Table 5 Synthesis of guideline recommendations for permanent teeth

Management of early carious lesions in permanent teeth

No caries removal

Site specific prevention

For proximal lesions; Identify and arrest early enamel-only lesions paying particular attention to the mesial surface of first permanent molars. Carry out site specific prevention and monitor with bitewing radiographs. Ensure that the parent/carer is fully aware of the potential impact on their child’s oral health [5].

SDCEP [5]

No caries removal

Fissure sealants

Fissure sealants should be used for both sound occlusal surfaces and early carious lesions [27].

For occlusal caries (or proximal lesions where site specific prevention is not suitable) place a resin fissure sealant [5]. If early occlusal dentinal caries is inadvertently sealed in, provided the sealant is maintained, the caries is unlikely to progress [5]. Clinically review sealant for wear and check integrity at every recall visit physically with a probe. If the sealant is worn, top it up [5]. If the sealant is not adherent to the tooth, remove it and replace. If the lesion has progressed, adopt an alternative management strategy [5]. Radiographically review in line with current recommendations [5]. If the tooth is only partially erupted, or the child’s cooperation is insufficient for placement of a resin fissure sealant or a restoration, consider the use of a glass ionomer material as a temporary sealant or restoration [5].

AAPD (Pit and fissure sealants) [27]

SDCEP [5]

No caries removal

Resin infiltration

Resin infiltration is indicated as an adjunct to preventive measures for primary and permanent teeth with small, noncavitated interproximal caries lesions to reduce lesion progression and for white-spot lesions to improve their clinical appearance [14].

AAPD (Pediatric Restorative Dentistry) [14]

Glass Ionomer Cement (GIC)

Do not use GIC; Evidence is insufficient to support the use of conventional or resin modified GIC (RMGIC) as a long-term restorative material in permanent teeth [14].

AAPD (Pediatric Restorative Dentistry) [14]

Management of deep carious lesions > 1/3 into dentine in permanent teeth

Selective caries removal

No material specified

For moderate occlusal and proximal dentinal caries - Carry out selective caries removal or, if necessary to allow sufficient depth and surface area for the restorative material, carry out complete caries removal prior to restoration, seal the remaining fissures [5].

For extensive occlusal and proximal dentinal caries - Carry out stepwise caries removal, temporise with an obvious temporary material and restore with a permanent restoration after 6 to 12 months. Seal the remaining fissures [5].

For a healthy pulp, where there is no pulpal exposure consider; protective liners (liner over floor of cavity when no exposure and all caries removed) or indirect pulp treatment by leaving caries over floor of cavity then placement of biocompatible liner for biological seal. The tooth should then be restored with a material that seals the tooth from microleakage [12].

Incomplete caries removal should be considered in primary and permanent teeth with deep caries and normal pulp status or reversible pulpitis when complete caries removal is likely to result in pulp exposure [12].

Do not use GIC as a long-term restorative material [14].

SDCEP [5]

SDCEP [5]

AAPD (Pulp therapy for primary and immature permanent teeth) [12]

AAPD (Pulp therapy for primary and immature permanent teeth) [12]

AAPD (Pediatric Restorative Dentistry) [14]

Atraumatic Restorative Technique. NB referred to as ITR in AAPD guidelines.

ART (ITR) using high-viscosity glass-ionomer cements may be used as single surface temporary restoration for both primary and permanent teeth [14]. Additionally, ITR may be used for caries control in children with multiple open caries lesions, prior to definitive restoration of the teeth. Evidence is insufficient to support the use of conventional or RMGICs as long-term restorative material in permanent teeth [14].

AAPD (Pediatric Restorative Dentistry) [14]

Indirect pulp therapy

In the presence of signs of irreversible pulpitis; ITR with glass ionomer cements may be used for caries control. Current literature indicates there is no conclusive evidence that it is necessary to re-enter the tooth to remove the residual caries.

Indirect pulp therapy (IPT) including selective and stepwise caries removal; leave caries, line and don’t re-enter [12].

AAPD (Pulp therapy for primary and immature permanent teeth) [12]

Use of bioactive materials

Bioactive materials can be used for remineralisation and pulp capping [14].

AAPD (Pediatric Restorative Dentistry) [14]

Complete caries removal (no material mentioned)

For permanent anterior teeth with advanced caries - Completely remove caries and restore or consider selective caries removal and restore [5].

SDCEP [5]

Management of caries into pulp in permanent teeth

Selective caries removal

No restorative material specified

In the presence of reversible pulpitis carry out stepwise or complete caries removal, taking care to avoid the pulp, and place a restoration. It may be necessary to provide a temporary dressing and review the tooth before placing a permanent restoration later (stepwise only as if complete then not deep enough to be into pulp) [5].

SDCEP [5]

Pulp caps

Bioactive materials can be used for remineralisation and pulp capping [14].

AAPD (Paediatric Restorative Dentistry) [14]

Selective caries removal as a pulp cap: In the presence of signs of irreversible pulpitis ITR with glass ionomer cements may be used for caries control. Current literature indicates there is no conclusive evidence that it is necessary to re-enter the tooth to remove the residual caries. IPT including selective and stepwise caries removal; leave caries, line and don’t re-enter [12].

AAPD (Pulp therapy for primary and immature permanent teeth) [12]

For small carious pulpal exposures place a direct pulp cap [12].

AAPD (Pulp therapy for primary and immature permanent teeth) [12]

Pulp Therapy

Partial pulpotomy

For larger exposures partial pulpotomy is indicated in a young permanent tooth, for a carious pulp exposure in which the pulp bleeding is controlled within several minutes. The tooth must be vital, with a diagnosis of normal pulp or reversible pulpitis. Use either CaOH or MTA [12].

AAPD (Pulp therapy for primary and immature permanent teeth) [12]

Full pulpotomy

A full pulpotomy is indicated in immature permanent teeth with carious pulpal exposure as an interim procedure to allow continued root development (apexogenesis). It also may be performed as an emergency procedure for temporary relief of symptoms until a definitive root canal treatment can be accomplished. Indications for apexification: non-vital permanent teeth with incompletely formed roots [12].

AAPD (Pulp therapy for primary and immature permanent teeth) [12]

Endodontic treatment – root canal therapy (Pulpectomy)

In the presence of irreversible pulpitis or dental abscess/periradicular periodontitis either carry out a root canal therapy or extract the tooth. To relieve symptoms, and to allow time for long term treatment planning, consider root canal therapy and dressing of the root canals, before deciding on extraction of a permanent tooth [5].

SDCEP [5]

Indications: a restorable permanent tooth with a closed apex that exhibits irreversible pulpitis or a necrotic pulp. For root canal-treated teeth with unresolved peri-radicular lesions, root canals that are not accessible from the conventional coronal approach, or calcification of the root canal space, endodontic treatment of a more specialised nature may be indicated [12].

AAPD (Pulp therapy for primary and immature permanent teeth) [12]

Other treatment

Regenerative endodontic technique

Indications: nonvital permanent teeth with incompletely formed roots [12].

AAPD (Pulp therapy for primary and immature permanent teeth) [12]

Extraction

In the presence of irreversible pulpitis or dental abscess/periradicular periodontitis either carry out a root canal therapy or extract the tooth. If the tooth is unrestorable, extract the tooth and try to avoid extractions at a child’s first visit if at all possible [5].

SDCEP [5]

Temporisation

If the tooth is unrestorable and child is unable to cope with the extraction (due to a learning disability or where behaviour management techniques have been unsuccessful), temporise the tooth, continue prevention and refer the child for specialist paediatric dental or orthodontic opinion [5].

SDCEP [5]