Introduction

Paediatric dentistry relates to the care of young patients. It focuses on: preventive dental care; the diagnosis, treatment planning and delivery of care requiring non‐pharmacological behaviour management; management of dental trauma and its consequences; the management of patients with special needs and children that are medically compromised; management of dental anxiety with the use of sedation techniques; and comprehensive oral care for patients under general anaesthesia.

Children have a right to the enjoyment of the highest attainable standard of health, and to facilities for the treatment of illness and rehabilitation of health.

United Nations Convention on the Rights of the Child, Article 24

Management of dental caries includes assessment of the child’s caries risk, understanding of the disease process at an individual level, appropriate assessment of the disease process, managing where deemed suitable with targeted prevention and when necessary a restorative intervention. This chapter will focus on the restorative management of caries in the primary dentition as other chapters will cover the restorative management in the permanent dentition. Several of the techniques for restorative procedures in primary teeth are similar to those for the permanent dentition and these should always be kept in mind. The individual elements of the care plan are common to all forms of dentistry; however, it is of the utmost importance to treat the child and not the tooth.

There are a number of challenges that clinicians face when treating children. Despite these challenges, there are many reasons why time, effort and resources should be spent to manage this patient group successfully (Table 17.1).

The principle aims when providing dental care for paediatric patients include:

• Keeping the primary and permanent dentition free from dental disease.
• Applying targeted prevention plans based on the patient’s caries risk status and using best available evidence and guidance.
• Reducing the risk of the child experiencing pain and anxiety due to dental disease or from treatment provided.
• Managing caries in the primary dentition at an early stage using the best techniques available ensuring that the teeth exfoliate at the natural time without causing pain.
• Instilling a positive dental attitude towards dental care now and for the future.

Untreated dental decay in children has a significant impact on their lives (Table 17.2).

The decision to restore carious primary teeth is complex. There are a number of factors that must be considered which are usually out of the control of the patient. The assessment of the patient should include a comprehensive clinical examination (extra‐ and intraoral), visual detection and radiographic evaluation of the carious lesions (Figure 17.1). Very young children and those who are anxious about dental treatment may find a full dental assessment frightening and may not cope with the full range of required diagnostic procedures. Behaviour management and modifications in approach, including a gradual introduction, should overcome these barriers. To make this decision several factors (Figure 17.2) must be considered.

Radiographic Assessment

There must be sound clinical indications to justify the exposure of children to x‐rays to obtain dental radiographs, as they are particularly susceptible to the effects of ionising radiation. Careful clinical examination should indicate the most appropriate radiograph to confirm the diagnosis and previous radiographs should always be examined. The importance of radiographs in treatment cannot be overstated (Figure 17.3).

The benefits of bitewing radiographs include:

• Detection of caries that cannot otherwise be seen.
• The use of bitewing radiography, in addition to clinical examination, increases the number of interproximal lesions detected by a factor of between 2 and 8.
• Estimation of the extent of lesions.
• Monitoring of lesion progression (repeat radiographs, depending on the patient’s caries risk status).

The frequency and recall with regards to radiographic exposure is dependent on the risk status of the child. For all high caries risk individuals, bitewing radiographs should be taken at the initial examination and at 6‐monthly intervals until no new or active lesions are apparent and the individual has entered another risk category. A child with little or no caries activity does not require bitewing radiographs at every recall appointment. Children with low caries risk should be radiographed at approximately 12–18 month intervals in the primary dentition and at approximately 2‐year intervals in the permanent dentition.

Once the decision has been made to restore a tooth, the operator must remember the differences in the anatomy of primary and permanent teeth. There are several key anatomical differences which affect disease progression, cavity design and restorative choices. Having knowledge of these will help with successful outcomes and reduce failure of the restorative care provided (Table 17.3).

Care Planning

The care plan for the patient will be determined by a number of the factors mentioned previously. The motivation of the child and parent, the extent of decay, the age of the child, the likely survival of the primary tooth, with any associated symptoms, will dictate your plan.

With this information, a care plan and philosophy of preventative management can be formulated (Tables 17.4 and 17.5). It is essential for any restorative intervention that there is good pain control accompanied by good behaviour management (Table 17.6). Usually this involves quadrant dentistry, minimising the number of visits and the use of local anaesthetic, and building up treatment in stages of complexity while gaining the child’s trust and confidence. This can be achieved by starting off with a simple procedure (e.g. fissure sealants) then moving onto move complex treatment (e.g. composite restorations) and if possible leaving extractions to the end.

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Prevention of caries in children age 0–6yrs
	Advice to be given	EB	Professional intervention	EB
Children aged up to 3 years	Breast feeding provides the best nutrition for babies	I
	From 6 months of age infants should be introduced to drinking from a free‐flow cup, and from age 1 year feeding from a bottle should be discouraged	II
	Sugar should not be added to weaning foods or drinks	V
	Parents/carers should brush or supervise toothbrusing	I
	As soon as teeth erupt in the mouth brush them twice daily with a fluoridated toothpaste	I
	Brush last thing at night and on one other occasion	III
	Use fluoridated toothpaste containing no less than 1000 pm fluoride	I
	It is good practice to use only a smear of toothpaste
	The frequency and amount of sugary food and drinks should be reduced	III, I
	Sugar‐free medicines should be recommended	III
All children aged 3–6 years	Brush at least twice daily, with a fluoridated toothpaste	I III	Apply fluoride varnish to teeth two times a year (2.2% NaF‐)	I
	Brush last thing at night and at least on one other occasion
	Brushing should be supervised by a parent/acrer	I
	Use fluoridated toothpaste containing more than 1000 ppm fluoride It is good practice to use onfy a pea size amount	I
	Spit out after brushing and do not rinse, to maintain fluoride concentration levels	III
	The frequency and amount of sugary food and drinks should be reduced	III, I
	Sugar‐free medicines should be recommended	III
Children aged 0–6 giving concern [e.g., those likely to develop caries, those with special needs	All advice as above plus: Use fluoridated toothpaste containing 1350‐1500 ppm fluoride It is good practioe to use only a smear or pea size amount Where medication is given frequently or long term request thai it is sugar free, or used to minimise cariogenic effects	I	Apply fluoride varnish to teeth two or more times. a year (2.2%NaF‐) Reduce recall interval Investigate diet and assist adoption of good dietary practice in line with the eatwell plate Where medication is given frequently or long term, liaise with medical practitioner to request it is sugar free, or used to minimise cariogenic effects	I V I
Prevention of caries in children aged from 7 years and young adults
	Advice	EB	Professional intervention	EB
All patients	Brush at least twice daily, with a fluoridated toothpaste	I	Appy fluoride varnish to teeth two times a year (2.2% NaF‐)	I
	Brush last thing at night and at least on one other occasion	III, I
	Use fluoridated toothpaste (1350‐1500 ppm fluoride)	I
	Spit out after brushing and do not rinse, to maintain fluoride concentration levels	III
	The frequency and amount of sugary food and drinks should be reduced	III, I