immature Necrotic Permanent Molars for Uncooperative Child: A Case Report with 12-Month Follow-up.

Uncooperative children with dental fear form a barrier in front of a pediatric dentist to provide appropriate treatment. This study reports a detailed management of a child with a previous bad dental experience and permanent immature necrotic molars. The painful phase of the treatment was accomplished under two sedation sessions and the molars were treated. The permanent molars were followed up for a year to verify the success of the treatment. Copyright:

INTRODUCTION

Uncooperative children are the greatest challenge faced by pediatric dentists during providing dental treatment.[1] Most children who present a lack of cooperation should be dealt with basic and advanced behavioral management techniques.However, we may use sedation or general anesthesia for some children who are unable to tolerate dental treatment procedures despite using all methods of communication and behavioral management.[2] Immature teeth with necrotic pulp are one of the worst scenarios in children dentition and pose a great challenge to pedodontists and endodontists.[3] The following case report aims to manage an uncooperative child with complex endodontic condition under conscious sedation and to assess the effect of mineral trioxide aggregate (MTA) and biodentine on apical lesion healing in necrotic immature molars in the child herself.

CASE REPORT

A 9-year-old female was referred to us for dental treatment due to her negative behavior and her lack of cooperation. Based on dental history, it was observed that teeth #36 and #46 were necrotic with open apices and apical lesions [Figure 1]. The study was conducted according to the guidelines of the declaration of Helsinki and approved by the institutional review board of Damascus University (protocol code 1403 and date of approval March 9, 2020). Informed consent was obtained from all subjects/caregivers involved in the study. The parents signed written consent forms to allow their child's case to be published. The case presented is part of a master's study by Yasser Alsayed Tolibah approved by the IRB, Damascus University college of Dentistry, Damascus, Syria (ID: 1403-9-3-2020).

Figure 1

A panoramic radiograph showing teeth #46 and #36 with extremely large carious lesions and periapical radiolucencies and large carious lesions in primary molars with absorbed roots

Management

The treatment of this session was done under intravenous moderate sedation using propofol (2 mg/kg and repeat 0.5 mg/kg as needed) [Figure 2a-f] in the presence of an anesthesiologist. The lower right permanent molar “46” was necrotic with apical lesions, and the distal root was immature with open apex, so it was decided to perform traditional root canal treatment. After drying all canals with large sterile paper points, the mesial canals were filled with gutta-percha (Gabadent, China) and AH plus sealer (dentsply sirona endodontics) using lateral condensation technique, while the distal root treated with biodentine (septodont, St maur-des-fossés) as an apical plug.

Figure 2

(a) The working length determination in distal root and cone fit in mesial roots. (b) Obturation of mesial root. (c) Final restoration in teeth #46. (d and e) Child relaxation during dental treatment under sedation. (f) Inserting biodentine with MAP system to the distal root

At the opposite side, the lower left permanent molar “36” had the same diagnosis of “46,” so it was treated in the same method as “36” but MTA (white proroot MTA, Dentsply, Tulsa, Ok, USA) has been used as an apical in two sessions due to time constraints. All primary molars were extracted. The child was discharged after ensuring the safety of the respiratory and cardiovascular function, the gradual return of awareness and reflexes, and her response to verbal commands. After 2 days, further treatment was done under oral sedation using 0.3 mg/kg oral midazolam with 3.7 mg/kg of hydroxyzine and pulse oximetry monitoring. Treatment was started 30 min after giving drugs. Under gingival anesthesia and rubber dam isolation, the temporary filling and the wet cotton pellet were removed and the setting of MTA was detected gently with #40 k-file (Mani, INK, Japan), then the remainder portion of the root canal was filled with gutta-percha (Gabadent, China) with AH Plus sealer (dentsply sirona endodontics) using lateral condensation technique and the pulp chamber was cleaned, and then it was restored with S.S.C [Figure 3]. Alginate impressions were taken of the child's upper and lower jaws 1 week after the previous session to make space maintainers; a fixed Nance appliance for the upper jaw and a fixed lingual arch for the lower. In the following session, the space maintainers were cemented to the permanent molars with a glass ionomer luting cement. The child was monitored clinically and radiographically for 1 month, 3 months, 6 months, and 12 months after treatment [Figure 4]. By observing the results, it was found that the healing of the apical lesion onset was faster under MTA plug and was closer to full recovery by 12 months.

Figure 3

Final restoration in teeth #36

Figure 4

Panoramic radiograph after 12 months of treatment

DISCUSSION

In this case, it was decided to provide dental treatment under sedation on dental chair. Protocol of treating necrotic immature molars was followed in,[4] where the entire treatment of tooth #46 with biodentine apical plug was accomplished in one session, whereas the treatment of tooth #36 with MTA apical plug was performed in two sessions. Q-Mix consists of bisbiguanide antimicrobial agent (2% chlorhexidine [CHX]), a polyaminocarboxylic acid calcium-chelating agent (17% ethylenediaminetetraacetic acid), and a surfactant (N-cetyl-N, N, N-trimethylammonium bromide-0.001 to about 3.0 weight percent) and deionized water. It has a good effect in smear layer removal, thus, the antimicrobial effect and smear layer removal are done in one step,[56] which allows to shorten the treatment time and finish the treatment in one session. The study of miçooğullari and çalişkan in 2018 found that using of biguanide based irrigant (CHX) as a final irrigation solution and finishing the endodontic treatment in one session had the same effect of using a calcium hydroxide paste as a temporary dressing for 2 weeks regarding postoperative pain and periapical healing.[7]

On radiographic observance, it was noted that initial periapical healing after 1 month was better under MTA plug and it was closer to full recover after 12 months compared to periapical healing under biodentine plug. This may due to the fact that MTA has superior marginal adaptation over biodentine which may influence sealing ability and clinical success.[89] Biodentine showed greater ability to produce apatite crystals and release of dental elements than MTA,[10] and it provides an appropriate environment for osteoblasts and periodontal ligament cells.[11] This may explain the appearance of a calcified barrier under the biodentine plug and its absence under the MTA plug after 12 months of follow-up.

CONCLUSION

Pediatric dentists often meet uncooperative children with different dental conditions, as they must be ready to receive the most difficult cases. Moderate intravenous sedation and minimal oral sedation are suitable solutions for managing anxious children with previous bad dental experiences, where they can be used according to the type of treatment to be completed within the session. In this case, we found that the periapical healing onset under MTA apical plug was faster and closer to full recovery through 1 year in comparing with biodentine apical plug.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that name and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.