early diagnosis and reversal of lesion progression is critical to maintaining

a sound oral balance. The diagnosis of children to be at high risk for the
development of caries is important. The American Academy of Pediatric
Dentistry (2007a) developed a caries-risk assessment tool referred to as the
CAT, which can be very helpful in identifying children that may be at a
higher risk for the development of caries. Clinical diagnostic techniques
are of absolute importance so that early lesions can be identified prior to
cavitation and an attempt for repair can be initiated.
Visual examination
Visual examination has been the primary method for diagnosing primary
and secondary caries. The specificity of visual examination shows great
variance through clinical trials (Wenzel et al., 1991; Verdonschot et al., 1992;
Lussi, 1993, 1996; Le and Verdonschot, 1994). A reason for the significant
differences in the visual examination is the differences in the status of
occlusal surfaces. Dentinal caries under an apparent intact occlusal surface
is difficult to detect. Low diagnostic sensitivity is associated with these
types of carious lesions (Creanor et al., 1990; Kidd et al., 1992a; Weerheijm
et al., 1992a, b).
The combination of visual examination and probing the enamel surface
with a dental explorer, although traditionally the standard of care, is not
recommended today because the dental explorer can transfer cariogenic
microorganisms from one site to another and damage the integrity of the
enamel surface, which can promote caries development (Loesche et al.,
1979; Ekstrand et al., 1987; van Dorp et al., 1988).
Secondary caries is very difficult to detect at early stages. Secondary
caries along the margins of restorations, referred to as wall lesions, cannot
be easily detected until it has progressed to an advanced stage (Kidd et al.,
1992b). Probing with dental explorers has been demonstrated to be not an
accurate method for diagnosing secondary caries (Merrett and Elderton,
1984).
Discoloration has been an integral component to clinical visual examination.
White spot lesions are the earliest signs of enamel demineralization.
Although these white spot lesions indicate early enamel demineralization
visually, the typical white spot lesion is approximately 500 μm in depth before
it becomes visually apparent. Discoloration is also an integral component
to the diagnosis of secondary caries (Kidd et al., 1995). Stained restoration
margins and ditched restoration margins are not necessarily signs of
dental caries, although they are indicators of greater risk for caries development
(Kidd and Beighton, 1996).
Transillumination
Bitewing radiographs have been the standard of care for evaluating proximal
surfaces of teeth. Fiber-optic transillumination (FOTI) has also beenmutans streptococci by 2 years of age are at higher
risk to develop caries
by age 4 than those that had not acquired the bacteria by age 2 (Kohler
et al., 1988). Likewise, children of mothers that have high levels of intraoral
bacteria are more susceptible to dental caries, the transmission of the
bacteria from mother to child being associated with the increased risk for
caries (Berkowitz et al., 1981; Berkowitz and Jones, 1985; Caufield et al.,
1988). There are bacterial testing systems available that can indicate bacteria
levels in the oral cavity and can be helpful in completing a risk assessment.
These diagnostic systems are specific to actual bacteria presence and
to bacterial acid production.
Antimicrobials
Chlorhexidine
Chlorhexidine has demonstrated antimicrobial effectiveness through numerous
well-controlled clinical trials (Lang and Brecx, 1986; Anderson,
2003). Chlorhexidine is 1,6-bis-4-chloro-phenyldiguanidohexane, a synthetic
cationic detergent. It has great bacteriostatic and bacteriocidal features
and was originally used to treat dermatologic infections, wound surfaces,
and eye and throat infections.
When chlorhexidine was originally tested for efficacy in plaque control,
10 mL of a 0.2% chlorhexidine digluconate rinse demonstrated successful
plaque control with subsequent inhibition of gingivitis (Davies et al., 1970;
L¨oe and Schi¨ ott, 1970). Other studies have demonstrated the effectiveness
of 0.12% chlorhexidine digluconate solution, the formulation available in
the United States, to effectively reduce plaque and gingivitis (Lang and
Briner, 1984; Siegrist et al., 1986).
The cationic chlorhexidine molecule binds to anionic compounds, such
as free sulfates, carboxyl and phosphate groups, and salivary glycoproteins
(R¨ olla and Melsen, 1975). This action will reduce the adsorption of proteins
to the tooth surface, delaying the formation of the dental pellicle. Chlorhexidine
molecules also coat salivary bacteria, which alter the mechanisms of
adsorption of bacteria to the tooth.
Chlorhexidine is active against gram-positive and gram-negative microorganisms,
as well as yeast cells. Due to the high cationic nature of
chlorhexidine, it has an affinity for the cell wall of bacteria and changes the
surface structures, whereby osmotic equilibrium is lost. This consequently
extrudes the cytoplasmic membrane and the cytoplasm precipitates, which
inhibits the repair of the cell wall (Davies, 1973).
The main side effects of chlorhexidine are staining of the teeth and,
taste and the content of ethyl alcohol. The stain on the teeth can be easily
removed with a pumice prophylaxis. Since chlorhexidine can temporarily
affect taste sensations, use around mealtimes is not recommended. The
high-alcohol content of chlorhexidine becomes a factor when using it with
children. Children must be of the age where they can expectorate the rinse
and not swallow it. Since this is a problem with very young childrenchild’s caregiver to prevent ingestion of undesirable
amounts of toothpaste
(American Academy of Pediatric Dentistry, 2007c). Toothbrushing should
be performed by an adult caregiver for children until at least age 5, when
coordination improves with the child’s toothbrushing. When the children
begin to brush their own teeth, the dentifrice should still be dispensed by
the caregiver, as well as having the brushing evaluated by the caregiver.
Toothbrushing should be performed twice per day (Chestnut et al., 1998).
When a child is old enough to effectively expectorate, more than a peasized
amount of dentifrice can be used to increase the level of fluoride
exposure.
Professionally applied topical fluoride
Fluoride varnish
Fluoride varnishes, although available in Europe for years as an anticaries
agent, is recognized by the U.S. FDA as a device to be used as a desensitizing
agent and a cavity-lining varnish (Beltran-Aguilar et al., 2000). Fluoride
varnish is available as 5% sodium fluoride (22,600 ppm fluoride) and 1%
difluorosilane (1,000 ppm fluoride). There is minimal information regarding
the effectiveness of fluoridated varnishes to enhance remineralization;
however, early data indicate that fluoride varnish has the potential to aid
in the remineralization of incipient caries (Sepp¨a, 1988; Attin et al., 1995).
The slow release of fluoride from fluoride varnish provides a sustained
fluoride release over a couple of days and offers excellent safety, since the
amount of fluoride released is so slow. Although 50,000 ppm sodium fluoride
is a relatively high dose, a minimal amount is applied (0.3–0.6 mL;
Figure 3.6) (Roberts and Longhurst, 1987). This can be converted to a range
of 5–12 mg of fluoride. Ekstrand and colleagues reported a low plasma
fluoride level following placement of a 5% fluoride varnish, which was
comparable to plasma fluoride levels experienced after toothbrushing with
a fluoridated dentifrice (Ekstrand et al., 1980). This level is significantly
lower than plasma fluoride levels seen after a professionally applied 1.23%
acidulated phosphate fluoride (Ekstrand et al., 1983).
Since the placement of fluoride trays in young children is difficult, cooperation
is difficult with young children to use slow-speed suction to remove
excess fluoride from the mouth as it dissipates from the delivery tray and
the inability to ensure young children will not swallow fluoride in a tray
delivery system—young children can benefit from fluoridated varnish. The
ease of varnish application, safety, and efficacy, comparable to 1.23% acidulated
phosphate fluoride gel, makes the use of fluoride varnish appropriate
for young children.
Professionally applied fluoride gels and foams
There are three professionaUtilizing the concept of minimally invasive dentistry, restoration is a last
resort when tooth surface cavitation appears. Teeth are restored with a
minimally invasive restorative protocol and biomimetic materials. By minimizing
the amount of tooth structure removed during cavity preparation,
natural tooth structure can be preserved. The selection of the appropriate
restorative material should be made in conjunction with the caries-risk
assessment.
Secondary caries is responsible for greater than 50% of all restorations
that are replaced (Mjor, 1997). Considerable fluoride release occurs during
the glass ionomer cement setting reaction and continues at very low
levels for years (Arends et al., 1995). The released fluoride is readily uptaken
by the cavosurface tooth margins of the restorative material, as well
as tooth structure proximally adjacent to a Class II restoration (Hicks et al.,
2003). Resistance to secondary caries at the cavosurface margins and adjacent
smooth surfaces to the glass ionomer cement restorative material has
been demonstrated (Donly et al., 1999a, b). As previously discussed, these
materials also uptake fluoride at the restoration surface and rerelease the
fluoride, the restorative material acting as a fluoride reservoir. Therefore,
there is an advantage of using glass ionomer cement restorations in children
who are of moderate caries risk for the prevention of secondary caries.
Glass ionomer cement/resin-modified glass
ionomer cement
Glass ionomer cement and resin-modified glass ionomer cement restorative
materials offer the advantage of self-adhesive bonding to tooth, as well
as the inhibition of adjacent proximal caries and secondary caries. The bond
strength of glass ionomer cement to enamel and dentin is not as strong as
that of resin-based composite; however, there is less technique sensitivity
associated with glass ionomer cements.
Clinicians are advised to use a Centrix (Shelton, CT) syringe to place
hand-mixed glass ionomer cements to reduce the concern of creating air
voids when placing the relatively “sticky” glass ionomer cement material.
After the glass ionomer cement is set or the resin-modified glass ionomer
cement is polymerized and set, finishing can be completed with carbide finishing
burs and polishing with abrasives. An unfilled resin is then applied
to the polished surface to keep the aluminum particles at the restoration
surface so that complete set of the acid–base reaction can occur over the
next 24 h, improving the compressive strength of the restoration.
Atraumatic restorative technique
The atraumatic restorative technique was initially introduced as a means
to restore teeth of individuals inUtilizing the concept of minimally invasive dentistry, restoration is a last
resort when tooth surface cavitation appears. Teeth are restored with a
minimally invasive restorative protocol and biomimetic materials. By minimizing
the amount of tooth structure removed during cavity preparation,
natural tooth structure can be preserved. The selection of the appropriate
restorative material should be made in conjunction with the caries-risk
assessment.
Secondary caries is responsible for greater than 50% of all restorations
that are replaced (Mjor, 1997). Considerable fluoride release occurs during
the glass ionomer cement setting reaction and continues at very low
levels for years (Arends et al., 1995). The released fluoride is readily uptaken
by the cavosurface tooth margins of the restorative material, as well
as tooth structure proximally adjacent to a Class II restoration (Hicks et al.,
2003). Resistance to secondary caries at the cavosurface margins and adjacent
smooth surfaces to the glass ionomer cement restorative material has
been demonstrated (Donly et al., 1999a, b). As previously discussed, these
materials also uptake fluoride at the restoration surface and rerelease the
fluoride, the restorative material acting as a fluoride reservoir. Therefore,
there is an advantage of using glass ionomer cement restorations in children
who are of moderate caries risk for the prevention of secondary caries.
Glass ionomer cement/resin-modified glass
ionomer cement
Glass ionomer cement and resin-modified glass ionomer cement restorative
materials offer the advantage of self-adhesive bonding to tooth, as well
as the inhibition of adjacent proximal caries and secondary caries. The bond
strength of glass ionomer cement to enamel and dentin is not as strong as
that of resin-based composite; however, there is less technique sensitivity
associated with glass ionomer cements.
Clinicians are advised to use a Centrix (Shelton, CT) syringe to place
hand-mixed glass ionomer cements to reduce the concern of creating air
voids when placing the relatively “sticky” glass ionomer cement material.
After the glass ionomer cement is set or the resin-modified glass ionomer
cement is polymerized and set, finishing can be completed with carbide finishing
burs and polishing with abrasives. An unfilled resin is then applied
to the polished surface to keep the aluminum particles at the restoration
surface so that complete set of the acid–base reaction can occur over the
next 24 h, improving the compressive strength of the restoration.
Atraumatic restorative technique
The atraumatic restorative technique was initially introduced as a means
to restore teeth of individuals intreatment
was not readily available (Frencken et al., 1994). Hand instruments
were used to remove caries; then chemically cured glass ionomer cement
was placed as the restorative material. This restorative technique originated
for use in third world countries, where access to dental treatment
was very difficult (Frencken et al., 1996; Phantumvanit et al., 1996). The
procedure did not require power for air or electrical operated handpieces
to remove caries and to light cure the restorative material. There have been
clinical outcomes reported with varying results; however, tooth extraction
may have been the only alternative treatment in many of these cases
(Frencken et al., 1998; Mallow et al., 1998; Holmgren et al., 2000).
In developed countries, where access to comprehensive dental care
is more readily available, glass ionomer cement or resin-modified glass
ionomer cement restorations can be effectively placed.
Class V restorations
Class V glass ionomer cement restorations can be very effective in the
primary dentition (Croll et al., 2001; Berg, 2002). These restorations are
not in stress-bearing areas; therefore, the compressive strength of the glass
ionomer cement restorative material is not a critical factor. Resin-modified
glass ionomer cement Class V restorations would be indicated to be
more preferable than resin-based composite restorations where good
isolation of the tooth is difficult or impossible (Figures 3.7 and 3.8). This is
particularly prevalent when treating young children where behavior can
FigureOcclusal restorations
Occlusal glass ionomer cement restorations have demonstrated clinical
success (Croll et al., 2001; Berg, 2002). Contemporary heavily filled glass
ionomer cements and resin-modified glass ionomer cements have compressive
strengths to withstand occlusal load and provide adequate wear properties
for the posterior primary dentition. Occlusal glass ionomer cement
restorations would be indicated when a tooth cannot be adequately isolated
to place a resin-based composite restoration. These are particularly
useful in children less than the age of 4, when cooperative behavior is not
anticipated.
Class II restorations
The clinical evaluation of Class II glass ionomer cement restorations in the
primary dentition has been promising (Vilkinis et al., 2000; Welbury et al.,
2000; Berg, 2002). Resin-modified glass ionomer cements have demonstrated
clinical success, some studies showing that it is as effective as
amalgam Class II restorations after 3 years (Donly et al., 1999b; Croll et al.,
2001). The advantages of not needing to acid-etched tooth structure before
restoration placement and knowing that the chemical setting reaction will
occur, even in the absence of light, makes the glass ionomers favorable for
the pediatric patient, where speed is critical and tooth isolation difficult.
Glass ionomer cements have varying degrees of radiopacity, which is
important when radiographically evaluating the proximal surfaces of
Class II restorations.
Class II glass ionomer cement preparation design is very similar to an
amalgam preparation design in the primary dentition (Figure 3.9). The
proximal box should be deep enough to break contact and the axial wall
should ideally extend 1.25 mm, unless caries removal creates the need to
extend further. The lateral walls should slightly converge toward the occlusal,
offering mechanical retention. The proximal box should be deep
Figure