Treatment Planning for Caries in the Primary Dentition

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Dental caries are a common disease in children, with 49% of 5-year-olds experiencing clinical decay¹. It also affects children from lower-income families more severely, with a fifth of 5-year-olds who receive free school meals experiencing extensive tooth decay¹.

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Treatment planning

Every treatment plan should be tailored to the individual patient’s needs and circumstances, and should always follow a comprehensive history and examination. Many children experience some level of dental anxiety and may have no experience of dental treatment, this should therefore be considered when creating a treatment plan.

The aim of treatment in primary dentition is to maintain teeth which are asymptomatic and free of pathology until exfoliation. 

A simple treatment plan may consist of several procedures and is often staged in order of increasing need of compliance, helping to acclimatise patients to treatment. The likely order of items on a possible treatment plan is shown below:

1. Emergency treatment/pain relief

2. Prevention:

• Oral hygiene instruction
• Diet advice
• Fluoride varnish
• Fissure sealants

3. Operative intervention:

• Preformed metal crowns
• Restorations
• Pulpotomies
• Extractions

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Pain relief

Pain should be addressed as a priority to minimise the negative effects of dental pain and infection on children.

Management options for pain secondary to caries

Temporary dressing to prevent sensitivity and food packing. 

Removal of the source of pain and infection:

• Extraction
• Access the pulp and establish drainage through the root canal
• Incision and drainage of any visible fluctuant swelling

Antibiotics may be prescribed where there are signs of systemic or spreading infection and local measures prove ineffective. Guidance on antibiotic prescribing in children can be found at SDCEP.org.uk.²

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Prevention

Prevention is the key to managing caries in children, as any restorative intervention will not be successful without it. It is also important for children to adopt good habits as they move into the permanent dentition.

Prevention should be given following ‘Delivering Better Oral Health‘ guidance³

Prevention consists of four key principles:

• Diet
• Oral hygiene
• Fluoride
• Fissure sealants

Diet advice

Examination and treatment appointments are good opportunities to discuss diet and provide appropriate advice.

All children
Reduce the frequency and the amount of sugary food/drink Keep sugar intake to mealtimes Use sugar-free medicine Only water to drink after brushing teeth at night
Children <3 years	Children over 3 years	High school-age children
Advise breastfeeding for babies where possible Free flow cups introduced from 6 months Discourage bottle use from 1 year	Investigate diet for high caries risk patients Advise on hidden sugars and a balanced diet	May require closer monitoring as they gain more freedom with their dietary choices

Table 1. Diet advice for children, based on Delivering Better Oral Health guidance³

Oral hygiene advice

All children should brush twice daily with a fluoridated toothpaste, and should be encouraged to ‘spit don’t rinse’.

Low-risk children <3 years:

• 1,000 ppm fluoride toothpaste
• Use a smear
• Brushing should be performed and/or supervised by a parent or carer

Low-risk children 3-6 years:

• 1,000-1,500 ppm fluoride toothpaste
• Use a pea-sized amount
• Brushing should be supervised by a parent or carer

Low-risk children 7+ years:

• 1,350 – 1,500 ppm fluoride toothpaste
• Adult amount
• Child can perform toothbrushing

For high-risk children of any age who give concern and may be likely to develop caries:

• 1,350 – 1,500 ppm fluoride toothpaste
• Commence professional interventions such as fluoride varnish, prescription-only fluoride sources, and reducing the recall interval

Professional fluoride intervention

In addition to the use of shop-bought fluoridated toothpaste, there are several additional fluoride interventions that can be prescribed or applied by a suitably trained dental care professional.

Fluoride varnish

2.2% fluoride varnish should be applied twice a year for all children.

This can be increased up to every 3 months for high caries risk children.

For children with severe asthma or multiple allergies, the colophony in fluoride varnish can precipitate adverse reactions – alternative colophony-free varnishes are available.

Fluoride prescriptions

High fluoride toothpaste:

• 2,800ppm (0.619%) fluoride can be prescribed from age 10
• 5,000ppm (1.1%) fluoride can be prescribed from age 16

Mouth rinse:

• Fluoride mouthwash can be prescribed from age 8
• Concentrations available are 0.05% fluoride daily or 0.2% fluoride weekly (nb. a daily routine may be easier to stick to than a weekly routine)

Fissure sealants

Why fissure seal?

Fissure sealants prevent caries by sealing pits and fissures to aid brushing and avoid plaque stagnation.

They provide a a simple, non-invasive introduction to dentistry for anxious children.

What to fissure seal?

Fissure seals can be used for:

• Occlusal and buccal/palatal fissures of first permanent molars as soon as possible after eruption (SDCEP 2018)⁴
• Occlusal and buccal/palatal fissures of second permanent molars in high-risk children
• Cingulum pits which can be present on some lateral incisors

Material choice for sealants

Resin-based:

• Tooth coloured or colourless
• Strong bond to enamel
• Requires excellent moisture control and good cooperation 

Glass ionomer based sealant:

• Often not tooth coloured
• Less moisture/technique sensitive so preferable in anxious/less cooperative children
• Potential to act as a fluoride reservoir

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Caries management

Reasons for restoring caries

There are many reasons to restore caries in children which are discussed below.

Avoidance of pain and infection

Pain and dental infections in children can result in:

• Time off school
• Sleep problems
• Difficulty eating
• Difficulties with concentration and social interaction
• Growth impairment (typically associated with excessive caries)

Improved tooth survival

Carious teeth which are filled have a better survival to exfoliation than those that don’t, irrespective of fluoride use.⁵

Avoidance of extraction due to pain or infection

Avoiding extractions is beneficial for a wide number of reasons including: 

• Preservation of aesthetics 
• Preservation of dental function
• Space maintenance and fewer adverse effects on developing dentition

Management options

The choice of management will depend on several factors including:

• Anterior or posterior tooth
• Depth of caries
• Chance of pulpal involvement
• Cooperation and compliance of the patient

Caries in anterior primary teeth

Primary incisor teeth usually exfoliate between ages 5-7.

Excellent oral hygiene, diet and professional fluoride varnish application is often sufficient to prevent caries progressing until exfoliation.

Primary canines do not exfoliate until around age 9-11 and so may require restoration. 

In these cases, caries removal and placement of a composite restoration may be indicated.

Caries with no pulpal involvement in primary molars

There are two primary options for the uncomplicated restoration of caries:

• Conventional restoration with composite, local anaesthetic and rubber dam where indicated
• Biological therapy; this generally involves the use of preformed metal crowns (PMC).

A novel technique which may become more prevalent in the future is silver diamine fluoride (SDF):⁸

• SDF is an emerging technique in the management of caries.
• It is a colourless, odourless liquid with both antibacterial and remineralising properties.
• SDF can be applied to carious lesions to arrest them with the view to either providing a permanent solution (restoration or extraction) once compliance has improved or as a way of preventing symptoms until the time that the tooth exfoliates.
• In the era of COVID-19, it also has the advantage of being a non-aerosol-generating procedure.
• SDF has some disadvantages, including severe black staining of the lesion and the need for the lesion to be cleansable (this may mean removing enamel with either an air rotor or excavator), which requires compliance from the patient and may generate aerosol.
• Not currently licensed for use in the treatment of caries in the UK and so GMC guidelines on off-label use should be followed if clinicians choose to use it for this purpose.⁹ Further reference should be made to the standard operating procedures available on the British Society of Paediatric Dentistry website.¹⁰

Choosing between composite and a preformed metal crown

Either intervention should only be used in the following circumstances:

• Asymptomatic (no pain, no swelling or sinus)
• No radiographic evidence of pulpal involvement or interradicular pathology
• Small carious lesions only – loss of no more than ⅓ of the marginal ridge. Any more indicates likely pulpal involvement due to large pulp horns of primary teeth¹¹

The decision to use a biological approach for the treatment of caries in primary molars should be made using clinical examination in conjunction with radiological examination.

Choosing a restorative technique: restoring caries with either a good quality composite or biological therapy (generally preformed metal crown (Hall technique) will improve Oral Health-Related Quality of Life (OHRQoL).¹²

Conventional composite restorations (when placed with optimal technique and moisture control) and preformed metal crowns (Hall technique) are equally effective, however:¹³

• A good quality composite requires compliance with caries removal, often local anaesthetic and a rubber dam. Understandably many young children find this hard to tolerate.
• In anxious or less cooperative children, a Hall technique crown will be preferable over a poor quality composite.
• Preformed metal crowns can cause less discomfort due to the lack of need for local anaesthetic or caries removal and are generally preferred by parents and children.
• There may be concerns about the appearance of preformed metal crowns. Consider terminology such as ‘pirate teeth’ or ‘princess crowns’ in treatment planning to aid acceptance of what is an easy and effective treatment, and one which is generally preferred by parents and children over a conventional restoration.¹⁴

	Composite	Preformed metal crown
Level of cooperation needed	High	Low
Level of moisture control required	High. Rubber dam should be applied where possible	Low
Local anaesthetic needed?	Ideally for complete caries removal	No
Aesthetic result	Good	Poor (but this should not be a primary concern)

Table 2. Considerations for composite vs preformed metal crown restorative techniques

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Teeth with pulpal involvement 

Signs which may indicate significant pulpal inflammation in primary teeth:¹⁵

• Sinus (nb. interradicular abscesses may drain through the gingival margin rather than through a sinus in the mucosa)
• Swelling (either intra or extra-oral)
• Radiographic pathology: the anatomy of primary teeth (notably the thin pulp chamber floor) means this often presents as interradicular radiolucency at the bifurcation.
• Pain which is spontaneous, severe or requires analgesia use.
• Radiographically visible deep caries.
• Extensive cavitation and loss of more than 1/3 of the marginal ridge. In these cases, it is very likely that there is pulpal inflammation.¹⁶

Treatment options

Treatment options for teeth with pulpal involvement include:

• Indirect pulp cap (IPC): removal of infected caries leaving the deeper caries in place to avoid exposure of the pulp. This gives the uninflamed/reversibly inflamed pulp a chance to heal.
• Pulpotomy: removal of coronal pulp, leaving the healthy or reversibly inflamed radicular pulp.
• Pulpectomy: removal of all coronal and radicular pulp. This is a complex procedure requiring a specialist and is rarely used in routine cases.
• Extraction

Pulpotomy

In many cases, a pulpotomy would be the ideal treatment of an asymptomatic, deep carious lesion. There is also evidence that indirect pulp caps have a similar or higher rate of success and are a viable biological alternative to a vital pulpotomy, requiring less tissue removal. The indications for both procedures are the same.¹⁷

However, in many cases, there are contraindications to this procedure and an extraction may be preferable:

• Pre-cooperative/anxious patients
• Symptomatic teeth 
• Any sign of infection, sinus or swelling
• Multiple teeth requiring pulp therapy (in these cases extraction is likely to be a more efficient treatment)
• Less than 2/3 root length remaining
• Unrestorable teeth
• Signs of internal resorption
• Immunocompromised children or those with medical conditions (e.g. congenital heart defects). These children may be more at risk from sepsis or endocarditis than from any residual infection and the infectious focus should be removed altogether. 

Advantages of pulpotomy/IPC vs extraction
Pulpotomy/IPC	Extraction
Space maintenance	Less risk of residual infection remaining
Less unwanted movement of adjacent teeth	Multiple procedures can be completed under general anaesthetic in anxious/less compliant patients
Avoidance of extractions which may require GA	Quicker, simpler procedure
Promotes a healthy attitude to dental health
Retaining tooth may improve aesthetics and function
Useful if extractions need to be avoided (e.g. in patients with medical contraindications or hypodontia of permanent teeth)
Maintains space and prevent unwanted movement of permanent teeth which may require future orthodontics

Table 3. Considerations when thinking about pulpotomy or indirect pulp capping vs extraction in primary teeth

Extractions

Where extraction of primary teeth is determined the best treatment option, there are three main anaesthetic and behavioural management options:

• Local anaesthetic (LA)
• Inhalation sedation (RA)
• General anaesthetic (GA)

A brief summary of the indications/contraindications of each can be found below. This is a guide and each case should always be considered individually.

Local anaesthetic		Inhalation sedation		General anaesthetic
+	–	+	–	+	–
Cooperative children	Needle phobia	Mild to moderate anxiety	Children unable to breathe through the nose	Pre-cooperative patients	Medical contraindication
Small number of, simple extractions	Dental anxiety	Strong gag reflex	Severe anxiety	Multiple extractions	Risks outweigh benefits (e.g. extractions for orthodontic benefit only)
Medical contra-indication to RA or GA	Very little past treatment experience	Conditions aggravated by stress (asthma or epilepsy)	Where an escort is not available	Severe anxiety	Patients who can cope with treatment without GA
	Multiple or complicated extractions	Avoidance of GA in some medical conditions which carry a higher risk	Medical contraindication (e.g. myasthenia gravis)	Surgical extractions
			Recent eye surgery

Table 4. Advantages and disadvantages of anaesthetic and sedation techniques

Considerations for extractions under general anaesthesia

General anaesthetic carries a fatality risk of around 1:40,000¹⁸and children can experience several unpleasant side effects such as:

• Nausea
• Dizziness
• Pain
• Tiredness

Any treatment plan requiring extractions under a general anaesthetic should always be carried out by a specialist and should be planned to minimise the risk of a foreseeable repeat anaesthetic. Some examples of ways in which this approach can be achieved are discussed below.

More radical treatment plans:

• Any teeth with a doubtful prognosis, even if potentially manageable with PMC or pulpotomies, will likely be extracted to avoid a repeat procedure

Planning GA as the last item on a treatment plan:

• If caries is intended to be managed with restorations or PMC’s, this should be done prior to GA in case compliance becomes an issue and the tooth requires extraction
• There should be NO unmanaged caries remaining immediately after a GA procedure

Radiographs:

• This will allow planning for the management of ALL carious lesions.
• If there is clinical caries warranting extraction there are likely to be other lesions which are not clinically visible.

Orthodontic opinion:

• This is not required for all GA procedures. However, it may be useful where balancing/compensating extractions are being considered, or where the first permanent molars are of poor prognosis.

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Editor

Dr Lucy Alderson

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Reviewer

Dr Deborah Denton

Senior Dental Officer

Rotherham NHS Foundation Trust

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References

1. Children’s Dental Health Survey Executive Summary England, Wales and Northern Ireland (2013) Pages 2-4.
2. Scottish Dental Clinical Effectiveness Programme (2016) Drug prescribing in Dentistry 3rd Edition.
3. Public Health England (2017) Delivering better oral health: an evidence-based toolkit for prevention. Third edition. Department of Health.
4. Scottish Dental Clinical Effectiveness Programm (2018) Prevention and Management of Dental Caries in Children.
5. Stephenson J, Chadwick BL, Playle RA, Treasure ET (2010) A competing risk survival analysis model to assess the efficacy of filling carious primary teeth. Caries Res. 44(3):285-93
6. Chadwick BL, Evans, DJP (2007) Restoration of class II cavities in primary molar teeth with conventional and resin-modified glass ionomer cements: a systematic review of the literature. Eur Arch Paediatr Dent. 8: 14–21.
7. Scottish Dental Clinical Effectiveness Programme (2017) Restricting the Use of Dental Amalgam in Specific Patient Groups Implementation Advice.
8. Timms L, Summer O, Deery C, Rogers HJ (2020) Everyone else is using it, so why isn’t the UK? Silver Diamine Fluoride for children and young people. Community Dental Health. 37, 143-149
9. General Medical Council. Prescribing unlicensed medicines. Available from: [LINK].
10. British Society Of Paediatric Dentistry (2020) Clinical Protocol for the Use of Silver Siamine Fluoride (SDF): Standard Operating Procedure (SOP). Available from: [LINK].
11. Duggal MS, Nooh A, High A (2002) Response of the primary pulp to inflammation: a review of the Leeds studies and challenges for the future. European Journal of Paediatric Dentistry. 3(3):111-4.
12. Bani Hani A, Deery C, Toumba J, Munyombwe T, Duggal M (2017) The impact of dental caries and its treatment by conventional or biological approaches on the oral health‐related quality of life of children and carers. International Journal of Paediatric Dentistry vol 28 issue 2. 30
13. Bani Hani A, Duggal M, Toumba J, Deery C (2018) Outcomes of the conventional and biological treatment approaches for the management of caries in the primary dentition. International Journal of Paediatric Dentistry Vol 28, Issue 1 pp12-22.
14. Innes N, Evans DJ, Stirrups DR (2007) The Hall Technique; a randomized controlled clinical trial of a novel method of managing carious primary molars in general dental practice: acceptability of the technique and outcomes at 23 months. BMC Oral Health 7: 1–21.
15. Rodd HD, Waterhouse PJ, Fuks AB, Fayle SA & Moffat MA (2006) UK National Clinical Guidelines in Paediatric Dentistry: Pulp therapy for primary molars.  International Journal of Paediatric Dentistry 16 (Suppl. 1): 15–16.
16. Duggal MS, Nooh A, High A (2002) Response of the primary pulp to inflammation: a review of the Leeds studies and challenges for the future. European Journal of Paediatric Dentistry. Sep 3(3):111-4.
17. Coll JA, Seale S, Vargas K, Marghalani AA, Al Shamali S, Graham L (2017) Primary Tooth Vital Pulp Therapy: A Systematic Review and Meta-analysis. Pediatric dentistry Vol 39. No1. Jan/Feb.
18. Royal College of Anaesthetists (2019) Risks associated with your anaesthetic Section 15: Death or brain damage. Available from: [LINK].

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