24.3 Pediatric Caries Prevention and Restorative Dentistry: Sealants, ART, Crowns and Material Choice
Key Takeaways
Pit and fissure sealants are recommended for primary and permanent molars of children at risk and can also arrest non-cavitated occlusal lesions; isolation is the most important factor in retention.
Glass ionomer sealants are useful as an interim measure on partially erupted molars where moisture control is poor.
Atraumatic restorative treatment removes soft caries with hand instruments and restores with high-viscosity glass ionomer, while an interim therapeutic restoration temporarily controls caries in young, uncooperative or special-needs patients.
Multisurface caries in primary molars of high-risk children is most durably restored with a preformed metal (stainless steel) crown, which outperforms multisurface intracoronal restorations.
Zirconia crowns for primary teeth need more tooth reduction and a passive fit because they cannot be crimped, whereas strip crowns use composite in a celluloid former.
Behavior guidance, early childhood caries, fluoride toothpaste doses, varnish and silver diamine fluoride are covered in the previous section, and pulp therapy and stainless steel crown technique are covered in the pulp therapy section. This section covers the remaining prevention and restorative choices.
Prevention Plan by Risk
| Measure | Low risk | High risk |
|---|---|---|
| Fluoride toothpaste twice daily | Yes (smear under 3 years, pea-sized 3-6 years) | Yes; spit, do not rinse |
| Professional fluoride varnish | Per recall | Every 3-6 months |
| Diet counseling | Routine | Detailed diet diary; reduce frequency of free sugars; no sugary drinks in bottles at night |
| Sealants | Deep fissures | All at-risk pits and fissures |
| Recall | 12 months or individualized | 3-6 months |
| Silver diamine fluoride, ITR | Not usually | Arrest of active cavitated lesions when restorations are not feasible |
Diet: the WHO recommends keeping free sugars below 10% of energy intake (ideally below 5%). Frequency matters more than amount. Xylitol and chlorhexidine products have limited evidence as routine caries preventives in children.
Pit and Fissure Sealants
Indications: deep pits and fissures in caries-susceptible primary and permanent molars (and premolars), especially soon after eruption; non-cavitated occlusal lesions (sealing arrests them). Evidence-based ADA and AAPD guidance (2016) supports sealants on primary and permanent molars and prefers them over fluoride varnish alone for occlusal caries prevention.
Technique (resin sealant):
- Isolation (rubber dam, cotton rolls with dry angles, or isolation devices): contamination with saliva is the main cause of failure.
- Clean the surface (brush or prophylaxis; avoid fluoride pastes containing oil if the manufacturer advises).
- Etch with 30-40% phosphoric acid for about 15-30 seconds (longer for primary enamel), rinse and dry until the enamel is chalky white.
- If contaminated, re-etch for a short time.
- Apply sealant into the fissures without air bubbles, light-cure, check retention with an explorer, and adjust occlusion.
- Check sealants at each recall and repair or replace when lost.
Materials: resin-based sealants (best retention when isolation is good); glass ionomer sealants (fluoride release, tolerate moisture) as an interim choice for partially erupted molars or when cooperation is limited.
Minimally Invasive Caries Management
| Approach | Description |
|---|---|
| Non-restorative cavity control | Open the lesion so it can be cleaned, plus fluoride; for lesions not suitable for restoration |
| Silver diamine fluoride | Arrests cavitated lesions; stains the lesion black (see ECC section) |
| Atraumatic restorative treatment (ART) | WHO approach: hand instruments remove soft caries; restore with high-viscosity glass ionomer; useful in field settings and anxious children |
| Interim therapeutic restoration (ITR) | AAPD term for hand or slow-speed removal of caries and placement of a glass ionomer to control caries until definitive care is possible |
| Hall technique | Preformed metal crown cemented without caries removal or tooth preparation (see pulp therapy section) |
| Selective caries removal | Leave affected dentin near the pulp to avoid exposure in deep lesions without irreversible pulpitis |
Restoring Primary Teeth
Cavity design differences in primary molars:
- Thinner enamel and dentin and large pulp horns: keep preparations shallow (about 1.5 mm total depth, just into dentin).
- The occlusal isthmus of a Class II preparation is narrow (about one-third of the intercuspal width); the proximal box walls follow the broad, flat contacts.
- Enamel rods in the cervical third of primary teeth slope occlusally, so a gingival bevel is not needed.
Material selection:
| Situation | Suitable materials |
|---|---|
| Small occlusal lesion | Composite, compomer, resin-modified glass ionomer |
| Two-surface lesion, low-to-moderate risk, tooth not near exfoliation | Composite, compomer, resin-modified glass ionomer |
| Multisurface lesions, high caries risk, after pulpotomy or pulpectomy | Preformed metal (stainless steel) crown: best longevity |
| Tooth close to exfoliation (within about 1-2 years) | Glass ionomer or ITR |
| Hypoplastic or MIH molars | Glass ionomer, stainless steel crowns |
| Primary anterior teeth | Composite, strip crowns, zirconia crowns, preveneered stainless steel crowns |
Amalgam use is being phased down under the Minamata Convention, and many services prefer alternatives in children.
Anterior crowns:
- Strip crowns: composite in a celluloid crown former; need enough tooth structure for bonding and good hemostasis.
- Zirconia crowns: excellent esthetics and durability, but they cannot be crimped, need more tooth reduction and a passive fit, and are cemented with glass ionomer or bioceramic cement.
- Preveneered stainless steel crowns: strong, with a white facing that can chip.
Special Health Care Needs
Children with disabilities or chronic illness often need intensified prevention (fluoride, sealants, sugar-free medicines), desensitization and sometimes sedation or general anesthesia for comprehensive care.
Exam Traps
- Saliva contamination after etching is the main reason sealants fail.
- A multisurface lesion in a high-risk primary molar is best restored with a stainless steel crown.
- Zirconia primary crowns cannot be crimped or adapted like metal crowns.
During placement of a resin sealant on tooth 36, the etched enamel is contaminated with saliva before the sealant is applied. What should be done?
Apply the sealant immediately, because saliva improves adhesion
Wipe the surface with a cotton roll and apply the sealant over it
Abandon sealants for this tooth and restore it with amalgam instead
Rinse, dry and re-etch briefly before applying the sealant
A 4-year-old at high caries risk has caries on the mesial, occlusal and distal surfaces of tooth 84, with no pulp involvement. Which restoration has the best expected longevity?
A preformed stainless steel crown
A temporary zinc oxide eugenol filling
A three-surface composite restoration
A glass ionomer sealant on occlusal pits
Which statement about atraumatic restorative treatment (ART) is correct?
It requires complete removal of all discolored dentin and a calcium hydroxide liner
It relies on composite resin bonded with a three-step etch-and-rinse system
It removes soft caries by hand and restores with high-viscosity glass ionomer
It uses a high-speed handpiece and amalgam under rubber dam in every patient it treats
Sections you finish are checked off in the contents.