Scottish Dental Clinical Effectiveness Programme SDcep

Prevention and Management of Dental Caries in Children Guidance in Brief

April 2010

Scottish Dental Clinical Effectiveness Programme SDcep

The Scottish Dental Clinical Effectiveness Programme (SDCEP) is an initiative of the National Dental Advisory Committee (NDAC) and is supported by the Scottish Government and NHS Education for Scotland. The Programme aims to provide userfriendly, evidence-based guidance for the dental profession in Scotland. SDCEP guidance is designed to help the dental team provide improved care for patients by bringing together, in a structured manner, the best available information that is relevant to priority areas in dentistry, and presenting this information in a form that can be interpreted easily and implemented.

Supporting the dental team to provide quality patient care

Scottish Dental Clinical Effectiveness Programme SDcep

Prevention and Management of Dental Caries in Children Guidance in Brief

April 2010

Drug Prescribing For Dentistry

Scottish Dental Clinical Effectiveness Programme ISBN 978 1 905829 09 5 First published April 2010 Scottish Dental Clinical Effectiveness Programme Dundee Dental Education Centre, Frankland Building, Smalls Wynd, Dundee DD1 4HN Email scottishdental.cep@nes.scot.nhs.uk Tel 01382 425751 / 425771 Website www.scottishdental.org/cep

Prevention and Management of Dental Caries in Children

Overarching Principles
Refer to Section 2 of the full guidance
Prevention and Management of Dental Caries in Children is designed to assist and support primary care practitioners and their teams in improving and maintaining the oral health of their child patients from birth up to the age of 16 years. The aims when providing dental care for children are:
to keep the primary and permanent dentition free from disease; to reduce the risk of the child experiencing pain or sepsis or acquiring

treatment-induced dental anxiety if dental caries does occur;

for the child to grow up feeling positive about their oral health and

with the skills and motivation to maintain it. To achieve these aims, the priorities for the dental team are:
to encourage the childs parent/carer to take responsibility for their

childs oral health, implement preventive advice at home and meet their obligations to bring their child for dental care;
to apply the full range of preventive measures to the highest standard

possible;
to focus on prevention of caries in the permanent dentition before

management of caries in the primary dentition;

if caries in the permanent dentition does occur, to diagnose it early,

and manage it appropriately;

to manage caries in the primary dentition using an appropriate

technique that maximises the chance of the tooth exfoliating without causing pain or sepsis, while minimising the risk of treatment-induced anxiety;
to identify as early as possible those children where there is doubt or

evidence about a parent/carers ability to comply with dental health preventive advice, support or treatment uptake, and to contact and work collaboratively with other agencies, especially the childs named Health Visitor, School Nurse or General Medical Practitioner.

Prevention and Management of Dental Caries in Children

Overarching Principles
In practice, the prevention and management of dental caries in children comprises several stages as illustrated below. Each stage of delivering care is outlined in this summary of the guidance. For a full appreciation of the recommendations and further advice on following them, refer to the sections within the full guidance that are cited within this Guidance in Brief. A Care Checklist is provided on page 12.

Assessing The Child

Section 3

Providing Additional Support

Section 13

Dening Needs and Developing a Personal Care Plan

Section 4

Providing Care

if child is in pain

Managing Pain
Section 5

Referral
Section 11

Caries Prevention
Section 6

Helping Children Accept Care

Section 10

if caries is present

Suspected Dental Neglect

Section 13

Managing Caries
Sections 7, 8 & 9

Recall
Section 12

The full guidance can be downloaded at www.scottishdental.org/cep.

2

Prevention and Management of Dental Caries in Children

Assessing the Child

Refer to Section 3 of the full guidance
Gain rapport with both the child and the parent/carer. Parent/carers are fundamental to improving the childs oral health. Communicate effectively with the child and the parent/carer, remembering not to talk over the child. Parent/Carer Motivation and Ability to Take Responsibility Assess the ability and motivation of the parent/carer, and the child if old enough, to take responsibility for the childs oral health. Encourage parent/carers to take responsibility for their childs oral health and caries prevention and reinforce this throughout your care of the child. Contact the childs Health Visitor or School Nurse as early as possible if multidisciplinary support is required. Consider whether dental neglect is a concern, and take appropriate action if necessary (refer to Section 13 of the full guidance). Taking a History Take a thorough medical, dental and social history that includes asking about current brushing practice, dietary habits and previous experience of any treatment. Use the information gathered to inform your assessment of the child and/or parent/carers attitude towards oral health and their ability and motivation to take responsibility for it.

Prevention and Management of Dental Caries in Children

Assessing the Child

Clinical Assessment Assess the childs plaque levels and discuss this with the child and the parent/carer. Carry out a meticulous clinical examination for the presence of caries. Include radiographic examination at the appropriate intervals unless there is a valid reason not to; record this in the patients notes. Assess for pain and signs and symptoms of dental sepsis (e.g. swelling, sinus, nonphysiological mobility); if identied, ensure it is managed. For the primary dentition, assess the risk of any carious lesions causing pain or sepsis, prior to exfoliation, before deciding on a management option. Caries Risk Assessment Assess if the child is at increased caries risk (patient history, previous caries experience, resident in an area of deprivation, healthcare workers opinion) and use this to inform the frequency of review radiographs, preventive care provided and the recall interval.

Prevention and Management of Dental Caries in Children

Dening Needs and Developing a Personal Care Plan

Refer to Section 4 of the full guidance
Agree a personal care plan and the visits required with the parent/carer. If required, contact the childs Health Visitor to arrange home and community support for preventive interventions. Provide care in the following order: manage pain (if present), provide caries prevention for all children, manage caries/asymptomatic sepsis (if present). Prioritise maintaining the rst and second permanent molars caries-free over managing caries in the primary dentition.

Managing Pain (if present)

Refer to Section 5 of the full guidance
Diagnose pain (reversible pulpitis, irreversible pulpitis or dental abscess) and manage it promptly. Avoid dental extractions on a childs rst visit if at all possible.

Prevention and Management of Dental Caries in Children

Caries Prevention
Refer to Section 6 of the full guidance
Consider action planning to improve compliance with preventive advice. Standard Prevention for all children Give toothbrushing advice at least once a year:
Brush at least twice daily, in the morning and last thing at night, Use the correct amount of a toothpaste with age-appropriate uoride

concentration:

Under 3 years old: use a small smear of paste containing not less
than 1000 ppm uoride

36 years inclusive: use a pea-sized amount of paste

containing not less than 1000 ppm uoride

7 years old or over: use paste containing 13501500 ppm uoride

Spit, dont rinse. Help children under 7 years old and continue to supervise older children

until condent in their brushing habits. In the early stages of providing care give hands-on brushing instruction. Give dietary advice at least once a year:
Restrict foods and drinks containing sugar to meal times. Drink only water or milk between meals. Snack on sugar free snacks (e.g. fresh fruit, carrots, peppers,

breadsticks, occasionally a little cheese).

Do not eat or drink after brushing at night. Be aware of hidden sugars in some foods and the acid content of

drinks. Apply sodium uoride varnish (5%) twice a year to children over 2 years of age (see note below).
Note A child who has been hospitalised due to severe asthma or allergy or who is allergic to sticking plaster may be at risk of an allergic reaction to varnishes containing colophony. In these cases, use an alternative colophony-free varnish or suggest use of other topical uoride preparations.

Prevention and Management of Dental Caries in Children

Caries Prevention

Enhanced Prevention for children at increased risk of caries Provide Standard Prevention at each recall visit (toothbrushing and diet advice and apply uoride varnish as above). Give hands-on brushing instruction at least once a year. Consider:

recommending 13501500 ppm uoride toothpaste for children

over 3 years old

the use of toothbrushing charts and disclosing tablets, and

providing free toothpaste and a free toothbrush

encouraging motivated parents/carers to oss the childs teeth

at the D/E/6 contacts immediately after brushing 2 or 3 times per week, particularly if enamel-only caries is present on the mesial of 6s

prescribing 2800 ppm uoride toothpaste for children over 10

years old Consider the use of toothbrushing charts and food and drink diaries. Apply sodium uoride varnish (5%) an additional 1-2 times per year to children over 2 years of age unless provided via Childsmile in nursery or school (see note). Place resin ssure sealants in susceptible pits and ssures.
If necessary, consider using glass ionomer cement as a temporary sealant. If unable to provide ssure sealants because of the child being pre-

cooperative or learning disabled, then refer the child to have this treatment provided. Check existing sealants visually for wear and physically with a probe for integrity/ leakage at every recall visit. Top up worn sealants if the child is still at increased risk of caries. Consider collaboration with the Health Visitor or School Nurse to provide community/ home support for preventive interventions.

Prevention and Management of Dental Caries in Children

Management of Caries in Permanent Molars

Refer to Sections 7 & 9 of the full guidance
For carious occlusal pits and ssures on rst and second permanent molars If ssure caries is suspected, only restore if there is either:
microcavitation

or
shadowing visible under the enamel adjacent to the ssure after

cleaning and drying the tooth or

dentinal caries clearly visible on a bitewing radiograph

In any of these cases, remove caries, place a restoration, and seal the remaining ssures. Otherwise place a ssure sealant alone, and review the tooth at every recall visit. For carious approximal surfaces on rst and second permanent molars Make it a priority to identify and arrest early enamel-only lesions on the mesial surface of 6s by:
applying uoride varnish, and monitoring for progression with

bitewing radiographs;
ensuring parent/carers are aware of the potential impact on their

childs oral health, and encouraging them to oss or use oss wands on the 6/E contact 23 times a week;
if the distal of the E is carious, considering managing the E with either

a restoration, a Hall crown or slice preparation (taking care to avoid iatrogenic damage to the 6), or even extraction of the E. For rst permanent molars of poor prognosis At around the age of 9 years, make an assessment of the likely prognosis of any 6s affected by caries. If prognosis is poor, consider planned loss.

Prevention and Management of Dental Caries in Children

Management of Caries in Primary Teeth

Refer to Sections 8 & 9 of the full guidance
Available management strategies include:
complete caries removal partial caries removal no caries removal, seal with restoration no caries removal, provide prevention-alone or after rst making the

lesion self-cleansing
extraction or review, with extraction only if pain or sepsis develops

Choose management options for carious primary teeth that balance a reduction in the risk of pain or sepsis from the tooth in the future with the childs ability to accept treatment now. Avoid operative interventions involving local anaesthetic until the child can cope. Do not use conventional glass ionomer cements for Class II restorations. Manage a primary tooth that is associated with sepsis (signs or symptoms of abscess, sinus, inter-radicular radiolucency, non-physiological mobility) with either a pulp therapy or an extraction; do not leave sepsis untreated. Closely monitor lesions managed with prevention only. Do not leave active caries in primary teeth unmanaged.

Prevention and Management of Dental Caries in Children

Helping Children Accept Treatment and Referral

Refer to Sections 10 & 11 of the full guidance
Use good behavioural management techniques to help children accept treatment. If this is unsuccessful, ensure that the child is referred to the appropriate service to receive care. Ensure that the childs dental pain is relieved before referring. Include all relevant information in the referral letter.

Recall
Refer to Section 12 of the full guidance
Assign a recall interval that is based on caries risk and is specic to the oral health needs of the child. If caries is not being effectively controlled, consider the need for additional multidisciplinary support.

10

Prevention and Management of Dental Caries in Children

Full Guidance
Supporting tools and a range of other information to assist the dental team deliver appropriate care are provided in the full guidance. These include:
illustrated step-by-step advice on individual
8 Manag ement of Caries Primary in Teeth
Partial
Prevention and Mana gement of Denta l Caries in Child ren

8.2

Remova Aim: to l and remove Restorat sufcient bonded ion adhesive carious tooth tissue restorative material, to enabl e an effect and thus inhibit ive marg further progression inal seal to be Advantage obtained of residu Evide s with a nce, largel al caries . y from private secondary practice, care and that this effective 25 Disadvanta approach . As caries ges can be Reduc is ed risk seal must left in the cavity of pulpa , the marg l expos be effect Reduc ure. progression inal ive to ed time prevent . for cavity less need caries preparation No evide for local anaes , nce, and Partic thesia. as yet, effective ularly suited that this in Prima approach to ART ry Care. approach. is
As it is imperative to obtain adhesive materials a comp lete preferred is likely to be most marginal seal option to slow for Class successful or arrest II lesion on Class caries progr s. I lesion ession, s, with the use preformed metal crown of plastic for prima s being ry mola the rs If neces sary, gain access to caries As this using a approach high-speed rarely requir local anaes handpiece. thetic is es the cutting usually unnecessary of sound dentine, .

Caries

Technique

clinical techniques

Remove supercial until there caries with is no obvio a slowand the speed handp cavity allow us caries visible iece or be place s an adequ at the d. enamel-den excavators, ate thickn tine juncti ess of restor Take ative mater on extra care ial to not to cause if cuttin g a Class iatrogenic II cavity around damage (see Sectio the adjac to adjac n 9.3). ent tooth ent teeth Placing Be aware may help. a matri of the x band pulp cham pulpal exposure. ber anato my to reduce the risk of

10 Hel ping

Prevention

and Mana

Childre

gement

n Accept

of Denta

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Care

in Child

ren

Figure

5 Asse

ssing

This diagra nt optio ns for m illustr the child to provid ates decisi e care with cario using good ons to be made this has us prim when consid been reliev behavioural ary teeth ed and ering referr manageme that there al for treatm nt techn are no iques medical ent after complicatio . It is assumed rst attem that if pting ns. the child is in pain,

manageme

47
YES

Is the patien or learnin t emotionally g disable d?

owcharts

for decision making about prevention and management options

Is there a need early extrac for tion carious teeth? of

YES

NO

NO

Is the child unlikely accept to treatm some pre-sc ent (e.g. hool childre n)?
YES

Support

Append

Preventio

ing To ols

ix 5

referral n and Man for inhala agem tion sedation ent of Den or GA and continue Enhanced Prevention

Consid

er

NO

tal Cari

to exfolia es in Chil tion? dren

YES

Are teeth

near

NO

Could teeth be manag a preven ed until the tion alone appro with child is treatment? able to ach accept (factors lihood to consider includ of pain; e: likeparent/carer extent s suppo of caries; hood of cooperation rt; likelideveloping)
YES NO

A5.1

Care Checklist a reminder of the essential

elements of the assessment, prevention and the management of caries in children (also included in this summary)

ced Prevention for a prevenappointment and review Going s monitor. and tive and through restora need for tive Build on this chec and likely programme includes extractions to return cooperation klist for all of the follow up appoin for and each child reassess essential tments? ability to childs patient elements is a treatmentaccept of carie Before s preventio means of con placing YES a child rming n and man NO on reca that the Provid agement. ll, ask your care eyou Enhanced and caries As part Preven self prov the follo manag ide tion of you unable ement. to wing: Extract r assessm If consider carry out treatm pulpal encourag using inhala ly involve ent of sedation referral for inhala ent, d the child ed the rst choice tion sedati teeth Enhancedor GA, and contintion on as parent/ca . have you regard Contin Prevention ue ue to brus : PreventionEnhanced hing, and rer to take resp and manag onsibility regular arranged ement caries attendan for the multidisc ce? oral heal iplinary th of their checked support via a Hea all exist child, part ing seala lth Visit icularly nts: or or Scho with visua ol lly, for Nurse, wear if required? physically with a probe, and top for integ rity/leaka ped up ge if necessary checked radiograp ? or reco hically the occl rded a sound usal and reason approxim checked not to? al surfa clinically ces of the and radio teeth? permanen graphica t molars lly for the pres for early checked ence of caries, whether sepsis asso (caries any prev arresting ciated iously with any , good selected plaque carious preventio carried control primary out and n-alo on surfa recorded ce of lesio ne caries man a caries considere agement n) and, risk asse d the poss if not, chos strategy ssment? ibility of is effe en an alter dental native strat ctive neglect As part and take egy? of you n appropri r preventi ate actio checked ve care n if susp that the have you ected? child and and thes : the pare e key mes nt/carer sages? understa brush nd the twice a critical importan day ce of thor use an ough toot appropri ate amo hbrushin unt of spit, g 1000 dont rinse ppm uoride given dieta toothpas ry advice? te applied sodium uoride varnish ssure (5%), or sealed all susc recorded reason eptible a valid not to? pits and reas on ssures not to? agreed if the child an actio is at incre n plan with the ased carie child and s risk, or parent/ca recorded rer to impr a valid ove com pliance with prev entive advi ce?

Care Che ckl

ist

Contin ue Enhanced Prevention, monitor lesions

Is parent attend /carer willing an to number adequate of

Provide

Enhan

Consid er referral for inhalation sedation or GA and continue Enhanced Prevention

67

88

Prevention Log for keeping a record of

Patient

85
Assess Date
Age 5-6 Examinati Provide on Fissure advice Advise seal 6s laterallyon brushing 6s Age 6-7 Examinati Provide on advice Age 7-8 Examinati Provide on advice Age 8-9 Examinati Provide on advice Assess prognosi of 6s s Age 9-10 Examinati Provide on advice
Current brushing practice Motivatio and paren n responsibi tal lity Caries

preventive interventions for an individual child

ABC Prev enti

Show new

on Log (Ages 5-10) Bring to attentio n

Brushing instructio n

Preventio

Diet

Show risk areas

Clinical
Radiograp Fluoride varnish

risk

Multiagen cy action requested or being provided

Snacks and Drinks advice

n and Man

Suppor

Care
Monitor occlusion prognosis and of 6s

Append

teeth

Fissure sealants: place, mon and top itor up

ting Too

agem

hs

ix 5
dren

ent of Den

ls

tal Cari es in Chil

Caries Prevention Reminder by Age a

Suppor

Append

Prevention

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ix 5

and Man

agement

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ls

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summary of preventive interventions appropriate for children year-by-year from birth to 16 years of age

Age 4 to 5 year s Assess

Caries

Standard

Prevent

Prev For all childr ention en

ion Rem

inder
Enha For childr nced Prev ention en caries risk, assessed as at incre in addit ased ion Prevention to Standard

Patient

Radiogra Motivati

phs

Parent/care Brushing rs ability and motivation practice Diet Caries risk

on Consider Consider use of taking initial action radiograph planning ABC bitewing s Preventi on Log Cons ider conta (Age s Hands 6) Health Bring to support 10-1cting on brush Visitor during ing instru atte Cons for ntio the idern ction early possible previously childs care dental if not given neglect Provide Provi Standard Clinical de advic each recall Prevention e Care 2 minu at least advice once per tes twice Hands at on brush year: Use daily a pea-s once a ing instru year ction at 1000 ppm ized amount Consider least of uori Spit, free brush dont rinse de paste Consider and paste Adult toothbrush supervision Consider disclosing ing charts Consider uoride recommending toothpaste 1350-1500 Provide Consider ppm advice at least contacts advising paren Restr once per t/carer ict sugar to oss to no more year: 4 times DE Provide than Drink per day Standard each recall only Prevention meals (may water or milk advice Motivate at now drink between milk) and be semi-skimm positive Consider Suga and supp use of ed r-free snack diet diarie ortive Consider Noth s only s use of ing action Be awar after brushing planning at Be awar e of hidden sugar night s in food e of acid conte Apply uori nt of drink s de varnis h 2 times per year Apply uori times per de varnish an addit year ional 1-2 Consider ssure sealing Monitor Es if coop existing erative indicated sealants and top up if

Toothbru

Date

shing

Assess

Age 10-1 Examinati 1 Provide on Fissure advice seal 7s Advise on brus hing 7s Age 11-1 Examinati 2 Diet Provide on Fissure advice seal 7s Advise on brus hing 7s Age 12-1 Examinati 3 Provide on Monitor Advice for changes in carie signs ofs risk and erosion Age 13-1 Topical Examinati 4 uoride s Provide on Advice Fissure
sealants

Current brushing practice

Brushing instructio emphasis n ing 7s Motivatio n child takinand responsibil g for preve ity ntion

Caries

Diet

Multiagen cy action requested being provi or ded Snacks and Drinks advice emphasisin g acid content of drink s

risk

Fluoride varnish

Radiograp

Fissure seala place, nts: mon and top itor up

Monitor occlusion

hs

sources of further information and contact

Age 14-1 Examinati 5 Provide on advice Age 15-1 Examinati 6 Provide on advice

details

95

The full guidance can be downloaded at www.scottishdental.org/cep.

11

Prevention and Management of Dental Caries in Children

Care Checklist
Before placing a child on recall, ask yourself the following: As part of your assessment of the child have you: encouraged the parent/carer to take responsibility for the oral health of their child, particularly with regard to brushing, and regular attendance? arranged multidisciplinary support via a Health Visitor or School Nurse, if required? checked all existing sealants:
visually, for wear physically with a probe, for integrity/leakage and topped up if necessary?

checked radiographically the occlusal and approximal surfaces of the permanent molars for early caries, or recorded a sound reason not to? checked clinically and radiographically for the presence of sepsis associated with any carious primary teeth? checked whether any previously selected prevention-alone caries management strategy is effective (caries arresting, good plaque control on surface of lesion) and, if not, chosen an alternative strategy? carried out and recorded a caries risk assessment? considered the possibility of dental neglect and taken appropriate action if suspected?

12

Prevention and Management of Dental Caries in Children

Care Checklist

As part of your preventive care have you: checked that the child and the parent/carer understand the critical importance of thorough toothbrushing and these key messages?
brush twice a day; use an appropriate amount of 1000 ppm uoride toothpaste; spit, dont rinse.

given dietary advice? applied sodium uoride varnish (5%), or recorded a valid reason not to? ssure sealed all susceptible pits and ssures if the child is at increased caries risk, or recorded a valid reason not to? agreed an action plan with the child and parent/carer to improve compliance with preventive advice? As part of your caries management have you: managed caries in the pits or ssures of 6s and 7s appropriately? managed enamel-only approximal caries in 6s and 7s effectively? considered the prognosis of any carious 6s and, if this is poor, considered planned loss? selected an appropriate management option for any active carious lesions in the primary dentition that you assess as likely to cause the child pain or sepsis before exfoliation? used appropriate behavioural management techniques to help the child to accept treatment or referred the child who is unable to accept treatment despite behavioural management techniques?

13

Prevention and Management of Dental Caries in Children

Notes

14

Prevention and Management of Dental Caries in Children is designed to assist and support Primary Care practitioners and their teams in improving and maintaining the oral health of their child patients from birth up to the age of 16 years. It provides clear guidance on what to do, when to do it and how to do it. It includes advice on: assessment of the child delivery of preventive care based on caries risk choosing from the range of management options available delivery of restorative care, including how to carry out specic treatments for children recall and referral providing additional support management of suspected dental neglect This Guidance in Brief presents the main recommendations within the full guidance. For more detailed advice about these recommendations and how to follow them, refer to the full guidance. Supporting tools to assist the dental team deliver appropriate care are also provided in the full guidance. As guidance, the information presented here does not override the clinicians right, and duty, to make decisions appropriate to each patient with their consent.

Scottish Dental Clinical Effectiveness Programme Dundee Dental Education Centre, Frankland Building, Smalls Wynd, Dundee DD1 4HN Email scottishdental.cep@nes.scot.nhs.uk Tel 01382 425751 / 425771 Website www.scottishdental.org/cep