DCA06DT Dental Treatment of Pediatric and Adolescent Patients _ __________________________________
Proportionately, the relationship of the mesial-to-distal dimensions of the crowns of deciduous teeth to the occlusal to gingival dimension is greater than the same relationship among permanent teeth. The occlusal table of the deciduous molars, upon which grinding and crushing of food occurs, is more narrow compared with the wide occlusal tables of the permanent molars. Deciduous molars also feature a prominent bulge in the mesio-buccal area near the gingival crest, which can be conducive to the retention of bacterial plaque at the gingival level and which poses a greater risk of the develop- ment of caries [4]. The roots of deciduous anterior teeth are more narrow in a mesial-to-distal direction compared to those of the anterior permanent teeth. The crown-to-root length ratio of deciduous molars is less than the same ratio in the permanent molars, as the roots of deciduous molars are longer in relation to the size of the crowns of these teeth. The apical anatomy of the decidu- ous molars can feature pronounced but slender curvatures that should be considered if the teeth must be extracted. The roots of the deciduous molars surround the crowns of the developing permanent maxillary and mandibular bicuspids. If an extrac- tion is indicated for any of the deciduous molars, care must be taken to avoid damage to the crowns of their permanent successors. Deciduous molars with fully formed roots can be challenging extractions. These slender and curved roots cannot withstand the degree of pressure utilized for the extractions of permanent molars and can fracture easily if excessive pressure is applied. Deciduous molar roots that fracture in the apical area may be difficult to locate and remove without damaging the permanent bicuspids. When the roots of the deciduous teeth lose their normal means of attaching to the bone via the periodontal ligament and become fused directly to the bone, this is called ankylosis [5]. Although ankylosis can affect any deciduous tooth, the molars are most often involved. Ankylosis interferes with the normal process of deciduous root dissolution to allow for the normal sequence of shedding of the deciduous teeth and replacement by the permanent teeth. Ankylosed teeth have a dull sound when they are percussed with an instrument and a submerged appearance when adjacent non-ankylosed decidu- ous teeth are shed and the permanent successors erupt into their proper position. They can delay the eruption of their permanent successor and allow for the unintentional drifting of the adjacent teeth or hypereruption of the opposing tooth. These problems can lead to functional and cosmetic problems that require orthodontic correction. Ankylosed teeth can be difficult extractions because they are fused directly to the bone and excessive pressure can lead to fracture of the deciduous roots, the supporting alveolar bone, and the developing per- manent tooth. Clinicians should not consider the extraction of any deciduous tooth, especially the molars, an easy procedure. High-quality radiographs that show the tooth’s root anatomy and its relation to the developing permanent tooth, the age and ability of the
patient to withstand a surgical procedure, the surgical skills of the clinician, and the clinician’s ability to establish rapport and treat pediatric patients should be considered before a surgical procedure is initiated. Referral to a pedodontist or oral surgeon should be considered if it is in the best interest of the patient. The enamel and dentin layers of deciduous teeth are thinner than those on permanent teeth. The pulp chamber, which includes the nerve supply, blood vessels, and supporting tis- sue, is relatively large in deciduous teeth, with a larger pulp chamber-to-clinical crown ratio than in permanent teeth. Pointed extensions of the pulp chamber (called pulp horns) are common in deciduous teeth and are much closer to the external surface of the tooth compared to permanent teeth. Due to these anatomic differences, dental caries spread faster in deciduous teeth and pulpal involvement can occur quickly. When a carious deciduous tooth will not be shed for a long time, it should be restored. Extension of decay into the pulp chamber will cause pain, necrosis, and local infection; infection can extend quickly between muscular planes to cause regional and even systemic involvement. Thus, carious lesions in decidu- ous teeth should be restored as quickly as possible to prevent odontogenic infections and tooth loss due to non-restorable caries. Even so, some parents may be reluctant to restore caries in primary teeth because they will ultimately be lost. Clear and complete parental education may help address this. RESTORING CARIOUS DECIDUOUS AND PERMANENT TEETH IN PEDIATRIC PATIENTS Dental caries are the most common childhood disease [6; 79]. Although tooth decay is usually managed with no untoward sequelae, complications from dental caries do occur, and if left untreated, caries can lead to meningoencephalitis, subdural empyema, and even death [7]. While this tragic circumstance is rare, it underscores the necessity to restore carious teeth whether they are deciduous or permanent. Early childhood caries (ECC) are lesions that occur in decidu- ous teeth between birth and 71 months of age. Deciduous teeth that have been restored or extracted due to extensive caries are also included in this definition [8]. The restoration of carious deciduous teeth or permanent teeth with incompletely formed roots and larger pulp chambers requires different restorative techniques and materials than those used to treat the perma- nent teeth of adults. There are numerous dental restorative materials available and several clinically acceptable techniques by which they can be placed. Clinicians should consider patient age, caries risk, abil- ity to cooperate, the expected duration of retention of a carious tooth or the stage of development of a permanent tooth, and the costs involved before any restorative dentistry is begun. Every clinician should be well versed in state laws regarding the consent that is necessary to initiate any treatment for minors.
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