Restorative Management of Primary Teeth

why do we restore primary teeth

medical and dental wellbeing are intertwined

children wth caries do not thrive physcially and mentally

what is SIMD

Scottish Index of Multiple Deprivation

scores based on pts wellbeing

why do we restore the primary dentition

form - get into functional ability

aesthetics

function - eating/speech

maintain space

acclimatisation

avoiding sepsis and infection to permanent successors

avoid extraction (esp GA is required)

what teeth are not in the primary dentition

premolars

D and E are succeeded by premolars

what can happen if a primary tooth is removed early

successor tooth germ will move usually forward and into gap and cause tooth germs to be in incorrect places

what is caries process

bacteria is fermented by carbohydrates and produces lactic acid byproduct and causes dissolution of enamel

what is the difference between primary and permanent teeth

smaller

thinner enamel

relatively larger pulp

pulp horns are closer to surface

contact points are wider

what are bad things about pulp being bigger in primary teeth

easier to hit pulp horn with bur

faster pulpal caries due to thinner enamel and dentine and also less mineralised

this causes not much reparative dentine

this causes irreversible pulpitis

where are the canals in primary teeth

upper; MB DB Palatal

lower; MB DB D

on D and E

what do tx plans need to be

achievable

diagnosis is fundamental

in kids it is harder

what are the stages of a tx plan

relief of pain

prevention at home - OHI, diet diary etc

professional prevention - Flouride varnish, sealants

caries management

what is the hierarchy of tx

start simple if u can - builds confidence with the child

acclimitisation is key

how does consent work for children

under 16- parental consent

a formal consent form needs to be signed

if a child disagrees with tx, if its within child best interest u still do it - if under 16

what is the difference between reversible/ irreversible pulptitis

reversible - stimulus removed and pain goes away, occurs when eating/ drinking,

irreverisble - constant, need painkiller, keeps away at night

what do we see clinically comparing reversible and irreversible pulpitis

reversible - eaely carious lesion

irreversible - lymphadenopathy, temp, extensive marginal ridge, sinus, swelling

what do we see on radiographs comparing reversible and irreversible pulpitis

reversible - caries into dentine

irrevrsible - radiolucency or into pulp

when do we restore or extract

reversible - restoration can rmeove pain

irreversible - pulpotomy, ectraction, pulpectomy

need to look at quality and quantity of tooth tissue left

consider age in relation to tooth germ movement

when do we restore

when possible!

compliant

good reason - hypodontia, space maintenance etc

when do we extract

balancing extraction - for ortho to maintain midline and keep both sides symmetrical eg extracting 2 Es to keep germs symmetrical

no compliance

no parental support

no attendance beyond pain relief - red flag

what is temporisation

can add temp dressing to stop pain if reversible pulpitis

can then add permanent restoration or extract based on success

what is stabilisaiton

child with gross cavitation

manages the child and remove food and no caries removal (or just from cavity margins) and add GI to buy time to properly to each rest. and stop remaining cavities from getting worse

why do we do stabilisation

preventing lesion progression

arresting caries in a long plan

preventing sensitivity in teeth close to the tooth to be restored outwith LA range

what is the sequence of operative care

start maxillary buccal section where painless LA can be acheived

delay IDBs

operative care must be integrated with preventative therapy or new lesions will develop

what is the typical sequence of tx

temp dressing if reversible pulpitis

prevention

simple rest

harder rest

then extractions etc

treat whole quadrant if needed IDB

then anterior restorations

how do we manage intracoronal/ crown restorations

minimal as possible

as quickly as possible due to thinner enamel and dentine

why is occlusal caries less common in primary molars

cusps are smaller and fissures are shallower and wider

indicates high caries rate

mesial pulp horn is usually higher than the distal but is usually straight forward to do

what is higher risk in primary teeth

caries

cracking/fracturing of enamel

small burs are needed

pulp horns are near the surface

what is minimata treaty

amalgam is said to not be good for environment, under 16, pregnant women or primary dentition

this happened in japan

how do we choose materials for restoration

relation to tooth - size of tooth and shape after the restoration

relation to pt - cooperation eg moisture control with composite

caries rate

aesthetic expectations

what do we not use GI for

never use GI for primary permanent restorations

what is compomer

mix of GI and composite

are mixed compositions

eg resin modified glass ionomer

mostly comp with a wee bit GI added

used cervically and is an option for perm rest for primary

how do we restore approximal caries in primary teeth

need BWs regularly from age 5

very minimal cavities due to pulp horns being higher

use crown for this

what does a stainless steel crown do

definitive restoration for class II cavities in primary molars

primary tooth holds key retentive factors to hold the crown

is best for durability, strength, wear

is mostly for large approximal but can also be for occlusal

when do we use stainless steel crowns

large class II

badly broken down teeth

following a pulpotomy

or for anomalies eg amelogenesis imperfecta

what is conventional and prep technique

remove caries and prepare tooth for crown

remove part of mesial distal and occlusal surfaces - about 1mm

the crown should just fit straught over

what are disadvantages of conventional and prep technique

need local as removig caries

easy to leave shpulder - wee bit juts out and can not be seated properly and become a plaque and food trap

what is hall technique

there is no prep or caries removal or use LA

just clear food out

just cement the crown straight on and cuts off bacteria substrate and stops caries getting worse sit patient

how do we put on a crown

sit the pt up

pick the size

get the child to bite it down

how do we do anterior primary restorarions

a sign of neglect

leave them unless pain as they are first teeth to exfoliate

if we need to restore its a sign of high caries risk

GIC cement can be used to buy time

composite resin is bet in cooperative cases

discing technique is used

what is discing

take a disc and polish the cavity down to stop food etc from sticking and makes the cavity self cleansing

for anterior teeth

what material do we use for anterior primary restorations

GI cement - good mechanical and chemical properties

not good for back teeth

and ils probably best for stabilisation or temporisation

composite is best when able to achieve moisyure contorl

what do we do for LA in kids

pulpal - use infiltration on all teeth up to Ds

a block is necessary for Es

can use a short needle for IDBs in kids

max dose - 1/10 cartridge per KG body weight for lidocaine

clear POIG

follow occlusal plane and angle lower when aiming IDB

what is rule of 10

child age + number of tooth

eg A =1 B=2

if over, use IDB, if under use iniltration

dont use IDB for extraction

what are advantages of hall crown

no la

no caries removal

desensitises kids

high success rate

low failure rate

avoids xla

what are disadvantages of hall crown

aesthetics

need seperators potentially

bite temporarily open

only suitable for caries in primary teeth