Minimal intervention dentistry in the management of the paediatric patient

Minimal intervention dentistry in the management of the paediatric patient IN BRIEF • Provides an overview of the applicability S. C. Leal1 VERIFIABLE CPD PAPER PRACTICE of minimal intervention dentistry to the management of carious lesions in children. • Emphasises the importance of carrying out a proper diagnosis for the decision making-process. • Presents treatment options for enamel and dentine carious lesions according to the principles of minimal intervention dentistry. Minimal intervention dentistry (MID) is a philosophy of care that aims to conserve tooth tissues throughout a persons’ life. This paper aims to review the literature on topics that are related to MID approaches for the management of dental caries and that can be applicable to the paediatric patient. Tools for caries diagnosis and early lesion detection are presented and discussed. More conservative and less invasive techniques for managing enamel and dentine carious lesions in primary and permanent teeth are compared to the traditional treatments. The traditional treatments are centred on the disease and on restoring its sequels, and have been shown to be insufficiently effective in controlling caries disease over time. In contrast, the MID philosophy has created potentially very suitable options for treating children that are considered more childfriendly, less anxiety provoking, preserve more tooth tissues and are equally good as the traditional treatments. INTRODUCTION Better understanding of the caries process, together with the improvement of dental materials in the last decades, enables the clinician to provide less invasive and much more conservative care than was previously possible. Consequently, the philosophy of how to deliver dental care, previously based on surgical approaches, has changed significantly, to a model of care named ‘minimal intervention dentistry’ (MID); the cornerstones of which are earliest detection and prevention of disease, followed by less invasive treatments.1 MID is an approach that aims to keep teeth functional for life.2 Therefore, it is applicable in every dental specialty, particularly paediatric dentistry. Thinking about providing oral care to a young patient while ignoring the concepts that govern MID is difficult. Besides all the benefits that the philosophy offers in terms of tooth tissue preservation, MID is considered a friendly approach, reducing patient anxiety and offering health-oriented treatment options.3 It can thus contribute to patient behaviour management; an accepted key factor in providing oral care to the paediatric patient.4 Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Darcy Ribeiro, Asa Norte, Barsília - DF, Brazil Correspondence to: S. C. Leal Email: 1 Refereed Paper Accepted 4th April 2014 DOI: 10.1038/sj.bdj.2014.449 © British Dental Journal 2014; 216: 623-627 Combination of clinical situations Cavitated dentine lesions Pain/abscess due to caries Diagnosis Diagnosis Fluoride therapy Non-operative approach Pain relief Sealant/infiltration Conservative restorative approaches No signs of carious lesions Enamel lesions Diagnosis Diagnosis Conventional restorative approaches Health maintenance through oral health promotion and prevention Factors that influence the decision-making process Child’s age Child’s cooperation Parent’s cooperation Dental setting Dentist’s expertise Cultural aspects Treatment costs Fig. 1 Scheme representing different clinical scenarios, possible intervention approaches based on MI concepts and factors that might influence the dentist decision-making process Because dental caries is the main oral health problem in childhood, this paper focuses on the evidence supporting the use of MID in preventing the occurrence of the first signs of the disease and, when disease is already present, treating it. It is important to note that this article is not aimed at covering all aspects of MID. Topics that are of special interest for caries control in children were selected. THE PAEDIATRIC PATIENT A child can present to a dentist with very distinct clinical situations or a combination of them, as shown in Figure 1. The best scenario would be one in which a child visits the dentist without any clinical BRITISH DENTAL JOURNAL VOLUME 216 NO. 11 JUN 13 2014 sign of dental caries. This would be hugely beneficial, enabling the establishment of an excellent dentist-patient relationship in terms of behavioural management, as only non-invasive procedures would be needed. Most importantly, such a situation increases the chances of keeping that child cariesfree, through planned regular return visits and motivating parents/caregivers to take responsibility for the oral health of the child. This aspect is extremely important, as the choice of visiting a dentist is not a decision made by the child, but by the parents or caregivers. Families should be provided with advice about essential home-based caries preventive programmes so that good oral 623 © 2014 Macmillan Publishers Limited. All rights reserved PRACTICE habits and attitudes can be established.5 Unfortunately, a considerable number of children have many carious teeth, even at a very young age. Although there is worldwide evidence of a decrease in caries prevalence, dental caries is still the most prevalent childhood disease,6 especially in vulnerable populations. According to the American Academy of Paediatric Dentistry the presence of one or more primary teeth with caries (cavitated or non-cavitated) in a child 71 months of age or younger is defined as early childhood caries. An international survey that aimed to compare the oral health condition of young children (26‑34 months of age) in five different countries showed a variation of caries prevalence, ranging from 17% (Germany) to 31% (Russia). Cavitated dentine lesions were considered to be the cut-off point for caries.7 If not controlled, these lesions will progress, causing pain and negatively affecting both child behaviour and family quality of life.8,9 In view of the fact that dental caries is preventable, a dental visit should occur before the first signs of the disease are present. Therefore, it is recommended that at approximately 12 months of age or just after a primary tooth starts to erupt a child should undergo the first oral evaluation.10 This recommendation is totally in line with the MID philosophy in which the individual, in this case the family of the young patient, should be empowered with regard to maintenance of oral health of the child. For that purpose, the first dental visit should be focused on the child’s medical/ dental history, identification of the child’s risk factors, establishment of an individual preventive oral health programme and finally, decisions about the child’s recall visits. Parents/caregivers should be advised regarding diet, oral hygiene and fluoride exposure. In cases where carious lesions are already detected, mi (...truncated)