Caries Management for Paediatric Patients PDF

**[CARIES MANAGEMENT FOR PAEDIATRIC PATIENTS]** **[AIMS]** **[01 Prevalence]** Review the prevalence of caries in paediatric patients **[02 Diagnosis]** Review caries diagnosis methods and caries classifications **[03 Management]** Recap guidance related to caries prevention and management te...

**[CARIES MANAGEMENT FOR PAEDIATRIC PATIENTS]** **[AIMS]** **[01 Prevalence]** Review the prevalence of caries in paediatric patients **[02 Diagnosis]** Review caries diagnosis methods and caries classifications **[03 Management]** Recap guidance related to caries prevention and management techniques **[04 Cases]** Review cases of pediatric patients with caries **[Objective]** To diagnose and appropriately prevent and manage caries in paediatric patients **[Caries]** "A biofilm-mediated, sugar-driven, multifactorial, dynamic disease that results in the phasic demineralization and remineralization of dental hard tissues" A multi-factorial disease resulting from genetic, environmental and behavioural factors *Dental caries is known to be, globally, the most widespread non-communicable disease* **[Early Childhood Caries]** Caries characterized by the presence of **one or more teeth** affected by **carious lesions** or with white spot lesions in primary teeth, **loss of teeth** due to caries, or **filled tooth surfaces** in affected teeth of a child aged **under six years**. *Children with early childhood caries have shown to have a higher number of teeth affected by progressive disease* **[Severe Early Childhood Caries]** - Age \< 3: smooth surface caries - Age 3-5: 1 or more cavitated missing or filled smooth surface in maxillary anterior teeth - Age 3: dmft \>4 - Age 4: dmft \>5 - Age 5: dmft \>6 - *Early childhood caries is classed as severe when there is presence of smooth surface caries in a child under the age of 3. From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) surfaces constitutes S-ECC* - *Risk factors include the primary caregiver having active caries, a child having more than three between-meal sugar-containing snacks or beverages per day and a child being put to bed with a bottle. Another significant risk factor is the caregiver having a low socio-economic status, leading to a lack of oral health knowledge and sometimes lack of access to healthier food options. Other risk factors include children taking certain medications and decreased salivary flow rates.* - *The bacteria most commonly associated with early childhood caries are mutans streptococci, which metabolises sugars, lowering the pH of plaque resulting in demineralisation of enamel. Mutans streptococci can be transmitted from mothers with untreated caries to the child, which when combined with frequent snacking can increase the risk of caries in the primary dentition.* **[PREVALENCE]** **Oral health survey of 5-year-olds 2022** England: 23.7% North West: 30.6% *The public health England survey of oral health of 5-year-old children is completed every 2 years.* *It was last completed in 2022 and found the prevalence of dentine caries in England to be 23.7%, similar to the results found in the 2019 survey.* *The prevalence of dentine caries in 5 year olds in the north west was the highest in England, at 30.6%.*  **Oral health survey of 5-year-olds 2022** England mean: 0.8 North West mean: 1.2 *Children from areas with a higher rate of socioeconomic depravation are also more likely to have a greater number of teeth with dental decay and a lower incidence of teeth treated with restorations.* **[CLASSIFICATIONS]**  Caries can be classified through the stages of disease severity. It is often thought of through the iceberg metaphor which has been widely used since 1994. - This model ranges from D0, known as subclinical lesions to, D4 - D1 lesions are thought of as white spot lesions, clinically detectable enamel lesions with intact surfaces - D2 are clinically detectable cavities limited to enamel - D3 is known as clinically detectable caries into dentine - D4 are lesions into pulp - ICDAS identifies carious lesions based on their clinical appearance, with 7 possible scores ranging from 0 to 6 - A score of 0 indicates a sound tooth - 1 the first visual change in enamel, seen only after a period of prolonged drying and restricted to a pit or fissure - A score of 2 denotes distinct visual changes in enamel - 3 is localized enamel breakdown without clinical visual signs of dentinal involvement - 4 is an underlying dark shadow from dentine - 5 a distinct cavity with visible dentine - And 6 an extensive distinct cavity with visible dentine **[CARIES RISK]** - Previous caries experience. Previous disease increases a child's risk of future caries, this is due to multiple risk factors including habits and high levels of mutans streptococci - Dietary habits, especially the frequency of sugary food and drink consumption - Social factors such as socioeconomic status - Oral hygiene habits and the use of fluoride - Medical history including developmental delays, physical disabilities and utilisation of medications high in sugar - A reduced salivary flow as a result of medical conditions or drug therapy can also increase caries risk - Caries in young children is often associated with high levels of mutans streptococci - Sometimes patients and their parents or carers may not be truthful -- you may sometimes just have a hunch related to the patients caries risk **[INFANT FEEDING]** **[Risk Assessment]** - Caries risk should be reassessed at each visit - Risk assessment should be based upon: - Patient history - Medical history - Socioeconomic status - dmft - Caries risk should be used to inform frequency of recall visits and preventative advice **[Diagnosis]** An evidence based, structured and systematic approach to caries diagnosis including disease staging - **Visual examination** - **Radiographs** - **Temporary tooth separation** - Fibre-optic transillumination - Magnification - Electric caries monitor - Diagnodent laser fluorescence Caries diagnosis should be an evidence based, structured and systematic approach and should include disease staging, as per the classifications mentioned earlier There are may aids to caries diagnosis. These include: - Visual examination - Radiographs such as bitewings -- as per FGDP, the need to expose children to ionising radiation should be carefully considered. Bitewing radiographs, even in very young children can aid diagnosis of interproximal and occlusal caries. It is recommended that high caries risk children have six-monthly bitewings taken until no new or active lesions are apparent and the child has entered another caries risk level. Bitewings should be taken annually in children with moderate caries risk and those with a low caries risk should have bitewings taken every 12-18 months in the primary dentition. Occlusal radiography can also aid diagnosis of anterior caries. - Temporary tooth separation with orthodontic separators can be used as a method to directly assess caries on approximal surfaces of the teeth. This method is most useful when assessing if a tooth is cavitated or not. Fibre-optic transillumination can be used as an adjunct to radiographs and can detect dentinal caries on approximal surfaces. - Electric caries monitor - Diagnodent laser fluorescence - Magnification **[Management]** - Age and cooperation - Patient and parent/ carer motivation - Extent of caries - Surfaces affected - Pulpal symptoms Treatment planning for carious primary teeth is different than that of permanent teeth, predominantly focussed on the limited lifespan of the tooth and autonomy of young children. Factors that should be considered when treatment planning for carious primary teeth include: - Age and cooperation of the patient - Motivation of the patient and parents/ carers - Extent of caries and surfaces affected - Pulpal symptoms - Treatment approaches can be broken down into preventative, biological and surgical management **[Prevention]** Preventative measures are dependent on a patients age and caries risk.  **[Children aged up to 3 years]** **[Children aged 3 to 6 years]**  **[Children aged up to 6 years giving concern because of caries risk]** **[Children from 7 years]**  **[Children from 7 years giving concern because of caries risk]** **[Recall]** - *NICE guidelines 2004 are used as an aid for clinicians to assign recall intervals between oral health reviews that are appropriate to the needs of individual patients.* - *The guidelines specify that the shortest interval between oral health assessments should be 3 months. A recall interval of less than 3 months is not normally needed for a routine dental recall. A patient may need to be seen more frequently for specific reasons such as disease management, ongoing courses of treatment, emergency dental interventions, or episodes of specialist care, which are outside the scope of an oral health review. The longest recall interval for patients under the age of 18 should be 12 months. There is evidence that the rate of progression of dental caries can be more rapid in children and adolescents than in older people, and it seems to be faster in primary teeth than in permanent teeth (see full guideline). Periodic developmental assessment of the dentition is also required in children. Recall intervals of no longer than 12 months give the opportunity for delivering and reinforcing preventive advice and for raising awareness of the importance of good oral health. This is particularly important in young children, to lay the foundations for life-long dental health.* **[Behavior Change]** - Improving Oral Hygiene - Increasing exposure to Fluoride - Reducing sugar intake and healthier eating - Regular dental assessments - *A patient's ability to change their behaviour is influenced by an array of individual, social and environmental factors, with socio-economic circumstances being a major influence * - *Changing behaviour should be considered as a cycle. It may start with patients being unaware of the issue, through a time when they are thinking about making a change, to when they are actively preparing to change by planning and setting goals, to when they are ready to act, and then trying to maintain the change avoiding relapse.* - *Toothbrushing can be facilitated through a number or methods. These include providing disclosing tablets to be used in the clinic and at home, alongside guidance with toothbrushing technique. Plaque charts can also be used as an aid in clinic. Patients can also be encouraged to use timers or toothbrushing apps to ensure they are brushing for the correct amount of time* **[Fluoride]** **[Toothpaste]** - Evidence supports use of fluoridated toothpaste - Evidence is less strong on fluoride concentrations 1450ppm toothpaste has slightly improved caries reduction rates in primary teeth than lower strengths of fluoridated toothpaste - *Increasing awareness and exposure to fluoride is recommended for patients with high caries risk.* - *There are many sources of fluoride, both natural such as food and drinks such as fish and tea and naturally occurring fluoridated water supplies and artificial including toothpastes, gels, varnishes, supplements, artificially fluoridated water supplies and artificially added to foods and drinks such as milk.* - *Evidence strongly supports the benefits of using fluoridated toothpaste vs non-fluoridated toothpaste. The evidence is however less strong for the effects of different fluoride concentrations. The Cochrane review completed in 2019 found the use of 1450ppm toothpaste to have a slightly improved rate of caries reduction in primary teeth when compared with lower strengths of toothpaste.* **[Mouthwash]** - 0.05%, 230ppm - Used at a different time to brushing - Greatly reduces caries incidence in permanent teeth - Careful patient selection *Children aged 8 and above giving concern due to caries risk can be prescribed a sodium fluoride mouthrinse. This is usually a daily mouthrinse of 0.05% strength, with 230ppm fluoride to be used at a different time to brushing.* *Randomised controlled trials have shown the use of fluoride mouthrinses to greatly reduce the caries increment in permanent teeth, with no adverse effects of its use. Careful patient selection is required for the prescription of fluoride mouthrinses, avoiding use in children with learning disabilities or those who cannot rinse.* **[Varnish]** - 2.25%, 23000ppm - Strong evidence base for fluoride varnish - prevention and caries arrest - 37% reduction in caries incidence - *There is a strong evidence base for the use of fluoride varnish. Duraphat varnish has a strength of 2.25%, with 23000 ppm. It can be used as a prevention tool or to arrest early caries such as white spot lesions.* - *It has been found that use of fluoride varnish as per delivering better oral health recommendations can provide a 37% reduction in caries incidence in primary teeth when evaluating patients DMFT.* **[Water]** - Strong evidence base - 1ppm WHO recommends maximum level 1.5mg/l - Toxicity in children = 5mg/kg - Lethal dose = 16mg/kg - *In the UK approximately 10% of the water is fluoridated -- this has been proven to be a cost effective prevention method and one which effectively reduces social inequalities of healthcare.* - *Current areas with a fluoridated water supply include parts of the west midlands, north east, east midlands, eastern England, the north west and Yorkshire. There are many arguments for and against water fluoridation. It is a safe method which has been proved to prevent caries. However, some see water fluoridation as mass medication, taking away freedom of choice. It also only currently targets a small proportion of the population.* - *1ppm is the accepted level, however the WHO recommends a maximum of 1.5mg fluoride per litre of water. This is to maximise oral health benefits whilst minimising the risks of fluorosis.* - *There is a strong evidence base for water fluoridation however it must be used in appropriate therapeutic ranges to avoid toxicity. Adverse effects of too much fluoride include fluorosis, if there is a high systemic uptake at a young age, GI upsets or in the most extreme scenarios, Death. Fluoride toxicity Is most commonly caused by children ingesting too much toothpaste, and is mainly seen in children under the age of 6. The known toxicity levels of fluoride in adults and children is 5mg per kg, with a lethal dose of 16mg/kg in children.* - *Fluoride supplements are also available for use in children however their effect is unclear in reducing the risk of caries in primary teeth.* - Water fluoridation reduces caries prevalence 14.8% increase in caries free children Mean dmft/DMFT reduction of 2.25 teeth - Water fluoridation reduces inequalities in dental health across social classes in 5 and 12 year olds **[Silver Diamine Fluoride]** **Off license** Indicated in asymptomatic, cavitated carious teeth **Riva Star** 38% silver fluoride 44800ppm fluoride **SMART technique** Silver modified atraumatic restorative technique - *SDF Is a topical solution, currently only licenced as a desensitising agent for non-carious lesions, but also used clinically off licence for caries arrest, especially indicated in those children who are unlikely to tolerate invasive treatment. The use of SDF can also be used as an aspect of acclimatisation and for caries management in pre-cooperative children.* - *SDF is indicated for use in asymptomatic but cavitated carious teeth, lesions that can be made cleansable, for patients with MIH and as a temporary measure prior to treatment under sedation or general anaesthetic, It can also me used as a caries detection agent. Contraindications to the use of SDF include pain, infection, lesions which are not arresting, radiographic signs of PA pathology, for patients concerned about appearance of anterior teeth, those with ulceration or allergies to any of the products found in the SDF solution.* - *SDF consists of silver, with antibacterial properties, fluoride and ammonia irons to stabilise the solution. Riva star, the only available preparation in the UK, is 38% silver fluoride, containing 44800ppm fluoride. SDF is known to be the most cariostatic of all fluoride agent.* - *SDF works to block the dentinal tubules to reduce sensitivity and remineralise the tooth structure. It also inhibits demineralisation of enamel and dentine and destruction of the dentine collagen matrix. The silver also provides some bacterial action against cariogenic bacteria.* - *The use of SDF off label is permitted in the UK if there is a strong body of evidence and no alternative licenced medication available. There is a great body of evidence to support the use of SDF for caries arrest, with systematic reviews finding an 81% reduction in active carious lesions. It has also been shown that, when compared with a placebo, fluoride varnish or no treatment, SDF can prevent caries in the entire dentition.* - *The main adverse effect of SDF is dark staining of carious tooth structure and surrounding soft tissues.* - *SDF can be used as part of the SMART technique to restore carious primary teeth. SMART stands for the silver modified atraumatic restorative technique, which involved a tooth being restored with GIC following application of SDF. This technique has the increased benefit of fluoride release from GIC. SDF can also be used prior to application of a preformed metal crown using the hall technique. There is currently no strong evidence in the form of randomised control trials to support the SMART technique.* **[Behavior Change]** - Improving Oral Hygiene - Increasing exposure to Fluoride - **Reducing sugar intake and healthier eating** - Regular dental assessments - *Independent of caries risk, all patients should receive dietary advice at their recall visits. However, those with a higher caries risk will likely need further encouragement, adjunct and support in order to promote behaviour change in their dietary habits.* - *The WHO has released guidance related to sugar intake for adults and children. They recommend reducing the intake of free sugars to less than 10% of total energy intake.* - *When giving dietary advice we can consider the three Ps -- it should be personal, practical and positive. It should focus on the amount and frequency of intake of foods and drinks containing free sugars and fermentable carbohydrates.* - *Children with a high risk of caries may require further support with their dietary advice, in the form of a 3 day diet diary. This should be completed over 2 week days and 1 weekend day and then reviewed at the patient's next visit. When giving feedback related to the diet diary your advice should be practical, constructive and supportive.* - *Advice should also be given related to the Eatwell plate, developed by public health England - the aim of this is to give recommendations related to eating a healthy, balanced diet.* - *Behaviour change related to recommended recall intervals should also be encouraged -- Dental check by one, mini mouthcare matters* **[Fissure Sealants]** - Effective caries prevention tool for permanent teeth - Insufficient , low-quality evidence to support use in primary dentition - *There is moderate quality evidence that the use of fissure sealants is an effective caries prevention tool for permanent teeth. A Cochrane review was released this year, evaluating the use of sealants as a caries prevention tool in the primary dentition. They found insufficient evidence of a difference in the development caries with fluoride releasing sealants vs no sealant. Evidence in general was of very low quality and it was concluded that further evidence is required related to the caries preventative effect of sealants in the primary dentition.* **[Preformed Metal Crowns]** - Outperform conventional restorations - 95% success rate when placed by Paediatric Dental Specialists - Treatment choice for carious lesions: Involving 2 or more surfaces Extensive one surface lesions - *Preformed metal crowns are known to be the gold standard restorative option for carious primary molar teeth. They work by denying the biofilm microbes their source of nutrition, preventing caries progression.* - *There are varying reports in the outcomes of PMCs when compared to conventional restorations. Innes, reports that the use of preformed metal crowns using the hall technique outperforms conventional restorations. However, Ala bani hani et al, 2018 found that there was no difference in the success rates of hall technique preformed metal crowns and conventional restorations when placed by paediatric dental specialists, the success rates of both options was around 95%. When treatment completed by GDPs has been evaluated, hall technique preformed metal crowns have lower long term failure rates* - *As the majority of studies suggest that PMCs outperform conventional restorations. For this reason, PMCs are recommended in the UK national guidelines in paediatric dentistry as the treatment choice for carious teeth with lesions affecting two or more surfaces or extensive one surface lesions.* - *They are most commonly placed using the hall technique, in order to reduce discomfort at the time of treatment and improve patient acceptability. However in some cases, where a good fit cannot be found or further interproximal space is needed, a conventional crown prep may be required. There has been no difference found in the long term prognosis of conventionally fitted crowns compared to those fitted using the hall technique.* - *The risk of failure of preformed metal crowns is lower than that of conventional restorations.* **[Contraindications:]** - Irreversible pulpitis - Signs of periapical pathology - Unrestorable caries - Risk of infective endocarditis - Nickel allergy or sensitivity  **[Atraumatic Restorative Technique]** - Soft caries removal followed by sealant with GIC or Composite - Hand instruments - Limited, low quality evidence - - - - **[CONVENTIONAL RESTORATION]** **Technique** - Stepwise - Partial caries removal - Complete caries removal - *Conventional restorations may be indicated when parents/ children are against the use of preformed metal crowns due to the aesthetic challenges.* - *There are different methods of caries removal when completing restorations, including the stepwise technique, partial caries removal and complete caries removal. Rickets et al. 2016 found that stepwise and partial excavation of caries reduced the incidence of pulp exposure in vital, carious primary teeth. There are also arguments for stepwise caries removal including a lower operative time, through to improve patient acceptability. Santamaria and Innes 2014 found the clinical and radiographic success rates of teeth with partial vs total caries removal to both be high, with no significant difference. However, there is still limited evidence available related to the long term failure rates and incidence of pulpal symptoms when completing partial compared with complete caries removal.* - *Materials available for conventional restoration of primary teeth include composite, RMGIC and GIC.* - *A systematic review completed by Jones and Taylor in 2018 found Composite and GIC to be comparable materials for restoring class 2 cavities in primary molars, however neither outperformed preformed metal crowns. RMGIC was shown to have the lowest incidence of secondary caries when used under rubber dam.* **[FICTION]** - **Prevention** alone - **Conventional restoration** with prevention - **Biological methods** and prevention - **No difference amongst the three groups** **[MINIMAL INTERVENTION DENTISTRY]** ***Minimal intervention dentistry for managing carious lesions into dentine in primary teeth: an umbrella review.*** - **Fissure sealants and resin infiltration** are **NOT recommended** for caries management in primary teeth - **Biannual application of 38% SDF** results in **higher caries arrest rates** vs single application - **PMCs are favored** over **conventional restorations** - There is **no evidence** to determine whether **PMCs are more effective than SDF** - There is **limited evidence** to favour **stepwise vs selective caries removal** - **ART** may be associated with an **increased risk of restoration failure** in **multi-surface lesions,** however is **adequate** in the treatment of **single surface lesions** - *The evidence for fissure sealants and resin infiltration focusses on their sealing ability therefore these techniques are not suitable in the management of carious primary teeth.* - *Biannual application of SDF results in higher caries arrest rates than when applied annually* - *Preformed metal crowns were favoured over conventional restorations but there was no evidence to determine whether they were more effective than SDF.* - *Selective and stepwise caries removal were effective techniques in reducing carious pulp exposures. There was no evidence to favour one technique over the other.* - *ART was also found to increase the risk of restoration failures of multi surface lesions, however was effective in managing single surface caries* **[PRIMARY TEETH]** **[INDIRECT PULP CAP]** - Deep carious lesions in symptom-free, vital teeth - 90% success rate - Coronal seal = Success **[DIRECT PULP CAP]** - Limited low-quality evidence - Tricalcium silicates (MTA) - *Indirect pulp capping can be considered in cases where there is a deep carious lesion in a symptom-free, vital tooth and have proven extremely high success rates of over 90% at three year follow up.* - *If the bulk of infected dentine is removed, a small amount of soft dentine can be left at the base of the cavity and a thin layer of setting calcium hydroxide or glass ionomer cement placed on the cavity floor, followed by the definitive restoration. This process is completed with an aim to eliminate microbes and stimulate secondary dentine formation, therefore maintaining pulp vitality* - *The main indicator of success for teeth with an indirect pulp cap is the coronal seal, with a stainless steel crown being gold standard* - *Regular clinical and radiographic reviews are essential to monitor the pulp's response to treatment* - *Direct pulp capping has been previously not indicated in the primary dentition due to poor success rates. There is still limited and low quality evidence supporting the practice of direct pulp capping, mostly taken from one study. Tricalcium silicates, mainly MTA but also biodentine, have shown to be the most effective materials for direct pulp capping, but there is a definite research need into the success of and most effective martials for direct pulp capping.* **[Pulp Therapy in Primary Teeth]** **[Indications]** - Space maintenance - Guidance of eruption - Aesthetics - Minimise pain and infection in cooperative children - Extractions not indicated due to medical history e.g. Bleeding disorders - Hypodontia of permanent dentition - General anaesthetic risks e.g. cystic fibrosis - *Indications for completing pulp therapy to save primary teeth include for space maintenance, guidance of eruption, for aesthetic reasons, to minimize pain and infection, for cooperative children with a positive attitude towards dentistry and for those who extractions would not be indicated due to their medical history such as those with bleeding disorders or hereditary angio-oedema. They may also be indicated in patients with hypodontia of the permanent dentition or those at risk if a general anaesthetic would be required to facilitate tooth extraction, such as patients with cystic fibrosis.* - *Pulp therapy would not be indicated for patients whose medical history puts them at risk of residual infection, for example immunocompromised patients or those at risk of infective endocarditis. It would also not be indicated if the tooth would be unrestorable after pulp therapy, if the tooth is close to exfoliation of has extensive internal root resorption, if the contralateral tooth has already been lost, if there is extensive pathology or if there are a number of carious teeth with pulpal involvement, generally more than 3 teeth.* **[Pulp Therapy in Primary Teeth]** **Vital Pulpotomy** - Ferric Sulphate or MTA - 100% 2 year success - 92% 4 year success **Pulpectomy** - Zinc oxide eugenol or vitapex - 86% 36 month success - *There are two techniques for pulp therapy in the primary dentition -- a vital pulpotomy and pulpectomy* - *A pulpotomy consists of removal of the coronal pulp, focusing on maintenance of radicular pulp. The process aims to to encourage tissue regeneration and healing at the site of pulp amputation. A pulpotomy should only be completed in a vital tooth and is indicated when the tooth is asymptomatic or the patient only has transient pain, or if there has been a carious or mechanical exposure of vital pulp tissue.* - *Following removal of coronal pulp tissue medicaments, such as MTA or ferrous sulphate can be placed directly onto the pulpal tissue in order to gain haemostasis, prior to placement of the definitive restoration. In cases of uncontrollable pulpal hemorrhage, alternative treatment methods will need to be carried out, such as pulpectomy or extraction.* - *Ferrous sulphate comes in a 15.5% formation and is used to promote pulpal haemostasis whilst maintaining vitality. When used for a pulpotomy it has been proven to have a 100% success rate over 2 years and a 92% success rate over 4 years* - *MTA is bioactive and induces hard tissue formation in the pulpal tissues. It has a 96.4% success rate at 30 months* **[Vital pulp therapy in primary teeth with deep caries:]** **[An Umbrella Review]** **[Paediatric Dentistry (2021)]** - **Indirect pulp capping is most successful VPT technique** Medicament used does not significantly affect the outcome - **Pulpotomy is the least successful technique** MTA and formocresol have the highest success rates - *An umbrella review focusing on vital pulp therapy in primary teeth with deep caries was published in 2021. This recognized that indirect pulp capping was the most successful treatment method and that the medicament used for this did not affect the outcome.* - *There was low quality evidence supporting direct pulp capping* - *Pulpotomy was shown to be the lease successful treatment option, however within this group MTA and formocresol had the highest success rates.* **[EXTRACTION]** - Unrestorable teeth - Severe infection/ swelling - High caries risk - Multiple carious teeth - Medical history at risk of infection - Pre-cooperative - *Extractions are often completed for teeth which are deemed unrestorable, patients with severe infection or swelling for patients with a high caries risk, multiple unrestorable carious teeth, patients with medical histories placing them at risk of infection and for those who are pre-cooperative to facilitate other methods of treatment. We often complete extractions under inhalation sedation or general anaesthetic for these patients.* - *When completing extractions of primary teeth we must consider indications for balancing with removal of the contralateral tooth, even when unaffected to prevent a centreline shift. Early loss of the primary canine in all but spaced dentitions will have the most effect on the patient's centre line. Although evidence for the balancing of primary canines is limited to case reports, it is widely accepted that, wherever possible, and especially in a very crowded dentition, loss of a primary canine should be followed up with the balancing extraction of the contralateral canine to decrease the risk of a centre-line shift.* - *The more crowded the dentition, the greater the importance to balance.* - *A balancing extraction of the first primary molar may also be indicated in extremely crowded dentitions. There is varying evidence related to balancing extractions of first primary molars, due to the low clinical significance of space loss in this area.* - *Risks of premature extraction of primary teeth include crowding of the permanent dentition and delayed eruption of permanent teeth* **[First Permanent Molars]** - Extraction when second permanent molar is developing (8-10 years) appears to cause less disruption to the occlusion - Balancing extractions are not recommended unless part of an orthodontic plan - **Upper Arch:** - Considerations given towards temporisation if crowding or space required for correction of class II incisor relationship **[Case 1]** 4-Year-Old Male **C/O** - Pain ULQ, taken time off school, required multiple courses of antibiotics. **MH** - Asthma **SH** - 5 siblings who have required GA extractions. Attended with dad who speaks limited English. **DH** - No previous dental treatment, Dad reluctant to have any teeth extracted. Discuss your clinical and radiographic findings. What is your diagnosis? List your preventative interventions/ advice What are the options for treatment? Are there any issues with consent? Any implications of the medical history? **[CASE 2]** 6-year-old male 'Black front teeth', previous pain from multiple quadrants Pulmonary stenosis (Congenital heart defect) Lives and attends with Grandma Irregular attender with no previous dental treatment other than F varnish application.  - Discuss clinical and radiographic findings - What are your diagnoses? - Prevention plan? - Are there any implications of the patients medical history on the treatment options? - What are your treatment options? - Are there any concerns for the consent process? **[CASE 3]** 11-year-old male Attended with Mum **C/O -** 1 previous episode of pain LLQ 3 months ago, kept awake at night. Required antibiotics for swelling. No pain since. **MH -** Epilepsy -- well controlled **SH -** Competitive runner **DH -** Has previously had restorations under LA -- coped well. Describe the radiographic findings What are your diagnoses? State the preventative advice and preventative intervention required. What are the implications of the patients SH? List your treatment plan and any treatment considerations. Are there any implications of the patients medical history? **[CASE 4]** 9-year-old female Attended with Parents **C/O --** Sensitivity from back teeth **MH --** Fit and well **SH --** Lives with parents and siblings **DH --** No previous treatment history Describe the radiographic findings What are your diagnoses? State the preventative advice and preventative intervention required. List your treatment plan and any treatment considerations. How might your plan change if this patient had Autism and ADHD?