Healing and Restoring Carious Primary Molars

A review of pertinent terminology

Theodore P. Croll, DDS | Constance M. Killan, DMD | Richard J. Simonsen, DDS, MS | Ari Kupietzky, DMD, MSc

In light of the fact that some international dentists, and now US dentists, do not remove any carious tissue whatsoever in diseased primary teeth before placing oversized, ill-fitting stainless steel crowns, it is appropriate to review the pertinent terminology (See Definitions)^1-6 and give thought to the potential sequelae of primary molar repair.

Traditionally, primary teeth infected with dental caries have been treated with a standard wound-healing protocol, initiated by the debridement of any dead or dying carious tooth substance. The debridement is followed by their restoration to useful form and function using dentin and enamel filling materials or, based on the amount of coronal damage, the patient's age, and the prospective exfoliation time, luted full coronal coverage after appropriate rotary tooth preparation, pulp protection, and marginal adaptation (ie, proper fitting) of a correctly sized preformed stainless steel crown. It is understood that the removal of decayed substance by judicious mechanical means aims to stop short of physically exposing the pulp space. Areas of deep carious penetration can be covered with a protective healing liner such as calcium hydroxide or calcium silicate/mineral trioxide aggregate, which provide excellent bactericidal action and biocompatibility. Dentistry refers to such restorative treatment as an "indirect pulp cap." An article by Aas and colleagues, "Bacteria of Dental Caries in Primary and Permanent Teeth in Children and Young Adults," provides an erudite and valuable overview of the bacteriology of dental caries and discusses the specific species of bacteria involved.⁷

The figures depict two extracted primary molars with preformed stainless steel crowns in place that had been managed in different ways. The tooth in Figure 1 was extracted at the normal exfoliation time (ie, 9 years postoperatively) because the succeeding permanent tooth was erupting into place. The molar in Figure 2 was extracted because of a dentoalveolar abscess associated with dental caries infection, which resulted in pulp death.

Definitions

Infection¹

1.		a: the state produced by the establisment of one or more pathogenic agents (such as a bacteria, protozoans, or viruses) in or on the body of a suitable host // an infection in his foot b: a disease resulting from infection // contagious infections // infections of childhood
2.		an act or process of infecting something or someone also: the establishment of a pathogen in its host after invasion
3.		an infectious agent or material contaminated with an infectious agent

Heal²

1.		a: to make free from injury or disease: to make sound or whole // heal a wound b:to make well again: to restore to health // heal the sick
2.		a: to cause (an undesirable condition) to be overcome: MEND // the troubles … had not been forgotten, but they had been healed —William Power b: to patch up or correct (a breach or division) // heal a breach between friends
3.		to restore to original purity or integrity // healed of sin intransitive verb : to become free from injury or disease: to return to a sound state // The cut has already healed.

Debride³

To remove dead, contaminated, or adherent tissue and/or foreign material. To debride a wound is to remove all materials that may promote infection and impede healing. This may be done by enzymes (as with proteolytic enzymes), mechanical methods (as in a whirlpool), or sharp debridement (using instruments).

Indirect Pulp Treatment^4,5

"Indirect pulp treatment is a procedure performed in a tooth with a deep carious lesion approximating the pulp but without signs or symptoms of pulp degeneration. The caries surrounding the pulp is left in place to avoid pulp exposure and is covered with a biocompatible material. A radiopaque liner such as a dentin bonding agent, resin modified glass ionomer, calcium hydroxide, zinc oxide/eugenol, or glass ionomer cement is placed over the remaining carious dentin to stimulate healing and repair."⁴

"It is important to remove the carious tissue completely from the dentinoenamel junction and from the lateral walls of the cavity in order to achieve optimal interfacial seal between the tooth and the restorative material, thus preventing microleakage," and "it is generally accepted that the carious tissue that should remain at the end of the cavity preparation is the amount that, if removed, would result in overt exposure."⁵

Restore⁶

1: GIVE BACK, RETURN
2: to put or bring back into existence or use
3: to bring back to or put back into a former or original state: RENEW
4:to put again in possession of something

References

1. Merriam Webster. Infection. Merriam Webster website. https://www.merriam-webster.com/dictionary/infection. Accessed March 16, 2020.

2. Merriam Webster. Heal. Merriam Webster website. https://www.merriam-webster.com/dictionary/heal. Accessed March 16, 2020.

3. Shiel WC Jr. Medical definition of debride. Medicine Net website. https://www.medicinenet.com/script/main/art.asp?articlekey=40481. Accessed March 16, 2020.

4. American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent teeth. American Academy of Pediatric Dentistry website. https://www.aapd.org/research/oral-health-policies--recommendations/pulp-therapy-for-primary-and-immature-permanent-teeth/. Accessed March 16, 2020.

5. Casamassimo PS, Fields HW, McTigue DJ, Nowak AJ. Pediatric Dentistry: infancy through adolescence. 5th ed. St. Louis, MO: Elsevier Saunders; 2013:338.

6. Merriam Webster. Restore. Merriam Webster website. https://www.merriam-webster.com/dictionary/restore. Accessed March 16, 2020.

7. Aas JA, Griffen AL, Dardis SR, et al. Bacteria of dental caries in primary and permanent teeth in children and young adults. J Clin Microbiol. 2008;46(4):1407-1417.

About the Authors

Theodore P. Croll, DDS
Clinical Professor
Pediatric Dentistry
Case Western Reserve University
School of Dental Medicine
Cleveland, Ohio
Cavity Busters
Doylestown, Pennsylvania

Constance M. Killian, DMD
Adjunct Associate Professor
Pediatric Dentistry
University of Pennsylvania
School of Dental Medicine
Philadelphia, Pennsylvania
Private Practice
>Doylestown, Pennsylvania

Richard J. Simonsen, DDS, MS
Executive Consultant for Dental Education
California Northstate University
College of Dental Medicine
Elk Grove, California

Ari Kupietzky, DMD, MSc
Visiting Professor
Department of Pediatric Dentistry
Rutgers School of Dental Medicine
Newark, New Jersey
Faculty Member
Department of Pediatric Dentistry
The Hebrew University-Hadassah School of Dental Medicine
Jerusalem, Israel