Restorative Procedure for Primary teeth

• What are the reasons to restore teeth?

  Most Important: Quality of life, Space maintenance, Unpredictable rate of caries progression/arrest, Prevent extractions (mental health)

  Less Important: Patient education/acclimatisation, Aesthetics, Parents wishes
• How do un-restored teeth affect a child's quality of life?

  • pain/infection
  • ability to speak, eat, play, learn, socialise, sleep
  • affects confidence
  • time away from school, fall behind in learning
  • Parents/carers time off work : financial impact
  • Impact greater amongst socially/economically disadvantaged
• What is the FiCTION Trial?

  • 2008 Multi-centre randomised controlled trial
  • 7 locations across UK, 72 general dental practices
  • 1058 children, age 3-7yrs at least 1 primary molar with caries in to dentine
  • Testing caries management: Conventional restoration + prevention (inc LA)◦ Biological management + prevention (no LA)◦ Prevention alone
  • Conclusion – no evidence of a difference in outcomes!

  
• What are the essential variables to think about when choosing between restoring and removing a tooth?

  • child
  • tooth
  • disease
• What things must be considered when deciding to restore or remove a tooth?

  • Time to exfoliation
  • Site/extent of lesion (restorability/remaining sound tooth tissue)
  • Risk or presence of pain/infection
  • Number of teeth affected
  • Child's co-operation/access/moisture control
  • Parents' wishes/demands
• At each appointment what helps achieve caries recognition?

  Check prescription from dentist Check history; clinical symptoms Extra-oral (facial swelling) Intra-oral:o Visual o Radiographic

  
• What is helpful when conducting a visual exam for caries recognition?

  Consider position of child Teeth must be clean and dry Good light is essential Know what is normal
• A radiographs a good way of determining caries in children?

  Yes, however: "Radiographs do not appear to be routinely employed for caries diagnosis and treatment planning in young children within general dental practice in the UK." Young et al. 1990

  Consider unnecessary exposure to x-rays"At least half the approximal lesions in primary molars of children aged 3 to 7 years would not be detected without radiographs." Kidd and Pitts 1990
• What is the selection criteria for Dental Radiography for posterior bitewing radiographs?

  • Essential adjunct to clinical examination
  • Should be considered even for pre-school children
  • Necessary for the detection of approximal caries
  • Risk assessment required first
• How often should bitewings be taken in accordance to severity of risk of caries?

  • high - BWs 6 monthly until no new/active lesions or risk cat changes
  • moderate - BWs anually until no new/active lesions or risk cat changes
  • low - BWs 12-18 monthly (prim dent) BWs 24 monthly (perm dent) can be extended if appropriate
• What are some alternative methods of caries detection?

  Fibre optic transillumination Electrical caries detection tools Laser fluorescence device
• What are the options for carious primary teeth?

  Non-restorative: site specific prevention, non-restorative cavity control, extraction

  Restorative: No caries removal restoration, Selective caries removal & restoration, Complete caries removal & restoration
• What does sit specific prevention do?

  Halts progression of caries and promotes remineralisation
• When is site specific prevention suitable?

  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

  Advantage: Non-invasive so acceptable to children

  Disadvantage: Relies on behaviour change
• What is the process for site specific prevention?

  • Highlight lesion
  • Agree process – parent accepts responsibility
  • Apply preventive measures: Toothbrushing instruction, Diet advice, Fluoride varnish 3 monthly, Silver diamine fluoride 6 monthly
  • Record
  • Review
• What are some facts about Silver Diamine Fluoride?

  Current increase in interest driven by Covid-19 Non-AGP Non-invasive Fits in with concept of MID Lots of evidence worldwide of efficacy Used "off-label"
• What IS Silver Diamine Fluoride?

  • Clear, odourless liquid
  • Commonly referred to as SDF
  • Technically correct spelling = silver diammine fluoride, Ag(NH3)2F
  • Silver = antibacterial
  • Fluoride proven to prevent and arrest caries
  • First approved for use therapeutically in Japan in the 1960’s
  • BUT currently not licensed in the UK for treating caries
• How is Silver Diamine Fluoride used?

  • Commonly 38%
  • 44,800ppm
  • pH 13
  • Applied in a similar way to fluoride varnish
  • Reviewed after 2-4 wks
  • Applied 6 monthly
• What Silver Diamine Fluoride product is currently licensed for use in the UK?

  • Riva Star 38% SDF conc
  • Licensed for management of sensitivity (not for the arrest of dental caries)
  • 44,800ppm Fluoride Stored in Fridge
• What are the advantages of SDF?

  - Bactericidal - Remineralises to fluorapatite - Occludes dentinal tubules
• How safe is SDF?

  - Fluoride toxicity 5mg/Kg- (Age + 4) x 2 (estimation of weight)- Duraphat (NaF 5%) - 0.25ml/5.6mg- SDF 1 drop - 2.24mg (4-6 lesions)- Maximum one capsule SDF per child no matter age or number of teeth- Half capsule SDF per 10kg- No lasting acute toxicity issues reported
• Is SDF effective in arresting caries?

  An Umbrella review in 2019 by Seifo et al collated systematic reviews focusing on the use of SDF in managing caries in the primary dentition Findings:- SDF is effective in arresting caries in the primary dentition - Insufficient evidence for its use in preventing caries
• Does the Office of the Chief Dental Officer in England recommend SDF?

  ' Management of caries in the primary dentition should favour minimally invasive oral healthcare including consideration of the use of less invasive measures such as:- SDF- Hall Crowns- Where appropriate consider extractions over tradition conservative approaches
• Why would this dentition not be indicated for SDF treatment?

  - SDF could cause significant staining on the labial surfaces of the upper anterior permanent dentition

  
• What are contraindications for the use of SDF?

  - Children suffering from dental pain/swelling/or recurring abscess ulceration - Children undergoing thyroid gland therapy/ on thyroid medication - Allery to silver/other metals- Pregnancy or breast feeding
• What is a non-dental/medication contraindication for the use of SDF?

  - Family refuses to consent for treatment
• How is written consent obtained for SDF?

  - patient information leaflet - describing treatment and impact on child- options - why is SDF recommended?- off label use- risks/benefits - tailored to family & patient
• What are the risks associated with SDF treatment?

  • Failure of treatment
  • Temporary - soft tissue stain (few weeks)- metallic taste
  • Permanent- stain clothing- tooth staining (restorations also)
• What comes in the Riva Star box?

  Silver capsules (SDF) (Silver)Potassium Iodide - reduce extent of stain (Green)Resin gingival barriers (paraffin is easier to use and better tolerated by children) Moisture control is essential
• What is the process for using SDF?

  - Gingival barrier (petroleum jelly)- Dry teeth- No caries removal needed - 1 x SDF silver capsule - Paint on directly to lesions- Consider green capsule (white precipitate produced which should turn clear)- Wait 1-3 mins after application - Dry teeth again- Consider toothpaste to help with taste
• What is the aftercare for use of SDF?

  - Biannual application of SDF - 2-4 week review to check treatment success
• Why is non-restorative cavity control used?

  To reduce the cariogenic potential of the lesion
• When is non-restorative cavity control suitable?

  1. Arrested caries

  2. Unrestorable tooth

  3. Tooth close to exfoliation

  4. Advanced lesions where other methods are not feasible

  Also: Non-invasive Relies on behaviour change Lesions need to be cleansable
• What is the process for non-restorative cavity control?

   Highlight lesion Agree process – parent accepts responsibility Make lesion cleansable Apply preventive measures:◦ Toothbrushing instruction◦ Diet advice◦ Fluoride varnish 3 monthly◦ SDF 6 monthly Record Review
• What are types of restorative materials?

  Preformed metal crowns Amalgam Composite Glass ionomer Compomers Fissure sealant
• When was amalgam stopped being used in primary teeth?

  July 1st 2018(Caveat - unless deemed necessary by the practitioneron the grounds of specific medical needs)
• What is the no caries removal method?


  Where the lesion is completely sealed from the oral environment to slow/arrest progression of carious lesion
• What are two methods used in the no caries removal method?

  • Hall Technique - suitable for advanced occlusal or proximal lesions
  • Fissure Sealant- suitable for non-cavitated occlusal or proximal lesions

  
• What is selective caries removal?

  The removal of sufficient carious tissue to enable an effective marginal seal with bonded adhesive material
• What are some facts about the selective caries removal method?

  - its suitable for advanced occlusal lesions- a reduced risk of pulpal exposure- a reduced time for cavity prep- may not require LA- conventional technique or ART (Atraumatic restorative technique) - MID