Pediatric Dentistry I (Dent 361)

Risk Assessment, Caries Prediction & Treatment Planning

Dr FEDA ZAWAIDEH
BDS (Jordan) , GradDipClinDent, DClinDent (Melb), JDB, GradDipClinDent, Melb), FRACDS, FRACDS (Paed) (Paed)

INTRODUCTION


Management of dental caries was based mainly on the identification of carious lesions followed by surgical intervention to remove and restore the infected tooth structure. Nowadays, caries management includes various management options that involve providing treatment, monitoring, of demineralized, nondemineralized, non-cavitated tooth surfaces, prevention, surgical intervention of primary lesions and repair or replacement of defective and failed restorations.

Clinical Decision Making for Caries Management in Children

(Tinanoff D, 2002)

Natural History of Caries Progression



Age of the child: The earlier that a child becomes colonized with the cariogenic bacterial group, mutans streptococci, the greater is the childs caries risk. Those teeth that are first exposed to a cariogenic environment generally will be the first to show signs of disease. Caries progression is dependent on the site of the lesion and level of risk and disease activity, as well as age. Caries activity can be assessed by observing the speed of progression of existing lesions or the incidence of new lesions. (Tinanoff D, 2002)

Caries Progression

Results indicate that 72-81% of lesions remain in enamel after 1 year. Progression in low risk groups took 3.5 yrs and in high risk group 1.5 years.

Caries Progression

Proximal lesion progression in permanent teeth was slower than that in primary teeth. Lesions may remain in enamel for up to 3 years. Evidence shows lesions limited into enamel may not require immediate surgical intervention.

CARIES RISK ASSESSMENT All children should have an assessment of disease risk before the final treatment plan is determined

Clinical decision making in the management of caries in children and adolescents requires an understanding of caries risk and risk indicators. Generally speaking, Risk is defined as the probability of incidence of an event within a certain period of time. Caries risk is the probability that a lesion will develop or that an existing lesion will progress during a specified period (Anusavice K, 2003).

Determination of caries risk is important for:

 

Assessment of the individual factors of existing carious lesions and of the caries risk situation. Repeated determination of the caries risk allows an evaluation of the success of, or the need for, modification of preventive measures. Indications of an increased caries risk in specific children in community preventive programs will allow selection of an individual preventive program in order to minimize the development of carious lesions.

(Reich et al, 1999)

Goal of Risk Assessment



The ultimate goal of caries risk assessment in dentistry is to deliver preventive and restorative care specific to an individual patient's need and to identify caries active individuals and convert them to caries inactive status and reduce their caries risk.

Risk Factor


A risk factor is defined as an environmental behavioral or biological factor confirmed by temporal sequence, usually in longitudinal studies, which, if present, directly increases the probability of a disease occurring. If absent or removed, it reduces the probability. Risk factors are part of the causal chain or they expose the host to the causal chain. Once the disease occurs, removal of the risk factor may not result in cure. (Anderson M, 2002)

Diagrammatic view of caries risk factors in children; The 3 primary factors and their subcategories of risk. (Anderson M, 2002)

AAPD Caries Assessment Tool (CAT)

CARIES RISK
LOW CARIES RISK  Caries free now  Access to water fluoridation  Favorable history: appropriate diet, dentally healthy sibs, good oral hygiene, motivated parents MODERATE CARIES RISK  One or two new lesions per year

CARIES RISK
HIGH CARIES RISK  Three or more new lesions per year  Commencing orthodontic treatment  Chronic illness or hospitalization  Medically compromised children  Social risk factors

Prediction Based On Past Caries Experience

 

The most powerful single predictor of future caries increment since it is a summary of the cumulative effect of all risk factors. The significance of this factor as a single reliable predictor was confirmed in a study conducted by Saemundsson et al (1997) on 9690 children aged 5-15 years of age who were ranked as low, medium and 5high risk by dentists or school dental therapists based on unrestored lesions on primary and permanent teeth and proximal caries scores. On the other hand, in adults, existing DMF- values are less sensitive for DMFpredicting future coronal caries but have a close correlation with the development of root caries. The use of caries experience in the primary dentition for the assessment of future caries in permanent teeth has also been advised in the literature based on the fact that the value of dmft recorded at 6 years of age was a strong predictor of caries occurrence between the age 7 and 13 years.

TREATMENT PLANNING SEQUENCE FOR CHILDREN

      

Emergency care, relief of pain Preventive care Surgical treatment Restorative treatment Orthodontic treatment Extensive restorative, further surgical management Recall and review

STEPS IN DIAGNOSIS & TREATMENT PLANNING

Collect general observations: Child/parent interactions, behavior  Address reason for presenting FIRST  Start with history: Medical, dental, family, social  Record past dental care


STEPS IN DIAGNOSIS & TREATMENT PLANNING

Conduct head and neck exam  Perform a complete oral examination  Use a thorough and detailed form  Establish a provisional diagnosis  Obtain any additional tests: Radiographs, study models, medical consults, etc..


STEPS IN DIAGNOSIS & TREATMENT PLANNING

    

Finalize diagnosis and treatment plsn Present case to patient/parents Outline recommended treatment plan Involve parents in planning Secure parental consent

TREATMENT PLAN SHOULD INCLUDE THESE FEATURES

   

Treat existing problems Prevent progression of existing problems Prevent anticipated future problems Plan periodic exams, preventive care and treatment

TREATMENT PLANNING CONCEPTS



Consider behavior (eg. Desensitizing app/procedure, modeling) Involve parent in treatment choices, but dont be dictated to! Incorporate prevention

TREATMENT PLANNING CONCEPTS



Plan efficient use of LA (QUADRANT THERAPY) Treat comprehensively with definitive treatment, not patchwork Consider full coverage if using GA

TREATMENT PLANNING CONCEPTS



Establish a follow up/review/recall plan based on established criteria (eg. AAPD) Make referrals in writing and expect a written report back

QUADRANT THERAPY


    

First visit: Examination, Diagnosis and treatment planning, Prophylaxis, OHI, dietary advice Second visit: Quadrant 1 Third visit: Quadrant 2 Fourth visit: Quadrant 3 Fifth visit: Quadrant 4, Fluoride application Review and recall SPACE MANAGEMENT IF EXTRACTION IS DONE

CASE PRESENTATION AND TREATMENT PLANNING

Biographic Data
       

Initials DOB Initial exam Age at exam Parents Marital status Siblings Residence

       

NH 13/11/1999 23/05/2003 3 years AO, AH Married No siblings Melbourne

Medical History
         

CVS Endocrine GIT Bleeding NORMAL UGS Respiratory CNS Allergies Past surgery Immunization up to date

Developmental History


Birth

Speech  Locomotion  Weight  Height



Full term, Normal delivery  Normal  Normal  100.8 cm, (50th)  15 kg, (50th)


Social History
Recently moved from Eritrea  Non-English speaking family Non Single child  Goes to Kinder  Good social development  Bottle-feeding at night Bottle

Dental History
Past dental history First dental visit  Referral Referred from North Yarra community health services for management of dental caries


Chief Complaint
Spontaneous pain in upper anterior teeth  Pain disturbing sleep  Pain interfering with eating


Preventive History
Use of systemic F Water Fluoridation  Use of topical F Fluoridated toothpaste


Head & Neck Exam

Facial symmetry  Eyes  Skin colour  Nails  Hair  TMJ  Lymph nodes


Symmetrical Brown Dark complexion Normal Normal Normal Normal

IntraIntra-oral Exam
SOFT TISSUES  Gingiva  Alveolar mucosa  Palate  Buccal mucosa  Tongue  Sublingual area  Soft palate  Oropharynx

NORMAL

IntraIntra-oral Exam-Cont ExamPeriodontal tissues  Oral hygiene

 

Normal Fair

IntraIntra-oral Exam-Cont ExamHARD TISSUES  Primary dentition stage  Extensive dental caries  Hypoplastic upper and lower central incisors

Occlusal Analysis
SOFT TISSUES

Facial profile  Lip line  Lip seal

 

Habits

TRANSVERSE RELATIONSHIP

Slightly convex Normal lip line Incompetent lips Everted lips None Normal

Occlusal Analysis Cont

A-P RELATION Class I  Primary Is Flush terminal  Primary Ms 2mm  Overjet VERTICAL RELATION  Facial type Mesiofacial 3mm  Overbite Primate spaces SPACING

Teeth Present
EDCBA EDCBA ABCDE ABCDE

Diagnosis
EARLY CHILDHOOD CARIES Behaviour Frankle ( - )

Treatment plan
PREVENTIVE PHASE  Oral hygiene instructions  Dietary counselling  Dental prophylaxis  Topical fluoride application  Antimicrobial therapy (CHX) RESTORATIVE PHASE  Under GA

TREATMENT PLAN
Oral hygiene instructions, Dietary advice, Prophylaxis, Fluoride application  Quadrant 1: Exo 51,52buccal, 54 MOD, 55 occlusal Review OH and diet changes  Quadrant 2: Exo 61, 64 MOD, 65 occlusal  Quadrant 3: 74 MOD, 75 occlusal  Quadrant 4: 84 DO, 85 occlusal  Review 3/12 for Fluoride application, OHI and monitoring


Treatment Performed
Oral hygiene instructions ( Brushing and Flossing)  Diet analysis  Parent education regarding feeding habits


Dental Treatment
   

PrePre-operative Rt & Lt BW Prophylaxis 52 Buccal- GIC Buccal54 MOD- Formocresol MODpulpotomy, IRM, SSC, Ketac cement 55 Occlusal- vitrebond liner, OcclusalGIC base, Amalgam restoration

Dental Treatment


84 DO- vitrebond liner, DOGIC, SSC, Ketac cement 85 Occlusal- vitrebond liner, OcclusalGIC, SSC, Ketac cement

Dental Treatment
64 MOD-vitrebond liner, MODGIC, SSC, Ketac cement  65 Occlusal- vitrebond Occlusalliner, Amalgam restoration


Dental Treatment


74 MOD- vitrebond liner, MODGIC, SSC, Ketac cement 75 Occlusal- Formocresol Occlusalpulpotomy, IRM, SSC, Ketac cement

Dental Treatment
Extraction of 51, 61  Duraphat application  Post-operative Rt & Lt BW. Post

Post GA Review
    

Good oral hygiene Diet modified Improved feeding and sleeping Overall improvement in the quality of life Prescribed CHX Gel

Prognosis
Very good prognosis  Excellent patient and parents compliance


Long Term Treatment

Review 3/12  BW,  OH and Diet monitoring,  Topical Fluoride application  Monitor growth changes

TREATMENT PLANNING EXCERCISES