Dental Techniques

Question 1

What is Site-Specific prevention suitable for?

Answer 1

• Primary tooth with initial lesion in occlusal or proximal surface
• Primary anterior tooth with initial lesion
• Primary tooth with arrested caries or when close to exfoliation
• Permanent tooth with initial lesion in proximal surface
• Permanent anterior tooth with initial lesion

Question 2

What is aim of Site-specific prevention?

Answer 2

• Stop enamel caries progressing and promote remineralisation of early lesions

Question 3

What to do when using Site-specific prevention?

Answer 3

• Show parent/carer and child the carious lesion and explain proposed treatment and important role they have in its success
• Ensure theyre fully aware of role and responsibility in its success
• Demonstrate effective brushing of lesion
• Give dietary advice
• Apply fluoride varnish to lesion 4 times per year
• Keep record to enable monitoring and alteration of treatment plan if lesion does not arrest e.g. radiographs
• At each visit assess presence or absence of plaque biofilm and record scores
• Review after 3 months and if not arrested consider alternative
• Continue to provide Enhanced prevention

Question 4

What is no caries removal and seal using Hall technique suitable for?

Answer 4

• Primary tooth with advanced lesion in occlusal or proximal surface

Question 5

What is the aim for Hall technique?

Answer 5

• Completely seal carious lesion so environment of plaque biofilm is altered sufficiently to slow or even arrest caries progression

Question 6

What is the outline of the Hall technique?

Answer 6

• Ensure child sitting upright
• Assess whether separators required (placing them 3-5days later removing them to fit the crown) required when broad tight contact between adjacent teeth
• If any possibility of crown endangering airway during fitting, make a handle with strip of sticking plaster and protect airway with gauze
• Select correct size of PMC (don’t seat crown through contacts prior to cementation as might be difficult to remove)
• Ensure PMC well filled with glass ionomer luting cement
• Seat PMC over tooth and ask child to bite down on crown or cotton wool placed on crown
• Check crown is seated evenly over tooth and through the contacts and ask them to bite down again
• Remove excess cement and clear contacts with floss
• Avoid excess cement reaching tongue as has a bitter taste that children dislike

Question 7

What is no caries removal and seal with a Fissure Sealant suitable for?

Answer 7

• Primary tooth with initial occlusal or proximal lesion
• Permanent tooth with initial occlusal or proximal lesion

Question 8

What is aim of seal with a Fissure sealant and no caries removal?

Answer 8

• Completely seal a noncavitated carious lesion from oral environment to slow or arrest caries progression
• If seal fails caries will progress

Question 9

What is the technique for Occlusal surface Fissure Sealant?

Answer 9

• Dry surface well and isolate with cotton wool
• Etch surface and wash away
• Place fissure sealant over pit or fissure caries to completely seal fissure
• Light cure

Question 10

What is the technique for proximal surface Fissure Sealant?

Answer 10

• Separate teeth by using orthodontic separators which are left in place 2-5 days or with progressive wedging of teeth at appointment (topical may be required)
• Isolate teeth ideally with rubber dam
• Protect adjacent tooth not to be etched by placing matrix strip
• Etch and rinse
• Place dry matrix strip and apply resin sealant to tooth surface
• Check no pooling around gingivae
• Light cure and use floss to check contact area

Question 11

What is an alternative technique for proximal surface using Icon?

Answer 11

• Clean tooth with toothbrush or prophy brush/cup with pumice/prophy paste
• Wash and dry tooth
• Place interdental wedge to create interdental space
• Place Icon-Etch syringe between teeth, apply etch. Leave 2 mins
• Remove syringe and dry 30secs
• Icon-Dry for 30sec and dry
• Place Icon-infiltration syringe between teeth, apply material and leave for 3 mins
• Remove syringe, remove excess with floss and light cure 40secs
• Repeat last two step
• Remove wedge and polish if necessary with polishing strip

Question 12

What is the aftercare for Fissure Sealants?

Answer 12

• Use radiography to monitor if lesion is progressing at intervals informed by caries risk assessment
• For occlusal sealants, check integrity of sealant with probe at each visit
• When occlusal fissure sealant worn enough to expose some fissures, apply fresh fissure sealant

Question 13

What is selective caries removal and restoration suitable for?

Answer 13

• Primary posterior tooth with advanced occlusal or proximal lesion
• Primary anterior tooth with advanced lesion
• Permanent tooth with moderate occlusal or proximal lesion
• Permanent anterior tooth with advanced lesion

Question 14

What is the aim of selective caries removal and restoration?

Answer 14

• Remove sufficient carious tooth tissue to enable an effective marginal seal to be obtained with bonded adhesive restorative material
• Inhibiting further progression of residual caries while minimising risk of iatrogenic pulpal damage

Question 15

Notes to consider when performing selective caries removal and restoration?

Answer 15

• LA not always needed for primary unless removing sound dentine but likely for permanent
• Hand excavation useful for cavity prep in primary teeth
• Obtaining marginal seal to arrest caries is essential and dependent on good cavity prep, important for long term effectiveness for permanent teeth
• For primary molars, plastic adhesive materials most successful on occlusal lesion and Hall technique preferred for multi-surface lesions

Question 16

What is the technique of selective caries removal and restoration?

Answer 16

• Gain access to carious tissue, may use high-speed and LA if indicated
• Remove superficial caries with slow-speed or excavators until no caries visible at enamel-dentine junction and cavity depth allows adequate thickness of restorative material to be placed
• Clear cavity walls to hard (scratchy) dentine to provide good surface for bonding
• Pulpally remove enough carious tissue to give adequate depth for durable restoration avoiding pulp exposure
• Remove any unsupported or undermined enamel
• Place restoration using adhesive material and bonding system. Don’t use conventional glass ionomer materials for restoration of multi-surface cavity
• Fissure seal unprotected pits and fissures and as many of the restoration margins as poss
• Monitor for caries progression using radiographs where appropriate

Question 17

When to stop removing caries for shallow to mod deep lesions?

Answer 17

• Caries likely to be removed until leathery or firm (feeling resistance to hand excavator)

Question 18

When to stop removing caries for deep lesions?

Answer 18

• Likely some soft dentine caries will be left
• Deforms when hand excavator pressed on to it and could be easily lifted
• Be aware pulp chamber anatomy to reduce risk of pulpal exposure

Question 19

What is the selective caries removal and restoration technique for primary incisors?

Answer 19

• Thoroughly clean the teeth with prophy paste
• Caries removal is minimal for LA not required
• Clean margin of cavity to ensure whole perimeter of restoration material will be placed on sound tooth substance
• Acid etch entire crown, wash, dry and apply bonding system
• Place comp restoration, either by hand building or using strip crowns

Question 20

What is the atraumatic restorative technique (ART) suitable for?

Answer 20

• Primary tooth with single surface lesion

Question 21

What is the aim of the atraumatic restorative technique?

Answer 21

• Prepare cavity and carry out restoration with minimal stress to child
• LA not needed so less stressful for child and advantageous for anxious children

Question 22

What is the atraumatic restorative technqiue?

Answer 22

• Ensure excavators and enamel chisels/gingival margin trimmers are sharp
• Advise child it will sound scratchy or picky
• Use firm finger rest
• If entrance to cavity too small with no access to carious dentine, enlarge it by placing enamel access cutter, dental hatchet or sharp small spoon excavator into breach in enamel/cavity and rotate instrument. This removes thin and unsupported enamel that might fracture when restoration is placed enabling access to carious dentine
• Remove caries and prepare cavity walls and floor (use cutting movement across lesion as minimises pain which occurs when pressure applied in pulpal direction increasing tubule fluid pressure that is transmitted to pulp
• Clean cavity with wet cotton pellet
• Dry cavity using dry cotton pellet, don’t use 3-in-1 as this will overly dry dentine
• Ensure proper isolation and maintain environment uncontaminated by saliva and blood
• Use encapsulated material
• Use high-viscosity glass ionomer. Don’t use conventional glass ionomer materials for restoration of multi-surface cavity due to unacceptably high failure rate
• Use finger press technique and hold until set
• Immediately rub petroleum jelly and press 20sec
• Advise patient to avoid eating for an hour after treatment

Question 23

What is stepwise caries removal and restoration suitable for?

Answer 23

• Permanent tooth with an extensive lesion in occlusal or proximal surfaces

Question 24

What is the aim of stepwise caries removal and restoration?

Answer 24

• Avoid pulp exposure in teeth with deep carious lesions by two-step removal technqiue

Question 25

What is the Two-step removal and restoration technqiue?

Answer 25

• Place LA and gain access to carious tissue using high-speed handpiece
• Remove carious tissue with slow-speed or excavators until cavity walls cleared to hard dentine
• Pulpally, selectively remove carious dentine until soft dentine reached. Remove enough tissue to place durable restoration avoiding pulp exposure
• Place restoration using adhesive material and bonding system or glass ionomer material
• Wait 6-12months
• Place LA and remove temp restoration
• A gap may be found beneath restoration where dentine dried out
• Remove any carious tissue until hard dentine is reached
• Place permanent restoration and consider fissure sealing to improve the seal

Question 26

What is non-restorable cavity control suitable for?

Answer 26

• Primary tooth with arrested caries or when tooth is unrestorable/close to exfoliation
• Primary tooth with advanced lesion where alternative methods not feasible

Question 27

What is the aim of non-restorative cavity control?

Answer 27

• Reduce cariogenic potential of lesion by altering environment of plaque biofilm overlying carious lesion through brushing and dietary advice

Question 28

What is the technique of non-restorative cavity control?

Answer 28

• Show parent/carer and child the carious lesion and explain proposed treatment and important role they have in its success. Confirm parent/carer is in agreement with this approach
• Ensure child made fully aware of role and responsibility
• Make lesion cleansable
• If approach accepted and agreed provide site-specific prevention;
• Demonstrate effective brushing of lesion
• Give dietary advice
• Apply fluoride varnish to lesion 4 times per year
• Keep record of site and extent of lesion to enable monitoring and change of treatment plan if lesion doesn’t arrest
• Keep record of agreed plan in notes. Assess plaque biofilm and record plaque scores
• Review lesion after three months and if active lesions not arrested or previously inactive become active then different strategy i.e. non-restorable = extraction
• Continue with Enhanced prevention

Question 29

What is the technique for making a lesion cleansable?

Answer 29

• Using high speed handpiece or hand instruments, remove undermined enamel adjacent to carious lesion making surface of lesion accessible to toothbrushing
• Resulting cavity form will vary in shape depending on lesion
• Extreme care required to avoid iatrogenic damage to adjacent teeth

Question 30

When is complete caries removal and restoration suitable?

Answer 30

• Primary tooth with advanced lesion in occlusal or proximal surfaces
• Primary anterior tooth with advanced lesion
• Permanent tooth with moderate lesion in occlusal or proximal surfaces
• Permanent anterior tooth with advanced lesion

Question 31

What is the aim of complete caries removal and restoration?

Answer 31

• Remove all infected carious tooth tissue and restore tooth to function

Question 32

When is complete caries removal not suitable?

Answer 32

• Primary teeth other techniques prefferred due to risk of pulp exposure and demanding nature for child and clinician
• For permanent teeth , technique not suitable for extensive lesions in premolars and molars - stepwise caries removal should be used

Question 33

What is the technique for plastic restorative material?

Answer 33

• LA before cavity prep as technique requires sound dentine to be cut
• Consider use of rubber dam
• Use high-speed to gain access and leave wall of enamel to protect adjacent tooth
• Remove caries with slow speed and excavators
• Be aware of pulp chamber to reduce risk of pulpal exposure
• Place restoration
• If at risk of pulpal exposure place indirect pulp
• Don’t use conventional glass ionomers for restoration of a multi-surface cavity due to unacceptably high failure rate

Question 34

How do you prevent iatrogenic damage?

Answer 34

• Prepare cavity margins using a wedge, gingival margin trimmers or matrix band on adjacent

Question 35

What is the technique for conventional preformed metal crown (PMC) preparation?

Answer 35

• Give LA
• Protect airway
• Consider use of rubber dam
• Remove caries (if at risk of pulpal exposure, place indirect pulp cap before placing glass ionomer cement dressing)
• Reduce occlusal surface enough to allow a straight probe to be passed across tooth surface when teeth are in occlusion.
• Cut mesial and distal slices
• Bur should pass through crown cervically in order to avoid creation of cervical ledge, as this will impede seating of crown. Wedge protects gingivae during distal preparation
• Wall of enamel left while cutting slice to ensure no iatrogenic damage to adjacent tooth.
• Once wedge removed, probe can pass freely from buccal to lingual through contact
• Select correct size of PMC, adjust to fit with crown contouring pliers or root/tooth forceps
• Cement PMC in place with glass ionomer cement, remove excess cement and clear contacts using floss

Question 36

What is Pulpotomy for primary molars (vital pulp therapy) suitable for?

Answer 36

• Pulpitis with irreversible symptoms (vital pulp)
• Primary molar with advanced carious lesion with no clear band of dentine visible radiographically that separates lesion and pulp

Question 37

What is the aim of pulpotomy for primary molars?

Answer 37

• Enable vital primary molar with pulpal disease to be retained free from pain and infection until exfoliation

Question 38

What are the contra-indications of pulpotomy?

Answer 38

• Teeth close to exfoliation or are unrestorable
• Children who are pre-cooperative or immunocompromised
• Cases requiring multiple pulp therapies where extraction is indicated

Question 39

What is the technique for Pulpotomy in primary molars?

Answer 39

• LA and consider use of rubber dam
• Cut large access cavity using high-speed handpiece, ensuring entire roof of chamber is cleares
• Remove contents of pulp chamber using slow-speed handpiece or sharp excavator
• Thoroughly irrigate pulp chamber with water from 3-in-1 syringe
• Avoid use of compressed air which can cause surgical emphysema
• Identify entrances to root canals which will be in corners of pulp chamber
• If still bleeding arrest haemorrhage by placing pledget of cotton wool dampened in ferric sulphate into pulp chamber, place another pledget on top and get child to bite down for approx 2mins (don’t use formocresol due to concerns about safety)
• If haemorrhage can’t be arrested or if root canals are necrotic consider pulpectomy or extraction
• Remove cotton wool and place mineral trioxide aggregate or similar material in pulp chamber. Or zinc-oxide-eugenol cement can be placed on pulp stumps and floor of pulp chamber
• Fill cavity with zinc-oxide-eugenol cement
• Place PMC following conventional prep (placing PMC on same appointment had evidence for improved prognosis of tooth)

Question 40

Why can primary molars be difficult for pulpotomy?

Answer 40

• The pulp horns are much higher and relative to central part of pulp chamber roof
• Root canals can be very divergent when leaving pulp chamber
• Care is needed to avoid perforating floor of pulp chamber which is very thin in primary molars

Question 41

What is the aftercare advice for pulpotomy in primary molars?

Answer 41

• Advise child and parent/carer that tooth might be a little uncomfortable when anaesthesia wears off and child may need analgesia
• Conduct radiographic review of pulpotomised primary molars annually

Question 42

How many canals does do primary molars have?

Answer 42

Maxillary - 3 canals, 2 buccal and 1 palatal

Mandibular - 2 canals, mesial and distal

Question 43

When are local measures for control of infection suitable for?

Answer 43

• Non-vital primary and permanent teeth with dental abscesses or periapical/periradicular periodontitist

Question 44

What is the aim of local measure for control of infection?

Answer 44

• Drain localised infection, thereby relieving pain and reducing risk of infection and need for antibiotics

Question 45

How to use local measures to control infection for primary teeth?

Answer 45

• Consider using gentle hand excavation of carious tissue to drain infection without LA to achieve open communication with necrotic pulp chamber
• If achieved by above method, advisable not to place any form of dressing that would further inhibit drainage
• For teeth tender before achieving drainage, corticosteroid dressing may be placed. Use a temp dressing material that can be easily removed by hand instruments for easy removal at next visit
• Incision into soft tissues to achieve drainage is rarely indicated in primary dentition and would require suitable anaesthesia

Question 46

How to use local measure in permanent teeth to control infection?

Answer 46

• Consider accessing pulp chamber to remove necrotic pulp and or achieve drainage
• In circumstances where a larger fluctuant intraoral swelling present, may be appropriate to undertake incision of swelling under LA

Question 47

What is extraction of primary or permanent teeth suitable for?

Answer 47

• Primary tooth that is unrestorable or of poor prognosis
• Permanent tooth that is unrestorable or of poor prognosis

Question 48

What is the aim of extraction of primary or permanent teeth?

Answer 48

• To relieve or avoid pain or infection when alternative management approaches are not feasible or are not in child’s best interest

Question 49

How to deal with a potential extraction in a child?

Answer 49

• Avoid dental extractions with LA on a child’s first visit if at all possible
• If child is in pain (pulpitis with irreversible symptoms), consider dressing tooth with cortico-steroid antibiotic paste and temporary dressing
• Where signs or symptoms of dental abscess/infection and extraction is either not poss or better delayed, build up child’s ability to cope to allow extraction to be carried out
• In some local measures may bring infection under control but if signs or symptoms of systemic involvement or spreading infection then antibiotics may be prescribed

Question 50

What is balancing extractions in primary dentition?

Answer 50

• Extraction of a contralateral tooth, performed in order to minimise centre-line shift and maintain symmetry of developing occlusion

Question 51

What are some things to consider and be aware of when balancing extractions?

Answer 51

Consider balancing extractions when:
- one C to be extracted
- one C has exfoliated prematurely due to eruption of permanent lateral incisor
- Centre-line shift is developing following extraction of one D

Be aware its not usually necessary when;
- loss of primary incisors
- loss of D’s unless centre-line shift developing
- loss of E’s

• if in doubt arrange orthodontic assessment

Question 52

What is the technique for avoiding iatrogenic damage when preparing multi-surface restorations?

Answer 52

• Access cavity with high-speed handpiece, leaving proximal enamel intact
• Remove caries using slow-speed
• Prepare proximal cavity margins using gingival margin trimmers only
• Complete restoration using wedges and matrix bands

Question 53

When is LA recommended to use?

Answer 53

• Any cavity prep that involves cutting sound dentine in both primary and permanent teeth.
• Dentine in primary is as sensitive as that of permanent teeth
• LA can be used successfully in children as young as 4 years
• Distraction techniques are most useful
• Need to be careful so child doesn’t develop mistrust phobia and dental anxiety

Question 54

Best way to give a LA injection?

Answer 54

• Ask child if they want to see what is going to make their tooth go to sleep. If they do show the syringe and make sure to emphasise how small the needle is and only a tiny part will go into their gum

To reduce the discomfort use;
- Topical anaesthesia
- Distraction
- Very slow injection technique taking at least 60 secs for an infiltration
- Intra-papillary injections rather than palatal injections

Question 55

What is the intra-papillary injection technique?

Answer 55

• Apply topical anaesthesia
• Give buccal infiltration adjacent to tooth you want to anaesthetise
• Draw imaginary line across base of one interdental papilla and drop perpendicular down onto the line. Where lines intersect, insert needle horizontally so as to pass between teeth on either side
• Advance needle 1-2mm and gently inject a drop or two of LA. Ensure needle remains in correct plane and does not become obstructed on interseptal bone or emerge from gingivae
• Advance another 1-2mm and inject another drop of LA
• Continue this while observing palatal aspect of mucosa in mirror
• After blanching is seen, withdraw needle and insert into blanched area on palatal side. Child will not feel this and needle can be advance further apically until complete anaesthesia achieved

Question 56

What is the WAND?

Answer 56

• Computerised LA delivery system consisting of microprocessor unit that accommodates LA cartridge.
• Allows constant slow flow-rate of anaesthetic sol irrespective of tissue resistance.
• Slow rate used for needle insertion to target area
• Faster rate used once correct location achieved.
• Used for conventional block’s, buccal infiltration and intra-ligamental techniques
• Useful for children with negative experiences of LA as doesn’t look like needle but its expensive and slower than conventional techniques