Operative Dentistry for the Primary Dentition: An Overview

Marvin H. Berman, DDS


It’s an undeniable fact that early childhood caries (ECC) is the most common disease in young children. Despite educational efforts, improved parent awareness, fluoridated water, toothpastes with fluoride, and beautifully designed toothbrushes, rampant caries in infants and toddlers continues to be a major problem.

There is no doubt that in many cases, heredity is a dominant factor (inherited susceptibility). Much new genome research is underway in an attempt to decipher nature’s secrets.

In addition to the gene factor, overuse of baby bottles with milk and various juices (especially at bedtime), random indulgence in sugary beverages, frequent between-meal ingestion of fermentable carbohydrates, and lack of a parent-supervised oral hygiene routine are all part of the ECC picture.

But my intention in this particular blog is to set aside for another time an intensive discussion of the etiology and prevention of dental caries and to focus primarily on “fixing the teeth” now that they’ve been damaged.

Principle #1

When encountering a very young child, you must first recognize that the primary dentition, the “baby teeth,” are important. The incisors don’t normally exfoliate until the ages of 5 to 7 years; the cuspids, not until 9 to 11 years; and the primary molars, not until 10 to 12 years. The integrity of the primary dental arch is essential to the long-term development of the permanent jaw architecture, so merely extracting the baby teeth should not be your first treatment option.

A very important caveat: The behavior of the child should not determine your treatment plan. It upsets me to no end when speaking with dentists and listening to their thought process, which goes something like this. “The child was screaming and crying or fidgeting, so I just did the best I could,” or “so I just took the tooth out,” or “so I just postponed treatment.”

In my lectures and in my writings through the years, I have devoted considerable time to discussing the management of reluctant or apprehensive child behavior by employing communication techniques and local anesthesia and eschewing mind-altering drugs. Negative child behavior should not trigger diminished clinical effort. A poor dental restoration is not “better than nothing.

Principle #2

In regard to local anesthesia (“the shot”), be confident in your ability to deliver a painless injection, using your charm and a topical anesthetic. When in doubt, give the shot. You certainly don’t want to inflict pain on the child. Remember that any lesion that approaches the dento-enamel junction is likely to elicit a pain response, so just do it!

Principle #3  

Your treatment plan should be governed by the philosophy of “Do it once and do it right.” Always take into account the normal lifespan of any particular tooth and restore it in the most thorough and diligent way to avoid repeat treatment.

For example, you have a 2-year-old child with a second primary molar that should be functional for another 6 to 8 years with extensive caries involving the pulp. You perform a pulpotomy, and now you’re restoring the tooth. This is not the time for a multi-surface composite or an amalgam. The best restoration in this instance is a stainless-steel crown—full coverage for the long haul.

Using the same thought process, when restoring teeth in a very caries-susceptible child, always extend your preparation to include any suspicious areas. A shadow in the mesial or distal interproximal area of a tooth on the radiograph should not be left unattended. Utilize restorative materials that have the best chance to survive intact until the tooth is ready to exfoliate.

Principle #4

When, encountering a child with a mouth devastated by neglected caries and suffering with pain, it is sometimes difficult to know where to begin treatment. I recommend a triage mentality, where you try to identify the areas that are causing the most discomfort and treat those teeth first.

Sometimes it’s a good idea to simply excavate the caries from the several worst teeth to alleviate the pain and stop the decay process. Then go back and restore those teeth more permanently a quadrant at a time.

A note: Let’s talk about money for a moment. When you have a child in trouble, and there is an apparent difficulty for the parents to afford treatment, your sense of duty kicks in. Remember, you are the doctor and you care about your patient, so your front desk people should manage the financial discussions.

They make the best arrangement possible with the parent, but you must still perform the treatment in the best interest of the child to the best of your ability. Yes, sometimes you end up providing free treatment. But don’t compromise your ethics. A practical example would be making a decision to extract a tooth instead of saving it because it costs less money. That would be a big-time no-no.

Principle #5

Finally, it is extremely important that you emphasize to parents the importance of giving more attention to a consistent hygiene routine, better control of between-meal eating habits, and more frequent dental checkups. And, set up a definitive recall schedule!

Dr. Berman is an internationally recognized pediatric dentist with a career as a successful practitioner and as a popular world-class lecturer spanning more than 5 decades. He’s still one of the principal dentists in a thriving practice in Chicago. He has been an ambassador for dentistry as a health reporter on CBS (News Radio 78) and via media appearances as a consumer advisor for the ADA, the Chicago Dental Society, and the Academy of Pediatric Dentistry and as co-author of Essentials of Modern Dental Practice. He has published numerous articles and is a member of many professional and service organizations including honorary membership in the Hinman Dental Society. He can be reached at marvy18@me.net.

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