Recent advancements in paediatric dentistry

tried to cover up most of the recent advancements in the field of pediatric dentistry in this presentation.

1. RECENT ADVANCEMENTS IN PAEDIATRIC DENTISTRY Dr. Aravindhan A, JR-2, Dept. of Paediatric and Preventive dentistry.

2. Contents Advancements in pain control Advancements in caries diagnosis Dental Implants Nano materials Silver diamine fluoride Advancements in Crowns for primary tooth Advancements in Naso Alveolar Moulding

3. Advancements in pain control Cook invented the modern dental syringe nearly 150 years ago . Here we see, 1.V ibrotactile devices, 2.C omputer-controlled local anesthetic delivery (CCLAD) systems, 3.J et injectors, 4.S afety dental syringes and 5. devices for Intra-Osseous (IO) anesthesia .

4. Vibrotactile devices   systems aimed at easing the fear of the needle take advantage of the gate control theory of pain management . GATE CONTROL THEORY?

5. VibraJect It is a small battery-operated attachment that snaps on to the standard dental syringe. It delivers a high-frequency vibration to the needle that is strong enough for the patient to feel. Researches evaluating the effectiveness of VibraJect , have shown mixed results. Nanitsos   et al .,and Blair have recommended the use of VibraJect for painless injection.

6. Dental vibe Its U-shaped vibrating tip attached to a microprocessor-controlled Vibra -Pulse motor. It gently stimulates the sensory receptors at the injection site, effectively closing the neural pain gate, blocking the painful sensation of injections . It also lights the injection area and has an attachment to retract the lip or cheek .

7. A ccupal Accupal provides pressure and vibrates the injection site 360° proximal to the needle penetration, which shuts the “pain gate” . After placing the device at the injection site and applying moderate pressure, the unit light up the area and begins to vibrate. The needle is placed through a hole in the head of the disposable tip, which is attached to the motor .

8. C omputer-controlled  L ocal   A nesthetic  D elivery  S ystems   Incorporated computer technology to control the rate of flow of the anesthetic solution through the needle.    Wand™   - first CCLAD- 1997 (U.S) Next generations: 1.Wand Plus 2 . CompuDent Comfort Control Syringe  -2001 (U.S) QuickSleeper and SleeperOne ( F rance ) Anaeject   and Ora Star (Japan)

9. wand This system enabled operator to accurately manipulate needle placement with fingertip accuracy and deliver the LA with a foot-activated control. The lightweight handpiece is held in a pen-like grasp that provides the user with greater tactile sensation and control. The greater control over the syringe and the fixed flow rates of the LA drug are responsible for a significantly improved injection experience.  

10. Comfort control syringe   N o foot pedal .  A base unit and a syringe   Has five pre-programmed speeds for different injection techniques.   more perceptive than that of the CompuDent system in the sense that the injection is controlled by hand. syringe is bulky 

11. Jet injectors Jet-injection technology is based on the principle of using a mechanical energy source to create a release of pressure sufficient to push a dose of liquid medication through a very small orifice, creating a thin column of fluid with enough force that it can penetrate soft tissue into the subcutaneous tissue without a needle. Syrijet MED-JET

12. S yrijet I t accepts the standard 1.8 mL cartridges of LA solution. permits the administration of a variable volume of solution from 0 to 0.2 mL . and is completely autoclavable .

13. Med jet D irected through a small orifice 7 times smaller than the smallest available needle in the world.  utilize low pressure delivery methods .

14. S afety dental syringes Use of a safety syringe minimizes the risk of accidental needle-stick injury. These syringes possess a sheath that ‘locks’ over the needle when it is removed from the patient's tissues preventing accidental needle stick .

15. Ultra Safety Plus XL syringe   Has a sterile disposable protective shield that is fitted with a dental needle into which anesthetic carpules are placed. UltraSafe Syringe The entire assembly is disposable and is not autoclavable .. Fully transparent.

16. HypoSafety Syringe   The needle can be retracted into the barrel of the syringe after the injection . RevVac safety syringe When the plunger reaches the bottom, after all medicine is administered, a further push on the plunger breaks the seal, and the needle retracts into the plunger.

17. D evices for intra-osseous anesthesia A im to inject local anesthetic solution into the cancellous bone adjacent to the apex of the tooth.  Stabident X-Tip IntraFlow

18. stabident A slow-speed hand piece with a latch contra-angle for the perforator and a standard dental anesthetic syringe for the needle. visible location in the attached gingiva distal to the tooth to be anesthetized. 

19. X tip the pilot drill itself a hollow tube through which a 27-gauge needle can pass. more post-operative pain  .

20. IntraFlow E ssentially a dental handpiece equipped with an injection system built into the body . single-step method  High maintenance costs Study by Remmers et al.,(2008), found IntraFlow to provide reliable anesthesia of posterior mandibular teeth in 13 of 15 subjects, compared to 9 of 15 with an inferior alveolar nerve block. Remmers T et al.,- The efficacy of IntraFlow intraosseous injection as a primary anesthesia technique . ,- J Endod . 2008 Mar; 34(3):280-3.

21. Single-tooth anesthesia (STA) D eveloped by the manufacturers of WAND (CCLAD). Dynamic Pressure Sensing (DPS) technology. Originally designed for use in medicine in epidural regional anesthesia . Helpful in intraligamentary injection.

22. Reversing local anesthesia Oraverse ( phentolamine mesylate ) ( FDA-2009) Prevents anesthetic lip bite injury. safe and effective in reducing soft tissue local anesthetic recovery time in adults and children as young as 6 years. dosage? Duration?

23. Future trends A nasal spray has shown to anesthetize maxillary anterior six teeth is set to be tested in an FDA Phase 3 trial, which will assess the spray's effectiveness compared to the current “gold standard” treatment - painful anesthesia injections .   Kovacaine Mist (3% tetracaine HCl with 0.05% oxymetazoline HCl ) Coronoid foramen and its block.

24. Advanced Methods of Caries Detection Digital radiographic methods • Digital image enhancement • Digital subtraction radiography • Tuned-aperture computed tomography (TACT). Visible light • Optical caries monitor • Quantitative fiber‑optic transillumination • Digital Image fiber‑optic transillumination • Quantitative light/laser‑ induced fluorescence (QLF). Laser light • DIAGNOdent – Laser autofluorescence . Electrical current • Electrical conductance measurement • Electrical impedance measurement. Ultrasound • Ultrasonic caries detector.

25. Digital Radiographic Methods Digital image enhancement • Resolution of unenhanced digital image is lower than radiographs • Range of gray shades is limited to 256, whereas in a radiographic film, over 1 million shades of gray appear • Contrast can be digitally enhanced using a mathematical rule often decided by the algorithm/filter • They are not practically used because they are very time-consuming. INDIRECT DIRECT

26. Digital subtraction radiography • A digital bitewing radiograph is taken and later a second radiograph of exactly the same region is produced with identical exposure time, tube current, and voltage. • By subtracting gray values for each coordinate of the first radiograph from equivalent coordinate of second, a subtraction image is obtained. • If no changes have occurred, the result of subtraction is zero.

27. Tuned Aperture C omputed Tomography (TACT) This method constructs radiographic section through teeth. The slices can be viewed for the presence of radiolucency . Slices can be brought together in a three-dimensional computer model called pseudo-hologram. TACT slices and pseudo-hologram can adequately detect small primary and secondary carious lesions

28. Optical caries monitor • Principle used is, scattering is stronger in demineralised enamel than in sound enamel surface • Light is transported through a fiber bundle to the tip of handpiece .

29. Digital imaging fiber‑optic transillumination (DIFOTI) Combining FOTI with a digital CCD camera. It uses a safe white light with which images taken from all the tooth surfaces can be digitally captured using a digital CCD and sent to a computer for analysis. When the teeth are transilluminated , areas of demineralized enamel or dentin scatter light and incipient caries appear darker in the resultant image. Images taken during different examinations can be compared for clinical changes between several images of the same tooth over time.

30. Quantitative light/laser‑ induced fluorescence It provides a fluorescent image of a tooth surface within yellow‑ green spectrum of visible light that quantifies mineral loss and size of the lesion. Light source is a special arc lamp based on xenon technology . Recording of florescent image is done with a yellow transmitting filter positioned in front of the color CCD sensor . Image is then digitized by the frame grabber and is available for quantitative analysis. Tooth is seen on a computer monitor as fluorescent green and dark areas indicate mineral loss or white spot lesions. At times, a red fluorescence appears that indicates leaking around restorations and sealants SOPROLIFE (light-emitting diode fluorescence tool).

31. DIAGNOdent ‑ laser autofluorescence It uses infrared laser fluorescence of 655 nm for the detection of occlusal and smooth surface caries. DIAGNOdent technology uses a simple laser diode to compare the reflection wavelength against a well-known healthy baseline to uncover decay. Carious tooth structure exhibits fluorescence proportionate to the degree of caries. DIAGNOdent pen- 2190.

32. Canary system The Canary System is a caries detection device, based on the energy conversion technology photothermal radiometry (PTR)– luminescence (LUM ). When low- power laser light energy pulsed at 2 Hz is absorbed by the tooth, two phenomena are observed: 1. the laser light is converted into LUM and 2. there is a release of heat (PTR ). The output, called the Canary Number (CN ) A nd is directly linked to the status of the tooth crystal structure . CN increase as early mineral loss from the tooth (incipient caries ). In contrast, as remineralization of the lesion progresses, there is a corresponding decrease in CN.

33. Electrical conductance measurement D emineralized tooth has more pores filled with water. Types. 1.site specific 2. surface specific 1. Vanguard electronic caries detector: 25 hz current. 0-9 reading 2. Caries meter: 400hz current. Conductance will be converted into Coloured lights. Green : No caries Yellow : Enamel caries Orange : Dentin caries Red : Pulpal involvement .

34. Electrical impedance measurement Electrical impedance measurement is a measure of degree at which an electric circuit resists electric current flow when a voltage is applied across two electrodes. Caries tissue has a lower impedance than sound tooth. It is also known as electronic caries monitor. CARIES SCAN PRO

35. Ultrasound Caries Detector Demineralization of natural enamel is assessed by ultrasound pulse‑ echo technique . Ultrasound interacts differently with different tissues. They have a frequency of >20,000 Hz and have all the properties of waves. An ultrasonic probe is used which sends and receives longitudinal waves to and from the surface of the tooth. Initial white spot lesions produce no or weak surface echoes, whereas sites with visible cavitation produce echoes with substantially higher amplitude. Useful in diagnosis of proximal caries.

36. Newer technologies 1. Multiphoton imaging 2. Infrared fluorescence 3. Infrared thermography 4. Terahertz imaging 5. Optical coherence tomography 6. Polarized Raman spectroscopy 7. Modulated (frequency‑ domain ) infrared photothermal radiometry. 8. Magnetic R esonance M icroimaging ( mrm ). 9. Near infrared light systems

37. Dental implants Definition: A prosthetic device made of alloplastic material implanted into the oral tissues beneath the mucosa and/or periosteal layer, and on/within the bone to provide retention or support to a prosthesis. The final restoration looks, feels, & functions like a natural tooth. Per ingvar branemark - swedish surgeon.

38. TILL DATE IT WAS BELIEVED THAT…. The replacement of teeth by implants is restricted to patients with completed craniofacial growth. There are two primary concerns: ( i ) First, if implants are present during several years of facial growth, there is a danger of them becoming embedded, relocated, or displaced as the jaw grows. ( ii) The second area of concern is the effect of prosthesis on growth.

39. SCANDINAVIAN CONSENSUS CONFERENCE IN SONKOPING, SWEDEN. 1996   It was agreed that implants should not be placed until growth and skeletal development is completed or nearly completed. Exceptions: 1. severe oligodontia 2. ectodermal dysplasia But several authors found that alveolar ridge loss is prevented in children with early loss of permanent tooth who treated with implants.

40. Growth of craniofacial structures…

41.  Implants in the mandibular anterior region can be placed to support an overdenture , from the age of around 6 years, when the median sutures of the mandible is closed. - National Institute of Health consensus Development Conference on Dental Implants at Bethesda,1988 . Whenever possible, implant placement must be delayed until the age of 15 years for girls and 18 years for boys . - T extbook of pediatric dentistry, Nikhil marwah .

42. Ledermann et al in their 7-year follow-up reported a 90% success rate on 42 endosseous dental implants placed in 34 patients aged 9 to 18 years . There was a positive soft and osseous tissue reaction to the implants, and most of the failures occurred because of subsequent traumatic injuries sustained during the healing phase after implant placement. The major complication reported was the failure of dental implants to respond to the vertical growth of adjacent teeth and alveolus due to ankylosis .

43.   Prachar and Vaneek present the results of a 5-year study on the use cylindrical or screw implants in adolescents of age 15-19 years . Regardless of the criterion used, the rate of success was always higher than 96% over the 5 years of study.

44. Implant procedure

45. Nano materials The American Physicist Richard Feynman through his lecture titled “there is plenty room at the bottom” delivered at Caltech in 1959 .  Japanese scientist Norio Taniguchi of the Tokyo University -1974- coined the term. Definition: Nanotechnology or nanoscience refers to research and development of an applied science at the atomic or molecular level. One nanometer is 1 billionth or 10 −9  of a meter.

46. The basic idea of nanotechnology is to employ individual atoms and molecules to construct functional structures. Nano materials synthesis Bottom – up approach Top – down approach

47. Application of nanotechnology in diagnosis and treatment I ncrease the efficiency and reliability of  in vitro  diagnostics. The radiation dose obtained using digital radiography with nanophosphor scintillators is diminished and high quality images obtained. O ptical nanobiosensor can also be used for diagnosing oral cancer.    Nanoshells have outer metallic layers that selectively destroy cancer cells while leaving normal cells intact.

48. Tissue engineering    Bone augmentation, cartilage regeneration of the temporomandibular joint, pulp repair, periodontal ligament regeneration and implant osseointegration . Bone grafts with better characteristics can be developed with the use of nanocrystalline hydroxyapatite . It was shown that nanocrystalline hydroxyapatite stimulated the cell proliferation required for periodontal tissue regeneration. “ Ability of nanocrystalline hydroxyapatite paste to promote human periodontal ligament cell proliferation ” - Wilhausen et al., J Oral Health Sciences 2008.

49. Bio- nano surface technology Roughening the implant surface at the nanoscale level is important for the cellular response that occur in the tissue. The nanoscale surface morphology augments area and thus provides an increased implant surface area that can react with the biologic environment.

50. Nano anesthesia  The gingiva of the patients is instilled with a colloidal suspension containing millions of active , analgesic, micron-sized dental robots that respond to input supplied by the dentist. After contacting the surface of crown or mucosa, the ambulating nanorobots reach the pulp via the gingiva sulcus , lamina propia and dentinal tubules , guided by chemical gradient, temperature differentials controlled by the dentist. N erve-impulse traffic in tooth that requires treatment. After completion of treatment, they restore sensation thereby providing patient with anxiety-free and needless comfort. Anesthesia is fast acting, and reversible, with no side effects or complications associated with its use.

51. Sterilization : Nanoparticles have also been used as sterilizing solution in the form of nanosized emulsified oil droplets that bombard pathogens -  Eco-True which was reported to have 100% destructive effect on HIV and germs. . Impression: Nanofillers are integrated into vinypolysiloxanes , producing a unique siloxane impression material that has a better flow, improved hydrophilic properties and enhanced precision detail. Nano needles and N ano tweezers .

52. Nano -robotic dentrifices ( dentifrobots ) Dentifrobots in the form of mouthwash or toothpaste left on the occlusal surface of teeth can clean organic residues by moving throughout the supragingival and subgingival surfaces . It metabolizes trapped organic matter into harmless and odorless vapors and performing continuous calculus debridement. These nanorobots can move as fast as 1-10 μ/s and are safely self-deactivated when they are swallowed.

53. Hypersensitivity care The dentinal tubules of a hypersensitive tooth have twice the diameter and eight times the surface density of those in nonsensitive teeth. Dental nanorobots could selectively and precisely occlude selected tubules in minutes using native logical materials, offering patients a quick and permanent cure.

54. Nano orthodontics R eduction in the frictional force produced by orthodontic movement by coating the orthodontic wire with inorganic fullerene-like tungsten disulfide nanoparticles (IF-WS 2 ). B rackets coated with the nitrogen-doped titanium oxide t hin film prevents biofilm accumulation over brackets. Orthodontic nanorobots could directly manipulate the periodontal tissues, allowing rapid and painless tooth straightening, rotating and vertical repositioning as well as rapid tissue repair within minutes to hours .

55. Nano composites   H igh degree of strength Resistance to abrasion Superior esthetics Polishablity Increase in flow. Ex: Ceram-X Mono .

56. Silver diammine fluoride Ag(NH 3 ) 2 F Ohaguro custom in japan . In which they used ohaguro dye made from gall nut powder to stain the tooth. Yamaga et al., discovered SDF from ohaguro dye. It has combined properties of silver nitrate and sodium fluoride. It inhibits S. mutans microflora . Thus it is a good antiplaque and anticariogenic agent. Ammine-(NH 3 ) Amine-(NH 2 )

57. Mechanism of SDF 44,800 ppm of Fluoride. 2,54,709 ppm of Silver. 38% SDF Ag ions F ions Killing of microorganisms in carious surface ZOMBIE EFFECT Remineralisation and penetrates deeper into dentin Blocks the dentinal tubules Arrest of sensitivity All of these lead to caries arrest .

58. Practical guidance by AAPD-2017 38% SDF Indications and usage : • High caries-risk patients with anterior or posterior active cavitated lesions. • Cavitated caries lesions in individuals presenting with behavioral or medical management challenges . • Patients with multiple cavitated caries lesions that may not all be treated in one visit. • Difficult to treat cavitated dental caries lesions. • Patients without access to or with difficulty accessing dental care . • Active cavitated caries lesions with no clinical signs of pulp involvement.

59. Preparation of patients and practitioners: • Universal precautions. • No operative intervention (e.g., affected or infected dentin removal) is necessary to achieve caries arrest. • Protect patient with plastic-lined bib and glasses. • Cotton roll or other isolation as appropriate. • Use a plastic dappen dish as SDF corrodes glass and metal. (pH- 10) • Carefully dispose of gloves, cotton rolls, and micro brush into plastic waste bag.

60. Procedure Remove gross debris from cavitation • Minimize contact with gingiva and mucous membranes • Dry with a gentle flow of compressed air (or use cotton rolls/gauze to dry) affected tooth surfaces. Apply SDF directly to only the affected tooth surface. • Dry with a gentle flow of compressed air for at least one minute. • Remove excess SDF with gauze, cotton roll, or cotton pellet to minimize systemic absorption. Continue to isolate site for up to three minutes when possible.

61. Post-operative instructions Eating and drinking immediately following application is acceptable. Several SDF clinical trials recommended no eating or drinking for 30 minutes – one hour. Zhi QH et al., Randomized clinical trial on effectiveness of silver diamine fluoride and glass ionomer in arresting dentine caries in preschool children . - J Dent 2012.

62. Application frequency M onitor caries lesion arrest after 2-4 week period and consider reapplication if necessary . Based on disease activity of individual. Biannual application is recommended. Fung M et al .,(2016) one-time SDF application in arresting dental caries lesions ranges from 47 percent to 90 percent. Yee R et al.,(2011) After a single application of 38 percent SDF, 50 percent of the arrested surfaces at six months had reverted to active lesions at 24 months.

63. Esthetic consideration : The hallmark of SDF is a visible dark staining that is a sign of caries arrest on treated dentin lesions. This dark discoloration is permanent unless restored. “ Pretreatment of dentin with SDF does not adversely affect bond strength of resin composite to dentin .” Selvaraj K, Sampath V, Sujatha V, Mahalaxmi S. Evaluation of microshear bond strength and nanoleakage of etch- andrinse and self-etch adhesives to dentin pretreated with silver diamine fluoride/potassium iodide: An in vitro study. Indian J Dent Res 2016.

64. Advancements in crowns Zirconia crowns Figaro crowns Biological crowns Luxa crowns

65. Zirconia crowns Zirconia crowns are very aesthetic and durable crowns, and they can be used in most situations where clinicians would place a stainless steel crown, strip crown or preveneered crown. Also known as, Ceramic steel . Passive fit of crown is advised. Trade names : 1 . Nu smile zr 2 . Kinder crowns zr 3 . EZ pedo crown 4. Kids e crown 5. Signature crown

66. Advantages : Strength Durability Esthetics Do not discolor Disadvantages : More tooth reduction is required Brittle Cannot be crimped and trimmed. High cost Shade options are limited .

67. Luting GIC is used to cement the zirconia crowns. Luthy et al., (2006), “Resin cement with MDP monomer is the recommended cement for monolithic zirconia crowns.” Sandblasting before cementation improves bonding. Immediate Post op 30 months follow up

68. Figaro crowns Reinforced fiber glass crown. Tooth colored BPA free- non mutagenic Non metallic. High strength. Flex fit technology- ( crimpability ) Thin margins- better marginal fit .

69. Luxa crowns Semipermanent composite crown . Technically simple Better durability Esthetics Patient compliance.

70. Procedure 1.5 mm tooth reduction is needed in all aspects. Approx. 40 seconds after the start of mixing, the filled impression will be placed in the patient's mouth and will stay there for approx. 1:45 - 2:20 minutes, that is, till the material is partially set. The impression will then be taken out and the material will be allowed to set outside patient's mouth up to approximately 5 minutes after the start of mixing. 

71. Luxa video

72. Biological crowns Replacement of decayed crown with either autologous or donated natural crown. Donor crown should be autoclaved and sectioned acording to the size of the recipient tooth. Extracted tooth should be stored in sterile water.

73. Advancements in NAM Modified muscle-activated maxillary orthopedic appliance Suri and Tompson  used a plate held in with outriggers. prevents cleft widening effect of tongue. unilateral cleft lip and palate patients. Suri S, Tompson BD. A modified muscle-activated maxillary orthopedic appliance for presurgical nasoalveolar moulding in infants with unilateral cleft lip and palate. Cleft Palate- Craniofac J 2004;41:225-9. 

74. Dynamic presurgical nasal remodeling Developed by Bennun and Figueroa . consists of two elements: 1. perfectly adapted conventional acrylic intraoral plate. 2. dynamic nasal bumper attached to the vestibular flange. Bennun RD, Figueroa AA. Dynamic presurgical nasal remodeling in patients with unilateral and bilateral cleft lip and palate: Modification to the original technique . Cleft Palate Craniofac J 2006;43:639-48

75. Active alveolar molding appliance Consists an alveolar molding plate with an expansion screw ( Jack screw ) fully opened . The appliance was activated by closing the expansion screw and by selective grinding and relining with denture base material. The premaxilla was retracted and the cleft gap was reduced within 3 months. Reducing tissue tension and scar formation. 

76. NAM with self retentive plate Ijaz et al.,2012 . unilateral CLP cases Consists a custom-made orthopedic plate incorporating nasal stent . The nasoalveolar orthopedic plate was made self-retentive by adding soft acrylic on its palatal surface in the defect part. There was no need of any extra oral attachment . Activation is done by adding soft liner in the palatal portion. 

77. Thank you all.

78. References Text book of P ediatric dentistry- Nikhil marwah Textbook of P ediatric dentistry- MS Muthu

79. QUESTIONS 1. which of the following advacement system in local anesthesia delviery utilizes gate control theory? A. Wand B. Vibraject C. nano anesthesia D. Jet injectors 2. Zombie effect is associated with which of the following A. nano composite materials B. SDF C. monocortical implants D. figaro crown

80. 3. Figaro crown utilizes which technology A. smooth fit technology B. crimp fit technology C. flex fit technology D. marginal fit technokogy 4. Implants can be placed in adolescent girls after A. 12 yrs B. 18 yrs C. 15 yrs D. 14 yrs

81. 5. identify the given image A. Caries scan pro B. diagnodent C. soprolife D. canary system