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Endodontics |
General anesthesia - Courtesy ROOTS
From: Thomas Shimko To: ROOTS Sent: Thursday, June 21, 2007 2:36 AM Subject: [roots] General anesthesia I would like to hear an opinion about management of this case. The 6.5 years old kid is scheduled next week for treatment under general anesthesia. Please say what to do with the first molars, especially #36 - Thomashi your treatment depends on the condition of pulp .if the pulp is vital the best way is apexogenesis with MTA . but if the pulp is aemi or partial necrosis u most save the remainig vital tissues and do like apexogesis.after all if the pulp is necrosis set ain apical barriers like calciuom haydroxide and MTA after it remaining of canal obturate with termoplastisized gutta percha - Kiamars lower first left molar: 1st: remove caries 2nd: assess restotability 3rd.(a) if restorable & vital: conservative (vital) pulp therapy 3rd.(b) if restorable & necrotic: attempting to revascularize the canal 3rd.(c) if non restorable: extraction? I am not that sure about this one; you might be want to treat the tooth just as if you were going to save it with the only purpose of maintaining bone until the child is old enough to have it extracted and replaced........Marcos Arenal Marcos, Would you attempt all this under general anesthesia ? Here they usually don't do it twice if possible - revasculization may need another treatment if it fails.... This is the problem here - definitive treatment in one session is needed - Thomas My Dear Thomas, Options 1) UR6 - Replacement of the amalgam filling UL6 - Probably RCT or extraction.... LL6 - Probably RCT or extraction..... LL6 - Fillling Option 2) Extractions of all the 6īs. As he is very young the bone will regenerate easily and the 7īs will occupy and close part of the space left by the 6īs but probably he will need some help from braces in the future Choose one treatm. or other depends in my opinion: 1. Grade of collaboration from the patient and parents: As you said now the patient is going to have the treatm done under general anesthethic, if you choose option 1 and he needs more treatm later, is he going to be cooperative to have it done in the chair or he will need again general anesthethic?? 2. If he already has a maloclussion that right now indicates that he will need braces.....Option 2 3. $$. PPP (Parentsī purchasing power ;-) : To pay 2 implants later (UL6, LL6) or an ortho treatment. - Marcela Hello, from the first look, it seemes to me this patient is afeected by MIH(Mlar -incisors hypomineralization) which affects first molars and frequently associated with incisors. so you should think of the following:( in my opinion) 1- LL6 to be extracted and compensation extaction of UL 6 is a must 2- consult an orthodontic about the dental relation betweeb UR6 and LR6 as you can see there is a space loss in the lower right side. assess the restorability of the UR6, if restorable then save both right 6s after the orthodontic consulation. 3- the long term plan is, to temporarly maintain all 6s until the age of 8.5-9 years, and then extract UR6,UL6,LL6 and assess LR6 , and if it is sound keep it and extract the rest. temporary treatment will be: Stainless steel crowns in all 6s except LL 6 you need to check the vitality, if vital Ca(OH)s over the pulp and restor it using Stainless stail crowns cemented with GIC. but inform the family about the possibility of the need of orthodontic treamtne in the future. 4- assess the primary teeth special Es. if in low prognosis status then extract them the above mentioned options are based on the government supported dental treatment., but worth considering.- Ahmed In Israel when you do a general anesthesia to a young patient, you need to treat ALL his dental problems. Treatment=Dental treatment.- Thomas Dear Thomas, At the risk of asking stupid questions, I would feel more comfortable knowing a little bit more before expressing my opinion. In particular, is the patient mentally, (emotionally/behaviorally) or physically or immunologically impaired? Is there something in the clinical examination that would dramatically alter our opinion of 36 from the radiographic interpretation? Not having those questions answered, I would offer this observation. The innate mechanisms for this child's pulp to respond to the insult of the caries, (all other things being normal), are at their greatest. There is a relatively hugh blood supply compared to an older patient. I would put pulp preservation procedures high on the list with plans to excavate the caries and and maintain all of the pulp if possible, to allow for natural strengthening of the crown. If the pulp is beyond that state I would remove the minimum amount of pulp that could reasonably be considered infected to allow the remaining odontoblasts to strengthen the remaining uninfected portions of the dentin interface. The best interocclusal space maintainer is a natural tooth. As we just heard from a cell biologist/prosthodontist, here at Roots VII, active eruption continues until about age 25 years and passive eruption well into the 50's so that is also a consideration when restoring the mandibular molar and thinking about possibility of adjusting occlusion of the opposing molar and primary molar to anticipate the occlusal plane for the future. It's disconcerting to see that no space maintenance was provided when the second primary molar was lost on the opposite side. I hope I'm giving answers to the questions you are asking.- Grant Dear Grant, I agree on all accounts. This is not a case I am treating. I don't do general anesthesia cases. It's a general practitioner that I work with that is treating this. I asked him about the child, he said that physically he is fine. He just can't be treated. To get this panoramic x-ray they needed TWO two hour sessions. I have offered him my advice, but want more opinions to help him decide - Thomas
