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8/10/2019 Techniques of Caries Management in Primary Dention
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BYDR.FAMUREWA B.A.
O.A.U.T.H.C., ILE-IFE NIGERIA.
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INTRODUCTIONAETIOPATHOGENESISMETHODS OF DIAGNOSIS
CARIES RISK ASSESSMENTTREAMENT TECHNIQUESCONCLUSION
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TREATMENT TECHNIQUES;NON-OPERATIVE/PREVENTIVE THERAPYCONVENTIONAL RESTORATIVE
TREATMENTATRAUMATIC RESTORATIVE TREATMENTCHEMOMECHANICAL APPROACHHALL TECHNIQUE
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Dental caries with its sequelae is the most commonclinical entity presenting to a paediatric dentalpractice
Dental caries is defined as localized, post-eruptive,pathological process of external origin involvingsoftening of hard tooth tissue & proceeding to theformation of cavity(WHO)
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This seminar focuses on the management ofestablished caries(cavitated & non cavitated) inprimary dentition.
Emphasis is not on various time tested andemerging novel preventiveapproaches(replacement therapy, caries vaccine).
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Dental caries is a multifactorial disease.Aetiological factors:
Dental plaque- Streptococcus mutans(initiation&cavitation), LactobacilliSubstrates- fermentable carbohydrateHost factors-tooth morphology, salivary flow
rateTime- frequency of cariogenic challenges
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Caries occur when oral environment favoursdemineralization.Caries is revesible to an extent!(remineralization)
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Prerequisite for caries diagnosis:Good lightingClean teethSharp eyesReproducible bitewing radiographs
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Visual method- Mouth mirror & blunt/ballended probe
Non cavitated appear as :Caries seen as white spot-dry teeth(in superficialdepth of enamel)Glossy white spot- arrested caries
Matt white spot- active cariesBrown/white spot- wet teeth(caries in enamel &may be in dentine)
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Cavitated lesions- usually active, may exposedentine or pulp
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Tactile methodBlunt ended probe- confirms the presence ofcavities, restoration & sealantsSharp probes are contraindicated- stickyprobe(probe fits fissure), breaks down weakdemineralized enamel(iatrogenic cavity!!),inoculation of caries free sites
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Radiographic methodBitewing radiographs-1 st choice for caries detectionPeriapical radiographsFor detection & progress monitoring
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Fibre-optic trans illumination(FOTI)Placement of a 0.5mm light source in theembrasure of posterior teeth. Carious lesion shows
as dark shadow
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Laser fluorescence deviceThis measures the fluorescence of tooth & that ofthe bi-product of bacteria in the carious lesion.
This produces a digital reading indicating thecarious status of teeth. Example is Diagnodent
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Electronic caries meterMeasures resistance of carious lesions & comparesthis to that of sound tooth structure
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NON-OPERATIVE/PREVENTIVETHERAPYCONVENTIONAL RESTORATIVETREATMENTATRAUMATIC RESTORATIVETREATMENTCHEMOMECHANICAL APPROACHHALL TECHNIQUE
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To cure/heal incipient caries(white lesions)To arrest caries progression
Suitable for high risk children.Four pillars of caries prevention:1. Diet modification2. Fluorides3. Fissure sealants4. Plaque control
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Diet modificationo Dietary history & dietary chart very importanto Frequency of intake NOT quantityo Discourage grazing or snacking btw meals o Frequent intake of carbonated drinks-
cariogenic & erosiveo Intake of sweet drinks, use of pacifier-nursing
bottle caries
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Diet modificationo Positive alternatives should be provided;
coconut, groundnut, sugar free chewing
gum(Orbit
)o Use of sugar free medications by medically
compromised children
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FluoridesSystemic & topical applicationsMechanisms of action in caries prevention;
1. Inhibition of demineralization(fluorapatite)2. inhibition of plaque bacteria(enolase).3. Enamel more stable & resistant to acid
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Fissure sealantsFissure & pits are prone to cariesLight cure & self cure resin(bis-GMA)GIC can be used as temporary sealants(anxiouschild)
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Guidelines for fissure sealantsapplication(British Society of PaediatricDentistry 2000) :
Patient selection1. Children with special needs- apply on occlusal
surfaces of 2 teeth
2. Children with extensive caries in their 1
dentition3. Children with no caries in 1 dention- no need
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Tooth selection1. Occlusal surface of 2 molar teeth; can be
applied on cingulum pits(upper incisors),
buccal pits(lower molars), palatal pits(uppermolars)
2. Sealants to be applied ASAP(good moisturecontrol)
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Tooth selection:3. Any child with caries on 1 st 2 molar should havethe fissures of unaffected of the 1 st 2 molars sealed
4. Occlusal caries affecting one/more 1 st 2 molarsindcate a need to fissure seal the 2 nd 2 molars assoon as they erupt
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Plaque controlToothbrushing- supervised, twice dailyFlossing- starting from early mixed dentitionProphylaxis- Scaling & PolishingAntimicrobial agents- adjuncts to mechanicalplaque removal. Indicated in high caries
children & medically compromised child
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Materials used in Paediatric Dentistry:Dental amalgam
Merits: simple, quick, cheap, durable & techniqueinsensitiveDemerits: not adhesive, need for mechanicalretention, environmental & occupational hazards
& public concern
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Composite resinMerits: aesthetics, adhesive, command set,reasonable wear property
Demerits: technique sensitive, expensive, needmoisture control
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Glass ionomer cement(GIC)-Aluminosilicatepowder+ polyalkenoic acid
Merits: adhesive, aesthetic, fluoride leaching
Demerits: long setting time, brittle, prone toerosion & wear, radiolucent.
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Factors affecting choice of materials:Age of patient- ability to cooperate & durabilityCaries risk: SS crown(in risk) than composite Level of child s cooperation
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ART Technique involves the use of handinstrument only to remove carious lesions &restoration of the cavity with sealing any adjacent
fissures using conventional GIC
Minimally invasive procedure- pain free &acceptable to children
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Chemomechanical caries removal (CMCR) is a noninvasive technique eliminating infected dentine viachemical agents aided by atraumatic mechanical
force.Restoration of cavities is done with compositeresins or GICCMCR preserves healthy dental tissues, avoidspulpal irritation(& exposure) & child s discomfort
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CMCR agents:N-monochloroglycine(NMG)= GK 101(1972)N-monochloroaminobutyric acid= Caridex (75)Carisolv- developed in Sweden in 1998.
Has 2 components:3 amino acids(glutamic acid, leucine & lysine)
+NaOHNa hypochlorite
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Papacarie developed in 2003(Brazil)Papacarie contains:
o Papain-extracted from leaves & fruits of Carica papaya. Acts by cleaving collagen moleculespartially destroyed by caries(tissues that lackprotease inhibitor, -1-antitrypsin)
o
Chloramine =Chlorine+ NH Chemically softens carious dentine; bactericidal
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Merits: no need of L.A, ultraconservation of soundtooth, risk of iatrogenic pulp exposure, precludesanxiety associated with drilling, no droplet
infection(from aerosol)Indications: dentally anxious patient, medicallycompromised child, physically handicapped child,patient with infectious air-borne diseases(TB)
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Developed by Dr. Norna Hall in 2006sealing in caries technique in 1 dentitionThe technique involves seating preformed metalcrown(SS Crown) over carious 1 molars with nocaries removal, tooth prep & local anaesthesiaHall technique was acceptable topatients(children), carer(parents/guardians) &treating dentists
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Contraindications Irreversible pulpitisDentoalveolar abscessPresence of buccal sinusNon physiological tooth mobilityInsufficient sound tooth tissue to retain crown
Interradicular pathology/ furcationinvolvement
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ContraindicationsUncooperative child- to allow for crownplacement without risk of aspiration
Child @ risk of bacterial endocarditis- managetooth with traditional restoration.Tooth near physiologic exfoliation
Where aesthetic is of concern to child/ parent
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Indications :Early to moderate proximal caries in 1 molarsActive caries in 1 molars with no sign &symptoms of pulp pathologyModerately advanced class I caries- no goodseal ffg conventional caries removal &restoration with adhesive material
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Indications :Non cavitated class I lesion- if patient is unableto accept fissure sealant or conventional
restorationCavitated class I lesion- if patient is unable toaccept partial caries removal technique orconventional restoration
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o Explain the procedure to the childo Let the child handle a spare crowno Crown as- shiny helmet, Princess crown
Tell the child that:o He/she will help by biting the crown into placeo Cement won t taste nice & can like salt or
vinegar crisps
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ArmamentariumMouth mirrorStraight probe- to remove separators(if used)Excavator- to remove crown if necessary &used to remove cementFlat plastic- to load crown with cement
Cotton wool rolls- for child to bite on & pushcrown over tooth; to wipe away excess cement
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Protecting the airwayo Sit the child upright oro Use gauze swab- place btw the tooth & tongue
with extension to oropharynx.Alternatively,
o Use elastoplast tape to secure the crown
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Locate & seat- fitting the crownPlace the crown over the toothSeat the crown either by finger pressure or the
child seats it by biting on it
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WipeRemove excess cement as soon as the crown isseated
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Check & cleanRemove excess cementFloss between the contact points
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The present advancement in knowledge ofcariology & overwhelming evidences of noveltechniques of caries management should lead to a
shift from Black s dogma of caries mgt to a moretooth conserving & child friendly approachesespecially in primary dentition.Proper & timely management of caries in primary
teeth is advocated to prevent untowardcomplications- premature tooth loss, facialcellulitis, e.t.c
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A Users Manual of Hall technique by D. Evans & N.InnesHandbook of Paediatric Dentistry edited by Cameron& Widmer
Paediatric Dentistry edited by Welbury & Duggal.Pickards Manual of Operative Dentistry 8 th EditionGanesh M, Parikh D(2011). Chemomechanical cariesremoval agents: review & clinical applications inprimary teeth. J. Dent. Oral HygSmales R.J. , Yip H(2000). The atraumatic restorativetreatment approach for primary teeth: review ofliterature. Pediatr Dent 22:294-298.
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