Management of Caries in Children Flashcards
What is the first priority of dental care in children?
keep 6s and 7s free from both occlusal and approximal caries
What is the next priority for dental care in children?
reduce the risk of any caries in primary dentition resulting in pain or sepsis before the tooth exfoliates
What is the caries pattern in young permanent dentition?
- pits and fissues
- interproximal
- buccal/cervical/labial
In mixed dentition caries rates are higher in what first molars?
higher caries rate in lower 6s compared to upper 6s
Caries in incisors is usually an indication of …
uncontrolled caries
What pits/grooves are most likely to be affected in mixed dentition?
- palatal upper 6s
- palatal upper laterals
- buccal lower 6s and 7s
What is the most affected tooth in the permanent dentition with caries?
first permanent molars
What is MIH ?
molar- incisor hypomineralisation
developmental condition that has to do with quality of enamel; enamel not mineralised sufficiently
enamel defects seen in molars and incisors
What is the consequence of MIH?
- increased caries risk
- can cause extensive breakdown of the 6s
What treatment should you consider for MIH of 6s with poor prognosis?
extraction
allow 7s to erupt into the space
How can you clinically assess the presence of caries in an examination?
- visual- clean, dry tooth, good eyes, blunt probe (blunt probe to remove desposits from fissures)
- orthoseperators
- DIAGNOdent, cariesd detector dyes
What adjunctive diagnostic tools can be used to diagnose caries?
- radiographs
- sensibility tests- nerves
- vitality testing- blood supply
It is possible for an exagerrated response to a sensibility test. True or false
true
What are the indications of PRRs?
- microcavitation
- shadowing under enamel
- dentine caries visible radiographically
State an advantage and disadvantage of PRRs
Advantage:
* may prevent future restorations
Disadvantage:
* needs careful long term monitoring and repair of fissure seals
Indications for PRRs are decreasing to prevent the loss of healthy tooth tissue. What is a better alternative?
high quality fissure sealant
When is a GI sealant with the “press finger” technique indicated?
for uncooperative children
instances where moisture control is difficult to obtain
as opposed to resin sealant where moisture control is imperaative
Briefly outline the press finger technique using GI
- place a small amount of GI on one finger tip and vaseline on the other
- if possible wipe tooth with cotton wool roll
- firmly apply finger tip with GI to the the tooth surface to be sealed
- keep finger in place for 2 minutes
- place 2nd finger in the mouth and rapidly switch fingers
- cover GI with vaseline before moisture contamination
How can you manage an enamel-only aproximal lesion in permanent molars?
- use orhtoseperators (take a week to work)
- apply fluoride varnish and monitor carefully
- inform patents and reinforce preventive advice
- demonstrate floss
> > icon resin infiltration- microinvasive technology to fill demineralised enamel in one procedure?
What is an advantage and disadvantage to using fluoride vanish to manage enamel- only aproximal lesions?
Advantage:
avoid class 2 restoration- destruction of tooth tissue and difficult for child and clinician
Disadvantage:
not proven
When is step-wise caries removal and restoration and appropriate in children?
suitable for a permanent tooth with extensive lesion on occlusal or proximal surfaces
What is the aim of stepwise caries removal ?
avoid pulpal exposure by selectively removing caries from the cavity walls
allows reactionary dentine to be laid down before the removal of the rest of the infected dentine
How is the stepwise procedure carried out?
- selective removal of caries from cavity walls
- sealing the remaining caries with adhesive restoration
- waiting 3-6 months for reactionary dentine to be laid down and then completing caries removal to hard dentine
When is the optimal time for extraction of the maxillary 6?
8.5-10
What is the consequence of sub-optimal extraction of maxillary 6s?
mesial rotation of 7s (mesial tilt)
distal drift of the 5s
What is the optimal time for extraction of the mandibular 6s?
loss before the optimum age of??
what is the optimum age?
8.5-10 years old
What is the consequence of extraction of mandibilar 6s before the optimum age?
5 drifts distally and rotates
What is the consequence of the extraction of mandibular 6s after the optimum age?
mesial tilting of the 7s
What age should you ideally extract permanent molars?
8.5 - 10 years old
What are the positive indicators for an extraction of first permanent molars?
- 8.5 - 10 years old
- furcation of second permanent molars
What is the benefit of extracting 6s when furcations are present on 7s?
allows 7s to erupt into acceptable occlusions with the 5s
As of 2017, ___% of 5 year old children in the NW have obvious decay experience
35%
highest of any other region in England
Why is caries progression in primary dentition rapid?
- smaller tooth
- larger pulp chambers
Primary teeth have broad contact areas. What is the consequence of this?
difficult to diagnose caries
There is early radicular pulp involvement in primary dentition as a result of caries. True or false
True
What are the characteristics of affected dentine?
firm
leathery
What does the pulp to in order to protect itself from bacterial ingress?
lays down reparative dentine
Outline reasons why pulpal involvment can occur quicly in primary dentition
- small teeth, large pulp chambers
- broad contact areas
- irreversible pathological changes before pulp exposire
- early radicular pulp involvement (pulp in the root canals)
How will caries arrest ?
if they are starved of carbohydrate
Caries progresses rapidly in primary teeth. True or false
true
Give an example of an effective method of starving carious lesions
preformed metal crown cememted with GI
provides a very effective seal and fluoride reservoir
State the most and least successful pulp capping techniques in children
most successful- indirect pulp capping
least sucessful- direct pulp capping
What type of teeth are less likely to respond to a vital pulpotomy? What should you consider if competent enough to try?
teeth with inflammed radicular pulp
consider a pulpectomy
(most likely to be an extraction)
When is a lateral oblique radiograph indicated in children?
if there is no cooperation for bitewings
How would you go about taking a lateral oblique radiograph?
- neck is extended to bring the mandble away from the cervical spine
- central ray is directed between the spine and the angle of the mandible
- teeth and jaws adjacent to the casette are imaged
What is the main cause of early childhood caries/bottle caries?
sleeping with a bottle
What teeth are mainly affected by ECC?
maxillary anterior teeth
1st molars
Why is ECC less common in canines?
this is because they erupt later
What is the management of ECC?
- only water at night
- fluoride varnish
- switch from bottle to cup
- fluoride toothpaste
What are the principle strategies for management of caries in the primary dentition?
- no caries removal, seal with crown using hall technique
- no caries removal, fissure seal
- selective caries removal and restoration- remove caries from walls, adequate depths of restorative material)
- pulpotomy
When should fissure sealants be used?
when caries is 1/3 into dentine
Selective caries removal was previously known as…
partial caries removal
List other options for managment of caries in primary dentition that are less supported by evidence
- site specific prevention- no caries removal, active prevention
- non-restorable caries control- no caries removal, modify cavity and make lesion cleansable, apply fluoride
- complete caries removal and restoration
- extractionr, or review with extraction if pain or infection develops
When should dental amalgam not be used?
- deciduous teeth
- children under 15
- pregnant/breastfeeding women excepted deemed to be strictly necessary by DP based on specific medical needs of the patient
What are the disadvantages of complete caries removal and restoration?
- risk of pulpal exposure
- LA use
- good moisture isolation required
Why would you consider extractions for carious Ds?
- this is because they are particularly small teeth
- large pulps
- thin enamel
- so caries can affect/extend into the pulp quite quickly
- if caries >2mm into dentine then consider extraction
What are the advantages of selective caries removal and restoration?
- reduced risk of pulpal exposure compared to complete caries removal and exposure
- less need for LA
- possible to remove caries with only hand instruments (ART)
What does ART stand for?
atraumatic restorative technique
What is a disadvantage of selective caries removal and restoration?
marginal seal must be effective
- must remove all caries on the margin
What does ART involve?
removal of caries with hand instruments and filling with RMGIC
What does the use of ART depend on?
- removal of soft caries
- good seal
- fluoride release
What methods can you use to restore primary incisors?
- handbuilding
- strip crowns
What are strip crowns and how do you use them?
- act as a template
- they are filled with composite
- place the filled strip crown on the etched and bonded tooth
What techniques involve no caries removal but sealing of the caries with a restoration?
- fissure sealant
- halls technique
What are the advantages of using a fissure sealant?
- no LA required
- no prep
- no risk of pulpal exposure
- no adjacent tooth damage
When can preformed metal crowns be used?
- hall crown technique
- following pulp treatment
What is present on the buccal surface of stainless steel crowns used for the halls technique?
- the tooth in palmer notation
- size of the stainless steel crown
What way can you ensure that you choose the right crown?
callipers can be used to measure the mesial-distal size of the tooth you intend to restore
What should you do on the first appointment when implementing the hall technique?
use othrodontic seperators to contacts
What does the second appointment fot the hall technique entail?
- no LA
- clean food debris and plaque from cavity
- cement pre-formed stainless steel crown with GI
- warn child and parent of “high bite”/occlusal interference, child may need calpol
What are the indications of the hall technique?
- class I non cavitated/cavitated lesion if pt is unable to tolerate conventional treatment
- class II lesions, cavitated or non cavitated
What are the contraindications of the hall technique?
- signs or symptoms of irreversible pulpitis
- clinical signs of pulpal exposure
- periradicular pathology
- unrestorable teeth using conventional methods- not able to hold the crown
You should never leave caries without preventive measures, restoring or extracting the tooth. True or false
true
When modifying a cavity to become self-cleansing, what other preventive measures should you implement?
- diet
- plaque control- TBI
- fluoride application
What are some reasons to justify restoration of the primary teeth
- easier to disrupt biofilm on restored teeth as opposed to broken down/cavitated teeth
- resolve symptoms
- limit the damage of caries
- ensure adequete function
- restore aesthetics
- maintain natural space available for developming permanent dentition r
What dental factors should you consider when managing caries in primary dentition?
- signs and symptoms
- tooth close to exfoliation- root development
- hypodontia
- early loss of other primary teeth
- number of carious teeth
What treatment shouldy you consider for a tooth with a carious lesion that is close to exfoliation and symptom free?
- leave tooth
- reinforce preventive advice
What is hypodontia?
absence of permanent teeth
What is the most common permanent tooth missing?
lower 5s
45, 35
If there is no obvious biofilm present on the surface of carious teeth (with arrested caries), what treatment can you provide?
- leave teeth
- reinforce with preventive measures
What treatment is indicated for in the presence of infection (e.g. sinus)?
extraction is likely to be indicated
What are the treatment options for caries with pulp involvment for primary dentition?
- indirect pulp cap
- pulpotomy
- pulpectomy
- preformed metal crowns?
- extraction
What improved the success rates for pulpotomy and pulpectomy procedures?
placement of a pre-formed metal crown for a seal
What is a pulpotomy?
minimally invasive treatment that involves the removal of the coronal pulp tissue
Why are pulpectomies less likely to be indicated as a treatment for primary dentition?
- rubber dam must be place as use of files
- root development/exfoliation?; is there enough root for this treatment?
What is a pulpectomy?
- similar to a root canal
- involve extirpation of the radicular pulp
What are some contraindications for extractions when deciding whether to retain or extract teeth?
- increased crowding, retaining decidious teeth can help improve this
- the earlier a tooth is lost, the more space there is lost
What is a balancing extraction?
extraction of contralateral tooth
extraction of the contralateral C (after one C extraction) to prevent centre line shift
When are balancing extractions indicated?
- one C is to be extracted due to dental disease
- one C has exfoliated early to to eruption of the permanent later incisor
- centre line shift developing following extraction of one D
When are balancing extractions not usually indicated?
- loss of primary incisors
- loss of Ds unless centre line shift developing
- loss of Es
What are indications for an extraction in recurrent infections?
- recurrent infection
- prevent unnecessary use of analgesics and antibiotics
- missing school
- difficulty eating
- damage to permanent successor
When should you leave teeth with only preventive measures? Give examples of preventive measures
- asymptomatic teeth close to exfoliation (>2/3 root resorption)
- arrested caries with no sign of infection (clinical and radiographical)
Diet
Toothbrushing
Fluoride varnish
What is the sequeale (consequence) of early loss of primary teeth?
- space loss
- crowding/impaction of permanent teeth
- early or late eruption of permanent teeth depending on stage of development
- damage to permanent teeth - rare- only if wrong extraction technique is used
When are success rates high for indirect pulp capping?
- when the pulp is not inflammed
- coronal restoration is sealed
Why are indirect pulp caps less successful when the pulp is inflammed?
- calcium hydroxide appears to encourage internal resorption if the pulp is inflammed
What is an effective alternative material for indirect pulp caps?
glass ionomer
however, no long term studies
Pulpitis is _______ whilst an abscess is ________.
inflammation
infection
Inflammation does not necessarily mean that there is infection. True or false
true
Direct pulp capping has a low success rate regardless of the size of the exposure. Why is this?
internal resorption is more common when placed over inflammed tissue
Why may you be better performing a pulpotomy as your first line treatment as opposed to direct pulp cap ?
this is because if pulp capping fails, subsequent pulp treatments are likely to fail
What is a vital pulpotomy?
vital, inflammed tissue is removed from the pulp chamber
medicament is then placed over radicular pulp stumps
coronal restoration is placed
What medicament is placed over pulp stumps in a vital pulpotomy? Give examples of more novel medicaments used in a vital pulpotomy
Ferric sulphate then ZOE
MTA
Biodentine
The success of a vital pulpotomy is dependent on…
the extent of the pulpal inflammation
Out of MTA and biodentine, which one has the better setting time?
biodentine
Outline the steps required for a pulpotomy
- assess need to save tooth
- radiograph
- LA
- rubber dam (saliva control) however more common not to have rubber dam in pulpotomy
- remove all caried from EDJ
- remove all soggy dentine
- remove the lid of pulp chamber completely
- remove as much soft dentine as possible
- remove pulp from pulp chamber using sharp large excavator or large round slow speed bur
- gently compress pulp remnants with dry cotton pledget
- bleeding should stop in a few minutes
- place cotton wool pledget moistened with ferric sulpgate in pulp chamber
- leave for 20 seconds and remove
- pulp remnants will have black residue- dry gently
- pack pulp chamber gently with ZOE cement to leave no voids
- restore cavity with GI
If bleeding does not stop after the removal of the coronal pulp in a pulpotomy, what is this an indication of?
radicular pulp inflammation
When radicular pulp inflammation is suspected, what are the indicated treatment options?
- pulpectomy
- extraction **
Give examples of pulpotomy medicaments
- formocresol
- calcium hydroxide
- ledermix
- ferric sulphate
- biodentine
Why is formocresol not gain regulatory approval for use today?
highly toxic
(fixes pulp tissue)
What is formocresol composed of ?
formaldehyde and tricresol in glycerine and water
CaOH is an effective medicament because…
it promoted biological healing
What is ledermix composed of ?
1% triamcinolone
3% demeclocycline
What is the benefit of ledermix?
- obtundant effect (lessens pain)
- bactericidal
- inhibits osteoclast activity
What is the benefit of ferric sulphate?
- haemostatic
- high clinical success rate
- less toxic than formocresol
What are the indications of a pulpotomy?
- preservation of the tooth is considered necesssary
- large proximal lesiosn with involvement of marginal ridge- radiograph shows caries extends further than 2/3 of dentine
- no radicular pulpitis
if there is marginal ridge involvement then it is also likely that there is pulpal involvement
How can you rule out radicular pulpitis?
- no history of spontaneous pain
- bleeding easily controlled when pulp is removed
- no abscess or fistula
Outline the process of a pulpectomy?
- pre-operative radiograph
- acces pulp chambers as for pulpotomy
- identify root canals
- no working length radiograph is taken (cooperation??)
- debride canals with hand files (rubber dam) staying within canal by 2mm
- copious irrigation with CHX (?NaOCl?)
- paper points to dry canal
- fill canals with vitapex/ZnO/CaOH
- restore with GI
zinc oxide eugenol and preformed metal crown
What is vitapex composed of?
- iodoform and calcium hydroxide paste
What is substantivity in dentistry?
prolonged association between a material and a substrate
e.g. CHX more substantive than NaOCl
Prolonged adherence of antiseptic to oral surfaces (teeth and oral mucosa)
