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Endodontic Management Of A Retained Primary Mandibular Second Molar In An

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Simranjeet Singh Gauri Malik

Postgraduate Institute of Medical Education and Research Christian Medical College Ludhiana
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 Indian Journal of Dental Sciences. www.ijds.in
June 2016
Issue:2, Vol.:8
Case Report
All rights are reserved
Indian Journal
of Dental Sciences
E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1
Simranjeet Singh
Endodontic Management Of A Retained 2
Gauri Malik
3
Primary Mandibular Second Molar In An Rupandeep Kaur Samra
4
Shivani Bhandari
Epileptic Adolescent
1
Reader, Dept Of Conservative Dentistry & Endodontics
Brs Dental College Panchkula, Haryana
2
Abstract Reader, Dept Of Conservative Dentistry & Endodontics
Seizure disorders and epilepsy represent neurologic conditions that commonly are seen among Christian Dental College Ludhiana, Punjab
3
patients requiring dental treatment. A thorough medical history should be taken and updated at Dept. Of Prosthodontics
every visit. Stability of the seizure disorder must be taken into account when planning dental Himachal Dental College, Sundarnagar, HP.
4
Lecturer
treatment. This article discusses the medical management and considerations in dental Gian Sagar Dental College, Banur, Patiala, Punjab
management of epileptic patients. In addition, the persistent primary tooth and its missing
Address For Correspondence:
permanent successor in the dental arch pose several hurdles in front of the clinician due to Dr. Simranjeet Singh, H.no. 107 / B 36, Vikas Nagar
doubtful survival of primary tooth. In this paper, highlights the root canal treatment of a retained Pakhowal road, Ludhiana, Punjab, India 141002
primary mandibular second molar in an epileptic patient. Mineral trioxide aggregate was used for Submission : 6th April 2015
root canal obturation. Accepted : 5th March 2016
Key Words
Retained primary teeth, epilepsy/seizure, root canal treatment. Quick Response Code

Introduction history revealed seizures that started

Epilepsy is a common chronic neurologic
disorder that is characterized by recurrent
unprovoked seizures caused by sudden
disorderly and excessive neuronal
discharge. Its prevalence in developing
countries like India being 5.59 per 1000
people.[1] According to the International
League against Epilepsy, epilepsy is
diagnosed when a person has 2 or more
unprovoked seizures.[2]
A seizure is classified as “partial” when
the electrical discharge causing it occurs
in a specific area of the brain or
“generalized” when the discharge affects
the entire brain cortex. When there is loss
of awareness, seizures are termed
complex. It is also classified based on the
cause, and it can be symptomatic (caused
by a developmental malformation),
idiopathic (when a genetic condition is
responsible) or cryptogenic (when the
cause is unknown).
Patients who have developmental
disabilities and epilepsy can be safely
treated in general dental practice. A
thorough medical history should be taken
and updated at every visit. Stability of the
seizure disorder must be taken into
account when planning dental treatment.
Case Report
An 18-year-old boy, accompanied by his
father, reported to the Department with
sharp continuous pain in left lower back
tooth region accompanied by sensitivity
to hot and cold since 1 month. Medical
during childhood. The frequency of
episodes have increased in the past few
years. Patient was on regular medication
for the seizures since past 4 years. The
last seizure occurred three weeks back.
Patient suspected seizure to have
occurred after he took some medication
prescribed by the private dentist. Clinical
examination revealed retained carious
deciduous left second molar (#75).
Radiograph revealed caries encroaching
pulp in relation to #75 with missing
successor permanent second premolar
(Fig.1).
Root canal treatment (RCT) of #75 was
planned.
Patient was referred to neurologist to
evaluate patient’s seizure status and
possible drug interaction. The patient had
unstable seizures. However, neurologist
advised root canal treatment under local
anaesthesia could be done but with
special precautions. Local anesthesia
Fig. 1 : Pre-operative Radiograph
with adrenaline was injected. However,
during the procedure patient developed a
seizure attack. Patient became
unconscious for few minutes with hands
fallen to sides in relaxed position. Pulse
was high. Patient complained of severe
headache on regaining consciousness.
Injection midazolam 10 mg was injected
intramuscularly immediately as
recommended by neurologist
beforehand.
Dental procedure was terminated and the
dental chair was placed in supine
position. All equipment was removed
from the oral cavity and any sharp, hard
or breakable objects were removed from
the area, patient was turned to the side to
minimize aspiration of oral secretions.
Patient was aggressive and
uncooperative and therefore temporary
restoration was placed and patient was
recalled for next appointment.
Patient’s appointment was scheduled for
next morning shortly after he had taken
his anticonvulsant medication.The
patient was relaxed by the dental staff and
nurses. He was introduced to the dental
equipment’s in a stepwise manner.
Injection midazolam 10mg was injected
intramuscularly, prior to the procedure.
Local anesthesia with Adrenaline

©Indian Journal of Dental Sciences. (June 2016, Issue:2, Vol.:8) All rights are reserved. 061

Fig. 2 : Working Length Iopa
(1:200,000) was administered slowly
after negative aspiration. Mouth prop
was placed. Access was established in
#75.Working length radiograph was
taken (Fig.2). Floss was tied on all hand
files before biomechanical preparation.
Adequate coronal flaring was done.BMP
was completed and CaOH2 dressing was
given.
In next appointment, again injection
midazolam was injected prior to the
procedure. Patient was cooperative and
comfortable. Obturation of #75 was done
with MTA (Fig.3). Wet cotton placed and
temporary restoration done. Post
obturation composite was done next day
followed by metal crown.
Standard protocols for dental
therapy[3]
1. A thorough patient’s health history
and complete seizure history is
necessary before initiation of any
dental treatment.
2. List all medications, including side
effects and potential drug
interactions. Frequent changes in
medications may suggest that
seizures are not optimally controlled
and it is prudent to delay non urgent
dental care.
3. Ensure patient has take his\her
routine medications, has eaten
normally, is not excessively tired, and
has not been recently ill before
starting dental treatment.
4. Stress and fatigue are one of the
factors that can trigger a seizure.
Reschedule appointment if patient is
tired.
5. Appointments should be scheduled
during a time of day when seizures
are less likely to occur, if predictable.
6. Light can be a trigger in inducing an
epileptic seizure. Therefore, dark or
colored glasses can be used as eye
protection and the operating light
must be controlled so it is directed
only into the mouth and not flashed
into the patient’s eyes.
©Indian Journal of Dental Sciences. (June 2016, Issue:2, Vol.:8) All rights are reserved.
Fig. 3 : Post-operative Radiograph
7. Aspirin and NSAIDS should be
avoided for post operative pain
control in patients taking valproic
acid because they can increase the
risk for bleeding.
8. Low doses of lidocaine are not
associated with seizures, although
accidental administration
intravenously could potentially
provoke a seizure (Table 1).
9. If a seizure occurs while a patient is in
t h e d e n t a l c h a i r, i m m e d i a t e
management should be done (Table
2).
Problems dentist may encounter[4] -
1. Trauma
- Minor oral injuries, such as tongue
biting
- Tooth injuries
- Increased risk of fracture
- Ensure adequate calcium and Vitamin
D supplementation
2. Periodontal Problems
- Gingival hyperplasia
- For elective surgery, laboratory
evaluation - including bleeding time,
fibrinogen level, prothrombin time,
partial thromboplastin time and von
Willebrand factor level - is needed to
assess the risk of peri- and
postoperative bleeding
3. Restorative & Prosthodontic
Problems
- Discouragement of Incisal
restorations
- The risk of aspiration is increased
during seizure, as is the porcelain
fracture of masticatory surfaces.
- For this reason, a fixed prostheses or
implant is preferable over removable
partial dentures, and all metal fixed
prostheses are preferred to porcelain.
- If a removable denture is
unavoidable, then a metal base is
preferred.
- Inclusion of additional abutments if
fixed partial dentures are to be used
- Use of metal base for complete
dentures.
- Replacement of missing teeth may
prevent the tongue from being caught
in the edentulous spaces during
seizures
- Acrylic facings on anterior crowns
can facilitate future repair should a
fracture occur
4. Drug Interactions
- Metronidazole, antifungal agents
(such as fluconazole) and antibiotics
(erythromycin) may interfere with the
metabolism of certain antiepileptic
drugs (Table 3).
Discussion
WHO data suggested that psychiatric and
neurological disorders, including
epilepsy, are among the most significant
contributors to the global burden of
human suffering.[5] Epilepsy usually
begins in childhood, potentially
impeding education, employment, social
relationships and the development of a
sense of self worth.[6] Patients living with
epilepsy have special needs during dental
treatment. The number of decayed and
missing teeth, the degree of abrasion and
periodontal indexes are significantly
worse in patients with epilepsy.[7] it is a
consequence of the combined effect of
neglected oral hygiene, oral cavity injury,
062
 and socioeconomic background.
In the present case, patient’s seizures
began during childhood. However, they
increased in frequency in recent years.
History revealed seizures to be unstable.
The episodes were frequent and patient
was on multiple medications for the
same. Patient was anxious and
apprehensive when he came for the
treatment. Root canal treatment was
planned for retained deciduous left
second molar (#75) without permanent
successor. It was determined to retain
these teeth as it was non mobile, with
good root and coronal structure, and
supporting alveolar bone, and could offer
an adult patient many years of service.[8]
Local anesthesia with adrenaline was
administered after negative aspiration
after consent from neurologist. However,
patient developed the seizure after few
minutes. It may be due to patient’s
anxiety related to past seizure episode.
Patient’s appointment was scheduled for
next morning shortly after he had taken
his anticonvulsant medication.[3] For
patients with uncontrolled seizures,
benzodiazepines (for example,
lorazepam 0.5 mg - 1.0 mg, midazolam 5-
10mg) may be given 30 to 45 minutes
before the procedure, especially if one of
the patient’s seizures could pose a danger
during the procedure.[9] In this case,
midazolam 10mg was injected
intramuscularly prior to the procedure.
Patient was introduced to the dental
equipment’s in a stepwise manner to
reduce his anxiety. Nowak[10] advocates
conditioning to the dental procedures by
“tell show do” approach, which was used
successfully during the treatment of our
patient. Mouth prop attached to dental
floss (for easy irretrievability) was used
as a precautionary measure to minimize
the risk for injury and aspiration during
Source of Support : Nill, Conflict of Interest : None declared
©Indian Journal of Dental Sciences. (June 2016, Issue:2, Vol.:8) All rights are reserved.
View publication stats
treatment.[3] Mouth and adjacent areas
were kept free of unnecessary equipment.
In this case, MTA was used for the
obturation of retained primary molar 8 Sletten DW, Smith BM, Southard
where succedaneous permanent tooth
was absent. MTA was preferred over
Gutta percha as it is biocompatible and
will not irritate periapical tissue if root
resorption of deciduous teeth occurs with
time. Rune and Sarnas (1984)[11] found
that the resorption of primary tooth root is 9 Vorkas CK, Gopinathan MK, Singh
a process that can occur even when
underlying permanent tooth is absent.
However the rate of resorption varies
widely among individuals and
diminishes with age. (Kurol and 10 Pigno MA, Blackman RB, Cronin RJ
Thilander, 1984)[12]
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and pattern of epilepsy in India. 11 Rune B, Sarnas KV. Root resorption
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1989; 30:389–99.
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