TREATMENT OF DENTAL CARIES IN
THE YOUNG PERMANENT DENTITION
• Introduction
• Assessment of caries risk
• Treatment decisions
• Diagnosis
• Recurrent caries
• Occlusal caries
• Class I restorations in young permanent teeth
• Approximal caries
• Alternatives to conventional cavity preparation
• Rampant caries
• Caries is a chronic disease. If it starts to affect the permanent teeth
the child patient is drawn into a cycle requiring ongoing care for the
rest of his/her life. Therefore when treating the young permanent
dentition we have to adopt an approach that considers and addresses
the whole disease process and not just treat the outcome of the
disease.
• Restoration of the young permanent dentition is part of a continuum
and cannot be regarded in isolation. Restoration is only one small part
of the child’s treatment. Essentially it is ‘surgery’ to remove the
carious infected area of the tooth and insertion of a suitable
substitute to restore the missing structure
Assessment of caries risk
• Caries risk assessment is essential for producing a holistic dental management plan
specific for the individual child. There are many questions to consider when planning
treatment of caries:
• Is there caries?
• Is it into dentine?
• When to monitor?
• When to treat?
• What is the family attitude to teeth?
• What cooperation can you expect?
• Are they at low risk of further caries?
• Are they at high risk of more caries developing?
The idea of a caries risk assessment for each child patient is to ensure that the chosen diagnostic
tests, preventive treatment, and any restorations are geared specifically to the needs for that
individual patient. Factors requiring consideration are:
1. present caries activity
2. past caries activity
3. parent/sibling caries activity
4. sugar consumption (food and drink)
5. oral hygiene
6. fluoride exposure
7. tooth morphology
8. Streptococcus mutans levels
9. saliva characteristics, flow rate, and consistency.
• Factors (1)–(7) will become clear when a full history and examination
are carried out Factors (8) and (9) will only come into play if there is
rampant caries that cannot be explained by the history.
Fig:1
An example of caries in a
12-year-old girl, who
sucked Polo mints non-
stop—‘six packets per
day’.
Treatment decisions
Important points in relation to treatment
• 1. Gaining access to the caries inevitably means destruction of sound tooth
tissue. The operator must keep this to a minimum consistent with complete
caries eradication.
• 2. Once the operator places an initial restoration, he/she cannot ‘undo’ it and
that tooth will inevitably require further restoration in its lifetime.
• 3. Every time an operator places a restoration, he/she destroys more of the
original tooth structure, thereby weakening the tooth.
• 4. Even though the occlusion in a young person changes as growth occurs and
teeth erupt, it is important to realize that when the operator places
restorations, he/she must replicate the original occlusal contacts in the tooth.
5. When treating an approximal lesion on one tooth with an adjacent
neighbor, the operator will almost certainly damage the latter.
6. When placing a class 2 restoration it is inevitable that there is some
damage to the periodontal tissues.
7. Repair and refurbishment of restorations instead of replacement
saves tooth structure.
Diagnosis
Many methods have been proposed, both alone and in combination.
These include:
• Visual Methods (Dry Tooth)
• Probe/Explorer (Used Only To Remove Debris)
• Bitewing Radiographs
• Electronic
• Fiberoptic Trans-illumination
• Laser Diagnosis.
At risk patient(medically,
previous caries high caries
risk)
Suspicion of Bite wing Remove Fissure monitor
caries selant or
caries radiographs
restoration
Visual
examination
No caries isolate Resin Check integrity
sealent Reinforce monitor
prevention
At risk tooth(deep fissures&
deep buccal grooves)
ALGORITHM FOR TREATING CARIES
Recurrent caries
• Visual examination and radiographs are the most common ways of
detecting recurrent caries.
• Recurrent caries is most commonly found at the gingival margins of
class II restorations, but often restorations will look a little ‘tatty’ at
recall so careful examination in good light is essential.
• Visually it is important to differentiate recurrent lesions from stained
margins on resin-based composite restorations. Alternatives such as
polishing or exploratory preparations adjacent to the lesion and repair
may be appropriate rather than replacing the whole restoration.
Occlusal caries:
• Establish a diagnosis, that a stained fissure is carious and is in dentin,
restorative treatment is indicated.
• Depending on the extent and occlusal load bearing treatment should
be decided.
• This includes
Fissure sealant.
PRR(Preventive resin restoration)
Class I restorations in young permanent teeth
If caries affects most of the occlusal fissure system, the clinician should
place a class I restoration.
• silver amalgam
• Composite resins
• Glass ionomer cements
• Resin-modified glass ionomer
Approximal caries:
• They occur relatively less as compared to occlusal caries.
• Occlusal caries should be managed immediately by sealing or PRR or
restoration.
• Approximal lesions in enamel should be managed by remineralization
and should be monitored.
Alternatives to conventional cavity preparation
• Atraumatic restorative technique (ART).
• Simple and modified atraumatic restorative technique (SMART).
• Air Abrasion
• Ozone therapy.
• Chemo mechanical caries removal (CMCR).
• Tooth preparation using lasers.
• Caries infiltration.
AIR ABRASION
• There has recently been resurgence of interest in air abrasion
technology with several different commercial units available.
• With air abrasion machines, aluminum oxide particles (27 or 50 um)
are blasted against teeth under a range of pressures (30-160 psi) with
variable particle flow rates
INDICATIONS OF AIR ABRASION
• Cleaning and removing stains and incipient caries from pits and
fissures prior to sealant and PRRs.
• Small class I, III, IV and V cavity preparations and selected class II
preparations.
• Repair and removal of composites, glassionomer and porcelain
restorations.
• Cleaning and preparation of castings, orthodonticbands and brackets
prior to cementation.
ADVANTAGES DISADVANTAGES
• Elimination of vibration, less voice and decreased • Dust is a practical problem. Control of dust
pressure containing free aluminum oxide is an ongoing
• Reduction in pain during cavity preparation, 85% challenge.
of patients do not require local analgesia. • The technique cannot remove leathery dentinal
• Less damaging pulpal effects than conventional caries or prepare extensive cavities requiring
hand pieces. classical retentive form.
• Less fracture and crazing of enamel and dentine • The tip does not touch the tooth and there is
during cavity preparation. no tactile sensation.
• Root canal access through porcelain crowns • Ability to remove sound structure rather than
without fracturing porcelain. carious substrate.
• In the preparation of PRRs, this technique gives • Potential risk of inhalation of aluminum
good result than conventional methods. particles.
AIR ABRASION
• Air-abrasion is another technique utilizing a mixture of watersoluble
sodium bicarbonate and tricalcium phosphate particles that is applied
onto the tooth surface using air pressure and shrouded in a
concentric water jet.
OZONE THERAPY.
• The technique uses laser detection of caries and Ozone treatment for
less than two minutes.
• Ozone readily penetrates through decayed tissue, eliminating the
ecological niche of cariogenic microorganisms as well as priming the
carious tissue for remineralization.
OZONE THERAPY.
ADVANTAGES DISADVANTAGES
• This simple approach avoids • Remineralization takes place
need of local anesthesia, drilling with the aid of topically applied
and filling. fluoride and rinses.
• Restricted to treat superficial • Hand pieces are still indicated
enamel and. root caries for deep carious lesions.
Chemo mechanical caries removal (CMCR).
• NaOCl was diluted and buffered with sodium hydroxide, sodium
chloride and glycine producing a solution of 0.05%
Nmonochloroglycine (NMG) having a pH of 11.4. This solution is
commercially known as GK101.
• The GK101 material is found to be more effective if glycine is
replaced by amino-butyric acid. The product is then known as
Nmonocholo D2 amminobytyrate (NMAB) and named as GK101E.
Chemo mechanical caries removal (CMCR).
• nominated system for treating anxious, medically compromised and
pediatric dental patients.
• Provides efficient removal of dental caries with no harm expected
either on the healthy dentine or the pulp tissues.
Chemo mechanical caries removal (CMCR).
ADVANTAGES DISADVANTAGES
• The results indicated no • Lengthy procedure is the only
remnants of the demineralized apparent drawback.
dentine were detected after • Unpleasant taste indicated by
treatment and the remaining few patients.
dentine was chemically and
clinically sound.
• Reducing the use of
conventional drilling and the
need for local anesthesia.
Lasers in dentistry:
Laser produce light energy with a narrow frequency range.
Some common lasers are as follows;
• Carbon Dioxide Laser 10.6µm
• Neodymium Yttrium Aluminum Garnet Laser 1.064µm
• Erbium Laser 2.94µm
• Argon Lasers 457-502nm
• Diode Lasers 904nm
Carbon dioxide lasers
• Soft tissue incision
• Aesthetic contouring of gingivae
• Treatment of ulcers
• Frenectomy and gingivectomy
• De-epithelization of gingival tissue during periodontal regenerative
procedures.
Neodymium: YAG
• Similar to above plus removal of incipient caries but because of depth
of penetration there is greater risk of collateral damage than with
dioxide lasers.
Erbium: YAG
• Caries removal
• Cavity preparation in both enamel and dentine.
• Preparation of root canals
Argon lasers
• Resin curing
• Tooth bleaching
• Treatment of ulcers
• Aesthetic gingival contouring
• Frenectomy and gingivectomy
Erbium lasers are used for cavity preparation
LASERS
ADVANTAGES DISADVANTAGES
• Laser use results in clean sharp • Cost.
margins in enamel and dentine. • The laser tip does not impinge
• The pulp is protected and safe as dental tissue so there is no
the depth of energy penetration proprioceptive feedback.
is negligible. • Technique sensitive.
• Patients report little or no pain.
• Time taken for cavity
preparation is short.
Caries Infiltration
• this unique treatment method provides an additional treatment option
between remineralization of carious lesions and their treatment through
restorative techniques.
• This “bridge” treatment provides a newly available opportunity to preserve
healthy tooth structure that would otherwise be lost during restoration;
most commonly Class II restorations. Resin infiltration provides for the
specific treatment of early carious lesions without the need to prepare
access preparations, thus protecting and fully preserving the hard tissue
surrounding the lesion. The treatment presents many advantages, especially
in pediatric dentistry. It is painless; therefore, it is well accepted by a
majority of patients in virtually all situations where it is applicable.
Advantages:
• Esthetic results on smooth surfaces
• Caries arrest at an early stage
• Preservation of healthy tooth structure
• Pain-free method, without anesthesia, or drilling
• By sealing the pore system, acids can no longer
Rampant caries:
• It is important to consider many factors that determine the treatment
of a child with a high caries rate.
• It may be possible to place temporary restorations whilst preventive
strategies are commenced as follows;
Dietary analysis
Plaque control
Fluoride
Fissure sealants
Regular recall
