Author | Norman Tinanoff DDS, MS


Sally presents for her first dental examination at age 4 years.  Sally lives in a fluoridated city, and has dental coverage through Medicaid.  Review of systems is non-contributory. She has never been hospitalized, takes no medications. The clinical exam reveals a developmentally appropriate, sociable child who weighs 18kg (40 lbs) and is 100 cm (40 in) tall.   

Clinical Photograph


She presents because her mother says that she has been up at for the last three nights because of a toothache on the lower left side.

The findings that are evident on clinical and radiographic examinations (see below) include:

·         A large lesion that is evident clinically on the distal & occlusal surface of the mandibular left first molar (L).

·         There is soft tissue swelling associated with this tooth. 

·         Clinically, there also are occlusal or occlusal-lingual carious lesions on the all of the second primary molars (A, J, K, and T), and

·         An occlusal lesion on the upper left right first primary molar (I).

·         Radiographically, there are changes interproximally on A, B, I, J, K, L, S, and possibly T.

Clinical Findings 

Radiographic Findings 

The immediate treatment needs of this patient are to address the chief complaint of pain in the lower left quadrant. A periapical radiograph also shows an interradiculary radioluciency associated with tooth L. What are the TWO best treatment options?

Explanation – Both answers “a” and “d” can be considered correct.  This tooth has irreversible pulpitis and either the entire pulp is indicated for removal or the tooth has to be extracted, depending on no root resorption, the wishes of the parent, and the behavior of the child. 

See Nonvital pulp treatment for primary teeth in, accessed Sept. 11, 2015.

Considering the bite-wing radiographs, the child’s age, the socioeconomic status of the child, and the potential for changing the child’s risk factors, what teeth would you treatment plan for interproximal restorations AFTER TREATMENT OF L?

Explanation -- There is no absolute “correct” answer.  However, one needs to consider the probability that some of these lesions that radiographically are still in enamel may or may not arrest.  Considerations for management of these lesions include the future caries risk of the child, if the parent will be reliable with regard to home preventive strategies (such as having her teeth brushed twice a day with fluoridated toothpaste), modify adverse dietary habits, and being consistent for recall appointments including fluoride varnish treatment at three month intervals. If there are reduced risk factors, increased protective factors, as well as no further progression of lesions, then the practitioner can continue with “active surveillance”:

Guidance for restorative dentistry for children ages 3-5.

Adapted from, accessed Sept. 11, 2015.
*Surveillance - recall appointment
**Active Surveillance - recall appointments, including careful monitoring of caries progression and prevention program

What pertinent questions can you ask the mother regarding the reasons for dental caries in this child:
1. Is/was your put to sleep with a bottle. If so what is/was in the bottle?
2. Does your child drink city water or bottled non-fluoridated water?
3. How often are Sally’s teeth brushed with fluoridated toothpaste and does she brush them herself or with adult supervision?
4. When did you first start brushing Sally's teeth?

Explanation – Current best practice to reduce the risk of ECC includes twice-daily brushing with fluoridated toothpaste for all children in optimally fluoridated and fluoride-deficient communities.  When determining the risk-benefit of fluoride, the key issue is mild fluorosis versus preventing devastating dental disease. A ‘smear’ or ‘rice-size’ amount of fluoridated toothpaste (approximately 0.1 mg fluoride; see Figure 1) should be used for children less than three years of age. A ‘pea-size’ amount of fluoridated toothpaste (approximately 1.25 mg fluoride) is appropriate for children aged three to six. Parents should dispense the toothpaste onto a soft, age-appropriate sized toothbrush and perform or assist with toothbrushing of preschool-aged children. To maximize the beneficial effect of fluoride in the toothpaste, rinsing after brushing should be kept to a minimum or eliminated altogether.

Comparison of a ‘smear’ (left) with a ‘pea-size’ (right) amount of toothpaste.

‘Smear’ – under 3 yrs.   ‘Pea-sized’ – 3 to 6 yrs.

Professionally-applied topical fluoride treatments also are efficacious in reducing prevalence of ECC. The recommended professionally-applied fluoride treatments for children at risk for ECC who are younger than six years is five percent sodium fluoride varnish (NaFV; 22,500 ppm F). An associated risk factor to the microbial etiology is high frequency consumption of sugars. Caries-conducive dietary practices appear to be established by 12 months of age and are maintained throughout early childhood. Frequent night-time bottle feeding with milk and ad libitum breast-feeding are associated with, but not consistently implicated in ECC.  Night-time bottle feeding with juice, repeated use of a sippy or no-spill cup, and frequent in between meal consumption of sugar-containing snacks or drinks (eg, sugar-added juice, formula, soda) increase the risk of caries.  While ECC may not arise from breast milk alone, breastfeeding in combination with other carbohydrates has been found in vitro to be highly cariogenic. Frequent consumption of between-meal snacks and beverages containing sugars increases the risk of caries due to prolonged contact between sugars in the consumed food or liquid and cariogenic bacteria on the susceptible teeth. The American Academy of Pediatrics has recommended children one through six years of age consume no more than four to six ounces of fruit juice per day, from a cup (ie, not a bottle or covered cup) and as part of a meal or snack 

Adapted from Accessed Sept. 11, 2015.

What risk factor is the most critical in assessing Sally’s caries risk?

Explanation -- Currently, there are no caries risk factors or combination of factors that have achieved high levels of both positive and negative predictive values. Although the best tool to predict future caries is past caries experience, it is not particularly useful in very young children since it is important to determine caries risk before the disease is manifest.  Children with white spot lesions should be considered at high caries risk because white spot lesions are precavitated lesions that are indicative of caries activity in the mouth. Plaque accumulation also is associated with caries development in young children. As a corollary to the presence of plaque, a child’s mutans streptococci levels, and the age that a child becomes colonized with cariogenic flora are valuable in risk assessment, especially in preschool children.

While there is no question that fermentable carbohydrates are a necessary link in the causal chain for dental caries, a systematic study of sugar consumption and caries risk has concluded that the relationship between sugar consumption and caries is much weaker in the modern age of fluoride exposure than previously thought. However, there is evidence that night-time use of the bottle, especially when it is prolonged, may be associated with early childhood caries. Despite the fact that normal salivary flow is an extremely important intrinsic host factor providing protection against caries, there is little data about the prevalence of low salivary flow in children.

Sociodemographic factors have been extensively studied to determine their effect on caries risk. Children with immigrant backgrounds have three times higher caries rates than non-immigrants. Most consistently, an inverse relationship between socio-economic status and caries prevalence is found in studies of children less than six years of age. Perhaps another type of sociodemographic variable is parents’ history of cavities and abscessed teeth that has been found to be a predictor of treatment for early childhood caries.

Below is a caries risk assessment form for children between 0-5 years of age:

Circling those conditions that apply to a specific patient helps the practitioner and parent understand the factors that contribute to or protect from caries.  Risk assessment categorization of low, moderate or high is based on preponderance of factors for the individual.  However, clinical judgment may justify the use of one factor in determining overall risk, for instance, frequent exposure to sugar containing snacks or beverages, or a dmfs score of greater than one.

Overall assessment of the child’s dental caries risk   High   Moderate          Low  

Adapted from Accessed Sept. 11, 2015.

Preventive therapy could include:
1. Diet analysis and counseling
2. Professional fluoride varnish treatment
3. Sealants on those molars that are not carious
4. Mouthwashing with chlorhexidine

Explanation -- Certainly, diet analysis, professional fluoride treatment and sealants on molars are the standard of care for reducing the caries progression (see below table).  Perhaps controversial is the fact that chlorhexidine is not included as a correct answer.  A recent review of antibacterial agents (xylitol, chlorhexidine, providone iodine) showed that these approaches may reduce salivary mutans streptococci levels, but have not shown a beneficial effect on early childhood caries incidence.

See the manuscript by Twetman and Dhar that is located in the ECC Resource Center, located in “Scientific Resources”, “2014 ECC Conference”.

Below is a preventive therapy protocol for children between 

In constructing a treatment plan for Sally, what is the most critical factor in preventing future caries?

Explanation – Preventing future caries is the key to successful treatment for Sally.  Her frequent consumption of sucrose-containing foods, combined with the probability of early colonization with MS, would most likely be the etiologies.  Mutans metabolize sugars to produce acids leading to decalcification and ultimately cavitation. High frequency sucrose exposure will increase the quantity of MS.  The lack of professional care, including inadequate home hygiene and absence of high-concentration fluoride exposure, only allows the bacteria in her mouth to remain on the teeth and continue to produce acids. 

Sally cries when she sees the dentist pick up the mirror and explorer. The best approach to prevent this would have been:

Explanation --Communicative management establishes a relationship with the child and allowing for the successful completion of dental procedures, and developing a positive attitude toward oral health. Associated with this process are the specific techniques such as “tell-show-do”. Tell-show involves verbal explanations of procedures in phrases appropriate to the developmental level of the patient (tell); demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined, nonthreatening setting (show); and then, without deviating from the explanation and demonstration, completion of the procedure (do). The objectives of tell-show-do are to teach the patient important aspects of the dental visit and familiarize the patient with the dental setting; and shape the patient’s response to procedures through de-sensitization.

It is decided that the mandibular left first molar need to be extracted. What is the maximum amount of 2% lidocaine with 1:100,000 epinephrine that should be given to this 40 pound child?

Explanation – Overdose of local anesthesia is much more likely in a child because of their low body weight.  Critical to understanding the maximum amount of local anesthetic is knowing the weight of the child that will be having restorative procedures.  For 2% lidocaine with 1:1,000 epinephrine the general standard for the maximum amount of local lidocaine is 4.4 mg/kg.  To convert 40 pounds to kilogram, divide by 2.2.  Thus, this child weighs 18 kg. 

Example Calculation

The maximum amount of lidocaine that can be given to this 20 kg child is:

18 kg X 4.4 mg/kg = 80 mg (approximately 2 cartridges).

Tooth T has deep caries. Sally has said that sometimes it hurts when she eats candy. The best treatment will include:

Explanation – The symptoms (intermittent pain of short duration) suggests that this tooth has reversible pulpitis.  Confirmation includes no radiographic radioluciencies, no soft tissue swelling, and no tooth mobility.  If it is concluded that the diagnosis is reversible pulpitis, then treatment is vital pulp therapy.   This can include not removing “woody (affected) dentin” directly above the pulp.  The affected dentin is then covered generally with a glass ionomer or calcium hydroxide material before the tooth is restored.

For a detailed information, please see Guideline on Pulp Therapy for Primary and Immature Permanent Teeth. Accessed Sept. 17, 2015.

Mandibular primary molar with “woody dentin” that is not removed before restoration

At the third recall appointment, you notice that her permanent molars are erupting in end-to-end occlusion. You can tell the mother:

Explanation -- It is common that the permanent molars will erupt in an “end-to-end” occlusion (See below Figure).  In many cases, this molar relationship will drift into a Class I molar relationship due to the concept of “leeway space” or "late mesial shift".  Leeway space is the result of the primary molars having greater mesial-distal dimensions that the succedaneous premolars.  In the mandible the leeway space is larger than in the maxilla, allowing the mandibular first molars to drift mesially more than the maxillary molars, thus converting an end-to-end molar relationship to a Class I relationship. 

Example of a child with an end-to-end molar relationship that converts to Class I