Paediatric Dental techniques (SDCEP restorative)

Question 1

What is site specific prevention suitable for?

Answer 1

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

Question 2

What is the aim of site specific prevention?

Answer 2

stop enamel progressing and promote remineralisation of early lesions

Question 3

What is site specific prevention?

Answer 3

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

Question 4

What is the minimum recommended interval for taking bitewing radiographs?

Answer 4

six monthly

Question 5

When is the hall technique with no caries removal suitable?

Answer 5

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)

Question 6

What is the aim of no caries removal and hall technique crown

Answer 6

To completely seal caries to alter environment of plaque biofilm slowing or arresting caries progression

Question 7

Outline of no caries removal and hall technique PMC

Answer 7

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

Question 8

When is a fissure sealant suitable

Answer 8

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

Question 9

What is the aim of a fissure sealant?

Answer 9

To completely seal a non cavitated carious lesion from the oral environment to SLOW or ARREST caries progression

Question 10

When is selective caries removal suitable?

Answer 10

Moderate - advanced occlusal/proximal lesions
(Permanent posterior tooth moderate lesions)

Question 11

Aim of selective caries removal

Answer 11

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

Question 12

How is selective caries removal carried out?

Answer 12

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

Question 13

When is atraumatic restorative technique suitable?

Answer 13

A primary tooth with a single surface lesion

Anxious, uncooperative child

Minimises stress (hand instrumentation on affected dentine only)

Question 14

Describe ART

Answer 14

-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

Question 15

When is stepwise caries removal required?

Answer 15

A PERMANENT tooth with an extensive lesion in occlusal or proximal surfaces

Question 16

What is the aim of stepwise caries removal?

Answer 16

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)

Question 17

Stage one of stepwise restorative technique

Answer 17

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

Question 18

Stage 2 of stepwise restorative technique

Answer 18

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

Question 19

When is non-restorative cavity control suitable?

Answer 19

PRIMARY TOOTH ONLY : arrested caries of tooth is unrestorable or close to exfoliation

advanced lesion where alternative methods are not feasible

Question 20

What is the aim of non restorative cavity control?

Answer 20

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

Question 21

How is non restorative cavity control carried out?

Answer 21

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

Question 22

When is complete caries removal suitable?

Answer 22

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)

Question 23

Aim of complete caries removal

Answer 23

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

Question 24

Considerations of complete caries removal

Answer 24

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

Question 25

What should be done for permanent premolars and molars with extensive caries?

Answer 25

stepwise caries removal - to increase distance of lesion to the pulp.

Question 26

complete caries removal restorative options

Answer 26

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

Question 27

When is a pulpotomy required and aims?

Answer 27

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

Question 28

When may you place a temporary dressing and review the patient’s pain later

Answer 28

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.

Question 29

Contraindications of pulp therapy

Answer 29

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.

Question 30

Pulpotomy steps

Answer 30

• 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

Question 31

When would you use local measures to control infection?

Answer 31

Non-vital primary and permanent teeth with dental abscesses or periapical periodontitis

Question 32

Aim of local measures to reduce infection

Answer 32

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

Question 33

When are antibiotics indicated?

Answer 33

Signs/symptoms of systemic involvement (fever), spreading infection or the child is medically compromised

Question 34

Local measures to reduce infection: primary vs permanent

Answer 34

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

Question 35

When would you extract?

Answer 35

A primary or permanent tooth which is of poor prognosis or is unrestorable

OTHERWISE:
-local measures to control infection

-pulpectomy

Question 36

When should an extraction be delayed?

Answer 36

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

Question 37

How can you reduce the discomfort of LA?

Answer 37

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)