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Pedodontics

Authors : Dr. Chunawala, Dr. Morawala Abdul, Dr. Sawant

Abstract :
Endodontic treatment in children can be a demanding task and, occasionally, a clinician may encounter bizarre situations that require both skill and patience. Many children are in the habit of placing various objects that can cause hard or soft tissue injuries in the oral cavity. This eventually results in foreign body lodgment into the pulp chamber or root canal leading to pain. This occurs most commonly in a tooth which is exposed to the oral environment either due to trauma or incomplete root canal treatment. As the foreign object can serve as a nidus for pain and infection in the root canal, prompt but cautious attempts must be made for its retrieval. This present article discusses an unusual case report of 13 year old child with presence of stapler pin in root canal, its retrieval and associated management of the involved tooth.

Introduction
Endodontic treatment in children can be a demanding task and, occasionally, a clinician may encounter bizarre situations that require both skill and patience. Many children are in the habit of placing various objects that can cause hard or soft tissue injuries in the oral cavity. This practice may even result in inadvertent insertion of foreign bodies within the pulp chamber or root canals1.However, occasionally, these objects may become lodged in the teeth. Such foreign objects may become a source of pain and infection, causing the patient to present to the dentist2.Foreign bodies are commonly found in the oral and nasal cavities of children, and are discovered by the dentist during routine examinations3.Theseobjects may be the result of the child's own action and may cause pain ,edema, and tooth fracture4. A foreign object found in pulp chamber or root canal of a tooth is often diagnosed accidentally. Removal of foreign objects from the root canal is a complicated procedure and these must either be removed from the root canal without changing the canal morphology or be bypassed 5. Careful instrumentation, irrigation and floatation are used to remove the obstruction6.

Case Report:
A 13 year old boy reported to the Department of Pedodontics and Preventive Dentistry, with a complaint of pain in the maxillary anterior region. The Patient gave history of fall in the school six months back & got his upper tooth fractured in the same incident. Patient had no relevant medical history. Patient had the habit of putting stapler pins in his mouth to clean the tooth. On intra oral examination Ellis class 3 fracture was seen with left maxillary central incisor [Fig 1]. Patient had no pain associated with the tooth. The pulp chamber of the tooth was open to the oral cavity. Thermal and electric pulp testing failed to elicit a response.
An intra-oral periapical radiograph revealed the presence of a linear radio-opaque object in the root canal, extending from the middle third to the immature apex of the root [Fig 2]. After taking the clinical and radiographic findings into consideration, it was decided that root canal treatment should be initiated, with an attempt to retrieve the foreign object and thereafter complete the root canal treatment. A conventional access cavity was prepared and the pulp chamber was cleared of debris by copious irrigation with saline solution.
Fig-1 Fig-2 Fig-3
Fig-4 Fig-5 Fig-6
Attempts were made to retrieve the object using 40size K-files (Mani, Inc., Nakaakutso, Japan) using a simple filing action; this was unsuccessful. A second radiograph was taken with a no 15 H- file (Mani, Inc., Nakaakutso, Japan) inserted in the canal space. Then using no 15, 20, 25,30,35,40 H- files (Mani, Inc., Nakaakutso, Japan) sequentially the foreign object was dislodged from the canal by engaging and pulling it coronally. To check for loosening of the object, an attempt was made to grasp the object with a tweezers. At this point, because it could be grasped adequately with the tweezers, the object was removed from the root canal with a slow, careful motion [Fig 3]. Canal was copiously irrigated with normal saline and 17% EDTA {BN Laboratories, Mangalore India}. It was decided to place a triple antibiotic paste as intra canal medicament as described by Hoshino et al. Using commercially available capsules of ciprofloxacin{Cifran 500 mg, Ranbaxy laboratories Ltd India} , Metronidizole {Metrogyl 400 mg, JB chemicals and Pharmaceuticals Ltd. India} and minocycline {Minoz 50 mg Ranbaxy laboratories Ltd India} . Following the removal of enteric coating of the capsules, the contents were pulverised using mortar and pestle and mixed with propylene glycol. The paste was packed into the root canal using lentulo spirals and hand pluggers. The access was sealed using glass ionomer cement.  Following 1 week recall visit, the tooth was found to be discolored. Subsequently, the canal was irrigated using normal saline and the triple antibiotic paste was thoroughly flushed out. Calcium hydroxide and iodoform intra-canal medicament was placed in the root canal [Fig 4]. Access was sealed by glass ionomer cement. The patient was recalled after 3 weeks. Healing of the peri-apical lesion was noted radiographically. Single step apexification procedure was done using white MTA [Fig 5]. Subsequently, the canal was obturated by lateral compaction using gutta-percha and AH plus sealer [Fig 6].

Discussion:
Children are innocent creation of God and are unaware of consequences of various activities they perform in their routine life. Complicated crown fractures involve enamel, dentin and pulp1 or a class 3 fracture (Ellis & Davey 1970). 25The incidence of complicated crown fractures ranges from 0.9% to 13% of all dental injuries26 and the most commonly involved tooth is the maxillary central incisor (Andreasen and Andreasen 1993). Untreated complicated crown fracture leaves the pulp chamber open placing the patient at risk of foreign body lodgment in pulp chamber.
Various foreign objects were reported to be lodged in the root canals and the pulp chamber, which ranged from pencil leads7, darning needles8, 2 metal screws9, to beads 10 and stapler pins11. Grossman 12 reported retrieval of indelible ink pencil tips, brads, a tooth pick, adsorbent points and even a tomato seed from the root canals of anterior teeth left open for drainage. Toida13 has reported a plastic chopstick embedded in an unerupted supernumerary tooth in the pre-maxillary region of a 12-year-oldJapanese boy. A staple pin in the root canal has been reported before. 24  For retrieval of foreign objects lying in the pulp chamber or canal using ultrasonic instruments, 14 the Masserann kit, 15 modified Castroveijo needle holders 16 have been used. The technique used in this case of file braiding was first described by Glick.
H files are suitable in this technique as their flute design is suitable for engaging the object. Foreign bodies in root canals can act as focus of infection. Actinomycosis following placement of piece of jewellery chain into a maxillary central incisor has been reported (Goldstein et al. 1972)17. Foreign bodies pushed through root canal into the sinus are one of the causes of chronic maxillary sinusitis of dental origin (Costa 2006)18. Hence, prompt attempts at their retrieval should be initiated. Nonetheless, retrieval of the object may become difficult when it is lodged in the periapical region. The use of an operating microscope is also beneficial. The microscope gives light and illumination inside the canal and provides the clinician with the ability to visualize any intraradicular obstruction and locate its position in relation to surrounding root canal walls .Nehme (2001)21 has recommended the use of operating microscope along with ultrasonic filing to eliminate intracanal metallic obstructions. Ethylenediaminetetraacetic acid has been suggested as a useful aid in lubricating the canal when attempting to remove the foreign object. Srivastava & Vineeta (2001)19 have suggested periapical surgery or intentional reimplantation to remove such objects. They reported retrieval of a straight pin lodged in the periapical area of maxillary central incisor by periapical surgery. Zillich &Pickens (1982)20 also resorted to the surgical approach for removing the apical portion of a hat pin lodged in a maxillary lateral incisor. Roig-Greene demonstrated a simple device, comprising a disposable 25-gauge dental needle, a thin segment of steel wire, and a small mosquito forceps, to remove broken silver cones.
McCullock22 suggested the removal of small amount of tooth structure to get the stucked foreign object free. Therefore, in the present case, a round diamond bur was used to widen the root canal orifice slightly, to promote better visualization of the foreign object.  According to Walvekar23 et al, if the foreign object is snugly bound in the canal, the object may have to be loosened first; it should then be removed with minimal damage to internal tooth structure to prevent perforation of the root. In the present case, H-type files (starting with No. 15 file and working up to No. 40) were used to loosen the object from the canal. Then, a No. 30 H-type file was inserted in the canal and a pullback motion was made, loosening the object. The object was finally retrieved with a tweezers that was able to grasp the stapler pin adequately.

 Hoshino et al.30determined that a combination of ciprofloxacin, metronidazole, and minocycline at a concentration of 25 micro g each per milliliter of paste was able to sterilize infected root dentin in vitro. Sato et al.31 found that this combination at 50 micro g of each antibiotic per milliliter was sufficientto sterilize infected root dentin in situ. Thus in this case Triple antibiotic paste was used for sterilization of the root canal.

Currently calcium hydroxide is used as an intracanal medication especially in cases of pulpal necrosis. The one presumed advantage of Ca(OH)2 over other types of medications is its antimicrobial properties attributed to its alkalinity 28. Ca (OH)2 also alters bacterial cell walls and denatures a potent endotoxin 29, lipopolysaccharide, thereby rendering it less antigenic. In this case calcium hydroxide was used as an intracanal medicament to promote healing of peri-radicular lesion

Mineral trioxide aggregate as an apexification material represents a primary monoblock. Appetite like interfacial deposits form during the maturation of MTA result in filling the gap induced during material shrinkage phase and improves the frictional resistance of MTA to root canal walls. The formation of nonbonding and gap filing appetite crystals also accounts for seal ofMTA27.   In this case, novel approach of apexification using MTA was done as it lessened the patient’s treatment time between first appointment and final restoration.

Presence of foreign objects in permanent anterior teeth has been well documented. Thus timely diagnosis and management of foreign object embedded in the root canal space should be done to prevent further complications like ingestion and chronic maxillary sinusitis.18 Complicated crown fractures should be managed promptly, and prolonged open drainage avoided in children if the risks of foreign body impaction are to be minimized.

conclussion
The removal of an unusual object from the root canal of a 13-year-old boy was accomplished with a simple technique and instruments commonly used in dental operatory. The present case report also highlights the importance of both careful radiographic evaluation and the ability to manage unexpected situations when endodontic treatment is performed in children.

Refernces:
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More References are available on request