Clinical decision making for caries management in children

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Derek Banks Date: February 20, 2009
Article title: Clinical decision making for caries management in children
Author(s): N Tinanoff, J Douglass
Journal: AAPD Journal
Volume (number): 24:386-392
Month, Year: 2002
Major topic: Pit and fissure caries
Minor topic(s): Diagnosis
Type of Article: Position paper
Main Purpose: Discuss decision making for caries management in children
Overview of method of research: Review
Findings: A few factors should be taken into consideration when treating caries: 1. Location and extent of the lesions, 2. patient’s age, 3. Assessment and reassessment of disease activity, 4. prior therapy outcomes, 5. natural history of caries progression, and 6. preferences and expectations of guardians and practitioners. Studies show that the earlier a child becomes colonized with s. mutans, the greater their caries risk. We can assess this with microbiological tests, but when carious lesions are already present in young children (especially on upper incisors and molar proximal surfaces) it goes without saying that these patients are high caries risk. When determining whether to take preventative measures or perform operative dentistry, one factor to consider is that buccal-lingual smooth surface lesions respond better to these regimens than cavitated fissure/proximal lesions. A few studies demonstrated the average growth rate of proximal enamel-only lesions, showing that in primary teeth it takes about a year for them to spread to the dentin. Permanent proximal lesions took from one to three years. Many different modalities are available for the diagnosis of dental caries, but although they may have high specificity (ability to rule out caries), none have a high sensitivity (ability to confirm the presence of caries. Interestingly, a study showed that bitewing radiographs showed better sensitivity than clinical exam in pit/fissure caries extending to the dentin. This paper mentions the fact that in in-tact sealant can seal-in and “deactivate” caries… as long as the integrity of the sealant maintains. This paper mentions risk factors for caries which include low birth weight, age of colonization, s.mutans levels, presence of visible plaque, and sociodemogaphic factors. Toothbrushing and avoiding sweets make sense on a microbiological level, but have yet to be proven in in vivo longitudinal studies. This paper recommends fluoride supplementation only in non-fluoridated communities in moderate-to-high risk patients whose parents understand risks and benefits. We should focus instead on the topical effects of fluoride. Toothbrushing is lauded mainly for its ability to deliver fluoride – moreso than for it’s plaque-reduction, interestingly enough.
Key points/Summary : This paper is best summed up by it’s recommendation that “dental care should be based on preventive services and supplemented by restorative therapy only when indicated.”
Assessment of article: Good position paper.