Wednesday, September 26, 2012

Future caries susceptibility in children with Early Childhood Caries following treatment under general anesthesia

Resident: Matthew Freitas
Author: A. Almeida, DDS
Journal: Pediatric Dentistry 22:4, 2000

-The purpose of this study was to assess the susceptibility of children to the future development of caries following comprehensive treatment of ECC under general anesthesia

-Retrospective study; Franciscan Children's Hospital in Boston, MA
-42 ECC children and 31 caries free control children
-ECC was defined as 1 or more carious lesions of max anterior teeth in children 1-5 yrs of age
-ECC children were treated in the OR within 1-4weeks of their initial visit
-Recalled at 6-9mo over a 2 year period; Bitewing radiographs were taken
-Carious lesions were recorded in two groups: new smooth surface caries (NSSC) and new pit and fissure caries (NPFC)
-ECC children were put on a more intensive preventive regimen: dietary counseling with parents, fluoride toothpaste and water, and daily flossing was encouraged 

-79% of ECC children compared to 29% control children had detectable carious lesions at subsequent recall visits.
-ECC children had a mean number 3.2 new carious lesions compared a mean of only 0.8 for controls.
-In addition, 17% of the ECC children were retreated in the OR.
-Prevalence of NSSC in the ECC group was significantly higher than controls.

-Despite preventive measures, ECC children are still highly predisposed to greater caries incidence. More aggressive preventative measures are required for this group; such as detailed diet modifications, shorter recalls, FV application, GelKam

The Continuum of Restorative Materials in Pediatric Dentistry – A Review for the Clinician

Resident: Jeff Higbee

Article: The Continuum of Restorative Materials in Pediatric Dentistry – A Review for the Clinician

Author: Joel H. Berg, DDS, MS

Purpose: Provide a brief review of the intracoronal restorative materials used for the modern pediatric dental practice.

 Materials Discussed: Glass ionomers, Resin-modified glass ionomers, Compomers, Resin composites

 Glass Ionomers:

- Contains fluoride which is released over time.

- Fluoride can be “recharged” by ambient fluoride which replenishes the fluoride in the GI material.

- Can be used as a liner, luting cement, or base/core material.

- Only restorative material with a true bond to tooth structure.

- COTE in GI’s is the most similar to tooth structure

- GI are brittle and will break or crack if subjected to strong opposing forces, GI have been reinforced with silver to make materials stronger.

Resin-Modified Glass Ionomers:

- Same as traditional GI but have resin material added to provide strength and the ability to “command-cure”.

- Because of the resin in the material there is a potential for polymerization shrinkage.


- Polyacid-modified resins

- These are essentially resin composites except that the resin monomers are modified to contain acidic functional groups capable of participating in acid/base reaction like GIs

- Hybrids of composites and GI’s

- Contain fluoride but at a significantly lower concentration than GI’s

- Normally require etching because they are essentially resins but some compomers can be placed in pedo teeth without acid etching

- Physical properties similar to resin based composites

- Considered as having the greatest ease of handling among non-amalgam materials

 Composite Resins:

- Most esthetically desirable material

- Contain a momomeric or polymeric resin that is filled to various levels with quartz or glass

- Very good physical and mechanical properties

- Flexural, compressive, and tensile strength meet or exceed that of amalgam

- Significant polymerization shrinkage occurs

- Available in a variety of shades

- Placement of a primer and bonding agent is necessary to allow resin composite adherence

- There are a variety of filler percentages ranging from unfilled to 85%

- There are macrofilled, microfilled, and hybrid filled RBC

- Many clinicians buy just one type of material and use it universally.  It is better to know each RBC components and indications for optimal results.


This is a good review of different types of materials we can use.  It is important to know the chemical makeup and clinical indications for these materials so that we can use each material for its intended purpose for ideal tx.  Did not discuss much of amalgam’s role in pediatric dentistry.

Microleakage of a new improved glass ionomer restorative material in primary and permanent teeth

Kyung-Hong Cal Kim

Microleakage of a new improved glass ionomer restorative material in primary and permanent teeth

Authors: Castro A, Feigal RF

Pediatric Dentistry 2002

To assess the microleakage of the new conventional GI, Fuji IXgp in comparison to another conventional GI, an RMGI, and a composite resin in primary and permanent teeth

Background Information:
ART (Atraumatic Restorative Treatment)
-“Strategy of care using chemically cured, intermediate restorative materials in countries where children do not have access to optimal care.”
-Caries removal using hand instruments only + GI restorative material w/ adhesive characteristics
Glass Ionomer
-Advantage: chemical adhesion to dentin and enamel, fluoride release, high tissue tolerance, and pulpal biocompatibility
-Disadvantage: Lack of strength, abrasion resistance and poor esthetics

Improvement of recent years is largely due to smaller mean particles

-Extracted permanent and primary teeth, randomly divided into 5 subgroups
--New Conventional GI (Fuji IXgp)
--Conventional GI (Fuji II)
--RMGI (Vitremer)
--Composite resin (TPH)
--New Conventional GI (Fuji IXgp) w/o conditioner
-Saucer-shaped cavity, 3.0mm in diameter and 1.0mm deep prepared in each tooth
-Teeth in each subgroup were then restored following manufacturer’s instructions
-50% aqueous solution of silver nitrate for two hours in darkness, then placed in the developer for 8 hours under fluorescent light
-Sectioned teeth (2x in permanent, 3x in primary) and results were recorded

Results and discussion:
-Microleakage in primary teeth: Fuji II (45%) > Fuji IX w/o conditioner (42%) > Fuji IX (24%) > TPH (16%) > Vitremer (9%)
-Microleakage in permanent teeth: Fuji II (76%) > Fuji IX w/o conditioner (46%) > Fuji IX (29%) > Vitremer (13%) > TPH (6%)
-Microleakage was observed more in primary teeth when restored w/ TPH
-Microleakage was observed more in permanent teeth when restored w/ Fuji II
-When conditioner was used, Fuji XIgp behaved similarly to RMGI or composite resin

Informative article comparing materials often used for dental restorations in pediatric dentistry. Authors acknowledged the study’s limitation that results in in vitro environment don’t always translate to in vivo environment. It was interesting that they compared microleakage of Fuji IX alone and Fuji IX + conditioner. Relatively poor performance w/o use of conditioner makes me think that Fuji IX is not a significantly better option (when compared w/ Fuji II) to do what the authors intended to do, using it in underdeveloped countries where optimal set of dental equipment may not be available.  

Resident: Mackenzie Craik

Article: Mutans Streptococci and Lactobacilli in Saliva After the Application of Fissure Sealants

Authors: Baca, Castillo, Bravo, Junco, Baca, Llodra

Journal: Operative Dentistry, 2002, 27, 107-111

Main Purpose:  To show that the application of fissure sealants can contribute to reducing the levels of cariogenic bacteria in saliva.

-Study was performed in two elementary schools in Spain.
-Permanent 1st molars were sealed in 31 children without caries and in 32 children with caries.
-Conventional methods were used to count mutans streptococci and lactobacilli in saliva before applying the sealant and at 4 weeks and 12 weeks after application.  

Key Points: 
-Dental fissures may serve as reservoirs for mutans streptococci, preventive measures should be taken to control microbial concentrations at these sites.
-No significant differences in bacterial load were observed in the children before sealants had been placed.
-At the 4 and 12 week checks the levels of Lactobacilli remained statistically unchanged in both groups. 
-Lactobacilli are detected less frequently in fissures.
-A significant reduction in mutans streptococci was seen in the children that did not have caries.
-Applying sealants doesn’t affect the salivary levels of MS in children with active caries.
-It was concluded that the fissure sealants in permanent first molars can help reduce salivary levels of mutans streptococci in children without caries.

Assessment: Part of the reason for the small sample size was due to loss of one or more sealants.  The sealants were placed by 1st year dental students, and this helps to explain the high number of failures.  
-A later study was done that was similar in nature and included a two year follow up, only lactobacilli were reduced in the sealed group.  This study selected children that were at medium to high risk, which may have affected the outcomes.

Tuesday, September 25, 2012

Healing of intraalveolar root fractures in patients aged 7-17 years

Resident Name: Sadler
Article Info: Healing of intraalveolar root fractures in patients aged 7-17 years
Cvek Andreason
Dental Traumatology 2001: 17:53-62
Main Purpose: Evaluate outcomes of root fractures and analyze elements which effect the outcome

Methods: Retrospective study of 208 fractured teeth in 183 patients from 1959-1973.  Teeth were treated with either rigid, flexible, or no splinting.  The study chose patients form this time period because there was no standard recommended treatment. 
Key Points:
·         69 teeth (33%) shows hard tissue healing
·         PDL and formation between fragments was seen in 17 (8%)
·         PDL alone was seen in 74 (36%)
·         Pulp necrosis was seen in 48 (23%)
·         Immature root formation, preserved vitality, and no displacement of crown segment were associated with higher success rates
·         Rigid splints had either no or negative effects on outcomes
·         Long term splinting is not necessary
·         Splinting of only slightly mobile teeth is not needed
Assessment of Article:  Nice read on root fractures.  Interesting that this is what they used to come up with the current recommendations. 

Preventing the Transfer of Streptococcus Mutans From Primary Molars to Permanent First Molars Using Chlorhexidine

Resident: Elliot Chiu
Title: Preventing the Transfer of Streptococcus Mutans From Primary Molars to Permanent First Molars Using Chlorhexidine
Author: Alaki et al
Journal: Pediatric Dentistry 2002
Purpose: To determine if placing a chlorhexidine wax on primary molars during the eruption of permanent first molars can prevent the transfer of SM
-14 children aged 5-7 with 2 erupting permanent first molars in the same arch (cusp tips visible)
-Children randomly assigned to treatment or placebo group
-Each child received either chlorhexidine or placebo wax on primary molars on one side. The other side was left as a control
-Saliva and plaque samples were obtained before treatment and after 1-4months when the permanent tooth was fully erupted
-Levels of SM and other bacteria were compared from the treated sides to control sides
Key Points
-Levels of SM and S. sanuinis were significantly lower in the chlorhexidine treated sides compared placebo and control
-Chlorhexidine treated sides lowered SM levels on the opposing control sides
-The reduced levels of SM in the occlusal fissures may remain suppressed by the competing flora in the fissures
This study shows good results, but a larger sample size than 14 subjects is needed, as well as a longer follow-up time to see if this treatment affects SM levels long term.

Monday, September 24, 2012

The Role of fluoride mouthrinses in the control of dental caries: a brief review

Resident: Todd Bushman
Literature review: The Role of fluoride mouthrinses in the control of dental caries: a brief review
By Steven M Adair DDS, MS
Pediatric Dentistry20:2, 1998

Main Purpose: To illustrate the benefits of Fluoridation programs and the benefit that fluoride has on preventing dental caries.  It also compares studies to determine the validity of past studies.

Main points:  Fluoride mouthrinses have generally proved to be effective in controlling caries in clinical studies. Caries reductions in North American studies have averaged about 30%. Large-scale school-based mouthrinse programs conducted during the 1970s, however, used historical controls at a time when caries rates were now known to be declining. Post-hoc analysis of the absolute (not relative) caries reductions in these studies showed that school-based fluoride mouthrinse programs were of questionable benefit from a cost standpoint. It ended up costing about the same dollar amount per student that it would cost to restore the cavities it prevented.  Fluoride mouthrinses have been shown to reduce demineralization and enhance remineralization of enamel adjacent to orthodontic bands and brackets. Benefits in adults have been less well documented. Use of fluoride mouthrinses by young children is discouraged until they have mastery of their swallowing reflexes.

School based F programs should be employed only in communities with population caries rates high enough to warrant a cost effective outcome.

Dentists should consider only recommending F mouthrinses to those of high risk.

Over the counter F rinses for children should only be given to those who have mastery of swallowing reflexes

Alcohol free over the counter rinses should be the product of choice for kids and adults with alcohol dependency

Assessment:  This paper demonstrates the benefits of F mouthrinses while also pointing out its limitations when compared to price effectiveness.  Overall These mouthrinses are effective in reducing caries and it is important that all kids be exposed to F in one form or another for optimal protection against caries.

Effect of 1.23% APF gel on fluoride-releasing restorative materials

Resident: Derek Nobrega
Title: Effect of 1.23% APF gel on fluoride-releasing restorative materials
Authors: Zafer C. Cehreli, DDSS, PhD; Ruya Yazici, DDS< PhD; Franklin Garcia-Godoy, DDS, MS
Journal: Journal of Dentistry for Children. September-October 2000.

Main Purpose: To evaluate the effect of a 1.23% APF gel on the surface morphological characteristics and surface roughness of one high-viscosity glass ionomer cement (HVGIC) and three Polyacid-modified resin-based composite (PMRC) materials compared to a resin based composite and two resin modified glass ionomer cementes (RMGIC).

Methods: One HVGIC (Fuji IX GP), three PMRCs (Dyract FP – Dentsply, F2000 – 3M, Compoglass F – Vivadent), two RMGICs (Vitremer – 3M, Fuji II LC), and one microfilled resin based composite (Silux Plus – 3M) were used. The fluoride gel used was 1.23% APF (Nupro APF). Twenty specimens were obtained for each material, which were divided into 2 subroups – 10 test, and 10 controls. The specimens were repeatedly exposed to the APF gel with cotton applicators for 1 minute every 6 months for four years. Average surface roughness was measured using a Surface Roughness Tester, and photomicrographs at a magnification of 1500X were taken for surface topography comparisons.

Key Points:
Microfilled Resin Based Composites
After APF treatment, there was a statistically significant increase in surface roughness for Silux Plus.

Poly-acid Modified Resin-based Composites
After APF treatment, surface roughness was higher only for Dyract FP and F2000. Compoglass F showed no significant effect after APF treatment.

Resin-Modified Glass Ionomer Cements
There were no significant changes in Fuji II or Vitrememer after APF treatment.

High Viscosity Glass Ionomer Cements
Fuji IX showed the highest surface roughness after APF.

Good article about the effects of APF on different kinds of restorations. Since APF can etch some restorations, including porcelain restorations and resin-based composites, it is important to note the number and types of restorations a patient has before deciding to use APF. In these cases, NaF is a more appropriate fluoride to use. 

Wednesday, September 19, 2012


-Triage and stabilize-Rule out spinal injury and refer as needed
-Documentation-How? Where? When?
-Important to know tetanus immunization status and get booster if more than 5 years and the wound is contaminated
-Gauge conciousness level
-Age appropriate responses
-History of nausea or vomiting
-Glasgow Coma Scale
            -Eye response, motor response, verbal response
- Rule out lacerations intra and extraorally
-Teeth injuries: Pulp exposure/fracture
-Bony fractures-Changes in opening/closing are visible.  Also seen on radiograph
-Treat quickly as healing occurs in 4-6 days.  Likely will want oral surgeon for fixation if needed
-Battle and racoon signs
-Skull fracture-CSF from nose
-Multiple images may be needed
-Document interpretation
-Soft tissue uses 1/4 exposure time
-SLOB rule
-Primary teeth keep simple due to behavior and lifespan of tooth
-Advise parents of possible outcomes of treatments
-Permanent luxations treated as soon as possible
-Color changes usually indicat pulpal necrosis of pigments.  TX not indicated if no symptoms present
-Pulp canal obliteration-Reparative dentin closes the canal
-Damage to developing teeth, ankylosis, resorption
-Tongue laceration – suturing indicated if bleeding is not controlled
-Through and through-suture both sides
-Lip-Begin on the outside-May want plastic surgery to do it.
-Eschar comes off at 7-10 days and may bleed
-Fixed appliance to stop contraction of wound worn for 6-12 months
-Plastic surgery needs to be involved with impression/treatment done under GA

Traumatic Injuries in the Primary Dentition

Resident: Mackenzie Craik
Title: Traumatic Injuries in the Primary Dentition
Author: Dr. Marie Therese Flores
Journal: Dental Traumatology 2002; 18: 287-298

Main Purpose: The main purpose and objectives of diagnosis and treatment of traumatic injuries affecting children with primary dentition are pain management and prevention of possible damage to the developing tooth germ.  

Methods: An online search in Medline was performed, using seven different strategies that included publications between 1981 and 2002.  A total of 75 articles were included and analyzed.  

Key Points: -Children with primary teeth are most frequently affected by luxation injuries.  To date treatment of these injuries has been based on clinical case report, expert opinion, and literature review.  There are few long term studies with adequate sample sizes relating to traumatic dental injuries in the primary dentition.  In most cases extraction has been the treatment of choice for luxated primary teeth.

-Logical sequence of trauma management is essential:
       -Pain control
       -Cleaning the area of trauma
       -Is sedation necessary?
       -If suturing needed, first start with those affecting the skin and later those in the mucosa.
       -Then examine the teeth.

-After traumatic injuries to the primary dentition, most complications are associated to infection due to caries.  

-Present guidelines consider treatment of caries-free primary teeth with acute trauma.

-Luxations are very common for children in their early years, although considered complicated injuries, most will heal spontaneously if proper oral hygiene program is followed.

-Acute dental injuries that require immediate treatment and pain control with local anesthetics are: complicated crown fractures, crown-root fracture, root fracture with the coronal fragment displaced, alveolar fracture, and extrusive luxation.

-Most children older than 42 months with acute dental injuries can be treated in a dental clinic.

-It is essential to promote oral hygiene techniques during the emergency visit to prevent further dental infections.
       -Give the child a soft diet for 15 days.
       -Brush teeth after each meal with a soft brush.
       -Topical use of chlorhexidine twice a day for one week.
       -Inform about possible complications so that treatment can be sought:

Tuesday, September 18, 2012

Chapter 34 Managing traumatic injuries in the young permanent dentition

Resident: Todd Bushman
Pinkham Chapter 34 Managing traumatic injuries in the young permanent dentition

Etiology and epidemiology of trauma in the young permanent dentition

Falls account for most dental injuries
Sports injuries
Auto accidents


It is essential to get a good medical history as well as details from the trauma.  You need to know if the patient lost consciousness or if they sustained significant head trauma that can manifest hours after the fact.

Clinical Examination

Vitality testing is important for permanent dentition where it is not in primary teeth.  It is important to note that vitality testing is unreliable in newly erupted teeth and teeth with open apices.  Teeth that has sustained trauma can test unreliably for several months as well.  Electrical testing is more reliable to cold and hot testing.  Radiographs are also an important diagnostic tool. You can use different angles to improve accuracy of diagnosis.

Treatment of traumatic injuries in permanent dentition.

·       Enamel fractures – if small it can be smoothed out or built up in composite if larger
·       Enamel and dentin fractures – place glass ionomer followed by a bonding agent.
·       Fractures involving pulp – depends on the following factors 1. Vitality of pulp 2. Times since exposure 3. Degree of tooth maturation 4. Restorability of tooth .  The goal is to maintain a vital pulp until the apex is completely formed.  Pulp therapies include the following:
1.     Direct pulp cap – rubber dam, cleaned with water, CaOH, composite.  If the tooth has incomplete root formation pulpotomy is advised
2.     Pulpotomy – Used if open long periods of time or large exposure.  Removal of at least 2mm of pulp until vital, CaOH, ZOE, Glass ionomer, then composite
3.     Pulpectomy – clean out necrotic pulp tissue and place CaOH for apexification so RCT can be performed at a later date.  Tricalcium phosphate powder can be used to make an apical plug so gutta percha can be used to finish the RCT.
·       Posterior crown fractures – Full coverage crowns and SSC indicated for vertical root fractures caused usually by trauma to the lower jaw.  Look for jaw fractures
·       Root fractures – If in the apical 1/3 it has a good prognosis.  The prognosis worsens as you more apically.  Manage with a splint for 2-3 months

Managing sequella to dental trauma.

·       Pulp canal obliteration – controversial treatment of RCT of pulpotomy if noticed.  Some say that pulpal necrosis is not likely and it is best to leave them alone.
·       Inflammatory resorption – treat tooth with CaOH after pulpal tissue removed to stop resorption.  Usually occurs after PDL damage and necrotic pulp.
·       Replacement resorption (ankylosis) – When PDL is destroyed and cementum comes in direct contact and fuses with Alveolar bone.  Treatment must be prompt. (did not say how to treat)

Treating luxation injuries in permanent dentition

·       Concussion – follow for signs of pathology
·       Subluxation – radiographs annually, RCT at first sign of pathology
·       Intrusive luxation – reposition orthodontically with light forces, extirpate pulp within 2 weeks
·       Extrusion – reposition and splint for 2-3 weeks, RCT should be started after splinting if apices closed.  If open you can wait for signs of necrosis
·       Lateral luxation – reposition and splint for 3-8 weeks. Same as above
·       Avulsion – store in Hanks solution while transporting to the dentist.  Reimplant tooth ASAP.  Splint and follow to see if there are signs of necrosis when RCT will be performed.

Splinting technique

·       Should be passive
·       Flexible
·       Allow for vitality testing
·       Easy to apply and remove

A Novel Multidisciplinary Approach for the Treatment of an Intruded Immature Permanent Incisor

Resident: Derek Nobrega
Title: A Novel Multidisciplinary Approach for the Treatment of an Intruded Immature Permanent Incisor
Authors: Shabtai Sapir, DMD; Evelyn Mamber, CD; Iris Slutzky-Goldberg, DMD; Anna B. Fuks, CD
Journal: Pediatric Dentistry. 2004. 26 (5) 421-425

Main Purpose: To review the treatment options for intruded immature permanent incisors, and to present a new modality of an elective internal strengthening of the immature root weakened by external root resorption.

Methods: Case report of a 7½-year-old girl who was referred to the Emergency Clinic of the Department of Pediatric Dentistry at the Hadassah School of Dental Medicine in Jerusalem. She had fallen 3 days earlier and #9 was totally intruded. The PA demonstrated the crown had a fracture close to the pulp and incomplete root formation. Immediate treatment consisted of OHI, cleaning tooth with chlorhexidine, and soft diet for one week. At 2 weeks, there were no signs of spontaneous re-eruption and orthodontic extrusion with a modified Hawley appliance was initiated. One week later a pulpectomy was performed and the pulp filled with calcium hydroxide paste. Two weeks later, external root resorption was noted. After 5 weeks of orthodontic extrusion, the tooth was restored with composite. Six months after injury, apexification was completed, and the tooth filled with gutta percha. Two months later the tooth was restored with a Luminex clear post and composite. After one year, orthodontic treatment was initiated to obtain a more ideal overjet, and at 5 years, the authors reported excellent results.  

Key Points:
1. Management of an intruded permanent tooth may consist of:
A.) observation for spontaneous eruption – only very mild intrusions
B.) surgical crown uncovering - seldom recommended - may interfere with periodontal healing
C.) orthodontic extrusion (with or without prior luxation of the intruded tooth) - recommended in most cases, since it is believed to facilitate remodeling of the supporting tissues and provides an early endodontic access
D.) partial surgical extrusion—immediately followed by orthodontic extrusion and surgical repositioning – rarely recommended due to the high rate of complications involved, including pulp necrosis, external root resorption, ankylosis,  marginal bone loss, contamination, and infection. In immature young teeth, there is also a risk of root fractures and iatrogenic exarticulation.
2. Cervical root fracture following endodontic treatment is the most frequent complication of orthodontically extruded teeth. A Luminex post enables resin to cure inside the canal to a depth of 11mm, which may strengthen the tooth to a level resembling an intact tooth and prevent fracture after external root resorption. 

Assessment: Interesting article showing a successful technique for strengthening a tooth after orthodontic extrusion and root canal therapy.  As this is only a single case report, it should be tested more before it is considered common practice. Also, I wonder if they had initiated the pulpectomy earlier, would they have prevented the external root resorption?

The Relationship of Dental Visits to Parental Knowledge of Management of Dental Trauma

Resident: Elliot Chiu
Title: The Relationship of Dental Visits to Parental Knowledge of Management of Dental Trauma
Journal: Pediatric Dentistry 2010
Author: R. Vergotine et al
Purpose: To see how much parents know about dental trauma management
-A survey was given to parents in 2 dental clinics in Milwakee. Questions included demographics, dental trauma experience, and trauma knowledge.
-296 recall patients and 171 new patients responded
-Most patients on Medicaid (79%)
-Broken tooth? 71% would seek a dentist
-Avulsion? 62% would seek a dentist
-Only 31% knew that avulsed permanent teeth could be replanted
-Only 25% of parents chose milk as a transport medium for avulsed teeth
-Trauma knowledge was not affected by history of previous dental trauma, sex, education, or insurance status
-Recall patients had more correct responses
This study shows the patient population at this clinic has very poor knowledge of dental trauma management. We spend a lot of chair time educating parents on diet/OH/caries, perhaps we should spend some time reviewing basics on trauma management.