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Dental Caries 1
Diagnosis, Risk Management, & Restoration
of Caries in Pediatric Dentistry
Ron Grothe, DDS, MS, MBA
Division of Pediatric Dentistry
University of Minnesota School of Dentistry
Objectives
(Textbook Chapters: 10, 16, 17,18)
Understand the caries process specific
to pediatric and medically-compromised
patients.
Understand rationale for prevention and
treatment of pediatric dental caries.
Understand the indications,
contraindications, and techniques for
pediatric dental restorations.
Modified Keyes Diagram
Stephan Curve
Diet and Caries
Dental Caries
Bacterial-induced tooth demineralization
or cavitation from imbalance between
protective factors and risk factors over
time. 2
Dental Caries
Most common chronic pediatric disease
(5X more children than asthma).
Most common oral health concern for children.
Infectious, communicable, multifactorial, chronic.
Initial acquisition of cariogenic bacteria from
primary caregiver.
Preventable.
Reversible in early stages.
Cure depends on patient compliance.
Untreated Caries by Age - NHANES
(National Health and Nutrition Survey Examination)
0
10
20
30
40
50
60
1971-1974
1988-1994
1999-2002
2-5 years
6-17 years
2-5 Year Olds with Untreated
Caries by Poverty Status (NHANES)
(National Health and Nutrition Survey Examination)
0
5
10
15
20
25
30
35
1971-
1974
1988-
1994
1999-
2002
Poor
Near
Poor
Non-
Poor
6-17 Year Olds with Untreated
Caries by Poverty Status (NHANES)
(National Health and Nutrition Survey Examination)
0
10
20
30
40
50
60
70
80
1971-1974
1988-1994
1999-2002
Poor
Near Poor
Non-Poor
2-5 year olds with untreated caries by
race and poverty level (NHANES)
0
5
10
15
20
25
30
35
40
45
1999-2002
White Poor
White-Not Poor
Black-Poor
Black-Not Poor
Mexican-Poor
Mexican-Not
Poor
6-17 year olds with untreated caries by
race and poverty level (NHANES)
0
5
10
15
20
25
30
35
40
45
50
1999-2002
White Poor
White-Not Poor
Black-Poor
Black-Not Poor
Mexican-Poor
Mexican-Not
Poor 3
Patient-Centered Consequences of
Childhood/Adolescent Caries
Pain
Infection (pulpal,
localized, cellulitis,
systemic)
Tooth loss/space
loss/malocclusion
Carious involvement of
additional teeth
Social stigma
Cost for dental
restoration/rehabilitation
Caries Patterns
Enamel Demineralization (white spot)
Early Childhood Caries
Smooth Surface
Pit & Fissure
Rampant
Arrested
Acquisition and Transmission of
Cariogenic Bacteria
(especially mutans streptococci, MS)
Vertical Transmission via saliva from
caregiver to child (example: pre-tasting
food with same spoon).
Horizontal Transmission via saliva
transfer within a group (examples:
siblings and day care center classmates)
Significance of Early Acquisition of
Cariogenic Bacteria
Early Acquisition = Major Risk Factor for Early
Childhood Caries
(Berkowitz 2003).
MS in plaque @ age 2 years had most caries by age
4 years
(Alaluusaua and Renkonen 1982).
89% of children having MS in plaque @ age 2 years
had caries by age 4 years (mean dfs score = 5)
(Kohler, et al 1988).
Mothers use of Xylitol in chewing gum = less vertical
transmission of MS @ age 2 years and 70% reduction
of dmfs @ age 5 years
(Soderling and Isokangas, 2000).
Definition: Early Childhood Caries (ECC):
> 1 decayed, missing (due to caries),
or filled tooth in child < 6 years old.
Severe ECC (S-ECC):
< 3 years: Any smooth surface caries.
3 5 years: > 1 anterior carious lesion,
or
3 years: DMF score > 4
4 years: DMF score > 5
5 years: DMF score > 6
Rampant Dental Caries
Sudden onset and rapidly progressing.
Often in teenagers.
History of low caries activity not always
predictive as patients enter teen years.
Soda Pop Decay
Sometimes Inadequate Saliva Flow
(should pool in floor of mouth during
examination) 4
Adolescence and Caries
Highest caries rate
Developmental pits and fissures
Immature permanent tooth enamel
Environmental factors
Inadequate daily oral hygiene
Cariogenic diet
Orthodontic appliances
Tobacco use
Eating disorders
AAPD Caries-risk Assessment Tool
Special Health Care
Needs Children
Impaired salivary
function/flow
General
Health
Conditions
Suboptimal Topical F
>3 daily non-meal
cariogenic exposures
Low SES caregiver
No usual dental care
Mother is caries-
active
Suboptimal systemic F,
optimal topical F
1-2 daily non-meal
cariogenic exposures
Midlevel SES caregiver
Irregular professional
dental care
Optimal Fluoride
Mealtime = primary
cariogenic exposure
High SES caregiver
Regular
professional dental
care (dental home)
Environment
Caries in 12 months
>1 white spot lesions
Anterior plaque
Radiographic caries
Ortho Appliances
Enamel Hypoplasia
Caries in 24 months
1 white spot lesion
Gingivitis
No caries 24
months
No white spots
No plaque/gingivitis
Clinical
Conditions
High Risk
Moderate Risk
Low Risk
Caries Progression & Restoration
Early Detection Technologies
DIAGNOdent (infrared laser
fluorescence): fluorescence = caries.
DIFOTI (digital imaging fiber-optic trans-
illumination)
QLF (quantitative light fluorescence)
DIAGNOdent
(www.kavousa.com)
Altered tooth substances and bacteria fluoresce when
they are exposed to a specific wavelength of light.
DIAGNOdent operates at a wavelength of 655 nm.
At this specific wavelength, clean healthy tooth
structure exhibits little or no fluorescence, resulting in
very low scale readings on the display.
However, carious tooth structure will exhibit
fluorescence.
DIFOTI
(www.difoti.com) 5
QLF
(www.inspektor.nl)
Topical Gel Fluoride
Fluoride Varnish
Systemic Fluoride Supplementation
0
½ mg
1.0 mg
6 16 y
0
¼ mg
½ mg
3 6 y
0
0
¼ mg
6 mo 3 y
0
0
0
0 6 mo
> 0.6
ppm F
0.3 - 0.6
ppm F
< 0.3
ppm F
Age
Topical Home Fluoride
Pediatric Considerations in
Choosing Restorative Materials
Efficiency - behavior management/pt.
age
Anatomy of Primary Teeth - Thinner,
irregular enamel, large pulps.
Transitional Dentition - Techniques &
materials that will last until primary
teeth exfoliate. 6
Amalgam Restorations
Correct
T-band
Incorrect
T-band
Indications for Amalgam Restorations
Class I restorations.
Class II restorations in primary molars when
the preparation does not extend beyond the
proximal line angles.
Class II restorations in permanent molars and
premolars.
Class V restorations in primary and permanent
posterior teeth.
Prefabricated Crowns (& crown form)
Indications for Steel Crowns: Primary Teeth
Pulpotomy and
pulpectomy.
Extensive multi-
surface caries and/or
fractures.
High caries-risk
patient.
Hypoplastic/hypocalcifi
ed carious teeth.
Failed alloy or resin
restoration.
Anterior and Posterior Steel Crowns
Steel Crowns in Permanent Teeth
Indications
Interim restoration
until appropriate
permanent can be
placed.
Developmental
defects.
Considerations
Periodontal Concerns
Nickel Allergies
Esthetics 7
Resin Restorations in Pediatric Dentistry
Pit and Fissure Sealants
Composite Resin
Intracoronal Restorations
Strip Crowns
Microfilled, hybrid, flowable
Glass Ionomers
Bases
Restoratives
(Cements later discussion)
Modified Glass Ionomers/Compomers
Resins versus Dental Amalgams

Esthetics Adhesiveness Mercury Content

Environmental Concerns
limit diet to one fish from
MN lake per week. Mercury phobias (no
evidence of adverse direct
health effects to patients) Chair time/technique sensitivity Dimensional change

Resins: > 2.0 %
polymerization shrinkage. Amalgam: + 0.2%
dimensional change.
Resin Spectrum
Least Filler: Sealant
More Filler:
Flowable Composite
Most Filler Content:
Composite Resin
Isolation
Sealants and Composite Resins
Successful bond requires maintaining
saliva-free tooth surfaces.
Rubber dam use whenever possible.
If unable to successfully isolate:
Do not place elective sealant.
Choose material other than resin for
restoration.
Success with Resins =
+
etchant,
primer,
bonding agent
Raincoat (Rubber Dam)
Clean field/better dentistry
Patient protection
Improved behavior, time
management, and successful
appointments 8
Rubber Dam Clamps
Tooth Buttons/Tooth Rings
W14A
W7
W8A
W14
W3
Do not ligate through holes for rubber dam
forceps. Instead:
Raincoat Sequence
1) Punch holes in raincoat (double-punch
hole for clamped tooth)
2) Stretch raincoat loosely over hanger
(frame)
3) Attach floss to button (clamp)
4) Place button on tooth/confirm secure fit
5) Stretch raincoat on hanger over button,
then other teeth
6) Adjust raincoat on hanger
Sealant Indications
Primary Molars:
Very selective
Deep stained grooves
Caries in other quadrants on same surfaces
Permanent Molars:
Deep caries-prone grooves + good isolation
Recently erupted
In conjunction with composite resin
restorations
Incisor lingual pits & premolars: prn
Sealant Technique
Unless
decay identified (or questionable) avoid
enameloplasty.
Include buccal and lingual pits and grooves.
Etch beyond areas to be sealed.
Sealant Failures
Inadequate isolation from saliva
Inadequate light cure
Voids from air bubbles
Buccal pits & lingual grooves
Repair/replace at recall appointment
if possible and no other treatme