Nursing caries is a unique pattern of dental caries seen in very young children due to prolonged, improper feeding habits.

CLINICAL FEATURES

It is a specific form of rampant caries.

Seen in infants and toddlers.

It affects the primary teeth in the following sequence,

Maxillary central incisors

Maxillary lateral incisors

Maxillary first molars

Maxillary canine and second molars

Mandibular molars

Progression of the lesion

Initially a demineralized, dull white area is seen along the gum line on the labial aspect of the maxillary incisors which remains undetected.

These lesions become cavities involving the necks of teeth in a ring like fashion.

Finally the whole crown is destroyed leaving behind brown, black root stumps.

MANAGEMENT

It can be divided into 3 visits

1st visit

All lesions should be excavated and restored

Indirect pulp capping procedures can be evaluated.

X-rays should be taken to assess the condition of the succedaneous teeth.

Collection of saliva for dtermining the salivary flow and viscosity.

Topical fluoride application.

Parent conselling

Parents should be questioned about the childs feeding habit, use of noctornal  bottles, use of pacifiers dipped in sweetening agents.

Parents should be asked to try weaning the child the bottle as a pacifier while in bed.

In case of a emotional dependence on the bottle, suggest the use of plain or fluoridated water.

The parents should be instructed to cleam the childs teeth after every feed.

Parents should be advised to maintain the diet record of the child for a week.

2nd visit

Scheduled one week after the 1st visit.

analysis of the diet chart and a detailed explanation on the disease of the childs teeth.

Isolate the sugar factors from the diet chart and replace them.

Re assess the restorations, and redo if needed.

Caries activity test can be repeated at monthly intervals.

3rd and subsequent visit

Restoring all grossly decayed teeth

Endodontic treatment should be carried out

Unrestorable teeth should be extracted

Crowns should be given on all endodontic teeth

Review and recall after every 3 months.

CONCLUSION

The main strategies for nursing caries should be to create awareness and alert prospective parents about the condition and its causes.

Thumb sucking is the placement of the thumb into various depths into the mouth.

CAUSES

Parents occupation

Working mother

Neglected child

Social adjustment and stress

Feeding practices

DIAGNOSIS

History

Determine the pschological component involved, Question regarding the frequency, intensity and duration of the habit.

Inquire about the feeding pattern and occupation of the parent.

Extra oral examination

The digits

The digits involved in the habit will appear reddened, exceptionally clean with a short finger nail.

Fibrous roughened callus may be present on the superior position.

Lips

Upper lip may be short and hypotonic.

Note the position of the lips at rest, wheter they are held together or part,

The position of the lips during swallowing should be the observed

The upper lip is passive or incompetent during swallowing

The lower lip is hyperactive which leads to a further increase in the proclanmation of the upper anterior teeth.

Facial form analysis.

The facial profile is either straight or convex.

Other features

Anterior open bite

Middle ear infections

Enlarged tonsils

Mouth breathing

Intra oral examination

Proclined maxillary anteriors with diastemas and retroclined mandibular anteriors

Buccal cross bite

Tendency to narrow palates

Mouth breathing, gum line etching, excessive staining of the lebule surface of the upper, central and laterals insiders.

TREATMENT

Psychological Therapy

A detailed history will help the clinician tro diagnose the underlying the psychologicalk disturbances of the child.

Thumb sucking incidences of children of 4 to 8 years in managable.

Adequate emotional support and concern should be provided by the parents.

Reminder therapy

It employs hot tasting, bitter flavored preparations or distasteful agents that are applied to the finger or thumbs. for eg. asafotida, quinine.

removable appliances like palatle cribe, palatle arch, lingual spurs. Fixed appliances like upper lingual tongue screen apperas to be more effective in breaking the habit.

Mechano therapy

Intraoral appliances attached to the upper teeth by bands fitted to the primary second molars or permanent first molars is effective.

Blue grass appliance

Quad helix

The terms Replantation and Implantation are often confused. replantation also referred to as reimplantation is the insertion of a tooth in its socket after its complete avulsion resulting from traumatic injury.

GUIDELINES FOR THE TREATMENT OF THE AVULSED TOOTH

Extra oral Time-

The avulsed tooth should be replanted immediately in its socket whenever possible. the dentist should instruct the patient or parent on replantation technique during the initaial emergency telephone call anbd should stress the importance of coming to the office immediately for follow-up splinting and treatment.

Storage media-

By replanting the tooth into its socket as soon as possible, not only is its extra time reduced, but also the tooth is restored to the best possible environment, conducive to maintaining the vitality and viability of the root surface and the periodontal ligament.

Ideal storage media include,

Patients saliva in the buccal vestibule or under the tounge

Milk

Water.

Management of the socket-

The less manipulation of the socket, better the prognosis of the replanted tooth.

Use light irrigation and gentle aspiration to remove any blood cloth present in the socket.

Do not curette or vent the socket.

Do not make a surgical flap unless bony fragments prevent replantation.

after replantation manually compress the facial and ligual bony plates.

Managemaent of the root surface-

To preserve the vitality of the root surface cells do not handle scrape, brush or remove any of the root surface.

If the root surface is dirty, rinse it clean with tap water.

If persistent debris remain on the root, use cotton pliers gently to pick away any debris or use a wet sponge to brush of gently.

Do not apply any medicements or chemicals to the root surface.

When to perform endodontic treatment?

It should be initiated within 7 to 14 days of replantation.

If the tooth apex is open monitor the replanted tooth every 2 weeks for revitalization of the pulp.

If pathological signs are noted then extirpate the pulp and continue with an apexification procedure using Calcium Hydroxide.

Filling Materials-

Use calcium hydroxide for treatment fillings after a minimum delay of 7 days post replantation and permanently obturate the root canal with Gutta-percha later.

Splinting-

The suggested splint is composed of acid etched reason alone or with soft arched wire, orthodotic brackets with wired arched or large monofilament with fishing line.

Leave the splint in place for 7 to 10 days.

Ask the patient not to bite on splinted teeth: prescribe soft diet.

Adjunctive Drug therapy-

Refer the patient for tetanus consultation within the first 48 hours and prescribe antibiotics only if indicated such as in a medically compromised patient or a contaminated avulsion.

HOW DO WE PREVENT IT?

Whenever possible a mouth guard should be worn during rough play or strenous athletics.

In addition an overjet of the teeth should be corrected because inadequate lip coverage predisposes patients to crown and root fractures and to avulsion of teeth.

IMMEDIACY OF REPLANTING THE TOOTH

Most experimental studies indicate that if the extra oral time is less than 30 minutes, the periodontal ligament will survive.

WHAT IS INTENSIONAL REPLANTATION?

It means the removal of the tooth for the purpose of extra oral endodontic treatment and the replacement of that tooth in its socket immediately.

The planned operation can be usually performed within 15 minutes.

WHEN IS IT INDICATED?

• When an instrument has been broken in the root canal and projects through the apical foramen.
• When mechanical obstruction of the root canal is present such as a pulp stone.
• When a perferation of the root cannot be easily contained,
• When the root canal is calcified an over filled root canal/ and the protruding filling material is irritating the peri apical tissues.
• A sharply curved root canal which cannot be negotiated.

CONTRA INDICATIONS

• Periodontal infections with tooth mobility
• Buccal or lingual plate that is destroyed or missing
• Septal bone at the bifurcation and trifurcation that is destroyed or missing.
• Likelihood that extraction of the tooth will fracture the crown.

The high susceptibility of pit and fissures to caries presents a major dental problem and provides the rationale for caries control of these areas.

Pit and Fissure Sealants are thin plastic coatings placed on the occlusal surface of postreior teeth which forms a mechanical barrier between tooth structure  and oral environment.

Pit and fissure sealant placed

COMPOSITION

A. Bowen’s resin (BIS-GMA): Polymerizes to yield a highly cross linked polymer.

B. Diluents (TEG-DMA): decreases the viscosity of BIS-GMA.

C. Opaquer (Titanium Dioxide): allows placement of the sealant to be monitored.

D. Fluoride releasing agent (Ytterbium Fluoride)

E. Polymerization activation chemicals.

CLASSIFICATION

The sealants can be differentiated in the following ways,

1. Polymerization methods:

a. Self activation (mixing 2 components)

b. Light activation

• First generation – ultraviolet light
• Second generation – self cure
• Third generation – visible light
• Fourth generation – fluoride releasing

2. Resin systems:

• BIS-GMA
• Urethane Acrylate

3. Filled and Unfilled

4. Clear or Tinted

INDICATIONS

Newly erupted tooth, both primary and permanent bicuspids and molars with complete recession of pericoronal operculum and with open and/sticky grooves and fissures.

Stained pits and fissures with minimum decalcification or opacification and no softness at the base of fissures.

The tooth in question should have erupted less than 4 years ago.

CONTRAINDICATION

Individual with no previous caries experience and well coalesced pit and fissures.  Monitor if the individual and the teeth are not at risk.

Radiographic or clinical evidence of caries on the proximal surface of the teeth should not be sealed.

Wide and self-cleansable pit and fissures.

Tooth that can not be isolated or partially erupted tooth.

Pit and fissures that have remained carious free for 4 years or longer.

CLINICAL  GUIDELINES  FOR  APPLICATION  OF  FISSURE  SEALANTS

Patient’s selection

1. Child with extensive caries in primary teeth.

Seal all the first permanent molars.

2. Children with special needs.

Medically compromised.
Mentally or physically handicapped.
From a disadvantaged social background.

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Tooth selection

1. Child with occlusal caries on one of the first permanent molar.

Seal the remaining sound first permanent molars.

2. Occlusal caries affecting one or more first permanent molars

Need to seal the second permanent molar as soon as they have erupted sufficiently.

3. Tooth should be sealed within 2 years of eruption.

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Doubt about the integrity of an occlusal surface on clinical examination.

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Take bite wing radiograph

a. If no sign of dentin involvement – Seal the surface as preventive measures.

b. Early dentin involvement – Investigate the fissures using dental burs (minimal composite filling, with fissure sealant to protect the rest of the occlusal surface).

c. Extensive caries involvement – Standard dental restoration should be inserted.

TECHNIQUE OF APPLICATION

Cleaning

The selected tooth surface should be cleaned first with a slurry of pumice and water.

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Washing and drying

Immediately following cleaning the tooth is washed with water and air dried.

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Etching

Occlusal surface is then etched with a 30-50% Phosphoric acid liquid or gel for 60 sec.

This creates microporosities, into which the resin extends and form tags which attach firmly to the tooth surface.

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Application of the sealant

Care must be taken when applying the material to avoid incorporating air bubbles.

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Curing

Material is cured according to the manufacturer’s instructions

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Recall

To ensure: still firmly adherent, no loss of sealant material, if needed must be replaced.

CONCLUSION

Sealants have been shown to be efficient, safe and an effective method of preventing pit and fissure caries and as such should be used by all dental personnel for prevention of dental decay.