Caries management in primary teeth
Management of caries in primary teeth
Key recommendations
For a child with a carious lesion in a primary tooth, choose the least invasive, feasible caries management strategy, taking into account: the time to exfoliation, the site and extent of the lesion, the risk of pain or infection, the absence or presence of infection, preservation of tooth structure, the number of teeth affected, avoidance of treatment-induced anxiety.
(Strong recommendation; low certainty evidence)
For a child in pain due to pulpitis in a vital primary 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; moderate certainty evidence)
There is increasing evidence that less invasive approaches to caries management based on altering the environment of the caries/plaque biofilm are effective in managing caries in the primary dentition. These methods reduce pulp exposure and may reduce treatment-induced anxiety.
There is moderate certainty evidence that pulpotomy is an effective means of treating a vital primary tooth with irreversible symptoms, mineral trioxide aggregate (MTA) being the most efficacious medicament for healing the root pulp.76
Further details about the development of the recommendations in this guidance can be found in Methodology.
Based on the available evidence, the principal strategies for managing caries in the primary dentition are:
- no caries removal, seal with a crown using the Hall Technique (see Hall Technique)
- no caries removal and fissure seal (see Sealant/infiltration)
- 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)
- pulpotomy (see Pulpotomy for primary teeth)
Other options which are less supported by evidence are:
- site-specific prevention (no caries removal, active prevention) (see Site-specific prevention)
- non-restorative cavity control (which may include no caries removal, making the cavity and lesion cleansable, fluoride varnish application, silver diamine fluoride application) (see Non-restorative cavity control)
- complete caries removal and restoration (see Complete caries removal)
If none of these options is feasible, an extraction, or review with extraction if pain or infection develops, is necessary (see Extraction).
Involving the child and parent/carer in treatment decision making will encourage their engagement in their care. By adopting a minimally invasive approach to caries management, the risk of upsetting the child and causing treatment-induced anxiety will be minimised. Non-invasive management of initial carious lesions avoids the child entering the restorative cycle.
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 primary teeth flowchart).
A table that illustrates the ranges of lesions for which these strategies can be considered is provided in Supporting Tools (see Options for management of carious primary teeth table).
There will usually be more than one treatment strategy for each lesion and the dentist must use clinical judgement to select the most appropriate option for each clinical situation. It is essential that every carious lesion is actively managed.
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.
Taking all relevant factors into account, establish which management options are appropriate and in the best interests of the child.
- The Management of caries in primary teeth flowchart and Options for management of carious primary teeth table can be used to inform management decisions for caries in the primary dentition. Further information about each type of carious lesion and management options can be accessed via the links below.
- Use of dental amalgam in primary teeth should be avoided.77
Consider using bitewing radiographs for treatment planning (see Assessing carious lesions).
Discuss potential management options with the child and the parent/carer.
Agree a caries treatment plan, staging care and re-assessing this plan as necessary (see Planning care).
Avoid operative interventions involving local anaesthetic until the child can cope.
Use a minimally invasive approach to caries management whenever possible.
If cooperation allows, consider carrying out a pulpotomy for a child in pain due to pulpitis with irreversible symptoms.
Manage a primary tooth which is associated with infection (signs or symptoms of abscess, sinus, inter-radicular radiolucency, non-physiological mobility) either by extraction (see Extraction) or, in certain circumstances consider referral for pulpectomy (see Primary tooth - pain or infection).
- In some cases, local measures to bring infection under control may be appropriate.
Avoid iatrogenic damage to the proximal surface of the adjacent tooth when preparing multi-surface cavities. When restorations involve the distal of Es, take particular care to avoid damage to the first permanent molar. The Hall Technique may be indicated.
Obtain valid consent from the child or their parent/carer, depending on the age of the child (see Planning care).
Carry out the treatment.
- Helping the family provides further information about helping the family accept treatment.
- Dental techniques provides further information about each technique.
Do not leave infection untreated.
Do not leave caries in primary 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).