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Referral and warning signs
When to refer
Refer ALL cases of dental caries to dental personnel (Dentist/Dental Officer/Dental Therapist at HC4+) for assessment and restorative treatment or extraction.
Red flags
- Severe, persistent, spontaneous toothache (suggests pulpitis/abscess).
- Facial swelling (suggests abscess/cellulitis).
- Fever associated with toothache/swelling.
Signs and symptoms
- Initially asymptomatic.
- Tooth sensitivity to hot, cold, or sweet stimuli.
- Localized toothache (may be intermittent initially, becomes persistent as decay progresses).
- Visible pits or holes (cavities) in the teeth.
- Discoloration (brown or black spots) on tooth surface.
- Pain on biting or chewing.
Risk factors
- Poor oral hygiene (plaque accumulation).
- Frequent consumption of sugary foods and drinks.
- Dry mouth (reduced saliva flow).
- Lack of fluoride exposure.
- Deep tooth pits and fissures.
- Malocclusion (crowded teeth harder to clean).
- Gingival recession (exposes root surfaces).
Diagnosis
Clinical assessment
Visual examination (detecting cavities, discoloration). Tactile examination with dental probe (detecting softened enamel/dentin, 'stickiness'). Patient symptoms.
Investigations
- Dental examination.
- Dental X-rays (Bitewings, Periapicals): Essential for detecting interproximal caries and assessing depth of lesion.
Diagnostic criteria
Clinical or radiographic evidence of demineralization/cavitation of tooth structure.
Differential diagnosis
- Pulpitis (more severe, persistent pain).
- Dentin hypersensitivity (pain brief, sharp, stimulus-provoked).
- Cracked tooth syndrome.
- Tooth erosion/abrasion/attrition.
- Developmental defects of enamel.
Management
Pharmacological treatment
- Pain Relief: Paracetamol 1g Q8H (Adult); 10-15mg/kg/dose Q8H (Child). OR Ibuprofen 400mg Q8H (Adult); 7-13mg/kg/dose Q8H (Child). (LOC: HC2)
Dental Treatment (Referral Required)
- Restoration (Filling): Removal of decayed tissue and replacement with filling material (amalgam, composite resin, glass ionomer). (LOC: HC4+)
- Fluoride Application: For early ('incipient') enamel lesions.
- Root Canal Therapy (Endodontics): If decay reaches the pulp. (LOC: RR)
- Crown: If extensive tooth structure loss.
- Extraction: If tooth is non-restorable or patient opts for removal. (LOC: HC4+)
Monitoring
Regular dental check-ups to detect new or recurrent caries.
Complications
- Pulpitis (inflammation of the tooth pulp).
- Periapical abscess (dental abscess).
- Cellulitis.
- Osteomyelitis (rare).
- Tooth loss.
- Pain, difficulty eating, nutritional impact.
Prevention
- Good oral hygiene (brushing with fluoride toothpaste, flossing).
- Dietary modification (reduce sugar frequency).
- Regular dental check-ups.
- Use of fluoride (toothpaste, water, professional application).
- Fissure sealants on susceptible teeth.
Patient education
- Explanation of caries process (bacteria, sugar, acid).
- Importance of oral hygiene and diet.
- Need for dental treatment (filling/extraction).
- Pain relief options.
- Preventive strategies.
Uganda-specific notes
Highly prevalent. Access to restorative care limited, leading to high rates of extraction. Prevention and early detection are crucial. Provide analgesia and refer.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 23, Section 23.2.2