Caries management for children and young people- strategies at the tooth level Flashcards
5 management strategies for caries in primary teeth
- Complete caries removal, and restoration
- Partial caries removal, and restoration
- No caries removal, seal with restoration
- No caries removal, provide prevention alone or after first making the lesion self-cleansing
extraction or review with extraction if pain or sepsis develops
how to choose managment option in caries in primary teeth
balance a reduction in the risk of pain or sepsis from the tooth in the future with the child’s ability to accept treatment now
- Avoid operative interventions which involve local anaesthetic until the child can cope
- Do not use conventional glass ionomer for permanent restorations
- Closely monitor lesions managed with prevention only
- DO NOT leave active caries in primary teeth unmanaged
how to manage a primary tooth with association to sepsis
(signs or symptoms of abscess, sinus, inter-radicular radiolucency, non-physiological mobility)
with either a pulp therapy or an extraction; do not leave sepsis untreated
Complete Caries Removal and Restoration
Technique for plastic restorative material
- Give LA before commencing cavity preparation as this will require sound dentine to be cut
- Gain access to caries using a high speed handpiece, leaving a wall of enamel to protect the adjacent tooth
- Remove caries with a slow-speed handpiece and excavators
- Be aware of pulp chamber anatomy to reduce risk of pulpal exposure
- Prepare approximal cavity margins with gingival margin trimmers to prevent iatrogenic damage to adjacent tooth
- Place the restoration
- If at risk of pulpal exposure, place an indirect pulp cap
- Do not use conventional glass ionomer materials for restoration of Class II (interproximal cavity) cavity due to the unacceptably high failure rate.
- Use Composire, compomer, resin modified glass ionomer, amalgam and preformed metal crowns may be suitable (depend on cavity)
- No longer legal to use amalgam in children teeth
- Use Composire, compomer, resin modified glass ionomer, amalgam and preformed metal crowns may be suitable (depend on cavity)
mercury regulation
- The Minimata Treaty is a global environmental treaty aimed at reducing the release of mercury into the environment.
- The EU’s Mercury Regulation has the same aim for the territory of the EU.
- Phase-down in use of dental amalgam advocated.
New rules in force – NO AMALGAM
- Primary Teeth
- Persons under 15 years of age
- Pregnant and breastfeeding women
- Exception- specific medical needs of the patient (what does that mean?)
5 restorative options for primary molars
- Composite
- Compomer
- Stainless Steel Crowns (preformed metal crowns)
- Glass Ionomer Cement (temporary restorations only)
- Resin modified glass ionomer
compomer
- Polyacid modified composites
- Dyract, Compoglass, Hytac
- Occlusal and 2 surface cavities
- Can’t set in the dark as only small GIC content.
- Must be light cured.
- Must have good isolation and moisture control
design of interproximal cavity in primary teeth
minimal interproximal cavity
Small as possible due to good bonding
9 indications for traditional preformed metal crowns (remove caries)
- 2 surfaces affected
- Extensive 2 surface lesions
- Pulpotomy / pulpectomy (no more dentinal fluid)
- Developmental defects
- # d primary molars (no more dentinal fluid)
- excess tooth surface loss (grinder)
- High caries
- Impaired OH
- Space maintainer
traditional prep for preformed metal crowns
- Give LA
- Remove caries
- If at risk of pulpal exposure, place an indirect pulp cap (molar shown has had temporary pulp therapy)
- Cut a mesial slice and a distal slice. The bur should pass through the crown cervically in order to avoid creation of a cervical ledge, as this will impede the seating of the crown
- Note how a wall of enamel is left while cutting the slice to ensure there is no iatrogenic damage to the adjacent tooth
- The wall will then fall away as the cut is completed cervically
- Note how a wall of enamel is left while cutting the slice to ensure there is no iatrogenic damage to the adjacent tooth
- Reduce the occlusal surface of the tooth enough to allow straight probe to be passed across the tooth surface when the teeth are in occlusion
how to prep for preformed metal crown
- Read pre op skills manual
- Occlusal, approximal, peripheral (smoothing of edges) reduction – OAP
- NO BUCCAL OR LINGUAL REDUCTION
- Snap fit, measure contra-lateral tooth, flatten proximally if necessary
- GIC cement – reduced microleakage, hold in place to reduce snapback
- Margins – clear excess cement, no overhangs distally, pull knotted floss through interproximal areas to clear cement
5 year survival of primary restorations
- Amalgam (historic) 80%
- Conventional GIC 66%
- Stainless steel crowns 92%
partial caries removal and restoration
- If necessary, gain access to caries using a high-speed handpiece
- As this approach rarely requires cutting of sound dentine, LA is usually unnecessary
- Remove superficial caries with a slow-speed handpiece or excavators, until there is no obvious caries visible at the EDJ and the cavity allows an adequate thickness of restorative material to be placed
- Take extra care not to cause iatrogenic damage to adjacent teeth if cutting a class II cavity. Placing a matrix band around the adjacent tooth may help
- Be aware of the pulp chamber anatomy to recue the risk of pulpal exposure
- Place the restoration, using adhesive and a bonding system.
- Do not use a glass ionomer materials for restoration of a Class II cavity
- Fissure seal the tooth surface and as many of the restoration margins as possible
- Monitor for any caries progression using radiographs where appropriate
- Inform the child and parent/carer of the approach taken and record the details in pt’s notes
3 advantages of partial caries removal and restoration
- Evidence largely from secondary care and private practice, this approach can be effective.
- Reduced risk of pulp exposure
- Reduced time for cavity prep, less need for LA
disadvanatges of partial caries removal and restoration
- As caries is left in the cavity, the marginal seal must be effective to prevent caries progression
- No evidence, as yet, that this approach is effective in primary care (now have fiction trial)
NO caries removal techniques
- seal with fissure sealant
- hall technique PFMC
- self-cleansing
GI as fissure sealant
Isolate tooth
- Gloved finger with GIC
- Vaseline on other
GIC then Vaseline straight after – hopefully hold in position for some time, not always possible
Hall Technique with PFMC
- The technique involves sealing caries into primary molars with a preformed metal crown (PMC)
- No LA, tooth preparation or caries removal is used
seal with fisure sealant
Place a fissure sealant over a non-cavitated pit or fissure caries, to completely seal the fissure system
If using this approach on a pre-cooperative child, consider using the press finger technique with a glass ionomer materials as a temporary measure
issue here in Tx by self-cleansing
This carious lower E has been managed with a prevention alone strategy (diet, OH).
This has not been successful as plaque is visible 4 months later and the caries appears active rather than dark, hard and inactive (arrested). Therefore, a more restorative based approach is now required.
technique for making a lesion self-cleansing
As only enamel and carious dentine are removed, the use of a local anaesthetic should not be necessary unless subgingival tooth preparation is required
- Using a high speed handpiece or hand instruments, remove undermined enamel adjacent to the carious lesion making the surface of the lesion accessible to toothbrushing and saliva
- The resulting cavity form will vary in shape depending on the lesion. It might be opening out of an occlusal lesion or result in a ‘slice preparation’, as shown in these photographs
- Apply fluoride wash
- Inform the child and parent/carer of the approach taken and record details in the pt’s notes
Partial caries removal
technique for primary incisors
- Thoroughly clean the teeth with prophylaxis paste
- Caries removal will be minimal so local anaesthesia is not required
- Acid etch the entire crown; wash, dry and apply a bonding system
- Try to maximise all remaining enamel
- Not last long time but may be sufficient for duration of tooth
- Place the composite restoration, either by handbuilding or using strip crowns
- Inform the child and parent/carer of the approach taken and record details in the pt’s notes
interproximal discing of primary anteriors
indications
- Exfoliation time close, pre-cooperative, extensive superficial/minimal interproximal
interproximal discing of primary anterior
advantage
simple, quick, open contacts
interproximal discing of primary anteriors
disadvantage
pulp, food impaction, space loss, aesthetics poor
interproximal discing of primary anteriors
technique
- Sandpaper discs, tapered stone or diamond in slow speed
- Tapered crown – narrower incisal
- Round off proximal surfaces
- Polish and fluoride varnish
3 indications for strip crowns on primary anteriors
- Enamel hypoplasia
- Dental anomalies – amelo, dentino
- Labial and interproximal caries
technique for strip crown anteriors
- LA and isolation
- Tapered prep – high speed diamond
- Shaded area
- Labial groove – aid retention
- 2mm incisal reduction
- Shaded area
- Cellulose acetate crown form and composite – using all available enamel for bonding
management of suscpious fissure on FPMs
Thoroughly clean the fissures of all debris, dry the tooth and view it with bright, direct light.
Take good quality radiographs
if there is:
- micro cavitation
- shadowing under enamel
- dentinal caries
remove caries and then place a conventional composite restoration limited to the site of the caries and fissure seal the remaining fissure system.
If the fissure is stained but none of the above apply then place a fissure sealant and review at recall appointment
caries in enamel only lesions in permanent teeth
- Using this technique caries can be detected via direct vision and microcavities repaired without having to resort to cutting a conventional interproximal cavity.
- Make it a priority to identify and arrest early enamel lesions on the mesial surface of FPM’s
- Where an enamel lesion is developing on a FPM next to a carious 2nd primary molar provide a preformed crown on the primary molar or make the area self cleansing- take care not to cause iatrogenic damage to the FPM.
what to do if uncertain interproximal lesion is cavitated
place separator
remove after 5 days or fall out
FPMs with poor prognosis management
- At around the age of 8-9 years, make an assessment of the likely prognosis of any 6s affected by caries. If prognosis is poor, consider planned loss.
- Radiographically ideal when there is the start of calcification of the bifurcation of the unerupted lower second molars. Ideally all premolars and 3rd molars should be present. (sometime will never be)
Good time to remove all 4 of teeth (radiograph, deep carious lesions)
- As uppers can over erupt and cause issues in occlusion
- Bifurcation of root evident
