Management of caries in Primary teeth Flashcards
What is the key recommendation for the management of caries in Primary teeth?
- For a child with carious lesion in primary tooth choose least invasive, feasible caries management strategy
- Take into account time to exfoliation, site and extent of lesion, risk of pain or infection, absence or presence of infection, preservation of tooth-structure, number of teeth affected, avoidance of treatment induced anxiety
What are the steps you as a dentist should take for management of caries in primary teeth?
- Take all factors into account, establish what management options are best for child
(dental amalgam in primary teeth should be avoided) - Bitewings for treatment planning
- Discuss potential options with child and parent/carer
- Agree caries treatment plan
- Avoid operative interventions involving LA until child can cope
- Use minimally invasive approach to caries management whenever poss
- Manage primary tooth associated with infection (signs and symptoms of abscess, sinus, inter-radicular radiolucency, non-physiological mobility) either by extraction or pulpectomy or local measures to bring infection under control
- Avoid iatrogenic damage to proximal surface of adjacent tooth when preparing cavities (Hall technique is useful)
- Obtain consent from child or parent/carer
- Carry out treatment
- Do not leave infection untreated
- Do not leave caries in primary teeth unmanaged
What are the signs and symptoms of infection/abscess?
- Swelling (intra- or extra-oral), redness, lymphadenopathy
- Sinus or abscess
- Pathological mobility or tooth tender to percussion
- Interradicular pathology radiographically
What to do if there are signs and symptoms of infection/abscess?
- Consider local measures to control infection
- Extract tooth or pulpectomy
What to do if the tooth is close to exfoliation?
- Non-restorative cavity control or Site-specific prevention
What to do is caries is arrested?
- Enamel is smooth, Dentine is hard and lesion likely to be dark in colour
- Non-restorative cavity control or site-specific prevention
What to do if caries is active and tooth non-restorable?
- Extract tooth
- Or try Non-restorative cavity control and review
What to do if caries is active, tooth is restorable and on a radiograph there is clear separation between carious lesion and pulp?
Anterior Tooth
Initial lesion - Site specific prevention
Advanced lesion - Selective caries removal, Complete caries removal or Non-restorative cavity control
Molar Tooth
Initial lesion - Fissure sealant or Site specific prevention
Advanced lesion - Selective caries removal or Hall technique
Molar, Proximal
Initial lesion - Site specific prevention or a sealant/infiltration
Advanced lesion - Hall technique or Selective caries removal
What to do if caries active, tooth restorable but no clear separation between carious lesion and pulp?
- Explain uncertain prognosis and consider management options
How do Initial caries in the occlusal surface present?
Visual diagnosis
- Teeth with nonactivated lesions (white spot lesions, discoloured or stained fissures)
- May be dentine shadowing or minimal cavitation where enamel is beginning to break down but no dentine is visible
Radiographic diagnosis
- Caries may be visible in outer third of dentine
What to do with initial caries on occlusal surface?
- Seal lesion by placing fissure sealant or carry out site-specific prevention
- If sealant is placed, monitor at each recall visit, top up sealant if worn or fractured. If lesion progressing adopt alternative management strategy
- If child unable to accept resin, consider glass ionomer sealant using press finger technique
- If child unable to accept any fissure sealant, consider sealing using Hall technique
- Only continue with selected approach if caries has arrested and no evidence progression
How does Advanced caries occlusal present on primary molars?
Visual diagnosed
- Teeth with cavitation or dentine shadow and visible dentine
Radiographic diagnosis
- Lesion visible within dentine and may extend into inner third
- Should be clear band of dentine visible that separates carious lesion and pulp
What to do with advanced carious lesion on occlusal surface of primary molar?
- If caries only present on occlusal surface, carry out selective caries removal and restore using composite, resin modified glass ionomer, compomer or glass ionomer
- If child not cooperative enough for selective caries removal with good adhesive restoration, seal in caries using Hall technique
- If proximal lesion also present, seal using Hall technique
- If extensive cavitation or tooth not restorable, consider non-restorative cavity control approach
How does Initial caries present proximally on primary molar teeth?
Visual diagnosis
- Teeth with white spot lesions or shadowing
Radiographic diagnosis
- May be enamel lesions but these do not extend into dentine
How to manage Initial caries Proximal on primary molars?
- Site specific prevention and monitor at each recall visit
- If lesion progressing, adopt alternative management strategy
- Or consider sealing lesion by placing sealant or resin infiltration and monitor at each recall visit, replacing as necessary to avoid lesion progressing
How do Advanced caries present proximally on primary molars?
Visual diagnosis
- Teeth with enamel cavitation and dentine shadow
- Or cavity with visible dentine
Radiographic diagnosis
- Lesions visible within dentine and may extend as far as inner third
- Should be clear band of dentine visible that separates pulp and carious lesion
- Where no clear band of dentine, likely that carious lesion has encroached on dental pulp and pulpotomy necessary
How to manage Advanced caries proximally in primary molars?
- Without removing caries, seal in caries using Hall technique
- Or selective caries removal and restore using composite, resin modified glass ionomer or compomer
- When symptoms of pain it may be because of food packing or pulpitis with reversible symptoms but diagnosis unsure - Temp dressing placed and patient reviewed 3-7 days later to check symptoms - Resolution of symptoms indicate pulpitis reversible and Hall crown or suitable restoration placed - symptoms worsen then extraction/ pulpotomy
- If unrestorable, consider non-restorative cavity control (lack of evidence and should be documented in patients records)
Why is the Hall technique preferred over restoration?
- Avoids possibility of iatrogenic damage to adjacent teeth from rotary instruments
How does Initial caries in anterior teeth present in primary teeth?
Visual diagnosis
- Teeth with white spot lesions/ areas of demineralisation confined to enamel
How do you manage initial caries in anterior primary teeth?
- Site-specific prevention
- Monitor at each recall visit and continue this approach if caries has arrested and no evidence of progressing
- If lesion progressing, adopt alternative management strategy
How does advanced caries in anterior primary teeth present?
Visual diagnosis
- Teeth with cavitation of dentinal shadow
How do you manage advanced caries in anterior primary teeth?
- Selective caries removal and restore using composite, resin modified glass ionomer, compomer, glass ionomer or strip crowns (preffered)
- Or Completely remove caries and restore
- Or carry out non-restorative cavity control
What is the description of Pulpitis with reversible symptoms?
- Pain provoked by cold/sweet stimulus
- Relieved when removed
- Pain intermittent
- Doesn’t affect child’s sleep
- Pulp vital and tooth tender to percussion
How to manage pulpitis with reversible symptoms in primary teeth?
- Place crown using Hall technique
- If occlusal lesion then selective caries removal, avoid pulp and restore using composite, resin modified glass ionomer, compomer or glass ionomer
- When symptoms of pain it may be because of food packing or pulpitis with reversible symptoms but diagnosis unsure - Temp dressing placed and patient reviewed 3-7 days later to check symptoms - Resolution of symptoms indicate pulpitis reversible and Hall crown or suitable restoration placed - symptoms worsen then extraction/ pulpotomy
- If tooth close to exfoliation, consider applying dressing
What is the description of Pulpitis with irreversible symptoms?
- Pain occur spontaneously
- If provoked by stimulus its not typically relieved when stimulus is removed
- Pain may last several hours and keep child awake at night
- Pain may be dull and throbbing, worsened by heat and alleviated by cold
- No signs or symptoms of infection such as sinuses or abscesses or periradicular pathology
- Pulp still vital although inflamed
- Not tender to percussion
How to manage Pulpitis with irreversible symptoms?
- If child anxious then gently remove gross debris from cavity and apply corticosteroid antibiotic paste under temp dressing
- If cooperative, open pulp chamber under local and apply corticosteroid paste directly to pulp then place dressing. Prescribe pain relief then carry out pulpotomy or extract tooth
What is the description of dental abscess/periradicular periodontitis in primary teeth?
- Pain if present may be spontaneous, child awake at night and easily localised by child
- Tooth show increased mobility and tender to percussion
- Clinical evidence of sinus, abscess or swelling
- Radiograohic evidence of interadicular pathology
How to manage dental abscess/ periradicular periodontitis in primary teeth?
- If child cooperative, extract tooth even if infection is asymptomatic
- Only in exceptional circumstance if tooth is restorable consider pulpectomy, may require referral
- In some cases local measures to bring infection under control is appropriate
- If child uncooperative refer to specialist for treatment
What does a radiograph with no clear separation between carious lesion and dental pulp look like?
- Radiograph shows carious lesion that extends to inner third of dentine
- No clear band of normal looking dentine visible that separated carious lesion and dental pulp
How to manage a carious lesion with no clear separation between lesion and dental pulp in primary teeth?
- When no signs or symptoms of pulpal pathology and degree of uncertanity around separation between lesion and pulp consider hall technique
- Uncertain prognosis discussed with parent/carer
- If signs and symptoms of pulpal pathology, carry out pulpotomy
What are teeth close to exfoliation?
- Teeth that are clinically mobile or radiographically show evidence of root resorption
How to manage teeth close to exfoliation?
- Site-specific prevention or non-restorative cavity control
When do primary molars exfoliate?
First primary - 9-11
Second primary - 10-12
How do teeth with arrested dentinal caries present?
- Surface of tooth hard when a ball ended probe drawn across it
- Often appear black or honey yellow appearance
How to manage teeth with arrested dentinal caries?
- Site-specific prevention or non-restorative cavity control
How do active dentinal caries present?
- Soft, moist and friable to touch
How does an unrestorable primary tooth present?
- Most of crown of tooth destroyed by caries or fractured making restoration imposs
- Or dental pulp is exposed and formed pulp polyp
How to manage unrestorable primary teeth?
- Non-restorative cavity control or extract tooth (esp if associated with infection)
- Avoid extractions at child’s first visit if poss
