___________________________________ DCA06DT Dental Treatment of Pediatric and Adolescent Patients
over SDF therapy if functional restoration is required. A consent form explaining these effects and limitations should be provided and signed by parents. The UCSF protocol and a sample consent form were published in the Journal of the California Dental Association and are available online at https:// www.dhcs.ca.gov/provgovpart/Documents/DTI/Domain 2/Domain-2-Informed-Consent-for-Silver-Diamine-Fluoride- Template.pdf [78]. CROWNS Restorative materials such as amalgam and composite resin are not the materials of choice when an extensive amount of deciduous coronal tooth structure has been destroyed by caries. In adults, such teeth are restored with full crowns of cast gold, porcelain-fused-to-metal, or a variety of all-ceramic options. However, when deciduous teeth that will not be shed for several years have extensive coronal caries and occlusal function must be restored, pre-formed stainless steel crowns are the restoration of choice. These stainless steel crowns can also be used to restore grossly carious permanent molars and bicuspids in children and adolescents in whom the roots of the teeth are not completely formed and in which adult occlusion has not yet been completed. In patients for whom amalgam or composite restorations have fractured or who have developed recurrent caries, these crowns may be used. The silver color of stainless steel crowns makes them unaesthetic, and the extended time for the preparation of the tooth, the trial fitting and contouring of the crown, and cementation can be beyond a pediatric patient’s ability to cooperate. Anterior deciduous teeth with extensive coronal caries can be restored with anterior strip crowns. This technique features the use of a pre-formed cellulose acetate strip crown into which the appropriate shade of composite resin material is inserted and then placed onto the tooth [16]. The composite material is light cured, and then the cellulose acetate strip crown is removed. Because this is a bonding procedure, isolation from blood and saliva is mandatory. The restoration of deciduous anterior or posterior teeth with stainless steel crowns or anterior strip crowns is an exacting procedure and should be attempted only by clinicians who have been appropriately trained. PULP CAPPING AND PULPECTOMY Carious involvement of the pulp of deciduous and permanent teeth of children and adolescents pose another restorative chal- lenge. Bacterial infiltration of the dental pulp initially presents with an inflammatory response that will culminate in the necrosis of the pulpal tissues. A localized abscess can form and evolve into cellulitis, which follows muscle and fascial planes and can ultimately lead to a disseminated systemic infection. In adults, carious involvement of the pulp of permanent teeth with fully formed roots is treated by root canal therapy or by extraction. While conventional root canal therapy cannot be performed on retained deciduous teeth or permanent teeth in which the roots are not completely formed, other procedures are available to treat pulpal tissue that has carious involvement.
Carious lesions that approach the pulp in a deciduous tooth can be treated by an indirect pulp capping technique. This procedure entails the removal of all of the carious dentin except the layer closest to the pulp. A medicament such as calcium hydroxide or zinc oxide-eugenol (ZOE) is then applied directly against this deepest layer of remaining caries. These compounds stimulate the pulp to produce reparative dentin beneath the carious lesion to stop the progression of caries and maintain pulpal vitality [17]. This technique can be done in one appointment, with amalgam or composite resin restoration placed over the layers of ZOE or calcium hydroxide. Another approach involves the placement of a temporary restoration over the ZOE or calcium hydroxide with a return visit in six to eight weeks to excavate any residual carious dentin and place the final restoration [18]. A direct pulp cap may be used when a carious lesion extends directly into the pulp of an otherwise healthy tooth without symptoms (e.g., pain, sensitivity to extremes of temperature). A material such as calcium hydroxide is applied directly to the area of pulpal exposure to stimulate reparative dentin [19]. This procedure usually has a poor prognosis in deciduous teeth, and if ineffective, a pulpotomy should be utilized. A pulpotomy is a procedure in which the entire inflamed coronal pulp is removed while the pulpal tissue within the roots is left intact. Upon removal of all caries and the achieve- ment of hemostasis within the pulp chamber, mineral trioxide aggregate (MTA), formocresol, or ferric sulfate is applied with either cotton pellets or a specific carrier directly to the pulpal tissue stumps until a clot forms. The tooth is subsequently restored with a base, such as intermediate restorative material (IRM). The ideal final restoration is a stainless steel crown for deciduous molars or an anterior strip crown for anterior teeth. The treatment of extensively carious immature permanent teeth, for which root formation and closure are years away, also presents as a unique restorative challenge. Immature permanent teeth with carious lesions that approach the pulp but with no or minimal symptoms can be treated with the one- or two-step indirect pulp technique. If a stainless steel crown or an anterior strip crown is utilized for the immediate restoration, it must be replaced by a permanent crown after root formation is complete. If the removal of the carious lesion causes a small (pinpoint) exposure to the pulp, with symptoms of pain, the direct pulp cap technique can used for immature permanent teeth [20]. Direct pulp caps of immature permanent teeth have a much better prognosis when compared to those of deciduous teeth. When an extensive carious lesion involves the pulp of imma- ture vital (non-necrotic) permanent teeth, the therapeutic goals are to eliminate pain and to provide treatment that will allow for the complete development of the root, including apexogenesis. This can only occur if the radicular pulp is left in a healthy state. After the inflamed pulpal tissue is removed, a layer of calcium hydroxide or MTA is placed over remaining exposed pulpal tissue [21]. A base (e.g., IRM) and a composite resin restoration complete the coronal seal.
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