Caries management for children and young people- strategies at the tooth level

Question 1

5 management strategies for caries in primary teeth

Answer 1

• 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

Question 2

how to choose managment option in caries in primary teeth

Answer 2

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

Question 3

how to manage a primary tooth with association to sepsis

Answer 3

(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

Question 4

Complete Caries Removal and Restoration

Technique for plastic restorative material

Answer 4

• 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

Question 5

mercury regulation

Answer 5

• 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?)

Question 6

5 restorative options for primary molars

Answer 6

• Composite
• Compomer
• Stainless Steel Crowns (preformed metal crowns)
• Glass Ionomer Cement (temporary restorations only)
• Resin modified glass ionomer

Question 7

compomer

Answer 7

• 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

Question 8

design of interproximal cavity in primary teeth

Answer 8

minimal interproximal cavity

Small as possible due to good bonding

Question 9

9 indications for traditional preformed metal crowns (remove caries)

Answer 9

• 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

Question 10

traditional prep for preformed metal crowns

Answer 10

• 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
• 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

Question 11

how to prep for preformed metal crown

Answer 11

• 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

Question 12

5 year survival of primary restorations

Answer 12

• Amalgam (historic) 80%
• Conventional GIC 66%
• Stainless steel crowns 92%

Question 13

partial caries removal and restoration

Answer 13

• 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

Question 14

3 advantages of partial caries removal and restoration

Answer 14

• 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

Question 15

disadvanatges of partial caries removal and restoration

Answer 15

• 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)

Question 16

NO caries removal techniques

Answer 16

• seal with fissure sealant
• hall technique PFMC
• self-cleansing

Question 17

GI as fissure sealant

Answer 17

Isolate tooth

• Gloved finger with GIC
• Vaseline on other

GIC then Vaseline straight after – hopefully hold in position for some time, not always possible

Question 18

Hall Technique with PFMC

Answer 18

• The technique involves sealing caries into primary molars with a preformed metal crown (PMC)
  
  • No LA, tooth preparation or caries removal is used

Question 19

seal with fisure sealant

Answer 19

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

Question 20

issue here in Tx by self-cleansing

Answer 20

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.

Question 21

technique for making a lesion self-cleansing

Answer 21

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

Question 22

Partial caries removal

technique for primary incisors

Answer 22

• 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

Question 23

interproximal discing of primary anteriors

indications

Answer 23

• Exfoliation time close, pre-cooperative, extensive superficial/minimal interproximal

Question 24

interproximal discing of primary anterior

advantage

Answer 24

simple, quick, open contacts

Question 25

interproximal discing of primary anteriors disadvantage

Answer 25

pulp, food impaction, space loss, aesthetics poor

Question 26

interproximal discing of primary anteriors technique

Answer 26

* Sandpaper discs, tapered stone or diamond in slow speed * Tapered crown – narrower incisal * Round off proximal surfaces * Polish and fluoride varnish

Question 27

3 indications for strip crowns on primary anteriors

Answer 27

* Enamel hypoplasia * Dental anomalies – amelo, dentino * Labial and interproximal caries

Question 28

technique for strip crown anteriors

Answer 28

* LA and isolation * Tapered prep – high speed diamond * Shaded area * Labial groove – aid retention * 2mm incisal reduction * Cellulose acetate crown form and composite – using all available enamel for bonding

Question 29

management of interproximal caries of 1st and 2nd PMs

Answer 29

Make it a priority to identify and arrest early enamel-only lesions on the mesial surface of 6s by: * applying fluoride varnish, and monitoring for progression with bitewing radiographs; * ensuring parent/carers are aware of the potential impact on their child’s oral health, and encouraging them to floss or use floss wands on the 6/E contact 2–3 times a week; if the distal of the E is carious, considering managing the E with either a restoration, a Hall crown or slice preparation (taking care to avoid iatrogenic damage to the 6), or even extraction of the E

Question 30

management of suscpious fissure on FPMs

Answer 30

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

Question 31

caries in enamel only lesions in permanent teeth

Answer 31

* 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 2^nd 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.

Question 32

what to do if uncertain interproximal lesion is cavitated

Answer 32

place separator remove after 5 days or fall out

Question 33

FPMs with poor prognosis management

Answer 33

* 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

Question 34

advantage of planned removal of poor prognosis FPMs

Answer 34

* In some situations, extraction of 6’s with poor long-term prognosis at the correct time can allow the development of a caries free dentition in the adolescent, without spacing. * Premolars (4,5) and 7s, spacing between so easy to clean when first come through but decreases with time

Question 35

disadvantage of poor prognosis FPMs

Answer 35

* Requires extraction of permanent molar teeth from young children, which is demanding for the child, and which may necessitate general anaesthesia, with associated risks.

Question 36

siver diamine fluoride use

Answer 36

* Colourless liquid * Silver fluoride stabilised in ammonia * 38% SDF – Riva star * For dentine hypersensitive only * Fluoride 44,800ppm – double duraphat * works * Occludes dentinal tubules * Silver – antibacterial * Fluoride – remineralisation * Arrests carries synergistically * Recommendation by WHO, IAPD and America

Question 37

silver diamine fluoride contraindications

Answer 37

* Signs of infection * Symptoms * Caries to pulp * Inflamed/ulcerated gingiva * Allergy – ingredients or heavy metals

Question 38

silver diamine fluoride placement need

Answer 38

* Toothpaste (to mask metallic taste) * Petroleum jelly * On lips and soft tissues to prevent temporary stain by SDF (3 weeks) * Protect gingiva * Petroleum jelly * Cotton wool roll for moisture isolation * Dry tooth (gauze, cotton wool roll) * SDF from fridge * Same for pt * One per appointment * Apply to tooth carious lesion, dry for 1 min and moisture isolation for 3 mins * Microbrush/gauze to remove excess * Remove gingiva barrier * Discolouration caries tooth tissues – stain dark colour over coming weeks * Inform as part of consent

Question 39

silver diamine fluoride follow up

Answer 39

* 2 weeks * Reapply if needed * 3-6 month recall based on caries risk, reapplication 6 monthly * Detect arrest by hardened tooth tissue

Question 40

3 advantages of silver diamine fluoride

Answer 40

* Simple technique for child and dentist * Not AGP * Good evidence for caries arrest

Question 41

2 disadvantages of silver diamine fluoride

Answer 41

* Stains caries black * Temporary soft tissue staining * requires monitoring

Question 42

Why is it important to get written consent for the use of SDF? Select one: a. It stains the carious teeth green b. It stains the carious teeth black c. It stains the carious teeth yellow d. It stains the carious teeth red

Answer 42

**b. It stains the carious teeth black**

Question 43

Which of the following is NOT a component of SDF? Select one: a. Ammonia b. Orthophosphoric Acid c. Silver d. Fluoride

Answer 43

b. Orthophosphoric Acid

Question 44

What is the fluoride concentration in SDF (Rivastar, SDI)? Select one: a. 36,800 ppmF b. 16,800 ppmF c. 28,400 ppmF d. 44,800 ppmF

Answer 44

d. 44,800 ppmF

Question 45

What is the major action of the fluoride in SDF? Select one: a. Decontamination of the teeth b. Remineralisation of hard tissue c. Preventing discolouration d. Neutralising acid produced by bacteria

Answer 45

**b. Remineralisation of hard tissue**

Question 46

What is the major action of the Silver in SDF? Select one: a. Antiviral b. Antibacterial c. Antifungal d. Antacid

Answer 46

b. Antibacterial

Question 47

Other than caries arrest what other clinical application does SDF have? Select one: a. Dentine Desensitisation b. Prevention of enamel discolouration c. Removal of organic debris in dentine tubules d. Caries prevention

Answer 47

a. Dentine Desensitisation

Question 48

Which of the following is NOT a contraindication to the use of SDF? Select one: a. No allergy to components of SDF b. Signs of infection c. Ulcerated gingivae d. Caries in the pulp

Answer 48

**a. No allergy to components of SDF**

Question 49

Which of the following is NOT a disadvantage of SDF? Select one: a. Arrests the caries process b. Required reapplication c. Stains caries tissue d. Can cause transient staining to lips and intraoral soft tissues as well as all external surfaces of the environment

Answer 49

a. Arrests the caries process