International Journal of Public Health Science (IJPHS)

Vol. 14, No. 3, September 2025, pp. 1276~1283

ISSN: 2252-8806, DOI: 10.11591/ijphs.v14i3.25253  1276

Interdisciplinary diagnostics and dental treatment: clinical case

report of a 13-year-old female patient

Dobrinka Mitkova Damyanova, Sirma Todorova Angelova, Yoana Rumenova Ruseva

Department of Pediatric Dental Medicine, Faculty of Dental Medicine, Medical University of Varna “Prof. Dr. P. Stoyanov”,
Varna, Bulgaria

Article Info ABSTRACT

Article history: The study was conducted at the Faculty of Dental Medicine, University
Medical-Dental Center, Varna, Bulgaria, in 2023, with permission and
Received May 31, 2024 informed consent from the parents and the patient. Patient K. Vl. Ts., 13
Revised Jan 24, 2025 years old from the city of Varna, comes without complaints. The reason for
Accepted Mar 6, 2025 the visit is a desire to consult an orthodontist and start orthodontic treatment.
The patient had a hospital stay at the age of 8 due to an operation -
adenoidectomy. PLI - Plaque index by Silness and Löe with a value equal to
Keywords: 1.58, which defines oral hygiene as satisfactory to poor. Exogenous
prophylaxis was performed. Treatment of plaque-associated gingival
Dental caries inflammation with professional oral hygiene and application of fluoride
Permanent teeth varnish every 3 months. Treatment of dental caries is operative: Teeth 27,
Preventive dentistry 36, 37, 47 - with caries occlusalis D 2-3, lesions - after minimally invasive
Risk assessment operative treatment with a glass-ionomer cement (GIC) placed, a definitive
Risk factors filling was made with photo-composite and sealant application of the healthy
pits and fossae of the fissure. Patients and their parents should be trained to
practice excellent oral hygiene during orthodontic treatment in order to
reduce the risk of developing dental caries.
This is an open access article under the CC BY-SA license.

Corresponding Author:
Dobrinka Mitkova Damyanova
Department of Pediatric Dental Medicine, Faculty of Dental Medicine
Medical University of Varna “Prof. Dr. P. Stoyanov”
84, Tsar Osvoboditel, 9000 Varna, Bulgaria
Email: [email protected]

1. INTRODUCTION
Back in the 1970s, authors applied the indices of gingivitis to an epidemiological study of gingivitis
among schoolchildren. Their observations, with minor differences, have been repeated in numerous studies:
the prevalence of gingivitis increases with age; it begins with the temporary dentition and peaks during
puberty [1]–[5]. The prevalence, severity, and duration of gingivitis have their explanations: i) increase in the
number of local areas of risk in the mouth, the accumulation of plaque and inflammatory changes associated
with the breach, and ii) influence of hormonal factors during puberty. It is interesting to know that the peak
of gingivitis during puberty does not have an analogous peak in plaque level (social factors) [6]–[10]. Timely
interdisciplinary diagnosis and treatment through orthodontic, orthopedic, therapeutic, implantology, and
periodontal methods at a modern level, provides optimal conditions for maintaining a healthy periodontium,
as well as to improve the aesthetic appearance, which is necessary to improve the quality of life of the
patients [11]–[18]. In their study, authors such as Kazeminia et al. [19], from a total of 164 articles (81
articles on the prevalence of dental caries in the temporary dentition and 83 articles on the prevalence of
dental caries in the permanent dentition), conduct a meta-analysis. The prevalence of dental caries for the
temporary dentition in children worldwide with a sample size of 80,405 was 46.2% and the prevalence of

Journal homepage: http://ijphs.iaescore.com

Int J Public Health Sci ISSN: 2252-8806  1277

dental caries in the permanent dentition associated with childhood worldwide was 1,454,871 or is 53.8%
[19]. The purpose of this study is to apply an interdisciplinary approach of diagnosis and preparatory
treatment with prophylaxis in pediatric dentistry to a 13-year-old female patient.

2. METHOD
Case report: history: The history was taken based on the testimony of the patient and his parent
(mother). Patient, 13 years old from the city of Varna, was admitted without complaints. The reason for the visit
is a desire to consult an orthodontist and start orthodontic treatment accordingly. History of oral diseases: The
last examination of the patient was 5 years ago - a preventive examination. Reports the presence of harmful
habits - grinding and clenching of the teeth during sleep. At about 6-7 years of age, difficulty breathing through
the nose was detected, and after consultation with an otorhinolaryngologist, the patient underwent an operation,
following the conclusion that the diagnosis was the cause of the harmful habit. Reported a past head trauma
about 5 years ago. There were no missing teeth.
Oral hygiene consists of cleaning the teeth in the morning and in the evening with a manual brush,
with medium hardness of the filaments and using a toothpaste - Sensodyne or Colgate. No mouthwash is used.
Intake of fluoride came only with the toothpaste. Reported frequent consumption of carbonated beverages
between main meals and less frequent consumption of sweets and other simple carbohydrates. General medical
history. The patient had a hospital stay at the age of 8 due to an operation - adenoidectomy. The mother did not
report any difficulties with the pregnancy and the childbirth, as well as taking medication during pregnancy. The
child does not take any medication and has no proven allergies. No general medical illnesses.
Examination: extraoral: no facial asymmetry, no cicatrices, the skin of the face has preserved turgor,
visible mucous membranes-no changes, rash units and swellings are not observed. No pathology in the
movement of the temporo-mandibular joint and trismus was detected. Intraoral examination: mucous
membrane: no pathological changes; gingiva: color: localized redness; texture: smooth; papillae: swollen;
gingival margin: swollen, red, thickened. Bite- distal bite (class II, 1 subclass), deep bite. Strongly protruding
upper incisors and sagittal distance between the two dental arches (overjet). Palatally inclined upper lateral
incisors and rotated premolars. Tongue: uncoated, normal color, rash elements not observed. All of the
patients’s permanent teeth had erupted (except the third molars), and it is expected that they have completed
their root development. We performed and analyzed an oral hygiene index: PLI - Plaque index by Silness and
Löe [20]. This index reflects plaque thickness only near the coronal edge. Assessment is by scraping with a
probe, without staining. The plaque index of an individual was determined by summing the values obtained for
each tooth and calculating the averages. To determine the plaque index, Silness and Löe reference values were
taken as a basis: plaque index 0: No plaque is in the area adjacent to the gingiva.
The Silness and Loe Plaque index has a four-point scale: i) Score 0: The tooth surface is clean;
ii) Score 1: The tooth surface appears clean, but dental plaque can be removed from the gingival third with a
sharp explorer); and iii) Score 2: Plaque is visible along the gingival margin (see Figure 1 and Table 1).
Based on the scoring system, plaque index = (2+1+1+2)/4 = 1.5. According to the plaque index system, this
means the plaque index for the tooth is moderate accumulation of soft deposit within the gingival pocket, or
the tooth and gingival margin which can be seen with the naked eye (see Figure 1 and Table 1).
Its value is equal to 1.58, which defines oral hygiene as satisfactory to poor. We applied modern
tools for early diagnosis - the ICDAS system [21]. ICDAS and the International Caries Classification and
Management System™ (ICCMS™), an international system for the diagnosis, detection, and evaluation of
caries lesions as shown in Table 2.
Dental caries diagnosis D3a was found on teeth 36, 17, 27, 37, 46, and 47 tooth with diagnosis
dental caries D2. Dental caries D1b was diagnosed on teeth 16, 12, 22, 24, 25. To date, the patient has not
had filling placed. Consultation and treatment by an orthodontist are necessary. Consultation with an oral
surgeon is also necessary; if necessary, treatment can be carried out by germectomy - by extraction of the
impacted 3rd molars (38 and 48).

Table 1. Scale and criteria for scoring the plaque index- PLI - Plaque index by Silness and Löe
PLI - Plaque index by Silness and Löe Criteria
0 Absence of microbial plaque
1 Thin film of microbial plaque along the free gingival margin
2 Moderate accumulation with plaque in the sulcus
3 Large amount of plaque in sulcus or pocket along the free gingival margin

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Figure 1. Representative teeth on which the patient's dental plaque accumulation was assessed

Table 2. ICDAS II 15/06/2012

Code Description
0 No enamel demineralization
1 Enamel demineralization limited to 50% of the enamel thickness and its outer surface
2 Demineralization (brown discoloration) between 50% of enamel and 1/3 of dentin
3 Demineralization (brown coloration) involving the middle third of the dentin
4 Demineralization (brown coloration) involving the inner third of the dentin

3. RESULTS AND DISCUSSION

Malocclusion is a worldwide dental problem. Many risk factors contribute to dental abnormalities,
including hereditary ones. Dental caries, pulpitis and periapical inflammations, traumatic injuries,
developmental abnormalities, and oral habits are the most common oral diseases in children that are strongly
associated with malocclusion [22]. The patient is at high caries risk - presence of active white caries lesions,
presence of plaque on the teeth, poor oral hygiene, and not regularly visiting as shown in Figure 2.
Sá-Pinto et al. [23] evaluate the scientific results regarding the relationship between malocclusion
and dental caries in adolescents. Orthodontic treatment is thought to increase the risk of dental caries. The
goals of orthodontic treatment in patients with malocclusion are to improve the esthetics of the maxillofacial
region and to optimize masticatory function by changing the position of the teeth [24], [25]. Orthodontic
treatment is associated with a reduced likelihood of a dental caries. Furthermore, there is no evidence
showing a relationship between the outcome of carious teeth and orthodontic treatment [26]. Authors such as
Seiffert et al. [27], conducted a scientific study evaluating the quality of clinical practice guidelines for the
prevention of dental caries in children and adolescents.
The tooth germ of the four permanent third molars, in the stage of formation of the dental crown, are
laid, and those of the lower jaw have a probable prognosis of staying retained or difficult eruption. The tooth
germ of the four third molars, in the stage of formation of the dental crown, are laid, and those of the lower
jaw have a probable prognosis of staying retained or difficult eruption. X-ray status: Orthopantomography
(OPG) was performed for diagnostic purposes and its quality was satisfactory. Root development of the teeth
is complete, without the third molars as shown in Figure 3.
Treatment plan: Motivation and education to improve the oral hygiene is provided. Treatment for
reducing the plaque on the teeth-the induced gingival inflammation-professional oral hygiene application of
fluoride varnish every 3 months. Treatment of the reversible lesions with tooth mousse for a period of 7
months every night after oral hygiene with the application of the cream on the dry enamel surfaces. The child
does not wash off the cream afterwards. A carious process was established-presence of carious process
indicators-active enamel lesions, presence of dentin cavitated lesions. Treatment begins with the
determination of the active, the stationary lesions, the reversible, and the irreversible lesions. The active
lesions are located under the plaque, in areas for the development of caries, the lesion has no clear
boundaries, it is rough, without transparency and without a shine, and the color is white. Inactive lesion-in
atypical areas, lack of a plaque, with clear boundaries of the lesion, has a shine, transparency, smooth, color -
white to brown. Active carious lesions require non-operative or operative preventive treatment. Inactive
lesions do not require treatment. Reversible lesions are D1a, D1b, and D2. They require non-operative
preventive treatment. In case of irreversible lesions, it is necessary to carry out operative treatment, preceded
by non-operative ones.

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Int J Public Health Sci ISSN: 2252-8806  1279

Figure 2. Photo documentation of the patient's primary examination, determination of the dental status

Figure 3. Orthopantomography (OPG) of the patient's permanent dentition, performed para-clinical

examination

A differential diagnosis between a deep fissure and occlusal caries is necessary. All of the molars
erupt with deep fissures. Fissures are maturing last and their mineralization is the weakest (post-eruption
maturation lasts up to 10 years after eruption). The enamel in the area of the deep fissures is extremely thin.
Plaque formation is enhanced and unobstructed-easy entry of food residues and microorganisms. Plaque in
the fissure cannot be affected by the self-cleaning mechanisms in the mouth. A permanent cariogenic
situation is created, which does not allow post-eruption remineralization. Fissure caries develops in many
occlusal areas because the fissures and pits on the occlusal surface of the newly erupted tooth are much more
than those in the adult individuals (highly detailed texture). The entrance of the deep fissure is narrowed, and
an extension exists below it. A toothbrush is unable to penetrate deep into these tight spaces. Even the single
bristle of the toothbrush is too large to enter and clean the fissure. Protection of these fissures is achieved by
application of sealants. In order to make a successful differential diagnosis, it is necessary: direct observation,
additional studies, indirect data, and establishing the presence of caries risk factors.

Interdisciplinary diagnostics and dental treatment: clinical case… (Dobrinka Mitkova Damyanova)
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The following was performed: operative treatment of dental caries: Tooth 27 - with occlusal caries,
lesion D3b - in the distal fossa. Operative treatment with a minimally invasive technique and a calcium
dihydroxide dressing, a glass-liner pad (GIC), and definitive filling with photo-composite were applied.
Tooth 37- caries oclusalis D2, performed minimally invasive operative treatment and filling with photo-
composite. Subsequent application of sealants of healthy fossae, fissures, and pits. We set the end of
treatment: definitive filling with photocomposite materials: Tooth 36 with D3a occlusal caries, after a
minimally invasive operative treatment, a glass-liner support was placed and obturation with photo-
composite and application of sealants of the healthy occlusal pits and fossae on the occlusal surface of the
fissure (definitive obturation class 1); tooth 47 oclusalis caries D2 – after minimally invasive operative
treatment and filling was made with photo-composite and application of sealants of the healthy pits and
fossae of the occlusal fissure (definitive filling class 1). Application of a sealant on the healthy pits and
fissures; tooth 36 with a carious lesion D3a on the occlusal surface – a support was made of glass liner (GIC)
and filling with photo-composite, after which a sealant was applied to the healthy pits and fissures
as shown in Figure 4.

Figure 4. Tooth 37 with a D2 carious lesion on the occlusal surface, after micro-invasive operative
preparation of a cavity, a definitive filling with photo-composite was made

Direct observation includes: Visual observation - requires good lighting, drying and clean teeth. Any
calculus deposition or presence of a plaque should be cleaned before examination, and the fissure may be
stained with food pigments. Tactile inspection using an atraumatic probe. Aggressive probing should not be
used because it may damage the superficial enamel layer and initiate an incipient carious lesion. Retention of
the probe in the fissure may result in a false positive or negative result. Early childhood oral health
management is performed in the pediatric dental clinics [28]–[30] to minimize the adverse impact of these
diseases on the teeth [31]–[33]. In recent years, there has been a significant increase in the number of patients
and/or parents seeking orthodontic treatment due to a number of psychosocial and esthetic improvements, not
only due to functional abnormalities [34]–[41]. Health indicates the degree of functional and psychological
integrity of the organism. Many authors in this field have found that oral health is directly related to the
patient's systemic condition in childhood up to 18 years of age [42], [43]. From our available literature, we
found that there is an increase in the need for orthodontic treatment in a large number of different cases of
patients visiting dental clinics [44]–[47]. There is also a need for proper planning in order to provide timely,
orthodontic services both at the individual level in the dental clinic and at the level of groups of children and
to assess the need for resources and methods of providing treatment techniques [48].

4. CONCLUSION
Patients and their parents should be trained to practice excellent oral hygiene during orthodontic
treatment. Oral health care is also important to reduce the risk of developing dental caries. Further studies are
needed to show a relationship between orthodontic treatment and the probability of treatment of new carious
lesions. Patients need regular preventive examinations and treatment in the dental clinic every 3 months or 4
times every year.

Int J Public Health Sci, Vol. 14, No. 3, September 2025: 1276-1283
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FUNDING INFORMATION
Authors state no funding involved.

AUTHOR CONTRIBUTIONS STATEMENT

This journal uses the Contributor Roles Taxonomy (CRediT) to recognize individual author
contributions, reduce authorship disputes, and facilitate collaboration.

Name of Author C M So Va Fo I R D O E Vi Su P Fu
Dobrinka Mitkova ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Damyanova
Sirma Todorova ✓ ✓ ✓ ✓ ✓ ✓ ✓
Angelova
Yoana Rumenova ✓ ✓ ✓ ✓ ✓ ✓ ✓
Ruseva

C : Conceptualization I : Investigation Vi : Visualization

M : Methodology R : Resources Su : Supervision
So : Software D : Data Curation P : Project administration
Va : Validation O : Writing - Original Draft Fu : Funding acquisition
Fo : Formal analysis E : Writing - Review & Editing

CONFLICT OF INTEREST STATEMENT

Authors declared no conflict of interest.

INFORMED CONSENT
We have obtained informed consent from all individuals included in this study.

ETHICAL APPROVAL
The study is authorized by the Commission for Ethics of Scientific Research at Medical University
of Varna with protocol-decision No. 40/30.10.2014, and was conducted at the Faculty of Dental Medicine,
University Medical-Dental Center, Varna, 2023, with permission and informed consent from the parents and
the patient.

DATA AVAILABILITY
The data that support the findings of this study are available from the corresponding author, [DMD],
upon reasonable request.

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BIOGRAPHIES OF AUTHORS

Dobrinka Mitkova Damyanova holds a specialization in dentistry and pediatric

dentistry. Since 2013, she is working in the Department of Pediatric Dentistry, Faculty of
Dental Medicine of Medical University of Varna. She has 41 publications and 16
participations in scientific congresses. She is the member of Bulgarian Dental Association
(BDA), Bulgarian Scientific Dental Association (BSDA), the National Association of Pediatric
Dentistry Doctors, European Organization for Caries Research (ORCA), and Union of
Scientists in Bulgaria. Her research interests include pediatric dentistry, restorative dentistry,
and operative dentistry. Since 2018, she is a Chief Assistant Professor in the Medical
University of Varna, Bulgaria, Faculty of Dental Medicine, Department of Pediatric Dental
Medicine. From April 2021, she holds the position of Associate Professor at the University of
Medicine in Varna, at the Faculty of Dental Medicine. She can be contacted at email:
[email protected] or [email protected].

Sirma Todorova Angelova gained a master’s degree at the University of

Economics in Varna, Bulgaria, in 2005 and in 2011, a Master's degree in Dental Medicine at
the Medical University of Varna. From 2011 to 2018, she worked as an assistant professor and
since 2018 as a Chief Assistant-Professor at Medical University-Varna. In 2015, she gained a
Certificate of Specialization of Pediatric Dentistry. In 2017, she gained a postgraduate degree
with the independent research: “Caries Risk Assessment and Prevention in Children Suffering
from Some Renal Disorders”. In 2019 was issued her monograph “Epigenetic and Genetic
Aspects of Oral Health in Children with Pyelonephritis”. In 2024, she holds an academic
degree of Associate Professor at Pediatric Dentistry at the Faculty of Dental Medicine,
Medical University of Varna. She can be contacted at email: [email protected].

Yoana Rumenova Ruseva is born in the city of Varna, Bulgaria. In 2016, she
graduated from secondary education at IV EG "Frederic Joliot Curie" in the city of Varna, a
foreign language profile (Spanish, English). She gained her Master degree of Dental Medicine
in 2022 in Medical University, Faculty of Dental Medicine of Varna, Bulgaria. Since 2022, she
has been a full-time assistant in the Department of “Pediatric Dentistry” at the Faculty of
Dental Medicine of the Medical University of Varna. From 2022, she has started her residency
in pediatric dentistry in the Department of Pediatric Dentistry at the University of Medicine in
the city of Varna and the Faculty of Dental Medicine. She can be contacted at email:
[email protected] or [email protected].

Interdisciplinary diagnostics and dental treatment: clinical case… (Dobrinka Mitkova Damyanova)