A 17 year young boy reported with multiple decayed teeth in his right and left upper and lower quadrants. His behavior was aggressive, antagonistic, not responsive to verbal commands and not coherent. Upon intra oral examination presence of deposits over the teeth and decayed teeth in upper front and right and left lower back teeth were found. After adequate behavior guidance (Management) through tell-show-do and desensitization, upon radiographic investigation with an (Orthopantomograph) OPG (Figure 1) revealed the presence of deep carious lesions involving pulp i.r.t 11, 21, 12, 34, 35, 44, 45, 47, for which root canal treatments were planned.
The young boy has a dental history, when he was 8 years, he visited dentist and had undergone extraction of mandibular first permanent molars. The extraction was uneventful with epileptic attacks.
The medical history of the young boy shows a co morbid condition of ASD and ADHD with probable epileptic attacks during stress. Autism spectrum disorders (ASD) and attention-deficit/hyperactivity disorder (ADHD) are childhood-onset neurodevelopmental disorders affecting key fronto-striatal and fronto-parietal circuits that are important for executive functions determining the higher life forms and behavior. Autism spectrum disorder (ASD) is an incapacitating disturbance of mental and emotional development that causes problems in learning, communicating, and relating to others. Attention-Deficit/Hyperactivity Disorder (ADHD) is a diagnostic category used to describe individuals who display developmentally inappropriate levels of inattention, impulsivity, and/or motor activity.
The discipline of special care dentistry provides complex care to the individuals with wide range of disabling conditions. These patients have psychical or physical disabilities that affect daily life activities and influence the delivery of health care, including dental care. To provide an effective and safe treatment for these individuals, in many cases, it is necessary to use general anesthesia (GA).
General anesthesia (GA) can assist in providing quality dental care in many patients who could not be treated otherwise. This is especially true for children with special needs who increasingly attend dental clinics for treatment. In spite of the different resources available – psychological methods, physical restriction and sedation which should be used in a scaled way – in some cases it eventually becomes necessary to use GA for carrying out the necessary dental treatment. This should not be used systematically for the convenience of the dental team, but rather should be seen as the last resource for treatment. After obtaining the informed consent and surgical profile of the young boy, pre anesthetic evaluation was performed by anesthetist. The young boy was posted under GA for attending all the dental needs in one visit. Nasotracheal intubation is preferred to ensure good access to the oral cavity. The anesthesiologist is responsible for starting intravenous fluids (IV), securing the necessary monitoring equipment, performing the intubation, and stabilizing the young boy. The boy’s mouth is opened with the aid of a molt mouth prop. Care should be taken not to impinge on the lips or tongue with the prop. The mouth is thoroughly aspirated. The pharyngopalatine area is sealed off with a strip of moist 3-inch sterile gauze approximately 12 to 18 inches long.
Supragingival scaling of the teeth was performed to remove deposits over the tooth surfaces. Root canal treatments were performed for 11, 21, 12, 34, 35, 44, 45, 47. After administration of local anesthesia, access opening was done with round bur by marathon dental micromotor under saline irrigation. Cleaning and shaping of the canals was achieved by x-smart rotary system. Tentative working lengths were measured with measurement tool in OPG (FIGURE 1). Tactile perception was used for working length determination. After adequate cleaning and shaping, the teeth were obturated with 0.06% gutta-percha by using AH Plus root canal sealer. Core buildups were done with multi core flow composite for better strength and support (FIGURE 2). The preventive dentistry procedures including pit and fissure sealants and fluoride varnish was applied to all the tooth surfaces (FIGURE 3). The entire procedure was accomplished in a span of 2 hours, as the planned time out for the anesthetist was 2 hours due to the complicated associated comorbid condition. The crowns could not be planned due to the time span available. The boy is under follow up for routine checkup (FIGURE 4) and preventive care.
Successful outcome for the special children treated under GA depends on the expertise of the medical and dental team and the ability of parents or caretakers to comply with preventive dental care for their children following GA. The parents of the child were delighted by the way the treatment plan was formulated and executed and have expressed their deepest gratitude to the team of doctors at Denty’s for undertaking their child, who has been rejected by most of the dentists over a period of 3 years.
Dr. Manohar Varma
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