Managing caries in primary molars: Dealing with small one or two surface carious lesions

Hello. And welcome to this lecture on managing caries

in primary molars: clinical tips and tricks. OK, so the point of this lecture is actually to focus on the clinical. I don’t want to get too bogged down into the theory behind should we restore, should we seal and all of these sorts of things. But there are two papers I want to just touch on. The first is the managing carious lesions one that you can see on the slide. This is a really, really important paper, and really nicely sets out the current thinking around caries removal, or when to leave caries behind. So I do think it’s worth your while having a look at that.

And some of the principles for that paper I will be applying to the clinical tips we’re going to be talking about. The other one I put up is a recent systematic review on atraumatic restorative technique, ART. And I think I really just put that here to say, I don’t think we’ll be talking about ART, maybe two years ago would have been, but nowadays I think as an approach it’s not something we will be discussing. OK. So our focus is going to be really on how can we help you with restoring primary molars in children. So we’re going to think about two real scenarios. I think it’s helpful to break into two scenarios.

And we’re only talking about patients with a hole, with enamel indenting breakdown. First scenario is a small one or two service lesion, not so big. Second scenario is a big one or two surface lesion. And the modifier that we’ll discuss is also cooperation as well, because that comes into it to. We’re assuming that the pulp is alive. I’m not talking about pulp treatment or pulpotomies or pulpectomies in this talk. So an underlying basis is that the pulp is still going. OK. And I think the other thing that we’re going to be sort of touching on is our theme is trying to do this as simply as possible. So if we can avoid inhalation sedation we will.

If inhalation sedation is required but we could avoid quite deep IV sedation we will. And again we’re also trying to avoid GA as well. So it’s trying to get this done in the chair in an easy and practical way. All right first scenario is a small hole in a child that can cooperate. And here, I think really we go for a classic drill and fill approach. It can be pretty simple to do. It’s less demanding of the material, and we’ll talk about materials in a minute. And has got a good chance of success. Certainly better than drill and fill in a larger hole. So how can we make this approach work?

I think a big problem is the avoidance of local anaesthesia. And often, if you’re doing any kind of restorative intervention, particularly if you might have to remove some dentin, you kind of need to think about using local anaesthesia. And having a numb tooth will mean doing a filling is likely to be more successful. So I think you need to think about firstly your pain management. As a throwaway, because I don’t know how many of you will do this, do you think about rubber dam? Those of us who use rubber dam and were taught rubber dam are evangelists for it, as it were. It certainly makes the restoration much nicer, it makes it nicer for the child.

It means the restoration is more likely to succeed. But I recognise that you’re not used to using it, it might be too much for you take up on. If you’re doing any kind of restoration, particularly, obviously a class II, don’t forget protecting into possible surfaces. We know that we’re cutting class IIs about 40% of the time, we cut the tooth. That’s next door to it, so make sure putting a wedge in or something like that to make sure it doesn’t happen. And remember, nowadays we are not removing all the caries. So if you look at that consensus paper, really we are going now towards leathery, if we’re fairly sure that the pulp is a fair way away.

If you’re getting close to the pulp, you might even stop at soft. OK. And really, the focus nowadays is getting the margin clear so that your restoration can give you a good seal. Because the seal is going to be really important for the long term success. OK. So thinking about cavity design. When I was trained, a while ago now, cavity design was very technical and we were given lots of rules. We were asked to almost, well to cut a cavity in a plastic tooth and show how perfect we could make it. A lot of that’s gone now, because really the cavity is influenced entirely by where the caries is.

But there are some principles that you might find make life easier for you. I think the first is think about using a 330 bur. That’s a pear shaped bur, 1 millimetre in diameter, about 1 and 1/2 millimetres length. And the nice thing about a 330 is it helps guide you to where you are with regards to the pulp, and also almost ready makes your attention for you. OK. So you want to keep within about half a millimetre of the ADJ to avoid going into the pulp. Like I say the 330 can help you with that. You want your line angles to be rounded, OK, nice and sinuous, less chance of propagation. If you do that.

And you will about 1 and 1/2 millimetres of bulk of restorative material to make sure there’s enough of it to stay intact and not fracture or chip or flip out. OK. So if you’re doing a filling, what’s the best material to use? As a nice systematic review I put on screen there, they didn’t look at preformed metal crowns, which we’ll touch on in a bit. They did look at compomers sorry, composites, glass ionomers. Over all, the evidence was poor, but what they did say was you shouldn’t be using a conventional glass ionomer otherwise resin modified glass as composites compromise are all much of a muchness. I’m not talking about amalgam.

Some of you may not be able to use amalgam anymore, as if you can still use amalgam at some point you’re going to have to stop using it. So I think we’ve stopped talking about amalgam as a restorative option for children.