___________________________________ DCA06DT Dental Treatment of Pediatric and Adolescent Patients
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. The prevention of dental caries remains the ideal approach. Teaching patients and their parents about the basic tenets of oral hygiene and motivating them to maintain periodic recall appointments are important parts of this preventive practice. An initial clinical and radiographic examination will reveal the presence of caries and the risk of developing future caries. Statistics have shown that decay in the pits and fissures causes about 80% to 90% of all caries in the permanent posterior teeth and cause approximately 44% of all caries in deciduous teeth [9]. Pits and fissures are more plentiful and pronounced in the premolars and molars, although pits of varying sizes and depths are also common on the lingual aspects of the maxillary central and lateral incisors as well. These narrow invagina- tions in the enamel are areas in which bacterial plaque can congregate and into which toothbrush bristles may not reach. Pit and fissure sealants may be placed to decrease the risk of caries in these areas. Studies have shown that the placement of a second-, third-, or fourth-generation resin-based material can decrease the caries incidence by 88% after two years and by 79% over a span of four years, although the quality of evidence is lower at this interval [10; 80]. Teeth with deeper pits and fissures and patients with poor oral hygiene will have a greater benefit from sealants than those with excellent oral hygiene or shallow pits and fissures. When recall appointments have been kept and oral hygiene has been maintained, sealants have an 80% to 90% retention rate after 10 years and a 65% retention rate after 20 years [11; 66; 80]. Several commercial resin-based sealant products are available. Before any sealants are set, the tooth should be cleaned and the surface etched with an acidic gel that causes the enamel surface to develop microscopic porosities into which the resin will flow. This is very technique-sensitive, as salivary contamina- tion of the etched surface will preclude the development of an adequate bond strength and cause the sealant to detach. A thin layer of material is placed into the desired pit or fissure, with an ultraviolet light used to set the material. Occlusion should always be checked after sealants are placed, as any excess in the sealant height could cause a fracture of the sealant and/ or traumatic occlusion of the teeth. Dental caries can develop despite the best preventive efforts of the patient and the dental staff. The most common materials used to restore deciduous teeth without pulpal involvement are dental amalgam and composite resins. The use of either material has advantages and disadvantages, and the material of choice should be based on the restorative needs of the patient.
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