A 17-year-old sixth-form college student presents at your general dental practice with several carious lesions, one of which is very large. How should you manage his condition?
History
Complaint
He complains that a filling has fallen out of a tooth on the lower right side and has left a sharp edge that irritates his tongue. He is otherwise asymptomatic.
History of Complaint
The filling was placed about a year ago at a casual visit to the dentist precipitated by acute toothache triggered by hot and cold foods and drink. He did not return to complete a course of treatment. He lost contact when he moved house and is not registered currently with a dental practitioner.
Medical History
The patient is otherwise fit and well.
Examination
Extraoral Examination
He is a fit and healthy-looking adolescent. No submental, submandibular or other cervical lymph nodes are palpable and the temporomandibular joints appear normal.
Intraoral Examination
The oral mucosa is healthy, and the oral hygiene is satisfactory. There is gingivitis in areas, but no calculus is visible, and probing depths are 3 mm or less. The mandibular right first molar is grossly carious, and a sinus is discharging on its buccal aspect. There are no other restorations in any teeth. No teeth have been extracted, and the third molars are not visible. A small cavity is present on the occlusal surface of the mandibular right second molar.
Investigations
What Further Examination Would You Carry Out?
Test of tooth sensibility (vitality) of the teeth in the region of the sinus. Even though the first molar is the most likely cause, the adjacent teeth should be tested because more than one tooth might be nonvital. The results should be compared with those of the teeth on the opposite side. Both hot/cold methods and electric pulp testing could be used because extensive reactionary (tertiary) dentine may moderate the response.
The first molar fails to respond to any test. All other teeth appear vital.
What Problems are Inherent in the Diagnosis of Caries in This Patient?
Occlusal lesions are now the predominant form of caries in adolescents after the reduction in relative caries incidence over the past decades. Occlusal caries may go undetected on visual examination for two reasons. Firstly, it starts on the fissure walls and is obscured by sound superficial enamel, and secondly, lesions tend to cavitate late, if at all, probably because fluoride exposure reinforces the ionic structure of the overlying enamel. Superimposition of sound enamel also masks small- and medium-sized lesions on bitewing radiographs. The small occlusal cavity in the second molar arouses suspicion that other pits and fissures in the molars will be carious. Unless lesions are very large, extending into the middle third of dentine, they may not be detected on bitewing radiographs.
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