For primary dentition 1

• 2020 oral health survery of 3 year olds

  10.7% decay with a DMFT of 3
• What are more important reasons to restore teeth?

  • quality of life for both child and carer (ie. lack of sleep, missing work/school)
  • space maintenance
  • unpredictable rate of progression and arrest
  • prevent XLA - MH
• Less important reasons to restore ?

  • pt education and acclimatisations
  • aesthetics
  • parent wishes
• What effects can non restored teeth have of quality of life?

  • pain and infection
  • affects speech, eat, play, learning, socialising and sleep
  • confidence
  • time away from school = lack of learning
  • parents = time off work = financial impacy
  • impact greater amongst socially / economically disadvantaged
• Financial implications of restoring teeth?

  • March 2019 = 90% kid hospital XLa due to caries
  • most common reason for hospital admission 6-10yr olds
  • hopsital XLA in 0-19 (2021/22) = 42,180 - 140/day
  • 50.9 million cost due to decay
• FiCTION Trial ?

  • 2008 multi centre RCT
  • 71 practices over 7 locations in UK
  • 1058 kids aged 3-7 who had at least 1 primary molar w caries into dentine
  • Tested 3 approaches to caries management
• What was the conclusion of the fiction trails

  no evidence of a difference in outcome
• What were the 3 approaches to caries management in the fiction trial ?

  1. conventional restoration + prevention inc. LA
  2. Bio management + prevention no LA
  3. prevention alone
• Essential variables in removing/restoring teeth

  child, tooth, disease
• Considerations when deciding to remove/restore a tooth?

  • time until exfoliation
  • site + extent of lesion (ie. the restorability and remaining soud tooth)
  • risk or prescence of pain / infection
  • no. of teeth affected
  • coop, access and moisture control
  • parents wishes
  • parents kids able to attend apt?
• at each apt?

  • check prescription from dentist 
  • Check history and clinical symptoms
  • Extra oral (swelling)
  • Intra oral (visual/radiographic)
• Visual exam?

  • position of child
  • teeth clean and dry
  • good light
  • know the normal
• Posterior BWs?

  • essential adjunct to exams
  • considered even for pre school children
  • Necessary for detection of approximal caries
  • Risk assessment needed first 
  • GGDP UK 2018
• High risk BW recommended intervals

  6 monthly until no new or active lesions
• Moderate risk BW recommended intervals

  Annual until no new/active lesions
• Low risk BW recommended intervals

  primary dentition = 12-18 monthly

  Permanent = 24 monthly

  
  

  can be extended if appropriate
• Other methods of caries detection?

  • fibre optic transillumination
  • electrical caries detection tool
  • laser fluorescence
• Non restorative options for carious primary teeth ?

  • site specific prevention
  • Non restorative cavity control
  • XLA
• restorative options for carious primary teeth ?

  • no caries removal restoration
  • selective caries removal and restorations
  • complete caries removal and restorations
• Site specific prevention

  aim: to halt progression and promote remineralisation

  
  

  suitable for:

  1. Early carious lesion on occlusal or proximal surface
  2. Early carious lesion on an anterior tooth
  3. Arrested lesions
  4. Teeth close to exfoliation

  
  

  non invasive so more acceptable but relies on behaviour change
• Process for site specific prevention?


  1. highlight lesion
  2. agree process and parent accepts responsibility
  3. Apply preventative measures = diet advice, FV 3/12, SDF 6 monthly, TBI
  4. record
  5. R
• Silver diamine fluoride ?

  • increase in interest driven by covid 19
  • Non AGP and non invasive
  • fits MID concept
  • +++ worldwide efficacy evidence
  • Used off label - not licensed in uk for Tx of caries
  • Clear and colourless liquid
  • silver = antibacterial
  • Ag(NH3)2F
• How is SDF used?

  • 38%
  • 44800 ppm
  • pH 13
  • applied in similar way to FV
  • Rv after 2-4 weeks
  • apply 6 monthly
• SDF Pt leaflet ?

  • produced by BSPD
  • To be used in BCHC 
  • Vital to consent process
  • Printable version on BSPD website
• Non restorative cavity control

  aim: reduce cariogenic potential of lesion

  1. suitable for:
  2. arrested caries
  3. unrestorable tooth
  4. close to exfoliation
  5. advance lesions where other methods not feasible

  non invasive, needs behaviour change and lesions need to be cleansable
• Non restorative cavity control process:?

  1. Highlight lesion
  2. Agree process 
  3. Make lesion cleanable 
  4. Apply preventative measures: TBI, Diet advice, FV 3/12, SDF 6/12
  5. Record 
  6. Review
• Restorative Materials

  • Preformed metal crowns
  • Amalgam
  • Composite
  • GI
  • Compomers 
  • FS
• Minimata Treaty ?

  • agreed 2013
  • reduce env pollution from mercury
  • phase down use of dental amalgam
  • from 1 july 2018 = not used in primary teeth UNLESS deemed necessary by practitioner on grounds of specific medical needs
• No caries removal

  aim: completely seal the lesion from the oral environment to slow and arrest progression

  Hall technique - suitable for advanced occlusal or proximal lesions

  FS - suitable for non cavitated occlusal or proximal lesions
• Selective caries removal?

  aim: remove sufficient carious tissue to enable an effective marginal seal w/ a bonded adhesive material

  • suitable for advanced occlusal lesions 
  • --- risk of pulpal exposure
  • --- time for cavity prep
  • May not require LA
  • Conventional technique or ART-MID
• Conventional technique ?

  • access caries w. fast HP is needed
  • Remove superficial caries until EDJ clear 
  • Clear cavity walls until hard and scratchy 
  • Ensure sufficient depth for restoration placement 
  • Remove undermined enamel 
  • Place adhesive, bonded restoration 
  • Fissure seal over the top 
• ART?

  • removes caries w hand instruments only
  • dev in tanzania
  • no LA
  • used for stabilisation
  • conserves sound tooth
  • Restoration w. GIC
  • technique sensitive
• ART Technique?

  1. Ensure instruments are sharp 
  2. Isolate with CWR
  3. Enlarge access if required
  4. Scoop out soft caries 
  5. Clean and dry cavity with CWP 
  6. Restore with GIC using finger pressure
  7. Cover with Vaseline
  8. Avoid eating for 1 hr 
• Complete caries removal?

  Aim: To remove all infected carious tissue and restore to function

  • suitable for advanced occlusal or proximal lesions 
  • +++ risk of pulpal exposure
  • Requires LA, fast HP + good moisture control
  • More demanding for child and clinician 
  • Other techniques generally preferred
• Complete caries removal technique ?

  1. LA
  2. rubber dam
  3. Access cavity 
  4. Remove caries
  5. matrix if required
  6. Line cavity if close to pulp
  7. Restore with composite
• How much SDF is needed

  F toxicity is 5 mg / kg

  weight = (age+4) x2

  1 drop SDF = 2.24 mg and can do 4-6 lesions

  Max is one capsule of SDF, half a capsule for 10 KG
• indications for SDF?

  • pre cooperative
  • asymptomatic caries in primary teeth
  • other Tx excluded
  • Delay Tx requiring sedation or GA
  • potential use for molar incisor hypomineralisation
• contraindications for SDF?

  • pain swelling
  • apthous ulceration
  • thyroid medication or gland therapy
  • pregnancy/breastfeeding
  • allergy to metals of symptoms
• Risks of SDF?

  • failure of Tx

  temporary :

  • soft tissue stain (few weeks)
  • metallic taste

  Permanent:

  • stain clothing
  • stain tooth and comp restorations
• SDF capsule content

  silver capsule: SDF

  green capsule: potassium iodide (reduces staining)

  come w resin gingival barriers but needs compliance - use vaseline instead