restorative procedures for primary dentition 1

what are the important reasons to restore primary teeth

• quality of life (child/carer)

• space maintenance (hold onto C and E)

• unpredictable rate of caries progression/arrest

• prevent extractions - MH (medical contraindications e.g. delayed healing, endocarditis)

why is the rate of caries faster in primary teeth

enamel is thinner therefore caries reaches dentine faster

from dentine = faster spread of caries

what are less important reasons to restore primary teeth

• patient education/acclimatisation

• aesthetics

• parent wishes

what are the effects to the quality of life

• may lead to pain, infection

• affects child’s ability to speak, eat, play, learn, socialise, sleep

• affects confidence

• time away from school = fall behind with learning

• parent/carer need to take time of work = financial impact

• impact greater amongst socially/economically disadvantaged

what are the financial implications

march 2019 = almost 90% hospital tooth extractions in 0-5 yrs was due to decay

commonest reason for hospital admission in 6-10 yrs

cost to NHS = £50.9 million due to decay

what was the fiction trial

• began in 2008

• multi centre RCT

• 7 locations across UK, 72 dental practices

• 1058 children, 3-7 yrs

• atleast 1 primary molar with caries into dentine

what did the fiction trial test for and what was the conclusion

testing 3 approaches to caries management:

• conventional restoration and prevention (inc LA)

• biological management and prevention (no LA)

• prevention alone

conclusion = no evidence of difference in outcomes

what to consider when deciding whether to restore or remove a primary tooth

• the child (cooperative?)

• the tooth

• the disease (extent? pulp involvement?)

what other thing should be considered when deciding to restore/remove tooth

time of exfoliation (check radiographs)

site and extent of lesion (restorability/remaining sound tooth tissue = saucer shaped tooth = not restorable)

risk or presence of pain/infection

number of teeth affected

childs cooperation /access /moisture control

parents wishes/ demands

what to do if a patient presents with this

need to extract tooth or else infections wont heal

what is the worst case of keeping a tooth with infection

sepsis = infection travels to the blood stream

what to do at each appointment for caries recognition

• check prescription from dentist

• check history (clinical symptoms)

• extra-oral (facial swelling)

• intra-oral (visual, radiographs)

how to do a visual exam

consider position of child (baby pts = knee-to-knee, or pts head on parents arm)

teeth must be dry and clean

good lighting

know what is normal

posterior bitewings radiographs

• essential adjunct to clinical examination

• should be considered even for pre-school children

• necessary for detection of approximal caries

• risk assessment required first

how many lesion are there

patient 6 yrs ? = 6 not fully erupted

if theres a cavity on distal of D = do radiographs as might find cavity in mesial of E

what are some other methods of caries detection

• fibre optic transillumination

• electrical caries detection tools

• laser fluorescence device

what are the non restorative options for carious primary teeth

• site specific prevention

• non-restorative cavity control

• extraction

what are the restorative options for carious primary teeth

• no caries removal restorations (preferred method for primary teeth)

• selective caries removal and restoration

• complete caries removal and restoration

what is the aim of site specific prevention

to stop progression of caries and promote remineralisation

its non-invasive so acceptable to children

relies on behaviour change (parents need to be on board)

what is site specific prevention suitable for

• early carious lesion on occlusal or proximal surfaces (in enamel)

• early carious lesion on an anterior tooth

• arrested lesions

• teeth close to exfoliation (+ asymptomatic = leave tooth alone)

what is the process of site specific prevention

• highlight lesion

• agree process (parent accepts responsibility)

• apply preventative measures (TBI, diet advice, fluoride varnish 3 monthly, silver diammine fluoride 6 monthly)

• record

• review (every 3 months)

what is silver diamine fluoride

non-AGP

non-invasive (MID)

used ‘off-label’ (used for somethings its not designed for)

duraphat = fluoride varnish = used for caries prevention

in UK prescribed silver diamine fluoride = used for dentine sensitivity NOT caries prevention

decribe what silver diamine fluoride is

clear, odourless liquid

silver = antibacterial

fluoride = remineralisation of enamel

NOT licensed in the UK for caries prevention

commonly 38%

44,800 ppm

pH 13 (protect soft tissues with vaseline)

how is silver diamine fluoride used

applied similar way to fluoride varnish

review after 2-4 weeks (if caries not arrested then reapply and then review in 6 months)

applied 6 monthly

what are the issues with using silver diamine fluoride

bad taste = apply toothpaste to child tongue

turns teeth/decay black (aesthetics and warn patient/carer beforehand)

need written consent (consent form 2)

temporary staining of clothes and soft tissues

what is the aim of the non restorative cavity control

to reduce the cariogenic potential of the lesion

non-invasive

relies on behaviour change

lesion needs to be cleansable

what is the process of the non restorative cavity control

highlight lesion

agree process (parent accepts responsibility)

make lesion cleansable

apply preventative measures (TBI, diet advice, fluoride varnish 3 monthly, SDF 6 monthly)

record

review

how is the lesion made cleansable

open cavity

remove overhang enamel

show parent how to get toothbrush to clean

make the cavity a dish shape

what are the different restorative materials

preformed metal crowns *

amalgam

composite *

glass ionomer

compomers

fissure sealants *

*for paediatric patients

is amalgam used in paediatric patients

not used in primary teeth

minimata treaty = phasing down of using amalgam due to environmental pollution from mercury

caveat = can use amalgam but unless deemed necessary by practitioner on the ground of specific medical needs

which patients are not allowed to have amalgam

pregnant and breastfeeding

<16 years old

what is the aim of no caries removal

to completely seal the lesion from the oral environment to slow/ arrest progression

what are the 2 different options for no caries removal

hall technique

fissure sealants

what is the hall technique suitable for

suitable for advanced occlusal or proximal lesions (cavitated lesions?)

what are fissure sealants suitable for

suitable for non-cavitated occlusal or proximal lesions (caries only in enamel)

what is the aim of selective caries removal

to remove sufficient carious tissue to enable an effective marginal seal with a bonded adhesive material

which patients is the selective caries removal suitable for

suitable for advanced occlusal lesions

reduced risk of pulpal exposure

reduced time for cavity prep

may not require LA

what are the 2 techniques for selective caries removal

conventional or ART (MID)

what is the conventional technique for caries removal

access caries using highspeed hand speed (LA needed)

remove superficial caries until ADJ is clear (slow speed bur)

clear cavity wall until hard and scratchy

ensure efficient depth for restoration placement

remove undermined enamel

place adhesive, bonded restoration

fissure seal over top (stops ingress of bacteria)

what is the atraumatic restorative technique (ART)

removal of carious tissue ONLY using hand instruments

no need for LA

can be used for stabilisation

conserves sound tooth tissue

restored with GIC

which lesions is the ART technique suitable for

only for occlusal lesion (NOT MO/DO)

can be used to treat rampant caries to stabilise it before proper treatment

describe the ART technique

ensure instruments are sharp

isolate with CWR

enlarge access if required

scoop out soft caries (excavator)

clean and dry cavity with CWP

restore with GIC using finger pressure

cover with vaseline (waterproof it)

avoid eating for 1 hour

what is the aim of complete caries removal

to remove all infected carious tissue and restore function

which patients is complete caries removal suitable for

suitable for advanced occlusal or proximal lesions

is the complete caries removal technique preferred

there’s higher risk of pulpal exposure

requires LA, high speed handpiece and good moisture control

more demanding for child and clinician

hence other techniques preferred (Hall technique)

when is the Hall technique used

no pulp involvement

no infection

early lesion (only in enamel)

describe the complete caries removal process

deliver LA

apply rubber dam

access cavity

remove caries (careful of pulp)

apply matrix if needed

line cavity if close to pulp

restore with composite