Caries Pattern and Diagnosis - Caring for Children and Young People

Question 1

define caries

Answer 1

disease of mineralised tissues; enamel, dentine and cementum, caused by action of micro-organisms on fermentable carbohydrates

Question 2

when and why can caries be arrested

Answer 2

in it’s very early stages the disease can be arrested since it is possible for remineralisation to take place

Question 3

what can decalcification present as

Answer 3

white / brown spot lesions

Question 4

what helps a tooth to remineralise

Answer 4

normal brushing with fluoride toothpaste

if the lesion is self cleansing

free flowing saliva

Question 5

how narrow is the fissure of a tooth

Answer 5

so narrow at its base that you cannot even get a single brush filament into it so it is impossible to clean

Question 6

why do we do fissure sealants

Answer 6

as part of prevention

because the base of the fissure is so narrow we cannot clean it ourselves

fissure sealants seal the fissures so that bacteria is unable to get into them and multiply in an area where we are unable to clean

Question 7

what is meant by the smooth surfaces of the tooth

Answer 7

• buccal
• lingual
• cervical areas

(more difficult to get caries in these areas)

Question 8

how would you determine the extent of interproximal caries

Answer 8

a clinical examination (not enough on its own)

and a radiograph

Question 9

what teeth do early childhood / nursing bottle caries affect

Answer 9

maxillary incisors
first molars
mandibular canines

Question 10

why are lower incisors usually not affected by early childhood / nursing bottle caries?

Answer 10

tend to be protected by the tongue

any saliva we do have at night time usually comes from the floor of the mouth so this also protects the lower incisors

Question 11

how can early childhood / nursing bottle caries occur

Answer 11

Child is put to bed with a bottle or feeding cup filled with something other than water (juice / milk)

The lactose from milk / sugars from juice can then cause this when the mouth is dried up overnight and the saliva is not flowing as much so then the milk / juice lies in the mouth

Question 12

what does the extent of early childhood / nursing bottle caries depend on

Answer 12

the length that this bad habit is ongoing

Question 13

how can recurrent / secondary caries occur

Answer 13

• restorations margins ditched / there is a crack in the restoration
• restoration has been leaking
• bacteria getting into the tooth
• caries can form under the restoration

Question 14

why is grey staining not uncommon in an amalgam restoration without caries

Answer 14

amalgam tattoos

Question 15

how can caries become arrested

Answer 15

patient follows oral hygiene and diet advice

work with fluoride application as well

Question 16

how does arrested caries present

Answer 16

dark brown

feel shiny and tough with a probe

Question 17

what is expected in “rampant caries”

Answer 17

• patient has more than 10 new lesions per year
• lower anteriors are affected

(if caries are in the lower incisors this is uncontrolled caries)

Question 18

what is the most common caries pattern in the primary dentition

Answer 18

• lower molars
• upper molars
• upper anteriors

Question 19

where is caries rare in the primary dentition

Answer 19

• lower anterior

- buccal / lingual surfaces (except in rampant caries)

Question 20

does occlusal caries affect the second primary molars or first primary molars more

Answer 20

second primary molars

Question 21

can interproximal caries occur in the primary dentition

Answer 21

not until contacts develop

tends to be lots of gaps in the primary dentition at the beginning
not until the child is around 3 years old when their 2nd primary molars have come through that the teeth start to tough

until contacts are formed the teeth are self cleansing so it is more difficult for interproximal caries to develop

Question 22

in the mixed dentition, is the caries rate greater in lower 6s or upper 6s

Answer 22

lower 6s

Question 23

what pits / grooves are worst affected in the mixed dentition

Answer 23

§ Palatal upper 6s
§ Buccal lower 6s
§ Palatal upper laterals
§ Cingulum pits of lateral incisors

Question 24

if caries is on the upper and lower incisors in the mixed dentition what is it called

Answer 24

uncontrolled caries

Question 25

where would we consider placing fissure sealants if the child is high caries risk

Answer 25

- FPM - second permanent molars - premolars

Question 26

what host factors can affect the caries pattern in the early permanent dentition

Answer 26

- reduced salivary flow | - high mutans count

Question 27

when might patients have a reduced salivary flow

Answer 27

certain medical conditions | patients with special needs

Question 28

what does a high mutans count mean

Answer 28

high level of bacteria in the mouth

Question 29

what caries management factors need to be considered that are specific to children

Answer 29

- parental involvement - patient involvement - dealing with 2 dentitions (mixed dentition)

Question 30

what needs to be included in the patient assessment

Answer 30

• Parent / patient management ○ Dealing with at least 2 people, sometimes more • Symptoms ○ Children sometimes get brought to the dentist for the first time only when they have symptoms - not a good method, want to see them before there is a problem • History of present complaint ○ Often if a child is in pain they will have been in pain for a longer time than an adult patient will have been in pain just because it takes longer to communicate to their parents how sore the pain actually is and for the parents to realise something is actually wrong ``` • Past dental history ○ Treatment experience to date ○ Oral hygiene habits ○ fluoride history ○ dietary habits ``` * Medical history * Social history * Caries risk assessment

Question 31

what do you look for in the extra-oral examination

Answer 31

Asymmetry | Nodes etc

Question 32

what do you look for in the intra-oral examination

Answer 32

``` ○ Soft tissues § Oral hygiene § Swellings § Sinuses § Ulceration § Gingival health ``` ``` ○ Hard tissues § Teeth present § Dental age § Occlusion § Loose / missing / extra teeth § Trauma § Dental abnormalities § Caries activity - Past and present ```

Question 33

what do you use for caries detection

Answer 33

``` > clinical examination > radiographs > sensibility testing > vitality testing > gentle probing to feel surface texture ```

Question 34

what is included in the clinical examination for caries detection

Answer 34

- visual / looking - ortho separators - caries detector dyes - laser

Question 35

what do you need for a good visual examination

Answer 35

§ Dry teeth § Good light § Sharp eyes FOTI - fibre optic transillumination can help

Question 36

what do sensibility tests test

Answer 36

if the nerve is working

Question 37

what kind of sensibility tests can you use and when would you use them

Answer 37

- hot - cold - electric tend to be more for older children with a permanent dentition as these tests are unreliable on very young children / primary dentition want to see if the tooth (nerve) will react to the different stimuli

Question 38

name the vitality test you can use and what does it test

Answer 38

tests blood supply | ``` laser dopler tends to be difficult to use due to big bulky size ```

Question 39

how is fibreoptic transillumination helpful

Answer 39

the light doesn't travel through carious material in the same way it travels through hard tooth tissue so it makes it easier to detect caries

Question 40

what needs to be considered when evaluating the dentition

Answer 40

* Tooth restorable? * Patient / parent compliance • Stage dental development (If we know the tooth is going to fall out soon what is the point in putting the child through a restoration / extraction) • Space management (Removing the second primary molar before the first permanent molar erupts can cause it to drift forward and take up the space of the premolar and results in a crowded dentition but can also use space maintainers to keep the space open) • Anticipated difficulties • Overall prognosis ○ Only one tooth - may as well do your best to fix it ○ 8 carious teeth then you are more looking at GA and extraction of them all

Question 41

what needs to be decided when restoring a tooth?

Answer 41

* Choice of restorative material * Choice of restorative technique * Ideally decide cavity shape / form and restoration before starting * Permanent Vs Temporary restorations

Question 42

when is "stabilisation" used

Answer 42

when a patient has too many problems to fix so you want to make the overall environment better

Question 43

what is included in stabilisation

Answer 43

* Prevent pain * Preventive therapy * Arrest restorable lesions ``` • Acclimatisation ○ Hand excavation ○ Use of carisolv / ART / IRM / GIC ○ Diet advice ○ OHI ``` * Decrease bacterial load in mouth * Improve OH by making areas easier to clean

Question 44

what is ART

Answer 44

ART = Atraumatic Restorative Technique | Used a lot in 3rd world countries where they wouldnt have dental drills etc

Question 45

what does carisolv do

Answer 45

dissolves carious dentine

Question 46

what does IRM stand for

Answer 46

intermediate restorative material

Question 47

how can you make areas in the mouth easier to clean to improve OH

Answer 47

By filling big cavities, even temporarily, the patient can then clean their mouth better as these holes would have been impossible to clean

Question 48

name 2 important elements in patient and parent compliance

Answer 48

motivation | co-operation

Question 49

explain motivation in terms of patient / parent compliance

Answer 49

○ Parent § Compliance with prevention regimes such as right foods in diet and ensuring oral hygiene is carried out § Attendance § Support at home ○ Child § Compliance § Oral hygiene

Question 50

explain co-operation in terms of patient / parent compliance

Answer 50

○ Parent § Own anxieties ``` ○ Child § Emotional maturity § Fears § Previous bad experience § Behavioural problems § Ability to co-operate ```

Question 51

list some things that should be considered with regards to the child's stage of development

Answer 51

• Primary teeth ○ Are they close to exfoliation? • Permanent molars ○ What is the long term prognosis? ○ Could extractions be part of the ortho treatment plan? ○ What about space maintainers?

Question 52

what does the effect of premature loss of primary teeth depend on?

Answer 52

§ Tooth size / jaw relation § Muscle behaviour § Age at loss § Tooth

Question 53

why would you use space maintenance

Answer 53

- maintain space if tooth (FPM/second primary molar/etc) lost in mixed dentition stage - prevent crowding

Question 54

name 2 types of space maintainers

Answer 54

- band and loop space maintainers | - distal shoe

Question 55

explain the band and loop space maintainer

Answer 55

used for a good compliant patient place an orthodontic band around the FPM and the loop then touches the distal surface of the first primary molar [can also be done if the first primary molar comes out prematurely then the space maintainer can be put on the second primary molar as a crown instead of a band]

Question 56

when is the distal shoe space maintainer used and how does it work

Answer 56

placed when the first permanent molar is still unerupted but the secondary primary molar is lost similar to band and loop, but on the loop there is a spike that goes into the bone that allows the FPM to slide up againt it when it is erupted to ensure it goes into the right space

Question 57

what results from early primary tooth extractions

Answer 57

* Increase crowding, increase tendency for space loss * Earlier removed, greater degree of space loss * Balancing / compensating extractions

Question 58

explain balancing / compensating extracting

Answer 58

Balance primary canines to prevent centre-line shift § Ie taking out on primary canine we then take out the one on the other side of the same arch to prevent the centre line of your teeth from moving If you take out an upper right canine and not the upper left canine, then the other incisor / anterior teeth will move towards the space and upset the midline Must always consider balance / compensation when removing first permanent molars don't really need to balance as or bs

Question 59

what happens in early loss of maxillary FPM

Answer 59

if lost before complete eruption of 7 then: § Rotation and mesial movement 7 § Distal drift of 5

Question 60

what happens in early loss of mandibular FPM

Answer 60

○ Loss after optimum age § Tilting 7s ○ Loss before optimum age § 5 drifts distally and rotates

Question 61

What are aims of treatment

Answer 61

* Relief of symptoms * Prevention of disease initiation and progression * Restore function and aesthetics

Question 62

to relieve symptoms, treatment depends on what

Answer 62

``` ○ Nature of the pain ○ Status of pulp ○ Stage of dental development ○ Level of patient compliance ○ Also parental factors ```

Question 63

what questions do you ask when taking a pain history

Answer 63

``` • Where is the pain? • What does the tooth feel like? • How long has the tooth been painful? • Does anything make it better or worse? • Kept awake? • Spontaneous or precipitated? ○ Does it only really feel painful when eating? • Relieved with analgesics or antibiotics? ``` remember the questions must be asked in a child friendly way

Question 64

what are emergency treatment options

Answer 64

• Caries excavation and sedative dressing • Pulp therapy ○ Pulpotomy ○ Pulpectomy • Drainage of pus • Extraction ○ LA with or without inhaled sedation ○ GA • (IV sedation only considered for 12 years and over) ○ More for young permanent dentition

Question 65

how can you optimise treatment conditions

Answer 65

* Pain-free LA | * Rubber dam

Question 66

how can LA be pain-free

Answer 66

○ Topical ○ Warm LA cartridge ○ Lower 6s rule § 6 years old or 6s erupting - use IDB § If the child does not have their lower 6s erupted then you can get away with doing infiltration instead of IDB ○ Intra-papillary infiltration avoids palatal injection § Makes it more comfortable

Question 67

how does rubber dam optimise treatment conditions

Answer 67

• Increase safety by decreasing ○ Damage to soft tissue ○ Risk of inhalation ○ Cross-infection ``` • Benefit to operator and patient by increasing ○ Isolation and moisture control ○ Retraction of gingivae and cheeks ○ Effective inhalation sedation ○ Patient confidence ○ Operator confidence ```

Question 68

what is a good sequence of restoration

Answer 68

``` • Fissure sealants • Preventive restorations • Simple fillings ○ Eg shallow cervical cavities • Fillings requiring LA but not into pulp ○ Upper arch first • Pulpotomies / pulpectomies • Extractions ```

Question 69

what are the different methods of caries removal

Answer 69

* Hand excavation * Rotary instruments • Chemo-mechanical removal ○ Caridex - N-monochloro-DL-2-aminobutyric acid (NMAB) ○ Carisolv gel - Amino acids and hypochlorite ○ Ozone ○ None of these are done in the dental school * Air abrasion * Lasers - Erbium-YAG

Question 70

list anatomical features of the crown of primary teeth and where possible say the clinical significance

Answer 70

> shorter = limited room for cavity prep so linings are not usually required > narrower occlusal tables > thin enamel / dentine > broad contact areas > enamel rods in gingival 1/3 extend occlusally = clinical caries only detected if large, bitewings are essential > marked cervical constrictions = enamel at floor of box not undermined > whiter = retention of SS crown

Question 71

list anatomical features of the pulp of primary teeth and where possible say the clinical significance

Answer 71

> large = limited room for cavity prep > pulp horns close to surface = pulp exposure easy

Question 72

list anatomical features of the roots of primary teeth and where possible say the clinical significance

Answer 72

> narrow mesio-distally = pulpectomy more difficult > long > slender > flared

Question 73

what do you need to consider about primary teeth in the clinical examination

Answer 73

○ Extent of lesion ○ When the marginal ridge has breakdown more than 2/3 of its length there is caries in the pulp so plan pulp treatment not simple restoration

Question 74

what do you need to consider about primary teeth in the radiographic examination

Answer 74

○ Proximity of caries to pulp? ○ >2/3 into dentine = pulp involved ○ Pathology / root length

Question 75

in general what do you need to consider when choosing the material and technique for restoring a tooth

Answer 75

○ Longevity of tooth - How long must it last? ○ Co-operation ○ Medical and dental history ○ Extent of lesion ○ Which tooth? ○ Oral hygiene ○ Diet history ○ Attitude ○ Parental preference