26 Minimal Interventional Treatment of Caries in Young Children: Clinical Cases
Case 1: A 6-Year-Old Boy with High Caries Risk
Age: 6 years
First visit: June 2010
Last visit: September 2010
Follow-up visit: May 2011
The patient came to the pediatric dental clinic for his first ever visit to the dentist. Both he and his mother were aware of the presence of cavitated caries lesions in the primary teeth and wanted to have them treated. According to his mother the patient had been complaining of tooth pain earlier, but felt no pain at the moment. No relevant general medical information was reported by the mother.
Clinical Findings (Tooth Level)
Oral examination revealed a mixed dentition with lower permanent central incisors and one upper permanent first molar already having erupted. The mucosa was healthy, the gingiva was inflamed, but no signs of periodontitis could be observed ( Fig. 26.1 ). Frank cavities could easily be detected in the upper primary molars.
Caries detection was based on visual–tactile examination combined with bitewing radiographs ( Fig. 26.2 ). For extensively carious teeth, radiographs depicting the periapical area were taken to support an eventual treatment decision regarding pulp therapy or extraction ( Fig. 26.3 ).
Tooth surfaces must be cleaned before caries assessment; otherwise initial caries lesions will not be detected. It does not matter whether the dental biofilm is removed with a rotating instrument or toothbrush. However, if the dental professional uses the toothbrush, it is possible to combine plaque removal with oral hygiene instructions to the patient/parents and to show them how the toothbrush can be as effective as the “professional rotating instrument.”
All primary molars were affected by active caries lesions at different levels of severity. Extensive cavitated caries lesions were clearly visible (ICDAS 6) in the upper primary molars ( Fig. 26.1a ). Tooth 55 was the most severely affected; only roots remained in the mouth. In the lower primary molars, approximal caries lesions were detected radiographically ( Fig. 26.2a, b ). An active noncavitated caries lesion (ICDAS 1) was detected in the occlusal surface of the upper permanent first molar. Only the anterior teeth were not affected by caries lesions. The d1ft count was 8 and the D1MFT was 1. Detailed information about each tooth surface is available in the dental examination scheme ( Fig. 26.4 ).
Caries Risk Assessment (Individual Level)
Caries risk assessment is based on the evaluation of a series of factors at the individual level, which may influence oral health positively or negatively (see Chapter 7).
Regarding the dietary habits, high and regular consumption of sweetened food and beverages from four to five times daily was reported by the mother. When asked about the frequency of consumption of drinking water, the mother informed us that the child almost never drinks water, but sweetened beverages like juice, tea, or soda. The family had access to fluoridated water and the child brushed his teeth with fluoridated toothpaste usually twice daily. Dental floss had never been used and tooth brushing was not assisted by an adult. Visible dental biofilm was present in 53% of the approximal sites, specifically at those with an adjacent tooth and an intact contact point. Dental plaque was assessed visually with no disclosing solution. If the dental plaque was not visible in the entrance of the approximal area, a probe was used to confirm the presence or the absence of approximal plaque. The occlusal surface of the permanent first molar was covered by thick biofilm.
Although disclosing solution may be helpful to show the dental plaque to the patient, thick plaque is easily visualized without it. Thick/mature dental biofilm is what the patient has to avoid. If only thin biofilm is detected, it means that the patient is able to control plaque acceptably.
The high caries experience (d1ft + D1MFT = 9), the cariogenic dietary habits, and the presence of a considerable amount of visible biofilm were relevant risk factors in the present case. However, the patient had regular access to fluoride sources (fluoridated water and fluoride toothpaste), did not use any medications, and had normal salivary flow. As a result, he was classified as being medium risk at present (53%), but this would have been higher in previous years.
Diagnosis and Treatment Plan
Based on the minimum interventional treatment concept, the treatment plan was focused on the prevention and arrest of caries, preserving dental tissues as much as possible. After a comprehensive examination and the caries risk assessment, treatment strategies were planned at two levels: the individual level and the tooth/surface level.
Oral Hygiene and Fluoride
The parents were instructed to have their son′s teeth brushed twice a day with regular fluoride toothpaste (1000–1500 ppm F–) and flossed once a day. As the child had access to fluoridated water, no other home-use fluoride product was prescribed. As the patient had active caries lesions, topical application of fluoride gel was recommended on a weekly basis. The mother was asked to help the child with tooth brushing once daily to ensure proper plaque control at least once a day, emphasizing that the quality of cleaning is more important than the frequency.
Instead of advising that parents should brush their child′s teeth before bedtime, let parents decide the best time of the day for them to do it. Explain how important it is to disorganize the dental biofilm once a day, and that a child needs help to do it properly. The chance of a good compliance is increased when the decisions are shared with parents.
Oral hygiene instructions were focused on two main aspects: plaque control in the occlusal surface of the erupting permanent first molar, and flossing the lower primary molars. The mother was shown how to reach the permanent first molar better by positioning the toothbrush transversally to the tooth. At the first visit, the child presented only one permanent first molar, but at the end of the treatment phase one more had partially erupted. The mother was instructed to brush the permanent molars first and then brush the other teeth.
Give clear oral hygiene instructions and prioritize what is most important for each case. Dental professionals usually say to the patient/parents, in a generic way, that tooth cleaning should be improved. Be specific: concentrate your explanation on the most important needs. Suggest that tooth cleaning should begin with tooth surfaces at risk of caries development or progression, that is, occlusal surfaces of permanent first molars partially erupted or tooth surfaces with initial enamel caries lesions.
The approximal caries lesions in the lower primary molars visualized on the radiographs were shown to the mother to emphasize the importance of daily flossing. It was mentioned that the extensive caries lesions in the upper teeth clearly started as approximal lesions and that flossing would help to avoid the progression of the noncavitated approximal caries lesions in the lower teeth.
Show the tooth surfaces with thick biofilm to the patient/parents. Show the difference between a clean and a dirty tooth surface. Encourage the patient to feel with his or her tongue the smoothness of a clean tooth surface in comparison to the roughness of a dirty one. These are simple and practical ways to make patients able to check the quality of their own tooth cleaning at home.
Dietary Counseling The influence of high frequency of sugar consumption on the cariogenic potential of the dental biofilm was explained to the mother.
Explain the association between sugar and dental biofilm with easy and clear words. Patients are usually advised to eat less sugar, because it causes caries. But this association is often not clearly explained. Encourage the patient to perceive in his or her own teeth how dental plaque will be thicker in the end of a day full of sugar, in comparison to another day when much less sugar was consumed.
The patient was instructed to reduce the consumption of sweetened food and beverages, particularly during the weekdays. It was emphasized that water should always be the first choice to relieve thirstiness instead of sweetened beverages.
Suggest some deals between parents and children like: “always have a glass of water before any other beverage.”
Diagnoses and treatment decisions are summarized in Table 26.1 . To eliminate plaque stagnation areas, the cavity on the distal surface of tooth 54 was temporarily filled with glass-ionomer cement and extractions were planned to be done at the beginning of the treatment.
Due to Caries progressiva profunda, teeth 55, 65, and 64 were extracted ( Fig. 26.5 ). Tooth 55 had only roots remaining and teeth 65 and 64 were extensively affected by caries with advanced root resorption, contraindicating pulp therapy. Due to advanced coronal destruction of tooth 55, tooth 16 had drifted mesially, causing loss of space in the arch. As it was necessary to regain space before placing a space maintainer, the patient was referred to the orthodontic clinic after the end of the treatment.
In the lower left side, noncavitated caries lesions were detected radiographically in the distal surface of tooth 74 and in the mesial surface of tooth 75, scored as D1 and E2, respectively (see Fig. 26.2b ). These lesions were considered as being progressive, although activity could only be affirmed by the local plaque level (no gingival bleeding, other assessments not feasible). Nonetheless, owing to the generally high caries risk, both caries lesions were treated by the infiltration technique ( Fig. 26.6 ).
In the lower right side the caries lesion at the distal surface of tooth 84 was cavitated (clearly detectable on the bitewing radiograph) and considered as being active (Caries progressiva media). The mesial surface of tooth 85 had a caries lesion scored radiographically as E2 ( Fig. 26.2a ). On tooth 84, caries was accessed by a vertical slot and the resulting cavity was filled with composite ( Fig. 26.7 ). During invasive treatment, cavity and activity status of 85 mesial was assessed thoroughly ( Fig. 26.7b ). The lesion was diagnosed as Caries progressiva superficialis that was not supposed to be hampered in progression by noninvasive measures only and thus was treated by the infiltration technique (alternatively sealing) ( Fig. 26.7c–e ).
When approximal caries lesions extend into dentin the probability of further progression is rather high. This fact supported the decision of infiltrating the approximal caries lesions of the distal surface of tooth 74, scored radiographically as D1. The approximal lesions of both 75 and 85 mesial were scored as E2. The decision for infiltrating these lesions was based on the fact that the patient had advanced caries lesions in many other approximal surfaces and relevant risk factors for caries progression were recorded during caries risk assessment.
On tooth 54 the temporary glass-ionomer was removed with a bur and caries removal in dentin was completed manually ( Fig. 26.8 ). In the same session a fissure sealant was applied onto the occlusal surface of tooth 16 ( Fig. 26.9 ), which presented an active noncavitated caries lesion scored as ICDAS 1 (more clearly visible in the distal fissure). The decision for sealing this occlusal surface was based not only on the presence of general risk factors for caries progression, but also because the surface was persistently covered by dental biofilm. As the lower permanent first molar was not erupted, the occlusal surface of the antagonist would remain without masticatory attrition and therefore susceptible to plaque stagnation for a considerable period of time. Due to the low compliance with brushing in the past, the fissure was referred to sealing rather than cross brushing or fluoridation only.
Clinical Aspect at the End of the Treatment (Fig. 26.10)
Ten months after the end of the treatment no clinical signs of new caries lesions were detected. Instructions for oral hygiene were reinforced, emphasizing the importance of cleaning the occlusal surface of the permanent first molars, with their being partially erupted. Follow-up radiographs were obtained to monitor the infiltrated approximal lesions after 10 months. No caries progression was detected ( Fig. 26.11 ). Regarding the management of space loss in the upper arch, the patient continued to be under the surveillance of the orthodontic clinic. The orthodontist was waiting for the upper permanent molars to erupt more, before inserting any orthodontic appliance.
Case 2: A 7-Year-Old Girl with Medium Caries Risk
Age: 7 years old
First visit: August 2010
Last visit: September 2010
Follow-up visit: June 2011
The patient came to the pediatric dental clinic for a routine visit. She first visited the dentist when she was 4 years old, and at that time had some of her primary molars filled under local anesthesia. She has never experienced tooth pain. Her last visit to the dentist was 2 years ago when a dental examination and a topical fluoride gel application were performed. Dental radiographs had never been performed. No relevant general medical information was reported by the mother.
Clinical Findings (Tooth Level)
Oral examination showed mixed dentition, with the permanent first molars and the permanent central incisors partially erupted and healthy soft tissues ( Fig. 26.12 ).
Caries detection was based on visual–tactile examination complemented by bitewing radiographs. Clinically, the distal surface of tooth 84 revealed a cavity (ICDAS 5). For the distal and mesial surfaces of tooth 85 and the distal surface of tooth 74, approximal caries lesions were detected radiographically ( Fig. 26.13 ). Tooth 85 had an enamel lesion scored as E1 in both the mesial and distal surfaces. Tooth 74 distal showed a dentinal lesion (D1).
The occlusal surfaces of the primary first molars (54, 64, 74, 84) had been restored with composite when the child was 4 years old. The primary second molars (55, 65, 75, 85) had occlusal fissure sealant. The permanent first molars showed no signs of early caries lesions. The lower permanent first molars were almost fully erupted, but the upper ones were partially erupted. The d1ft count was 5 and D1MFT was 0 ( Fig. 26.14 ).
Caries Risk Assessment (Individual Level)
Medium consumption of sweetened food (up to three times a day) and low consumption of sweetened beverages was reported by the mother. Visible dental biofilm was present in 56% of the approximal sites and on the occlusal surfaces of the erupting permanent first molars ( Fig. 26.15 ). For the API index, the plaque was assessed visually in the approximal sites without using disclosing dye. When there was no visible plaque in the entrance of the approximal site, a probe was used to confirm the absence/presence of plaque.
The family had access to fluoridated water and the child usually had her teeth brushed with fluoride toothpaste three times a day. Tooth brushing before bedtime was assisted by the mother occasionally. Dental floss had never been used. Although the patient had a relatively high caries experience (d1ft = 5), other risk factors such as sugar consumption were less severe. Besides, she had regular access to fluoride sources, did not use any medications, and had normal salivary flow. According to the current status the patient was classified as low-to-medium risk (33%), but had been at higher risk for caries in earlier years.