Paediatric Dental techniques (SDCEP restorative) Flashcards
What is site specific prevention suitable for?
Initial lesions in primary tooth on occlusal/ proximal surface (anterior and posterior)
Permanent teeth with initial proximal caries
Arrested caries or tooth near exfoliation
Evidence more for permanent teeth
What is the aim of site specific prevention?
stop enamel progressing and promote remineralisation of early lesions
What is site specific prevention?
Demonstration of effective brushing of lesion - multi surface lesion may involve lateral movement
Dietary advice
Apply fluoride varnish to the lesion x4 a year
an alternative strategy is required if the lesion isn’t being kept free of plaque
review to see if active lesion is now arrested/arresting/inactive–>active
What is the minimum recommended interval for taking bitewing radiographs?
six monthly
When is the hall technique with no caries removal suitable?
on a primary tooth with an advanced lesion in an occlusal or proximal surface
must have unaffected dentine between the lesion and the pulp and must be able to achieve an adequate seal
Before marginal ridge breakdown as subsequent mesial migration of tooth behind reduces M-D width making PMC harder to fit (early detection of multi-surface lesions with RGs vital)
What is the aim of no caries removal and hall technique crown
To completely seal caries to alter environment of plaque biofilm slowing or arresting caries progression
Outline of no caries removal and hall technique PMC
Child upright
Assess contact point after separators
Gauze to protect airway/handle to hold crown
Size selection - bounce back just above contacts (do not seat all way through - difficult to remove)
Fill PMC with GI luting cement
Seat PMC on tooth (buccal surface is side with letters)
Assess crown is seated evenly and through contacts
Bite down/cotton wool roll
Remove excess cement and clear contacts with floss
Cement bitter - avoid tongue
When is a fissure sealant suitable
a primary tooth or permanent tooth with initial occlusal or proximal lesion
mainly effective on permanent teeth and doesn’t require LA, tooth prep or caries removal.
Any high risk child
What is the aim of a fissure sealant?
To completely seal a non cavitated carious lesion from the oral environment to SLOW or ARREST caries progression
When is selective caries removal suitable?
Moderate - advanced occlusal/proximal lesions
(Permanent posterior tooth moderate lesions)
Aim of selective caries removal
removing sufficient tooth tissue to enable a good marginal seal restoration bonded on after, inhibiting further progression of caries reduces the risk of pulp exposure and the time required for cavity prep
How is selective caries removal carried out?
gain access with fast HP and LA if needed
Remove superficial carious tissue (slow HP or excavators) until no obvious caries at EDJ and thick enough for material , leave hard/scratchy (may be stained) dentine for bonding on cavity walls (aesthetic issues w/ anteriors)
Pulpally:
-Remove all soft infected dentine in shallow lesions - some leathery and firm affected dentine may be left
-Some soft infected dentine may be left in deep lesions - deforms when pressed and could easily be lifted - to avoid pulp exposure. Remove unsupported enamel
Either:-
Plastic adhesive restoration (GIC) - single surface occlusal
(avoid GIC onmulti surface due to high failure rate)
OR
PMC hall technique - multi surface
-better peripheral seal
Fissure seal unprotected pits, fissures and restoration margins.
NOTE:
Primary molars:
LA not always req (smaller, less tissue to remove)
ART hand excavation may be used
When is atraumatic restorative technique suitable?
A primary tooth with a single surface lesion
Anxious, uncooperative child
Minimises stress (hand instrumentation on affected dentine only)
Describe ART
-No LA (sound dentine is not removed)
-Hand instrumentation for access, removing unsupported enamel, removing caries and prep cavity:
sharp enamel chisels, enamel cutters, hatchets and excavators
-Cavity is cleaned with wet cotton pellet and dried with dry cotton pellet
(3 in 1 will over dry dentine)
MAINTAIN ISOLATION
-high viscosity GIC with finger press technique (vaseline over it for 20 seconds and press)
*DO NOT use conventional GIC as high failure rate in multi-surface lesions
Avoid eating for an hour
When is stepwise caries removal required?
A PERMANENT tooth with an extensive lesion in occlusal or proximal surfaces
What is the aim of stepwise caries removal?
avoid pulpal exposure in teeth with deep caries by using a 2 step removal technique
intermediate temporary restoration will inhibit further caries progression and allow reactionary dentine to be laid down (further distance from pulp)
Stage one of stepwise restorative technique
LA
-Gain access using fast HP and remove superficial caries using slow HP/excavator until hard dentine on walls and pulpally until soft dentine reached and enough tissue removed for durable restoration
- achieve effective marginal seal with temporary restorative material (coloured preferred for removal at stage 2)
Temp restoration inhibits caries progression and allows reactionary dentine to be laid down and increases distance to pulp
Stage 2 of stepwise restorative technique
After 6-12 months
LA
Remove temp restoration
(may be a gap underneath where the dentine dried out)
remove any carious tissue remaining until you reach hard or sound dentine
Place permanent restoration and may fissure seal occlusal restorations to improve the seal
When is non-restorative cavity control suitable?
PRIMARY TOOTH ONLY : arrested caries of tooth is unrestorable or close to exfoliation
advanced lesion where alternative methods are not feasible
What is the aim of non restorative cavity control?
Reduce the cariogenic potential of the tooth by altering the environment of the plaque biofilm overlying the carious lesion through brushing and dietary advice as opposed to sealing with restoration or crown
How is non restorative cavity control carried out?
Explain to parent and child their role in the success of the treatment
Make the lesion cleansable if necessary (enamel overhangsor if dentine not exposed) then provide site specific prevention (brushing of lesion , dietary advice, fluoride varnish x4 a year)
If arrested, caries will appear dark and hard - the presence of plaque on the lesion will show that the prevention hasn’t worked.
Review 3 months
-check plaque on lesion
If ineffective:
unrestorable teeth - extraction
restorable - alternative strategies
When is complete caries removal suitable?
Primary teeth with advanced occlusal or proximal lesions / ant
Permanent teeth with moderate lesion in occlusal or proximal surfaces / ant
SAME AS SELECTIVE CARIES REMOVAL (perm post tooth = moderate lesion only o/w do stepwise)
Aim of complete caries removal
Remove ALL infected carious tissue and restore the tooth to function
NOTE: not a recommendation usually - partial caries removal better (pulp exposure, bonding restorations to carious dentine (infected - soft/affected-firm/leathery) can arrest progression
Considerations of complete caries removal
In primary teeth - other technqiues are favoured to reduce risk of pulp exposure (thinner enamel)
involves LA, high speed handpieces and moisture control - demanding for child and clinician
Not suitable for perm posterior teeth with extensive lesions = stepwise instead
What should be done for permanent premolars and molars with extensive caries?
stepwise caries removal - to increase distance of lesion to the pulp.
complete caries removal restorative options
Placement of plastic restorative material
Preformed metal crown
- remove caries - if risk of pulp exposure:
-indirect pulp cap and GIC dressing
-occlusal reduction,mesial and distal slices
-cement with GIC
When is a pulpotomy required and aims?
Pulpitis with reversible symptoms
A primary molar with an advanced carious lesion with no band of dentine visible between the pulp and the lesion.
Aim is to eliminate pain and infection until exfoliation
When may you place a temporary dressing and review the patient’s pain later
If the pain may be due to food packing or reversible symptoms, a temporary dressing with antibiotic corticosteroid paste may be placed and symptoms reviewed in 3-7 days
If the symptoms resolve, the pulpitis was reversible and a permanent restoration or hall technique may be placed - otherwise carry out pulpotomy is symptoms persist.
Contraindications of pulp therapy
tooth is close to exfoliation
Unrestorable
Pre-cooperative
Immunocompromised
Roots are resorbing means conventional endodontics isnt carried out- just remove pulp chamber and place PMC
Cases requiring multiple pulp therapies where extraction is required.
Pulpotomy steps
- LA an drubber dam
-Access with fast HP and remove pulp chamber with slow HP or sharp excavator
-Irrigate, identify canals
AVOID PERFORATING FLOOR which is thin in primary molars - higher horns - divergent canals
-Arrest haemorrhage with ferric sulphate
(If bleeding doesn’t stop or canals are necrotic, consider pulpectomy or extraction - apical or canal infection indicates these two tx options - pulpectomy isnt ideal as roots resorbing, abscess or infection requires drainage through local measures or extraction etc)
Place MTA/ZOE on floor of PC and pulp stumps (not CaOH as causes resorption) then fill cavity with ZOE
Prepare and place conventional PMC on same appt for better prognosis
When would you use local measures to control infection?
Non-vital primary and permanent teeth with dental abscesses or periapical periodontitis
Aim of local measures to reduce infection
drain localised infection , relieve pain, reduce need for antibiotics and reduce chance of infection spreading
Subsequent treatment of cause will still be necessary ad this is to control initial symptoms
Abx only considered if systemic involvement of spreading infection/immunocompromised child
When are antibiotics indicated?
Signs/symptoms of systemic involvement (fever), spreading infection or the child is medically compromised
Local measures to reduce infection: primary vs permanent
Primary teeth:
-hand excavation of caries to drain infection without LA = achieve an open comunication with the nerotic pulp chamber
-avoid dressings as would block drainage
For tender teeth a corticosteroid dressing may be placed followed by an easily removable temp restorative material by hand instruments
Rarely incise soft tissues in primary dentition - this would require anaesthesia
Permanent teeth:
-access pulp chamber completely for drainage = remove necrotic pulp
-incise the fluctuant swelling under LA
When would you extract?
A primary or permanent tooth which is of poor prognosis or is unrestorable
OTHERWISE:
-local measures to control infection
-pulpectomy
When should an extraction be delayed?
Avoid XLA on the childs first visit if possible
Dress a painful tooth (irreversible pulpitis) with a cortico-steroid antibiotic paste and temporary dressing/local measures to control infection
Build up child’s coping ability
prescribe ABS if systemic/spreading/immunocompromised
How can you reduce the discomfort of LA?
place topical anaesthesia
Distraction
A slow injection technique: at least 60 seconds for an infiltration - pull tissues taught
Intra-papillary injections instead of palatal injections - effective palatal anaesthesia in primary teeth after buccal infiltration (perp needle, in between teeth on buccal side)
