CARIES MANAGEMENT Flashcards
What is early and severe early childhood caries
Early Childhood Caries (ECC):
• dmfs* ≥ 1 in any primary tooth in a child < or equal to 71 months old
Severe Early Childhood Caries (S-ECC):
• Any sign of smooth surface caries in a child < 3 yo.
• dmfs ≥ 1 (smooth surface cavity) in 1° maxillary anterior teeth at age 3-5 yrs
• dmfs ≥ 4 (age 3 yrs)
• dmfs ≥ 5 (age 4 yrs)
• dmfs ≥ 6 (age 5 yrs)
Caries presentation
- demineralisation
- pit and fissures
- smooth surface
- occult
- recurrent/secondary
- arrested
What does clinical evidence for high risk caries consist of
- New lesions
- Premature extractions
- Anterior caries or restoration
- Multiple restorations
- No fissure sealants
- Fixed appliance orthodontics
- Partial dentures
Dietary habits: high risk?
- Frequent consumption of foods and drink containing free sugars
- Dried fruits, honey, fruit smoothies and fresh fruit juice containing cariogenic sugars
- Timing eg last hour before bed
Social history: high caries risk
social deprivation
High caries in siblings
Low knowledge dental disease
Irregular attendance
Ready availability of snacks
Low dental aspirations
Fluoride use: high caries risk
- drinking water not fluoridated
- no fluoride supplements
- no fluoride toothpaste
Plaque control : high risk
- infrequent ineffective cleaning
- poor manual control
Saliva : high caries risk
- low buffering capacity
- high S mutans & lactobacillus counts
MH
- medically compromised
- physical disability
- xerostomia
- long term cariogenic medicine
Radiographs for high risk
Every 6 months for all high caries risk until no new or active lesions are apparent and individual has entered another risk category
Enamel lesion outer half tx
- record lesion location
- review and preventive treatment
Enamel lesion : inner half
- preventive therapy
- monitored periodically
Early dentine lesion - tx?
- great risk of cavitation
- therefore restore ?
Radiographic assessment low caries risk, primary Vs permanent
- 12-18 month intervals in primary
- 2 year intervals in permanent dentition
Other ways to detect caries
- tooth separation eg ortho separators
- transillumination
- electrical caries detection
- laser fluorescence
What to consider: retain or extract
- tooth restorability
- caries risk
- MH (oncology haem immunology)
- pt parent compliance
- dental development stage
- space management
what are the ICDAS codes
0: sound tooth surface
1: visual enamel change, after air drying
2: visual enamel change, when wet
3: localised enamel breakdown when wet
4: underlying dark shadow from dentine
5: distinct cavity, visible dentine
6: over 1/2 surface distinct cavity with visible dentine
Ortho implications with primary teeth
- centre line shift: balance Cs (if XLA one C, XLA the other side) ONLY Cs
- increased crowding increases the tendency for space loss
- earlier tooth XLA = greater amount of lost space
Restorative therapy benefits
- stop caries progression
- restore tooth structure integrity
- preventing spread of infection into pulp
- preventing shifting of teeth due to loss of tooth structure
Restorative therapy risks
- lessening longevity of teeth by making them more susceptible to fracture
- recurrent lesions
- restoration failure
- pulpexposed during excavation
- iatrogenic damage to adjacent teeth
- tx induced anxiety
Stabilisation - consists of:
- preventive therapy
- preventing pain and further infection
- arrest or stabilise restorable lesions EG hand excavation, ART, IRM/GIC, diet advice, OHI
- acclimatisation
- removal of unrestorable teeth
- Fuji triage = well suited
RMGIC benefits
Benefits:
- biocompatible
- adhesive: bonds chemically to enamel and dentine
- reasonable wear and fracture resistance
- fluoride release
- working time
- command set
- less moisture sensitive than composite
- improved aesthetics compared with GIC
RMGIC DISADVS
- care with mixing
- sensitising: avoid contact of uncured components with skin
- inferior physical properties compared with composite
Composite resin benefits
- physical properties
- adhesive: bonds chemically to enamel and dentine
- can support existing remaining tooth structure
- GOOD: wear resistance, longevity, aesthetics
- wide range of materials for many different applications
Composite resin disadvs
- requires more exacting technique compared with GIC or PMCs
- hydrophobic; excellent moisture control is obligatory eg rubber dam
- increased cost
PMCs benefits (4)
- good wear resistance
- low failure rate
- low incidence of recurrent caries
- simple technique
PMC disadvs
- poor aesthetics
- unsuitable for patients with nickel allergies
Management options of caries in anterior primary teeth
- Prevention
- Proximal disking
- Strip crowns
- Extraction
Aims and indications of topical fluoride
- prevent new/arrest active/reverse early caries
Indications:
- early cervical decalcification, pre-cooperative child
- evidence of changed eating/bottle habits
Proximal stripping indications
- exfoliation time close
- pre cooperative
- extensive superficial/minimal interproximal
Proximal stripping advs and DISADVS
Advs:
- simple and quick
- opens contacts, renders self cleansing and saliva flow
DISADVS:
- pulp!
- food IMPACTION
- space loss
- poor aesthetics
Proximal stripping: technique
- Soflex paper discs, tapered stone/diamond in slow speed
- Tapered crown: narrower incisally
- Round off proximal surfaces
- Polish and apply fluoride varnish
3) strip crowns technique
- LA and rubber dam
- tapered prep: high speed diamond
- labial groove
- 2mm incisal reduction
- CELLULOSE ACETATE CROWN FORM
- COMPOSITE
Also useful for:
- enamel hypoplasia
- dental anomalies eg AI/DI
What teeth to consider with tx planning
- unerupted maxillary incisors
- poor prognosis first permanent molars
- un erupted maxillary canines
- retained primary molars
If patient 11 years old in mixed dentition what must you be able to palpate
- canines - buccally
- if you can’t palpate, must take DPT to assess
- if palpated palatally must refer
What can delayed loss of second primary molars can be indication of?
- developmentally absent second premolars
acute management of a paeds pt who has a primary tooth diagnosed with reversible pulpitis ?
- if possible, gently excavate the softest layer of coronal caries:
Place a glass ionomer cement (GIC) or other temporary restoration (Kalzinol or Intermediate Restorative Material.). If the pain settles, a more definitive restoration will be required when time permits and as part of a comprehensive treatment plain (see later).
SOOD:
2. - Could do GIC or SDF and monitor and see if signs of irreversible pulpitis develop and reassess (eg if you weren’t sure that it was going into irreversible/unsure if clear band of dentine present and large cavity there) and later put hall crown if doesn’t turn into irreversible pulpitis
- Could put hall crown as your acute management if you have clinical space and also depending on compliance
Acute management of multiple painful carious lesions
- With multiple cavitated teeth, would place GIC on all those multiple teeth
management for multiple carious teeth that aren’t painful
Would just wait until you get to your definitive management (carry out prevention, get some acclimatisation)
Acute management for irreversible pulpitis primary tooth
- if not cavitated, could remove some caries depending on compliance and use ledermix or odontopaste
- If cavitated can directly place ledermix or odontopaste
- ALWAYS REMEMBER COMPLIANCE OF THE PT
Difference between odontopaste and ledermix and how can you make them more effective
- both one and the same thing
- Just brand names, just depends what’s available
- Both are steroid and antibiotic paste
- Ideally the more you extirpate the more effective eg if you get it directly onto the pulp
What medical history may lead you to avoid using odontopaste and why
- allergy to clindamycin (contained in odontopaste)
What is the principle of tx outcome after a paeds pt comes out of GA, and how can that affect tx planning?
- Principle is that the end of GA, pt needs to be dentally fit bc don’t wanna do a second GA
- Restorative tx under GA depends on facilities and availability’s - certain lists = restorative care under GA
- Simple technique (XLA) may be carried out if the list is limited
- EXAM ANSWER: depending on GA availability, restorative work can be carried out OR extractions carried out (if quite close to the pulp, wouldn’t risk it (2/3s into dentine) and would XLA. Outer 1/3 dentine = may then just do hall crown while under GA
What kind of PMC might you be able to carry out for pts at risk of IE
Conventional PMC with LA and full caries removal bc you’re removing the caries aka source of bacteria
What MH would make you avoid pulpectomy and pulpotomy
- risk of IE due to risk of introducing bacteria into blood stream
Impact of early childhood caries
Pain
Disruption of growth and development
Disruption of intellectual development
Disruption of quality of life
Sepsis or infection or ludwigs angina
Space loss:
- deviation of midline
- crowding
- IMPACTION
- ectopic eruption
- cross bite
^can be prevented with space maintainer but …
- overall health
- ^ have to be under GA and miss school
