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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.
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• 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.
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• 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
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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.
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• 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.
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• 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.
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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.
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• 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.
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• “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.
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• 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
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• 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.
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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
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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.
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• 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.
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•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.
Page 16
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.
CrollTP,NicholsonJW.Glassionomercementsinpediatricden5stry:reviewoftheliterature.PediatrDent2002;24:423-429.
• Placementofaadhesivelybondedresin-basedcompositeoveraresin-modifiedglassionomerden5nreplacementlayeralmostguaranteesnopost-opera5vesensi5vityfortheyoungpa5ent.
CrollTP,NicholsonJW.Glassionomercementsinpediatricden5stry:reviewoftheliterature.PediatrDent2002;24:423-429.
• GICorresin-modifiedGICphotochemicallybondstotheden5n.Theneedforden5nbondingadhesiveiseliminatedwithGIC.
• BondingagentforthecompositeisplacedovertheGIorRMGI.
DonlyK,J,Garcia-Godoy,FG.Theuseofresin-basedcompositeinchildren:anupdate.PediatrDent2015;37:136-143.
Page 17
CriteriaforSuccess• Vitalityispreserved.
• Nopain,sensi5vityorswelling.
• Noradiographicevidenceofinternalorexternalresorp5onorotherpathologicchanges.
• Con5nuedapexogenesis.
• ObtainPAevery6months(ifpossible!).
VitalPulpTherapyforPrimaryMolars
AmericanAcademyofPediatricDen5stry.Pulptherapyforprimaryandimmaturepermanentteeth.PediatrDent2018/19;40(6):343-351.
HandbookofClinicalTechniquesinPediatricDen5stryed.JaneA.SoxmanWileyBlackwell2015
Consent• Illustra5onsincreasedparentalacceptance/coopera5onanddecreasedparentalanxietyforrecommendeddentaltreatment.
• Children’sbehaviorimprovedaswell.
WangSJ,BriskieD,ChunHuJC,MajewskiR,etal.Illustratedinforma5onforparenteduca5on:Parentandpa5entresponses.PediatrDent2010;32:295-303.
“Thecoronalpulpisamputated,andtheremainingvitalradicularpulp5ssuesurfaceistreatedwithalong-termclinically-successfulmedicamentsuchasBuckley’sSolu5onofformocresolorferricsulfate.”
AmericanAcademyofPediatricDen5stry.Pulptherapyforprimaryandimmaturepermanentteeth.PediatrDent2018/19;40(6):343-351.
Indica5onsforPulpotomy• *Complaintofspontaneous(unprovoked)paininacariousprimarymolar.
• Radiographicevidenceofpulpalinvolvement.(carefulrefalseinvolvementwithocclusalcaries)
• Cariouspulpexposureduringprepara5on.
• Nomobilityorpainwithpercussion.
Page 18
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.
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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.
Page 20
• 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.
Page 21
• 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)
Page 22
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.
Page 23
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.
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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.
Page 25
• 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.
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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
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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.
Page 28
• 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.
Page 29
• 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.
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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
HandbookofClinicalTechniquesinPediatricDen5stryed.JaneA.SoxmanWileyBlackwell2015
Pre-VeneeredPrimaryMolarCrowns• Lightandextralightcolors• Canappearbulky• Gingivalhealthmaybecompromised(?)• Highercost• Requiremoretoothreduc5on• Cannotcrimporplacestrongocclusalforcetoseat
• Passivefitwithfinger• Insurancecode:D2934
• Dofirstprimarymolarforfirst5me.
• Selectthecrownsizepriortoprep.Useacooonforcepstocomparethecrownwiththechild’sprimarymolar.Chooseacrownsizethatlooksmostlikethechild’stooth.
• Requiresmuchmorereduc(onthanSSC.
• *Prepareset-upandparentforpulpexposure.
Page 31
• 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.
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• 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.
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• 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.
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• Primarytoothenamelisthinner,lessmineralized,moreporousandaprisma5ccomparedtopermanentenamel.
• Zirconiacrownsdonotcauseexcessenamellosstooccludingprimarymolars.
Johnson-HarrisD,ChiquetB,FlaitzCetal.Wearofprimarytoothenamelbyceramicmaterials.PediatrDent2016;38:519-522.
Extrac5onofPrimaryDen55on
HandbookofClinicalTechniquesinPediatricDen5stryed.JaneA.SoxmanWileyBlackwell2015
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.
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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.
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• 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.
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• 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.