Table 4 Synthesis of the guideline recommendations for primary teeth on management of carious lesions
Treatment option | Recommendation | Guideline(s) that the recommendation is derived from | |
|---|---|---|---|
Caries-related | Restoration-related | ||
Management of early carious lesions in primary teeth | |||
No caries removal | Fissure sealants | For sound occlusal surfaces and early carious lesions [5, 27] | SDCEP [5] AAPD Pit and Fissure sealants [27] |
No caries removal | Resin infiltration | AAPD Paediatric Restorative Dentistry [14] SDCEP [5] | |
Site specific prevention | No restoration required | For occlusal and interproximal caries, intervene if the lesion is progressing (transitioning) [5, 14] | SDCEP [5] AAPD Pediatric Restorative Dentistry [14] |
Active surveillance | No restoration required | Non-cavitated (white spot) caries lesions [14] | AAPD, Pediatric Restorative Dentistry [14] |
Management of deep carious lesions > 1/3 into dentine in primary teeth | |||
No or selective caries removal | Preformed metal crowns (PMC) | Multi-surface lesions on posterior teeth: A preformed metal crown is the restoration of choice (with SDCEP advocating the Hall technique) [5, 14]. | SDCEP [5] AAPD (Pediatric Restorative Dentistry) [14] |
Preformed metal crowns indicated for high-risk children with large or multi-surface cavitated or non-cavitated lesions on primary molars. (General recommendation for guideline is selective caries removal) [14]. | AAPD (Pediatric Restorative Dentistry) [14] | ||
Resin-based composites | Resin-based composites can be used as Class I and Class II restorations in primary and permanent molars [14]. | (AAPD, Pediatric Restorative Dentistry) [14] | |
Selective caries removal | PMC for proximal lesions PMC or plastic restoration for occlusal lesions | For teeth with a healthy pulp and no pulpal exposure, reversible pulpitis or when complete caries removal is likely to result in pulp exposure [5, 14, 27]. | SDCEP [5] AAPD (Pediatric Restorative Dentistry) [14] AAPD (Pit and fissure sealants) [27] |
For teeth with advanced occlusal caries incomplete caries removal with restoration using plastic restoration [5]. | SDCEP [5] | ||
It is essential to ensure a good seal with a permanent restoration A preformed metal crown is the material of choice for interproximal cavities [5]. | SDCEP [5] | ||
Indirect pulp therapy | Indicated for primary teeth with deep caries, with success being independent of the type of medicament used, therefore this should be dictated by clinician preference [14]. | AAPD (Paediatric Restorative Dentistry) [14] | |
Complete caries removal | No material recommended | Only advocated for anterior teeth and if a child cannot co-operate with caries removal [5]. | SDCEP [5] |
Silver diamine fluoride (SDF) | No restoration mentioned | Advocated for: • High caries-risk patients with anterior or posterior active cavitated lesions • Cavitated caries lesions in individuals presenting with behavioural or medical management challenges • Patients with multiple cavitated caries lesions that may not all be treated in one visit • Difficult to treat cavitated dental caries lesions • Patients without access to or with difficulty accessing dental care • Active cavitated caries lesions with no clinical signs of pulp involvement. • Teeth with deep caries lesions should be closely monitored clinically and radiographically [16, 34] | AAPD, SDF [16] EAPD [34] |
Non-restorative cavity control | No restoration required | Can be considered if selective caries removal and conventional restoration or preformed metal crown placement using the Hall technique is not suitable or the tooth is unrestorable [5]. | SDCEP [5] |
Atraumatic restorative treatment (ART). NB sometimes referred to as intermediate therapeutic restoration (ITR) by AAPD guidelines | No specific restorative material mentioned | For children at moderate and high risk of caries, cavitated or enlarging carious lesions should be restored [5]. ART is appropriate for single surface cavities but not multi-surface [5]. For large symptomatic carious lesions: Incomplete caries removal, dressing with glass ionomer cement and review symptoms in three to seven days [35]. ITR may be used until permanent restorations can be placed [35]. | SDCEP [5] AAPD (Caries Risk Assessment and Management) [35] |
Management of caries into pulp in primary teeth | |||
SDF | SDF is not recommended for carious lesions into pulp in primary teeth [16]. | AAPD (SDF) [16] | |
Selective caries removal | No restoration type mentioned | Consider for deep caries and normal pulp status or reversible pulpitis when complete caries removal is likely to result in pulp exposure [14]. | AAPD (Paediatric Restorative Dentistry) [14] |
PMC (Hall Technique) | Place a crown using the Hall Technique or if an occlusal lesion, carry out selective caries removal, avoiding the pulp, and restore using composite, resin modified glass ionomer, compomer or glass ionomer [5]. | SDCEP [5] | |
Radiopaque liner and restoration with a material that completely seals the dentine from the oral environment | For deep carious lesions without evidence of periradicular pathology a radiopaque liner such as a dentine bonding agent, resin modified glass ionomer, calcium hydroxide, or mineral trioxide aggregate (MTA) (or any other biocompatible material) is placed over the remaining carious dentin to stimulate healing and repair [12]. The liner that is placed over the dentin (calcium hydroxide, glass ionomer, or bonding agents) does not affect the indirect pulp therapy (IPT) success. The tooth then is restored with a material that seals the tooth from microleakage [12]. | AAPD Pulp Therapy for Primary and Permanent teeth [12] | |
ART NB – this is referred to as ITR (Intermediate Therapeutic Restoration) in AAPD Guideline | In the presence of symptoms When there are signs of reversible pulpitis and using glass ionomer cement 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 [12]. Where there are symptoms of pain that may be due to food packing or pulpitis with reversible symptoms, but the diagnosis is uncertain, a temporary dressing can be placed into the cavity and the patient reviewed 3–7 days later to check symptoms. Resolution of the symptoms at review will indicate that the pulpitis was reversible, and a Hall crown or suitable restoration can then be placed [5]. If symptoms do not resolve or worsen then extraction or pulpotomy should be considered [5]. If the tooth is close to exfoliation, consider applying a dressing. When deciding whether to undertake a pulpotomy or extract a tooth; If the child is anxious, and/or it is their first visit, gently remove gross debris from the cavity, and apply corticosteroid antibiotic paste under a temporary dressing. Ideally, if cooperation permits, open the pulp chamber under local anaesthesia and apply corticosteroid paste directly to the pulp, then place a dressing. Prescribe pain relief then carry out a pulpotomy or extract the tooth at a later date [5]. | AAPD (Pulp therapy for primary and immature permanent teeth) [12] SDCEP [5] | |
For multi-surface lesions, a stainless-steel crown is the restoration of choice. Amalgam or composite resin can provide a functional alternative when the primary tooth has a life span of two years or less [12]. | (AAPD, Pulp therapy for primary and immature permanent teeth) [12] | ||
Biocompatible material | Direct pulp caps are recommended using a biocompatible material or MTA [12, 14]. Bioactive materials can be used for remineralisation and pulp capping [14]. | AAPD (Pulp therapy for primary and immature permanent teeth) [12], AAPD (Paediatric Restorative Dentistry) [14] | |
Pulp Treatment | |||
Pulpotomy | Use MTA, formocresol, and tricalcium silicate in vital primary teeth with deep caries lesions treated with pulpotomy due to pulp exposure during carious dentin removal with the ultimate decision being clinical preference. Do not use calcium hydroxide (CaOH) in vital primary teeth with deep caries lesions treated with pulpotomy due to pulp exposure during carious dentin removal [17]. Where a radiograph shows no clear separation between the carious lesion and the dental pulp, it is likely that the carious lesion has encroached significantly on the dental pulp and a pulpotomy will be necessary. For a child in pain due to pulpitis in a vital primary tooth with irreversible symptoms and no evidence of dental abscess, consider carrying out a pulpotomy to preserve the tooth and to avoid the need for an extraction. If the child is cooperative, extract the tooth, even if the infection is asymptomatic [5]. | AAPD (Use of vital pulp therapies in primary teeth with deep caries lesions) [17] SDCEP [5] | |
Pulpectomy | Pulpectomy should be considered for non-vital primary teeth without preoperative root resorption and should be considered as preferable compared to lesion sterilisation tissue repair (LSTR) [10]. In exceptional circumstances if the tooth is restorable, consider a pulpectomy, which may require referral [5]. In some cases, local measures to bring infection under control may be appropriate. If the child is uncooperative refer to a specialist for treatment [5]. | AAPD (Use of Non-Vital Pulp Therapies in Primary Teeth) [10] SDCEP [5] | |