American)Associa,on)of)Orthodon,cs)The)Key)to)Excellence))withThe$Ortho)Pedo$Connec/on
Jane)A.)Soxman,)DDS)))))))Diplomate,)American)Board)of)Pediatric)Den,stry
•Trauma&from&braces/toothbrush•Sodium&Laryl&Sulfate6&detergent&in&toothpaste•Pyrophosphates&in&tartar&control&toothpastes•&Genetics•&Stress•&Autoimmunity•Hematinic&deficiency&associated&with&low&serum&iron,&folic&acid,&and&vitamin&B1,&B2,&B6,&B12&from&malabsorption
•&Celiac&Disease
Apthous&Ulcers
• Use&toothpaste&without&Sodium&Laryl&Sulfate&6&SLSRembrandt&&Canker&Sore,&Biotene,&Tom’s&of&Maine,&Sensodyne&Original&Flavor&and&Cool&Gel,&Squigle&(xylitol&w.&fluoride)6&Homestead&Market&16888623461906/www.Homesteadmarket.com
• Orabase&(Colgate)
• Vitamin&E
Vitamins• Daily&multivitamin&supplements&did¬&result&in&a&reduction&in&recurrent&apthous&stomatitis&(canker&sores).
• B&12&deficiency&may&be&clinically&evident&with&tongue&depapillation.
Lalla&RV,&Choquette&LE,&Feinn&RS&et&al.&Multivitamin&therapy&for&recurrent&apthous&stomatitis.&JADA&2012;143:3706376.
Celiac&Disease
• Gluten6sensitive&enteropathy
• Permanent&intolerance&of&gluten&protein&in&wheat,&rye&and&barley
• Damage&to&intestines&causing&malabsorption&of&nutrients&&
Dental&Materials
• To&check&gluten&contents:&www.withoutthewheat.com/Dental&Products.html&
Perleche/Angular&Cheilosis• Candida&Albicans
• Superficial&exudative&crust&with&ulcerated&appearance
• Saliva&collects&in&folds
• Riboflavin&deficiency&with&superimposed&fungal&infection
• Nystatin&Cream/Ointment& 100,000&U/gm&&&&(15&or&30gm)
• Must&treat&for&48672&hours&after&resolution&of&symptoms&&
• Change&toothbrush&&
Maxillary&Removable&Appliances• Clean&with&an&ultrasonic&cleaner&(not&just&sonic)
• Retainer&Brite&(Kosher)&SoniBrite,&Efferdent,&Polident
• Soak&in&diluted&bleach&for&10&minutes– 1&part&scented&bleach&:&10&parts&water– Bleach&bath&lasts&for&about&a&week
Streptococcal&Pharyngitis
• 10%&have&sore&throat&and&fever
• Vesicles&or&ulcers&suggest&viral
• Beefy&red&uvula&or&exudate&suggests&strep
• Not&contagious&after&24&hours&of&antibiotic&therapy&
• Orthodontic&retainers&should&be&soaked&in&Listerine,&and&the&patient&should&rinse&with&Listerine&if&tolerated.
• When&the&Ab&prescription&is&filled,&two&new&toothbrushes&should&be&purchased.&&&One&brush&is&begun&24&hours&after&beginning&the&antibiotic,&and&the&other&is&begun&upon&completion&of&the&antibiotic.
Wind&Instruments&&&Occlusion• Playing&a&wind&instrument&is¬&a&significant&etiological&factor&in&the&development&of&a&malocclusion.
• Playing&a&brass&instrument&with&a&large&cup6shaped&mouthpiece&may&predispose&a&musician&to&develop&a&lingual&crossbite&or&lingual&crossbite&tendencies.&
Grammatopoulos&E,&White&AP,&Dhopatkar&A.&Effects&of&playing&a&wind&instrument&on&the&occlusion.&Am&J&Dentofacial&Orthop&2012;141:1386145,&
DECALCIFICATIONMost&common&complication&of&fixed&
orthodontic&appliance&therapy
White&Spot&Lesions6WSL
“...subsurface&enamel&porosities&&resulting&from&carious&demineralization&that&appear&as&milky&white&opacity&on&smooth&surfaces.”
Hamdan&AM,&Maxfield&BJ.&Tufekci&E&et&al.&Preventing&and&treating&white6spot&lesions&associated&with&orthodontic&treatment.&JADA&2012;143:7776783.&
• Orthodontists,&general&dentists,&parents&and&patients&all&agreed&there&is&joint&responsibility&for&prevention&of&white&spot&lesions.
• 17%&of&patients&indicated&that&their&parents&were&responsible&for&white&spot&prevention.
• 72%&of&parents&felt&they&were&responsible&for&prevention&of&white&spots.
27
• 28%&of&patients&did¬&recall&receiving&any&instruction&in&the&prevention&of&white&spots.
• 55%&of&parents&believed&that&the&chid&should&have&had&more&instruction&in&prevention.
• 19%&of&parents&indicated&they&would¬&or&might¬&recommend&braces&to&a&friend&if&their&child&had&white&spots&post&treatment.
28
• 60%&of&orthodontists&indicated&that&white&spots&made&the&teeth&look&“a&lot&worse”.
• “Orthodontists&may&feel&frustrated&because&they&cannot&prevent&the&development&of&white&spot&lesions,&especially&in&uncooperative&patients.”
Maxfield&BJ,&Hamdan&AM,&Tufekci&E&et&al.&Development&of&white&spot&lesions&during&orthodontic&treatment:&Perceptions&of&patients,&parents,&orthodontists,&and&general&dentists.&&Am&J&Orthod&Dentofacial&Orthop&2012;141:3376344.
29
CRACaries&Risk&Assessment
Vs
DRADecalcification&Risk&Assessment
Decalcification&Risk&Factors
AnkyloglossiaHigh&Lip&LineIncompetent&Lip&PostureTrue&Red&Hair&with&FrecklesWearing&GlassesShort&Clinical&CrownsPoor&Grooming
AsthmaGERDBulimiaSwim&TeamErosive&Foods&and&DrinksSocial&Stress6&School/Family/Income&Level&Prolonged&TreatmentADHDPregnancy&with&Emesis
Continually&Disrupt&the&Biofilm
• Medications&to&treat&asthma&may&decrease&the&secretion&of&saliva.
• Salivary&reduction&is&associated&with&an&increase&in&lactobacilli&and&increased&caries&susceptibility.
43
• Powdered&inhalers&have&pH&less&than&5.5&(ph&for&hydroxyapatite&dissolution).
• Fall&in&pH&lasts&about&30&minutes&after&use&of&the&oral&inhalers.
Shaw&L,&Al6Dlaigan&YH,&Smith&A.&Childhoodasthma&and&dental&erosion.&J&Dent&Child&2000;68:1026106.
44
• Relaxation&of&the&esophageal&sphincter&results&in&gastro6esophageal&reflux&with&gastric&acid&pH&1.1
• Children&with&asthma&are&5.5×&more&likely&to&be&diagnosed&with&gastro6esophageal&reflux&disease.
Thakkar&K,&Boatright&RO&et&al.&Gastroesophageal&reflux&and&asthma&in&children:&A&systemic&review.&Pediatrics.&2010;125:e9256e930.
46
Improperly&Maintained&Pool&Chlorination
• Rapid&enamel&erosion&and&staining&occurs&from&the&chemically&treated&swimming&pool&water.
• Low&pH&levels
Dr.&Leila&Jahangiri&&NYU&College&of&Dentistry.&Dentistry&Today&News,&2011;30:8.
• Both&original&flavor&and&sour&varieties&of&candy&are&potentially&erosive,&with&sour&candies&having&a&higher&erosive&potential.– Jolly&Rancher& Malic&Acid– Life&Savers& & Citric&Acid– Mike&&&Ike& & Citric&and&Malic&Acid– Twizzlers& & Citric&AcidWagoner&SN,&Marshall&TA,&Qian&F&et&al.&In&vitro&enamel&erosion&associated&with&commercially&available&original6flavor&and&sour&versions&of&candies.&JADA&2009;140:9066913.
Sour&Patch&Kids
• Soft&drink&intake,&even&of&relatively&short&duration,&can&reduce&enamelµhardness.&
• Soft&drinks&should&be&avoided&during&orthodontic&treatment.
Van&Eygen&I,&Vannet&VB,&Wehrbein&H.&Influence&of&a&soft&drink&with&low&pH&on&enamel&surfaces:&An&in&vitro&study.&Amer&Jour&Orthod&and&Dentofacial&Orthop.&2005;&128:3726377.
52
Critical&pH
• The&pH&below&which&demineralization&dominates&and&results&in&a&net&dissolution&of&tooth&enamel.&
• For&most&individuals,&this&pH&is&5.5.
Stoodley&P,&Wefel&J,&Gieseki&A,&deBeer&D&et&al.&Biofilm&plaque&and&hydrodynamic&effects&on&mass&transfer,&fluoride&delivery&and&caries.&JADA&2008;139:118261190.&
Acid&and&Sugar&Content&of&Some&Common&Beverages
) ) ) ) pH)))))))))Gm)sugar/12)ozBaPery)acid) 1) ) ) 0Lemon)juice) 2) ) ) 0Coke)) ) 2.5) ) ) 39Pepsi) ) 2.4) ) ) 41Sunny)Delight) 2.4) ) ) 30Snapple) ) 2.4) ) ) 27Mountain)Dew) 3.1) ) ) 46Gatorade) ) 2.7) ) ) 14
Welch’s)White) 2.8) ) ) 37
)))Grape)Juice
Diet)Coke) ) 3.2) ) ) 0
Sprite/7)Up) 3.3) ) ) 26
Iced)Tea)w/o) 3.8) ) ) 0
Apple)Juice) 3.2) ) ) 23
Orange)Juice) 3.8) ) ) 46
A&W)Rootbeer))4.8) ) ) 46
2%)Milk) ) 6.8) ) ) 16.5
Tap)Water)) 6.7) ) ) 0)
Propel Grape 2.98 Gatorade 2.92-3.08 Powerade 2.76-2.865 Hour Energy 2.81Red Bull 3.37Red Bull Sugar Free 3.27
Poonam J, Hall-May E, Golabek K et al. A comparison of sports and energy drinks-Physiochemical properties and enamel dissolution. Gen Dent 2012;60:190-197.
• The&addition&of&calcium&to&100&percent&juices&decreases&enamel&erosion.
• Recommend&calcium6fortified&juice&to&patients&who&are&at&risk&for&enamel&erosion.
Davis&RE,&Marshall&TA,&Qian&F,&Warren&JJ&et&al.&In&vitro&protection&against&dental&erosion&afforded&by&commercially&available,&calcium6fortified&100&percent&juices.&ADA&2007;138:159361598.
58
• Hypothalamic&pituitary&adrenal&cortical&secretions&are&increased&with&financial&stress&and&low&socioeconomic&status.
• High&risk&caries&was&associated&with&high&salivary&levels&of&cortisone.
• Enamel&surfaces&were&thinner&&&softer.
Boyce&WT,&Besten&PKD&et&al.&Social&inequalities&in&childhood&dental&caries:&The&convergent&roles&of&stress,&bacteria&and&disadvantage.&Soc&Sci&Med&2010;71:164461652.
Attention&Deficit&Hyperactivity&Disorder&6&ADHD
Most&common&developmental&disorder&among&school&children.
Blomqvist&M,&Ahadi&S,&et&al.&Dental&caries&in&adolescents&with&attention&deficit&disorder:&A&population6based&follow6up&study.&Eur&J&Oral&Sci&2011;119:3816385.
• Neurobehavioral&syndrome– Inattention– Impulsive&and/or&over6activity– Learning&problems– Poor&peer&relationships– Low&self&esteem
Waldman&HB,&Perlman&SP.&Children&with&attention&deficit&disorder&and&learning&disability:&Findings&from&the&first&national&study.&J&Ped&Dent&2004;71:1016104.&
• Managed&with&oral&drugs:
Stimulants&to&increase&the&production&of&dopamine&and&norepinephrine
–Ritalin6&taken&263×/day–Concerta6&long&acting&up&to&12&hours–Adderall–Strattera
• May&need&two&doses&per&day
•Long6acting&and&extended
•Do¬&appoint&first6thing&in&am&or&last&in&pm
•Sometimes&take&a&“drug&holiday”&due&to&some&slowing&of&growth&related&to&height&and&weight
• More&orthodontic&emergencies66especially&lost&retainers
• Use&fixed&or&non6compliant&appliances
• See&more&often
• Prophy&more&often
• Problem&with&time&perception6&Toothbrush&with&timer&or&brush&for&one&song
• Children&with&ADHD&experience&a&higher&incidence&of&traumatic&dental&injuries.
• Timing&for&orthodontic&treatment&of&at6risk&maxillary&permanent&incisors&should&be&considered.
Sabuncuoglu&O.&Traumatic&dental&injuries&and&attention6deficit/hyperactivity&disorder:&Is&there&a&link?&Dent&Traumatol&2007;23:1376142.&
“Gone&are&the&days&when&the&development&of&cavities&is&tied&generically&to&consuming&too&much&candy,¬&brushing&enough,&or¬&getting&enough&fluoride.”
Filoche&S,&Wong&L,&Sissons&CH.&Oral&Biofilms:&Emerging&concepts&inµbial&ecology.&J&Dent&Res&2010;89:8618.
• Despite&the&lack&of&any$preventive&care&program&or&additional&fluoride,&50%&of&patients&had&resistance&to&decalcification/white&spot&lesions.
Readers’&Forum&White&spot&lesions:&Prevention&and&treatment.&Am&J&Orthod&Dentofacial&Orthop&2010;&138:6906696.
69
White&Spots
• Show&what&the&patient&started&with.&&&&
•Record&in&the&patient’s&chart&the&white&spots&or&decalcification&that&is&present&prior&to&beginning&treatment.&
•Show&to&parent&and&child.
First&Visit&After&Banding• White&spots&can&form&within&4&weeks.
• For&patients&with&high&risk,&consider&first&visit&after&banding&in&364&weeks&rather&than&than&668&weeks.
Maxfield&BJ,&Hamdan&AM,&Tufekci&E,&et&al.&Development&of&white&spot&lesions&during&orthodontic&treatment:&Perceptions&of&patients,&parents,&orthodontists,&and&general&dentists.&&Am&J&Orthod&Dentofacial&Orthop&2012;141:3376344.
• Decalcification&at&the&gingival&margin&is&a&sign&of&an&active&carious&process&even&in&the&absence&of&frank&cavitation.&&
• The&carious&process&may&be&suspended&via&remineralization&with&active&intervention.
Van&der&Veen&MH,&Mattousch&T,&Boersma&JG.&Longitudinal&development&of&caries&lesions&after&orthodontic&treatment&evaluated&by&quantative&light6induced&fluorescence.&Am&J&Orthod&Dentofacial&Orthop&2007;131:2236228.&&
Have&a&Plan&
• DRA&and&a&targeted&preventive&care®imen&to&control&the&biofilm.
• Harden&the&enamel&to&prevent&dissolution.&Mineral&loss&with&pH&less&than&5.5.
• Add&a&protective&layer&or&coating&to&the&enamel.
Spin/Power&Brush
• Oscillating6rotating&technology&removes&more&plaque&and&decreases&gingival&recession.
• Philips&Sonicare
• Oral6B&Triumph
• Power&brush&removed&12618%&more&plaque&than&toothbrush&with&brushing&performed&by&a&dental&hygienist.&
• Significantly&more&plaque&removal&at&1&and&2&minute&intervals&with&power&brush.
Taschner&M,&Rumi&K,&Master&AS&et&al.&Comparing&efficacy&of&plaque&removal&using&professionally&applied&manual&and&power&toothbrushes&in&467&year&old&children.&Pediatr&Dent&2012;34:61665.
• High&caries&risk&adolescents&undergoing&orthodontic&treatment&should&be&using&a&5000ppm&toothpaste.&
Al6Mulla&A,&Karlsson&L,&Kharsa&S,&Kjellberg&H,&et&al.&Combination&of&high&fluoride&toothpaste&and&no&post6brushing&water&rinsing&on&enamel&demineralization&using&an&in6situ&caries&model&&with&orthodontic&bands.&Acta&Odontologica&Scandanavica&2010;68:3236328.
80
Modified&Fluoride&Toothpaste&Technique:&MFTT
• Spread&2cm&of&fl&toothpaste&evenly&in&both&arches.
• Brush&for&2&minutes.&Do¬&expectorate.• Sip&of&water&and&filter&the&slurry&of&toothpaste&and&water&in&between&the&teeth&for&30&seconds.
• No&further&rinsing&and&no&eating&or&drinking&for&2&hours.
• Brush&twice&a&day.
• This&method&increased&the&fluoride&concentration&and&prolonged&contact&of&fluoride&with&the&teeth.
• With&the&slurry,&there&was&more&even&distribution&of&the&dentifrice.
• Not&eating&for&2&hours&permits&longer&exposure&for&the&elevated&fl&concentration.
Al&Mulla&AH,&Al&Kharsa&SA,&Birkhed&D.&Modified&fluoride&toothpaste&technique&reduces&caries&in&orthodontic&patients:&A&longitudinal,&randomized&clinical&trial.&Am&J&Orthod&Dentofacial&Orthop&2010;138:2856291.
CPP6ACP&Casein&phosphopeptide&and
amorphous&calcium&phosphateRECALDENT&TM
• CPP&is&a&milk&derived&phosphopeptide&that&binds&calcium&and&phosphate&to&enamel.
• Bio6available&ratio&of& &5&CA:&3&Phosphate:&1&Fl
• Exact&same&ratio&as&healthy&enamel
• CPP/Casein&phosphopeptide&keeps&calcium,&phosphorus&and&fluoride&in&ionic&form&in&solution,&so&ideal&as&remineralizing&agent&for&enamel.
• Contraindicated&for&sodium&benzoate&or&milk&allergy&due&to&casein&but&ok&for&lactose&intolerant.&
• Gluten&free.
MI Paste to Prevent Demineralization
• Patients&undergoing&orthodontic&treatment.
• Used&MI&Paste&Plus&or&placebo&paste&in&fluoride&tray&for&minimum&of&365&minutes&each&night&after&brushing.
85
• MI&Paste&decreased&the&number&of&white&spot&lesions&already&present&and&helped&prevent&development&of&new&WSL.
Robertson&MA,&Kau&CH,&English&JD&et&al.&MI&Paste&Plus&to&prevent&demineralization&in&orthodontic&patients.&Am&J&Orthod&Dentofacial&Orthop&2011;140:6606668.
86
• Only&sold&on&on6line&pharmacy
• Can&be&sold&in&practice
• Order&from&Mountainside&Medical&www.mountainside6medical.com&
• Fax&or&scan&with&office&phone&#&on&rx.&&800632367063&
• Rinsing&the&mouth&with&a&fluoridated&rinse&assists&in&caries&prevention&by&elevating&oral&fluoride&levels.
• Rinsing&with&a&rinse&that&does¬&contain&fluoride&after&brushing&will&significantly&reduce&salivary&fluoride&concentration.
Duckworth&RM,&Maguire&A,&et&al.&Effect&of&rinsing&with&mouthwashes&after&brushing&with&a&fluoridated&toothpaste&on&salivary&fluoride&concentration.&Caries&Res&2009;43:3916396.
• ACT&and&Fluorigard&226ppm
• Phos6Flur&200ppm&plus&phosphoric&acid& 22x&stronger&than&ACT&or&Fluoriguard
•LISTERINE&TOTAL&CARE&ZERO• Phosphoric&acid&for&enhanced&fl&uptake• 221ppm&fluoride
• When&flossing&is&compromised&by&orthodontic&appliances,&an&interproximal&brush&should&be&recommended.
Arici&S,&Alkan&A.&Comparison&of&different&toothbrushing&protocols&in&poor6toothbrushing&orthodontic&patients.&Eur&J&Orthod&2007;29:4886492.
• Elastic&ligature&ties&imbibe&fluoride&and&may&function&as&fluoride&reservoirs&slowly&releasing&fluoride&adjacent&to&the&brackets.
Wiltshire&WA.&In&vitro&and&in&vivo&fluoride&release&&from&orthodontic&elastomeric&ligature&ties.&Am&J&&Orthod&Dentofacial&Orthop&1999;115:2886292.
• One&application&of&fluoride&varnish&placed&around&orthodontic&brackets&can&reduce&enamel&demineralization&by&40%&over&a&three&month&period.
• Application&every&three&months&has&been&recommended.
Farhadian&N,&Miresmaeili&A,&Esiami&B,&et&al.&Effect&of&fluoride&varnish&on&enamel&demineralization&around&brackets:&An&in6vivo&study.&Am&J&Orthod&Dentofacial&Orthop&2008;133:S956S98.
Pit&&&Fissure&Sealants
• Sealants&applied&from&the&gingival&surface&of&the&bracket&to&the&free&gingival&margin.
• Effectively&sealed&the&enamel&surfaces&adjacent&to&orthodontic&brackets.
101
• Ultraseal&XT&Plus&(ultradent)&provided&significant&reduction&in&enamel&demineralization&adjacent&to&orthodontic&brackets.
Benham&AW,&Campbell&PM,&Buschang&PH.&Effectiveness&of&pit&and&fissure&sealants&in&reducing&white&spot&lesions&during&orthodontic&treatment:&A&pilot&study.&Angle&Orthod&2009;79:3376344.
• Opal&Seal6&38%&filled&with&glass&ionomer&and&nano6fillers
• Placed&on&enamel&prior&to&bonding&bracket• Compatible&with&any&bonding&system&• Light6cured• Fluorescing&properties66detectable&under&a&UV&black&light
• Reduces&need&for&patient&compliance.
Ultradent102
• L.E.D.&Pro&Seal6&Light6cured&filled&sealant&placed&around&orthodontic&brackets.
• Significant&reduction&in&demineralization&and&the&barrier&was¬&reduced&with&toothbrush&abrasion.
• Reduces&need&for&patient&compliance.
Buren&JL,&Staley&RN,&Wefel&J&et&al.&Inhibition&of&enamel&demineralization&by&an&enamel&sealant,&Pro&Seal:&an&in&vitro&study.&Am&J&Orthod&Dentofacial&Orthop&2008;133:5886594.
103
Opalescence&Treswhite&Ortho
• Whitens&around&and&under&brackets
• Eliminates&bacteria
• 8%&hydrogen&peroxide&to&whiten
• $43.99&for&box&of&10&
• 12&month&shelf&life
• The&use&of&five&xylitol&lozenges&per&day&resulted&in&higher&plaque&pH&and&reduction&in&the&risk&of&demineralization&during&fixed&orthodontic&treatment.
Sengun&A,&Sari&Z,&Ramoglu&ST,&Malkoc&S&et&al.Evaluation&of&the&dental&plaque&pH&recovery&effectof&a&xylitol&lozenge&on&patients&with&fixedorthodontic&appliances.&&Angle&Orthod&2004;74:2406244.
105
After&Debanding
• Only&40%&of&white&spot&lesions&improved&in&the&first&6&months&following&debanding.
• Give&a&few&weeks&time&for&white&spots&to®ress&with&the&calcium&and&phosphate&in&the&saliva.
• Remineralization&techniques&should&be&continued&to&help&with&lesion&repair&post&debanding.
Mattousch&TJH,&van&der&Veen&MH&et&al.&Caries&lesions&after&orthodontic&treatment&followed&by&qualitative&light&fluorescence:&A&26year&follow6up.&Eur&J&Orthod&2007;29:2946298.
Go&Slowly&at&First• Allow&slower&fluoride&penetration&initially&to&permit&remineralization&from&the&base&of&the&lesion&to&the&outer&surface.
• Remineralization&can&occur&from&saliva&or&with&low&concentrations&of&fluoride.
Hamdan&AM,&Maxfield&BJ.&Tufekci&E&et&al.&Preventing&and&treating&white6spot&lesions&associated&with&orthodontic&treatment.&JADA&2012;143:7776783.&
Chewing&Gum
• Increases&the&production&of&saliva&supersaturated&with&calcium,&phosphate,&and&hydroxyl&ions&by&up&to&10×&the&normal&rate.
• Assists&in&remineralization&of&enamel.• Boosts&the&ability&to&neutralize&and&buffer&plaque&acids.
• Assists&in&clearing&food&residues.
• Sugar6free&gum&provides&higher&salivary&bicarbonate&ions&with&stimulated&saliva.
• The&positive&effect&of&the&bicarbonate&ions&is&nullified&in&the&process&of&buffering&the&acid&formed&from&gum&sweetened&with&sugar.
• Cariogenicµorganisms&can&“learn”&to&metabolize&sorbitol&when&their&sugar&supply&is&diminished.
• These&sameµorganisms&starve&with&xylitol&because&xylitol&can¬&be&metabolized&by&the&cariogenicµorganisms.
Burt&BA.&The&use&of&sorbitol6and&xylitol6sweetened&chewing&gum&in&caries&control.&JADA&2006;137:1906196.
• Xylitol&suppresses&and&inhibits&S.&mutans.&
• Unlike&sorbitol,&xylitol&is¬&fermented&by&S.&mutans&or&S.&sobrinus.
Hildebrandt&GH,&Sparks&BS.&Maintaining&mutans&streptococci&suppression&with&xylitol&chewing&gum.&J
Xylitol&Gum
• Chew&465×&per&day&for&5&minutes
• &0.761gm/pc
• High&Caries&Risk:&7gm/day
• Moderate&Caries&Risk:&4gm/day
• Children&can&tolerate&up&to&45gm/day
• Gum&containing&Recaldent&(casein6phosphopeptide&amorphous&calcium6phosphate)&reduced&interproximal&caries&progression&by&17%.&(Trident&Xtra&Care)
• Chewed&three&sticks/day&five&days/week&and&used&Fl&toothpaste.
Morgan&MV,&Adams&GG,&et&al.&The&anticariogenic&effect&of&sugar6free&gum&containing&CPP6ACP&nanocomplexes&on&approximal&caries&determined&using&digital&bitewing&radiography.&Caries&&Res&2008;&42:1716184.
• Study&group,&age&12618&years&of&age,&used&1gm&of&CPP6ACP&morning&and&night&for&12&consecutive&weeks&after&using&a&1,000ppm&fluoridated&toothpaste.
• CPP6ACP&paste&significantly&reduced&white&spots.
Bailey&DL,&Adams&GG,&et&al.&Regression&of&post6orthodontic&lesions&by&a&remineralizing&cream.&J&Dent&Res&2009;88:114861153.
• After&braces&removed,&MI&Paste&Plus&(900ppm&Fl)&used&for&8&weeks&or&a&single&application&of&PreviDent&fluoride&varnish&to&WSL.
• Neither&MI&Paste&Plus&nor&fluoride&varnish&were&more&effective&than&normal&home&oral&hygiene&to&improve&WSL&over&an&8&week&period.
Huang&GJ,&Roloff6Chiang&B,&Mills&BE&et&al.&Effectiveness&of&MI&Past&Plus&and&PreviDent&fluoride&varnish&for&treatment&of&white&spot&lesions:&A&randomized&controlled&trial.&Am&J&Orthod&Dentofacial&Orthop&2013;143:31641.
MI&PASTE&at&home&for&WSL• Apply&with&finger&or&Q6Tip&to&WSL.• Leave&in&place&for&5&minutes.• Do¬&rinse/eat/drink&for&at&least&30minutes.
• Do¬&use&overnight&in&custom&tray/ortho&retainer&because&teeth&become&dehydrated,&making&WSL&more¬iceable.
• Apply&at&least&2×&each&day&for&a&minimum&of&5&minutes.&
• One&can¬&overuse&MI&Paste.
INFILTRATION))CONCEPT
)INCIPIENT)INTERPROXIMAL)CARIES)AND)WHITE)SPOTS
DMG)AMERICA
ICON• HCL&acid&to&open&lesion.&Low&viscosity&resin&is&drawn&deep&into&the&pore&system.&&Similar&to&a&sponge&drawing&up&liquid.
• The&resin&completely&fills&the&pores,&replaces&lost&tooth&structure.
• The&white&spot&disappears,&the&anatomical&shape&and&color&of&the&tooth&are¬&altered.&
DMG&America
Bleaching
• The&surrounding&enamel&may&be&whitened,&camouflaging&WSL.
Hamdan&AM,&Maxfield&BJ.&Tufekci&E&et&al.&Preventing&and&treating&white6spot&lesions&associated&with&orthodontic&treatment.&JADA&2012;143:7776783.&
• 10%&carbamide&peroxide&
!Cost&! Safety! Efficacy!Most&all&safety&data&on&10%&CP! 18&months&shelf&life
• Hydrogen&peroxide&releases&50%&in&the&first&30&minutes.
• Pulpitis&may&occur.&Enamel&is&semipermeable&and&bleach&seeps&through&dentin&to&pulp.
• 5000ppm&toothpastes&(not&with&WSL),&MI&Paste&or&toothpaste&with&potassium&nitrate&will&decrease&sensitivity.&
• Can&put&in&bleaching&tray&for&10630&minutes&before&or&after&bleach.
Tray
• Does)not)have)to)cover)the)en,re)crown.
• Bleach)travels)up)the)en,re)crown)due)to)the)diffusion)gradient.
• 30)minutes)to)one)hour)a)day)is)adequate)for)young)pa,ent.
Autism&Spectrum&Disorders
Autistic&Disorder
Asperger&Syndrome
Pervasive&Developmental&Disorder
AUTISTIC&DISORDERBrain&based&developmental&disorder
• 1:150&children&2007
• 1:110&children&2009
• 1:88&American&children&
• 1:54&boys
• Same&methodology&being&used
• Extreme&variations&in&IQ,&speech&&&functioning
• Debate&as&to&genetic&defects,&environmental&factors&or&combination&of&both&factors.
• Some&suggest&an&immunological&component.
• But&truly&is&a&debate&at&this&time.
Diagnosis
• Primarily&on&behavioral&observation
• Focus&on&mouth¬&eyes
• Onset&prior&to&age&3
• Pediatricians&now&routinely&screen&at&age&18&and&24&months
Prior&to&VisitTo&access&cooperative&potential
Can&she&sit&for&a&haircut?&(ADHD&too)
&
• Are&there&any&strong&fears?
• How&does&he&communicate?&Sign?
• What&his&best&time&of&day?
Involve&the&Parent/Therapist
• Parent&can&come&to&the&office&and&take&digital&photos&to&make&an&album&for&the&child&of&office,&staff&&&doctor.
• Ask&parent&about&cues&for&tolerance&level.
Calming&Devices
• Lead&weights,&lead&apron• Earphones/headphones• Movie
Hernandez&P,&Ikkanda&Z.&Applied&behavior&analysis.&Behavior&management&of&children&with&autism&spectrum&disorders&in&dental&environments.&JADA&2011;142:2816287.
• May&exhibit&over6responsiveness&to&sensory&stimuli.&&
• Eliminate&or&reduce&environmental&sensory&stimuli
–quiet&–&suction–phones–music&(but&also&may&help)Polido&SL,&Mallioux&Z,Coleman&G&et&al&Oral&care&and&sensory&sensitivities&in&children&with&autism&spectrum&disorders.&Spec&Care&Dentist&2011;31:1026110.
• There&are&no&evidence6based&techniques&for&behavior&modification&that&can&manage&the&problematic&behaviors&of&children&with&ASD&in&the&dental&environment.
Hernandez&P,&Ikkanda&Z,&Applied&behavior&analysis.&Behavior&management&of&children&with&autism&spectrum&disorders&in&dental&environments.&JADA&2011;142:2816287.
Medications&&&DRA
• Psychotropic&medications&cause&xerostomia.
• If&accompanying&seizure&disorder,&anti6seizure&medications&cause&gingival&overgrowth&and&xerostomia.
ASPERGER&SYNDROME
highest&functioning&form&of&autism
• Unlike&Autism,&no&delay&in&language,&cognition,&self&help&skills&or&adaptive&behavior
• Better&language&acquisition6”talk&before&walk”
• Prevalence&more&common&in&males
• Majority&diagnosed&between&5&&&9&yrs
• Robotic,&flat&modulation&with&raspy&voice
• Difficulty$in$reading$non1verbal$social$cues
• Can&perform&own&oral&hygiene
• Often&off&task&because&of&own&agenda
Rada&RE.&Controversial&issues&in&treating&the&dental&patient&with&autism.&JADA&2010;141:9476953.
Blaxill&MF.&What’s&going&on?&The&question&of&timetrends&in&autism.&Public&Health&Rep.2004;119:5366551.
Friedlander&AH,&Yagiela&JA,&Paterno&VI,&Mahler&ME.&The&neuropathology,&medical&management&and&dental&implications&of&autism.&JADA&2006;137:151761527.
www.autismspeaks.org
Obtaining&Consent&for&Treatment
• Brochures&or&articles66not&so&good
• Photographs
• Example&appliances
• Dolphin&Aquarium&Videos&
Two&weeks&after&detailed&explanation&for&informed&consent,&40%&of&parents&could¬&answer&questions®arding&their&children’s&treatment&and&proposed&procedures.
Tahir&MAM,&Mason&C,&Hind&V.&Informed&consent:&optimism&versus&reality.&Br&Dent&J&2002;193:2216224.&
The&Adolescent
• Not&good&at&delaying&gratification
• Explanation&better&than&criticism
• Reactive
• Give&lots&of&choices
–Methods&for&Flossing
–Toothbrush/Powerbrush
–Fluoride&Rinses
–Flavors&of&Alginate
–Colored&Ties
Parental&Presence
• Want&to&see&first6hand&what&is&occurring.
• Believe&they&can&improve&child’s&behavior.
• Can&use&parental&presence&to&provide&additional&information®arding&treatment:&Decalcification&risks&or&oral&hygiene&concerns.
We&need&Angel’s&undivided&attention,&and&we&want&to&give&our&undivided&attention&to&Angel.&&You&may&come&to&check&on&Angel&any&time&you&wish.&&We&shall&let&you&know&immediately&if&we&feel&things&would&go&better&with&your&presence.
Your&mere&presence&provides&support.
