Recommendations

The permanent teeth most vulnerable to decay in childhood and adolescence are the permanent molars. Caries most commonly develops at just two sites on permanent molars: at the base of pits and fissures, and on the proximal surfaces, just below the contact point. Both these sites present challenges to the clinician in terms of caries diagnosis and caries management.

Children may present with first permanent molars with advanced caries. In addition, approximately 15% of children will be affected by molar incisor hypomineralisation (MIH) to some degree. If a first permanent molar is assessed as having a poor life-time prognosis (whether from caries or MIH), and the second permanent molar second permanent molar is not yet erupted, then it may be in the child’s best long term interests to extract the first permanent molar, allowing the second permanent molars to erupt into its place.

• Develop the child’s personal care plan to prioritise keeping permanent teeth caries free.

• With a high index of suspicion for caries, thoroughly examine all first and second permanent molars, focusing on the base of pits and fissures and the proximal surfaces just below the contact points.

• Taking all relevant factors into account, establish which treatment options are appropriate and which are in the best interests of the child.

• The flow diagram here and the table here can be used to inform management decisions for caries in the permanent dentition.
• Dental amalgam should not be used in the permanent teeth of a child or young person under 15 years of age unless exceptional circumstances can be justified.

• Avoid iatrogenic damage to the proximal surface of the adjacent tooth when preparing multi-surface cavities.

• When managing a dentinal lesion, choose a technique that reduces the likelihood of pulpal exposure and maintains tooth structural integrity.

• When caries or MIH involves the first permanent molars, consider prognosis and planned loss.

• If a first permanent molar is assessed as needing a restoration, consider temporising it until prevention is established and the child’s cooperation is sufficient to cope with the planned treatment.

• For first permanent molars with MIH:

• if there are carious lesions which are not severe, are not sensitive, do not require restoration and are unlikely to in the future, provide enhanced prevention, including fissure sealants, and monitor.
• if there is good quality enamel with small defects that require restoration, use adhesive restorative materials. Indirect restorations extending onto sound enamel have better longevity, and it may be necessary to modify the cavity shape to achieve this.
• if the molars are sensitive, use glass ionomer cement as a fissure sealant.

• Discuss the potential management options with the child and the parent/carer.

• Agree a caries treatment plan, staging care as necessary.

• Obtain valid consent from the child or their parent/carer depending on the age of the child.

• When restoring permanent teeth in children, ensure this is done to the same high standard as for adults to maximize the longevity of restorations and to minimise the amount of treatment required later in life.

• Do not leave infection or caries in permanent teeth unmanaged.