BY

DR.FAMUREWA B.A.
O.A.U.T.H.C., ILE-IFE NIGERIA.

INTRODUCTION
AETIOPATHOGENESIS
METHODS OF DIAGNOSIS
CARIES RISK ASSESSMENT
TREAMENT TECHNIQUES
CONCLUSION

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TREATMENT TECHNIQUES;
NON-OPERATIVE/PREVENTIVE THERAPY
CONVENTIONAL RESTORATIVE
TREATMENT
ATRAUMATIC RESTORATIVE TREATMENT
CHEMOMECHANICAL APPROACH
HALL TECHNIQUE

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Dental caries with its sequelae is the most common

clinical entity presenting to a paediatric dental
practice

Dental caries is defined as localized, post-eruptive,

pathological process of external origin involving
softening of hard tooth tissue & proceeding to the
formation of cavity(WHO)

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This seminar focuses on the management of

established caries(cavitated & non cavitated) in
primary dentition.

Emphasis is not on various time tested and

emerging novel preventive
approaches(replacement therapy, caries vaccine).

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Dental caries is a multifactorial disease.

Aetiological factors:
Dental plaque- Streptococcus mutans(initiation&
cavitation), Lactobacilli
Substrates- fermentable carbohydrate
Host factors-tooth morphology, salivary flow
rate
Time- frequency of cariogenic challenges

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Caries occur when oral environment favours

demineralization.
Caries is revesible to an extent!(remineralization)

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Prerequisite for caries diagnosis:

Good lighting
Clean teeth
Sharp eyes
Reproducible bitewing radiographs

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Visual method- Mouth mirror & blunt/ball

ended probe
Non cavitated appear as :
Caries seen as white spot-dry teeth(in superficial
depth of enamel)
Glossy white spot- arrested caries
Matt white spot- active caries
Brown/white spot- wet teeth(caries in enamel &
may be in dentine)

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Cavitated lesions- usually active, may expose

dentine or pulp

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Tactile method
Blunt ended probe- confirms the presence of
cavities, restoration & sealants
Sharp probes are contraindicated- sticky
probe(probe fits fissure), breaks down weak
demineralized enamel(iatrogenic cavity!!),
inoculation of caries free sites

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Radiographic method
Bitewing radiographs-1st choice for caries detection
Periapical radiographs
For detection & progress monitoring

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Fibre-optic trans illumination(FOTI)

Placement of a 0.5mm light source in the
embrasure of posterior teeth. Carious lesion shows
as dark shadow

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Temporary tooth separation-approximal caries

Use of orthodontic separators
interdentally(posterior teeth)- patient is reexamined later in five days time

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Laser fluorescence device

This measures the fluorescence of tooth & that of
the bi-product of bacteria in the carious lesion.
This produces a digital reading indicating the
carious status of teeth. Example is Diagnodent

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Electronic caries meter

Measures resistance of carious lesions & compares
this to that of sound tooth structure

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Family & social history

.

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NON-OPERATIVE/PREVENTIVE
THERAPY
CONVENTIONAL RESTORATIVE
TREATMENT
ATRAUMATIC RESTORATIVE
TREATMENT
CHEMOMECHANICAL APPROACH
HALL TECHNIQUE

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To cure/heal incipient caries(white lesions)

To arrest caries progression
Suitable for high risk children.
Four pillars of caries prevention:
1. Diet modification
2. Fluorides
3. Fissure sealants
4. Plaque control

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Diet modification
o Dietary history & dietary chart very important
o Frequency of intake NOT quantity
o Discourage grazing or snacking btw meals
o Frequent intake of carbonated drinkscariogenic & erosive
o Intake of sweet drinks, use of pacifier-nursing
bottle caries

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Diet modification
o Positive alternatives should be provided;
coconut, groundnut, sugar free chewing
gum(Orbit)
o Use of sugar free medications by medically
compromised children

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Fluorides
Systemic & topical applications
Mechanisms of action in caries prevention;
1. Inhibition of demineralization(fluorapatite)
2.
inhibition of plaque bacteria(enolase).
3. Enamel more stable & resistant to acid

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Fissure sealants
Fissure & pits are prone to caries
Light cure & self cure resin(bis-GMA)
GIC can be used as temporary sealants(anxious
child)

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Guidelines for fissure sealants

application(British Society of Paediatric
Dentistry 2000):
Patient selection
1. Children with special needs- apply on occlusal
surfaces of 2 teeth
2. Children with extensive caries in their 1
dentition
3. Children with no caries in 1 dention- no need
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Tooth selection
1. Occlusal surface of 2 molar teeth; can be
applied on cingulum pits(upper incisors),
buccal pits(lower molars), palatal pits(upper
molars)
2. Sealants to be applied ASAP(good moisture
control)

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Tooth selection:
3. Any child with caries on 1st 2 molar should have
the fissures of unaffected of the 1st 2 molars sealed
4. Occlusal caries affecting one/more 1st 2 molars
indcate a need to fissure seal the 2nd 2 molars as
soon as they erupt

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Plaque control
Toothbrushing- supervised, twice daily
Flossing- starting from early mixed dentition
Prophylaxis- Scaling & Polishing
Antimicrobial agents- adjuncts to mechanical
plaque removal. Indicated in high caries
children & medically compromised child

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Materials used in Paediatric Dentistry:

Dental amalgam
Merits: simple, quick, cheap, durable & technique
insensitive
Demerits: not adhesive, need for mechanical
retention, environmental & occupational hazards
& public concern

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Composite resin
Merits: aesthetics, adhesive, command set,
reasonable wear property
Demerits: technique sensitive, expensive, need
moisture control

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Glass ionomer cement(GIC)-Aluminosilicate

powder+ polyalkenoic acid
Merits: adhesive, aesthetic, fluoride leaching
Demerits: long setting time, brittle, prone to
erosion & wear, radiolucent.

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Resin modified glass ionomer cement(RMGIC)

Merits: adhesive, simple to handle, command set,
aesthetic
Demerits: water absorption, some are radiolucent.
Polyacid modified composite resin(compomer)
Merits: radiopaque + above; Demerit- as above

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Stainless steel crowns

Merits: durable, protect & support residual tooth
structure
Demerits: tooth prep, patient cooperation &
unsightly
Indications & containdications

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Factors affecting choice of materials:

Age of patient- ability to cooperate & durability
Caries risk: SS crown(in risk) than composite
Level of childs cooperation

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ART Technique involves the use of hand

instrument only to remove carious lesions &
restoration of the cavity with sealing any adjacent
fissures using conventional GIC
Minimally invasive procedure- pain free &
acceptable to children

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Chemomechanical caries removal (CMCR) is a non

invasive technique eliminating infected dentine via
chemical agents aided by atraumatic mechanical
force.
Restoration of cavities is done with composite
resins or GIC
CMCR preserves healthy dental tissues, avoids
pulpal irritation(& exposure) & childs discomfort

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CMCR agents:
N-monochloroglycine(NMG)= GK 101(1972)
N-monochloroaminobutyric acid= Caridex(75)
Carisolv- developed in Sweden in 1998.
Has 2 components:
3 amino acids(glutamic acid, leucine & lysine)
+NaOH
Na hypochlorite

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Papacarie developed in 2003(Brazil)

Papacarie contains:
o Papain-extracted from leaves & fruits of Carica
papaya. Acts by cleaving collagen molecules
partially destroyed by caries(tissues that lack
protease inhibitor, -1-antitrypsin)
o Chloramine =Chlorine+ NH
Chemically softens carious dentine; bactericidal

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Toluidine blue- a photosensitive pigment that

fixes into the bacterial membrane
Found to be effective against S. mutans
Procedure
Carisolv gel is applied on the carious lesion
Remove carious dentine after 30sec
Cavity to be restored with adhesive restorative
material
o

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Merits: no need of L.A, ultraconservation of sound

tooth, risk of iatrogenic pulp exposure, precludes
anxiety associated with drilling, no droplet
infection(from aerosol)
Indications: dentally anxious patient, medically
compromised child, physically handicapped child,
patient with infectious air-borne diseases(TB)

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Developed by Dr. Norna Hall in 2006

sealing in caries technique in 1 dentition
The technique involves seating preformed metal
crown(SS Crown) over carious 1 molars with no
caries removal, tooth prep & local anaesthesia
Hall technique was acceptable to
patients(children), carer(parents/guardians) &
treating dentists

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Contraindications
Irreversible pulpitis
Dentoalveolar abscess
Presence of buccal sinus
Non physiological tooth mobility
Insufficient sound tooth tissue to retain crown
Interradicular pathology/ furcation
involvement

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Contraindications
Uncooperative child- to allow for crown
placement without risk of aspiration
Child @ risk of bacterial endocarditis- manage
tooth with traditional restoration.
Tooth near physiologic exfoliation
Where aesthetic is of concern to child/ parent

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Indications :
Early to moderate proximal caries in 1 molars
Active caries in 1 molars with no sign &
symptoms of pulp pathology
Moderately advanced class I caries- no good
seal ffg conventional caries removal &
restoration with adhesive material

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Indications :
Non cavitated class I lesion- if patient is unable
to accept fissure sealant or conventional
restoration
Cavitated class I lesion- if patient is unable to
accept partial caries removal technique or
conventional restoration

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Explain the procedure to the child

o Let the child handle a spare crown
o Crown as- shiny helmet, Princess crown
Tell the child that:
o He/she will help by biting the crown into place
o Cement wont taste nice & can like salt or
vinegar crisps
o

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Armamentarium
Mouth mirror
Straight probe- to remove separators(if used)
Excavator- to remove crown if necessary &
used to remove cement
Flat plastic- to load crown with cement
Cotton wool rolls- for child to bite on & push
crown over tooth; to wipe away excess cement

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Armamentarium

Orthodontic biting stick- can be used in seating

crown.
Band forming pliers- for adjusting crowns.
Adams plier can be used for this purpose.
Gauze- to protect airway & wipe off excess
cement

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Protecting the airway

o Sit the child upright or
o Use gauze swab- place btw the tooth & tongue
with extension to oropharynx.
Alternatively,
o Use elastoplast tape to secure the crown

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Stages of fitting the crown:

Size
Aim to fit the smallest size of crown which will
seat
Select the crown which covers all the cusps &
approaches all the contact points with spring
back feeling.

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Fill- preparing the crown for cementation

Dry the crown & fill with GIC luting cement(no
air inclusion)
Dry the tooth before cementation
If cavity is large, place some cement prior to
crown placement.

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Locate & seat- fitting the crown

Place the crown over the tooth
Seat the crown either by finger pressure or the
child seats it by biting on it

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Wipe
Remove excess cement as soon as the crown is
seated

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Seat further
Once youre satisfied with the position of the
crown, instruct the patient to keep biting on the
gauze placed between the teeth

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Check & clean

Remove excess cement
Floss between the contact points

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The present advancement in knowledge of

cariology & overwhelming evidences of novel
techniques of caries management should lead to a
shift from Blacks dogma of caries mgt to a more
tooth conserving & child friendly approaches
especially in primary dentition.
Proper & timely management of caries in primary
teeth is advocated to prevent untoward
complications- premature tooth loss, facial
cellulitis, e.t.c
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A Users Manual of Hall technique by D. Evans & N.

Innes
Handbook of Paediatric Dentistry edited by Cameron
& Widmer
Paediatric Dentistry edited by Welbury & Duggal.
Pickards Manual of Operative Dentistry 8th Edition
Ganesh M, Parikh D(2011). Chemomechanical caries
removal agents: review & clinical applications in
primary teeth. J. Dent. Oral Hyg
Smales R.J. , Yip H(2000). The atraumatic restorative
treatment approach for primary teeth: review of
literature. Pediatr Dent 22:294-298.
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