What are the treatment options for carious teeth?

Treatment Options for Carious Teeth

The primary treatment options for dental caries include preventive measures with fluoride application, conservative restorative approaches based on caries depth, and endodontic therapy for pulpal involvement, with the goal of preserving tooth structure and maintaining pulpal health whenever possible. 1

Diagnostic Assessment

Initial Examination

• Visual inspection is the first-line assessment method for detecting dental caries
• Bitewing radiography is the primary radiographic examination for detecting caries in both primary and permanent teeth 1
• Periapical radiographs are indicated as supplementary imaging for:
  • High caries risk patients
  • When pulpal involvement is suspected 2, 1

Special Diagnostic Considerations

• For suspected pulpal involvement: Periapical radiographs using paralleling technique with film holders 2
• For presence of fistula: Intraoral radiograph with gutta-percha cone inserted into the fistula 2
• CBCT is not recommended as first-line examination but may be used for unclear cases after traditional intraoral examination 2

Treatment Algorithm Based on Caries Severity

1. Early/Incipient Caries (Enamel Only)

• Prevention and remineralization:
  • Professional topical fluoride application (0.9% fluoride ion at neutral pH) 3
  • Home care with fluoride toothpaste 4
  • Dietary counseling to reduce sugar intake 5
  • Regular dental check-ups

2. Moderate Caries (Enamel and Dentin without Pulp Exposure)

• Conservative restoration:
  • Selective removal to firm dentine 6
  • Restoration with tooth-colored dental material 2
  • For primary teeth: If child's behavior precludes restorative care, the tooth fracture area can be smoothed or left untreated if smooth to touch 2
  • Monitor for signs of pulpal necrosis until exfoliation 2

3. Deep Caries (With Potential Pulp Involvement)

• Pulp preservation approach:
  • For permanent teeth with immature apex: Selective removal to soft dentine or stepwise removal 6
  • For primary teeth: Selective removal to soft dentine 6
  • Pulpotomy or pulpectomy if pulp is exposed 2
  • If child's behavior precludes pulp therapy, extraction may be indicated for primary teeth 2

4. Severe Caries with Pulpal Necrosis

• Endodontic therapy or extraction:
  • Root canal therapy for permanent teeth with mature roots 2
  • Extraction if tooth is non-restorable or if patient's behavior precludes proper treatment 2
  • Monitor for signs of infection: gingival swelling, increased mobility, parulis (gum boil) 2

Special Considerations for Different Dentitions

Primary Teeth

• More conservative approach may be warranted
• If behavior precludes proper treatment, extraction may be considered
• Monitor for signs of pulpal necrosis: tooth discoloration (gray), parulis, or swelling 2
• Parents should be advised about potential for crown discoloration, pulp canal obliteration, or pulpal necrosis 2

Permanent Teeth

• Preservation of tooth structure is critical
• For immature teeth: Focus on maintaining pulp vitality to allow continued root development 2
• For mature teeth: Root canal therapy is usually the treatment of choice when pulp is exposed 2

Prevention Strategies

Professional Interventions

• Topical fluoride application (maximum 4 treatments per year) 3
• Sealants for high-risk surfaces
• Regular professional cleaning

Home Care Recommendations

• Regular brushing with fluoride toothpaste
• Interdental cleaning with floss or interdental brushes 5
• Dietary control of fermentable carbohydrates 5, 7
• Use of additional technologies based on ecological principles to modify oral biofilm 7

Important Caveats and Pitfalls

• Overtreatment risk: Avoid unnecessary removal of tooth structure; bacterially contaminated or demineralized tissues close to the pulp do not need to be removed 6
• Undertreatment risk: Failure to address caries can lead to pulpal necrosis, abscess formation, or spreading infection 8
• Restoration material considerations: Non-acidic fluoride (neutral pH) is recommended for patients with ceramic or composite restorations 3
• Follow-up importance: Regular monitoring is essential, especially after pulp therapy or conservative management of deep caries
• Child abuse awareness: Consider child abuse as a possible etiology in any child younger than 5 years with severe tooth injury 2

By following this evidence-based approach to caries management, clinicians can minimize morbidity, preserve tooth structure, maintain pulpal health, and improve long-term outcomes for patients with carious teeth.