Treatment Planning for Caries in the Primary Dentition

Dental caries are a common disease in children, with 49% of 5-year-olds experiencing clinical decay1. It also affects children from lower-income families more severely, with a fifth of 5-year-olds who receive free school meals experiencing extensive tooth decay1.
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Treatment planning
Every treatment plan should be tailored to the individual patient’s needs and circumstances, and should always follow a comprehensive history and examination. Many children experience some level of dental anxiety and may have no experience of dental treatment, this should therefore be considered when creating a treatment plan.
The aim of treatment in primary dentition is to maintain teeth which are asymptomatic and free of pathology until exfoliation. 
A simple treatment plan may consist of several procedures and is often staged in order of increasing need of compliance, helping to acclimatise patients to treatment. The likely order of items on a possible treatment plan is shown below:
1. Emergency treatment/pain relief
2. Prevention:

Oral hygiene instruction
Diet advice
Fluoride varnish
Fissure sealants

3. Operative intervention:

Preformed metal crowns
Restorations
Pulpotomies
Extractions

Pain relief
Pain should be addressed as a priority to minimise the negative effects of dental pain and infection on children.
Management options for pain secondary to caries
Temporary dressing to prevent sensitivity and food packing. 
Removal of the source of pain and infection:

Extraction
Access the pulp and establish drainage through the root canal
Incision and drainage of any visible fluctuant swelling

Antibiotics may be prescribed where there are signs of systemic or spreading infection and local measures prove ineffective. Guidance on antibiotic prescribing in children can be found at SDCEP.org.uk.2

Prevention
Prevention is the key to managing caries in children, as any restorative intervention will not be successful without it. It is also important for children to adopt good habits as they move into the permanent dentition.
Prevention should be given following ‘Delivering Better Oral Health‘ guidance3
Prevention consists of four key principles:

Diet
Oral hygiene
Fluoride
Fissure sealants

Diet advice
Examination and treatment appointments are good opportunities to discuss diet and provide appropriate advice.

All children

Reduce the frequency and the amount of sugary food/drink
Keep sugar intake to mealtimes
Use sugar-free medicine
Only water to drink after brushing teeth at night

Children <3 years
Children over 3 years
High school-age children

Advise breastfeeding for babies where possible
Free flow cups introduced from 6 months
Discourage bottle use from 1 year

Investigate diet for high caries risk patients
Advise on hidden sugars and a balanced diet

May require closer monitoring as they gain more freedom with their dietary choices

Table 1. Diet advice for children, based on Delivering Better Oral Health guidance3
Oral hygiene advice
All children should brush twice daily with a fluoridated toothpaste, and should be encouraged to ‘spit don’t rinse’.
Low-risk children <3 years:

1,000 ppm fluoride toothpaste
Use a smear
Brushing should be performed and/or supervised by a parent or carer

Low-risk children 3-6 years:

1,000-1,500 ppm fluoride toothpaste
Use a pea-sized amount
Brushing should be supervised by a parent or carer

Low-risk children 7+ years:

1,350 – 1,500 ppm fluoride toothpaste
Adult amount
Child can perform toothbrushing

For high-risk children of any age who give concern and may be likely to develop caries:

1,350 – 1,500 ppm fluoride toothpaste
Commence professional interventions such as fluoride varnish, prescription-only fluoride sources, and reducing the recall interval

Professional fluoride intervention
In addition to the use of shop-bought fluoridated toothpaste, there are several additional fluoride interventions that can be prescribed or applied by a suitably trained dental care professional.
Fluoride varnish
2.2% fluoride varnish should be applied twice a year for all children.
This can be increased up to every 3 months for high caries risk children.
For children with severe asthma or multiple allergies, the colophony in fluoride varnish can precipitate adverse reactions – alternative colophony-free varnishes are available.
Fluoride prescriptions
High fluoride toothpaste:

2,800ppm (0.619%) fluoride can be prescribed from age 10
5,000ppm (1.1%) fluoride can be prescribed from age 16

Mouth rinse:

Fluoride mouthwash can be prescribed from age 8
Concentrations available are 0.05% fluoride daily or 0.2% fluoride weekly (nb. a daily routine may be easier to stick to than a weekly routine)

Fissure sealants
Why fissure seal?
Fissure sealants prevent caries by sealing pits and fissures to aid brushing and avoid plaque stagnation.
They provide a a simple, non-invasive introduction to dentistry for anxious children.
What to fissure seal?
Fissure seals can be used for:

Occlusal and buccal/palatal fissures of first permanent molars as soon as possible after eruption (SDCEP 2018)4
Occlusal and buccal/palatal fissures of second permanent molars in high-risk children
Cingulum pits which can be present on some lateral incisors

Material choice for sealants
Resin-based:

Tooth coloured or colourless
Strong bond to enamel
Requires excellent moisture control and good cooperation 

Glass ionomer based sealant:

Often not tooth coloured
Less moisture/technique sensitive so preferable in anxious/less cooperative children
Potential to act as a fluoride reservoir

Caries management
Reasons for restoring caries
There are many reasons to restore caries in children which are discussed below.
Avoidance of pain and infection
Pain and dental infections in children can result in:

Time off school
Sleep problems
Difficulty eating
Difficulties with concentration and social interaction
Growth impairment (typically associated with excessive caries)

Improved tooth survival
Carious teeth which are filled have a better survival to exfoliation than those that don’t, irrespective of fluoride use.5
Avoidance of extraction due to pain or infection
Avoiding extractions is beneficial for a wide number of reasons including: 

Preservation of aesthetics 
Preservation of dental function
Space maintenance and fewer adverse effects on developing dentition

Management options
The choice of management will depend on several factors including:

Anterior or posterior tooth
Depth of caries
Chance of pulpal involvement
Cooperation and compliance of the patient

Caries in anterior primary teeth
Primary incisor teeth usually exfoliate between ages 5-7.
Excellent oral hygiene, diet and professional fluoride varnish application is often sufficient to prevent caries progressing until exfoliation.
Primary canines do not exfoliate until around age 9-11 and so may require restoration. 
In these cases, caries removal and placement of a composite restoration may be indicated.
Caries with no pulpal involvement in primary molars
There are two primary options for the uncomplicated restoration of caries:

Conventional restoration with composite, local anaesthetic and rubber dam where indicated
Biological therapy; this generally involves the use of preformed metal crowns (PMC).

A novel technique which may become more prevalent in the future is silver diamine fluoride (SDF):8

SDF is an emerging technique in the management of caries.
It is a colourless, odourless liquid with both antibacterial and remineralising properties.
SDF can be applied to carious lesions to arrest them with the view to either providing a permanent solution (restoration or extraction) once compliance has improved or as a way of preventing symptoms until the time that the tooth exfoliates.
In the era of COVID-19, it also has the advantage of being a non-aerosol-generating procedure.
SDF has some disadvantages, including severe black staining of the lesion and the need for the lesion to be cleansable (this may mean removing enamel with either an air rotor or excavator), which requires compliance from the patient and may generate aerosol.
Not currently licensed for use in the treatment of caries in the UK and so GMC guidelines on off-label use should be followed if clinicians choose to use it for this purpose.9 Further reference should be made to the standard operating procedures available on the British Society of Paediatric Dentistry website.10

Choosing between composite and a preformed metal crown
Either intervention should only be used in the following circumstances:

Asymptomatic (no pain, no swelling or sinus)
No radiographic evidence of pulpal involvement or interradicular pathology
Small carious lesions only – loss of no more than ⅓ of the marginal ridge. Any more indicates likely pulpal involvement due to large pulp horns of primary teeth11

The decision to use a biological approach for the treatment of caries in primary molars should be made using clinical examination in conjunction with radiological examination.
Choosing a restorative technique: restoring caries with either a good quality composite or biological therapy (generally preformed metal crown (Hall technique) will improve Oral Health-Related Quality of Life (OHRQoL).12
Conventional composite restorations (when placed with optimal technique and moisture control) and preformed metal crowns (Hall technique) are equally effective, however:13

A good quality composite requires compliance with caries removal, often local anaesthetic and a rubber dam. Understandably many young children find this hard to tolerate.
In anxious or less cooperative children, a Hall technique crown will be preferable over a poor quality composite.
Preformed metal crowns can cause less discomfort due to the lack of need for local anaesthetic or caries removal and are generally preferred by parents and children.
There may be concerns about the appearance of preformed metal crowns. Consider terminology such as ‘pirate teeth’ or ‘princess crowns’ in treatment planning to aid acceptance of what is an easy and effective treatment, and one which is generally preferred by parents and children over a conventional restoration.14

 
Composite
Preformed metal crown

Level of cooperation needed
High
Low

Level of moisture control required
High. Rubber dam should be applied where possible
Low

Local anaesthetic needed?
Ideally for complete caries removal
No

Aesthetic result
Good
Poor (but this should not be a primary concern)

Table 2. Considerations for composite vs preformed metal crown restorative techniques

Teeth with pulpal involvement 
Signs which may indicate significant pulpal inflammation in primary teeth:15

Sinus (nb. interradicular abscesses may drain through the gingival margin rather than through a sinus in the mucosa)
Swelling (either intra or extra-oral)
Radiographic pathology: the anatomy of primary teeth (notably the thin pulp chamber floor) means this often presents as interradicular radiolucency at the bifurcation.
Pain which is spontaneous, severe or requires analgesia use.
Radiographically visible deep caries.
Extensive cavitation and loss of more than 1/3 of the marginal ridge. In these cases, it is very likely that there is pulpal inflammation.16

Treatment options
Treatment options for teeth with pulpal involvement include:

Indirect pulp cap (IPC): removal of infected caries leaving the deeper caries in place to avoid exposure of the pulp. This gives the uninflamed/reversibly inflamed pulp a chance to heal.
Pulpotomy: removal of coronal pulp, leaving the healthy or reversibly inflamed radicular pulp.
Pulpectomy: removal of all coronal and radicular pulp. This is a complex procedure requiring a specialist and is rarely used in routine cases.
Extraction

Pulpotomy
In many cases, a pulpotomy would be the ideal treatment of an asymptomatic, deep carious lesion. There is also evidence that indirect pulp caps have a similar or higher rate of success and are a viable biological alternative to a vital pulpotomy, requiring less tissue removal. The indications for both procedures are the same.17
However, in many cases, there are contraindications to this procedure and an extraction may be preferable:

Pre-cooperative/anxious patients
Symptomatic teeth 
Any sign of infection, sinus or swelling
Multiple teeth requiring pulp therapy (in these cases extraction is likely to be a more efficient treatment)
Less than 2/3 root length remaining
Unrestorable teeth
Signs of internal resorption
Immunocompromised children or those with medical conditions (e.g. congenital heart defects). These children may be more at risk from sepsis or endocarditis than from any residual infection and the infectious focus should be removed altogether. 

Advantages of pulpotomy/IPC vs extraction

Pulpotomy/IPC
Extraction

Space maintenance
Less risk of residual infection remaining

Less unwanted movement of adjacent teeth
Multiple procedures can be completed under general anaesthetic in anxious/less compliant patients

Avoidance of extractions which may require GA
Quicker, simpler procedure

Promotes a healthy attitude to dental health
 

Retaining tooth may improve aesthetics and function
 

Useful if extractions need to be avoided (e.g. in patients with medical contraindications or hypodontia of permanent teeth)
 

Maintains space and prevent unwanted movement of permanent teeth which may require future orthodontics
 

Table 3. Considerations when thinking about pulpotomy or indirect pulp capping vs extraction in primary teeth
Extractions
Where extraction of primary teeth is determined the best treatment option, there are three main anaesthetic and behavioural management options:

Local anaesthetic (LA)
Inhalation sedation (RA)
General anaesthetic (GA)

A brief summary of the indications/contraindications of each can be found below. This is a guide and each case should always be considered individually.

Local anaesthetic

Inhalation sedation

General anaesthetic

+

+

+

Cooperative children

Needle phobia
 

Mild to moderate anxiety
 

Children unable to breathe through the nose
 

Pre-cooperative patients
 
 

Medical contraindication
 

Small number of, simple extractions
 

Dental anxiety
 

Strong gag reflex
 

Severe anxiety
 

Multiple extractions
 

Risks outweigh benefits (e.g. extractions for orthodontic benefit only)
 

Medical contra-indication to RA or GA
 

Very little past treatment experience
 

Conditions aggravated by stress (asthma or epilepsy)
 

Where an escort is not available
 

Severe anxiety
 

Patients who can cope with treatment without GA

 

Multiple or complicated extractions
 

Avoidance of GA in some medical conditions which carry a higher risk
 

Medical contraindication (e.g. myasthenia gravis)
 

Surgical extractions

 

 

 

 

Recent eye surgery
 

 

 

Table 4. Advantages and disadvantages of anaesthetic and sedation techniques
Considerations for extractions under general anaesthesia
General anaesthetic carries a fatality risk of around 1:40,00018and children can experience several unpleasant side effects such as:

Nausea
Dizziness
Pain
Tiredness

Any treatment plan requiring extractions under a general anaesthetic should always be carried out by a specialist and should be planned to minimise the risk of a foreseeable repeat anaesthetic. Some examples of ways in which this approach can be achieved are discussed below.
More radical treatment plans:

Any teeth with a doubtful prognosis, even if potentially manageable with PMC or pulpotomies, will likely be extracted to avoid a repeat procedure

Planning GA as the last item on a treatment plan:

If caries is intended to be managed with restorations or PMC’s, this should be done prior to GA in case compliance becomes an issue and the tooth requires extraction
There should be NO unmanaged caries remaining immediately after a GA procedure

Radiographs:

This will allow planning for the management of ALL carious lesions.
If there is clinical caries warranting extraction there are likely to be other lesions which are not clinically visible.

Orthodontic opinion:

This is not required for all GA procedures. However, it may be useful where balancing/compensating extractions are being considered, or where the first permanent molars are of poor prognosis.

Editor
Dr Lucy Alderson

Reviewer
Dr Deborah Denton
Senior Dental Officer
Rotherham NHS Foundation Trust

References

Children’s Dental Health Survey Executive Summary England, Wales and Northern Ireland (2013) Pages 2-4.
Scottish Dental Clinical Effectiveness Programme (2016) Drug prescribing in Dentistry 3rd Edition.
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Scottish Dental Clinical Effectiveness Programm (2018) Prevention and Management of Dental Caries in Children.
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