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From: Catherine Mincy
Sent: Thursday, March 30, 2006 4:19 PM
Subject: [roots] Opinions?
This kid came in today. I see at least one of these every month or two.
She is 10 years old.
I tried to photo the bitewings, but they aren't very clear.
She has interproximal decay on 3,4,5,12,13,&14. Marginal decay
around the amalgam on #19. She has Diagnodent readings of 24 & 30
on the lower second molars which are not even fully erupted yet.
7,8, & 10 are definite pulp exposures, #9 is close.
Now here's the kicker. We saw this kid in Feb of 2004. At that
point she had decay on the 1st molars. None of the anterior teeth
were decayed at all. So what do you do here? Doing the endo isn't
all that difficult. But she's 10. Do you do full coverage crowns on
a 10 year old? In the past, I've done buildups and tried to keep
them in place until the kid is 15 or so. But it's pretty much a
losing battle. Either they knock them out playing basketball or
more likely, they drop out of treatment and don't show up again until
they have a new crop of cavities. This child also has Mississippi
Medicaid which will pay for the root canals and composite buildups,
but will only pay for stainless steel crowns.
And more importantly, how do you break the cycle of decay?
This kid is growing decay as fast as the teeth are erupting.
Obviously home care is pretty much up to her. I mean it's not unusual
to have parent overlook decay on posterior teeth, but they have to
either be pretty unaware or pretty uncaring to not notice big holes
in their daughter's front teeth like this and want to do something about it.
Any thoughts? - Catherine
ALSO: This is my first attempt at resizing photos for email.
If they are too small, I will try again.
You gotta get to the etiology. This ain't normal.
Probably a pepsi habit.
I start the line of questioning by saying:
"Do you drink carbonated beverages like mountain dew or pepsi?"
"Ok, is it a six-pack a day, twelve pack a day, more?"
"Maybe three or four" or some such answer.
"Are you chugging them, or sipping on them all day?"
With adults, same line, but include any beverage that can have
added sugar, and also lemon water/lemonaide and the like. Even a
sipping juice habit.
With teens or young adults, smoking and drugs as well. Invariably,
with this pattern of decay, there is always an identifiable habit.
This amount of destruction does not come this rapidly with just
"not brushing" - John Khademy
Maybe those Chuppa Chups (lolly on a stick)? Something localised
to the anteriors - Simon
The enamel on those teeth and some of the adjacent teeth looks
dysplastic with those white patches. and caries are developing fast
around them, may be even before her parents could spot! >
Obviously she has caries only on those teeth and on those restored 6s,
which is not very bad! I think the caries are due to the defective
enamelogenesis she is loosing the battle here.
May be full crowns and periodic fluoride applicationon other teeth as well.
please take care of the lower second premolar which is not erupted fully.
there seem to be a radioluscent halo around it. do you see
something?? - Vipin
No, actually, she has interproximal decay on all upper premolars and
the upper 6s. The lower second molars are partially erupted and
I can already get reading over 20 on what little of the occlusal table
I believe the white spots visible are early decalicification,
indicating that left untreated she'll develop decay on all these facial
surfaces as well. - Mincy
A good temporary denture and Iím not kidding. These are a lose, lose,
lose, lose, lose etc etc etc situation. She is never going to
change. OK, you donít agree, but Iíll tell you what. You fix her up
just like she was your grandchild and in 2 or 3 years you see
her again and if she isnít bombed out again, Iíll come to wherever you
practice and take you to dinner and give you a $1000. I have
tried to deal with Medicaid and treat them as close to the way Iíd
treat my own grandkids and I have never been successful in getting
a long term change in the direction they are going. Iím not saying
that it doesnít happen, but for all the money that is thrown into
mouths of Medicaid patients, it is a waste. Sorry to sound
insensitive and be PC incorrect, but that is my experience. Terry
IMO, glass ionomer wherever possible. GI is also an ideal material
to use a sealant/restorative with "chalky" enamel situations.
Also looks like lots of liquid sugar going on. Stabilization is the
key, but most of that is up to the patient. It all depends on
whether she "gets it" or not. These are tough cases. - Arturo
I don't believe in GI. Good composite restorations and intensive
fluoride prevention plus diet consultation. GI will not work at all.
- Maciej Bodal, Poland
Maciej, We have different opinions on this. While GI may not be a
final restorative material I have personally used it in these types
of cases through the "stabilization" period with great success.
Once stabilized it does need to covered with composite or replaced
depending on what is needed. Of course, most of the stabilization
success depends on the patient. - Arturo
I agree with Arturo with regards use of GI in such cases. But my
problem in such a case is how to establish the stability has been
achieved after initial treatment? two tools that I consider useful are
1. periodic readings from diagnodent
2. salivary count for Smutans (CRT system by ivoclar is useful)
But as many rooters said earlier on this thread, it is to important
to identify etiology and patient, and parents should OWN up the
I have found chlohexidine varnish application (once in 3 months) has
good effect on decreasing the smutans count in saliva and plaque,
with or without other aids like fluoride. Check the refrence articles
mentioned. Unfortunately I do not have the soft copy to send
Hope this was useful - Venkat
Dear Arturo , I have a completely
different opinions on GI. They are weak and they tend to disappear
after time. They simply dissolve.
As Monty Duggal from Leeds said - they are good materials to bad dentists.
why should one repeat the same work after some time instead
of doing it once the correct way. The success lies in fluoride
prevention, good oral hygiene and changing the diet. Treatment without
the prevention is like replacing windows in burning house. - Maciej Bodal, Poland
OK, purely for argument's sake...this kid is 10 years old.
I think there is a certain legitimacy to fire prevention now.
Emergency measures to stop the disease process. Ideally, I can
implement fluoride, oral hygiene, and improved diet right now.
Realistically....not gonna happen.
BUT...if you can save the teeth now...I'd say it's less a matter
of replacing windows in a burning building, more like saving the
substructure even if you can't put out all the pockets of
smoldering embers. Then maybe, just maybe as she grows and matures,
I can educate her and help her change the habits that are leading
to these problems. It's a long shot. - Mincy
The easiest way is to prescribe Elmex gel for brushing her teeth
once a week at home and fluoride varnish at the office every 4-6 weeks
plus serious talk with parents. You should try. Fingers crossed. - Maciej Bodal, Poland