Assessment of FPMs of poor prognosis

Consider the patient’s age and stage of dental development (e.g. whether SPMs have erupted).

• Extraction of FPMs of poor prognosis between 8-10 years old may cause less disruption to the occlusion, when SPM eruption into FPM space is desired. 

Assess the capacity of the patient to receive complex dental care, including consideration of any surgical, restorative, and orthodontic treatment that might be required.

Explore the aspirations and values of the child and parent for short-term and long-term dental care.

Consider the availability of services, including location, waiting times for potential assessment or treatment, and cost implications for the patient.

Determine if there is pain or infection associated with any FPMs. 

Assess each FPM to determine whether it is likely to be of poor prognosis. Useful indicators include:

• advanced occlusal or proximal carious lesions or new caries around existing restorations
• hypomineralisation that has caused sensitivity, breakdown and/or cavitation of enamel
• cavitation and loss of tooth substance in a pattern that makes effective restoration with adhesive restorative materials unfeasible, and indirect restorations are not indicated
• signs or symptoms of pulpal involvement
• signs or symptoms of dental infection

Management of MIH teeth is complicated by their hypersensitivity, and affected FPMs can be difficult to fully anaesthetise.⁸² Assessing for MIH related hypersensitivity can help avoid potentially traumatic experiences with associated increase in dental fear.

Determine the patient’s caries risk and suitability for orthodontic treatment.

Assess the occlusion.

Image shows a molar tooth with an advanced occlusal lesion.

To supplement the clinical assessment, obtain a good quality dental panoramic radiograph and any additional intraoral radiographs to take into account:

• whether all teeth are present (including third permanent molars and second premolars)
• the condition of the overall dentition
• the mesio-distal angulation of the SPM (if unerupted)
• the developmental stage of the SPM bifurcation (if unerupted)

Radiograph showing bifurcation of lower SPM forming.

When deciding on extractions (see Management of FPMs of poor prognosis), consider each FPM individually.