Management of compromised first permanent molars

Question 1

Name one of the teeth most prone to caries?

Answer 1

First permanent molars (6’s)

Question 2

Whats the problem of caries in the first permanent molars?

Answer 2

Getting food trapped and pain

Question 3

What are the treatment options?

Answer 3

Extraction, maintain until ideal time for removal or retain

Question 4

What 4 factors can extraction depend on?

Answer 4

• Extent of crowding
• Presenting malocclusion
• Stage of dental development
• if maxillary or mandibular

Question 5

When is the ideal time for extraction of the 6’s?

Answer 5

When the root bifurcation of the 7’s is forming (8-10 years)

Question 6

What is the goal for extraction?

Answer 6

Mesial migration of the 7’s to replace the 6’s

Question 7

What are the advantages of extraction (3)?

Answer 7

• Immediate resolution of symptoms or infection
• One off procedure with favourable cost:benefit if timed well
• Space created may be used to alleviate posterior crowding, reduce overjet and create space for eruption of the 8’s

Question 8

What are the disadvantages of extraction (4)?

Answer 8

• loss of permanent tooth (esp. if no 8’s)
• may need sedation/GA
• consequence of early/late extraction
• may increase ortho treatment time and complexity

Question 9

What happens if the 6 is extracted too early?

Answer 9

Distal tipping of the 5 (less engaged by primary teeth roots)

Question 10

What happens if the 6 is extracted too late?

Answer 10

Mesial tipping of the 7 (can be more problematic)

Question 11

What is balancing extraction?

Answer 11

Extraction on opposite side of arch to prevent unwanted tooth movements (i.e. movement of midline)

Question 12

What is compensation extraction?

Answer 12

Extraction of tooth on opposing arch to prevent occlusal problems (overeruption) - especially of upper 6’s

Question 13

n.b.

Answer 13

We rarely balance 6’s but sometimes compensate them especially if its the lower 6’s that have over-erupted

Question 14

What are the different methods of maintaining a carious tooth?

Answer 14

• RCT
• Indirect pulp capping
• Direct pulp capping
• Partial pulpotomy

Question 15

What are the issues with RCT treatment?

Answer 15

• open apices
• poor prognosis (36% success)
• needs lifetime management of the tooth

Question 16

What is the preferred treatment for a compromised first permanent molar?

Answer 16

Indirect pulp capping

Question 17

What is indirect pulp capping?

Answer 17

Incomplete caries removal (leave in the deepest part), place CaOH then restoration = stimulates production of tertiary dentine

Question 18

What is direct pulp capping?

Answer 18

CaOH is place directly not exposed pulp after caries removal

Question 19

What is a partial pulpotomy?

Answer 19

Removal of part of the pulp (just a couple of mm until healthy pulp is reached (usually for larger exposure)

Question 20

What treatments do we use to maintain a tooth for extraction?

Answer 20

Stainless steel crowns, conventional or resin modified GIC

Question 21

What different restorative materials can we use on compromised first permanent molars?

Answer 21

• Composite
• Compomer
• Cast onlay
• Amalgam

Question 22

When are cast onlays especially useful?

Answer 22

Esp. with hypo mineralised teeth affecting the marginal ridge in patches (full cusp coverage helps to protect)

Question 23

What different things should be taken into consideration when managing compromised first permanent molars?

Answer 23

• Extent of lesion or defect
• Quality of enamel
• Moisture control
• Pt. co-operation
• Dentist choice/experience
• Symptoms/hypersensitivity (needs more than just intracoronal)
• Caries risk

Question 24

What different patient factors are there?

Answer 24

• Motivation and dental awareness
• Oral hygiene
• Cost
• Pt. preference
• Behavioural/co-operation
• Symptomatic (i.e. pain, sensitivity and pulpal symptoms)
• Medical factors (cardiac problems, immunocompromised, any medical issue that means cannot extract under GA)

Question 25

What different dental factors are there?

Answer 25

• Extent of lesion and restorability
• Presence and condition of remaining dentition (DPT)
• Enamel defects (prone to further breakdown, extension, colour and position to predict the future)
• Vitality
• Stage of dental development/dental age

Question 26

What different orthodontic factors are there?

Answer 26

• Need for ortho input (timing to future ortho e.g. elective xla of other 6’s)
• Malocclusion (influences timing of removal)
• Hypodontia

Question 27

What are the benefits of temporising with GIC?

Answer 27

• Tolerant of moisture contamination
• Fluoride release
• Easy to place

Question 28

What are the problems with temporising with GIC?

Answer 28

• Poor physical properties

- No full coverage and doesn’t help with sensitivity

Question 29

What are the benefits of temporising with a stainless steel crown?

Answer 29

• Prevents further breakdown
• Relieves sensitvity
• longevity
• relatively quick and inexpensive
• single visit

Question 30

What are the problems with temporising with a stainless steel crown?

Answer 30

• Technically more challenging
• LA often required
• Monitor eruption of 7’s (potential impaction risk)
• Occlusion

Question 31

What is the technique of placing a stainless steel crown?

Answer 31

+/- LA, can place separators (extra appt. but easier), may need some prep (round over line angles and proximal slice), select crown size (n.b. standard size is v. tall, we only want 1 mm subgingivally), trim and crimp gingival part of crown, smooth roughened surface with green stone, isolate and cement with GIC