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NorthCarolinaDentalSocietyClinical Techniques in Pediatric Dentistry

Jane A. Soxman, DDS Diplomate, American Board of Pediatric Dentistry

May 16, 2019

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“TheAAPDhasstatedthattheclinicalprac5ceofpediatricden5stryhastobedrivenbyscienceandevidence-basedden5stry(EBD).However,ourspecialtymustrecognizetheneedforbothEBDandageprovenclinicalexperience.”

KupietzkyA,Fuks,A.Thekeeperofthemeaningandtheeraofevidencebasedden5stry.PediatrDent2018;40:250-252.

Evidence-Based Treatment & Clinical Experience

Thebodyofevidenceisgrowingwithrecommenda5onfornon-invasivetreatmentsuchaschemicaltreatmentorHalltechnique.

BanerjeeA,FrenckenJEetal.Contemporaryopera5vecariesmanagement:Consensusrecommenda5onsonminimallyinvasivecariesremoval.BrDentJ2017;223:215-222.

Non-Invasive Treatment

Chemomechanical-CMCR• Tissuespecificac5onwithabilitytodiscernbetweeninfectedandaffectedden5n

• Goodan5microbialac5vity• Non-irrita5ngtopulp• Nodiscolora5ontotoothstructure• Nointerferencewithproper5esofrestora5vematerials

• Longshelf-lifeReddyMVC,ShankarAJS,PentakotaVGetal.Efficacyofan5microbialpropertyoftwocommerciallyavailablecariesremovalagents.JIntSocPrevCommunityDent2015;5:183-189.

• CarisolvgelandPapacariegel• Rubberdamrequired• Gelapplied,rinsedaway,reappliedun5lgelnolongercloudy

• PapacarieremovedmorebacteriaandlessexpensivethanCarisolv

El-TekeyaM,El-HabashyL,MokhlesNetal.Effec5venessof2chemomechanicalcariesremovalmethodsonresidualbacteriainden5nofprimaryteeth.PediatrDent2012;34:325-330.

• Carisolvgelwithhandinstrumentswascomparedtorestora5onwithrotarybur.

• MTAappliedwithdepthof2mmandrestoredwithcomposite.

AliAH,KollerGetal.Self-limi5ngversusconven5onalcariesremoval:Arandomizedclinicaltrial.JDentRes2018;97;97:1207-1213

HallTechnique

AmericanAcademyofPediatricDen5stry.Pediatricrestora5veden5stryPediatrDent2018/19;40(6):330-342.

HallTechnique

Preformedstainlesssteelcrownsplacedwithoutlocalanesthesia,cariesremovalortoothprepara5on.(OutofUK-48%usinginScotland-successratesupto5years).

InnesNP,EvansDJ,S5rrupsDR.Sealingcariesinprimarymolars:randomizedcontroltrial,5-yearresults.JDentRes2011;90:1405-1410.

HallTechnique

HighlycontroversialintheUnitedStates

AmericanAcademyofPediatricDen5stry.Pediatricrestora5veden5stryPediatrDent2018/19;40(6):330-342.

• Openbiteresultsduetonoocculsalreduc5on.

• Occlusionadjuststonormaloccluso-ver5caldimensionin15-30days.

vanderZeeV,vanAmerongenWE.Influenceofpre-formedmetalcrowns(Halltechnique)ontheocclusalver5caldimensionintheprimaryden55on.EurArchPaediatrDent2010;11:225-227.

• Mayuseorthodon5cseparatorsforafewdaysbeforeproceduretoopeninterproximals.

• Crownfilledwithglassionomercement.

• Fingerpressuretoseatandthenchild’sownbi5ngforce.

SealeNS,RandallR.Theuseofstainlesssteelcrowns:Asystema5cliteraturereview.PediatrDent2015;37:147-162.

HallTechniquewithSDF

• Lesionprogressionandbacterialtoxinscouldproduceapulpi5s.

• SDFapplica5onwouldkillthebacteriaanddeac5vatetheremainingnutrients.

HorstJ,FrachellaJC,DuffinS.Responsetoleoertotheeditor.PediatrDent2016;38:462-463.

• StainlesssteelcrownsplacedusingtheHalltechniquevsconven5onalshowedgreatermarginalleakage--buccalmarginmost.

• Resincementshowedleastmicroleakage,followedbyglassionomerandpolycarboxylatecement.

ErdemciZY,CehreliSB,TiraliRE.Hallversusconven5onalstainlesssteelcrowntechniques:Invitroinves5ga5onofmarginalfitandmicrolekageusingthreedifferentlu5ngagents.PediatrDent2014;36:286-290.

• Hallstainlesssteelcrowns(SSC’s)showedsimilarsuccessratestoconven5onallyplacedSSC’s.ClarkW,GeneserMetal.SuccessratesofHalltechniquestainlesssteelcrownsinprimarymolars:Aretrospec5vestudy.GenDent2017;65:32-35.

• Bothhadsuccessratesof95%.TheHandbookofPediatricDen5stry.AJNowak&PSCasamassimo,eds.p.160.AmericanAcademyofPediatricDen5stry,2018.

ITRInterimTherapeu5c

Restora5on

AmericanAcademyofPediatricDen5stry.Policyonearlychildhoodcaries(ECC):Uniquechallengesandtreatmentop5ons.PediatrDent2018/19;40(6):63-64.

HandbookofClinicalTechniquesinPediatricDen5stryed.JaneA.SoxmanWileyBlackwell,2015

W.H.O.

Alterna5ve/Atrauma5cRestora5veTechnique(ART)

Forrestora5onorpreven5oninpopula5onswhohavelioleaccesstodentalcareorserngswheretradi5onalcarecannotbeperformed

“Theatrauma5crestora5vetechniquecanbeconsideredaneffec5veapproachtotrea5ngearlychildhoodcariesinyoungchildren.”

ArrowP.Restora5veoutcomesofaminimallyinvasiverestora5veapproachbasedonatrauma5crestora5vetreatmenttomanageearlychildhoodcaries:Arandomizedcontrolledtrial.CariesRes2016;50:1-8.

InterimTherapeu5cRestora5on

• Whentradi5onalcavityprepara5onandrestora5oncannotbeperformedduetobehavior,youngageorspecialneeds.

• Canbuysome5meifdefini5vetreatmentisnotabletobeperformedormustawaitavailabilityofanesthesiologistforofficeprocedureoropera5ngroom5me.

• Notadefini5verestora5on.Follow-upplannedwithfinalrestora5oninfuture.

• Glassionomercariescontrol(GICC).Glassionomeristhematerialofchoiceforrestora5on.

• Takeslessthan5minutesandcanbeperformedattheini5alvisitforachildwithoneormoreopen,asymptoma(ccariouslesionsconfinedtoden5n.

• Nohistoryofunprovoked/spontaneouspain.

• Performedwithoutarubberdam&withoutlocalanesthesia.

• Provideshigherlong-termsuccesspriortooravoidanceofvitalpulpotomytreatment.

• 95-97%survivalateroneyear.

• TwosurfaceARTinprimarymolarshasbeenshowntobeareasonablealterna5vetoconven5onalrestora5onforupto2years.

RaggioDP,HesseD,LenziTL,GuglielmiAB,BragaMM.Isatrauma5crestora5vetreatmentanop5onforrestoringocclusoproximalcarieslesionsinprimaryteeth?IntJPaediatrDent2013;23:435-443.

• Cementanorthodon5corspacemaintainerbandtoholdGIfor2-surface.

• Theuseofglassionomertorestoreinterproximalcariesinprimarymolarsisatreatmentop5on.

• Teethwerefollowedfor2-3years.

• Therewasnosta5s5callysignificantdifferencebetweenGICandcomposite.

TedescoTK,CalvoAFBetal.ARTisanalterna5veforrestoringocclusoproximalcavi5esinprimaryteeth.IntJPaediatrDent2017;27:201-209.

• Atrauma5crestora5vetreatmentwithglassionomercementandamalgamrestora5onshadthesamelevelsofmicroleakageater2.5years.

• Mul5plesurfacerestora5onshadmoregapsandmicroleakagethansinglesurfacerestora5onswithbothrestora5ons.

MijanMC,LealSC,etal.AreclinicallysuccessfulamalgamandARTrestora5onsinprimarymolarsmicrogapfree?JAdhesDent2018;20:25-32.

• Studycomparedmicrobialcountswithtotalorpar5alremovalofcariousden5ninordertoavoidpulpotomytreatment.

• Nodifferenceinmicrobialcountsunderrestora5onater3-6monthswithorwithoutcompleteremovalofcariousden5n.

LulaEC,Monteiro-NetoV,AlvesCM,RibeiroCC.Microbiologicalanalysisatercompleteorpar5alremovalofcariousden5ninprimaryteeth:Arandomizedclinicaltrail.CariesRes2009;43:354-358.

• Cooonpelletsoakedwith1%chlorhexidineappliedforoneminute,airdried&glassionomerplacedinprep.

• Cavitydisinfec5onwithchlorhexidinereducedmicrobialcountsbeneaththerestora5on.

JoshiJS,RoshanNM,SakeenabiBetal.Inhibi5onofresidualcariogenicbacteriainatrauma5crestora5vetreatmentbychlorhexidinedisinfec5onorincorpora5on.PediatrDent2017;39:308-312.

• Low-costbrandsofglassionomerhavelowersurvivalratescomparedtothetradi5onalbrandofglassionomercements.

BuytheBest!

OlegarioIC,PachecoAetal.Low-costGIC’sreducesurvivalrateinocclusalARTrestora5onsinprimarymolarsateroneyear.JDent2017;57:45-50.

• Non-painfulsuperficialdecayisremovedwithaspoonexcavatororslowspeedwitha#4or#6roundbur.

• SmartBursIISSWHITE-removesdecayedden5nonly.Accessopeningmustbepresentorwouldhavetobecreatedwithcarbidebur.

• Glassionomeristhepreferredrestora5vematerial.Resinmodifiedglassionomeralsorecommendedduetolongerserng(working)5me&moreesthe5c.

GlassIonomer• Capsuleswithrechargeablefluoriderelease.

• Mix/triturateaccordingtomanufacturer’sinstruc5onsandplaceimmediatelyinprep.

• Working5mevarieswithmaterial,butusuallyabout1minute15secondsfromstartofmixing.

• Finish(ifyoudare)atermaterial’sset5me.

• CapsuleApplier/CapsuleExtruder

• Glassionomerisletinplaceun5lchildcancooperateforfinalrestora5onorseda5on/opera5ngroomisscheduled.

• Thebacterialcountssignificantlydecreasewithinthecariouslesion.

• Theden5nwillremineralizeandpulpotomymaybeavoided.

• CodeD2941InterimTherapeu5cRestora5on-primaryden55on-”Placementofanadhesiverestora5vematerialfollowingcariesdebridementbyhandorothermethodforthemanagementofearlychildhoodcaries.Notconsideredadefini5verestora5on.”

• Highviscosityglassionomerprovidesover90%successrateover3years.

• Theserestora5onsareanacceptablealterna5vetoamalgamsingle-surfacerestora5ons.

HilgertLA,deAmorimRG,etal.Ishigh-viscosityglass-ionomer-cementasuccessortoamalgamfortrea5ngprimarymolars?DentMater2014;30:1172-1178.

Resin-ModifiedGlassIonomer

• Addi5onoftheresincomponentwithglassionomerdecreasesini5alhardening5meandhandling.

• Significantlyincreaseswearresistanceandphysicalstrengthsofthecement.

CrollTP,NicholsonJW.Glassionomercementsinpediatricden5stry:reviewoftheliterature.PediatrDent2002;24:423-429.

GlassIonomer

• Fluoridereleasing• Coefficientofthermalexpansionliketoothstructure

• Chemicallyadherestotoothstructure• Setsthroughacid-basereac5on• Bondstocompositeresin

BUT• Lowcompressiveandflexuralstrength-poorwear

• Resin-modifiedimprovesphysicalproper5es

• Resinsimproveflexuralstrengthandreducesolubility

• Lightcure

•Resin-ModifiedGlassIonomersproperlysetwithtwodifferentmechanisms.

• RMGIacid-basereac(onandvisiblelightpolymeriza(onreac(oncompeteandinhibitoneanotherduringserng.

• Findingsrecommendthatsomeoftheself-curingGIreac5onsshouldbepermioedtooccurformanysecondspriortolightcuringinordertoenhancetheuniquebenefitsoftheRMGI.

BerzinsDW,AbeyS,etal.Resin-modifiedglass-ionomerserngreac5oncompe55on.JDentRes2010;89:82-86.

• Newlesionsatthemarginsofcompositerestora5onsarethepredominantcauseforfailureandreplacementofrestora5onsinprimaryteeth.

• Thereisamoderatestrengthofevidencethatglassionomercementsmayreducetheincidenceofrecurrentcariesinthemarginsofocclusoproximalrestora5onsinprimaryteeth.

RaggioDP,TedescoTK,CalvoAFBetal.Doglassionomercementspreventcarieslesionsinmarginsofrestora5onsinprimaryteeth?JADA2016:147;177-185.

Conven5onalvsBiologicTreatmentAsymptoma5cprimarymolarswithlesionsextendingintoden5n.

– Conven5onalapproach-Completecariesremovalw.pulptherapywhenindicated.

– Biologicapproach-Indirectpulpcap(InterimTherapeu5cRestora5on)orHalltechnique.

Bothapproachesexcellentresults.

BanihaniA,DuggalMetal.Outcomesoftheconven5onalandbiologicaltreatmentapproachesforthemanagementofcariesintheprimaryden55on.IntJPaediatrDent2018;28:12-22.

SilverDiamineFluorideBecameavailableAugust2015

MarketedasAdvantageArrestbyElevateOralCareLLC

SoxmanJA.Noninvasivetreatmentforcavitatedlesionsinprimarymolars.GenDent2016;64:8-9.

AmericanAcademyofPediatricDen5stry.Policyonuseofsilverdiaminefluorideforpediatricdentalpa5ents.2018/19;40(6):51-54.

• Non-invasiveprocedurew/olocalanesthesiaforasymptoma5ccaries.“BuyTime”

• Canbeappliedanywhere.

• Simplicityoftx-Appliedw.microsponge.

• Lowcost(similartofluoridevarnish).

• Evidence-basedarrestofcariesprogression.

• Bothfluorideandsilverionscontributetomechanismofac5onasan5microbials.

• Hydroxyapa5teistransformedtoFluoroapa5te,whichislesssolubleinanacidenvironment.

• SilverionsactonthebacterialcellwallandinhibitDNAreplica5on,killingbacteria.

• Cariousden5nisstainedblack.

FungMHT,WongMCM,LoECM,ChuCH.Arres5ngearlychildhoodcarieswithsilverdiaminefluoride-Aliteraturereview.OralHygHealth.2013;1:1-5

• D1354InterimCariesArres5ngMedicamentApplica5on.About160dropsper8mlvial.Unitdoseavailable.Shelflifeis3years.

• “Whenbacteriakilledbysilverionsareaddedtolivingbacteria,thesilverisre-ac5vatedsothateffec5velythedeadbacteriakillthelivingbacteriaina“zombieeffect”.”

• Thisaidsinexplaininghowthesilverdepositedonthebacteriaandden5nproteinswithinthelesionprovidessustainedan5microbialeffects.

• Applyonetotwo5mesperyearun5ltoothexfoliates.

HorstJA,Ellenikio5sH,MilgromPM.UCSFprotocolforcariesarrestusingsilverdiaminefluoride.FromPADentJour2017;Jan/Feb:14-27.

• Ag(NH3)2F-pH10AmmoniastabilizestheFl

• Silverallergyiscontraindica5on.

• Rela5vecontraindica5onsaremucosi5soranyinflamma5onthatdisruptstheprotec5vebarrierprovidedbystra5fiedsquamousepithelium.Wouldcauseincreasedabsorp5onanddiscomfortwithcontact.

• Safetymargindoseis0.95mg/kg.

• Recommenda5onisonedropper10kgpertreatmentvisit.

• Smallestchildwithcariesmaybeabout10kg.– Averageweightfor1-yearold(22pdsgirl&23boy)

• Onedropis9.5mgAg&treats5teeth.

• Weeklyintervalsatmost.

HorstJA,Ellenikio5sH,MilgromPM.UCSFprotocolforcariesarrestusingsilverdiaminefluoride:ra5onale,indica5onsandconsent.PADentJour2017;Jan/Feb:14-26.

• Whenden5nisdried,theSDFpenetratestheporousbodyofthelesion.Thedrierthelesion,themorepenetra5onofthesilver.

• Forexample,thinkofacrackincementthatwouldbefilledwithcement,theliquidpenetratestheden5naltubuleswithacapillary-likeac5on.Silverprecipitatesinthetubulesandplugs.

• Aterini5alapplica5on,dosecondapplica5oninaweekortwotocheckhardness.

• Hardnessofden5nshowslesionarrested.Silverisessen5alforthehardeningofthelesion.

• Protect5ssues.Cooonrollisola5on.Vaselineongingiva.

• *Clean&drywithcompressedair.

• Microsponge(2sizes)toapplyormicrofiberbrush,rubbingforoneminute.Donotdrywithcompressedairaterapplica5on.

• Dry1-2minutes.Nolightcure!Immediatediscolora5on.

• Donotpermitsalivatotouch.

• Applica5ontwiceperyearismosteffec5ve.

• Applica5on5mebetween31.2&83.5seconds.

• Noassocia5onfoundbetweenapplica5on5meandcariesarrest.

• Pa5entscheckedat3weekstodetermineneedforreapplica5on.Efficacyevaluatedbyden5ncolor,textureandpresenceofanypain.

• Mostparentsagreedorstronglyagreedthatisaneasy,painlessprocedureandnotconcernedwithdarkcolorofteeth.ClemensJ,GoldJ,ChaffinJ.Effectandacceptanceofsilverdiaminefluoridetreatmentondentalcariesinprimaryteeth.JPublicHealthDent.2018;78:63-68.

• Clearliquidstainsskin,clothes&allsurfaces.–Wipeface/lipsw.2X2dippedinsaltwater–Mr.CleanMagicEaserwithpumiceandwaterforcountertops

• Skinexfoliateswithin2weeks.Stainmustbedrilledoutoftooth.

• Colorchangeofden5noccursoveroneweek.

• Anyonelicensedtoplacetopicalfluoridecanapply.

• Concernsare:Lackoffollow-up,SDFdoesnotrestoreformandfunc5onandhowlongdura5onofcariesarrest.

• Wrioenconsent,whichincludescoloredphotographsofteethpost-applica5on,shouldbeobtained.

• Whenappliedtwiceannually,mosteffec5veinprimaryincisorsandbuccal/lingualsmoothsurfaces.

NelsonT,ScooJM,CrystalYO,BergJH,MilgromP.Silverdiaminefluorideinpediatricden5strytrainingprograms:surveyofgraduateprogramdirectors.PediatrDent2016;38:212-217.

• Stainonprimarymolarsmoreacceptablethanincisors,butparentspreferredstaintoseda5on/generalanesthesia.

CrystalYO,JanalMN,HamiltonDSetal.Parentalpercep5onsandacceptanceofsilverdiaminefluoridestaining.JADA2017;148:510-518.

• SDF“bleeds”andcandiscolor“pre-clinical”whitespotlesions.Thisstaincanpolishedoffwithafinishingbur.

• Failuresd/t:

– Foodimpac5onwithlargeocclusallesions(ITR)–Highcariogenicdiet– Lowfluorideexposure– Poororalhygiene

• Twicethefluorideasfluoridevarnish-44,800ppmvs22,600ppm

• Preven5veeffectsgreaterwithoneapplica5onofSDFthan2-45meswithfluoridevarnishorchlorhexidinevarnish.

HorstJA.Theuseofsilverdiaminefluorideforearlychildhoodcaries.Oct.30,2016.Audiopresenta5on.OakstonePublica5ons.Prac5calReviewsinPediatricDen5stry.2016;Vol.30.No.10.

• 10%-38%formula5ons

• 38%SDFmoreeffec5vetreatmentforcariesarrest.44,800ppmFluoride

• Whenappliedtwiceperyearprovides80%reduc5onincariesprogressionandnewlesions,whichistwicethatoffluoridevarnish.

CrystalYO,NiedermanR.Silverdiaminefluoridetreatmentconsidera5onsinchildren’scariesmanagement.PediatrDent2016;38:466-471.

• CombinewithFlvarnishat3mo.intervalsforhighCRA.

• Ammoniumhexafluorosilicate(SiF)containssilicaratherthansilver;sodoesnotcausethestainofSDF.

• Thean5bacterialac5vityisnothashighasSDF.

• An5bacterialagentscanbeadded.

• Needsmoreinves5ga5onbeforeclinicaluse.

SavasS,KucukyilmazE,Uzer-CelikE.Effectsofremineraliza5onagentsonar5ficialcariouslesions.PediatrDent2016;38:511-518.

• Pretrea5ngden5nwithSDFdoesnotimpedethebondingstrengthofcompositeresintoden5n.

• Esthe5cconcernd/tcompositewillbedark.

WuDI,VelamakanniS,DenissonJ,etal.Effectofsilverdiaminefluoride(SDF)applica5ononmicrotensilebondingstrengthofden5ninprimaryteeth.PediatrDent2016;38:148-153.

• SDFreleasessilverionswhichinhibitgrowthofSmutansandreducemetabolicac5vityofplaque.

• SDFdoesnotinterferewiththebondstrengthbetweenglassionomercementandcariousprimaryden5n.

• Whenthechildcanco-operate,finalrestora5onscanbeperformed.

PuwanawirojA,TrairatvorakulC,DasanavakeAP.Microtensilebondstrengthbetweenglassionomercementandsilverdiaminefluoride-treatedcariousprimaryden5n.PediatrDent2018;40:291-295.

SMART

SilverModifiedAtrauma5cRestora5veTechnique

SDFandConven5onalGlassIonomerCement

INDICATIONS/PROCEDURESilverdiamine8luoride(SDF)isanantibioticliquid.SDFisusedoncavitiestohelpstoptoothdecay.SDFmayneedtobeappliedevery6-12monthsandfollow-upisnecessary2weeksafterapplication.Insomecases,8luoridevarnishmaybealternatedwithSDFapplicationeverythreemonths.Monitoringisessentialandyourchildmustbeseeneverythreemonthstoevaluateef8icacyoftheSDF.

Thetoothorteethtobetreatedaredriedandcottonrollsand/orgauzeareusedtoisolatethetoothorteeth.SDFisappliedforoneminuteanddried.Thetoothorteetharethenrinsedwithwater.

SDFdoesnoteliminatetheneedfor8illingsorcrowns.Formandfunctionarenotrestored.Oncebehaviorpermits,ifadditionalprocedurescanbeperformed,afeeforthattreatmentwillbeincurred.

CONTRAINDICATIONSSDFiscontraindicatedwithanallergytosilverorifanyirritationorulcersarepresentintheoralcavity.

RISKSPermanentblackstainwilloccuronthetoothorteeththataretreatedwithSDF.SDFcanshedintothesalivaandcausestainontheotherteeth.IftheSDFaccidentallytouchesthegums,stainmayoccurbutshouldbegonewithinafewweeks.

ALTERNATIVESNotreatment,butdecaywilllikelyprogressresultinginpainorabscessrequiringanextraction.Restorationwithtooth-colored8illingsorcrownsifbehaviorpermits.Referralforsedationforde8initivetreatment.

Ihavereadtheindications/procedure,contraindications,risksandalternativestotreatment.IhaveseenaphotographofstainedteethtreatedwithSDF.Allquestionshavebeenansweredtomysatisfaction.

IUNDERSTANDTHETREATEDTEETHWILLBEPERMANENTLYSTAINEDBLACK.IUNDERSTANDTHATSDFDOESNOTRESTORETHETOOTH(TEETH)BUTSLOWSTHEDECAYPROCESSANDTHATDECAYCANSTILLPROGRESS,ESPECIALLYINCAVITATEDAREAS(TEETHWITHHOLESINTHECHEWINGSURFACE).

IndirectPulpTherapyforYoungPermanentMolars

AmericanAcademyofPediatricDen5stry.Pulptherapyforprimaryandimmaturepermanentteeth.PediatrDent2018/19;40(6):343-351.

HandbookofClinicalTechniquesinPediatricDen5stryed.JaneA.SoxmanWileyBlackwell2015

Indica5onsforIPT

• Nosymptomsofpulpi5sandPAdoesnotshowcariousinvolvementofpulpchamber.

• Insteadofcrea5ngapulpexposure,requiringendodon5ctreatmentwithcompleteexcava5onofcaries,thedeepestdecayisletinplace.

• Somestatethatbycon5nuingexcava5onintothepulp,infectedden5nchipsaredisplacedintothepulp,thusincreasingtheriskofpulpalinflamma5on.

• Aterexposureduetocaries,thepulp’srepaircapacityisques5onable.

• Youngpermanentmolars/hypoplas5cmolars.

IPTforYoungPermanentMolars

• Allowscomple5onofrootmatura5onpriortoendodon5ctreatment.

• Persistentlong-termfollow-upisrequiredwithPAevery6months.

• One-stepnowrecommendedoverstepwise.

• Inanasymptoma5cyoungpermanentmolar,leavingsomecariesbehindandplacingafinalrestora5onwithagoodsealhasabeoeroutcomethanstepwisecariesremoval.

MaltzM,GarciaR,JardimJJ,etal.Randomizedtrialofpar5alvs.stepwisecariesremoval:3-yearfollow-up.JDentalRes2012;91:1026-1031.

• Par5alcariesremovalwithamalgamorcompositerestora5onhad99%successratewithasinglesessionvs86%successratewithstep-wiseexcava5on.

• Singlesessionisbeoerforbehaviorconsidera5ons,costandfollow-up.

MaltzM,JardimJJ,MestrinhoHDetal.Par5alremovalofcariousden5ne:amul5centerrandomizedcontrolledtrailand18-monthfollow-upresults.CariesRes2013;47:103-109.

• Toothtreatedonfirstappointment.

• Noplantore-entertoothforpulpotomy.

• Largeroundburw.slowspeedpreferabletospoonforcariesexcava5on.

• Mayleave1-2mmofleatheryden5noverpulp.

• Affectedden5nshouldbeabletoremineralizeduetodecreasednumberofmicro-organisms.

SomeIndirectCappingAgents• Glassionomer• Calciumhydroxide-Dycal,UltraCalXS• Bio-Cap-Resin-ionomeradhesivelinerwithfluoride• Geristore• MTA• TheraCalLC• Bioden5ne

• NeoMTA&NeoMTAPlus

ToS5mulateHealingandRepair

• Bioden5ne(calciumsilicate)andFujiIXperformedthesameclinically,butradiographicallyBioden5neshowedimproved“healing”oflesions.

• Bioden5neismorealkaline.

HashemD,MannocciFetal.Clinicalandradiographicassessmentoftheefficacyofcalciumsilicateindirectpulpcapping:Arandomizedcontrolledclinicaltrail.JDentRes2015;94:562-568.

• Sterilewax,calciumhydroxideandglassionomercementusedasadentallinerforstepwiseexcava5ontopreventpulpalexposurewithcompleteexcava5onofdeepcaries.

• Allthreeshowedincreaseinden5nhardness,totalorpar5aloblitera5onofden5naltubulesanddecreaseinbacteria.

CorraloDJ,MaltzM.Clinicalandultrastructuraleffectsofdifferentliners/restora5vematerialsondeepcariousden5n:Arandomizedclinicaltrial.CariesRes2013;47:243-250.

• Glassionomer&inertwaxplacedaterpar5alcariesremoval.

• Restoredwithcomposite.

• Openedater60days.

• Sealingthecavityisolatesthebacteriafromtheoralcavityandbiofilm.

• Cessa5onofthecariousprocesspermitsbiologicalresponseofthetooth.

•Den5nreorganiza5onandmineralchangeswerenotdependentontheindirectpulpcappingmaterialprovidingevidencethatthearrestofthecariesisnotmaterial-drivenbuthost-driven.

•Repairandregenera5onintheden5n/pulpcomplexissimilartonaturalwoundhealing.

KuhnE,ReisA,ChibinskiACR,etal.Theinfluenceoftheliningmaterialontherepairofinfectedden5ninyoungpermanentmolarsaterrestora5on:Arandomizedclinicaltrail.JConservDent2016;19:516-521.

GlassIonomers:MaterialofChoice• Simpleplacement.

• Minimizespossibilityofpost-opera5vesensi5vityindeeprestora5ons.

• Layeringnotnecessaryduetonopolymeriza5onshrinkage.

• Inlargerestora5onswiththinouterwalls,thepolymeriza5onshrinkagewithcompositecancausefractureofcusps.

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• Coefficientofthermalexpansionsimilartotoothstructure.

• Fluoride-releasingandan5-microbialproper5es---restora5onofchoicewhencariogenicproper5esareimportant.

• Ionicbondwithtoothsurfacethatisconsistentthroughoutthelifeoftherestora5on.

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ResinModifiedGlassIonomer

• Mustbe70-80%glassionomerinordertobecalledaresinmodifiedglassionomer.

• 20%polyacrylicacid-Increasesthebondbycondi5oningcollagenandden5n.

• RMGbondschemicallytotoothstructure.

• Fluoridereleasingrestora5vematerialshaveanan5-carieseffect,reportedmostlyastheirremineraliza5on.

Butalso…• Glass-ionomercements(GIC)canpreventcariogenicbacteriafrommakingasmuchacid.

NakajoK,ImazatoS,TakahashiY,KibaW,etal.Fluoridereleasedfromglass-ionomercementisresponsibletoinhibittheacidproduc5onofcaries-relatedoralstreptococci.DentMater2009;25:703-708.

Awell-sealedrestora5oniscri5calforthesuccessofIPT.

Bjorndal,L.Indirectpulptherapyandstepwiseexcava5on.PediatrDent2008;30:225-229.

• Calciumhydroxideisverysolubleandnotagoodchoiceadjacenttoresin,whichhashydroscopicproper5esthatmakewateravailablewithintherestora5on.(CaOHinterfereswithcompositeset-RobertLoweDDS)

• Glassionomercement(GIC)isagoodbaseorlinerwithresin-basedcomposite.

DonlyK,J,Garcia-Godoy,FG.Theuseofresin-basedcompositeinchildren:anupdate.PediatrDent2015;37:136-143.

Lamina5onSandwichTechniqueStra5fica5on

• Combina5onofglassionomerforden5nreplacementandbondedresin-basedcompositeenamelreplacement.


• Placementofaadhesivelybondedresin-basedcompositeoveraresin-modifiedglassionomerden5nreplacementlayeralmostguaranteesnopost-opera5vesensi5vityfortheyoungpa5ent.


• GICorresin-modifiedGICphotochemicallybondstotheden5n.Theneedforden5nbondingadhesiveiseliminatedwithGIC.

• BondingagentforthecompositeisplacedovertheGIorRMGI.

DonlyK,J,Garcia-Godoy,FG.Theuseofresin-basedcompositeinchildren:anupdate.PediatrDent2015;37:136-143.

CriteriaforSuccess• Vitalityispreserved.

• Nopain,sensi5vityorswelling.

• Noradiographicevidenceofinternalorexternalresorp5onorotherpathologicchanges.

• Con5nuedapexogenesis.

• ObtainPAevery6months(ifpossible!).

VitalPulpTherapyforPrimaryMolars



Consent• Illustra5onsincreasedparentalacceptance/coopera5onanddecreasedparentalanxietyforrecommendeddentaltreatment.

• Children’sbehaviorimprovedaswell.

WangSJ,BriskieD,ChunHuJC,MajewskiR,etal.Illustratedinforma5onforparenteduca5on:Parentandpa5entresponses.PediatrDent2010;32:295-303.

“Thecoronalpulpisamputated,andtheremainingvitalradicularpulp5ssuesurfaceistreatedwithalong-termclinically-successfulmedicamentsuchasBuckley’sSolu5onofformocresolorferricsulfate.”


Indica5onsforPulpotomy• *Complaintofspontaneous(unprovoked)paininacariousprimarymolar.

• Radiographicevidenceofpulpalinvolvement.(carefulrefalseinvolvementwithocclusalcaries)

• Cariouspulpexposureduringprepara5on.

• Nomobilityorpainwithpercussion.

ComplaintofPain

• Childrenmaynotrecallexperiencesofpainanddifficulttoobtainaccuratehistoryofpain.

• Parentwillbemorereliableforchild’shistoryofcomplaintregardingpain.

VergheseST,HannallahRS.Acutepainmanagementinchildren.JPainRes2010;3:105-123.

Cariesmayextendintothefurca5onwithoutanypainfulsymptoms.

FigueriredoMJ,deAmoriumRGetal.Prevalenceandseverityofclinicalconsequencesofuntreatedden5necariouslesionsinchildrenfromadeprivedareaofBrazil.CariesRes2011;45:435-442.

RadiographicEvalua5on• Theboneinthefurca5onoftheprimarymolarisaffectedbythetoxinsthattravelthroughtheaccessorycanalsinthefloorofthepulpchamber.

• Thisresultsinlossofthelaminaduraanddecreasedradiopacity.

• Extrac5onindicatedforint/extresorp5on.

InternalResorp5on• Alwaysassociatedwithextensiveinflamma5onintheprimaryden55on.

• Therootsoftheprimarymolarareverythin.Ifinternalresorp5oncanbeseenonaradiograph,aperfora5onhasusuallyoccurred.

• Extrac5onisindicated.

CampJ.Diagnosisdilemmasinvitalpulptherapy.PediatrDent2011;30:197-205.

• Inaddi5ontobitewingradiographs,aperiapicalradiographshouldalsobeobtainedpriortoapulpotomyprocedure.

• Ifmorethansixmonths5mehaselapsedsincefilmsobtained,obtainanotherfilmpriortoatwo-surfacerestora5oninacariesac5vechild.

• Cariesmayhaveprogressed,andapulpotomymaynowbenecessary.

IndirectPulpTherapy-IPT

• Nosignsorsymptomsofpulpaldegenera5on.

• Cariesclosesttothepulpisletinplace.

• Infectedden5nisremoved.

• Affectedden5n,whichhasthepoten5altoremineralizeremains.

• Carieslessthan1mmawayfromthepulp.

• Coveredwithabiocompa5blematerial.

• Calciumhydroxidehasbeenmaterialofchoiceinthepastduetoalkalinebiocompa5bleproper5esandinduc5onofrepara5veden5n.

• Resin-modifiedglassionomerhascomparablesuccesstocalciumhydroxidebutisbeoeratpreven5ngmicroleakage.

• Lesspainfulsincenopulpalentry.

• Significantlygreatersurvivalrateater3yearscomparedtoformocresolorferricsulfatepulpotomy.

CollJA.Indirectpulpcappingandprimaryteeth:Istheprimarytoothpulpotomyoutofdate?PediatrDent2008;30:230-236.

WunschPB,KuhnenM,BrickhouseTH.Retrospec5vestudyofthesurvivalratesofindirectpulptherapyversusdifferentpulpotomymedicaments.PediatrDent2016;38:406-411.

• Agoodcoronalsealpostvitalpulptherapyisessen5altodecreaseleakageandbacterialcontamina5on.

• Stainlesssteelcrownsprovideabeoersealthanamalgamandhavefewerrestora5onfailures.

SonmezD,DuruturkL.Successrateofcalciumhydroxidepulpotomyinprimarymolarsrestoredwithamalgamandstainlesssteelcrowns.BrDentJ2010;208:E18;discussion408-409.

Proximalcariouslesionsonprimarymolarsareassociatedwithgreaterpulpalinflamma5oncomparedtolesionsofthesamedepthontheocclusalsurface.

KassaD,DayP,etal.Histologicalcomparisonofpulpalinflamma5oninprimaryteethwithocclusalorproximalcaries.IntJPaediatrDent2009;19:26-33.

• Cariesintheprimaryden55onwillpredictcariesinthepermanentden55on.

• Startwithcaries-freeprimaryden55ontohavecaries-freepermanentden55on.

Hall-ScullinE,WhiteheadHetal.Longitudinalstudyofcariesdevelopmentfromchildhoodtoadolescence,JDentRes2017;96:762-767.

CariousPulpExposure

• Inprimarymolars,pulpotomyisbestchoiceifclinicalexposurewithbleeding.

• Infectedden5nispropelledintothepulpchamber,infec5ngthe5ssue.

PulpotomyvsPulpectomy?

• Nogingival/mucobuccalswelling• Nosinustract/parulis• Noexcessivemobility• Noacutepain

Whenapulpotomyisperformed,thecoronalpulpiscariouslyinvolved,andtheradicularpulpisconsideredtobefreeofinfec5on.

MedicamentsPulpotomyFormocresolMTA:Mineral trioxideaggregatePortlandCementFerricsulfate GlutaraldehydeElectrosurgeryLaserSodiumHypochloriteBioden5neNeoMTA&NeoMTAPlus

Pulpectomy

ZincoxideeugenolCalciumhydroxideIodoformpaste: Kri-pasteVitapex/Metapex-CaOHplusiodoform

• In2013,82%ofresidencyprogramstaughttheuseofformocresol(Fc)forpulpotomy.

• Mineraltrioxideaggregateandferricsulfaterankednextinuse.

WalkerLA,SandersBJetal.Currenttrendsinpulptherapy:Asurveyanalyzingpulpotomytechniquestaughtinpediatricdentalresidencyprograms.JDenChild2013;80:31-35.

• Formocresol(Fc)s5llmostcommonlytaughtmedicamentforpulpotomy.

TheHandbookofPediatricDen5stry.AJNow&PSCasamassimo,eds.p.140.AmericanAcademyofPediatricDen5stry,2018.

MTAvsFerricSulfatevsFormocresol

• MTAresultedinhigherradiographicsuccessattwoyearsthanFerricSulfateorFormocresol.

ErdemAP,GuvenY,BalliB,etal.Successratesofmineraltrioxideaggregate,ferricsulfate,andformocresolpulpotomies:A24-monthstudy.PediatrDent2011;33:165-170.

MTA• MTAresultedin100%successratesat36months.

• PrimarymolarsrestoredwithSSC.• Promotesden5n-bridgeforma5on.

GodhiB,TyagiR.SuccessrateofMTApulpotomyonvitalpulpofprimarymolars:A3-yearobserva5onalstudy.IntJClinPediatrDent2016;9:222-227.

• MTAwascomparedtoIRMforqualityofseal.

• Teethsoakedinmethylenebluefor24hrsand28days.

• Teethsec5onedandevaluatedfordyepenetra5on.

• MTAprovidedbeoersealthanIRM.

FartoJ,SahliCC,BojJR.MicroleakageofMTAinprimarymolarpulpotomies.EurJPaediatrDent2017;18:183-187.

• Earlychildhoodcarieswithhighlyvirulentbacterialstrains.

• Circula5ngmicroorganismsmaylocalizeinareasofinflamma5on.KumarSubramanian,DDS

• Microleakageatcrownmarginsmayresultinfailureofpulp/SSC.“Clinicallyclosed”marginmaybeopen30-50micrometers&bacteriamaybe1micrometerindiameter.RobertA.Lowe,DDS

• Usebioac5vecementACTIVIABioACTIVECEMENT(Pulpdent),CeramirCrownandBridge(Doxa),BioCemUniversalBioAc5ve(NuSmile)

FerricSulfate• Hemosta5cagentthatagglu5natesbloodproteins.

• Thebloodreactswithbothferricandsulfateionsandtheagglu5natedproteinformsplugsthatoccludethecapillaries.

• Offersanon-aldehydeop5onforthosewhoareconcernedaboutformocresol’scontroversy.Interna5onalAgencyforResearchonCancerclassifiedformaldehydeascarcinogenicforhumansinJune2004.

FerricSulfateforvitalpulpotomyhasbeenchallengedbecauseFSapplica5ondoesnotallowforproperclinicalevalua5onofthequalityofthehemorrhagefromtheradicularpulp.

DoyleTL,CasasMJ,KennyDJ,JuddPL.Mineraltrioxideaggregateproducessuperioroutcomesinvitalprimarymolarpulpotomy.PediatrDent2010;32:41-47.

FerricSulfatewasfoundtocauseinternalresorp5onandsubsequentfailures.

WunschPB,KuhnenMM,BrickhouseTH.Retrospec5vestudyofthesurvivalratesofindirectpulptherapyversusdifferentpulpotomymedicaments.PediatrDent2016;38:406-411.

?CalciumHydroxide• Over3-yearfollow-up,aterpulpotomywithferricsulfate,formocresol,laserandcalciumhydroxide.

• FerricsulfatemostsuccessfulandCaOHleasteffec5ve.

HuthKC,Hajek-Al-KhatarN,WolfP,etal.Long-termeffec5venessoffourpulpotomytechniques:3-yearrandomizedcontrolledtrail.ClinOralInvest2012;16:1243-1250.

Bioden5ne• Tricalcium-silicatematerialsimilartoMTA.

• Beoereaseofhandlingandcolorstability.(Nobismuthoxideandsetsupinminutes)

• Hasperformedwellaspulp-cappingagent.

DeRossiA,SilvalABetal.Comparisonofpulpalresponsestopulpotomyandpulpcappingwithbioden5neandmineraltrioxideaggregateindogs.JEndod,2014;40:1362-1369.

Bioden5nevsMTA• Bothperformedclinicallyandradiographicallyequallyaswellater24months.

• Mainadvantageofbioden5neoverMTAishigherviscosityandnodiscolora5on.

BaniM,AktasN,CinarCetal.Theclinicalandradiographicsuccessofprimarymolarpulpotomyusingbioden5neandmineraltrioxideaggregate:A24-monthrandomizedclinicaltrial.PediatrDent2017;39:284-288.

• Primarymolarpulpotomyrequiresavitalradicularpulpnomaoerwhatmedicamentisused.

• Ifthepulpchamberisdry,hasanodor,orcontainspurulentmaterial,extrac5onisindicated.

*****SealeNS,CollJA.Vitalpulptherapyfortheprimaryden55on.GenDent2010;58:194-200.

Mobility

Evidence-BasedGuidance• Panelwasunabletomakerecommenda5onofsuperiorityofanymedicamentduetolackofstudiesforcomparison.

• MineralTrioxideAggregate(MTA)andformocresolhadhighest(moderate)qualityofevidence.

• FerricSulfateandlasersfollowed.

DharV,MarghalaniAA,CrystalYOetal.Useofvitalpulptherapiesinprimaryteethwithdeepcariouslesions.PediatrDent2017;39(5):E146-E259.(Panel)

PulpotomyArmamentarium• Localanesthesiaw.epinephrine

• Rubberdam

• Cureoe/Spoonfor5ssuetags

• Sterile#6or#8roundburinhighspeed

• Sterilesaline,2%chlorhexidineorNaOCLforirriga5onwithmonojectsyringe

• 4%ar5caineinfiltra5onvsblockwith2%lidocaineforpulpotomywerecompared.

• Thetwoanesthesiatechniquesshowedequivalentefficacyforbothpulpotomyandextrac5onofmandibularprimarymolars.

AlzahraniF,DuggalMS,etal.Anesthe5cefficacyof4%ar5caineand2%lidocaineforextrac5onandpulpotomyofmandibularprimarymolars:Anequivalentparallelprospec5verandomizedcontrolledtrail.IntJPaediatrDent2018;28:335-344.

PulpBleedingColor

• PulpalbloodwascollectedinacapillarytubeandcolormeasuredwithLEDspectrophotometer.

• Darkerthecolor,themoreinflamma5onwithhigherwhitebloodcellcount.

• Ifs5llbleedingater5minutesanddarkred,pulpectomyshouldbeperformed.

AAminBdiNA,PartoMetal.Pulpbleedingcolorisanindicatorofclinicalandhistohematologicstatusofprimaryteeth.ClinOralInves5g2017;21:1831-1841.

• “Nodirectlinkbetweenachievementofhemostasisandinflammatorystatusofthedentalpulpseemstoexist.”

MutluayM,ArikanV,SariSetal.Doesachievementofhemostasisaterpulpexposureprovideanaccurateassessmentofpulpinflamma5on?PediatrDent2018;40:37-42.

• Cooonpellets-size1

• Cooonforceps

• Preferredmedicament

• (2x2tosqueezeoutformocresolfromcooonpelletifusingformocresol)

• IRM(reinforcedZOEwithpolymerfibers)MTAorNeoMTA

• Wetcooon5ppedapplicatorsforcompressingIRM/NeoMTA

PulpotomyProcedure

• Perform1mmocclusalreduc5onforSSC.

• Removeallperipheral&superficialcariespriortoenteringthepulpchamberwithsterile#6or#8roundburinhighspeed.

• Createlargeenoughaccessopeningtopermitvisualiza5onofcanalorificesandremoveledgesthatcouldhide5ssuetags.

ContaminatedwaterfromdentalunitwaterlinesintroducedMycobacteriumabscessusduringirriga5onanddrillinginpulpotomyprocedures.(FerricSulfate)

PeraltaG,Tobin-D’AngeloMetal.Notesfromthefield:Mycobacteriumabscessusinfec5onsamongpa5entsofapediatricden5stryprac5ce-Georgia2015.MMWRMorbMortalWklyRep.2016;65:355-356.

• Asize1cooonpelletisdippedintheBuckley’sformocresolandcompressedina2x2becauseformocresolisverycaus5c.FUMESONLY

• Thepulpalfloorisveryporousininfectedprimarymolars.Ifthepelletissaturatedwithformocresol,thedrugcanpenetratethroughtheaccessorycanalsinthefurca5onandcauseaseverereac5oninthefurca5on5ssue.

• Aone-minuteapplica5onoffull-strengthBuckley’sformocresolshowedcomparablesuccessratestoafive-minuteapplica5onoftheone-to-fivedilu5onoffull-strengthBuckley’sformocresol.

KurjiZA,SigalMJ,AndrewsP,etal.Aretrospec5vestudyofamodified1-minuteformocresolpulpotomytechnique.PartI:Clinicalandradiographicfindings.PediatrDent2011;33:131-138.

• PlacetheFCpelletsnuglyoverthepulpalstumpsandcoverwithdrypelletsfor1minute.

• Besurelipiscoveredwiththerubberdam.Thelipwillbenumbinthemandible,sothechildwouldbeunawareofburningifusingformocresol&itcontactsthelip.

• Anexplorerorcooonpliersmaybeusedtoremovethecooonpellets.

• TheFCpelletsareneverletinthepulpchamberun5lasecondvisitandformocresolisnevermixedwiththeIRM.

• ThepulpchamberiscompletelyfilledwithathickmixofZOEandpacked5ghtlywithawetcooon-5ppedapplicator.

PrimaryMolarPulpectomyReduceoreliminatetheinfec(ngbacteria

• Thoroughrootcanaldebridementwithbarbedbroachorendofile-GENTLY!

• 1mmshortofapex.size25-35endofile.(40)

• Appropriatean5bacterialirriga5on-NS/NaOCl.

• Drywithsterilepaperpoint.

Vitapex&Metapex

• Iodoform40.4%,calciumhydroxide30.3%,silicone22.4%.Highlyradiopaque.

• Premixedpasteinsyringewithflexible5ps--getcurved--andplunger-typedispensingforaccesstoapex.

• Extraandintraradicularresorp5onbymacrophages.

•Iodineiniodoformhasan5bacterialproper5es.

•Irrigatewithsodiumhypochlorite.(3%ChlorCid)

EstrelaC,RodriguesdeAraujoEstrelaC,HollandraACB,etal.Influenceofiodoformonan5microbialpoten5alofcalciumhydroxide.JApplSci2006;14:33-37.

•Bacteriacolonizeinthepulpcanalspace&biofilmofbacteriaforms.Copious&repeatedirriga5onnecessarytoremovebiofilm.KumarSubramanianEndodon5cChallengesinPediatricDen5stryAnnualAAPDmee5ng

• Verys5ckywheninjec5ng.Con5nuetoextrudefromsyringeaspullingoutofcanal.

• Pressextrudedpasteincoronalareabackdownintotheroots.

• CondensethickmixofZOE(IRMisreinforcedZOE)overorificesandfillcoronalarea.

• PlaceSSC/pre-veneeredorzirconiacrown.

• CanalsouseZOEpasteinthecanals.

• Vitapexresolvedfurca5onpathologyatafasterratethanZOEat6monthsbutat12monthsbothmaterialshadsimilarresults.

TrairatvorakulC,ChunlasikaiwanS.Successofpulpectomywithzincoxide-eugenolvscalciumhydroxide/iodoformpasteinprimarymolars:aclinicalstudy.PediatrDent2008;30:303-308.

FullCoverageRestora5ons

HandbookofClinicalTechniquesinPediatricDen5stryed.JaneA.SoxmanWiley-Blackwell2015

HighCariesRiskAssessmentLargePrepara5on/WideIsthmus

Pulpotomy/PulpectomySevereHypoplasiainPermanentMolar

IfGeneralAnesthesiaNecessarytoTreat

EarlyChildhoodCaries-ECC

• “Oneormoredecayed(noncavitatedorcavitatedlesions),missing(duetocaries),orfilledtoothsurfacesinanyprimarytoothinachildundertheageofsix.”

AmericanAcademyofPediatricDen5stry.Earlychildhoodcaries(ECC):classifica5ons,consequences,andpreven5vestrategies.PediatrDent2018/19;40(6):60-64.

SevereEarlyChildhoodCariesS-ECC• Anysignofsmooth-surfacecariesinachildyoungerthan3yearsofage.

• Ages3-5years-Oneormorecavitated,missing(duetocaries)orfilledsmoothsurfacesinmaxillaryprimaryanteriorteethordmfscore>or=to4atage35atage46atage5

AmericanAcademyofPediatricDen5stry.Earlychildhoodcaries(ECC):classifica5ons,consequences,andpreven5vestrategies.PediatrDent2018/19;40(6):60-64.

• Thereisapoten5alforsignificantincreaseinintrapulpaltemperaturewhenlightcuringacompositeinamoderatelydeepprepara5oninprimarymolars.

• Occlusalprepara5ons1.5mmindepthwith1mmofpulpalfloorthickness.

VinallCV,Garcia-SilvaTC,LouJSBetal.Intrapulpaltemperatureriseduringlightac5va5onofrestora5vecompositesinaprimarymolar.PediatrDent2017:39;E125-E130.

CompositeResinRestora5on&SecondaryCaries

Den5n-resinmarginscreateanareathatpermitssecondarybacterialinfec5onandrecurrentcariesinahighcariesriskchild.

BourbiaM,MaD,CvitkovitchDGetal.Cariogenicbacteriadegradedentalresincompositesandadhesives.JDentRes2013;92:989-994.

• Biofilm,numberofrestoredsurfaces,andpulptherapyaffectthesurvivalofcompositeresinrestora5onsinearlychildhoodcaries.

• 34.8%ofrestora5onssurvivedat30months.

CampagnaP,PintoLT,LenziTLetal.Survivalandassociatedriskfactorsofcompositerestora5onsinchildrenwithearlychildhoodcaries:Aclinicalretrospec5vestudy.PediatrDent2018;40:201-214.

• Biodegrada5onoccursin5meduetouptakeofwaterandbreakdownbysalivaryenzymesandacidfrombacteria.(DieCal)

• Mechanicaldegrada5onoccurswiththermalstressandocclusalforces.

GAPFORMATION

NedeljkovicI,TeughelsWetal.Issecondarycarieswithcompositesamaterial-basedproblem?DentMater2015;31:e247-e277.

• S.Mutanshasesteraseac5vityatlevelsthatdegraderesin-basedrestora5vematerials,contribu5ngtosecondarycaries.

• CompositesdonothavetheabilitytoincreasethelocalpH,whichleadstoincreasedlevelsoftheacidogenicbacteriaandhighercariogenicityofthebiofilm.

• Recurrentcariesoccurmoreotenwithcompositethanwithamalgam.

• Restora5onwithSSCprovideslongersuccessthancompositerestora5oninmandibularfistprimarymolars.

• Survivalrateswere>90%over5years.

MaupomeG,YepesJFetal.Survivalanalysisofmetalcrownsversusrestora5onsinprimarymolars.JADA2017;148:760-766.

• Resin-basedcomposite(CC),glassionomer(GI)andresin-modifiedglassionomercement(RMGIC)werecompared.

• RMGICmostresistanttobiodegrada5onfollowedbyGIandCC.

GautamAK,ThakurRetal.Degrada5onofresinrestora5vematerialsbystreptococcusmutans.JClinPediatrDent2017;41:225-227.

• Atwo-yeartrialshowednosignificantdifferenceinsurvivalratebetweenpreformedmetalcrowns(95%)vsresinmodifiedglassionomer/compositerestora5ons(92.5%)aterpulpotomy.

AmericanAcademyofPediatricDen5stry.Pediatricrestora5veden5stry.PediatrDent2018/19;40(6):330-342.

• Enamelprismsaredisorganizedwithlowerenamelhardness,contribu5ngtocon5nuedenamelbreakdown.

• Bacteriafounddeepinporousenamelcontributetohypersensi5vity.

• Conven5onalamalgamorresinrestora5onmaynothaveaposi5veoutcome--SSC

FagrellTG,DietzW,JalevikBetal.Chemical,mechanicalandmorphologicproper5esofhypomineralizedenamelifpermanentfirstmolars.ActaOdontologicaScandavica2010;68:215-222.

�234

• Stainlesssteelcrownsprovideaviableinterimrestora5onun5llaboratoryfabricatedcrownscanbeplacedonyoungpermanentmolarswithseverehypoplasia,mul5surfacecaries,cuspalfractureorameolgenesisimperfecta.

• SSC’shadan88%successrateovera45.18monthperiod.

DiscepoloK,SultanM,etal.Inves5ga5onofadultstainlesssteelcrownlongevityasininterimrestora5oninpediatricpa5ents.IntJPaediatrDent2017;27:247-254.

• Ceramicshavebeoermarginalfitandarelessplaquereten5ve.Normalcrowncontouroffersimprovedperiodontalhealthandesthe5cs.

• PreformedSSC’sarepreferabletocast-metalceramicorall-ceramiccrownsduringchildhoodandadolescence,butperiodontalstatusmustbefollowed.

Koleven5A,SakellariD,ArapostathisKNetal.Periodontalimpactofpreformedmetalcrownsonpermanentmolarsofchildrenandadolescents.PediatrDent2018;40:117-121.

CrownSelec5on• Beforetheprepara5on,measuretheM-DwidthoftheprimarymolarwithammrulerorBoleygauge.

• MaynotbeabletousethecorrectcrownforamaxillaryfirstprimarymolarduetoM-Dtoothlosswithcariesorunusualmorphology.

Useacrownfromoppositeside/oppositearch

• CrimpM-DwithHoweplierw.spaceloss.

SSCArmamentarium

• Mirror/Explorer• Pre-contoured/pre-crimpedSSC’s• Localanesthesia• Rubberdamisola5on• #6or#8roundcarbideburfor1mmocclusalreduc5on

• #170or169Lcarbideburforinterproximalreduc5on

• Woodenwedgefordistalofsecondprimarymolarifthefirstpermanentmolariseruptedandcontac5ngdistalofprimarymolar

• Crowncrimper/Howeplier• Cement-GI,polycarboxylateor*selfadhesiveresincement(dualcureanddonotover-drytooth)

• Bites5ck

• Wetcooon5ppedapplicators/2x2’s

• Flosswith4-5knotssegmentally5ed

“Esthe5cCrownsrequireanewmindset”

QuotefromDr.AnneC.O’Connell


Pre-VeneeredPrimaryMolarCrowns• Lightandextralightcolors• Canappearbulky• Gingivalhealthmaybecompromised(?)• Highercost• Requiremoretoothreduc5on• Cannotcrimporplacestrongocclusalforcetoseat

• Passivefitwithfinger• Insurancecode:D2934

• Dofirstprimarymolarforfirst5me.

• Selectthecrownsizepriortoprep.Useacooonforcepstocomparethecrownwiththechild’sprimarymolar.Chooseacrownsizethatlooksmostlikethechild’stooth.

• Requiresmuchmorereduc(onthanSSC.

• *Prepareset-upandparentforpulpexposure.

• Reduceocclusal2mmwithfootballdiamondordonutbur.

• Reducemesialanddistalwithfinetaperedroundenddiamond.

• Reducebuccalandlingualwithcoarsetaperedroundenddiamond.

• Featheredgesub-gingival1-2mmwithfinetaperedroundenddiamond.

• Try-incrown.Passivefitwithfingerpressure.

• Checkthatinterarchdistanceis2mmwithtry-in.

• Ifdoingmorethanonecrown,try-inallcrownsatsame5meincaseneedtodomoreM-Dreduc5on.

• Checkocclusionwithar5cula5ngpaper.

• Glassionomercement.Loadcrownfullytobesurenovoids.Usecooon5ppedapplicatortoseatwithslightpressurefromoppositearch.

• Cleanexcesscementwithwet2x2.

• Checkocclusion.Whiterubberpointtoadjustand/oradjustopposingprimarymolar.

RepairingChippedFacings• Placearubberdam• Roughenthefacingadjacenttotheexposedmetalwithanabrasivebur

• Theexposedmetalissandblasted• ESPESil,asilanecouplingagentforbondingtometals,isappliedandlettodryfor30seconds

• Opaquecompositeappliedandlightcured• Compositetomatchveneerappliedandcured

KratunovaE,DentScB,O’ConnellAC.Chairsiderepairofpreveneeredprimarymolarstainlesssteelcrowns:Apilotstudy.PediatrDent2015;37:46-50.

ZirconiaPrepara5on

• Donutorfootballburfor2mmocclusalreduc5on.

• Coarseroundendtapereddiamondfor0.75-1.5mmen5recircumferencestar5ngatthegingivalmargin.Keepburstraightup&down.

• Fineroundendtapereddiamondfor1-2mmsubgingivalpreptoCEJ.IMPORTANTSTEP!!!

• Preponlycounterclockwisewhendosubgingivalprepara5ontoreduce5ssuemacera5on.

CommonProblems

• Inadequatesubgingivalprepara5on.

• Inadequatepreparoundthecollarofthetooth.Properreduc5onwiththisstepwillnotonlymakeprepsmaller,butpermituseofacrowncloserinsizetotheoriginaltooth.

• Inadequateinterproximalreduc5onandmustkeepburver5cal,notslanted.

• Ver5calwallsofprepshouldberoundednearocclusaltoavoidinternalbinding.

• Didnotpreparecare-giverorobtainconsentforpulpotomy.

• Usepinktry-incrown(s)

• Passivefit

• Checkocclusionbeforecement

• Occlusalorinterproximaladjustmentwillremoveglazeandcreateweakenedareaswiththinceramic

MAKETHETOOTHFITTHECROWN

• Rinsetooththoroughly.Salivaandbloodwillbindtotheinternalareaofthezirconiacrownandimpedebond.

• Bloodmayshowthroughzirconia.Hemostasismustbeachievedpriortocementa5on.

• Ifdonothavetry-incrowns,cleaninsideofzirconiacrownwithalcohol,peroxide,orsandblastwithaluminumoxidepriortoplacingcement.

• Mayreducecollarwithdiamondinhighspeedwithcopiouswatercoolant-excessiveheatwillcausemicro-fractureofzirconia.(Probablynotagoodidea!)

• Beoertoadjustocclusionofopposingtooth

• Fillcrowncompletelywithglassionomercementorresin-modifiedglassionomercement.

• Variouscementswerecomparedformicroleakage.

• Resincementismostop5mumlu5ngagent.

Al-HajAliSN,FarahRI.Invitrocomparisonofmicroleakagebetweenpreformedmetalcrownsandaesthe5ccrownsofprimarymolarsusingdifferentadhesivelu5ngcements.OurArchPaediatrDent.2018pubaheadofprint

• Donotdisturbun5lcementset--holdwithfingerpressure

• Removesizewithspoonorprophypaste

• Autoclaveforsterilizing

• CodeD2929

• ZirconiaprimarymolarcrownsshowsimilarperformancetoSSCsat24months.

DonlyKJ,SasaI,ContrerasCIetal.Prospec5verandomizedclinicaltrialofprimarymolarcrowns:24-monthresults.PediatrDent2018;40:253-258.

• Zirconiacrownshaveadvantageofesthe5cappearance.

• Zirconiacrownsshowedlessplaqueaccumula5onandbeoergingivalhealththanSSC.

• Fractureandmildstainingmayoccurwithzirconiacrowns.

TaranPK,KayaMS.Acomparisonofperiodontalhealthinprimarymolarsrestoredwithprefabricatedstainlesssteelandzirconiacrowns.PediatrDent2018;40:334-339.

• Primarytoothenamelisthinner,lessmineralized,moreporousandaprisma5ccomparedtopermanentenamel.

• Zirconiacrownsdonotcauseexcessenamellosstooccludingprimarymolars.

Johnson-HarrisD,ChiquetB,FlaitzCetal.Wearofprimarytoothenamelbyceramicmaterials.PediatrDent2016;38:519-522.

Extrac5onofPrimaryDen55on


In this Happy Tooth Chest you will find a teeny, tiny tooth of mine. And while I lay where dreams are made, maybe we can make a trade.

LocalAnesthesia

HandbookofClinicalTechniquesinPediatricDen5stry ed.JaneA.SoxmanWileyBlackwell2015

Thenumberonereasonchildrengiveforfearofgoingtotheden5stisthefearoftheinjec5on.

AlShareedM.Children’spercep5onoftheirden5sts.EurJDent2011;5:186-190.

Combative Behavior and/or

Avoidance Behavior

TopicalAnesthesia• Temporarylossofsensa5on2-3mmindepth.

• Contactforminimaldura5onof2minutes.

• Nodirectpropor5onalrela5onshipbetweendura5onofcontactandclinicaleffec5veness.

• Decreasesdiscomfortforneedlepenetra5on&rubberdamclampplacement.

PriyathamS,NuvvulaS.Intraoraltopicalanesthesiainpediatricden5stry.IntJPharmBioSci2016;7:346-353

Vibra5on

• Vibra5ons5mulusiscounter-s5mula5onthatreachesthebrainbeforepainsensa5on.

• Aoributedtogatecontroltheory.

• S5mula5onofthelargerdiameterAbetafiberscancloseaneural“gate”tonocicep5vesignals,reducingpainpercep5on.

• Painreliefenhancedbysimultaneousac5va5onofnervefibersthatconductnon-noxiouss5muli.

• Vibra5ons5mulushasbeenshowntosignificantlyreducepainwithinjec5oncomparedtouseoftopicalanesthesiaalone.

PriyathamS,NuvvulaS.Intraoraltopicalanesthesiainpediatricden5stry.IntJPharmBioSci2016;7:346-353

• DentalVibesignificantlyreducedinjec5ondiscomfortinpa5ents10-17yearsofage.ChingD,FinkelmanM,LooCY.Effectofdentalvibeinjec5onsystemonpainduringlocalanesthesiainjec5onsinadolescentpa5ents.PediatrDent2014;36:51-55.

• DentalVibesignificantlyreducedinjec5onpainin6-12year-oldchildren.ShilpapriyaM,JayanthiM,ReddyVNetal.Effec5venessofnewvibra5ondeliverysystemonpainassociatedwithinjec5onoflocalanesthesiainchildren.JIndianSocPedodPrevDent2015;33:173-176.

• Boneisveryporouswithrapiduptake.

• Injectslowly

• Buccalinfiltra5onusuallyadequateinmandibleratherthanblockunderage8

PanoramaicFilms&ModelsAnalyzed• 1.26mmbelowocclusalplaneinfullprimaryden55on.

• 0.33mmabovetheocclusalplaneasfirstpermanentmolarerupts.

• 1.54mmaboveocclusalplanewhenfirstpermanentmolarfullyerupted.

• 1.64mmaboveocclusalplaneaspermanentlateralincisorserupt.

• 1.98mmaboveocclusalplaneaspermanentsecondmolarerupts.

• 2.9mmaboveocclusalplanewhenpermanentsecondmolarfullyerupted.

ShuklaRH,TikuA.Correla5onofmandibularforamentoocclusalplaneasaclinicalguideforinferioralveolarnerveblockinchildren:Adigitalpanoramicradiographicstudy.CentempClinDent2018;9:372-375.

• Placethumbextra-orallyonposteriorborderoframusandindexfingerinthecoronoidnotch,thedeepestdepressionontheanteriorborderoftheramus.

• Barrelofsyringeonoppositecornerofmouth.

• Short27gaugeneedleforyoungpediatricpa5ent.Usuallydonotneedblockunderage8.

• Mandibularforamenlies1/2to2/3ofthetotalwidthofthewidthoftheramusmeasuredfromtheanteriorborder.

EparsJ-F,MavropoulosA,KiliaridisS.Influenceofageandver5calfacialtypeontheloca5onofthemandibularforamen.PediatrDent2013;35:369-373.

• 5-7yearoldchildrenreceivingIAN.

• Distrac5onwithaudiovisualglasseswasaneffec5vemeanstoreducepainwithinjec5onoflocalanesthesia.

El-SharkawiHFA,HousseinyAA,AlyAM.Effec5venessofnewdistrac5ontechniqueonpainassociatedwithinjec5onoflocalanesthesiaforchildren.PediatrDent2012;34:142-145.

• Prolongednumbnesswith4%Septocainefrom3to5hours.

• Primarilyinchildrenyoungerthan7yearsofage.

• Lipmostcommonsiteforaccidentalinjury.• Notrelatedtoinjec5onsite.• Informparents-IncludewithConsent.

AdewumiA,HallM,GuelmannMetal.Theincidenceofadversereac5onsfollowing4%septocaine(Ar5caine)inchildren.PediatrDent2008;30:424-428.

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