Restorative Management of Primary Dentition

Question 1

Give three general reasons why we restore the primary dentition

Answer 1

• medical and dental wellbeing is of paramount importance - dental health is intertwined with general health and development
• dental infections have detrimental effects on health
• children with caries may not thrive physically, emotionally or intellectually compared with caries free individuals

Question 2

How does restoring the primary dentition help?

Answer 2

• restores form
• restore aesthetics
• restore function: eating and speech
• maintain space
• acclimatisation
• avoiding sepsis and infection to permanent successors
• avoid extraction especially if GA is required

Question 3

What is the name given to describe trauma which affects the permanent successor?

Answer 3

Turner’s tooth - enamel hypoplasia

Question 4

List some important considerations in primary teeth in comparison to permanent teeth:

Answer 4

• smaller
• enamel is thinner
• pulp is relatively larger
• pulp horns are nearer the surface
• contact points are flatter and wider
• more rapid progression of caries and identification of demineralisation is difficult due to the anatomy and morphology of primary teeth
• primary pulps have same potential to produce secondary and tertiary dentine as their permanent counterparts

Question 5

How many and in what position are the pulp canals in

a) lower molars
b) upper molars

Pulp horns taper fairly high into the crowns, but in particular which site?

Answer 5

3 canals in upper and lower molars (usually)

a) lower canals are MB, ML and D
b) upper canals are MB, DB and P

Pulp horns taper fairly high into the crowns, especially mesially

Question 6

List in order, the stages of a treatment plan:

Answer 6

1. Relief of pain
2. Prevention at home
3. Professional prevention e.g. fluoride varnish, fissure sealants
4. Stabilisation of caries
5. Restorations
6. Pulp therapy
7. Extractions

Behaviour management and reinforce prevention at every visit

Question 7

Give an insight into the hierarchy of treatment

Answer 7

• Start with something simple, pleasant procedures moving on as the patients confidence and compliance improves towards more technically demanding or unpleasant tasks
• Wise to end the course of treatment on a pleasant task such as prevention, providing positive reinforcement and erasing any less pleasant memories

Question 8

Who must consent to treatment?

What must be explained?

Answer 8

Treatment cannot be carried out without parental consent. The parent has a role in the development of the treatment plan

The disease process has to be explained in a language they understand as does the management with clinical and radiographic findings being utilised

Question 9

What are some common causes of toothache in a child?

Answer 9

• abscesses
• caries
• trauma
• tooth wear
• infection
• soft tissue lesion
• exfoliation/eruption

Question 10

Give an overview of reversible pulpitis:

a) HPC
b) Examination findings
c) Radiographs

Answer 10

a) History: precipitated by sweet/hot/cold/fresh air, pain stops when stimuli removed, short duration, mainly occurs when eating
b) On examination: may find an early carious lesion
c) Radiographs: will show caries into dentine

Question 11

Give an overview of Irreversible Pulpitis:

a) HPC
b) On examination
c) Radiographically

Answer 11

a) History: constant, relieved only by analgesics, kept awake, syptoms may have started as reversible pulpitis but now the pain is constant
b) On examination: lymphadenopathy, raised temperature, extensive marginal ridge destruction, sinus, intra-oral swelling
c) Radiographically: caries close to pulp, radiolucency

Question 12

Should you restore or extract?

Answer 12

• depends upon tye of pulpitis
• quality and quantity of remaining tooth tissue
• previous extractions and edentulous space

Question 13

When should you restore a tooth in a pulpitis situation?

Answer 13

• most other carious teeth are restorable
• patient is keen to save and compliant
• good reasons such as space maintenance, hypodontia

Question 14

When should you extract a tooth?

Answer 14

• balancing extractions
• non-compliance
• no parental support
• no attendance beyond pain relief

Question 15

What is temporisation? Are there any important considerations?

Answer 15

Placement of a temporary dressing is effective in relieving pain until a restoration can be completed, extracted or if the tooth needs to be kept under observation for a period

• the material should not be detrimental to the pulp, produce a good seal and not conflict with the proposed final restoration

Question 16

What is stabilisation?

Answer 16

• managing children woth continual poor OH with active high amounts of caries needs thought and should be stabilised first before any definitive restorations provided
• often involves removal of caries from cavity margins, dressing, buying time for cooperation to improve and treatment of other restorable teeth

Question 17

What is the value of stabilisation?

Answer 17

• in the pre-cooperative patient: preventing lesion progression
• multiple carious lesions - arresting caries in a long plan
• prevention of sensitivity in teeth close to the tooth to be restored that day and out the range of LA

Question 18

What is the best sequence of operative care?

Answer 18

• where possible, start in the maxillary buccal segment, painless LIA can be achieved
• delay IDBs until patient confidence and understanding has been achieved
• operative care must be integrated with preventative therapy or new lesions will develop during course of treatment

Question 19

What is the typical sequence of treatment in a paediatric patient?

Answer 19

• temporary dressing
• OHI/prevention/placement of fissure sealants
• simple minimal restorations
• restorations, pulp therapy, extractions (MAXILLA FIRST)
• operative treatment in mandible IDB, treat whole quadrant if and when possible
• anterior restorations