A comprehensive oral and dental management of an epileptic and intellectually deteriorated adolescent
A 15-year-old right-handed boy, accompanied by his mother, arrived at the Pediatric Dentistry Department, Rural Dental College, Loni after seeking treatment without success in a private dental clinic. His chief complaint was pain in the upper front region of jaw associated with front teeth.\nDuring history taking, the mother reported that the patient's “crises” began at 6 years of age. Since then, there have been frequent episodes in which he turned his eyes up, shook, stiffened, contorted his body, and clenched his fists. She could not ascertain if there was any loss of consciousness, during these episodes. She had consulted a pediatrician and a neurologist for evaluation of his general and neurological evaluation. Neurological examination reports revealed that, the patient presented with some spontaneous myoclonic jerks of right and left arms. The diagnosis of right and left focal epileptic fits, which were secondarily generalized was made. Language and learning difficulties were diagnosed as the patient had been repeating his fifth grade for 5 years. Medical reports also revealed that the patient was initially on carbamazepine 200 mg twice/day and risperidone 1 mg/day for 6 years. The drug therapy was changed at the age of 12 years by discarding the risperidone and increasing the carbamazepine dosage to 600 mg/day. The mother did not understand that a diagnosis of epilepsy had been made because of her lack of education. Patient's routine hematological investigations were within the normal limits.\nAt first dental visit patient was extremely anxious about the dental clinical environment. The patient was relaxed by the dental staff and nurses. He was introduced to the dental equipment's in a stepwise manner. Tell-show-do approach was very helpful in this patient. The oral examination revealed numerous grossly decayed teeth with poor oral hygiene []. Root stumps were present for 31, 32, 41, and 42. Endodontic treatment was carried out for 21 and 22 by the previous dentist with iatrogenic mishaps. Intraoral periapical radiographs revealed extruding gutta-percha point beyond the apical foramen in association with 21 and a broken endodontic file at the apical 3rd of 22 []. The patient had underwent extractions of first permanent molars in 3rd and 4th quadrants by the previous dentist at the age of 14 years. The patient's dental occlusion was entirely deranged. The case was diagnosed as adolescent dental caries with special health-care needs. Treatment plan was formulated for the patient with following goals in mind:\nEducation and motivation of the parent for improvement of patient's oral hygiene Minimizing the pain in maxillary anterior region Reducing and treating other carious teeth Stabilizing the occlusion Improving the masticatory efficiency Improving the salivary flow rate Improving the overall oral health. Patient's parent was informed about the diagnosis, were explained about the treatment plan and the need for endodontic, surgical, and prosthetic rehabilitation. After the motivation of the parent, they were willing for the treatment and were ready to keep up the appointments. In the initial appointments, a thorough oral prophylaxis was carried out, and 0.12% chlorhexidine oral rinses twice daily were prescribed at home. A salivary substitute like mouthkote solution was prescribed to minimize the oral dryness.\nAfter obtaining the neurologist's consent, the blood reports, and under an antiepileptic drug regime, endodontic surgery was planned for 21 and 22 along with endodontic retreatment for the same. Following oral prophylaxis and administration of a local anesthetic (lignocaine and adrenaline injection I.P. (Harson Laboratories, Baroda, Gujarath, India) a semilunar incision was placed with no. 15 blade on the attached gingiva extending from mesial aspect of 21 and until the distal aspect of 22. A bony window was made with surgical round carbide bur (no. 8R, SS White Company, Dental Avenue India, Pvt. Ltd., Mumbai, India) mounted on a slow speed handpiece (NSK, PANA AIR; Nakanishi Inc., Shimohinata, Tochigi-Ken, Japan) under copious normal saline irrigation []. The extruded gutta-percha was excised from the apical 3rd of 21. Furthermore, the broken endodontic file was removed from the apical 3rd of 22. A complete curettage of the area was carried out followed by suturing of the flap with 3-0 non-resorbable black surgical silk suture (Ethicon, Johnson and Johnson Ltd., Mumbai, India) []. The endodontic treatment was repeated with 21 and 22 followed by treatment with 11 and 12. Postoperatively antibiotics and analgesics were prescribed for 5 days. Patient's pain was relieved completely after the endodontic surgery, and endodontic treatment and the healing of the surgical area was uneventful.\nThe clinical crowns of maxillary incisors were compromised as a result of caries, hence prior to planning for extracoronal fixed restorations on these teeth, and it was mandatory to restore them with custom made the post and core. The 2/3rd of gutta-percha was removed from the endodontically treated maxillary incisors root canals with the help of no. 2 Peeso reamer (Prime Dental Products, Mumbai, India) for post-space preparation. Post-space impression was made using blue inlay wax (Inlay Wax Medium, GC Corporation, Tokyo, Japan) along with the fabrication of core with the blue inlay wax for the four maxillary incisors. The casting was carried for the impressions of post and core. The custom made the post and core were trail fitted on the four maxillary incisors and then were cemented with Type 1 Glass Ionomer cement (GC Corporation, Tokyo, Japan) []. Extra-coronal porcelain fused metal (PFM) restorations were given on the four maxillary incisors after []. Meanwhile, extractions of the anterior root stumps in the lower arch were carried out. All the procedures were carried out under antiepileptic medication, with Neurologist's and Parental consent. The extraction sockets were allowed to heal till a period of 4-6 weeks.\nAfter the complete healing of the extraction sockets, diagnostic impressions were made for the arches using irreversible hydrocolloid (Alginate) impression material (Imprint Alginate Impression Material, Mumbai, India). Special tray was fabricated on the diagnostic cast for the dual impression technique. After border molding and final impression of mandibular edentulous region under physiological loading, using non-eugenol impression paste (IMAGE, Eugenol Free Impression Paste, Prime Dental Products, Mumbai, India) and the anatomical (dentulous) region was recorded using alginate pick up impression []. The master casts were obtained, and a surveying of the master casts revealed larger amount of lingual undercuts, so a labial flange flexible denture was planned. After blocking out of all the undercut areas and the diagnostic wax up, Face bow transfer was carried out, and centric jaw relation was recorded. The jaw relation record was quite difficult for this patient and required repeated training at home by the parent as well as in the dental operatory by the dentist. Try-in was carried out after the teeth arrangement. A flexible Valplast partial denture (Katara Dental Laboratories, Mumbai, India) was fabricated and was inserted in the lower arch []. Patient's comfort, speech, and acceptance for the treatment were assessed. The patient and his parent were happy and satisfied with the treatment being carried out. There was a significant improvement in the speech as well. The entire treatment was completed in 8 months due to intellectual deterioration of the adolescent. After the insertion of removable prosthesis to the patient, it needs to be changed after a period of 6-8 months until the age of 17-18 years unless the maxillo-mandibular growth of the patient is ceased. The patient was regularly followed-up every month.