Title Page

Foreword

Preface

Acknowledgements

Chapter 1 Paediatric Cariology: Management and Myth

Aim

Outcome

Introduction

So Why Should We Restore the Primary Dentition?

The Chronology of the Development of the Dentition

Childhood Fever and Caries Susceptibility

Myths

Calcium Deficiency

Breastfeeding and Teeth?

Do “Soft” Teeth Run in the Family?

Inherited defects

“Family” caries

Medicine

Practical Tips

Chapter 2 Diagnosis of Dental Caries

Aim

Outcome

Introduction

The First Visit

Examination

Extra-oral Examination

Intra-oral Examination

Caries Risk Assessment

Previous Disease

Dietary Factors

Social Factors

Fluoride Use and Plaque Control

Medical History

Saliva

Bacteria

Fissure Shape

The Dentist’s Hunch

Risk Categories

The Carious Process

Enamel Caries

White spot detection

Microscopy of a white spot

Progression of Enamel Caries

Enamel Caries in the Fissures

Caries of the Dentine-Pulp Complex

The histological zones found in dentine caries

Caries progression through dentine

Cariology in Primary Teeth

Primary teeth

Caries Diagnosis

The Caries Diagnostic Examination

Clinical Visual

Systematic

Clean

Illumination

Dry

Put the sharp probe away!

Radiographs

Bitewings

Orthopantomogram (OPT)

Bimolar view

Periapicals

Processing and viewing radiographs

How frequently should a radiographic examination be performed?

Adjuncts and Novel Aids to Caries Diagnosis

Magnification

Fibre Optic Transillumination (FOTI)

Temporary Tooth Separation (TTS)

Laser Fluorescence

Electric Caries Meter (ECM)

Recording Caries

Summary

Practical Tips

Paediatric Cariology

Authors:

Marie Thérèse Hosey

Christopher Deery

Paula Jane Waterhouse

Editors:

Nairn H F Wilson

Marie Thérèse Hosey

Quintessence Publishing Co. Ltd.

London, Berlin, Chicago, Paris, Milan, Barcelona, Istanbul, São Paulo, Tokyo, New Delhi, Moscow, Prague, Warsaw

British Library Cataloguing-in Publication Data

Deery, C.
Paediatric cariology - (Quintessentials of dental practice; 14. Paediatric dentistry/orthodontics; 2)
1. Dental caries in children - Treatment
I. Title II. Hosey, Marie-Therese Wilson, III. Waterhouse, P.J.
617.6 ′7 ′0083

ISBN 1850973121

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the written permission of the publisher.

ISBN 1-85097-312-1

Foreword

It is very sad that so many children continue to suffer the ravages of dental caries and are faced with the prospect of dental interventions, possibly including one or more general anaesthetics, at a young age. Indeed, it is very sad that many more children are not caries-free, given that caries is a preventable disease.

Paediatric Cariology is an excellent addition to the rapidly expanding Quintessentials of Dental Practice series. Understanding, preventing and, in particular, managing caries in children may not be viewed by some as one of the more glamorous aspect of the clinical practice of dentistry but, if done well, is widely accepted to be one of the most rewarding. More often than not, the challenge is to deal with at least three things at one and the same time – the child as the patient, the caries and the parent who may be anxious, guilt-ridden or, in the more difficult cases, indifferent. Not an easy task, but one that can be simplified if familiar with the latest thinking and clinical guidance as contained in this most helpful, easy-to-read, well illustrated book.

As has come to be expected of books in the Quintessentials of Dental Practice series, the focus, as in the present book, is on up-to-date knowledge and understanding of immediate practical relevance. This book fulfils this expectation and, as such, may be used to great benefit in the care of children. Paediatric dentistry has changed a great deal in recent years and is set to change further with the increasing use of alternative materials and techniques and attainable improvements in the oral health of children. Paediatric cariology is an aspect of clinical practice that practitioners need to keep informed on. This book provides the ideal means to meet this need.

Nairn Wilson
Editor-in Chief

Preface

Managing caries in children is a challenge to every dentist. The aim of management for every dental team is to provide care, which helps a child to become dentally aware, avoid iatrogenic damage and to grow to be a fit young adult with healthy teeth. This is principally achieved by empowering the child and their carer with preventive advice so that they value dental health and know how to maintain it.

The prevention of dental caries is always the first priority in paediatric dental care and this involves the whole dental team, often supported by community health improvement initiatives, especially water fluoridation.

Unfortunately, when caries occurs in the primary dentition the morphology of the primary molars, in particular, leads to early pulpal involvement. Therefore, early diagnosis, although often difficult, is important to simplify treatment. Luckily, pulp therapies and preformed crowns are relatively easy to perform and the addition of these techniques to the dental therapist armamentarium is a great asset to the dental team in the UK.

We hope that this book will, firstly, inspire better routine preventative care and, secondly, provide dental operators (dentists and therapists alike) with the modern diagnostic tools and restorative techniques to manage caries in children in primary care dentistry in the UK.

Acknowledgements

We express our gratitude to Dr Howard Moody, Dr Chris Longbottom and Mr Toby Gilgrass for supplying some of the photographic images. Thanks to Hazel, Ed and Richard – our long-suffering spouses – for all your support during the preparation of this book.

Chapter 1 Paediatric Cariology: Management and Myth

Aim

This chapter aims to emphasise the importance of the management of caries in children in respect of their continued dental, emotional and educational development. In addition, various myths surrounding paediatric cariology will be discussed.

Outcome

Upon reading this chapter, the practitioner should have gained an understanding of the importance of ensuring that children remain free of both acute and chronic dental pain and appreciate the contribution of the primary dentition, in particular, to overall health and development. The dental team should also be familiar with the chronology of the development of the dentition and appreciate how knowledge of this assists in determining the effect of common childhood illnesses upon the dental hard tissues.

Introduction

Dental caries is one of the most prevalent of human diseases. This disease involves the mineralised tissues of the teeth, namely enamel, dentine and cementum, caused by the action of microorganisms on fermentable carbohydrates. It is characterised by demineralisation of the mineral portion of these tissues followed by the disintegration of their organic material. The disease can result in bacterial invasion and death of the pulp and the spread of infection into the periapical tissues, causing pain. In its early stages, however, the disease can be arrested since it is possible for remineralisation to occur. Over recent years there has been a decline in the prevalence of caries in the Western World. Possible reasons for this include the widespread use of fluoride (especially in toothpaste), changes in the diet, the increased use of antibiotics, and possible changes in the virulence of microorganisms.

The decline in caries prevalence has been greatest on the smooth surfaces of teeth. The pit and fissured surfaces of the molar teeth now have the greatest disease susceptibility, although buccal and palatal pits and fissures remain caries prone. The decline in caries, however, has not been uniform but skewed. The Scottish Health Boards’ Dental Epidemiological Programme survey carried out in 1992/93 showed caries in 7% of 12-year-old children.

Unfortunately, many dental practitioners do not see the value in restoring the primary dentition. This reinforces the view of many parents that primary teeth are expendable. We hope that this book will encourage dentists, dental therapists and hygienists to develop their skills to meet the challenge of treating the young child and promote a change in attitude in those who do not value the primary dentition (Fig 1-1).

Fig 1-1 A visit to the dentist should be a pleasant experience.

So Why Should We Restore the Primary Dentition?

It is becoming increasingly clear that dental health is intertwined with general health and development. Pain and infection have a detrimental effect on health. These are obvious in the child with acute pain, but chronic toothache also causes problems. A child with chronic dental pain cannot thrive and all carious teeth are likely to cause pain and sensitivity from time to time, resulting in:

loss of sleep
mood, behaviour changes and poor concentration
uncomfortable eating, with subsequent loss of appetite and failure to meet developmental milestones: height, weight and head (brain) circumference.

Therefore, the child with dental caries may not thrive physically, emotionally or intellectually, compared to the caries-free child (Figs 1-2 to 1-4). Where children are concerned, their medical, and particularly dental, well-being is of paramount importance. Even relatively simple dental problems can impact upon the medical or educational needs of children, especially on those already diagnosed with medical disorders or learning disabilities.

Fig 1-2 Young child with carious upper incisors and an abscess on tooth 51.

Fig 1-3 Caries-free child with (a) primary teeth and (b) permanent teeth.

Fig 1-4 Child who has had multiple teeth extracted (a) intra-oral view and (b) extra-oral view.

The dental practitioner should aim to motivate the patient and their family by demonstrating that teeth are not disposable and restore primary dentition because it helps:

restore form
restore aesthetics
restore function (mastication and speech)
maintain space for the permanent teeth (Fig 1-5)
acclimatisation
avoid pain and sepsis – avoid damage to the permanent teeth
avoid extraction, particularly under general anaesthesia
avoid sepsis and surgical intervention in the medically compromised child.

Fig 1-5 Primary teeth act as a natural space maintainer for the permanent teeth.

The Chronology of the Development of the Dentition

The development of the primary and permanent dentitions is affected by:

genetic factors
nutrition
somatic growth and development.

There is little variation reported between different races in the timing of eruption of the primary dentition. Racial variation, however, can be seen in the eruption of the permanent dentition – for example, Asian children complete their dental development faster that their Caucasian peers. Therefore, care must be applied when dentists seek to compare an individual child to the “normal” eruption times (Table 1-1).

Table 1-1 **Eruption dates of primary teeth and secondary teeth**
Primary Teeth	Eruption Time (Months)
Central incisor	6
Lateral incisor	9
Canine	18
First molar	12
Second molar	24

Calcification commences 4–6 months in-utero
Root formation complete 12–18 months after eruption

Secondary Teeth	Eruption Time (Years)	Calcification Starts (Years)
Central incisors	7	0.3
Lateral incisors	8	0.3/1*
Canine	9 /12*	0.3
First premolar	10	2
Second premolar	11	2
First molar	6	Birth
Second molar	12	3
Third molar	16–24	8–14
*lower/upper
Root formation complete 2–3 years after eruption

Studies in Peru, on malnourished children, have shown that infants were delayed in the eruption of their primary teeth. This link between nutrition, dental development and general growth can also be seen in premature and low birthweight babies. These babies will “catch-up” on their dental development once their nutrition and medical problem has been rectified and somatic growth will “catch up” with the normal milestones for length, weight and head circumference.

A nutritionist often investigates children who fail to meet their normal developmental milestones. Such children may be placed on dietary supplements: these are generally carbohydrate-rich and so oral hygiene and fluoride therapy are of paramount importance. Other children are referred for dental care to manage dental pain, which may be deterring adequate food intake.

The dental team plays a key role in infant growth and development.

Childhood Fever and Caries Susceptibility

Common childhood illnesses can affect the coincidental dental hard-tissue formation. This can result in hypomineralisation and discolouration. As soon as this is diagnosed, the dental team should be alerted to the fact that the child will have a high caries risk and consequently needs personalised, enhanced preventive management.

Teeth affected by childhood fevers have increased susceptibility to dental caries due to:

Table of Contents

Paediatric Cariology

Authors:

Marie Thérèse Hosey

Christopher Deery

Paula Jane Waterhouse

Editors:

Nairn H F Wilson

Marie Thérèse Hosey

Quintessence Publishing Co. Ltd.

London, Berlin, Chicago, Paris, Milan, Barcelona, Istanbul, São Paulo, Tokyo, New Delhi, Moscow, Prague, Warsaw

Foreword

Preface

Acknowledgements

Chapter 1