RECENT ADVANCES IN PEDIATRIC DENTISTRY

SILVER DIAMINE FLOURIDE(SDF),LASERS IN PEDODONTICS,ZIRCONIA CROWNS IN PEDODONTICS

1. RECENT ADVANCES IN PEDIATRIC DENTISTRY

2. Use of Silver Diamine Flouride in management of Dental caries in children

3. Silver diamine fluoride (SDF) is a liquid substance used to help prevent tooth cavities (or caries) from forming, growing, or spreading to other teeth. SDF is made of: silver: helps kill bacteria water: provides a liquid base for the mixture fluoride: helps in remineralization ammonia: helps the solution remain concentrated so that it’s maximally effective against cavity resonance

4. THE PROBLEM: DENTAL CARIES IN CHILDREN   Fast progression  • Has a significant impact on quality of life • Affects a subset of the population very early and aggressively Children with caries in primary dentition are 3 times more likely of having caries in permanent dentition.                         Alm A et al 2007 Caries Res , Peretz B et al 2005, Ped Dent 

5. WHY SDF IN PEDODONTICS ?

6. Traditional treatment:  1)Restorations Require significant cooperation from the patient 2)Expensive  3)Technique sensitive

7. THE PROBLEM: Treating Dental Caries in children Advanced forms of behavior management: • Nitrous oxide           • moderate sedation          • general anesthesia   Increase cost, risk and add barriers to care

8. Outcomes of various studies on SDF          Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries "silver-fluoride bullet". Journal of Dental Research 2009; 88(2): 116-125. [ PubMed ] Caries arrest Caries prevention Silver diamine fluoride 96% 70% F varnish 21% 58%

9. SDF Meta-Analysis  At 12 months: SDF caries arrest was 89% higher than other materials or placebo

10. Randomized Clinical Trial of 12% and 38% Silver Diamine Fluoride Treatment M H T Fung   ,  D Duangthip   ,  M C M Wong   ,  E C M Lo   ,  C H Chu   Arrest rates after 30 months:          67% once a year           76% twice a year  2x/year by location:          Max ants 86%           Max post 57%           Mand ants 92%           Mand post 62%

11. SDF Treatment Considerations Does not require caries removal Poses minimal risks  Inexpensive  Easy to apply Minimally invasive treatment Twice a year for caries arrest Can be combined with F varnish at 3 month intervals Could be monitored and re-applied after 2-4 weeks for reapplication in large posterior lesions. No lasting acute toxicity issues reported

12. Indications;  Interim treatment for patients who can’t receive traditional restorative treatment for whatever reason: pre-cooperative, special needs, delayed treatment, etc… Contraindications;   Silver allergy  Tooth that is symptomatic or pulpally involved Presence of stomatitis or ulcerative gingival conditions ​

13. SDF: Technique

14. Dispense 1 drop for 4-6 teeth on glass dappen dish  Place Vaseline on lips • isolate with cotton rolls  Apply SDF with microbrush to caries lesion and rub for 1 min  Air dry  Light curing accelerates precipitation onto dentin.

15. SIDE EFFECTS OF SDF : Staining and Gingival Irritation

16. Recommended Protocol for Potassium Iodide(KI)- Staining Reversal

17. Conclusions:

18. Zirconia Crowns In Pedodontics

19. Esthetic Restorations On Primary Teeth Have Long Been A Challenge For the pediatric dentist. A Variety Of Restorative Options Using Full Coverage Are Available For anterior primary Teeth Such As SSC, Polycarbonate Crowns, preveneered Ssc, bonded Resin Strip Crowns, And Recently Introduced zirconia crowns. The Most Obvious Advantage Of Zirconia Crowns Is Their Excellent esthetics, which Is Far Superior To Other Pediatric Crown options.

20. Some techniques used for restoring complete crown coverage include polycarbonate crowns, acid etched crown, stainless steel crown (SSC), open–faced SSC with veneer placed on chair side, and commercially available preveneered SSC.  The effective and efficient usage of these techniques is complicated due to technical, functional, or esthetic hurdles. Prefabricated zirconia crown (EZ-Pedo, Loomis, CA, USA; NuSmile ZR Primary Crowns, Houston, TX, USA; Hu-Friedy Mfg. Co., LLC, Chicago, IL, USA; Kinder Krowns, St. Louis Park, MN, USA; Cheng Crown, Exton, PA, USA; Zirkiz-Hass Corp. Korea) is an exceptionally strong ceramic crown and offers more esthetic and biocompatible full coverage for primary incisors and molars.  They are anatomically contoured, metal free, completely bio-inert, and resistant to decay.

21. Zirconia is well-known polymorph that occurs in three different forms: monoclinic (M), tetragonal (T), and cubic (C).  Pure zirconia is monoclinic at room temperature and remains stable up to 1170°C. Above this temperature, it transforms into tetragonal and then into cubic phase at 2370°C.  During cooling, the tetragonal phase transforms back to monoclinic in a temperature ranging from 100°C to 1070°C.  The phase transformation taking place while cooling is associated with a volume expansion of approximately 3%–4%. Zirconia has a unique ability to resist crack propagation by being able to transform from one crystalline phase to another, and the resultant volume increase stops the crack and prevents it from propagating .

22. PROPERTIES OF ZIRCONIA Zirconia has demonstrated high wear resistance, excellent biocompatibility, and superior corrosion resistant.  Three type of zirconia are currently used in dentistry; these are yttria stabilized tetragonal zirconia polycrystal (Y-TZP), magnesia partially – stabilized zirconia and zirconia toughened alumina.  Y-TZP is a monolithic zirconia that consists of equiaxed partially stabilized tetragonal grains. Because of the superior mechanical properties of Y-TZP ceramics, these materials have a wide range of clinical applications, from implant abutments and single-tooth restorations to fixed partial dentures involving several elements. The most obvious advantage of zirconia crowns is their excellent esthetics, which is far superior to other pediatric crown options.

23. CLINICAL ASPECTS Tooth preparation and cementation procedure are important clinical steps in a crown placement.  The presence of adequate clearance, proper angulations, and visible knife edge finish lines helps to preserve gingival health and less plaque accumulation.  Adequate preparation of the tooth will significantly improve esthetics, crown fit reduces chances of veneer fracture and saves chair time.  The tooth should be prepared to fit the crown so that the crown fits the tooth passively without using pressure.  The preparation of tooth for zirconia crown takes more time, and so this crown not recommended for children who are fearful and unable to cooperate for longer procedures.  It is difficult to adjust a zirconia crown because it is ceramic and cannot be trimmed with scissors like a traditional SSC, it is necessary to use a high speed, fine diamond burs with lots of water because excessive heat could cause fractures in the crown's ceramic structure.  Occlusal and interproximal adjustments are not recommended, as these will remove the crown's glaze and possibly create a weak area of thin ceramic.  It is very important that zirconia crowns fit passively because they are made of solid zirconia and do not flex, attempt to sit with force will result in fracture and adjustment with bur result in microfracture.  The appropriate size crown should fit passively and completely subgingivally without distorting the gingival tissue.

24. DRAWBACK OF ZIRCONIA CROWNS AND SOLUTIONS FOR THESE DRAWBACKS A concern for zirconia crown is cementation.   Etching and bonding of zirconia are not possible because of lack of silicone of glass ceramic.  Sandblasting has been reported to introduce microcrack into zirconia, etching with phosphoric acid or hydrofluoric acid have no effect on overall retention of restoration .Conventional or self-adhesive resin cements have been recommended as luting agent for zirconia crowns. It requires significantly more time to prepare the tooth for fitting the crown.  Bleeding from the gum, due to anxiety or inflammation, may hinder the setting of the cement used to bond the zirconia crown to the tooth.  With crying or inability to sit still and fully cooperate for the procedure, an SSC would be preferable; since the preparation of the tooth and fitting an SSC takes much less time, but with the latest innovations manufacturers are trying to minimize these factors.  Ez-Pedo has introduced Zir-Lock ultra, mechanical undercuts to increase crown retention .   Another point to consider is that zirconia crowns not contaminated with blood or saliva have better adhesion to cement and to solve this problem NuSmile came up with the try-in pink crown

25. CONCLUSION Although clinical long-term evaluations are a critical requirement to conclude that zirconia pediatric crowns have good reliability.  It is expected that in the near future, prefabricated zirconia crowns could be an easy, restorative option to traditional stainless steel and composite strip crowns due to their unparalleled advantages.  Zirconia crowns offer high-end esthetics, superior durability, and easy placement compared to composite restorations and strip crowns

26. LASERS IN PEDODONTICS

27. Treating a pediatric patient with laser for oral and dental procedure is beneficial as it is less fearful to the child and better accepted by parents.  When clinician uses the laser for surgical or pulpal procedure, children become more cooperative and it also enhances the treatment outcome. It is used for caries prevention, early diagnosis, cavity restoration, management of traumatized teeth, and minor oral surgical procedure in child patients and seems to soon become the gold standard in pediatric dental practice.

28. Soft-Tissue Applications of Laser 

29. Frenectomy And Treatment Of Ankyloglossia When hyperactive labial frenum is present, a laser-assisted frenectomy could be done with Er: YAG laser in an attempt for diastema closure.Er: YAG laser is also used for surgical management of severe tongue tie or ankyloglossia in infants and children.

30. Gingival Recontouring And Crown Lengthening CO 2  laser is used for gingivectomy procedure.It is also used for surgical removal of soft-tissue tumor in the oral cavity. With the advent of diode laser, nowadays, clinicians prefer to reproduce gingival esthetics as a part of comprehensive orthodontic treatment The advantage of using the laser in gingivectomy and gingival recontouring is that it provides a bloodless field and also sterilizes the wound by reducing the microbial load exposed to laser radiation.

31. Exposure Of Unerupted Tooth To expose a unerupted or partially erupted tooth for orthodontic bracket or button placement laser is used. As the laser-assisted surgical field is relatively bloodless, immediate placement of bracket or button can be done. Er: YAG, Nd:YAG, and Er-Cr: YSGG are mainly used for this purpose.

32. Pulpotomy Of Primary Teeth Using Laser For the preservation of pulp vitality lasers of different wavelength are used with a power of 0.5–1 W.  They are used in pulse mode without water and at a low frequency for the duration of 10 s to avoid coagulation. CO 2  laser can be used for pulpotomy in the primary tooth at a power of 1–4 W and they should be used in a noncontinuous manner to avoid excessive laser energy exposure to pulp tissue. Formation of carbonized layer on the surface of the root canal is a disadvantage of using several laser exposure for complete pulp tissue removal, and this layer should be removed by irrigation using 3% H 2 O 2  and 5.25% NaOCl. In 1989, Ehihara reported better wound healing in amputated pulp tissue after Nd:YAG pulpotomy. Diode laser used for pulpotomy of primary teeth showed 100% success rate after a follow-up of 1 year and proved to be a better alternative to ferric sulfate and electrosurgery from clinical and radiographic point of view.  In 1999, Jeng-fen Liu  et al . evaluated the effects of laser pulpotomy in primary teeth and found all the teeth which underwent laser irradiation were clinically successful in a 6 months follow-up visit except one.

33. Direct And Indirect Pulp Capping Of Young Permanent Teeth Using Laser CO 2  laser is used for direct pulp capping as it controls hemorrhage and sterilizes the exposure site which facilitates better placement of calcium hydroxide paste at exposure site and induces favorable clinical outcome.This laser irradiation is usually performed at a power of 1–2 W The laser energy has a obtundant and sedative effect on inflamed pulpal tissue, and it can also close the dentinal tubule. The mechanism by which it helps in indirect pulp capping is thought to be similar to the sedative effect produced by laser in pulpitis.

34. Other Soft tissue applications

35. Hard Tissue Applications Of Laser

36. Removal Of Caries, Old Restoration, And Cavity Preparation Er: YAG laser is effectively used for caries removal from both enamel and dentin without causing thermal injury to underlying vital pulp tissue. It also removes old glass ionomer and composite resin restoration by ablation. Cavity prepared by LLLT is similar to that of the air-rotor except for the floor which is not smooth.

37. Pit and fissure sealants Laser can be used for fissurotomy, cleaning, and conditioning of pits and fissures before sealant application. Erbium laser is mostly used for fissurotomy procedure. Application of laser does not eliminate the need of acid etching before sealant application. The formation of enamel cracks and resulting microleakage at sealant enamel interface are the disadvantages of this technique which can be prevented by curing the sealant material using argon laser.  In primary teeth, surface conditioning with Er-Cr: YSGG laser does not have any effect in reducing microleakage at sealant enamel interface.

38. Diagnodent and caries detection Laser fluorescence is used for caries detection which reproduces a near accurate result and also speed of clinical diagnosis. Laser fluorescence at a wavelength of 655 nm is effectively used for the detection of occlusal caries, hidden caries, and occult lesion in primary and permanent teeth.  Diagnodent is a commercially available device which uses laser fluorescence technology. Argon laser at a wavelength of 488 nm is used for quantitative detection of demineralization, particularly in interproximal surfaces. It is more effective in caries detection for primary teeth.

39. Contraindications of Laser Use and Its Limitations Laser should be used with caution in patient having cardiac pacemaker It is also not advised to use in cardiac patient with a history of anginal chest pain and arrhythmia Use of laser in dental practice requires intensive training and minute precision. The high cost of laser armamentarium is also a disadvantage in developing country like India The cost-effectiveness of treatment provided by laser is questionable; moreover, lasers of different wavelength are required for different oral and dental procedure. It should be used with precaution in patient with immunocompromised state as there is a potential chance of disease transmission through aerosol during the laser procedure.

40. Clinical Recommendation in Pediatric Practice Laser can be used as an alternative to different hard tissue and soft-tissue oral procedure in pediatric patient. Modifications in clinical procedure and additional use of high-speed handpiece may be needed in pediatric dental practice. Use of protective eyewear specific for specific laser wavelength is mandatory for dentist, dental team, and also for the patient. The dental team should have received educational training program in laser before using it in the pediatric population.

41.  Laser Safety The use of protective eyewear is mandatory as it causes ocular hazards. The operator must be cautious about accidental exposure to nontarget tissue and the operating area should have a limited accessibility for other persons to minimize its hazardous effects. The presence of flammable materials in laser surgical room should be avoided as it can produce combustion hazards. The use of explosive anesthetic gases is contraindicated when laser surgery is planned under general anesthesia. Moreover, it has to be ensured that the laser is in good working condition and all safeguard are in proper position.

42. Conclusion Although it has some cost- and training-related disadvantages, its use in pediatric dental procedure is well accepted by the patient and their parents. Due to its minimal invasiveness patients of pediatric age group show cooperative behavior during dental procedure.  Although its effectiveness in the diagnosis of dental caries, prevention of caries, endodontic management of deciduous and permanent teeth, and different soft-tissue procedure is well documented, further research regarding its efficacy in pediatric dental procedure is still needed

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