Caries management in permanent teeth
Management of caries in permanent teeth
Key recommendations
For a child with a carious lesion in a permanent tooth, choose the least invasive, feasible caries management strategy taking into account: the site and extent of the lesion, the risk of pain or infection, preservation of tooth structure and the health of the dental pulp, avoidance of treatment-induced anxiety, lifetime prognosis of the tooth, orthodontic considerations and occlusal development.
(Strong recommendation; low certainty evidence)
For a child or young person in pain due to pulpitis in a vital permanent tooth with irreversible symptoms and no evidence of dental abscess, consider carrying out a pulpotomy to preserve the tooth and to avoid the need for an extraction.
(Conditional recommendation; low certainty evidence)
There is increasing evidence to support the use of less invasive approaches to caries management in permanent teeth (as in the primary dentition) based on altering the environment of the caries/plaque biofilm. These methods reduce pulp exposure and help maintain tooth structural integrity.
There is low certainty evidence that pulpotomy is as effective as root canal therapy in permanent teeth and there are no significant differences in effectiveness between pulpotomy (partial/full) and direct pulp capping or pulpectomy.78 The effectiveness of several materials used in vital pulp therapy has been established.
Further details about the development of the recommendations in this guidance can be found in Methodology.
The principal evidence-based strategies for managing caries in the permanent dentition are:
- site-specific prevention (see Site-specific prevention)
- selective caries removal and restoration (i.e. walls prepared to hard dentine with adequate depth for restorative material, previously known as partial caries removal) (see Selective caries removal)
- complete caries removal, and restoration (see Complete caries removal)
Another option which is less supported by evidence is:
- no caries removal and fissure seal (see Sealant/infiltration)
Additional treatments that might be required for managing carious permanent teeth are:
- pulpotomy (see Pulpotomy for permanent teeth)
- pulpectomy/root canal therapy
- extraction (see Extraction)
The permanent teeth most vulnerable to decay in childhood and adolescence are the permanent molars.79 Caries most commonly develops at just two sites on permanent molars: at the base of pits and fissures, and on the proximal surfaces, just below the contact point. Both these sites present challenges to the clinician in terms of caries diagnosis and caries management.
Children may present with first permanent molars with advanced caries. In addition, approximately 15% of children will be affected by molar incisor hypomineralisation (MIH) to some degree.80 If a first permanent molar is assessed as having a poor lifetime prognosis (whether from caries or MIH), and the second permanent molar is not yet erupted, then it may be in the child’s best long-term interests to extract the first permanent molar, allowing the second permanent molars to erupt into its place (see First permanent molars of poor prognosis).
For the terminology used in this guidance to describe and define carious lesions in primary and permanent teeth see Lesion classification.
A flowchart to assist in making decisions about management options is provided in Supporting tools (see Management of caries in permanent teeth flowchart).
A table that illustrates the range of lesions for which these strategies can be considered is provided in Supporting Tools (see Options for management of carious permanent teeth table).
It is essential that every carious lesion has some active management. In children and young people, carious lesion activity is more changeable than in adults because they are less likely to have established oral health-related behaviours. Consequently, lesion activity is not one of the main influences in determining treatment. In this guidance, all lesions in permanent teeth have been considered to be active or likely to become active.
For details of the clinical techniques for these management options, see Dental techniques. This includes advice on avoiding iatrogenic damage to adjacent teeth when preparing multi-surface cavities, and use of local anaesthesia. For advice on referral for sedation and general anaesthesia, see Referral.
Develop the child’s personal care plan to prioritise keeping permanent teeth caries free.
- The primary dentition is transient, while the permanent dentition must last the child for life.
With a high index of suspicion for caries, thoroughly examine all first and second permanent molars, focusing on the base of pits and fissures and the proximal surfaces just below the contact points.
Taking all relevant factors into account, establish which treatment options are appropriate and which are in the best interests of the child.
- The Management of caries in permanent teeth flowchart and Options for management of carious permanent teeth table can be used to inform management decisions for caries in the permanent dentition. Further information about each type of carious lesion and management options can be accessed via the links below.
- Dental amalgam should not be used in the permanent teeth of a child or young person under 15 years of age unless exceptional circumstances can be justified.77
Avoid iatrogenic damage to the proximal surface of the adjacent tooth when preparing multi-surface cavities.
When managing a dentinal lesion, choose a technique that reduces the likelihood of pulpal exposure and maintains the structural integrity of the tooth.
If a first permanent molar is assessed as needing a restoration, consider temporising it until prevention is established and the child’s cooperation is sufficient to cope with the planned treatment.
When caries or MIH involves the first permanent molars, a comprehensive assessment will be required to evaluate the prognosis of these teeth and determine both an immediate and long term treatment plan, as detailed in First permanent molars of poor prognosis.
For first permanent molars with MIH:
- If there are carious lesions and/or enamel breakdown which are not severe, are not sensitive, do not require restoration and are unlikely to in the future, provide enhanced prevention, including fissure sealants, and monitor.
- If there is good quality enamel with small defects that require restoration, use adhesive restorative materials. Indirect restorations extending onto sound enamel have better longevity, and it may be necessary to modify the cavity shape to achieve this.
- If the molars are sensitive, use glass ionomer cement as a fissure sealant (see Professionally-delivered interventions).
Discuss the potential management options with the child and the parent/carer.
Agree a caries treatment plan, staging care as necessary (see Planning care).
Obtain valid consent from the child or their parent/carer depending on the age of the child.
Carry out the treatment.
- Helping the family provides further information about helping the family accept treatment.
- Dental techniques provides further information about each technique.
When restoring permanent teeth in children, ensure this is done to the same high standard as for adults to maximise the longevity of restorations and to minimise the amount of treatment required later in life.
Do not leave infection untreated.
Do not leave caries in permanent teeth unmanaged.
If at any time you have concerns about attendance, compliance or the child’s wellbeing, be prepared to provide additional support (see Providing additional support).