The Hall Technique: Food for Thought

A novel technique using preformed metal crowns for managing carious primary molars in general practice A retrospective analysis. Innes et al. BDJ (2006) 200: 451-454.

No local analgesia or tooth preparation Ultraconservative (no) caries removal; sealed under SSC

Halls Clinical Trial Design

Patient
Age 4-9; good quality radiographs Matched decay in similar teeth

1 tooth Treated with crown

Contralateral tooth treated with filling

procedure details recorded

procedure details recorded

Halls Clinical Trial Algorithm

treatment appointment
emergency appointments recorded

1 year recall

emergency appointments recorded

2 year recall

Hall Technique Procedure

Child upright Smallest size of crown which would seat was chosen Should cover all cusps with feeling of spring back No attempt to seat crown at try in

Hall Technique Procedure, cont

Crown placed over tooth and partially seated until crown engaged with the contact points Finger removed and child encouraged to bite into place Or crown fully seated with firm finger pressure alone Extruded cement removed from margins Child asked to bite firmly on the crown for 2 3 minutes or crown held with firm finger pressure

Results from DDS View

Dentists estimation of discomfort experienced by child Hall Technique Conventional Technique

1 - no apparent discomfort 2 - very mild, almost trivial 3 - mild, not significant 4 - moderate, but child coped 5 - significant and unacceptable Total number of patients

61 32 25 12 2 132

33 36 34 23 6 132

Preferred Technique by DDS, Child and Parent

Child

Parent

Dentist
7

The Future?
Esthetic full coverage restorations Used with a GIC and acrylic system Crown form concept has adaptable margins and reported and strength

good seal

The PedoNatural Crown

Pre-op Crown Forms Post-op

TM

www.PedoNaturalCrown.com

Summary of Evidence

SSCs outlast other restorations Manipulation of the tooth and the crown can be minimalized with no apparent effect on quality No posterior non-metal crown has been shown to perform as well as the stainless steel crown

Shadow of a Doubt: A New Clinical Dilemma in Composite Dentistry

Composite dentistry has created a new set of clinical dilemmas for the pediatric dentist. Caries sealed into teeth is advised to be arrested. Shadows under sealants may be stain or caries. Radiolucencies under various composite formulations may be bases, caries or voids.

10

Shadow of a Doubt: Evidence?

Reseal all broken sealants Caries is arrested under sealants Visual caries diagnosis is as good as explorer or digital Composite longevity <amalgam< stainless steel crown

11

Todays Teen Dilemma: Treating Incipiencies in Permanent Teeth

The advent of Dew Mouth and similar carbonated beverage related caries patterns challenges the pediatric dentists traditional skills to manage these with least invasive techniques

12

Beyond Prevention But Before Restoration Resin Infiltration

When bitewings show incipient lesions beyond remineralization Hydrochloric acid (15%) for 90-120 seconds Infiltrate with fluid resin, floss excess away and light cure Preliminary evidence suggests that enamel is resistant to decalcification

13

Does It Work: Early Results

Paris S, Meyer-Lueckel H. Radiographic comparison of lesion progression after infiltration and standard therapy in vivo-18 months follow-up. Split mouth design One tooth received infiltration All patients were instructed on F toothpaste use and flossing

14

Management of Occlusal Surfaces

No compelling evidence for how best to manage these surfaces on young permanent teeth Risk assessment has marginal sensitivity and specificity We really dont know which teeth should be sealed, receive enameloplasty, or have composites placed The type of composite (filler content) is also a clinicians choice The use of bases also has little evidentiary support

15

MYTHBUSTERS

Troothbusters

Fluoride use in infants and pre-school aged children is controversial. More Fluoride Myths ? Mechanisms of action and dosages continue to be debated. Initial fluoride supplement dosages were empirical. Fluoride is ubiquitous in a childs diet. Fluorosis reports are increasing. Should caries risk of children be performed before fluoride prescribing? The shotgun approach is no longer acceptable. Is fluorosis preferable to caries? Should non-dentists apply fluoride varnish? We are floundering in a fluoride fog! Will EBD lead us out of the fog?

Recent fluoride factoids

Bottled water and caries increase. Formula, breast milk and fluoride. Risk periods for dental fluorosis Fluoride toothpaste- a pea, a smear or none?

Bottled water and caries

Bottle water sales leveled off in 2008. Most bottled water has little fluoride. FDA health claim for bottled water? Evidence? No conclusive evidence of an association between increased caries and bottle use.

1. 2.
3.

Cochrane- nothing ADA EBD- nothing PubMedAn investigation of bottled water use and caries in the mixed dentition. Broffitt B, Levy SM, Warren JJ, Cavanaugh JE. J Public Health Dent. 2007 Summer;67(3):151-8. For the dental patient. The facts about bottled water. J Am Dent Assoc. 2003 Sep;134(9):1287.

Formula, breast milk and fluoride

Myths or facts?

Evidence Breast milk- 0.02 ppm.

Koparal et al 2000 Breast milk has little fluoride. Infant formula should beFluoride mixed in infant formula causing fluorosis- weak evidence. with fluoride free water. Hujoel et al 2009 Soy based formula has little Soy based formula-up to 0.70ppm. fluoride. Pagliari et al 2006 All infants should receive a Prenatal fluoride supplements have no benefits fluoride supplement beginning Leverett et al 1997 shortly after birth. Reexamine the use of fluoride supplements during Pregnant mothers should receive the first 6 years. a fluoride supplement. Ismail and Hasson 2008

1. Topical fluoride as a cause of dental fluorosis in children (In preparation)

Risk period for dental fluorosis

EB response: Maxillary permanent central incisors appear most at risk from fluoride during the first 24 months of life, especially between 6 and 24 months. Timing is important but the cumulative duration of a fluoride level must also be noted.

May CM Wong1, Anne-Marie Glenny2, Boyd WK Tsang1, Edward CM Lo1, Helen V Worthington2, Valeria CC Marinho3

ADA EBD: 1. Fluoride supplements, dental caries and fluorosis: a systematic review Ismail AI, Hasson H. Journal of the American Dental
Association. 2008; 139(11):1457-68

2. Risk periods" associated with the development of dental fluorosis in maxillary permanent central incisors: a metaanalysis Bardsen A. Acta Odontol Scand. 1999; 57(5):247-56 PubMed: 1. Fluoride supplements, dental caries and fluorosis: a systematic review. Ismail AI, Hasson H.
J Am Dent Assoc. 2008 Nov;139(11):1457-68.

Duration of fluoride exposure rather than the specific period better explains the development of fluorosis.

2.Considerations on optimal fluoride intake using dental fluorosis and dental caries outcomes--a longitudinal study.
Warren JJ, Levy SM, Broffitt B, Cavanaugh JE, Kanellis MJ, WeberGasparoni K. J Public Health Dent. 2009 Spring;69(2):111-5.

3. Timing of fluoride intake in relation to development of fluorosis on maxillary central incisors.

Hong L, Levy SM, Broffitt B, Warren JJ, Kanellis MJ, Wefel JS, Dawson DV. Community Dent Oral Epidemiol. 2006 Aug;34(4):299-309

22

Ribbon, Pea or smear- how much toothpaste on the brush?

1. Brushing twice a day- one just before bed and supervised 2. Smear for high risk children under 2 years 3. Pea sized amount for children 2-5 years. 4. Rinsing after brushing should be kept to a minimum 5. Tooth brushing should began as soon as the primary teeth erupt 6. No evidence to support the wiping of the infants predent alveolar ridges

Ribbon of 1000ppm F toothpaste=1g=1mg of fluoride Children under 6 years swallow 2460% toothpaste from their brush Pea size amount= g Unregulated amounts of fluoride toothpaste can contribute to fluorosis 1. Prevention and management of dental decay in the preschool child.
SIGN 2005

2. Fluoride recommendations for high-risk children MCHB- DHHS 2007 3. Guideline on Fluoride therapy.
AAPD 2008.

23

Medical Advances in Pediatric Health

MYTHBUSTERS

Trooth-Busters

25

Myths About Devices

If its embedded, its premedded is a common misconception in dentistry. With more foreign objects being used in pediatric health care, what is the evidence for using antibiotics?

26

VP Shunts: Anything New?

Used for CSF drainage Classically have been premedicated with ABs Now may have electronic controls so sensitive to some office devices No need for ABs except maybe in first six months while epithelialization is taking place

27

Baclofen Pump Continuous Medication for CP

Baclofen is a muscle relaxant to address spasticity in CP The baclofen pump system is intrathecal delivery of GABA The system is a catheter and pump - a round metal disc, about 1 inch thick and 3 inches in diameter surgically placed under the skin at the abdomen No IE coverage needed

28

Gastrostomy (GT) Feeding: Why?

Used for children with global delays with poor oral motor function Efficient feeding takes far less time Better nutrition because actual intake measured Minimizes aspiration of food and bacteria into lungs

29

Why So Much Calculus?

Salivary gland changes? Decreased saliva flow due to medications? Chronic state of dehydration? Lack of hygiene? Lack of chewing and food abrasion? Increased serum calcium?

30

Evidence on more frequent cleaning: Jawadi A et al. found that there was an association between calculus and aspiration pneumonia (AP) Brown L et al. found that use of an OTC tartar reduction dentifrice was more effective than regular fluoride-containing child toothpaste in preventing calculus accumulation in tube fed children Calculus reduced > 50% with TCTP

Managing Calculus Build Up

31

Imaging: What You Need to Know

MRIs are distorted because of metallic dental restorations, but do not compromise treatment Increased use of interventional radiology and 3D imaging make this an issue Is CT or MRI needed for improved outcomes? Cone beam CT and risk of future cancers and evidence of any benefit medicine is seeing a rash of new unexpected cancers now being attributed to CAT scans

Vitamin capsule
Titanium implant

ssc

32

Non-Invasive Heart Procedures

Pacemakers Stints and other devices Ask the MD The underlying heart disease is usually the determinant of need for IE

33

Other Concerns
Pacemakers and other programmable devices are susceptible to electromagnetic radiation Shielding and refinements in cellphones and devices reducing risk No IE coverage needed

34

What About Solid Tumors?

Limb sparing rather than amputation is becoming more common in bone tumors Consult with heme/onc MD about antibiotic coverage

35

MD/DDS Joint-Joint Statement

American Dental Association/American Academy of Orthopaedic Surgeons. Antibiotic prophylaxis for dental patients with total joint replacements. JADA 2003;134:895-9. This was update of 1997 policy No antibiotics for pins, plates, and screws and none for most The risk-benefit ratio for use of antibiotics does not support use in joint replacement patients Might consider use of antibiotics if patient is immunocompromised , in first 6 months post-operatively or has a history of previous replacement gone bad due to infection Consult with orthopedic surgeon when in doubt

36

What is a Vagal Nerve Stimulator ?

Alters blood flow in thalamus Thalamic blood correlated with seizure thresholds Exact mechanism of action is unknown Intractable epilepsy Treatment-resistant clinical depression No IE coverage needed

37

CVADs may be used in cancer, Central Venous Access cystic fibrosis, IDDM, bleeding disorders for TPN, blood products and sampling AKA: in-dwelling cath, Hickman, Broviac, Medi-port Prone to infection but almost always due to skin organisms Antibiotics are not necessary and in fact discouraged

Devices

38

Cochlear Implants

39

Cochlear Implants: What Do I Need to Know?

If infected, probably due to OM or skin organisms Chorda tympani injured in about 40% of surgeries so taste may be altered temporarily No antibiotic premed is needed

40

Juvenile Diabetes: The Pump

Insulin pumps are becoming more common Patients with pumps went from 6600 to 195,00 from 1990-2002 Clinically shown to reduce hypoglycemia and glycosuria Provide insulin small doses into abdominal subcutaneous fat No antibiotic coverage needed

41

Im No Slug I Know My Drugs!

But Do You? Pediatric care has advanced rapidly and many medications are being re-examined for use in conditions previously treated with other medications some may surprise challenge your understanding of disease pathophysiology

42

Botox: Hope for Sialorrhea?

Jongerius et al: Effect of botulinum toxin in the treatment of drooling: a controlled study. Pediatrics 2004;114(3):620-27. Both transdermal scopolamine and injected Botox reduced drooling but Botox had fewer and less significant side effects Maximum effect was at 2-8 weeks post-injection

43

Botox: Replacing Surgery for Limb Contractures in Cerebral Palsy

Abnormal muscle balance in CP leads to contractures Selective dorsal rhizotomy and tendon release surgery may be replaced by Botox

44

Self-Mutilation Botox isBotox: being tested to reduce neuropathologic Management chewing in cases of closed head injury, toxic coma, and other neurologic conditions Botox offers the advantage of localized rather than systemic effects

45

Methotrexate: Low Dose Use

Traditional anticancer drug used in many pediatric cancers Now used for rheumatoid arthritis, psoriasis, cancers, lupus and other immune-based disorders Always check blood counts

46

Thalidomide: For Immune Disorders

Thalidomide caused an epidemic of phocomelia in Great Britain in the second half of the 20th century when used by pregnant women for nausea Children, adolescents and young adults with refractory JRA, psoriasis, severe ulcerative conditions, sickle cell and lupus may take thalidomide Sarmadi M, Ship JA. Refractory major apthous stomatitis with systemic immunosuppressants: a case report. Quintessence Int 2004;35:39-48

47

What About Induced (Intended or Not) Hypocoagulation

Aspirin and Coumadin for heart disease Aspirin or similar compounds for joint pain in JRA Heparin for dialysis at any age (can be reversed)

Discontinuation for dental surgery not always necessary When taking low dose for reduction of platelet aggregation, may not be necessary Blood tests such as bleeding time and platelet function tests unreliable

48

Aspirin: Keep Taking It! Douketis JD, Berger PB, Dunn AS et al. The perioperative

management of antithrombotic therapy. American College of Chest Physicians evidenced-based clinical practice guidelines (8th edition). Chest 2008;133:299S-339S. No need to discontinue aspirin for dental procedures No need to do platelet function assays which may be equivocal Be sure to advise the MD because it may be assumed ASA will be stopped Nasal intubation is not contraindicated in patients taking low dose ASA

49

Flip-Flop for 1st Line Asthma Drugs

Redding GJ et al. Changes in recommended treatment for mild and moderate asthma. J Family Pract 2004;53:692-700.
Children with exacerbations < 6 weeks apart, > 4 episodes of wheezing per year and have risk factors of atopy, allergic rhinitis and wheezing qualify for controller therapy and are considered to have persistent asthma Inhaled corticosteroids now the first line of defense ICs improve lung function Cromolyn not considered front line Long-acting beta-2 adrenergic agonists no longer used as monotherapy because of lung deterioration

50